Overlook Medical Center

“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: 49077 Based on observation, medical record review, staff interviews, review of video surveillance, and review of facility documents, it was determined the facility failed to ensure that staff utilize de-escalation techniques with patients in accordance with training and education. Findings include: On 08/08/2025 at 10:15 AM, Staff (S)6 confirmed that all Emergency Department (ED) staff receive de-escalation training as part of annual learning. At 11:46 AM, upon request, S15 provided an incident report and stated that the facility has security footage of the incident. The incident report indicated that P1 attempted to elope from the ED on 07/29/25 at 9:20 PM and pulled the fire alarm. S21 arrived at the scene and attempted to prevent P1 from eloping. However, S21 was assaulted by P1 multiple times. Staff members present lowered P1 to the ground, P1 began spitting at staff. P1 was transferred to a stretcher, and restraints were applied. At 12:03 PM, a review of the video surveillance of the 07/29/2025 incident was conducted in the presence of S4 and S15, who confirmed respectively that they were able to identify P1 and staff in the video. Camera view location “Hallway Stairwell 17” dated 07/29/25 at 9:15 PM, revealed the following: S24, S25, S30, and S33 followed P1 as he/she leaves the ED, attempting to redirect P1 back to the ED by gesturing towards the doorway with hands guiding P1 on his/her shoulder. P1 then pulled the fire alarm, attempted to swing his/her arm towards S30, and shoved S30 away. S21 appeared from behind P1 and wrapped his/her arms around the back of P1’s neck. P1 escaped from S21’s hold and struck S21 multiples times in the face with closed fists. P1 was lowered to the floor by S24, S25, and S30 and was held down with assistance from S33 until more help arrived. P1 was transported back to the ED. P1’s face was covered with towels and was unable to be visualized. At 12:27 PM, during an interview with S15, it was stated that S21’s handling of P1 was “inconsistent with Iron Temple training (De-Escalation Training). S15 stated that a more appropriate hold would have been to grab an appendage, such as a wrist. S15 stated that S21 has been out on leave since the incident and was scheduled to return to work on 08/15/25. S15 stated that S21 will need to retake Response Control Training (RCT). S15 stated that all security officers are required to become certified in RCT upon hire. The certification is good for two years, but security officers were also required to have a monthly RCT skills assessment. At 1:32 PM, S15 stated that all security officers have arranged for retraining and that by the end of the week 80% of all security staff will have completed RCT retraining. P1’s medical record was reviewed in the presence of S12, and revealed the following: On 07/03/2025, P1’s maxillofacial CT scan study result stated, “... partial left globe rupture with minimal blood in the posterior chamber. 2. Left lateral facial/periorbital/supraorbital soft tissue hematoma 3. Left lamina papyracea fracture ...” The Physician’s ED Course note by S34, dated 07/03/2025 at 1:03 AM, stated, “ ... I reevaluated patient at bedside. Patient is no longer agitated and is now letting me examine [his/her] face I have informed [him/her] that [he/she] has an injury to the globe. I have explained that [he/she] will likely need to be transferred for several injuries of the face/eye. On examination, [he/she] has profound periorbital edema with ecchymoses. Eyelids are swollen and patient is unable to open [his/her] left eye secondary to swelling of the lids. With very limited pressure, attempted to lightly retract eyelids, but unable to do so ...” Upon request, S1 provided documentation that all staff involved in the incident with P1 on 07/29/25 were up-to-date with de-escalation training. On 08/11/2025 at 09:47 AM, upon interview, S33 stated they were not able to see P1’s face while on the floor. S33 stated that P1 was laying on his/her left side while on the floor. S33 heard someone tell P1 “stop spitting.” S33 stated that someone had placed a towel over P1’s face to protect the staff from being spat on. A review of the staff education content titled, “Iron Temple Response Control Techniques” dated 2025 revealed the following: “The Safe State is the central concept of the RCT Program. It refers to a physical and psychological state in which an individual is no longer exhibiting behavior or intent that poses a danger to themselves, to staff, or to others in the surrounding environment. Achieving a Safe State may involve verbal redirection, strategic positioning, or only when necessary, controlled embracing techniques ...” “ ... Terminology and Key Concepts: ... 3. Embracing Techniques: low impact, compassionate holds that communicate support rather than control used to reduce resistance and help an individual feel secure. 4. Point of Contact: The first part of the individual’s body you make intentional contact with. Key points: wrist, elbow, and upper torso ...” “ ...Stabilization and Leverage ... to avoid spitting ... lightly place your palm on the patient’s cheekbone and gently turn their head away from you.” Facility policy titled, “Patient Rights and Responsibilities” effective date: 07/26/2024 stated, “ ... The patient has a right to receive care in a safe setting ...” At 2:00 PM, the above findings were confirmed with S1, S12, S13, S15, S16, S17, S18, S19, and S20.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 43214 Based on review of the facility’s Emergency Department (ED) Logs, review of facility policy and procedure, review of five (5) of twenty (20) medical records (Patient (P)11, P12A & P12B, P15 and P19), and staff interview, it was determined the facility failed to ensure all entries in the log are complete and accurate. Findings include: Facility policy titled, Emergency Care & Transfers of Individuals with Emergency Medical Conditions (EMTALA), effective 4/30/2024, states, “ ...Procedure ...4. Each AHS hospital campus shall maintain a central log to track the care provided to each individual who comes to the ED seeking care for a medical condition and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted, and treated, stabilized and transferred, or discharged. ...” Review of the ED Log for P11 indicated the patient’s disposition was “AMA [Against Medical Advice].” P11 presented to the facilities ED on 4/29/24/24 at 6:51 PM with a chief complaint of “Cyst.” P11’s vital signs were obtained, and lab work completed. At 11:41 PM, the ED note stated, “Husband walked out with patient.” Review of the ED Log for P12A indicated the patient’s disposition was “Eloped.” P12A presented to the facilities ED on 4/12/24/24 at 1:11 PM with a chief complaint of “Medical Screening Exam.” P12A was triaged at 1:22 PM and vital signs were obtained. At 5:56 PM, the ED Notes state, “Patient called several times for [sic] room without response. Patient was called on cell phone and reports that [he/she] left after [his/her] doppler test. Patient was then advised on the importance of staying for results and plan of care. Patient stated, “I’ll come at 7 tomorrow.” Review of the ED Log for P12B indicated the patient’s disposition was “AMA [Against Medical Advice].” P12B presented to the facilities ED on 4/12/24/24 at 6:59 PM with a chief complaint of “Follow-up.” P12B was triaged at 7:25 PM and vital signs were obtained. At 9:49 PM, the ED Nurse Note stated, “Per registrar pt [patient] left.” Review of the ED Log for P15 indicated the patient’s disposition was “Eloped.” P15 presented to the facilities ED on 8/4/24 at 12:20 AM with a chief complaint of “Drug Overdose.” P15 was a minor who was seen by a provider at 12:32 AM. P15 was seen by a psychiatrist who recommended inpatient behavioral health treatment. P15’s parents did not agree with the plan and wanted to take P15 home. After discussing with the facilities legal counsel and reviewing the risks and benefits with P15’s medical doctors, P15’s parents took P15 home. Review of the ED Log for P19 indicated the patient’s disposition was “AMA [Against Medical Advice].” P19 presented to the facilities ED on 7/27/24 at 1:11 PM with a chief complaint of “Chest pain.” P19 was seen by a provider at 1:52 PM and had treatment orders placed. When the provider returned to see P19 at 5:10 PM, P19 had left the ED before treatment was complete. On 10/11/24 at 1:45 PM, during the exit conference, these findings were discussed with S1(Risk Manager), S2(Council, Risk & Litigation), S3(CNO), and S31(CMO). 48414”

“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: 43214 Based on review of medical records (Patient (P) 1, and P11), review of facility policy and procedure and staff interviews, it was determined the facility failed to ensure the patient’s right to have their pain assessed and managed. Facility policy titled “Pain Assessment/Management”, effective 1/10/2023, states, “ ... Procedure: 1. Emergency Department (ED) Pain Assessment a. Personnel: The ED nurses will work in conjunction with the practitioners to evaluate a patient’s level of pain and implement non-pharmacological as well as pharmacological treatments to alleviate or lessen the pain. ...c. Pain will be assessed initially and routinely. This pain assessment will be documented in the medical record. The nurse will escalate a report of new or different pain. D. If pain is present, assessment may include but is not limited to: location, rating, description, pain, indicators, scale used, and interventions implemented, as appropriate for the patient. ... f. Appropriate pain management is offered based on clinical evaluation. When necessary, the practitioner may choose to prescribe pharmacological therapy to treat the patient’s pain. ...4. Reassessment of Pain a. After the administration of pharmacological and/or non-pharmacological interventions, a reassessment is completed within 60 minutes. B. After the administration of Opioids, a reassessment and respiratory rate are completed within 60 minutes. ...” Facility policy titled “Emergency Department Triage,” effective 12/27/2022, states, “ ...Procedure: 1. Quick Triage: ...a. Components of quick triage include: ...ii. Vital Signs/Pain ...Age appropriate Pain scale is utilized. ... Facility policy titled “Patient Rights and Responsibilities,” effective 7/26/2024, states, “ ... Procedure: ...The patient has the right to a concerned team committed to pain relief and prevention and to expect and receive appropriate assessment, management, and treatment of pain as an integral component of that person’s care, in accordance with N.J.A.C. 8:43E-6. ...” On 10/10/24 at 10:15 AM, P1’s medical record was reviewed. Review of the ED timeline indicated P1 presented to the facility’s ED on 6/13/24 at 2:55 AM with a chief complaint of “Drug Overdose/Psychiatric Evaluation.” P1 was brought to the facility via EMS and reported taking pills, however did not know what they were. P1’s initial pain assessment was complete at 2:59AM and P1 rated his/her pain as 0-No pain. At 4:40 AM, P1 had an episode of PTSD, where he/she was aggressive and threatening to staff, had to be restrained, and was given IM [intramuscular] medications to calm him/her down. At 5:10 AM, P1 was placed in 4 point locked restraints which were removed at approximately 8:33 AM, when the patient’s behaviors subsided. P1’s medical record does not contain any record of any injuries being sustained during these events. P1 was seen by the crisis counselor on 6/13/24 at 10:28 AM. The Crisis Progress Note from 6/13/24 at 10:28 AM states, “ ...Met with patient, who is now calm and cooperative. Pending final disposition. Patient expressed back pain 9/10- informed medical team of same.” The ED timeline states, “ ...12:27:46 [12:27 PM] Orders Placed; Medications- acetaminophen (TYLENOL) tablet 975 mg [milligram]; ibuprofen tablet 60 mg ...”. P1 received both the 975 mg Tylenol and 600 mg ibuprofen by mouth at 12:36 PM. Review of P1’s medical record lacked evidence of a pain assessment completed before the medications were given or a pain reassessment done after the medications were given. On 10/10/24 at 2:15 PM, a review of P1’s medical record was conducted in the presence of S6 (ED Nurse Manager) and S24 (ED Educator). The orders for the pain medications administered to P1 on 6/13/24 were reviewed with S24. S24 confirmed a pain assessment was not completed before or after the medications were given to P1. When asked if a pain assessment should have been completed, S24 stated, “a patient’s pain should be reassessed with any changes in condition.” On 10/10/24, at 11:00 AM, P11’s medical record was reviewed. Review of the ED timeline indicated P11 presented to the facility’s ED on 4/29/24 at 6:51 PM, with a chief complaint of “Cyst.” At 7:00 PM, the ‘Chief Complaints Updated,’ stated, “Cyst (on left side back x 1 week, pain increasing, denies fevers).” At 7:00 PM, P11’s vital signs were documented, with a 9/10 left back pain on the numeric pain assessment scale. At 7:03 PM, an order was placed for “Acetaminophen (TYLENOL) tablet 975 mg.” At 11:40 PM, P11’s ED disposition was set to AMA (Against Medical Advice). There was no documentation that the medication was administered or refused by P11. P11’s medical record lacked evidence that his/her pain was treated or reassessed during the four (4) hours and 49 minutes that P11 was in the ED. On 10/10/24 at 2:00 PM, S13 confirmed these findings. 48414”

“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: 39228 Based on observation, review of facility policy and procedure, review of manufacturers instructions for use (MIFU), and staff interview, it was determined that the facility failed to ensure that: 1) hand hygiene procedures are performed to minimize the spread of infection in two of two areas toured (A0749); 2) reusable patient care equipment is disinfected in accordance with the MIFU in one of three observations and facility policy in three of three observations (A0749); and 3) clean supply storage areas are kept free of potential contamination in one of one observations (A0749). Cross Reference: 482.42(a)(2) Infection Prevention and Control and Antibiotic Stewardship Programs: Infection prevention and control program organization and policies”

“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, review of manufacturer’s instructions for use (MIFU), and staff interview, it was determined that the facility failed to ensure that: 1) hand hygiene procedures are performed to minimize the spread of infection in two of two areas toured; 2) reusable patient care equipment is disinfected in accordance with the MIFU one of three observations and facility policy in three of three observations; and 3) clean supply storage areas are kept free of potential contamination in one of one observations. Findings include: 1. Facility policy titled, “Hand Hygiene,” effective date 02/24/2023, stated, “... Indications for Hand Hygiene for all healthcare workers (HCW): HCWs will use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Before and after patient contact. ... When moving from a dirty body site to a clean body site during patient care. ... After touching a patient or the patient’s immediate environment. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal. ... Procedure for performing hand hygiene: ... Soap and water: wet hands, apply soap, and lather for 15 seconds, then rinse. Alcohol-based hand rub or hand gel (ABHR: [sic] Dispense product, completely cover the entire hand, fingers, up to wrists, and rub until dried. ... A. Hand washing: ... 3. Rub hands together vigorously for at least 15 seconds covering all surfaces of hands and fingers ... F. Gloves: The HCW will follow these glove guidelines: a. Perform hand hygiene immediately before applying gloves and after removal. b. Use gloves whenever contact with blood, body fluid or other potentially infectious matter is present ... as a part of transmission-based precautions, ... c. Change gloves when moving from a dirty to a clean or sterile activity involving patient care. d. Remove gloves after completing care for the patient or finishing the work activity requiring gloves. ...” On 8/19/24 at 10:44 AM, during a tour of the Neonatal Intensive Care Unit (NICU), in the presence of Staff (S) 8, the Manager of Infection Control, an observation of the cleaning and disinfection of a Giraffe Incubator by S10, a Sec/Tech (Secretary/Technician) was conducted in Room 14. At 11:27 AM, S10, with gloved hands, cleaned the humidifier reservoir portion of the incubator with Cavi Wipes XL disinfection wipes and placed it on a countertop located in the room. S10 then removed his/her gloves, performed hand hygiene with soap and water for six seconds at a sink located in the room, dried his/her hands with a paper towel, reapplied new gloves and then continued to clean and disinfect the incubator. At 11:32 AM, S10, with gloved hands, placed two empty containers of Cavi Wipes XL disinfection wipes into a waste receptacle located next to the sink in the room. S10 then removed his/her gloves, performed hand hygiene at the sink with soap and water for eight seconds, dried his/her hands with a paper towel, then reapplied new gloves. At 11:38 AM, S10 cleaned the clear plate and the mattress portions of the incubator and placed them onto the countertop next to the sink. S10 then removed his/her gloves, performed hand hygiene at the sink with soap and water for six seconds, reapplied new gloves, and then placed the clear plate and mattress back into the incubator. At 11:44 AM, upon completion of the cleaning and disinfection of the incubator, S10 removed his/her gown and gloves, performed hand hygiene at the sink for seven seconds, dried his/her hands with a paper towel, and then replaced the humidifier reservoir back onto the incubator. At 11:58 AM. the above findings were confirmed with S8. On 8/19/24 at 11:26 AM, during an observation in the NICU, S12, a Physician Assistant, entered Bay 4 and donned (put on) gloves without first performing hand hygiene. S12 cleaned the earpieces of the stethoscope at the bedside. Without removing his/her gloves and performing hand hygiene after cleaning the stethoscope, S12 proceeded to assess the patient. After performing an assessment, S12 removed his/her gloves and wrote on papers brought into the bay from the nurse’s station. S12 did not perform hand hygiene after removing his/her gloves and prior to writing on the papers. At 11:32 AM, while in Bay 3 assessing the patient, S12’s cellphone began to ring. S12 removed one PPE (personal protective equipment) glove and without removing the other glove or performing hand hygiene, S12 answered the cell phone. At 11:51 AM, S33, a NICU RN (Registered Nurse), took the workstation on wheels (WOW) that was in Bay 4 and brought it into Bay 7. S33 did not clean any of the WOW surfaces after removing it from Bay 4 and before entering Bay 7. S33 removed PPE gloves from a box and placed them on the WOW countertop prior to donning the gloves. S33 donned the gloves, and then removed them to go to another area to briefly check another patient. Upon returning, S33 applied hand sanitizer and without allowing it to dry, touched the controls on the pump at Bay 8 used to deliver the patient’s nasogastric (NG) tube feeding. S33 performed hand hygiene and then donned gloves and began typing on the keyboard of the WOW in Bay 7. S33 took the scanner from the WOW into the isolette to scan the neonate’s identification bracelet. S33 did not remove his/her gloves and perform hand hygiene after touching the WOW and before contact with the patient and items within the immediate vicinity of the patient. On 8/19/24 at 1:47 PM, an observation of the cleaning and disinfection of OR (Operating Room) 1, in the Labor and Delivery OR Suite, was conducted in the presence of S6, the Labor and Delivery Nurse Manager, S8 and S29, Assistant Manager of Infection Prevention. S8 stated that a tubal ligation procedure was conducted in the room prior to the observation. At 1:49 PM, S21, a Scrub Nurse, with gloved hands, removed, inspected, and then the wiped instruments with a white colored gauze, that were used in the OR procedure, one by one, from a basin that had light, red-colored water, and then placed the instruments into a metal mesh-like basket that was sitting on a metal table covered with a blue drape. At 2:05 PM, after removing, inspecting, and wiping all of the instruments, S21, did not remove his/her gloves, did not perform hand hygiene, and then picked up a bottle of Ecolab OptiPro Gel Instrument Pre-Cleaner solution that was sitting on top of a laminated paper that contained facility information, from a countertop in the OR, and then sprayed the instruments with the solution. At 2:10 PM, S21 then removed his/her gloves, gown, and face shield, and placed them into a waste receptacle in the OR. S21 did not perform hand hygiene and then without wearing PPE gloves, picked up the metal basket that contained the soiled instruments and proceeded to touch the metal door handle and exit the OR. At 2:11 PM, S21 re-entered the OR and then with ungloved hands, rolled up the blue drape that the metal mesh-like basket that contained the soiled instruments was sitting on, from the OR table and then placed it into a waste receptacle. S21 did not perform hand hygiene and then applied new gloves. On 8/19/24 at 3:08 PM, the above findings were confirmed with S8. 2. Facility policy titled, “Cleaning, Disinfecting and Storage of Non-Critical, Reusable Patient Care Equipment,” effective date 9/12/2022, stated, “... Procedure: 1. Medical equipment should be cleaned and disinfected in accordance with the manufacturer’s instructions (IFU). ... 9. All equipment must be cleaned/disinfected before and after use on patients. ... 12. All equipment that travels from patient-to-patient should be cleaned/disinfected at the point of use. 13. If equipment cannot be cleaned/disinfected immediately it should be moved to the soiled utility room until it can be cleaned /disinfected. ... 23. Team members using the workstations on wheels (WOW) are responsible for intermittent cleaning of the devices, including but are not limited to computer keyboards, mice, and bar code scanners. Cleaning should be done: ... c. Prior to entry and upon exiting the patient room ... Steps in Cleaning: 1. Follow the manufacturer’s instructions for cleaning, disinfecting, and maintaining medical equipment. ... 4. ... d. Avoid cross contamination, ... APPENDIX I ... ITEMS ... Workstation on Wheels (WOWs) ... WHEN TO CLEAN ... After each patient use ...WHO CLEANS ...User ...” On 8/19/24 at 10:43 AM, during a tour of the NICU, S9, Assistant Nurse Manager of the NICU, explained that patient Room 14 is used to clean and disinfect the isolettes when it is not occupied by a patient, due to limited space in the NICU for the cleaning and disinfection of the isolettes. At 10:44 AM, in the presence of S8, an observation of the cleaning and disinfection of a Giraffe Incubator, by S10, was conducted in Room 14. S10 explained that the soiled incubator was placed into the room on 8/19/24 at 6:00 AM and that Room 14 was a clean room when the soiled incubator was placed in it. S8 confirmed that Room 14 was last cleaned on 8/16/24. S10 stated he/she disassembles the incubator, then individually cleans, and disinfects each piece with CaviWipes XL disinfectant wipes and then reassembles it. At 10:45 AM, without first cleaning and disinfecting the countertop, S10 placed a blanket down on the countertop, then removed two porthole seals from the side portion of the incubator, cleaned and disinfected them with CaviWipes and then placed them on top of the blanket. S10 stated the blanket was clean. At 10:52 AM, S10 opened a drawer located under the side door of the incubator and removed a white plastic insert, wiped it with the CaviWipes and then placed it directly onto the countertop next to the blanket that had the clean porthole seals on it. At 10:57 AM, S10, without disassembling the door from the incubator first, opened the side door of the incubator, rotated the outer wall of the door downward and then proceeded to wipe the outer wall of the door and then the inner wall of the door with CaviWipes. Review of the Giraffe Incubator Operator’s Manual stated, “... Maintaining the Incubator Disassembling the incubator for a complete cleaning ... 5. Remove the side doors by pushing in on either of the spring loaded buttons located at the bottom corners of the door (C) and lifting the door out of its hinges (D). ...” At 11:00 AM, S10, without first cleaning and disinfecting the countertop, removed the mattress from the incubator, cleaned, and disinfected it then placed it on another countertop in the room, that was adjacent to a sink. S10 then removed the “Clear Plate” portion of the incubator, wiped it with CaviWipes, then leaned it up against the mattress on the countertop. S10 then removed the rotating bed portion of the incubator, wiped it down and placed it directly onto the countertop in front of the clear plate and mattress. S10 then proceeded to one by one, remove, clean and disinfect the x-ray tray, the translation deck, the tilt platform, and the pan and placed them on top of the rotating bed. At 11:15 AM, S10 proceeded to clean and disinfect the back area of the incubator that had an electrical cord on the lower portion of it. S10 cleaned the back portion, then unraveled the cord that was attached to the back of the incubator. While holding the cord, S10 removed several CaviWipes from a container while touching the uncleaned cord to back area of the incubator that was just disinfected and then wiped the cord with the CaviWipes. S10 did not reclean the area that the uncleaned cord had touched. At 11:27 AM, S10 washed his/her hands with soap and water in the sink in Room 14 that was directly adjacent to the cleaned equipment (mattress, clear plate, rotating bed, the x-ray tray, the translation deck, the tilt platform, and pan) on the countertop. At 11:30 AM, S10, without first cleaning and disinfecting the countertop and the humidifier reservoir, removed the humidifier reservoir from the incubator and placed it on the countertop directly next to the cleaned porthole seals. At 11:32 AM, S10 then picked up the humidifier reservoir from the countertop, cleaned and disinfected the outside portion of it with CaviWipes and then, without cleaning and disinfecting the countertop first, placed the humidifier reservoir back onto the countertop. When questioned by the surveyor regarding the cleaning of the interior portion of the humidifier reservoir, S10 stated that if the reservoir had been used by the last patient, then he/she would just rinse it out in the sink with tap water and let it dry. S10 did not clean the interior portion of the reservoir during the observation. Review of the Giraffe Incubator Operator’s Manual stated, “... Maintaining the Incubator Cleaning and disinfecting individual components ... Disassemble the humidifier reservoir. Clean the interior with a mild detergent-disinfectant solution. Rinse and thoroughly dry the parts before reassembly. ...” At 11:32 AM, S10 washed his/her hands with soap and water in the sink in Room 14 that was directly adjacent to the cleaned equipment (mattress, clear plate, rotating bed, the x-ray tray, the translation deck, the tilt platform, pan) on the countertop. At 11:35 AM, S10, without first re-cleaning and disinfecting the port hole seals, reassembled them onto the door of the incubator. At 11:36 AM, S10, without first re-cleaning and disinfecting the rotating bed, the x-ray tray, the translation deck, the tilt platform, and the pan portions, re-assembled them back into the incubator. At 11:38 AM, S10 re-cleaned and disinfected the clear plate and the mattress that were on the countertop next to the sink, and then without cleaning and disinfecting the countertop first, placed them back onto the same countertop. At 11:41 AM, S10, without first re-cleaning and disinfecting the clear plate, the mattress, and the humidifier reservoir, re-assembled them back into the incubator. The above findings were confirmed with S8 at 11:58 AM. On 8/19/24 at 11:26 AM, during observation in the NICU, S12 entered Bay 4 and proceeded to assess the patient and write on papers that he/she had brought into the bay and placed on the counter of the WOW. After completing the assessment of the patient in Bay 4, S12 took the same papers and placed them on a table/stand located beneath the patient’s heart monitor in Bay 3. S12 did not disinfect the tabletop of the WOW after removing his/her papers. At 11:32 AM, while in Bay 3, S12’s cellphone began to ring. After speaking on the phone, S12 placed his/her pen in his/her scrubs pocket, placed the papers he/she was documenting on back at the nurse’s station and exited the unit. S12 did not disinfect the table/stand beneath the heart monitor where the papers from the nurse’s station and the tabletop of the WOW in Bay 4 had been placed. At 11:51 AM, S33, a NICU RN, took the WOW that was in Bay 4 and brought it into Bay 7. S33 did not clean any of the WOW surfaces after removing it from Bay 4 and before entering Bay 7. Shortly after, S33 performed hand hygiene, donned gloves, and began typing on the keyboard of the WOW in Bay 7. S33 then took the scanner from the WOW into the isolette of the patient in Bay 7 to scan the neonates identification bracelet. S33 returned the scanner to the WOW without any cleaning or disinfection. During an interview at 12:15 PM, S33 was asked about the frequency of cleaning of the WOW and the scanner. S33 stated that both are cleaned at the beginning and end of each shift. When asked if the scanner should be cleaned after being brought into the isolette and between patient use, S33 stated that he/she “can’t tell you for sure” if they are cleaned in between patients but confirmed that he/she did not clean the scanner or WOW. Facility policy titled, “Surgical Areas Cleaning,” last reviewed 9/1/2022, stated, “Purpose: The Surgical and Operating Room (O.R.) are the most critical areas of the hospital. Extreme care must be taken to ensure the following schedule is carried out rigorously and in accordance with departmental procedures and AORN standards to include OR areas, ... Procedure: ... Surface cleaning is completed using a damp wipe method. ... Daily Routine Cleaning Between Case Cleaning (AORN ENV Cleaning Recommendation 11) 1. Remove soiled waste and linen ... 3. Wash O.R. table, ... and furniture with germicidal solution. ...” On 8/19/24 at 1:47 PM, an observation of the cleaning and disinfection of OR 1, in the Labor and Delivery OR Suite, was conducted in the presence of S6, S8, and S29. At 1:49 PM, S21, a Scrub Nurse, with gloved hands, removed and wiped instruments that were used in a OR procedure, that were soaking in a basin filled with light, red-colored water, located next to a metal table covered in a blue drape, and then placed the instruments in a metal basket that was sitting on the blue drape. At 2:05 PM, S21, wearing the same gloves, picked up a bottle of Ecolab OptiPro Gel Instrument Pre-Cleaner solution that was sitting on top of a laminated paper that contained facility information, from a countertop in the OR. S21 sprayed the instruments in the metal basket with the solution and then placed the bottle on the blue drape next to the metal basket that contained the soiled instruments. S21 then removed the bottle from the blue drape and placed it back on top of the laminated paper on the countertop. At 2:12 PM, S22, an Environmental Aide, entered OR 1. At 2:24 PM, S22 cleaned and disinfected a green colored “Metadyne” mat that was located on the top and middle portion of the OR bed with Oxycide Daily Disinfectant Cleaner Wipes. At 2:26 PM, S22 then placed an uncleaned black arm board on top of the clean Metadyne mat and then proceeded to pick it up off the mat, clean and disinfect it, then placed it back on top of the Metadyne mat. S22 did not reclean the Metadyne mat prior to placing the clean arm board on it. At 2:29 PM, S22 was observed to clean and disinfect the countertop area that had the Ecolab OptiPro Gel Instrument Pre-Cleaner solution sitting on top of the laminated paper. S22 did not clean the bottle that S21 had touched or the laminated paper that the solution was sitting on. At 2:36 PM, S22 wiped both sides and the front portion of an opened red container labeled “Sharps.” S22 did not wipe the tan colored top portion of the container. At 2:40 PM, S22 removed an uncleaned mattress from the infant “Panda Warmer” located in OR 1 and placed it on top of the following unopened/unused supplies (one 8 french (fr) suction catheter mini tray, one 10 fr suction catheter mini tray, one 14 fr suction mini tray, two pulse oximetry sensors, one box that contained a stethoscope, one paper measuring tape) that were sitting on top of a black plastic container that contained supplies on a shelf next to the warmer. S22 then proceeded to clean and disinfect the infant warmer. At 2:43 PM, S22 then placed the uncleaned mattress onto the clean bed of the warmer, then picked up the mattress, cleaned and disinfected it, and then placed it back on to the bed portion of the warmer. S22 did not reclean the bed portion of the warmer prior to placing the clean mattress on it. At 2:45, S22 stated “the cleaning is done and now I just have to clean the floors.” At 2:46 PM, a portable metal crib that had a mattress covered with a pillowcase in it was observed next to the infant Panda warmer. Upon interview at the time of discovery, S6 was questioned about whether the pillowcase should have been removed from the mattress and the if the portable crib should have been cleaned and disinfected. S6 stated “yes the pillowcase should be changed out and the crib should be cleaned as well.” Upon discovery, S6 ensured the crib would be cleaned. S6 was then interviewed regarding the unopened/unused supplies that were placed on the shelf next to the infant warmer. S6 stated that the supplies are typically kept in the drawer located in the infant warmer but that sometimes the staff will remove them per the neonatologist’s preference and that the black plastic container on the shelf is called a “resuscitation box” and is used for immediate intubation. S6 stated that the unused supplies should have been discarded and that the resuscitation box should have been cleaned and disinfected. Upon discovery, S6 ensured the supplies would be discarded and the resuscitation box would be cleaned. The above findings were confirmed with S8 at 3:08 PM. 3. Facility policy titled, “Cleaning, Disinfecting and Storage of Non-Critical, Reusable Patient Care Equipment,” effective date 9/12/2022, stated, “... Utility Areas and Storage of Medical Equipment: ... 4. Clean supplies should be stored: a. At least 8 inches off the floor ... c. Outside of external shipping boxes ...” On 8/19/24 at 11:07 AM, during an observation in the NICU, S32, a staff member from Materials Management, was observed dragging cardboard boxes of Enfamil Infant formula along the floor and through the door into the Breastmilk Storage Room. Upon entering the Breastmilk Storage Room, S32 had stacked the two cardboard boxes of Enfamil on top of the garbage can lid. S32 then took each box and placed it on the counter while he/she unloaded the individual formula packages into cabinets. The counter contained clean, unused infant feeding supplies such as feeding tubes in various sizes. S32 did not clean the countertop after placing the cardboard boxes that had been on the floor and the lid of the garbage can upon it. This observation was confirmed with S9 who stated that it was not the usual process to bring boxes into the storage room in this way. 39228”