Hackensack University Medical Center

“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: 51437 Based on observation, medical record review, review of facility documents, and staff interview, it was determined the facility failed to ensure nursing staff verified nasogastric (NG) tube placement in accordance with facility policy, for one of three patients reviewed (Patient (P) 1) with NG tubes. Findings include: Facility Policy titled, “Gastrointestinal Tube-Enteral Feeding Management for Adults” last approved on 08/2023 states, “...Verifying Placement...Verify NGT [Nasogastric Tube], OGT [Orogastric Tube], Weighed Feeding Tube placement at 4-hour intervals after continuous feeding are started...In addition to verifying placement via tube length/markings the RN [Registered Nurse] must assess the patient for signs and symptoms of feeding tube misplacement. These symptoms include:... Diarrhea, vomiting, and/or abdominal distention if the tube is misplaced in the small intestine...” A review of Patient (P)1’s medical record was conducted in the presence of Staff (S)3 and S7 and revealed that on 2/12/26 at 5:22 PM, P1 arrived at the Emergency Department (ED) with “Chief Complaint: Wound Check.” At 9:49 PM, P1 was admitted to the hospital for symptomatic bradycardia. Documented evidence on the “NG [Nasogastric]/OG [Orogastric] Tube 02/12/26 Nasogastric Left nostril” section of the “Flowsheets” indicated that “Tube Length/Markings” was assessed as follows: On 2/13/26, “Tube Length/Markings” was documented at 08:05 AM and 15:30 [03:30 PM]. On 2/14/26, “Tube Length/Markings” was documented at 08:00 AM. On 2/15/26, “Tube Length/Markings” was documented at 07:00 AM. On 2/16/26, “Tube Length/Markings” was documented at 07:00 AM. On 2/18/26, “Tube Length/Markings” was documented at 22:40 [10:40 PM]. The medical record lacked evidence that “Tube Length/Markings” was assessed every four hours in accordance with facility policy. This was confirmed with S7 on 04/16/26 at 1:42 PM during medical record review. The “Abdomen” section of the “Default Flowsheet Data” lacked evidence of a nursing assessment for abdominal distention every four hours in accordance with facility policy. Additionally, the medical record lacked evidence that a bowel sound assessment was completed by nursing staff from 2/10/26 through 2/18/26. This was confirmed with S1 on 04/17/26 at 11:30 AM during medical record review. A “Consults” note signed by [ICU Fellow] on 02/26/26 23:45 [11:45 PM] states, “...Impression: Acute resp [respiratory] failure due to aspiration.” During an interview on 4/16/26 at 10:49 AM, S8 stated “...we constantly do placement checks ... The head-to-toe assessment is done at 8:00 AM, and redone at 12:00 PM, and 4:00 PM. If the patient has an NG tube, the assessment will be more abdominal focused.” On 4/16/26 at 10:36 AM, when asked what the process is for NG [nasogastric] tube maintenance was, S6 explained, the nurses will frequently flush the NG tube, and make sure the medications are crushed well. S6 stated, “a part of the nursing assessment for NG tubes would be completing vital signs, ensure the NG tube didn’t coil, check the measurement, check for distention, and assess bowel movements.” On 4/16/26 at 10:49 AM, during interview, S8 stated, “for NG tubes, I always check placement, there is a mark on the NG tube for placement.” During interview with S9 on 4/16/26 at 10:55 AM, when asked the process for when a patient has an NG tube, S9 stated, “I will document where the NG tube placement is ... I will pull a residual and listen to bowel sounds. I assess the nose around the site and document if the patient is having a lot of bowel movements from the tube feedings.” 51555”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48414 Based on medical record review, staff interview, and review of facility documents, it was determined, the facility failed to ensure that allegations of abuse are reported immediately by staff and escalated to the appropriate administrative staff (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patients. On 10/10/25 at 12:03 PM, an Immediate Jeopardy (IJ) was identified for the facility’s failure to inquire about details of a patient’s allegation of sexual abuse from a staff member and, follow the chain of command of reporting the alleged abuse. On 10/10/25 at 12:57 PM, Staff (S) 1, S2, S5, S15, and S16 were notified and the IJ template was provided. An acceptable removal plan was received on 10/10/25 at 2:08 PM. The facility took immediate actions and provided re-education to the emergency department Registered Nurses on the policy, “Professional Chain of Command and Escalation.” Upon interview, staff were able to speak to the escalation process if there is a concern for patient safety. The State Agency was able to verify implementation of the removal plan on 10/10/25 at 3:14 PM and the IJ was resolved. Verification of the implementation was completed through signed attestation of staff education and staff interviews. Cross Reference: 482.13(c)(2) Patient Rights: Care in Safe Setting”

“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: 48414 Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that allegations of abuse are reported immediately by staff and escalated to the appropriate administrative staff. Findings include: The facility policy titled, “Professional Chain of Command and Escalation” effective 6/24, stated, “ ... Purpose: To outline the roles, process, communication, and documentation to intervene on behalf of the patient or family with regard to the medical management of the patient’s care or patient safety. Nurses are obligated to work toward resolution of identified real and potential problems within the system that may affect patient care. If the nurse is unable to resolve such issues independently, the team member is obligated to present the issue in a timely manner to successively higher levels of command until a satisfactory resolution is achieved. ... Policy: Registered Nurses will follow a clearly defined and communicated method to escalate patient care concerns in order to facilitate patient safety and/or medical management. Procedure: 1. RN’s [Registered Nurse’s] have the responsibility to exercise the professional chain of command and to retain responsibility to continue to escalate the issue until it is resolved in a satisfactory manner. 2. ...The RN will use critical thinking skills to assess the priority of the various assessment measures based on patient condition and safety. ...” The facility policy titled, “HMH Code of Conduct”, effective 5/25, stated, “ ...Purpose and Scope. ...The Code of Conduct (Code) is the foundation of [facility name] Corporate Compliance Program and contains standards of conduct. ...The Code of Conduct strongly supports and promotes [facility name] Mission, Visions, and Beliefs. Responsibilities relating to the Code include: Each ...medical staff member ...are expected to read and adhere to the Code. All team members are also expected to be familiar with all detailed policies, procedures, and rules that apply to their positions. ...COMPLIANCE: It is Not Just the Law; It is the Right Thing to Do. Everyone has the obligation to report any suspected violations of the Code of Conduct. The Code provides a confidential mean for reporting suspected violations without fear of reprisal or retaliation. ... Failure to comply with this Code of Conduct can include: ... (3) failing to act in a timely and reasonable manner once an issue is known, or (4) failing to report a suspected violation in a timely manner. ...” On 10/9/25 at 10:17 AM, an interview was conducted with S5, who stated the incident that occurred on 9/30/25 involving Patient (P)1 and S18. S5 stated, the assistant nurse manager notified [him/her] that S18 was accused of sexually assaulting P1 in the emergency department. It was reported to S5, that P1 told S12 that a male staff came into the room and performed an EKG and touched the patient inappropriately. S5 stated, upon entering P1’s room with security and risk management, P1 stated that someone came in the room and placed two EKG leads under their right and left breast, and both hips, then touched their [private area] in between their legs twice. S5 offered to call the police, and P1 indicated that they had already contacted them. S5 confirmed that the incident was escalate up the chain of command to the Chief Nursing Officer and the Chief Medical Officer. On 10/9/25, P1’s medical record was reviewed with S5 which revealed the following: P1 presented to the Emergency Department (ED) on 9/29/25 with a chief complaint of rash. P1’s medical record lacked evidence of an order for an EKG, and there was no EKG results documented. On 10/9/25 at 1:24 PM, during a telephone interview, S12 stated that when the Respiratory Therapist (RT) walked out of the room after obtaining a blood gas specimen, they told S12 that the patient was upset and wants to talk to a supervisor. According to S12, upon entering the room P1 was teary eyed and stated, “this morning someone came into my room with burgundy scrubs, he came into the room and said ‘EKG’, had the EKG stickers, lifted my shirt and put two stickers under each breast and two on the hips. Then he touched me down there.” S12 stated that P1 was pointing to the [private area] upon stating they were touched down there.” S12 then stated, that he/she administered medications to P1 and apologized. When asked if the night shift nurse discussed this incident during shift report, S12 stated, “no [he/she] did not tell me.” S12 further stated, “the patient said [he/she] told the other nurse, and the nurse said sorry too.” On 10/10/25 at 10:20 AM, during a telephone interview, S17 stated, “I wasn’t aware of what happened or see it.” S17 stated that around 7:00 AM, he/she went into P1’s room and P1 was asking vague questions about EKG’s and what it was ordered for. S17 indicated that P1 stated, he/she was confused because [S18] touched the top of their pants area and gestured to “that area.” S17 stated, “I did not feel like [he/she] was in any distress from what I got.” During the interview, S17 indicated he/she did not review P1’s medical record to check if an order was placed for an EKG. On 10/10/25, upon review of S17’s written statement dated 9/30/25 at 3:12 PM, it stated, “ ...When I went to give the patient her medication, ... the patient stated, ‘I got an EKG done. What do you guys need EKG’s for?’ I said, It’s pretty standard, most doctor’s just want a baseline.’ I thought nothing of it as patient’s need EKG’s all time. The patient then asked, ‘Where do they normally place the EKG stickers?’ I proceeded to show [the patient] that I think it was on both upper arms, legs, chest, below the breast and lower abdomen. [The patient] then stated, ‘I’m not sure what happened because that fat Indian guy touched my pants’ and proceeded to gesture around the upper pants area, which I assumed was moved to place stickers on the lower abdomen. I said, ‘I’m not sure exactly, they might have been moved to place stickers on your abdomen.’ [The patient] said, ‘Oh okay,’ and asked if [he/she] can be unhooked from the monitor to go to the bathroom. Then ... we both walked out of the room. She was in no obvious distress.” On 10/10/25, upon review of S5’s written statement dated 10/1/25 at 11:28 AM, it stated, “ ...[S19] stated that it was just escalated to [him/her] that a patient in [Room#] was stating they were sexually assaulted by someone who was performing an ECG [electrocardiogram]. [S19] said that the day shift RN, [S12] ... told [them] that the patient said [he/she] was touched inappropriately during an ECG by a male team member. ... [S12] told me the patient was crying. ... [S12] began relaying the story stating the patient told [S12] that [P1] tried to tell the night nurse that something strange had happened, that [P1] asked the night shift RN, ‘why did I have an ECG’ and ‘where do you put the leads for an ECG’ and that the night nurse said that sometimes ECGs are ordered so they can get a baseline for the patient but that [he/she] didn’t know why this patient had an ECG at that time. [S12] relayed that the patient told [him/her] that [he/she] said to the night RN that a tech, ... came in to do an ECG and touched [P1] under [P1’s] panties. ... Neither the night RN nor [S12] were able to tell us if the ‘touching’ was [him/her] placing the leads on [P1’s] lower abdomen or if [P1] was touched someone [sic] else. ... The patient stated the tech came into the room between 6-6:40 am and said ‘ECG’, [P1] said he never asked if he could touch [P1]. He placed a led [sic] on [P1’s] left breast and one on [P1’s] right, he then placed two leads under [P1’s] left breast and two leads under [P1’s] right. Then ... put his hands under [P1’s] panties and placed a lead on [P1’s] lower right hip and lower left hip and touched [P1]. I explained that sometimes, we do place leads on the lower hips and that I was sorry for the graphic question but could [P1] be very specific about where he ‘touched’ [P1]? Was it on the hips with the leads or in the middle between [P1’s] legs. [P1] replied, “he touched me under my panties, between the legs. He touched my lips, twice. ...” On 10/10/25 a review of the Police Incident Report dated 9/30/25 at 9:47 AM, revealed, “ ...The victim reported the suspect placed multiple EKG leads on [his/her] body. The victim further reported that after putting the leads on [his/her] chest/breast area, the suspect proceeded to grab and feel [his/her] chest/breasts. The victim reported after the EKG test was performed, the suspect began to take the leads off. In the process of taking the leads off, the victim reported the suspect stuck [his/her] hands down [his/her] pants onto [his/her] vagina rubbing it twice. The suspect then left the area. The victim reported [he/she] then reported the incident to two nurses. ...” On 10/10/25 at 12:57 PM, the above findings were discussed with S1, S2, S5, S15, and S16 which revealed that P1 reported an allegation of sexual assault to S17. S17 failed to inquire about details of the allegation and follow the chain of command of reporting the alleged abuse. This resulted in the patient having to report to another staff member before action was taken. Upon request, S5 was unable to provide any re-education provided to staff related to the process of receiving and reporting patient care concerns to facilitate patient safety. When asked if any education or re-education has been provided to the staff since the incident occurred, S5 stated, “no.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 39223 Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to implement their policy requiring a physician/licensed individual practitioner’s order to access a patient’s temporary dialysis central venous catheter (CVC) to obtain a blood sample for routine laboratory (lab) work. Findings include: A review of Patient (P)7’s medical record revealed that the patient was admitted on 08/11/25 with a diagnosis of plasma cell leukemia and history of hemodialysis treatments. Prior to admission, on 05/09/25, P7 had a tunneled right internal jugular permacath (a type of CVC) placed for hemodialysis treatments. Further review of P7’s medical record revealed the following: Documentation on 08/13/25, 08/17/25, and 08/23/25 indicated that blood samples were obtained by the Registered Nurse (RN) from the dialysis CVC for routine lab work. An order was placed on 08/11/25 at 7:43 AM for, “... Central Venous Care and Site Assessment (as per policy) ...” There lacked documented evidence of an order specifying the hemodialysis CVC can be utilized to obtain blood for routine lab work. During an interview on 09/04/25 at 11:10 AM, Staff (S)4 stated that RNs can access a CVC to draw blood samples for ordered labs. S4 stated that a hemodialysis catheter, for example a Shiley, could be accessed by the RN as well if an order was placed. During an interview on 09/04/25 at 12:51 PM, S1 stated that an order is required to access the central line. During an interview on 09/04/25 at 1:19 PM, S24 stated that the order for CVC care and maintenance indicated that the RN should refer to the facility policy and procedure on CVC’s. S24 explained that it included standard care such as, “flushing, changing the insertion site dressing, and lab draws.” S24 stated that lab draws are included in the care and maintenance of a CVC order without it needing to specifically state it can be accessed for hemodialysis patients. Facility policy titled, “Central Venous Access Device (CVAD) Care & Maintenance in Adult Patients,” stated, “... Key Points: ... Registered Nurses who are validated for the care and maintenance of a central venous access device can use a dialysis catheter for IV access and blood draw in emergent situations ONLY when an order is placed in the electronic medical record by the Nephrologist, LIP [licensed independent practitioner], Intensivist or critical care fellow or vascular surgeon. ... Avoid using a hemodialysis catheter for routine blood sampling, blood transfusions, or other infusion medications ...””

“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: 36420 Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure an effective infection control program to prevent and control the spread of infectious diseases. Findings include: 1. The facility failed to ensure that staff in the neonatal intensive care unit (NICU) wore facemasks in accordance with facility policy in two of seven patient treatment areas observed (Cross refer to Tag A 0749). 2. The facility failed to ensure that reusable infant feeding equipment is maintained in accordance with facility procedure for one of one type of reusable bottle observed (Cross refer to Tag A 0749). 3. The facility failed to ensure that reusable patient care equipment is disinfected in accordance with facility policy in two of three observations (Cross refer to Tag A 0749). 4. The facility failed to ensure that hand hygiene procedures are performed to minimize the spread of infection (Cross refer to Tag A 0749). 5. The facility failed to ensure that Super Sani-Cloth Germicidal Disposable Wipes container lids are kept closed when not in use in two of five treatment areas observed (Cross refer to Tag A 0749). 6. The facility failed to ensure that clean privacy curtains that were available for use, are stored in designated clean areas in the NICU. (Cross refer to Tag A 0749). 7. The facility failed to ensure that its MSSA/MRSA [Methicillin-Susceptible S. aureus/Methicillin-resistant S. aureus] Infection Control Plan was immediately implemented in response to a potential outbreak of MSSA for two of two MSSA colonized patients reviewed (Cross refer to Tag A 0750). 8. The facility failed to ensure that staff documented the implementation of contact precautions in accordance with provider orders for four of five NICU infants with contact isolation orders (Cross refer to Tag A 0750).”

“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: 36420 Based on observation, review of facility policy and procedure, and staff interview, it was determined that the facility failed to ensure that: 1) staff in the neonatal intensive care unit (NICU) wore facemasks in accordance with facility policy in two of seven patient treatment areas observed; 2) reusable infant feeding equipment is maintained in accordance with facility procedure for one of one type of reusable bottle observed (Dr. Brown’s); 3) reusable patient care equipment is disinfected in accordance with facility policy in two of three observations; and 4) hand hygiene procedures are performed to minimize the spread of infection; 5) Super Sani- Cloth Germicidal Disposable Wipes container lids are kept closed when not in use in two of five treatment areas observed; and 6) privacy curtains used in patient rooms, that are available for use, are stored in designated clean areas in the NICU. Findings include: 1. During a tour of the NICU on 4/17/23, staff were observed with facemasks below their nares as follows: At 11:02 AM, Staff (S) 41, a Registered Nurse (RN), was observed in an occupied patient room in the “Small Baby” area with his/her the facemask below his/her nares. Upon interview, S41 stated that his/her mask “always falls down.” At 11:18 AM, a staff member was observed exiting the Clean Supply Storage area pushing a cart that contained a large box. The staff members mask was below his/her nares. At 12:42 PM, in the Continuing Care area, S35, a RN, was observed entering a patient room to talk to the infant’s family member at the bedside. S35 had his/her facemask below the nares while at the bedside. At 1:16 PM, upon re-entry to the “Small Baby” area, S41 was observed at a patient bedside with his/her mask below the nares. Upon seeing the surveyor, S41 lifted his/her facemask to cover his/her nose. At 1:40 PM, in the Continuing Care area, S35 was observed administering intravenous (IV) medication to an infant. S35 had his/her mask below the nares during the entirety of the procedure. At 2:10 PM, in the Continuing Care area, S35 exited an occupied patient room with his/her mask below the nares. Facility policy titled, “HMH COVID-19 Universal Pandemic Precautions for Patient Care Settings,” last revised 12/2023, states, “... Protocol: A. Respiratory protection for Team Member, Physicians and Licensed Independent Practitioners (LIPs) ... e. TMs [team members], physicians and LIPs will be required to wear a mask, regardless of COVID-19 Level, in the following situations: ... ii. In a specific area of the hospital/facility identified by clinical leadership where highly vulnerable patients are receiving care (e.g. NICU) or there is a high risk of transmission (e.g. inpatient behavioral health unit).” 2. During a tour of the Continuing Care area of the NICU on 4/17/23 at 12:30 PM, staff were observed washing infant feeding bottles in the sink. S8, the NICU Educator, stated that the Dr. Brown’s bottles are washed in the sink with dish detergent after each feeding and reused for 24 hours before being sent down to central processing for sterilization. S34, a Registered Nurse who normally works in the Mother/Baby unit, was asked about the process for cleaning the reusable bottles. S34 described the process and showed this surveyor a basin in which the bottle and its parts were currently drying for the bottle he/she had been observed washing. The basin also contained a silicone bottle brush that staff stated was dedicated to each infant and would also be sent down for sterilization. The bottle parts were drying on a white towel and/or wash cloth within the basin. This was not in accordance with the facility procedure which states that the bottle parts would be dried on a sterile towel. On 4/18/24 at 10:45 AM, S22 and S23, both NICU Charge RN’s, stated that the sterile towels used for drying bottles and their parts are blue not white. Staff confirmed that the white towels observed being used for drying were not sterile. On 4/17/24 at 12:49 PM, two silicone bottle brushes were at the sink near the door to the Transition room. Upon interview, S8 could not say why the bottle brushes were at the sink or to which baby they belonged. S8 asked the RN’s working in Continuing Care area if anyone knew the reason the bottle brushes were left at the sink and staff were unable to identify why they were left at the sink as each baby using reusable bottles on the unit had a dedicated brush. S8 stated that the bottle brushes would be removed. Facility procedure titled, “Dr. Brown Bottle Cleaning Guideline,” last revised 08/2019, states, “... 2. Patient Use Process a. At the start of the day shift (7 am), the nurse will pick up a sterilized bottle system, nipple, new wire cleaning brush and new bottle brush b. The bottle, nipple, small wire cleaning brush and bottle brush once opened can be used for 24 hours. ... e. The bottle brush will be sanitized daily by central processing ... 3. Cleaning instructions after each use ... Rinse all bottle components, and place to air dry on a sterile towel in the clean basin located in the patient’s room. ...” 3. During tour of the Small Baby area on 4/17/24 at 1:23 PM, S36, a RN, was observed at the bedside in the Small Baby area. S36 returned a glucometer (a device used to measure the concentration of glucose in the blood) to a nurse’s station and was then asked about the process for cleaning the glucometer after use. S36 stated that he/she had already cleaned the glucometer prior to returning it to the nurse’s station and that he/she had used a “purple top” wipe (Super Sani Cloth) for 1 minute. This was not in accordance with facility policy which was to use a bleach wipe. This was confirmed with S8 who stated that the “purple top” wipes were an approved disinfectant but that bleach wipes were to be used per facility policy. Facility policy titled, “Blood Glucose Monitoring at Point of Care Testing Sites,” last revised 04/2024, states, “... Section F: Cleaning and Maintenance ... Cleaning guidelines 1. Meters MUST be disinfected with PDI bleach wipes in between each patient and allowed to dry for the full disinfectant time of 4 minutes. Use of other chemicals could result in meter damage. ...” During a tour of the Continuing Care area on 4/17/24 at 1:40 PM, S35 was observed exiting a patient room with gloved hands and placing a scanner used for medication administration onto a holder at the nurse’s station. Staff then returned to the patient’s bassinet and connected the IV medication to the patient’s IV tubing and administered the medication. S35 did not clean the scanner after removing it from the patient’s room and before placing it at the nurse’s station. S8 stated that the scanner should be cleaned with a “purple top” wipe when it comes out of a patient room after use. At 1:49 PM, S35 was asked about the cleaning of the medication scanner. S35 stated that there was no protocol for the cleaning of the scanner and that “[I] guess you can use the purple top wipes.” On 4/18/24 at 10:45 AM, S22 and S23, both NICU Charge RN’s, stated that the scanner in the “Sunshine Room” (the Continuing Care area) is the only place where a medication scanner is not dedicated to each patient. Staff stated that the scanner should be sanitized after each use. Facility policy titled, “Care and Maintenance of Patient Environment and Equipment,” last revised 12/2023, states, “... Policy: ... Equipment and the surrounding environment in all departments shall be cleaned and have low level disinfection performed according to manufacturer’s instructions routinely, before/after patient contact, and when visibly soiled.” 4. During a tour of the Continuing Care area on 4/17/24 at 1:40 PM, S35 was observed exiting a patient room with gloved hands and placing a scanner used for medication administration onto a holder at the nurse’s station. S35 then returned to the patient’s bassinet and connected the IV medication to the patient’s IV tubing and administered the medication. S35 did not remove his/her gloves and perform hand hygiene after using the medication scanner and prior to administering IV medication. 39228 On 4/17/24 at 11:25 AM, during a tour of the NICU, S12, an Equipment Technician, cleaned and disinfected a Giraffe OmniBed with PDI Super Sani-Cloth Germicidal Disposable Wipes, in the Soiled Holding Room. At 11:54 AM, during the observation, S12, with gloved hands, wiped the mattress of the OmniBed with a Super Sani-Cloth then placed the mattress on the pan portion of the OmniBed. S12 then removed his/her gloves, did not perform hand hygiene, reapplied new gloves and wiped the mattress again with a Super Sani-Cloth. At 12:02 PM, while wearing the same gloves, S12 cleaned two gasket pieces of the OmniBed then placed them on a countertop in the room. S12 then removed his/her gloves, did not perform hand hygiene, and then reapplied new gloves and proceeded to reassemble the OmniBed with the cleaned equipment. On 4/17/24 at 1:45 PM, S18, EVS (Environmental Service), cleaned and disinfected patient room in the Continuing Care Area, after the patient who had occupied the room was transferred to another room in the NICU. At 1:48 PM, S18, with gloved hands, cleaned and disinfected a freestanding refrigerator in the room then removed his/her gloves, did not perform hand hygiene, and applied a new pair of gloves. S18 then removed PDI Super Sani-Cloth Germicidal Disposable Wipes from an EVS cart located outside of the room, re-entered the room, and proceeded to wipe down the patient monitor, the monitor screen, the cords attached to the monitor, the wall mounted thermometer and other wall mounted equipment. S18 then exited the room, removed his/her gloves, did not perform hand hygiene, and applied new gloves. S18 then removed PDI Sani-Cloth Bleach Germicidal Disposable Wipes from a container located on the EVS cart outside of the room, re-entered the room and wiped down a chair. Upon interview on 4/18/24 with S19, Director of Infection Control, confirmed that S12 and S18 should have performed hand hygiene between glove changes when cleaning and disinfecting the patient environment, equipment, and surfaces. Facility policy titled, “Hand Washing and Hand Hygiene,” last revised 12/2021, stated, “ .... Procedure: ... C. Hand Washing/Hand Hygiene Indications ... after contact with ... environment. ... after removing gloves. ...” 5. On 4/17/24 at 12:26 PM, during a tour of the NICU, a container of Super Sani-Cloth Germicidal Disposable Wipes, used by staff for the cleaning and disinfection of patient care equipment, was observed on top of an equipment cart located outside of a room in Annex B, with the lid open. Upon discovery, an interview was conducted with S14, a Registered Nurse, who explained that the lid should be closed, and that a staff member had probably cleaned something earlier and did not close it. At 1:38 PM, during a tour of the Continuing Care area of the NICU, another open container of Super Sani-Cloth Germicidal Disposable Wipes with the lid open, was observed on top of a bedside equipment cart located outside of a room. There were no observed staff members utilizing the wipes upon discovery. On 4/18/24 at 11:56 AM, S15, EVS Group Leader, provided the facility document titled, “[facility name] Approved Disinfectants” that stated, “Germicidal Wipes (Purple Top) Super Sani-Cloth Germicidal Disposable Wipes ... Used to clean & disinfect equipment ... keeping the container closed after use ...” 6. On 4/17/24 at 12:35 PM, during a tour of the NICU, the Housekeeping Closet, located in a hallway within the NICU, contained an EVS (Environmental Services) cart, and housekeeping supplies and equipment. In the closet was an open box of “On the Right Track Holistipure Magic Waves Recyclable Curtains” that S15, EVS Group Leader, stated were the privacy curtains used in patient rooms. The box contained a large pack of curtains that were unopened, covered in clear plastic and available for use. Upon interview at the time of discovery, S15 stated, “we usually store them here so that the EVS staff can have them handy to change in the rooms.” S19, Director of Infection Control, who was also present at the time of discovery stated, “they should be stored in the Clean Supply room.””

“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: 36420 Based on medical record review, review of documents, and staff interview, it was determined that the facility failed to ensure that: 1) its MSSA/MRSA [Methicillin-Susceptible S. aureus/Methicillin-resistant S. aureus] Infection Control Plan was immediately implemented in response to a potential outbreak of MSSA for two of two MSSA colonized patients reviewed (Medical Record [MR] 6 and 7); and 2) staff documented the implementation of contact precautions in accordance with provider orders for four of five Neonatal Intensive Care Unit (NICU) infants with contact isolation orders (MR3, 4, 5, and 6). Findings include: 1. A review of the “MSSA/MRSA Infection Control Plan” developed by the facility and placed into effect on 4/16/24, in response to an increased number of Bacteremia cases caused by MSSA, indicated the following: “In collaboration with the hospital Infection Control team and Epidemiologists, the NICU has developed a plan for testing, isolation, and decolonization of identified patients. Testing: (effective immediately) All patients will be swabbed on Tuesday and Friday mornings ... Isolation: (effective immediately) Contact isolation for all patients testing positive for MSSA or MRSA ... Decolonization: (effective immediately) Treatment for any patient who tests + [positive] for MSSA or MRSA ... Prophylactic treatment for any high risk patient ... Birth gestational age [less than or equal to] 32 weeks ... Birth Weight [less than or equal to] 1500 grams ... Current Central Line ... Treatment: (effective immediately) Mupirocin 2% ointment [used to treat skin infections caused by bacteria] BID [twice daily] x [times] 5 days ...” A review of MR6 revealed that swabs were sent for S. aureus testing on 4/16/24 and a positive result for MSSA was documented on 4/16/24 at 1740 [5:40 PM]. Contact isolation was ordered on 4/17/24 at 10:27 AM, 16 hours and 47 minutes after the result was determined and documented by the laboratory. Mupirocin 2% ointment was ordered on 4/17/24 at 11:01 AM, 17 hours and 21 minutes after the result was determined and documented by the laboratory. A review of MR7 revealed that swabs were sent for S. aureus testing on 4/16/24, and a positive result for MSSA was documented on 4/16/23 at 2004 [8:04 PM]. Contact isolation was ordered on 4/17/24 at 10:19 AM, 14 hours and 15 minutes after the result was determined and documented by the laboratory. Mupirocin 2% ointment was ordered on 4/17/24 at 11:07 AM, 15 hours and 7 minutes after the result was determined and documented by the laboratory. During an interview with S22 and S23, both Neonatal Intensive Care Unit (NICU) Charge Registered Nurse’s (RN), on 4/18/24 at 2:35 PM, staff stated that the reason for the delay in orders was because the tests resulted at night. On 4/19/24 at 10:15 AM, S32, the Microbiology Supervisor, was interviewed. S32 stated that the laboratory operates 24 hours per day, seven days per week. S32 stated that the laboratory staff was not given any special instruction regarding notification of positive MSSA results and stated that staff would not typically notify nursing staff of a positive MSSA test. On 4/19/24 at 10:20 AM, the above timeline for the results of positive MSSA colonization results to provider orders entered in accordance with the facility “MSSA/MRSA Infection Control Plan” was confirmed with S19, the Director of Infection Control, in the presence of S1, the Director of Regulatory Affairs. S19 stated that since positive MSSA patients are not usually isolated or treated the results were not flagged as abnormal. S1 stated that the hospital’s electronic system would not automatically flag a positive MSSA result. S1 and S19 confirmed that there was no process initiated to communicate the MSSA test results as they became available, which resulted in the above delay in implementation of the “MSSA/MRSA Infection Control Plan.” 2. A review of MR3 revealed that an order for contact isolation was entered by the provider on 4/16/24 at 1551 (3:51 PM). Nursing documentation in the “Precautions” section of the flowsheet indicated that the infant was on “Universal” precautions on 4/16/2024 at 0800 (8:00 AM) and was changed to “Contact isolation” at 1910 (7:10 PM), three hours and 19 minutes after the order was entered by the provider. A review of MR4 revealed that an order for contact isolation was entered by the provider on 4/16/24 at 1526 (3:26 PM). Nursing documentation the “Precautions” section of the flowsheet indicated that the infant was on “Universal” precautions on 4/16/24 at 0730 (7:30 AM) and 1900 (7:00 PM). The precautions were documented as “Contact isolation” on 4/17/24 at 0830 (8:30 AM), 17 hours and four minutes after the provider order was entered. A review of MR5 revealed that an order for contact isolation was entered by the provider on 4/16/24 at 1535 (3:35 PM). Nursing documentation in the “Precautions” section of the flowsheet indicated that the infant was on “Universal” precautions on 4/16/2024 at 0730 (7:30 AM) and was changed to “Contact isolation” at 1930 (7:30 PM), three hours and 55 minutes after the order was entered by the provider. A review of MR6 revealed that an order for contact isolation was entered by the provider on 4/17/24 at 1027 (10:27 AM). Nursing documentation in the “Precautions” section of the flowsheet indicated that the infant was on “Contact isolation” as of 1920 (7:20 PM), eight hours and 53 minutes after the order was entered by the provider. During an interview on 4/18/24 at 12:32 PM, S23 stated that staff do not update the medical record when contact isolation is initiated and will document a change in precautions with the next assessment. Facility policy titled, “Nursing Documentation” last revised 04/2022, states, “... Key Points: ... Document all interventions and reassessment of the interventions and any observable changes in the patient’s general condition, his symptoms and behavior, and ongoing evaluation of the current status of the patient.””