Phelps County Regional Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50151 Based on observation, interview, record review, and policy review, the hospital failed to follow their policies and procedures to report changes in the patient’s condition, critical result values and provide emergency care in a timely manner for three discharged patients (#20, #22 and #27) of four patient records reviewed. These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient’s Rights. Please refer to A-0144.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 50151 Based on observation, interview, record review, and policy review, the hospital failed to follow their policies and procedures to report changes in the patient’s condition, critical result values and provide emergency care in a timely manner for three discharged patients (#20, #22 and #27) of four patient records reviewed. These failures had the potential to affect the quality of care and safety of all patients. Findings Included: Review of the hospital’s policy titled, “Quick Response Team (QRT),” dated 03/2024, showed the purpose of the team was to provide early and rapid interventions to promote better patient outcomes and reduce the number of in-house cardiac arrest (when the heart suddenly and unexpectedly stops pumping) and hospital deaths. Review of the hospital’s policy, “Critical Value List and Result Notification,” dated 04/2025, showed the nurse notifies the ordering physician of all critical values, unless the physician had already provided orders and/or the patient is receiving on-going treatment. When the ordering or on-call physician cannot be reached within 30 minutes of receiving the critical value, the nurse should activate the medical chain of command. Review of the hospital’s policy, “Critical Test Results,” dated 03/2024, showed a critical result could be any imaging finding, reasonably believed to have a serious impact on the patient’s health, when not emergently acted upon. Critical results should be communicated to the ordering physician within 30 minutes from the time the critical result was identified. Review of Patient #20’s medical record, dated 04/05/26, showed: - At 9:30 AM, she presented to the hospital’s Emergency Department (ED) for fever, generalized weakness and palpitations (a sensation that the heart is racing, pounding, fluttering, or skipping a beat). She had purulent (pus), foul-smelling drainage from her port (a small medical appliance installed beneath the skin in the chest region and connects the port to a vein and is used to administer medications and draw blood) site. - Her past medical history included cancer, chronic kidney disease (CKD, ongoing, gradual loss of kidney function) and cardiomyopathy (a disease in which the heart muscle weakens and becomes enlarged making it hard to deliver blood to the rest of the body). She denied chest pain or shortness of breath. - Her vital signs (VS, measurements of the body’s most basic functions: pulse/heartbeats normal 60 to 100 per minute) were obtained and within normal ranges except for her heart rate (HR, the number of times the heart beats within a certain time period, normal pulse/heartbeats for adults range from 60 to 100 per minute), which was 154. - A medical screening exam (MSE) was provided and included an electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) and laboratory testing. Her hemoglobin (Hgb, a protein in red blood cells that carries oxygen throughout the body, normal is 11.2 - 15.7 grams per deciliter [g/dL]) was 7.2, troponins (a type of blood test that measures whether or not a person is experiencing a heart attack, normal is less than 0.01) were elevated and her white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood, normal is 4.500-11,000 cells per microliter [K/mm3]) was elevated at 48.4. K/mm3. - She was started on antibiotics and received a unit of packed red blood cells (PRBC, specific blood cells that have been separated from whole blood cells, for administration into a vein). Her neurological (neuro, relating to or affecting the nervous system) assessment showed she was alert, awake, and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time) with clear speech and Glasgow Coma Scale (GCS, estimates coma severity. The maximum score is 15 which indicates a fully awake patient) was 15. - At 1:02 PM, she was admitted for observation services (assessment, treatment, and reassessment, to determine whether a patient will require further inpatient treatment or could be safely discharged) to the Telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) floor. She reported that she had a headache to the Hospitalist (physician who primary professional focus is the general care of hospitalized patients). Intravenous (IV, in the vein) antibiotics were continued and she was started on Heparin (a medication used as a blood thinner or to prevent blood clots from forming) for elevated troponins. - On 04/06/26, her neuro assessment was unchanged. - On 04/07/26 at 9:00 AM, her neuro assessment was unchanged. - At 9:30 PM, her neuro assessment showed she responded to voice only, was unable to follow commands, had delayed responses and made incomprehensible sounds. Her GCS was 10. Despite the documented changes in her neuro assessment, the changes were not reported to her physician when they were initially identified . She continued to receive intravenous (IV, in the vein) Heparin. - On 04/08/26 at 5:50 AM, the patient was unresponsive to a sternal rub (painful pressure applied with the knuckles to the center of the chest of a patient who is not alert to elicit a response) and the physician was contacted and informed of the changes in her neuro assessment. - At 5:53 AM, the physician ordered a stat (immediately) computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) of the head. - At 06:51 AM, CT scan showed she had a large right acute subdural hematoma (a pool of blood between the brain and it’s outermost covering). The family was notified for treatment planning. - At 9:59 AM, she was transferred to a floor and was made comfort care (a patient care plan that is focused on symptom control, pain relief, and quality of life at the end of life) only. - At 3:23 PM, the patient expired. Review of the hospital’s undated event report for Patient #20 titled, “Safety Event Manager LAI20099947,” showed: - Patient #20 had a decline in level of consciousness (LOC) over a 24-hour period. - After the patient became unarousable to a sternal rub, the physician was notified. - A stat CT was ordered showing a large right acute subdural hematoma. - The Heparin was discontinued at 6:22 AM on 04/08/26. - Comfort measures were initiated per family request. - It was recommended to close the event with increased monitoring for similar occurrences. During an interview on 05/27/26 at 3:10 PM, Staff N, Chief Nursing Officer (CNO), stated that staff had not been consistent and required more education with the escalation process and event reporting. During an interview on 06/08/26 at 8:19 AM, Staff E, Director of Acute Medical Services, stated that she expected nursing to notify the provider for all mental status changes or call a QRT. Neuro assessments were done once per shift or with changes to mental status or as ordered. After the event with Patient #20, she educated the shift manager and the night Registered Nurse (RN) with 1:1 education. She could educate the floor daily in huddles, follow-up huddle emails, and group meets which were usually sent weekly or three times monthly. She did not do a huddle or group meeting regarding Patient #20’s event. Review of Patient #22’s medical record, dated 04/15/26, showed: - At 1:26 PM, he was a 73-year-old who presented to the hospital to have a stent placed (A tiny tube placed into an artery, a vein, or another structure such as the ureter [tube that carries urine] to hold the structure open). - His past medical history included coronary artery disease (CAD, the narrowing or blockage of the coronary arteries usually caused by the buildup of cholesterol and fatty deposits on the inner walls of the arteries), high blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80), stroke (a medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) with aphasia (an impairment in the understanding or verbalizing ideas by language, such as reading, writing, or speaking; due to injury or disorders of te brain) and an aortic dissection (a tear in the inner layer of the large blood vessel branching off the heart) repair. - Prior to his stent placement, he was at his neuro baseline. He was able to follow commands and was A&O x 3. - At 4:06 PM, he was transported to the recovery room. When he arrived, he pulled off monitoring cables, pulled an intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) out and reported he was unable to see. - At 4:35 PM, he was still unable to see and would not follow commands. A QRT Stroke Alert was called. A CT head and CT angiography (CTA, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones], computer and intravenous [IV, in the vein] injection of substance to produce detailed images of blood vessels and tissues in the body) were ordered. The QRT transported the patient to CT but could not perform the exams. - At 5:09 PM, he returned to the recovery room from CT. - At 5:45 PM, the provider admitted him to the hospital. The recovery room nurse gave report to the floor nurse. The floor nurse contacted the provider to make sure he was appropriate to be admitted to a medical-surgical floor. The provider believed he was appropriate to be admitted to the floor and instructed the nurse to reach out if she was concerned about the patient. - At 6:05 PM, the recovery room nurse contacted the provider again about his neuro status changes. The provider informed the nurse he was not concerned and his symptoms were most likely caused from the sedation (to induce a state of drowsiness and relaxation) he received for the stent placement. - At 7:13 PM, he was transferred to the inpatient floor from the recovery room. He was unable to answer any questions but had his eyes open. He was severely aphasic (an impairment in the understanding or verbalizing ideas by language, such as reading, writing, or speaking; due to injury or disorders of the brain) and his National Institutes of Health Stroke Scale (NIHSS, a tool used by healthcare providers to quickly assess the severity of a stroke experienced by a patient) was elevated. The provider was contacted who gave medication orders to relax the patient, for the CTs to be completed. - At 7:56 PM, the CT of the head showed no bleeding in or around the brain and the CTA showed he had an acute stroke. A telehealth (remote delivery of healthcare services while the health care provider is at a separate location, including exams and consultations, through video and telephone communication) neurologist was consulted for recommendations. - At 8:56 PM, the care team decided he needed to be transferred to a hospital for a higher level of stroke care. - There was no documentation that showed the patient’s changes in condition were escalated up the chain of command, after the nurse’s concerns were dismissed. Review of the hospital’s document titled, “Safety Event Manager ELJ20113478,” dated 04/18/26, showed: - On 04/15/26, Patient #22 was transferred to the recovery room after a stent was placed. When he arrived, he was confused, uncooperative and unable to follow commands. Prior to having the stent placed, he was A&O x 3, was able to get up out of bed on his own and had not reported any visual changes. - At 4:20 PM, a QRT Stroke Alert was called. A CT of the head and CTA of the head and neck were ordered. - The recovery room nurse contacted the provider and informed him the CT of the head was not performed due to the patient not being able to follow commands or hold still while the CT was performed. She requested a medication to relax the patient for the CT to be performed. The nurse reported the provider dismissed her concerns and believed his neuro changes were related to the sedation medications he received for the stent placement. - Eventually the provider gave orders for a medication to relax the patient for the CT exams. At 7:15 PM, the CT of the head was completed, which showed he had an acute stroke. During an interview on 05/27/26 at 9:20 AM, Staff M, Risk Management Director, stated that Patient #22’s incident went for peer review, but the findings were confidential and she was unable to provide any education or disciplinary actions were provided to the provider who dismissed Patient #22’s neuro changes. The hospital investigated Patient #22’s incident and determined the contributing factors to the incident were the physician did not take the concerns reported to him seriously and the concerns were not escalated up the chain of command. She did not know if education on escalating up the chain of command was provided as a result the incident but hospital staff had received education on the process within the last year. She did not know if it was provided house-wide or to the recovery room staff. Although requested, the provider involved in Patient #22’s incident was not available for an interview. . Review of Patient #27’s medical record dated, 04/18/26, showed: - At 9:16 AM, She was a 91-year-old who presented to the ED for nausea, vomiting and abdominal pain. She reported she developed abdominal pain on 04/15/26, which progressed to severe pain. The pain had improved with some aching and intermittent burning sensation. She also reported feeling feverish and weak. - Her past medical history included chronic kidney disease (CKD, ongoing, gradual loss of kidney function) and anemia (low amounts of oxygen rich blood, causes paleness and weakness). Her HgB level two months prior was 6.7. - At 9:25 AM, she was provided with a medical screening exam (MSE) and her VS were within normal ranges. - At 11:13 AM. Her Hgb was 6.7 and a unit of PRBCs was ordered. - At 12:41 PM, a test to determine if there was blood in her stool was performed and was negative. - The patient was admitted to the hospitalist service for anemia and weakness. - At 11:18 PM, she transferred to a bedside commode and was found to have expressive aphasia, a left facial droop and left-hand weakness. A QRT was activated. - On 04/19/26 at 3:44 AM, she was transferred to the ICU with low BP and increased work of breathing. She was lethargic (weak, sluggish), reported abdominal pain on the right and started to vomit. Her BP began to drop and she was started on a continuous IV medication to increase her BP. A CT of the head performed showed she had an acute (sudden onset) and evolving stroke (a medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients). A Neurologist (a physician who specializes in the care of the nervous system) was consulted and determined treatment for acute stroke was limited due to continued blood loss. - At 4:53 AM, the provider was notified of the patient’s low BP, most recent HgB result of 5.5 and that a CT of the abdomen was completed. - At 5:08 AM, the provider ordered two units of PRBCs and additional laboratory tests were ordered. - At 5:58 AM, a CT of the abdomen showed she was losing arterial blood (oxygenated blood that runs through the arteries) into her and the provider arranged for the patient to be transferred to another hospital for a higher level of care. The provider who ordered the CT of the abdomen was not notified within the hospital’s critical result notification timeframe. - At 6:52 AM, she was transferred to another hospital by helicopter. Review of the hospital’s document titled, “Safety Event Manager RTT,” dated 04/20/26, showed: - Patient #27 was not provided diagnostic testing when she showed clinical signs of blood loss and requests from the ICU nurse. - A CT of the abdomen showed a large and active bleed, her Hgb continued to drop after she received blood, and the Radiologist (a medical doctor specializing in diagnosing and treating diseases and injuries using medical imaging techniques) failed to notify the provider who ordered the CT of the critical findings. - The patient required a transfer to a higher level of care due to the delay. During a telephone interview on 05/28/26 at 11:00 AM, Staff N, Medical Hospital Imaging Manager, stated that he performed the investigation into Patient #27’s incident. The Radiologist who read her CT of the abdomen was a contracted radiologist. Eventually, he spoke with the radiologist who admitted he did not call the critical results to the ordering physician. It was expected that critical findings found on a CT, be reported to the ordering physician within 30 minutes. He did not know if the contracted radiologist was re-educated or received any disciplinary action, since the radiologist was not employed by the hospital. Although requested, the hospital did not provide any education regarding reporting critical findings after the event. 51292”

“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: 48359 Based on observation, interview and policy review, the hospital failed to: - Prepare a clean work surface prior to performing patient care for two current patients (#5 and #16) of 13 patients observed; - Cleanse the intravenous (IV, in the vein) tubing port prior to IV medication administration for one current Operating Room (OR) patient (#16) of one OR patient observed; - Perform hand hygiene (wash hands with soap and water or hand sanitizer) and glove changes during patient care for one current OR patient (#16) of one OR patient observed; - Perform hand hygiene and glove changes for one dietary staff member of four staff members observed; - Clean OR equipment prior to providing care for one current OR patient (#16) of one OR patient observed; - Follow their internal policy for skin preparation for one current OR patient (#16) of one OR patient observed; - Discard a previously opened single-use sterile (completely clean and free from germs) gauze package, and used the gauze bandage for one OR patient (#16) of one OR patient observed; - Ensure staff members removed OR masks between OR procedures; - Ensure hair and jewelry were covered by hospital attire and/or hair coverings within the OR and Sterile Processing Department (SPD); - Remove dirty urinals from overbed tables for two current patients (#6 and #9) of two patients observed; - Perform daily and weekly kitchen cleaning; - Ensure open dates were marked on open frozen food items; - Discard an apple retrieved from a hospital unit that was placed in the kitchen sugar bin; - Discard expired (past the date of safe use) food items in the patient nutrition room for one patient care unit of seven patient care units observed; - Discard an open single-use package of a dried food item in the patient nutrition room for one patient care unit of seven patient care units observed; and - Ensure expiration dates were written on food items in the patient nutrition room for one patient care unit of seven patient care units observed. The severity and cumulative effects of these systemic practices resulted in the hospital’s non-compliance with 42 CFR 482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs and resulted in the hospital’s failure to ensure quality health care and safety. Please refer to A-0749 for details.”

“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: 40189 48359 50496 Based on observation, interview and policy review, the hospital failed to: - Prepare a clean work surface prior to performing patient care for two current patients (#5 and #16) of 13 patients observed; - Cleanse the Intravenous (IV, in the vein) tubing port prior to IV medication administration for one current Operating Room (OR) patient (#16) of one OR patient observed; - Perform hand hygiene (wash hands with soap and water or hand sanitizer) and glove changes during patient care for one current OR patient (#16) of one OR patient observed; - Perform hand hygiene and glove changes for one dietary staff member of four staff members observed; - Clean OR equipment prior to providing care for one current OR patient (#16) of one OR patient observed; - Follow their internal policy for skin preparation for one current OR patient (#16) of one OR patient observed; - Discard a previously opened single use-sterile (completely clean and free from germs) gauze package, and used the gauze bandage for one OR patient (#16) of one OR patient observed; - Ensure staff members removed OR masks between OR procedures; - Ensure hair and jewelry were covered by hospital attire and/or hair coverings; - Remove dirty urinals from overbed tables for two current patients (#6 and #9) of two patients observed; - Perform daily and weekly kitchen cleaning; - Ensure open dates were marked on open frozen food items; - Discard an apple retrieved from a hospital unit that was placed in the kitchen sugar bin; - Discard expired (past date of safe use) food items in the patient nutrition room for one patient care unit of seven patient care units observed; - Discard an open single-use package of a dried food item in the patient nutrition room for one patient care unit of seven patient care units observed; and - Ensure expiration dates were written on food items in the patient nutrition room for one patient care unit of seven patient care units observed. Review of hospital’s policy titled “Standard Precautions (also known as universal precautions, avoiding contact with patients’ bodily fluids by means of wearing gloves, goggles and face shields),” revised 03/2021, showed: - All staff are to wash their hands immediately after gloves are removed and when otherwise indicated to avoid transfer of microorganisms (organisms, such as bacteria, too small for the naked eye) to the environment. - Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. - Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and wash hands immediately to avoid transfer of microorganisms to the environment. - Procedures for the routine care, cleaning and disinfection of environment surfaces should always be followed. - Scrub the port of invasive lines with alcohol using friction before injecting an IV medication. Review of hospital’s policy titled “Cleaning of ORs at the End of Day,” revised 02/2009, showed staff will wipe down all equipment with disinfectant. During the OR Suite Terminal Cleaning (a thorough, deep cleaning of a room to include the ceiling, walls and floors) a cleaning agent will be used to clean the stem and base of the OR table. Review of the hospital’s policy titled, “Skin Preparation,” revised 06/2012, showed when using a betadine (a solution that kills germs on the skin) preparation kit, use one sponge over the area to be prepared, discard the sponge and repeat the process using a fresh sponge. Concurrent observations on 05/29/24 at 9:30 AM in the OR showed: - Staff GG, Certified Registered Nurse Anesthetist (CRNA, registered nurses [RNs] who have obtained graduate-level education and board certification in anesthesia), failed to place a barrier prior to inserting an intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) and placed sterile IV supplies on Patient #16’s blanket. - Staff HH, CRNA, failed to cleanse the IV tubing port prior to administering IV medication to Patient #16. - Staff CC, Surgical Services Director; Staff FF, Physician; Staff GG, CRNA; and Staff HH, CRNA; failed to perform hand hygiene prior to putting on gloves when providing care to Patient #16. - Staff CC, Staff GG and Staff HH failed to change gloves and perform hand hygiene when he/she touched Patient #16, touched inanimate objects and continued to provide care to Patient #16. - Staff CC picked trash off the OR floor and continued to provide care to Patient #16 without performing hand hygiene or changing her gloves. - Staff CC placed a gauze bandage found in a previously open single-use package on Patient #16’s new IVC site. - Staff EE, Registered Nurse (RN), failed to perform the second surgical site skin preparation with a fresh betadine sponge for Patient #16. - Two OR computer monitors had brown, dried drips of an unknown substance on the front of each screen. The OR table base had drops of a brown substance. Observation on 05/28/24 at 2:15 PM, in the Oncology Unit, showed Staff Q, Licensed Practical Nurse (LPN), placed Patient #5’s IV supplies on her overbed table prior to the removal of the IV and failed to clean the dirty surface or place a barrier down. Observation on 05/28/24 at 3:25 PM showed Staff T, Dietary Aide, mixed fruit and yogurt with gloved hands, wiped his nose with a gloved hand and failed to perform hand hygiene and a glove change before returning to mixing the yogurt and fruit. Observation on 05/28/24 at 2:23 PM, in the Oncology Unit, showed a dirty urinal on the overbed table next to Patient #6’s water cup. Observation on 05/28/24 at 2:32 PM, in the Oncology Unit, showed a dirty urinal on the overbed table next to Patient #9’s water cup. During an interview on 05/28/24 at 2:20 PM, Staff Q, LPN, stated that she kept the supplies on the opened package and did not think they touched the surface of the table. She stated that it was not normal practice to clean a surface before it was used for patient care. During an interview on 05/28/24 at 3:25 PM, Staff T, Dietary Aide, stated that the normal process was to change gloves and wash hands after he touched his face. During an interview on 05/28/24 at 2:36 PM, Staff R, RN, stated that it was a problem for a dirty urinal to have been set next to a patient’s water cup. She stated that it should have been on the patient’s bed siderail. Review of the hospital’s policy titled, “Attire in Surgery,” revised 12/2013, showed: - The head/hair cover must cover all exposed head and facial hair. - Masks are not to be left dangling around the neck. - Jewelry including earrings and necklaces that cannot be contained or confined within the surgical attire should not be worn in the semi-restricted and/or restricted areas of the surgery department. Observation on 05/29/24 at 9:25 AM showed Staff JJ, RN, walked into the OR staff breakroom with a mask dangling around his neck. Concurrent observations on 05/29/24 at 10:15 AM showed Staff KK, Sterile Processing Department (SPD, area designated to clean, prepare, sterilize [process that eliminates viruses and bacterial], store and track reusable medical and surgical instruments or equipment) Lead Technician, had hoop earrings visible outside of her hair covering; and Staff LL, SPD Technician, had gauge earrings, a necklace and hair visible outside of her attire and hair covering. Although requested, the hospital failed to provide a policy that directed staff on when and how to clean the kitchen. Observation on 05/28/24 at 3:23 PM showed the kitchen grill hood had a thick buildup of grease and debris. Review of the hospital documents titled, “Diet Office, Checker Station, Nourishment Station Checklist,” dated 04/01/24 through 05/20/24, showed the daily cleaning of the desktops, counter surfaces and front cabinets was not done on 05/13/24, 05/14/24, 05/15/24, 05/16/24 and 05/17/24. Review of the hospital documents titled, “Catering Cleaning Checklist,” dated 04/01/24 through 05/20/24, showed the daily cleaning of the buffet dishes, silverware bins, carts, cover plates, bowls and the right side of the refrigerator and door was not done on 04/06/24, 04/07/24, 04/13/24, 04/14/24, 04/20/24, 04/21/24, 05/04/24, 05/05/24, 05/13/24, 05/18/24, 05/19/24, 05/25/24 and 05/26/24. Review of the hospital documents titled, “Six AM Starter Cleaning List,” dated 04/01/24 through 05/20/24, showed the daily cleaning of the work area counters, top and bottom, plate dispenser and base table were not cleaned on 04/01/24 and 04/03/24. The pots and pans sink was not cleaned on 04/01/24, 04/03/24 and 04/17/24. Review of the hospital document titled, “Carts Cleaning Checklist,” dated 04/01/24 through 05/20/24, showed the daily sweeping and mopping of the coolers and freezer was not done on 05/18/24. Review of the hospital documents titled, “Dish room/Beverage Cleaning Checklist,” dated 04/01/24 through 05/20/24, showed: - The daily sanitizing of the outside and door seal of the ice machine was not done on 04/01/24, 04/03/24, 04/11/24, 04/12/24, 04/14/24, 04/18/24, 04/29/24, 04/30/24, 05/01/24, 05/03/24 and 05/19/24. - The daily cleaning of the carts and the wiping of the inside and outside of the dish machine was not done on 04/14/24, 04/18/24 and 05/19/24. - The daily cleaning of the under roller and end table was not done on 04/14/24, 04/18/24, 05/04/24, 05/05/24 and 05/19/24. - The daily wiping in the beverage station, conveyor belt and beverage cooler was not done on 04/18/24. - The weekly cleaning of the dish room, beverage cooler and change trays was not done the week of 04/29/24. - The weekly cleaning of the dish room walls was not done the week of 05/13/24. - The weekly cleaning of the dish room ceiling vents and tiles was not done the week of 05/20/24. Review of the hospital documents titled, “Seven AM Grill Cleaning List,” dated 04/01/24 through 05/20/24, showed the daily wiping of counters, filling of the condiments and cleaning of the cart, sneeze guards, shelf above the sneeze guards and nacho cheese machine was not done on 04/06/24, 04/07/24, 04/13/24, 04/14/24, 04/20/24, 04/21/24, 05/04/24, 05/05/24, 05/18/24, 05/19/24, 05/25/24 and 05/26/24. Review of the hospital documents titled, “Nine AM Grill Cleaning List,” dated 04/01/24 through 05/20/24, showed the daily cleaning of the ice cream catch tray, warmer, counter tops, cart, blender, microwave, microwave stand, plate station and table next to the ice cream machine was not done on 04/20/24. Review of the hospital documents titled, “Hot Food Production Cleaning Checklist,” dated 04/01/24 through 05/20/24, showed: - The daily cleaning of the outsides and tops of the ovens was not done on 04/05/24. - The daily cleaning of the plate heater outside and lids was not done on 04/12/24. - The daily wiping of the inside of the ovens was not done on 04/10/24, 04/11/24, 05/02/24, 05/20/24, 05/22/24 and 05/23/24. - The daily cleaning of the fryers and fryer baskets was not done on 04/10/24, 04/11/24, 05/02/24, 05/04/24, 05/05/24, 05/13/24, 05/20/24, and 05/23/24. - The daily cleaning of the stove burn plates was not done on 05/22/24. - The daily changing of the trays in the pass-through hotbox was not done on 05/21/24 and 05/22/24. - The weekly cleaning of the inside of the plate cleaner was not done the week of 04/29/24. - The weekly cleaning of the delime steamers was not done the week of 05/13/24. - The weekly cleaning of the reach in freezer was not done the week of 05/20/24. Review of the hospital documents titled, “Café’ Daily and Weekly Cleaning List,” dated 04/01/24 through 05/20/24 showed: - The daily cleaning of dining room tables and floors was not done on 04/04/24, 04/05/24, 04/14/24, 04/17/24, 04/18/24, 04/19/24, 05/15/24, 05/20/24, 05/21/24, 05/23/24, 05/25/24 and 05/26/24. - The daily cleaning of the cappuccino machine and nozzles was not done on 04/04/24, 04/05/24, 04/08/24, 04/09/24, 04/11/24, 04/12/24, 04/14/24, 04/15/24, 04/16/24, 04/17/24, 04/18/24, 04/19/24, 04/20/24, 04/21/24, 04/29/24, 04/30/24, 05/01/24, 05/02/24, 05/03/24, 05/04/24, 05/05/24, 05/15/24, 05/25/24 and 05/26/24. - The weekly cleaning of the inside of the wrap cooler was not done the week of 04/15/24. - The daily cleaning of the donut case and toaster was not done on 04/02/24, 04/04/24, 04/05/24, 04/06/24, 04/07/24, 04/13/24, 04/14/24, 05/25/24 and 05/26/24. - The daily cleaning of the front of the ice and water machine, water and ice spouts, coffee and tea drains and coffee and tea pots was not done on 04/08/24, 05/25/24 and 05/26/24. - The weekly cleaning of the cup and lid dispenser’s baskets was not done the weeks of 04/08/24 and 04/15/24. - The weekly cleaning of the coffee filter baskets was not done the weeks of 04/08/24, 04/15/24 and 04/29/24. - The daily cleaning of the back counter and front cabinets, glass in serving area, and dessert cart glass was not done on 04/13/24, 04/14/24, 05/14/24, 05/25/24 and 05/26/24. Review of the hospital documents titled, “Delbert Day Cancer Institute (DDCI) Cleaning Checklist,” dated 04/01/24 through 05/20/24 showed: - The weekly cleaning of the clean storage area was not done the weeks of 04/29/24, and 05/20/24. - The weekly cleaning of the syrup caddy was not done the weeks of 04/01/24, 04/29/24, and 05/20/24. - The weekly cleaning of the cup and lid holder was not done the week of 04/29/24. - The weekly cleaning of the condiment caddy was not done the weeks of 04/01/24 and 04/29/24. - The weekly cleaning of the top of the ice maker was not done the weeks of 04/01/24, 04/08/24 and 04/29/24. - The weekly cleaning of the sleeve holder was not done the week of 04/08/24. - The weekly cleaning of the clean storage area was not done the weeks of 04/08/24, 04/29/24, and 05/20/24. - The weekly cleaning of the under counter refrigerator was not done the week of 04/08/24. - The weekly wiping of the walls was not done the weeks of 04/01/24, 04/08/24, 04/15/24. - The daily cleaning of the microwave, cooler doors, cookie oven, clean trap, top of the brewer, trashcan and sanitizer/soap dispensers was not done the week of 04/29/24. Although requested, the hospital failed to provide a policy that directed staff on how to date food items in the kitchen. Observation on 05/28/24 at 3:35 PM showed one expired milkshake and six boxes of opened frozen food without dates opened marked on the boxes in the walk-in freezer. Observation on 05/28/24 at 3:15 PM showed an apple wrapped in a paper towel was found in a sugar bin in the kitchen. Review of hospital’s policy titled “Floor Stock,” revised 01/2006, showed stocked items will have an expiration date placed by the Food Service personnel who stocked the floor. Observation on 05/28/24 at 2:00 PM in the Labor and Delivery patient nutrition room showed: - An expired multiuse bottle of coffee creamer on the countertop. - An opened, single-use package of coffee grounds in a drawer. - Packets of broth, sweetener, sugar and tea bags in a tray without written expiration dates. - Fourteen single wrapped cheese packets in the refrigerator drawer without written expiration dates. During an interview on 05/30/24 at 10:00 AM, Staff NN, Chief Nursing Officer (CNO), stated that staff were to follow the five moments of hand hygiene as written in the hospital’s policy. The hospital needed to provide unit and staff specific training in all areas. She expected a clean surface for medication administration and patient care supplies. In the OR, she expected a surgical table or drape was used to create a clean surface. She expected the IV port was scrubbed with alcohol before all IV medication administrations. She stated the scrubbing of the port was a “standard practice.” She expected the policy for OR skin preparation was followed. A betadine preparation included two sponges. A previously opened gauze container was contaminated and she expected staff to discard the bandage, not use the bandage for patient care. She expected the OR tables and monitors were clean. It was the OR staff members responsibility to ensure the room was clean prior to bringing the patient into the OR. Environmental Services staff perform the OR cleaning. OR staff were to ensure the environment was safe and clean. She stated that staff were to remove used urinals from the patient’s overbed table to keep the urinal away from food, water, medications and supplies. Staff were to clean the surface when a urinal was removed from the overbed table. Urinals were stored on the bedside rail. Kitchen staff were to follow the five moments of hand hygiene. She expected items in dated bags in the patient nutrition area to remain in the dated bags. All expired food and supply items were discarded. She expected the kitchen was cleaned daily. She expected the Nutrition Services Director to observe and ensure the completion of the kitchen cleaning. She expected the kitchen cleaning logs were 100 percent completed. Freezer items were labeled with an open date and items without open dates in the freezer were discarded. During an interview on 05/29/24 at 2:45 PM, Staff SS, Quality and Infection Prevention Executive Director, stated that she expected hand hygiene was performed before touching a patient, after touching a patient, after touching equipment and before providing patient care. She expected glove changes when moving between clean and dirty items/areas. Hand hygiene and glove changes were performed after an item was picked off the floor. She expected hand hygiene and glove changes when a staff member touched their face/nose. She expected staff to clean an area or place a barrier before setting down IV supplies. She expected the IV port was scrubbed with an alcohol wipe with every IV medication administration. A betadine skin preparation should follow the hospital policy and use two sponges. She expected opened, unused single-use supply package items were discarded and a previously opened single-use item was not used for patient care. Dirty monitors and the dirty OR table base did not meet her expectations for a clean OR. Visible hair and jewelry in the OR and SPD did not meet her expectations. She expected dirty urinals were placed on the patient’s bed siderail. Expired food was discarded. All items in the patient nutrition rooms required dates of expiration. Items in the dated bags remained in the bags for patient use. Open single-use food packages were discarded, not stored in the patient nutrition room drawer or refrigerator. She expected written expiration dates on frozen food items. During an interview on 05/29/24 at 10:20 AM, Staff CC, Surgical Director, stated that she expected staff members to wash their hands with glove changes. She expected glove changes and hand hygiene when moving between clean and dirty objects. She expected the port of IV tubing was cleansed with an alcohol wipe before IV medication administration. Clean items for patient care should not be placed on the patients blanket or bedside table. A clean barrier was to be prepared before items were placed on a surface. A previously opened package of sterile gauze was discarded, not used for patient care. She expected unused, single-use package items were discarded. Masks were not worn dangling from a staff member’s neck. Masks were removed between patient procedures. She did not know what the substance was on the OR monitors. The dirty monitors and the dirty OR table base did not meet her expectations for a clean OR. There should not be any visible jewelry or hair in the OR or SPD. Hospital attire and hair covers were to completely cover jewelry and hair. During an interview on 05/28/24 at 3:15 PM and 05/29/24 at 3:20 PM, Staff J, Nutrition Services Director, stated that if a staff member “touched themselves,” they were to remove their gloves, perform hand hygiene and re-glove. The hood vent was cleaned by the cooks every week. She performed rounds to observe for kitchen cleanliness. Her rounds were not documented. Opened single-use food items were discarded, not stored in a drawer or the refrigerator. The unit staff were responsible to discard expired multi-use creamer bottles. The apple wrapped in a paper towel found in the sugar bin was “probably picked up from a hospital unit and the kitchen staff member did not yet discard the apple.” The apple did not belong in the sugar bin. The current process was to date the box when a frozen food item was opened. The frozen item was good for one month after the date opened. There was no policy to show how to date frozen items for expiration when opened.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 48359 Based on interview, record review and policy review, the Governing Body failed to ensure professional oversight for staff education related to patient safety events for two patients (#22 and #27) of two patients reviewed and failed to follow their internal policy to report to the Bureau of Hospital Standard (BHS) visitor to patient abuse for one patient (#27) of one patient reviewed. The severity and cumulative effect of this practice resulted in the hospital’s non-compliance with 42 CFR 482.12 Condition of Participation (CoP): Governing Body and resulted in the hospital’s failure to ensure quality health care and safety to all patients.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to ensure staff were educated related to patient safety events for two patients (#22 and #27) of two patients reviewed and failed to follow their internal policy to report to the Bureau of Hospital Standards (BHS) visitor to patient abuse for one patient (#27) of one patient reviewed. The severity and cumulative effect of this practice resulted in the hospital’s non-compliance with 42 CFR 482.13 Condition of Participation (CoP): Patient’s Rights and resulted in the hospital’s failure to ensure quality health care and safety to all patients.”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review, the Chief Executive Officer (CEO) failed to ensure professional oversight for staff education related to patient safety events for two patients (#22 and #27) of two patients reviewed and failed to follow their internal policy to report to the Bureau of Hospital Standard (BHS) visitor to patient abuse for one patient (#27) of one patient reviewed. These failures had the potential to affect the quality of care and safety for all patients. Findings included: Review of the hospital’s untitled and undated document showed that all administrative leaders report to Staff EE, CEO. Review of the hospital’s policy titled, “Education,” revised 04/2019, showed the hospital will provide educational opportunities for staff which will assist them to remain proficient and current in the healthcare field. General education programs will be offered to all hospital employees throughout the year. General nursing continuing education programs are identified each year by the nursing administration. Topics for presentation will be identified by a variety of sources including event reports and physician suggestions. Review of the hospital’s policy titled, “Abuse and Neglect,” revised 04/2023, showed the Chief Nursing Officer (CNO) or Associate Vice-President (VP) of Clinical Services and Infection Prevention will report patient abuse/mistreatment by visitors as soon as possible to the BHS. Findings of the investigation are communicated to appropriate individuals and entities. Review of the hospital’s document titled, “Safety Event Manager,” dated 10/29/23, showed: - On 10/27/23 at 6:30 PM, Patient #22’s ventilator (a machine that supports breathing) settings were changed, and a verbal order was placed under Staff Z’s, Physician, name without his knowledge. - At 9:15 PM, the ventilator settings order was noticed, and the ventilator was changed to the initial settings. - The changed ventilator settings resulted in a “drastic” increase in work for breathing. - The patient’s prognosis was extremely poor, but the ventilator changes accelerated her death. - Staff Z, recommended no significant ventilator changes were made without informing the physician. If changes were made, documentation was to be provided for why the changes were made. Verbal orders for significant, non-routine changes were not to be made under the physician’s name without his/her knowledge. Review of the hospital document titled, “Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to fine the root cause),” dated 01/04/24, showed: - On 12/28/23, Patient #27 was intubated (a process where a healthcare provider inserts a tube through a person’s mouth or nose down into their windpipe when a person is not breathing on their own) and sedated with an intravenous (IV, in the vein) drip of Versed (medication that causes you to sleep) and Fentanyl (medication for severe pain). - Patient #27’s IV tubing was accessed by a visitor with a needle he brought. - The visitor made a deliberate attempt to withdraw medication from the patient’s IV tubing. - The patient became agitated and began thrashing. - The nurse noticed blood and medication were dripping from the IV tubing from a puncture site. During an interview on 01/24/24 at 11:00 AM, Staff EE, CEO, stated that he was responsible for the entire hospital. All senior leadership reported to him. He was responsible for ensuring staff were educated. He stated that education needed to be provided at a “broader level.” The hospital had been too focused on the specifics of an event and had not recognized learning opportunities for others. The hospital needed to provide education to everyone to raise awareness and ensure meaningful education that included the whys of an event. During an interview on 01/24/24 at 8:40 AM, Staff A, CNO, stated that there was no hospital-wide education provided in response to the events. She stated that she had not reported Patient #27’s event to the BHS because she had not recognized the event as a visitor to patient abuse and had not anticipated the media response. During the interview, she recognized that Patient #27’s event was a visitor to patient abuse. During an interview on 01/24/24 at 1:00 PM, Staff C, Quality and Infection Prevention Executive Director, stated that Patient #27’s event was not reported to the BHS because she had not viewed the event as a visitor to patient abuse. She had not expected media coverage. During the interview, she recognized that Patient #27 was abused by the visitor. She stated that there was no hospital-wide education provided in response to the events. She understood the necessity to educate all staff in response to events. During a telephone interview on 01/24/24 at 11:35 AM, Staff Z, Physician, stated that education had only been provided to the respiratory therapists (RT) in response to Patient #22’s event. During an interview on 01/24/24 at 9:20 AM, Staff Y, Respiratory Department Director, stated that she provided one-to-one education for each RT, no education was provided to other staff. During an interview on 01/23/24 at 3:05 PM, Staff R, Intensive Care Unit (ICU, a unit where critically ill patients are cared for) Director, stated that she had spoken with the ICU staff regarding the event with Patient #27. No education was provided to staff outside of the ICU. She did not know why the event was not reported to the BHS.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to provide staff education related to patient safety events for two patients (#22 and #27) of two patients reviewed and failed to follow their internal policy to report to the Bureau of Hospital Standards (BHS) visitor to patient abuse for one patient (#27) of one patient reviewed. These failures had the potential to affect the quality of care and safety for all patients. Findings included: Review of the hospital’s policy titled, “Education,” revised 04/2019, showed the hospital will provide educational opportunities for staff which will assist them to remain proficient and current in the healthcare field. General education programs will be offered to all hospital employees throughout the year. General nursing continuing education programs are identified each year by the nursing administration. Topics for presentation will be identified by a variety of sources including event reports and physician’s suggestions. Review of the hospital’s policy titled, “Abuse and Neglect,” revised 04/2023, showed the Chief Nursing Officer (CNO) or Associate Vice-President (VP) of Clinical Services and Infection Prevention will report patient abuse/mistreatment by visitors as soon as possible to the BHS. Findings of the investigation are communicated to appropriate individuals and entities. Review of the hospital’s document titled, “Safety Event Manager,” dated 10/29/23, showed: - On 10/27/23 at 6:30 PM, Patient #22’s ventilator (a machine that supports breathing) settings were changed and a verbal order was placed under Staff Z’s, Physician, name without his knowledge. - At 9:15 PM, the ventilator settings order was noticed, and the ventilator was changed to the initial settings. - The changed ventilator settings resulted in a “drastic” increase in work for breathing. - The patient’s prognosis was extremely poor, but the ventilator changes accelerated her death. - Staff Z recommended no significant ventilator changes were made without informing the physician. If changes were made, documentation was to be provided for why the changes were made. Verbal orders for significant, non-routine changes were not to be made under the physician’s name without his/her knowledge. Review of the hospital document titled, “Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause),” dated 01/04/24, showed: - On 12/28/23, Patient #27 was intubated (a process where a healthcare provider inserts a tube through a person’s mouth or nose down into their windpipe when a person is not breathing on their own) and sedated with an intravenous (IV, in the vein) drip of Versed (medication that causes you to sleep) and Fentanyl (medication for severe pain). - Patient #27’s IV tubing was accessed by a visitor with a needle he brought. - The visitor made a deliberate attempt to withdraw medication from the patient’s IV tubing. - The patient became agitated and began thrashing. - The nurse noticed blood and medication were dripping from the IV tubing from a puncture site. During an interview on 01/24/24 at 11:00 AM, Staff EE, Chief Executive Officer (CEO), stated that education needed to be provided at a “broader level.” The hospital had been too focused on the specifics of an event and had not recognized learning opportunities for others. The hospital needed to provide education to everyone to raise awareness and ensure meaningful education that included the whys of an event. During an interview on 01/24/24 at 8:40 AM, Staff A, CNO, stated that there was no hospital-wide education provided in response to the events. She stated that she had not reported Patient #27’s event to the BHS because she had not recognized the event as a visitor to patient abuse and had not anticipated the media response. During the interview, she recognized that Patient #27’s event was a visitor to patient abuse. During an interview on 01/24/24 at 1:00 PM, Staff C, Quality and Infection Prevention Executive Director, stated that Patient #27’s event was not reported to the BHS because she had not viewed the event as a visitor to patient abuse. She had not expected media coverage. During the interview, she recognized that Patient #27 was abused by the visitor. She stated that there was no hospital-wide education provided in response to the events. She understood the necessity to educate all staff in response to events. During a telephone interview on 01/24/24 at 11:35 AM, Staff Z, Physician stated that education had only been provided to the respiratory therapists (RT) in response to Patient #22’s event. During an interview on 01/24/24 at 9:20 AM, Staff Y, Respiratory Department Director, stated that she provided one-to-one education for each RT, no education was provided to other staff. During an interview on 01/23/24 at 3:05 PM, Staff R, Intensive Care Unit (ICU, a unit where critically ill patients are cared for) Director, stated that she had spoken with the ICU staff regarding the event with Patient #27. No education had been provided to staff outside of the ICU. She did not know why the event was not reported to the BHS.”