Uch-Memorial Health System

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 52287 Based on interviews and documents reviewed, the facility failed to ensure pain and vital signs were assessed in accordance with the provider’s orders in one of three surgical patients’ records reviewed. (Patient #1) Findings include: Reference: The Southern Region - Regulatory, Pain Assessment and Reassessment guideline provided by the facility read, when performing pain reassessment, at a minimum, document response to relief measures within 60 minutes and any additional interventions (provider notification, new orders received, etc.). 1. The facility failed to ensure pain and vital signs were assessed in accordance with the provider’s orders. A. Document Review i. Review of Patient #1’s medical record revealed Patient #1 presented to the facility on 11/14/25 at 6:52 a.m. for an outpatient hernia (when the intestine bulges through a weak spot in the muscle wall) repair surgery. At 9:18 a.m., Patient #1’s surgery was performed. According to a Phase 1: Vital Sign Monitoring order placed by the anesthesiologist at 9:57 a.m., vital signs included blood pressure, respiratory rate, oxygen saturation (SpO2 - measures the percentage of oxygen in the blood), electrocardiogram (EKG - assesses heart rate and rhythm), and pain assessment. At 9:57 a.m., the anesthesiologist also placed a Phase 2: Vital Sign Monitoring order, which instructed staff to assess vital signs when the patient was transferred to Phase 2 and then every 30 minutes. At 2:18 p.m., Patient #1 was transferred to the Phase 2 recovery area (a transitional stage, which prepares the patient for discharge). At 2:20 p.m., the RN performed a vital signs and pain assessment, which revealed the patient’s pain was 7/10 (severe). At 3:32 p.m., oxycodone (pain medication) 5 mg was administered, one hour and 12 minutes later. At 5:17 p.m., Patient #1 was transferred from the Phase 2 recovery area to the medical floor for further care of uncontrolled post-operative pain. The medical record failed to reveal reassessments of Patient #1’s vital signs or pain from 2:20 p.m. to 5:17 p.m., a period of 2 hours and 57 minutes. This was in contrast to the Phase 2: Vital Sign Monitoring provider’s order, which read, vital signs were to be assessed every 30 minutes. This was also in contrast to the Pain Assessment and Reassessment guideline, which read, response to relief measures and additional interventions should have been documented within 60 minutes. Further medical record review revealed Patient #1’s pain remained uncontrolled until 11/15/25 at 4:23 p.m., when an anesthesia provider performed a rectus sheath (a fibrous sleeve enclosing muscles in the abdominal wall) nerve block (a local anesthetic injection to reduce pain). B. Interviews i. An interview was conducted on 5/18/26 at 9:30 a.m. with registered nurse (RN) #1. RN #1 stated pain created a harmful stimulus to the body. RN #1 stated untreated pain placed patients at risk for a trauma response (an automatic, involuntary survival reaction triggered when the nervous system senses danger) and feelings of hopelessness. ii. An interview was conducted on 5/20/26 at 3:42 p.m. with RN #2. RN #2 stated vital signs included blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, and pain assessment. RN #2 stated nurses should have performed pain assessments every 30 minutes during phase two of recovery. RN #2 further stated pain control allowed the body to rest and heal after surgery. iii. An interview was conducted on 5/21/26 at 9:43 a.m. with perioperative associate nurse manager (Manager) #4. Manager #4 stated staff were required to assess and document vital signs and pain every 30 minutes. Manager #4 stated surgery caused pain, and nurses should have addressed pain early to maintain the patient’s comfort. Manager #4 stated the patient’s pain should have been addressed immediately. This was in contrast to the medical record review, which revealed Patient #1 had not received pain medication for one hour and 12 minutes after reporting 7/10 pain. Manager #4 stated uncontrolled pain increased the risk for prolonged recovery. These interviews were in contrast to the medical record review for Patient #1, which revealed vital signs and pain assessments had not been assessed every 30 minutes as ordered by the provider.”

“Condition of Participation: Pharmaceutical Se CFR(s): 482.25 §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service. This Condition is not met as evidenced by: 49541 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.25 Pharmaceutical Services, was out of compliance. A-0502 All drugs and biologicals must be kept in a secure area, and locked when appropriate. Based on observations, interviews, and document reviews, the facility failed to ensure prescription pads and medications in the triage area were securely stored to prevent unauthorized access in one of one observations in the emergency department (ED). Additionally, the facility failed to ensure expired medications were not readily available for patient use in one of one observation in the ED.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 52664 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.42 Infection Prevention and Control and Antibiotic Stewardship programs, was out of compliance. A-0749 - 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. Based on observations, interviews, and document review, the facility failed to ensure staff followed infection control practices and policies in two out of two observations of patients in isolation. Additionally, the facility failed to ensure staff cleaned equipment in accordance with facility policies and manufacturer instructions for use (IFU) in one out of one observations in the emergency department (ED).”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 49541 Based on observations, interviews, and document reviews, the facility failed to ensure prescription pads and medications in the triage area were securely stored to prevent unauthorized access in one of one observations in the emergency department (ED). Additionally, the facility failed to ensure expired medications were not readily available for patient use in one of one observation in the ED. Findings include: Facility policies: The Controlled Medication Management Policy read, controlled substances outside of pharmacy will be maintained in either an Automated Dispensing Cabinet (ADC) or a locked drawer/cabinet located within a locked area. The Medication Management Operations Policy read, drug storage areas shall be segregated from food storage areas. Non-controlled medications not stored in an ADC shall be stored in a secured/locked location unless those areas are under constant (24 hour) supervision by staff. A secured location may be a cabinet, locked drawer, emergency kit, cart (e.g., crash cart, anesthesia cart), or locked medication closet. Medications should be secured at all times and should be inaccessible to patients and visitors. Medications should only be removed from their secure location when immediate administration is anticipated. All medications in the manufacturer’s original container will be considered to have expired on the last day of the specified month and year, unless a date is specified. Expired, damaged, contaminated, deteriorated, or any unusable medications shall be immediately removed from available stock and returned to Pharmacy for proper disposal if a pharmacy is on-site. Multiple-dose injectable medication vials (MDV) should be dated with a revised expiration date using an approved sticker when the vial is opened or removed from recommended storage conditions. Vial should be discarded on the earliest occurrence of the following criteria: expiration date has been reached or passed (28-day beyond use dating or sooner if indicated) unless otherwise instructed by the manufacturer FDA-approved labeling, or Center for Disease Control (CDC)/Colorado Department of Public Health and Environment (CDPHE) instructions for vaccines. References: The Centers for Disease Control (CDC) Injection Safety, Preventing Unsafe Injection Practices, Key Point for Multi-Dose Vials, 3/26/24, retrieved from: https://www.cdc.gov/injectio nsafety/hcp/clinicalsafety/CDC_AAref_Val=https://www.cdc.gov/injectionsafety /providers/provider_faqs_multivials.html read, a MDV of liquid medication contains more than one dose of medication and is approved for repeated use. MDVs are labeled by the manufacturer and typically contain an antimicrobial preservative to help limit the growth of bacteria. The preservative does not have an effect on viruses, nor does it provide complete protection against bacterial contamination. Assign medications packaged as MDVs to a single patient whenever possible. MDVs used for more than one patient should be kept and accessed in a clean medication preparation area away from immediate patient treatment areas. If an MDV enters an immediate patient treatment area, dedicate it for single-patient use only. Examples of immediate patient treatment areas include operating and procedure rooms, anesthesia and procedure carts, and patient rooms or bays. The United States Pharmacopeia (USP) General Chapter 797 recommends unopened MDVs be discarded according to the manufacturer’s expiration date. Once an MDV is opened (needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer states another date for an opened vial. The beyond-use date should never exceed the manufacturer’s original expiration date. The Lidocaine HCL 1% Injection IFU read, Lidocaine hydrochloride injection should be employed only by clinicians who are well versed in diagnosis and management of dose-related toxicity and other acute emergencies that might arise from the block to be employed and then only after ensuring the immediate availability of oxygen, other resuscitative drugs, cardiopulmonary equipment and the personnel needed for proper management of toxic reactions and related emergencies. Delay in proper management of dose-related toxicity, underventilation from any cause and/or altered sensitivity may lead to the development of acidosis, cardiac arrest and, possibly, death. The Xylocaine 1% Injection IFU read, injections for infiltration and nerve block should be employed only by clinicians who are well versed in diagnosis and management of dose-related toxicity and other acute emergencies that might arise from the block to be employed and then only after ensuring the immediate availability of oxygen, other resuscitative drugs, cardiopulmonary equipment and the personnel needed for proper management of toxic reactions and related emergencies. Delay in proper management of dose-related toxicity, underventilation from any cause and/or altered sensitivity may lead to the development of acidosis, cardiac arrest and, possibly, death. Cardiovascular manifestations are usually depressant and are characterized by bradycardia, hypotension, and cardiovascular collapse, which may lead to cardiac arrest. The Sensorcaine 0.5 % Injection IFU read, depending upon the route of administration, local anesthetics are distributed to some extent to all body tissues, with high concentrations found in highly perfused organs such as the liver, lungs, heart, and brain. The safety and effectiveness of local anesthetics depend on proper dosage, correct technique, adequate precautions, and readiness for emergencies. Resuscitative equipment, oxygen, and other resuscitative drugs should be available for immediate use. The rapid injection of a large volume of local anesthetic solution should be avoided, and fractional (incremental) doses should be used when feasible. Acute emergencies from local anesthetics are generally related to high plasma levels encountered during therapeutic use of local anesthetics or to unintended subarachnoid injection of local anesthetic solution. 1. The facility failed to ensure blank prescription pads and medications in the ED were securely stored to prevent unauthorized access. A. Observations i. On 8/25/25 at 10:45 a.m., observations were conducted in the triage area in the ED which revealed an unsecured drawer readily accessible to patients. Further observations revealed the drawer contained 11 blank prescription sheets, two opened vials of Sensorcaine 0.5% Injection (local anesthetic that numbs a specific area of the body to block pain), stored with Heinz condiment packets. During the observation, unit manager (Manager) #6 stated medications should not have been stored with food. Manager #6 also stated the blank prescriptions were considered controlled substances and should not have been left unsecured. Manager #6 stated there was a potential for patients to have accessed the blank prescriptions, forged a narcotic medication order, overdosed, and died. Further observations of the ED revealed an unlocked cabinet that contained one Xylocaine 1% 50mL (local anesthetic that numbs a specific area of the body to block pain) multidose vial, one Bupivacaine 0.5% 50mL (local anesthetic that numbs a specific area of the body to block pain) multidose vial, and three Sensorcaine 0.5% 50mL multidose vials. Manager #6 stated that medications should be secured at all times. Observations on 8/25/25 were in contrast to The Controlled Medication Management Policy which read, controlled substances outside of the pharmacy will be maintained in either an ADC or a locked drawer/cabinet located within a locked area. Additionally, observations on 8/25/25 were in contrast to The Medication Management Operations Policy which read, drug storage areas shall be segregated from food storage areas. Non-controlled medications not stored in an ADC shall be stored in a secured/locked location unless those areas were under constant (24 hour) supervision by staff. A secured location included a cabinet, locked drawer, emergency kit, cart (e.g., crash cart, anesthesia cart), or locked medication closet. Staff secured medications at all times and kept them inaccessible to patients and visitors. Staff only removed medications from their secure location when they anticipated immediate administration. These observations were also in contrast to the Lidocaine HCL 1% Injection, Xylocaine 1% Injection, and Sensorcaine 0.5 % Injection IFUs which read, injections and local anesthetics were to be administered only by clinicians experienced in diagnosing and managing dose-related toxicity and other acute emergencies, and only with immediate access to oxygen, resuscitative drugs, cardiopulmonary equipment, and qualified personnel. Delayed or improper management of toxicity, underventilation, or altered sensitivity could result in acidosis, cardiovascular collapse, cardiac arrest, and death. B. Interviews i. On 8/25/25 at 2:23 p.m., an interview was conducted with assistant nurse manager (Manager) #5. Manager #5 stated blank prescription sheets were considered controlled substances and needed to be locked up to prevent unauthorized access. Manager #5 stated if a staff member or patient had access to a blank prescription, they could forge a narcotic prescription, which could result in an overdose or death. Manager #5 stated it was the staff’s responsibility to keep medications and prescription pads secured to prevent unauthorized access. ii. On 8/25/25 at 1:56 p.m., an interview was conducted with nurse manager (Manager) #6. Manager #6 stated they did not know why the prescription pads were unsecured and the prescription pads were only utilized during electronic charting downtime. Manager #6 stated they destroyed prescription sheets by tearing them up and disposing of them in a locked shredder box with Manager #5 as a witness. Manager #6 stated the facility treated blank prescription pads as controlled substances. Manager #6 stated unauthorized staff or patients could divert the blank prescription sheets and fill a narcotic prescription, which could result in overdose or death. Manager #6 stated all medications had to be secured and if patients had access to medications, were at risk of taking the medications, potentially resulting in an adverse reaction. iii. On 8/27/25 at 1:39 p.m., an interview was conducted with critical care pharmacist (Pharmacist) #7. Pharmacist #7 stated prescription pads were to be treated as controlled substances. Pharmacist #7 stated prescription pads were to be stored locked in the Pyxis or in the Schedule II controlled substance safe. Pharmacist #7 stated blank prescription pads were like blank checks that allowed staff or patients to write narcotic prescriptions. Pharmacist #7 stated there was a risk of diversion, as patients could sell or take narcotic medications, which could result in overdose and death. Pharmacist #7 stated injectable anesthetic medications had to be stored to prevent unauthorized access. Pharmacist #7 stated injectable anesthetic medications, if given at high doses, could cause seizures, cardiac dysrhythmias, and death. Interviews on 8/25/25 and 8/27/25 were in contrast to the observations on 8/25/25 which revealed unsecured multiple blank prescription sheets and vials of medications. 2. The facility failed to ensure expired medications were removed and not available for patient use. A. Observations i. On 8/25/25 at 10:45 a.m., observations conducted in the ED triage area revealed an unlocked cabinet and drawer which contained expired medications available for patient use. Examples included: a. Two opened Sensorcaine 0.5 % 50mL multidose vials, which were not labeled with the date the medication was opened or the expiration date. b. One opened Xylocaine 1% 50mL multidose vial not labeled with the date the medication was opened or the expiration date. c. One opened Bupivacaine 0.5% 50mL multidose vial with a discard after date of 12/16/24. d. Two opened Sensorcaine 0.5% 50mL multidose vials with a discard after date of 3/10/25. e. One opened Sensorcaine 0.5% 50mL multidose vials not labeled with the date the medication was opened or the expiration date. ii. Upon request, staff were unable to provide the open date or expiration date of the undated multi-use vials. This was in contrast to the CDC Injection Safety, Preventing Unsafe Injection Practices, Key Point for Multi-Dose Vials, which read, once an MDV was opened, the vial should have been dated and discarded within 28 days. This was in contrast to the Medication Management Operations Policy which read, all medications in the manufacturer’s original container were considered expired on the last day of the specified month and year, unless a specific date was provided. Staff were to immediately remove expired, damaged, contaminated, deteriorated, or otherwise unusable medications from available stock and return them to the pharmacy for proper disposal when a pharmacy was on-site. Staff dated MDVs with a revised expiration date using an approved sticker when the vial was opened or removed from recommended storage conditions. Staff discarded the vial at the earliest occurrence of the following: the expiration date had been reached or passed (28-day beyond-use dating or sooner if indicated), unless otherwise directed by the manufacturer’s FDA-approved labeling, CDC, CDPHE, or vaccine instructions. B. Interviews i. On 8/28/25 at 2:20 p.m., an interview was conducted with Registered Nurse (RN) #8. RN #8 stated medications should not be given after the expiration date. RN #8 stated medical and pharmacy staff were responsible for checking medication expiration dates. RN #8 stated medications given after the expiration date might not work because they could degrade and lose their effectiveness. RN #8 stated multidose vials were only good for 28 days after being opened, after which they had to be disposed of. RN #8 stated injectable medications given after the expiration date put patients at risk for infection. ii. On 8/25/25 at 1:56 p.m., an interview was conducted with Manager #6. Manager #6 stated ED staff were responsible for checking for expiration dates. Manager #6 stated multidose vials could not be used beyond the expiration date or 28 days after opening. Manager #6 stated medications should not be administered after the expiration date due to loss of effectiveness and risk of infection. iii. On 8/27/25 at 1:39 p.m., an interview was conducted with Pharmacist #7. Pharmacist #7 stated multidose medication vials should not be administered after the expiration date or 28 days after being opened. Pharmacist #7 stated medications given after the expiration date might not be effective. Pharmacist #7 stated injectable medications given after the expiration date put patients at risk for infection. Interviews conducted on 8/25/25 and 8/27/25 were in contrast to the observations on 8/25/25, which revealed multiple expired medications were readily available for patient use.”

“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: 52664 Based on observations, interviews, and document review, the facility failed to ensure staff followed infection control practices and policies in two out of two observations of patients in isolation. Additionally, the facility failed to ensure staff cleaned equipment in accordance with facility policies and manufacturer instructions for use (IFU) in one out of one observations in the emergency department (ED). Findings include: Facility policies: The Transmission-Based Precautions Policy read, isolation/transmission based isolation precautions are designed for the care of patients known or suspected to be infected by epidemiologically important pathogens spread by airborne transmission, droplet transmission, and/or by contact with skin or contaminated surfaces. In order to prevent the transmission of any known or suspected infectious disease, healthcare professionals have the responsibility and authority to place a patient under transmission-based precautions when isolation is indicated. Personnel, including medical, nursing, ancillary, support, volunteers, and students, are responsible for observing isolation protocols and complying with the use of personal protective equipment as indicated. Isolated Patient Transportation and Ambulation: Healthcare professional personal protective equipment (PPE) is removed and hand hygiene performed immediately before leaving the room to transport or ambulate the patient outside of their room. Multi-Patient Use Equipment: For equipment that cannot be designated single patient use, it is cleaned and disinfected prior to moving between patients according to the manufacturer’s instructions for use or best practice as determined by Infection Prevention. The Isolation of Patient with Suspected and Confirmed C. difficile (a bacteria that can cause severe diarrhea and inflammation of the gut) and Norovirus tip sheet read, suspected AND confirmed Clostridioides difficile (C. diff), isolate immediately upon suspicion with special contact isolation precautions. PPE required: gown and gloves. Wash hands with soap and water after patient care. Clean with Bleach Wipes (PDI Orange top) with a 4-minute wet time. References: The Super Sani-Cloth IFU read, highly compatible disinfection wipe for non-invasive medical devices and non-porous hard surfaces. Product efficacy for bacteria on pseudomonas aeruginosa, staphylococcus aureus, and enterococcus hirae. The Sani-Cloth Bleach germicidal disposable wipe IFU read, bleach-based disinfectant designed to help protect patients, staff, and facilities by killing the most clinically relevant organisms in just four (4) minutes. Proven efficacy against 52 microorganisms, including C. diff spores, Canida auris, and 14 Multi-Drug Resistant Organisms (MDROs) such as MRSA and VRE. 1. The facility failed to ensure staff followed isolation precautions with patients who were potentially contagious with an infectious disease. A. Observations i. On 8/25/25 at 12:13 p.m., observations were conducted in the ED. Further observations in Care Unit 3 revealed emergency medical services (EMS) brought Patient #1 to Care Unit 3 Room 5 gave report, and notified facility Patient #1 had C.diff. ED staff did not stop, don (put on protective wear) personal protective equipment (PPE), and walked in and out of the C.diff isolation patient room and did not perform hand hygiene with soap and water. On 8/26/25 at 2:32 p.m., observations were conducted in the Intensive Care Unit (ICU). Further observations in the ICU revealed a staff member did not doff (removal of protective wear) PPE and stepped out of an isolation patient room. Further observations revealed staff member did not remove their gloves, did not perform hand hygiene, touched an isolation cart with gloved hands, opened cart, removed supplies potentially contaminating the cart and walked back into the isolation room. Observations on 8/26/25 were in contrast to the Transmission-Based Precautions Policy which read, personnel including nurses and EMS staff, were responsible for observing isolation protocols and complying with the use of personal protective equipment as indicated to prevent transfer or organisms. B. Document Review i. Medical record review revealed, on 8/27/25 at 8:49 a.m., Patient #1 was admitted to ED Care Unit 3 Room 5 and diagnosed with C.difficile. Further review of the medical record revealed ED Provider #2 notes stated Patient #1 had significant diarrhea, a recent antibiotic course, and was placed on C. diff contact precautions. This was in contrast to observations of Care Unit 3 Room 5 which did not reveal staff adhering to contact precautions (wearing a gown and gloves upon entering the patient room) as ordered by the provider. C. Interviews i. On 8/28/2025 at 5:21 p.m., an interview was conducted with infection prevention director (Director) #3. Director #3 emphasized the importance of donning and doffing PPE, and clean processes to reduce the risk of cross-contamination (bacteria transferred from one object to another). Director #3 stated all staff received annual training on C. diff infection prevention which included isolation signage and contact precautions. Staff were instructed to doff PPE and perform hand hygiene with soap and water. Director #3 stated transmission of C.diff spores could pose a risk to immunocompromised patients. 2. The facility failed to ensure equipment used for patient care were cleaned in accordance with facility policy and IFU. A. Observations i. On 8/27/25 at 10:43 a.m., observations were conducted in the ED Care Unit 3 which revealed radiology technician (Tech) #1 with a portable x-ray machine in Patient #1’s room. Further observations revealed Tech #1’s PPE gown was untied at the waist, and the waist ties hung loosely. Tech #1 removed their PPE in the patient’s room and performed hand hygiene with hand sanitizer. Tech #1 cleaned the x-ray machine with a Super Sani-Cloth at the doorway, and missed high-touched surfaces including the touch screen. At this time Tech #1 stated they were supposed to tie their PPE gown at the neck and waist. Tech #1 stated if they did not wear their PPE appropriately it increased spread of C. diff. Tech #1 stated they were to clean the X-ray machine with Sani-Cloth Bleach wipes as Super Sani-Cloth would not kill the C. diff bacteria or spores. Tech #1 stated if the equipment was not cleaned appropriately, the cleaning agent would not kill off the viruses and bacteria, and placed the patients and staff at risk for infections. The interview with Tech #1 was in contrast to the observations of Tech #1. Tech #1 did not clean the X-ray machine with the Sani-Cloth Bleach wipes as required by the transmission based precautions policy and the Sani-Cloth Bleach wipe IFUs which instructed to be used to kill C. diff spores. ii. Observation of the security camera footage was reviewed on 8/27/25 at 3:27 p.m. with security manager #4. Observation of the security camera footage of the south end of Care Unit 3 ED hallway revealed on 8/27/25 at 10:39 a.m., Tech #1 exited a C. diff isolation room with a student and did not clean the x-ray machine with a Sani-Cloth Bleach wipe. This was in contrast to the transmission-based precautions policy which read, multi-patient equipment that could not be designated single patient use, it was cleaned and disinfected prior to being moved between patients according to manufacturer’s instructions for use or best practice as determined by Infection Prevention. B. Interviews i. On 8/28/2025 at 5:21 p.m., an interview was conducted with Director #3. Director #3 stated all staff receive annual training on C. diff infection prevention which included IFU training, isolation signage, product use, and contact precautions. Staff were instructed to remove equipment from the patient room, doff PPE, perform hand hygiene with soap and water, and disinfect with Sani-Cloth Bleach wipes outside the room to prevent recontamination. Director #3 emphasized the importance of donning and doffing PPE, and clean processes to reduce the risk of cross-contamination (bacteria transferred from one object to another), particularly for immunocompromised patients. Director #3 stated failure to disinfect equipment appropriately could result in transmission of C. diff spores, (bacteria resisting heat and chemicals) which can survive for months on surfaces, and stressed the expectation radiology staff follow these protocols.”