Tanner Medical Center-East Alabama

“. K3 Building: 0101 K6 Plan Approval: 10/21/2016 K7 Survey Under: 2012 New K8 HOSP (CAH) Generator: One Diesel, Caterpillar 600 kW (installed 2017) FACP: Firelite MS900 UDLS (installed 2017) Private Fire Hydrant: One FM-200 System: One in Basement Server Room (installed 2017) Locking Devices: Full Time Magnetic at OR and Emergency Room Nurses’ Stations, one delayed egress Smoke Detection: Complete Beds: 15 Census: 7 Type of Structure: 2016 Two story with a basement protected non-combustible, Type II(222). The facility has a complete automatic sprinkler system. During a routine recertification survey conducted on this date, the requirements of 42 CFR, Subpart 482.41 were not met as evidenced by the following deficiencies of the 2012 NFPA 101 Life Safety Code (LSC), the 2012 NFPA 99 Health Care Facilities Code and the standards referenced by these codes, as observed by the LS Surveyor while accompanied by the facility maintenance personnel. .”

“Horizontal Exits CFR(s): NFPA 101 Horizontal Exits Horizontal exits, if used, are in accordance with 7.2.4 and the provisions of 18.2.2.5.1 through 18.2.2.5.7, or 19.2.2.5.1 through 19.2.2.5.4. 18.2.2.5, 19.2.2.5 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain a horizontal exit per the requirements of: 2012 NFPA 101, 18.2.2.5, 7.2.4.3.1, and 8.3.5.1 This deficiency affects 1 of 2 two-hour fire barriers (tenant separation walls). Findings include: During a tour of the facility, the surveyor observed an unsealed penetration of a red cable in the 2-hour fire barrier (tenant separation wall), over the door between the Hospital Emergency Department Lobby near the vending machines and the Medical Office Building. A member of the maintenance staff was present when this deficiency was identified. .”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 41792 . Based on review of documentation, the facility failed to maintain the fire alarm system per the requirements of: 2012 NFPA 101, 18.3.4.1, and 9.6.1.3 2010 NFPA 72, Table 14.3.1(9)(h) This deficiency affects all smoke detectors. Findings include: During a tour of the facility, the facility failed to provide documentation of conducting semi-annual visual inspections on the smoke detectors within the past 12 months. A member of the maintenance staff was present when this deficiency was identified. .”

“Corridors - Areas Open to Corridor CFR(s): NFPA 101 Corridors - Areas Open to Corridor Spaces (other than patient sleeping rooms, treatment rooms and hazardous areas), waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are in accordance with the criteria under 18.3.6.1 and 19.3.6.1. 18.3.6.1, 19.3.6.1 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain areas open to the corridor per the requirements of: 2012 NFPA 101, 18.3.6.1 (1) (c) This deficiency affects 1 of 7 smoke compartments. Findings include: During a tour of the facility, the surveyor observed the First Floor Main Lobby Wheelchair Storage space was open to the corridor, and did not have an electrically supervised automatic smoke detection system. This space did not allow direct supervision by the facility staff from a Nurses’ Station or similar space. A member of the maintenance staff was present when this deficiency was identified. .”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 NEW Smoke barriers shall be constructed to provide at least a one hour fire resistance rating and constructed in accordance with 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations of fully ducted HVAC systems. 18.3.7.3, 18.3.7.4, 18.3.7.5, 8.3 Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of: 2012 NFPA 101, 18.3.7.3, 8.5.1, 8.5.6.2, and 8.5.6.3 This deficiency affects 2 of 7 smoke compartments. Findings include: During a tour of the facility, the surveyor observed an unsealed 1 1/4” conduit used as a chase for 1 gray cable in the smoke barrier, above the ceiling in the C.T. Room. This is the east wall between the C.T. Room and the Emergency Department. A member of the maintenance staff was present when this deficiency was identified. .”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the electrical wiring and equipment per the requirements of: 2012 NFPA 101, 18.5.1.1, and 9.1.2 2011 NFPA 70, 314.27 (2) and 410.5 This deficiency affects 1 of 1 electrical rooms on the 2nd floor. Findings include: During a tour of the facility, the surveyor observed exposed wiring from a flexible conduit coming out of the bottom of Panel C2LA in the 2nd floor Electrical Room. A member of the maintenance staff was present when this deficiency was identified. .”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the oxygen cylinders per the requirements of: 2012 NFPA 99, 11.6.2.3 (11), 11.3.2.3 and 11.6.5.4 This deficiency affects all oxygen cylinders in the outside liquid oxygen fenced-in area. Findings include: During a tour of the facility, the surveyor observed the facility failed to protect the oxygen cylinders located outside in the liquid oxygen fenced-in area against continuous exposure to direct rays of the sun where extreme temperatures prevail. A member of the maintenance staff was present when this deficiency was identified.”

“PATIENT CARE SERVICES CFR(s): [The doctor of medicine or osteopathy-] (iv) Periodically reviews and signs the records of all inpatients cared for by nurse practitioners, clinical nurse specialists, or physician assistants. (v) Periodically reviews and signs a sample of outpatient records of patients cared for by nurse practitioners, clinical nurse specialists, certified nurse midwives, or physician assistants only to the extent required under State law where State law requires record reviews or co signatures, or both, by a collaborating physician. This Standard is not met as evidenced by: 49797 Based on medical record (MR) review, and interviews it was determined the facility failed to meet the requirement for periodic review by the physician of the records for all inpatients cared for by the nurse practitioner (NP). This deficient practice did affect all 20 of 20 MR’s reviewed, and had the potential to affect all patients admitted to the hospital. Findings include: The MRs reviewed revealed all patients were cared for by a NP, and there was no evidence of physician periodic review. An interview was conducted on 8/22/24 at 12:48 PM with Employee Identifier # 1, Administrator, who confirmed there was no documentation the physician periodically reviewed the NP’s inpatient records.”

“PA, NP & CLINICAL SPEC RESPONSIBILITIES CFR(s): The physician assistant, the nurse practitioner, or clinical nurse specialist members of the CAH’S staff-- (i) Participate in the development, execution and periodic review of the written policies governing the services the CAH furnishes; and This Standard is not met as evidenced by: 49797 Based on review of hospital policies and interviews with the staff it was determined the hospital failed to have a nurse practitioner (NP) participate in the development and/or review of the Critical Access Hospital (CAH) policies. This had potential to affect all patients served by the hospital. Findings include: Review of the Governing Body meeting minutes dated 6/27/24 and hospital policies revealed no documentation nurse practioners participated in the development and/or review of the CAH policies. An interview was conducted on 8/22/24 at 12:20 PM with Employee Identifier # 1, Administrator, who confirmed the NP’s do not participate in the review or revision of CAH policies.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iii) Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the CAH. This Standard is not met as evidenced by: 49797 Based on review of hospital policies and interviews with the staff, it was determined the hospital failed to have the following Critical Access Hospital (CAH) policies: Conditions requiring consult and/or patient (pt) referral. Periodic review /evaluation (eval) of services by the CAH. This had potential to affect all patients served by the hospital. Findings include: Review of the hospital policies on 8/22/24 revealed no documentation of the required CAH policies. An interview was conducted on 8/22/24 at 12:20 PM with Employee Identifier # 1, Administrator, who confirmed the hospital does not have policies addressing conditions requiring consult and/or pt referral, and periodic review /eval of services by the CAH.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. This Standard is not met as evidenced by: 40119 Based on observations, review of hospital policies and procedures, and interviews, it was determined the facility failed to ensure: 1. All food available for patient use was labeled and not expired. 2. Stored freezer food was protected from possible contamination. 3. Covers to protect food were used appropriately to maintain the temperature of each hot item at the appropriate level. 4. All hot food items temperature was checked to ensure hot items were at a minimum of 135 degrees Fahrenheit. This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors. Findings include: Hospital Policy: Food Safety and Sanitation Policy Number: FNS II 4-01 Revised Date: 1/19 Policy: All local, state, and federal standards and regulations will be followed to assure a safe and sanitary food and nutrition services department. Procedure: ...4. Food Storage... a. Stored food is handled to prevent contamination and growth of pathogenic organisms... Hospital Policy: Label and Date Marking Food Items Policy Number: FNS II 3-40 Reviewed Date: 1/24 Policy: All foods placed in storage areas will be labeled with product identification...and product expiration date. Purpose: To reduce the risk of infection in patients, employees, and visitors. Procedure: ...Prepackage/Shelf stable items such as Salad Dressings, Picante Sauce, Bar-B-Que Sauce, etc... 2. Date on the label. Expiration date 7 days after opening... Hospital Policy: General HACCP (Hazard Analysis and Critical Control Point) Guidelines for Food Safety. Policy Number: FNS II 3-17 Reviewed Date: 1/24 Policy: It is the goal of the Food Service Department to maximize food usage to avoid waste... Procedure: Educate and monitor food and nutrition services staff on the following: ...7. Food Temperature for meal service. a. Check to be sure the staff takes food temperatures correctly and records temperatures. Hospital Policy: Service Standards Policy Number: FNS I 1-5 Reviewed Date: 1/23 Policy: Serving standards will be used for all food items. This includes all service areas... Procedure: ...2. Serving Hot Food: Use covers to protect food and beverages and to maintain the temperature of each hot item at the appropriate level... 3. Serving from the Hot Food Table: ...All hot food items must be kept at minimum 135 degrees Fahrenheit. 1. An observation was conducted in the Dietary Department refrigerated and freezer areas on 8/20/24 at 10:04 AM with Employee Identifier (EI) # 11, Emergency Department Nurse Manager, the following items were found in the refrigerated area: a. Opened Salsa Picante sauce 1 gallon container without a date the item was opened. b. Opened Asian Sesame sauce 1 gallon container without a date the item was opened. c. Opened Sweet Teriyaki sauce 1 gallon container with a best by date of 4/11/24 and without a date the item was opened. d. Opened Sweet Pickle Relish 1 gallon container without a date the item was opened.. e. Opened orange sauce number 5 bottle without a date the item was opened. f. Opened gallon container of what appeared to be sliced Jalapeno’s. There was no label on the container and no date the item was opened. g. Four Non Fat Cultured Buttermilk half gallon containers with the expiration date of 8/9/24. The staff failed to ensure all food available for patient use was labeled and not expired. The following items were found in the freezer area located on the floor under the raw chicken boxes with evidence of a pink substance frozen to the floor within 3 inches away from the items: a. A Box of Frozen Vegetables. b. A Box of crinkle cut wedge potatoes. c. A Box of baby cut carrots. The staff failed to ensure stored freezer vegetables were protected from possible contamination from the raw chicken. An interview was conducted on 8/20/24 at 2:56 PM with EI # 10, Dietary Manager, who verbalized all stored food in the freezer area should be on a shelf and not located on the floor where possible contamination could occur. EI # 10 confirmed the staff failed to ensure all food available for patient use was labeled, and not expired. 2. An observation was conducted in the Dietary Department on 8/20/24 at 11:32 AM with EI # 13, Dietary staff, to observe patient tray plating. Prior to the plating, the silver covers of the pot pie, peas, and carrots were askew which allowed heat from the dishes to escape. During the plating, EI # 13 failed to check the food temperature of the pot pie, peas, and carrots prior to placing the food on the patient trays. An interview was conducted on 8/20/24 at 2:53 PM with EI # 10, who confirmed the staff failed to ensure covers to protect food were used appropriately, and all hot food temperatures were checked per policy.”

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 40119 Based on review of medical records (MR), hospital policy and procedure, and interviews, it was determined the facility failed to ensure staff: 1. Performed wound assessments per the hospital policy. 2. Notified the physician of wounds and obtained wound care orders. These deficient practices did affect three of four MRs reviewed with wounds, including Patient Identifier (PI) # 12, PI # 14, and PI # 8 had the potential to affect all patients admitted to the hospital with wounds. Findings include: Hospital Policy: Skin Surveillance and Treatment Policy Number: NR.01.086.0 Revised Date: 3/24 Purpose: To provide guidelines to maintain skin integrity, prevent formation of pressure injuries, and treat various stages of skin breakdown. Policy: Skin integrity will be assessed upon admission, every 12 hours, and with any clinical change. Procedure: ...II. Assess Skin Integrity. A. Pressure Ulcer Staging... B. Wounds of unknown etiology on admission. 1. Document location, size, and a detailed description of wound. ...V. Documentation: Document the wound assessment on the admission database initially and then continue to document with each assessment or dressing change. A. Location of wound. B. Stage pressure ulcer... C. Appearance of wound bed (pink, red, slough, or eschar). D. Exudate appearance (serous, purulent, none) and amount (minimal, moderate, and copious). E. Size in cm (centimeters) (length x width x depth). F. Odor (present of not present). G. Inflammations (present with measurement or not present). H. Undermining (present- measure depth in cm and designate location by using face of a clock, or not present). I. Description of periwound. 1. PI # 12 was admitted to the hospital on 7/27/24 with a diagnosis of Community Acquired Pneumonia due to Pneumococcus. Review of the nursing assessment dated 7/28/24 revealed the patient had a Coccyx wound, a skin tear to the right posterior right arm, a skin tear to the right posterior hand, and a skin tear to the left posterior arm. There was no documentation the physician was notified to obtain wound care orders. Review of 15 of 15 nursing notes dated 7/28/24 to discharge date of 7/29/24 revealed no documentation of the coccyx wound type and wound assessments for the coccyx wound, the right posterior right arm wound, the right posterior hand wound, and the left posterior arm wound per hospital policy. An interview was conducted on 8/22/24 at 12:12 PM with Employee Identifier (EI) # 3, Special Projects Manager, who confirmed there was no documentation of the patient’s wound type and wound assessments per hospital policy. 2. PI # 14 was admitted to the hospital on 8/19/24 with a diagnosis of Urinary Tract Infection. Review of the nursing assessment dated 8/20/24 revealed the patient had a pressure injury to the sacrum. Review of 3 of 3 nursing notes dated 8/20/24 revealed no documentation of the stage of the pressure injury, the exudate of the wound, the appearance of the wound bed, the presence of odor, inflammation presence, undermining presence, and a description of the periwound. An interview was conducted on 8/21/24 at 4:05 PM with EI # 14, Director of Nursing Development and Informatics, who confirmed the wound assessment to the sacrum was not performed per the hospital policy. 50417 3. PI # 8 was admitted to the hospital on 6/14/24 with a diagnosis of Closed Nondisplaced Fracture of Right Acetabulum, Initial Encounter. Review of the nursing assessment dated 6/15/24 revealed the patient had a laceration to the left lower extremity (LLE). There was no documentation the physician was notified to obtain wound care orders. Review of 3 of 3 nursing assessments dated 6/15/24 to discharge date of 6/17/24 revealed no documentation of the laceration to the LLE and wound assessments per hospital policy. An interview was conducted on 8/21/24 at 2:43 PM with EI # 2, Accreditation Manager, who confirmed there was no documentation of physician notification and wound assessments per hospital policy.”

“NURSING SERVICES CFR(s): §485.635(d)(3) All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. This Standard is not met as evidenced by: 30952 Based on facility policy, medical record (MR) review, and interview, it was determined the facility failed to ensure the staff flushed the implanted port, a central venous access device, according to the physician order and facility policy. This affected Patient Identifier (PI) # 31, one of one implanted port record reviews, and had the potential to negatively affect all patients with central venous devices treated at the facility. Findings include: Facility Policy Title: Established and Managing Venous Access: Peripheral IV (intravenous), External Jugular Catheter, Midline, PICC (peripheral inserted central catheter), Ports, and Dialysis Catheters Revised: 3/24 ...Policy: ...II. Documentation of...assessment, and discontinuance will be completed using the...central access intervention. ...III. Ports and connectors will be disinfected prior to each access. ...E. “Accessing Implanted Ports”... I. Blood Sampling via Central Access: ...Flush with 10-20 ml NS. 1. PI # 31 was admitted to outpatient services on 6/19/24 with a diagnosis of Other Specified Abnormal Findings of Blood Chemistry. Review of the physician’s orders dated 6/19/24 revealed orders to flush port per protocol and repeat every 6 (six) weeks. Flush with 10 milliliters (mL) normal saline (NS) followed by 500 units (U) Heparin and clamp. Draw all requested labs from port. Review of the Nursing Note dated 6/19/24 at 12:56 PM revealed the following documentation: port flushed, blood drawn port de-accessed. MR review revealed heparin 500 U was administered to the implanted port. There was no documentation staff followed the physician’s order and flushed the implanted port with normal saline. An interview was conducted on 8/20/24 at 11:45 AM with Employee Identifier (EI) # 6, Nurse Manager, Outpatient Services, who confirmed staff failed to document the port was flushed with NS per the physician order and policy.”

“RECORDS SYSTEM CFR(s): Reports of physical examinations, diagnostic and laboratory test results, including clinical laboratory services, and consultative findings; This Standard is not met as evidenced by: 30952 Based on review of MR (medical records), hospital Medical Staff Bylaws, and staff interview, it was determined the facility failed to ensure all history and physicals were completed per the medical staff bylaws. This deficient practice affected Patient Identifier (PI) # 39, and PI # 38, two of six outpatient surgery/procedure records reviewed, and had the potential to negatively affect all patients admitted for outpatient surgery. Findings include: Tanner Medical Center Alabama Inc (Incorporated)...Tanner East Alabama Medical Staff Bylaws Volume I: ...Reviewed 3/2024 ...General Provisions... 9.6 Histories and Physicals A medical history and physical examination shall be completed for each hospital patient no more than thirty days before or 24 hours after admission or registration. A history and physical must be completed prior to any surgery or procedure requiring anesthesia. ...When the medical history and physical examination is completed within 30 days before admission or registration, the medical staff physician...must complete and document an updated examination of the patient within twenty-four hours after admission or registration, but prior to surgery or procedure... 1. PI # 39 was admitted to the facility outpatient surgery department on 5/8/24 with diagnoses including Upper Abdominal Pain, and History of Melena. MR review revealed a history and physical (H&P) dated 3/21/24 completed by a Nurse Practitioner (NP) on a clinic visit encounter. The H&P was signed by the physician on 5/6/24. Further MR review revealed a colonoscopy and esophagogastroduodenoscopy was performed on 5/8/24. There was no H&P completed within 30 days of the surgical procedures. An interview was conducted on 8/21/24 at 11:30 AM with Employee Identifier # 5, Nurse Manager, Surgical Services, who confirmed the history and physical was not completed within 30 days of the surgical procedure. 2. PI # 38 was admitted to the facility outpatient surgery department on 4/17/24 with a diagnosis of Colon Cancer Screening. MR review revealed a H&P dated 2/6/24 completed by a NP on a clinic visit encounter. The H&P was signed by the physician on 4/14/24. Further MR review revealed on 4/17/24 a Colonoscopy with Polypectomy was performed. There was no H&P completed within 30 days of the surgical procedures. An interview was conducted on 8/21/24 at 11:30 AM with EI # 5, who confirmed the H&P was not completed within 30 days of the surgical procedure.”

“ANESTHETIC RISK AND EVALUATION CFR(s): (1) A qualified practitioner, as specified in paragraph (a) of this section, must examine the patient immediately before surgery to evaluate the risk of the procedure to be performed. (2) A qualified practitioner, as specified in paragraph (c) of this section, must examine each patient before surgery to evaluate the risk of anesthesia. (3) Before discharge from the CAH, each patient must be evaluated for proper anesthesia recovery by a qualified practitioner, as specified in paragraph (c) of this section. This Standard is not met as evidenced by: 30952 Based on review of facility policy and procedure, medical record (MR), and interview, it was determined the facility failed to ensure the anesthesia consent included the anesthetic type, technique, and risks. This affected Patient Identifier (PI) # 39, one of six outpatient surgery record reviews, and had the potential to affect all patients who received anesthesia. Facility Policy Title: Pre-Anesthesia Evaluation Revised Date: 5/24 Purpose: To establish guidelines for pre-anesthesia evaluation to be used...by anesthesia staff...to provide anesthetics. ...Procedure: 1. Pre-Anesthesia Evaluation ...B. Indications for the type anesthetic...risks and benefits will be discussed...plan...developed...and the proposed procedure... Findings include: 1. PI # 39 was admitted to the facility on 5/8/24 for outpatient surgery with diagnoses including Upper Abdominal Pain, and History of Melena. Review of the Consent to Operate or Perform Special Diagnostic Treatment of Service on 5/8/24 included Colonoscopy with Possible Biopsy, and Examination of Esophagus and Stomach, Possible Biopsy, Possible Dilation. Review of the Informed Consent for Anesthesia and/or Sedation dated 5/8/24 revealed no documentation of the type of anesthesia, anesthesia technique, and anesthesia risks. An interview was conducted on 8/21/24 at 11:30 AM with Employee Identifier # 5, Nurse Manager, Surgical Services, who confirmed the consent documentation failed to include the type of anesthesia, technique, and risks.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 30952 Based on review of the facility hand hygiene policy and procedure, the Centers for Disease (CDC) Injection Safety recommendation for Providers, observations, and interview, it was determined the facility failed to ensure the staff: 1. Performed hand hygiene before medication preparation, after glove removal, prior to donning clean gloves and after contact with inanimate objects in the immediate vicinity of the patient. 2. Cleaned the medication vial septum with alcohol before needle insertion. This affected three of five patients observered for medication administration including Patient Identifiers (PI) # 32, PI # 5, PI # 19, and two of two dietary observations and had the potential to negatively affect all patient’s treated at the facility. Findings include: Facility Policy # IC.03.03.0 Title: Hand Hygiene Revised: 13/19 Purpose: ...To reduce the transmission of pathogenic organisms and the incidence of healthcare associated infections ... To guide compliance for ...hand hygiene ... Policy: ...All employees are responsible for maintaining adequate hand hygiene ...set forth on this policy ... Procedure: ...use hand rub or soap and water to clean their hands: ...Before preparing medications. Between each medication administrations Before donning gloves ...and after removing gloves ... After contact with inanimate objects in the immediate vicinity of the patient. ...When using soap and water to clean hands... Apply enough soap to cover all surfaces of the hands and fingers. Rub hands together vigorously for at least 15-20 seconds. Rinse hands... Use disposable towel to turn of (off) the faucet... CDC Injection Safety Resources for Providers ...Safe Injection Checklist for Clinicians Feb. 7, 2024 INJECTION SAFETY CHECKLIST The following Injection Safety checklist items are a subset of items that can be found in the CDC Infection Prevention Checklist for Outpatient Settings: Minimum Expectations for Safe Care. The checklist...appropriate for both inpatient and outpatient settings, should be used to systematically assess adherence of healthcare providers to safe injection practices. Assessment of adherence should be conducted by direct observation of healthcare personnel during the performance of their duties. Injection Safety Practice Performed? ...Proper hand hygiene, using alcohol-based hand rub or soap and water, is performed prior to preparing and administering medications. ...Injections are prepared using aseptic technique in a clean area free from contamination or contact with blood, body fluids, or contaminated equipment. ...Needles and syringes are used for only one patient (this includes manufactured prefilled syringes and cartridge devices such as insulin pens. ...The rubber septum on a medication vial is disinfected with alcohol prior to piercing... 1. An observation was conducted in dietary for the plating of patient trays on 8/20/24 at 11:32 AM with Employee Identifier (EI) # 13, dietary staff. During the observation, EI # 13 failed to perform hand hygiene prior to donning gloves to plate the patient trays. An interview was conducted on 8/20/24 at 2:53 PM with EI # 10, Dietary Manager, who confirmed the staff failed to perform hand hygiene per the hospital policy. 2. A medication pass observation was conducted on 8/20/24 at 12:01 PM with EI # 7, Registered Nurse (RN) on the medical unit to administer an outpatient antibiotic intravenous (IV) infusion for PI # 32. EI # 7 exited the nurse station and entered the medication room. EI # 7 failed to perform hand hygiene before gathering supplies, alcohol, normal saline (NS) flushes, infusion tubing and preparing Vancomycin IV. An interview was conducted on 8/22/24 at 2:00 PM with EI # 1, Director of Nurses, Administrator, who confirmed staff failed to follow the facility hand hygiene policy. 3. An observation was conducted in dietary to observe dishwashing procedure on 8/20/24 at 1:28 PM with EI # 12, dietary staff, and EI # 13. During the observation, EI # 12 performed hand hygiene with soap and water. EI # 12 placed soap on hands then immediately placed hands under the water failing to rub hands together for 15-20 seconds. EI # 12 then used bare hand to turn the faucet off. During the observation of the dishwashing procedure for the patient trays, EI # 13 donned gloves twice without performing hand hygiene. EI # 13 failed to perform hand hygiene prior to donning gloves. An interview was conducted on 8/20/24 at 2:54 PM with EI # 10 who confirmed the staff failed to perform hand hygiene per the hospital policy. 4. A medication pass observation was conducted on 8/21/24 at 8:27 AM with EI # 16, RN, on the medical unit for oral, injectable, and IV medication administration for PI # 19. During medication administration, EI # 16 documented on the electronic medical record, located in the patient room next to the bed, then performed patient care such as the administration of intravenous medication without performing hand hygiene after contact with an inanimate object in the immediate vicinity of the patient. An interview was conducted on 8/22/24 at 12:18 PM with EI # 3, Special Projects Manager, who confirmed the staff failed to perform hand hygiene per the hospital policy. 5. A medication pass observation was conducted on 8/21/24 at 8:32 AM with EI # 8, RN, on the medical unit for oral, injectable, and IV medication administration for PI # 5. EI # 8 exited the nurse station to the medication room. EI # 8 gathered supplies, alcohol, saline flushes, oral and injectable medications, prepared Protonix IV and poured a cup of water. EI # 8 failed to perform hand hygiene before beginning medication preparation. During medication preparation, EI # 8 inserted the needle of a syringe into a Protonix vial without first cleaning the septum with alcohol. EI # 8 failed to follow aseptic technique during IV medication preparation. EI # 8 entered the patient room, performed hand hygiene, and donned gloves. EI # 8 administered Lovenox injectable, and discarded the needle into the sharp’s dispenser. EI # 8 removed gloves and donned clean gloves. EI # 8 failed to perform hand hygiene after glove removal and before donning clean gloves. An interview was conducted on 8/21/24 at 9:12 AM with EI # 8 who confirmed the deficient hand hygiene practices. 40119”