St Rose Hospital

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 40968 Based on interview and record review, the facility failed to provide discharge planning assessments within 48-hours for one of five sampled Patients (Patient 9). This failure resulted in Patient 9 to experience delayed or unsafe discharge from the facility. Findings: During a review Patient 9’s face sheet, undated, indicated Patient 9 was admitted to the facility on 3/31/26 and was discharged on 4/20/26. During a concurrent interview and record review on 5/6/26 at 3:26 p.m., with Case Management Director (CMD), Patient 9’s Nurse Case Manager (NCM) Initial Assessment was completed on 4/5/26. CMD, stated hospital policy for completing initial assessment by NCM was within 48 hours of admission. CMD also stated, Patient 9’s initial assessment was completed five days after admission. CMD added, it was important to complete Patient 9’s assessment timely to identify patient needs during hospitalization and upon discharge.”

“STANDARD TAG FOR NUCLEAR MEDICINE SERVICES CFR(s): 482.53 Standard-level Tag §482.53 Condition of Participation: Nuclear Medicine Services If the hospital provides nuclear medicine services, those services must meet the needs of the patients in accordance with acceptable standards of practice. This Standard is not met as evidenced by: 49983 Based on interview and record review, the facility failed to provide nuclear medicine services in accordance with acceptable standards of practice when the facility: 1. Gave one (Patient 22) out of thirty reviewed patients an incorrect type of radiopharmaceutical (radioactive drug used for certain imaging tests and procedures) 2. Did not consent Patient 22 for the correct type of radiopharmaceutical 3. Did not document the error or patient notification of the error in Patient 22’s medical record. This failure had the potential to result in Patient 22 being exposed to the incorrect type of radiopharmaceutical without understanding the risks and benefits and could result in other medical professionals not knowing about Patient 22’s radiation exposure. Findings: During a record review of facility’s document titled, “Medical Records Consult”, dated 7/28/25, Patient 22 was admitted to the facility on 7/28/25 for a Myocardial Perfusion Scan (a test used to evaluate blood flow to the heart muscle). During a concurrent interview and record review on 5/5/26 at 3:01 p.m. with Radiologic Technologist 1 (RT1) and Manager of Diagnostic Imaging (DI), facility’s documents titled, “Diagnostic Imaging Requisition” for Patient 22, dated 7/28/25, “Cardiology Worksheet: NM Myocardial Perfusion” for Patient 22, dated 7/28/25, “Diagnostic Imaging” for Patient 22, dated 7/28/25, and an untitled document described as “Hot Lab Log Book”, dated 7/28/25, were reviewed. DI stated the “Hot Lab Log Book” indicated on 7/28/25, Patient 22 received a dose of 29.4 millicuries (mCi, a unit of radioactivity, named after Marie Curie, a pioneer of radiation therapy) of Medronate (MDP) Tc-99m Non-HEU (a specialized radioactive drug used for bone scans). DI stated Patient 22 should have received 30 mCi of Sestamibi Tc-99m Non-HEU (a specialized radioactive drug used for Myocardial Perfusion tests). DI stated that facility’s documents titled, “Diagnostic Imaging Requisition” for Patient 22, dated 7/28/25, “Cardiology Worksheet: NM Myocardial Perfusion” for Patient 22, dated 7/28/25, “Diagnostic Imaging” for Patient 22, dated 7/28/25 did not include documentation of the incorrect dose of MDP Tc-99 Non-HEU given to Patient 22 on 7/28/25. During a concurrent interview and record review on 5/7/26 at 2:21 p.m. with facility’s Radiation Safety Officer (RSO), facility’s documents titled “Medical Records Consult” for Patient 22, dated 7/28/25, “Stress Echo Procedure” for Patient 22, dated 7/31/25, procedure images from Patient 22’s Myocardial Perfusion Scan, dated 7/28/25 and 7/29/25, “Diagnostic Imaging Requisition” for Patient 22, dated 7/28/25, “Cardiology Worksheet: NM Myocardial Perfusion” for Patient 22, dated 7/28/25, “Diagnostic Imaging” for Patient 22, dated 7/28/25, and an untitled document described as “Hot Lab Log Book”, dated 7/28/25 and 7/29/25 were reviewed. RSO stated there is no mention in the chart for Patient 22 of the incorrect dose of MDP TC-99m Non-HEU received on 7/28/25 or that the patient was notified of the error. RSO stated documentation of the error and subsequent patient notification should be included in the medical record. During a concurrent interview and record review on 5/7/26 at 2:23 p.m. with RSO, facility’s untitled document described as “Hot Lab Log Book”, dated 7/29/25 was reviewed. RSO stated the “Hot Lab Log Book”, dated 7/29/25, indicated on 7/29/25, Patient 22 returned for the stress portion of the study and received 12.3 mCi of Sestamibi. RSO stated patients usually receive approximately 30 mCi for the stress part of the study and it is not documented why Patient 22 received 12.3 mCi of Sestamibi instead of the usual 30 mCi of Sestamibi. During a concurrent interview and record review on 5/7/26 at 2:25 p.m. with RSO, facility’s documents titled “CONSENT FOR PERSANTINE, LEXISCAN, ADENOSINE, DOBUTAMINE STRESS TEST”, for Patient 22, dated 7/28/25, were reviewed. RSO stated the consent form indicated the radioactive substance that would be administered was Thallium. RSO stated the radioactive substance administered to Patient 22 was Sestamibi. RSO stated Thallium and Sestamibi are not the same and patients should be informed of what type of radioactive substance they are receiving and the consent form is incorrect and should be updated. During a review of the facility’s policy and procedure titled, “MYOCARDIAL PERFUSION, SPECT, SINGLE OR MULTIPLE STUDIES, AT REST AND/OR STRESS”, undated, indicated the dosage for sestamibi for Myocardial Perfusion scans for stress is 30 mCi.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 46658 Based on observation, interview and record review, the facility failed to ensure staff followed isolation precautions (actions implemented in addition to standard precautions that are based upon the means of transmission for the infectious agent in order to prevent or control infections) when: 1. a speech therapist (ST) did not disinfect two plastic containers when leaving a contact isolation room (isolation precaution which infection can spread though contact with patient or surfaces contaminated by the patient), contaminated their hands with the containers and then handed wound care supplies to a wound care nurse who was performing wound care. 2. Registered Nurse 1 (RN 1) performed a blood draw (collection of blood from a vein using a needle) without wearing gloves and subsequently reached into an equipment cart to obtain a syringe without performing hand hygiene. These failures had the potential to spread infection through contaminated patient care equipment potentially leading to death. Findings: 1. A review of Patient 22’s physicians order titled, “View Order Detail,” undated, indicated Patient 22 had an order for “Contact Precautions Continuous” started on 3/31/25. During an observation on 4/7/25, at 11:29 a.m., ST was in Patient 22’s room performing a swallow evaluation. ST had a plastic container, with food items inside, set on a table in the room. A sign at Patient 22’s room indicated Patient 22 was on contact precautions. A review of Patient 23’s wound care note titled, “Care Assessments Wound Assessment,” dated 4/7/25, indicated Patient 23 had three pressure injuries on the right lower extremities and a pressure injury to the sacrum and had wound dressings changed on 4/7/25. During an observation on 4/7/25, at 11:49 a.m., as ST was preparing to leave Patient 22’s room, ST placed the plastic container on the lid of a linen basket for Patient 22’s room. After doffing their personal protective equipment and performing hand hygiene, ST picked up the container and without sanitizing the container, went to the nurses station. ST placed the container on the table next to a computer and began to document care. During an observation on 4/7/25, at 11:58 a.m., while at the nurses station, a wound care nurse asked ST to bring a wound care dressing to Patient 23’s room. Without performing hand hygiene, ST reached into a bin containing wound care equipment and procured a wound care dressing for the wound care nurse. Patient 23’s doorway did not indicate Patient 23 was on any isolation precautions. During an interview on 4/7/25, at 12:10 p.m. with ST, ST stated Patient 22 was on contact precautions for vancomycin resistant enterococcus (VRE). ST stated they had performed hand hygiene but didn’t wipe the plastic containers with anything. ST stated they did not perform hand hygiene between leaving Patient 22’s room and handing the wound care nurse the wound care dressing. ST stated it would be expected to wipe the container after leaving a contact precaution room to prevent contamination and spread of infection. During an interview on 4/8/25, at 3:10 p.m., with Nursing Manager (NM), NM stated Patient 22 was on contact isolation for VRE due to a history of a positive VRE lab test. NM stated facility practice was to place patients with a history of VRE on contact precautions even if current lab tests did not detect VRE. 2. A record review of Patient 21’s emergency department provider note titled, “Emergency Department Note,” dated 4/7/25, indicated Patient 21 was in the emergency department for gastrointestinal bleeding (bleeding in the gastrointestinal tract) and weakness. The provider note indicated Patient 21 needed to have a type and screen lab draw (a blood test to determine blood type compatibility for potential blood transfusion). During a record review of Patient 21’s laboratory results titled, “Diagnostics, Blood Bank Tests,” dated 4/7/25, indicated Patient 21 had a type and screen lab drawn on 4/7/25, at 1:30 p.m. During a concurrent observation and interview on 4/7/25, at 1:28 p.m., with Infection Preventionist (IP), RN 1 was at Patient 21’s bedside performing a blood draw. RN 1 was drawing blood from the intravenous catheter (device placed directly in the vein for blood access) without wearing gloves. IP stated staff were expected to follow standard precautions and needed to wear gloves while drawing blood. RN 1 finished drawing blood with one syringe and then, without performing hand hygiene and still without gloves, reached into an equipment cart and obtained another syringe to draw additional blood from Patient 21. During an interview on 4/7/25, at 1:30 p.m., with RN 1, RN 1 stated staff were expected to wear gloves when drawing blood, and perform hand hygiene before moving on to another task. During an interview on 4/8/25, at 10:10 a.m., with IP, IP stated breaks in infection control such as not wearing gloves or failure to sanitize equipment had the potential for infection spread to other patients. A review of facility policy and procedure (P&P) titled, “Isolation Precautions (Transmission Based Precautions),” dated 1/2025, indicated the policy purpose was to “prevent spread of infection through prompt initiation of infection control measures ...prevent transmission of infections between patients ...all patients will be treated according to Standard Precautions at all times ...standard precautions apply to: A. Blood ...gloves should be donned whenever there is a possibility of contact with patient’s blood ...this protects both the patient and the healthcare workers...hand hygiene should be practiced before donning a pair of gloves.” The P&P further indicated, “Contact precautions ...these precautions are used to reduce risk of transmission of resistant microorganisms by direct or indirect contact with a patient and/or patient’s environment ...examples of these organisms are multiple drug-resistant organisms such as ...VRE ...if using common equipment or items, then adequately clean and disinfect them before use for another patient.””