Eskenazi Health

“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: 48061 Based on document review and interview, facility staff failed to maintain equipment education of cleaning potty/shower chair, orientation, and competencies related to the operation of facility Rack Washer for 4 of 4 personnel files reviewed (A3 [Manager of Environmental Services], A4 [Environmental Services], A6 [Supervisor/Educator Environmental Services], and A8 [Manager of Environmental Services]); and failed to receive approval from Infection Prevention prior to implementing a change in cleaning process for facility potty and/or shower chairs The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 48061 Based on document review, observation, and interview, facility staff failed to conduct preventative maintenance per manufacturers guidelines for 1 of 1 Rack Washer, and failed to conduct preventative maintenance on facility potty chairs, and/or facility shower chairs. Findings include: 1. Manufacturers guideline titled, “ KS-88 Rack Washer”, version 1.05, publication date 03/2021, indicated under section VIII. Service and Maintenance: PUMP. The Alvey Pan Washer is equipped with a vertical immersion pump without seals. Pump discharge pressure is 35 to 45 PSI. To help prevent pump damage periodically check pump casing for any foreign matter. Grease pump motor every six months. Check direction of rotation after electrical maintenance. Periodic Service and Maintenance. 1. Check filter screens twice daily. Check more frequently with heavy cleaning load. 2. Check nozzles for clogging twice daily. This can be done at noon break and after shut down. 3. Check twice daily to see that spray hubs turn freely. 4. Drain solution from the trap and flush at least once daily. 5. Keep washer exterior free from an accumulation of items , which may block air circulation to pump. The exterior appearance may be maintained by wiping with a damp cloth. Stainless steel wax or polish may be applied if desired. 2. Manufacturer’s guideline for shower/potty chairs titled, “PVC HEALTHCARE EQUIPMENT OWNER’S MANUAL”, no policy number, revised 2008, indicated under Proper Care & Maintenance: PVC Piping and Casters. Provide weekly maintenance to obtain maximum usage. 3. In interview on 3/6/26 at approximately 11:00 am with A3 (Manager of Environmental Services) confirmed the Cart Wash Machine has been out of service on and off since 10/2025. A3 confirmed no preventative maintenance schedule exists for the Rack Washer, potty and/or shower chairs. A3 confirmed H1 (Acute Care Hospital) currently has no policy or procedure for the Rack Washer daily maintenance and/or preventative maintenance.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48061 Based on document review and interview, the facility staff failed get approval from Infection Prevention prior to implementing a change in cleaning process for facility potty and/or shower chairs. Findings include: 1. In interview on 3/6/26 at approximately 11:00 am with A3 (Manager of Environmental Services) confirmed the two-step cleaning process for the potty/shower chair was implemented by environmental services, but was not approved by facility infection control. 2. In interview on 3/6/26 at approximately 2:30 pm with A7 (Infection Prevention Director) confirmed the two-step process was not approved by facility Infection Prevention team, but should have. A7 confirmed facility does not have a policy and/or procedure related to the Rack Washer, potty chairs, and/or shower chairs. A7 confirmed no reported infections related to patient potty chairs/shower chairs during the months of October 2025-January 2026. A7 confirmed organisms specific to potty/shower chairs are not part of the quarterly Infection Control data.”

“IC PROFESSIONAL TRAINING CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (iv) Competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of infection prevention and control guidelines, policies, and procedures. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility staff failed to maintain competencies and education related to proper cleaning of potty/shower chair, and the operation and/or maintenance of facility Rack Washer for 4 of 4 personnel files reviewed (A3 [Manager of Environmental Services], A4 [Environmental Services], A6 [Supervisor/Educator Environmental Services], and A8 [Manager of Environmental Services]). Findings include: 1. Review of A3, A4, A6, and A8 personnel files lacked documentation of cleaning potty/shower chair training, Rack Washer education, orientation, and/or competencies. 2. In interview on 3/6/26 at approximately 10:50 am with A4 (Environmental Services) confirmed no formal facility training for the Rack Washer. 3. In interview on 3/9/36 at approximately 11:20 am with A2 (Chief Risk Management) confirmed personnel files lacked documented of training for EVS supervisors related to the Rack Washer.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 49709 Based on document review, the facility failed to ensure patient’s pain was appropriately managed for 1 of 20 patient medical records (MR) reviewed . (patient P1) Findings include; 1. Review of P1 medical record indicated the following: (A) The patient presented to F1, Acute Care Hospital, ED via emergency medical services (EMS) transport on 05/27/2024 at 1730 hours with chief complaint of burn. (B) At 1935 hours on 5/27/24, Nurse Practitioner (A14) evaluated P1 and indicated they sustained flash burns to the left upper extremity, left chest, and face, mix of superficial and superficial partial full-thickness burns. (C) At 2026 hours on 5/27/24, the patient received morphine injection 4 mg. At 2124 hours, pain reassessment was completed with a score of 7 on a pain scale of 0 - 10. The MR lacked documentation that the patients continued pain was addressed and treated. (D) Nurses notes at 2124 on 5/27/24 indicated the patient tolerated the dressing change poorly. The MR lacked documentation of interventions to alleviate the patients pain during the dressing change. (E) The patient was discharged at 2129 hours on 5/27/24.”