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Based on record review, observation, interview and personnel review the facility failed to ensure: 1) 1 registered nurse (RN #2) conducted hand hygiene according to professional standards and 2) 1 RN (#1) did not receive proper tuberculosis (TB) surveillance. These failed practices placed patients at risk for nosocomial (hospital acquired) infections. Findings:

Hand Hygiene

Patient #17

Record review on 10/25/16 revealed Patient #17 was admitted to outpatient surgery for a colonoscopy (a scope of the large bowel).

During an observation on 10/25/16 at 7:15 am RN #1 entered the preoperative room. After labeling the IV (intravenous) bag tubing, the RN used the Chloraprep (a preoperative antiseptic skin preparation) applicator to clean Patient #17's left forearm. RN #1 then donned a pair of disposable gloves, without first performing hand hygiene, started an IV in the Patient's arm and taped it down. During the procedure blood had leaked onto gurney side rail and the floor. The RN then changed gloves, and without performing hand hygiene, used to same Chloraprep applicator used on the Patient's skin to clean the gurney rail. The RN continued by obtaining several wipes from a canister of CaviWipes (a disinfectant) and wiped the blood from the floor. RN #1 removed the soiled gloves, and without performing hand hygiene, donned a new pair of disposable gloves. The RN placed 3 cardiac patches on the Patient's chest wall, removed the gloves, and without performing hand hygiene, rolled the Patient onto the gurney next door to the procedure room.

After Patient #17 transferred from the gurney to the procedure table, RN #1 helped position the Patient with pillows. Without performing hand hygiene, the RN donned a new pair of disposable gloves. During the procedure, RN #1 changed disposable gloves multiple times without performing hand hygiene.

After the procedure the Patient eliminated a large amount of liquid from the rectum which soiled the hospital gown, pads and bedding. After assisting Surgical Tech (ST) #1 with the clean-up, RN #1 removed the soiled gloves, and without hand hygiene, donned a new pair of disposable gloves. The ST removed her soiled gloves, and without performing hand hygiene, donned a new pair. The RN then carried the soiled linen out of the room.

Patient #18

Record review on 10/25/16 revealed Patient #18 was admitted to outpatient surgery for an endoscopy (a visual scope of the throat, stomach, and upper small bowel) and a colonoscopy.

Observation on 10/25/16 revealed Patient #18 transferred to a procedure table, where RN #1 assisted the Patient with positioning, tucked the Patient's gown up, and tucked some disposable pads under the Patient's buttocks. The RN then removed the soiled gloves, and without performing hand hygiene, donned a new pair of disposable gloves.

RN #1 then labeled a specimen vial, removed both gloves, retrieved another specimen vial from the cabinet, and without performing hand hygiene, donned a new pair of disposable gloves. After labeling another vial, the RN removed the gloves and tossed them in the trash. Without performing hand hygiene, the RN began placing the vials in plastic baggies. RN #1 then donned a new pair of disposable gloves.

After the Physician was finished performing the endoscope, RN #1 took the scope over to the sink and began cleaning it. The RN then removed the soiled gloves, and without first performing hand hygiene, donned a new pair of disposable gloves. The RN then assisted with repositioning the Patient on the table.

During the procedure RN #1 charted in the medical record, assisted with positioning the Patient and with collecting specimens. Multiple times during the procedure, the RN changed disposable gloves without performing hand hygiene between glove changes.

During an interview on 10/25/16 at 1:15 pm, when asked about the facilities policy for hand hygiene, the OR Manager stated staff were to perform hand hygiene each time they changed their gloves. The OR Manager stated he did a monthly audit of hand hygiene and stated his department was at 100% compliance with hand hygiene.

During an interview on 10/26/16 at 8:53 am the Director of Performance Improvement (PI) stated it was difficult to get into the Surgery Department to do hand hygiene surveillance. During the interview the Director of PI confirmed it would be difficult to have a 100% compliance with hand hygiene.

Review of the surgical departments hand hygiene surveillance for the past 6 months revealed the Surgery Department was at 100% compliance.


Review of the facility policy "Perioperative Hand Hygiene", dated 9/30/15, revealed "1) Perform hand washing...before putting on gloves and after removing gloves or other personal protective equipment (PPE); any time there is a posibility that there has been contact with blood, body fluid, or other potentially infections ,aterials or contaminated surfaces..."


TB Surveillance

Personnel review on 10/27/16 at 8:00 am revealed RN #2's TB test was documented as "Questionnaire 7/20/16".

Review of RN #2's "TUBERCULOSIS ANNUAL SURVEILLANCE HEALTH QUESTIONNAIRE", dated 2/20/15, revealed RN #2 documented an "Allergic Rx [reaction]" to the TB skin test.

During an interview on 10/27/16 at 1:20 pm, the Employee Health Nurse was asked about RN #2's allergic reaction to the TB skin test and why no follow up was done. The Employee Health Nurse said a QuantiFERON-TB Gold (QFT) should be done for allergic reactions and then the staff would follow up with a provider. QFT is a blood test used as an aid in diagnosing Mycobacterium tuberculosis infection, primarily latent (infected with TB but clinical illness does not develop) or inactive.

Review of the facility policy, "+PPD Follow-up Protocol for Tuberculosis", last revised 7/18/16, revealed "...Test for TB infection...skin test..." or "...QuantiFERON-TB Gold test...Physical Exam with a Provider...Chest x-ray..."
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Based on record review and interview the facility failed to ensure 4 patients (#'s 1; 9; 10; 15) signed their consent for treatment on the day of service. This failed practice placed the patients at risk for not being fully informed of their proposed medical treatment and placed patients at risk for pressure and/or coercion. Findings:

Record review from 10/25-27/16 revealed the following patients presented to the hospital for treatment:
Patient #1 on 10/24/16;
Patient #9 on 6/12/16;
Patient #10 on 10/13/16; and
Patient #15 on 10/13/16.

Record review of Patient #'s 1; 10; and 15's medical record revealed there was no signed "Authorization for Treatment and Promise to Pay (Assignment of Benefits)" for their most recent hospital stay.

Patient #9's "Authorization for Treatment and Promise to Pay (Assignment of Benefits)" was signed by the Patient 3 days after admission.

During an interview on 10/27/16 at 2:30 pm, the Director of Performance Improvement was asked if Patient #'s 1; 9; and 15 had consents for treatment for their dates of service listed above. She confirmed there were no signed consents for treatment for the dates listed above. In addition she said there was no policy.

During an interview on 10/27/16 at 3:15 pm the Administrator confirmed the facility did not have a policy on consents for treatment. In addition, the Administrator confirmed Patient #'s 1; 9; 10; and 15 did not have consents for treatment for the dates listed above.

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Based on record review and interview the facility failed to inform each swing bed (SB) resident before, or at the time of admission of services available in the facility and the charges for those services, including any charges for services not covered, for 3 residents (#'s 3; 5; and 10) reviewed. This failed process denied the residents the right to the knowledge of which services would be covered by their SB stay and what services they would be financially responsible for. Findings:

Review of Resident #'s 3; 5; and 10 medical records contained no information about the items and services that were included in nursing facility services under the State plan and for which the resident may not be charged and other items and services the facility offers and for which the resident may be charged, and the amount of charges for those services.

Review of the admission packet provided to the SB residents upon admission, revealed no information about the cost of care and what items were not provided by the facility.

During an interview on 10/27/16 at 1:29 pm, the Inpatient Care Coordinator and Registered Nurse #3 confirmed the admission information provided to the SB residents was not specific about costs.
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Based on record review, interview and policy review the facility failed to ensure residents' activities program was designed to meet the individualized needs of 3 swing bed status (SB-a hospital bed used to furnish skilled level of care) residents (#'s 3; 5; and 10), based on a comprehensive assessment and the interests, mental and psychosocial well-being of each resident. This failed practice placed residents at risk for not receiving meaningful activities designed to enhance their quality of life. Findings:

Resident #3

Record review on 10/26-27/16 revealed Resident #3 was admitted to SB status on 9/26/16. Further review revealed the Resident's record did not contain an activity assessment that addressed the Resident's activity preferences, lifestyle patterns and hobbies.

The Resident's record revealed no care plan for activities that identified goals and interventions for meaningful activities.

Resident #5

Record review on 10/26-27/16 revealed Resident #5 was admitted to SB status on 10/21/16. Further review revealed the Resident's record did not contain an activity assessment that addressed the Resident 's activity preferences, lifestyle patterns and hobbies.

The Resident's record revealed no care plan for activities that identified goals and interventions for meaningful activities.


Resident #10

Record review on 10/26-27/16 revealed Resident #10 was admitted to SB status on 10/13/16. Further review revealed the Resident's record did not contain an activity assessment that addressed the Resident's activity preferences, lifestyle patterns and hobbies.

Further review of the Resident's record revealed no care plan for activities that identified goals and interventions for meaningful activities.

During an interview, when asked about the activity program and how the facility determined what to provide to the residents, on 9/26/16 at 9:30 am, Registered Nurse (RN) #3 stated the facility had an I-pad, movies and coloring books. In addition sometimes groups would come in and provide music for the residents. When asked how the facility individualized the programs based on each resident's needs, RN #3 replied it was reviewed during the Thursday morning care conferences.

During an interview on 10/26/16 at 11:17 am, when asked about the activity program for the residents, the Occupational Therapist (OT) stated the facility had a calendar that listed some activities and the facility provided coloring books and movies. When asked about an activities assessment, the OT stated the nurse does the initial assessment.

During an interview on 10/27/15 at 9:53 am, The Rehabilitation Therapy Manager (RTM) stated he was not aware of an activity assessment (used to determine past interests, hobbies, occupations, as well as current likes and dislikes). The RTM stated he was not aware of any care plans for activities but stated he would check with OT.

Observation of the inpatient/SB care conference on 10/27/16 at 10:05 am -11:00 am, when reviewing Resident #3, the nurse speaking stated Resident #3 "Enjoys the adult coloring books." No information about activities was discussed for Resident #'s 5 and 10.

Review of the facility policy, "Swing Bed Activities", revised 9/28/16, revealed "...The physical therapy staff will visit the resident within three (3) days of admission to the swing bed to assess the resident's needs and interests and to initiate care planning."
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Based in record review, interview and policy review the facility failed to ensure 3 swing bed (SB) residents had comprehensive individualized nursing care plans that addressed all areas concern, listed goals, expected outcomes, and interventions. This failed practice placed the residents at risk for not receiving appropriate interventions and placed them at risk for poor outcomes. Findings:

Resident #3

Record review on 10/26-27/16 revealed Resident #3 was admitted to SB status on 9/26/16 with diagnosis that included ambulatory dysfunction. Review of the admission nursing assessment, dated 9/26/16, revealed the Resident wore hearing aids; glasses; had fragile and irritated skin; used a cane walker to ambulate; had edema (swelling) to the feet and ankles; and self-care deficit.

Review of the comprehensive care plan revealed only falls and a history of alcohol abuse were addressed. There were no identified problems, goals, or interventions for the Resident's other identified concerns, including diet concerns and the level of ADL (activities of daily living) assistance needed to provide care.

Resident #5

Record review on 10/26-27/16 revealed Resident #5 was admitted to SB status on 10/21/16 with diagnoses that included dementia and agitation. Review of the nursing assessment, dated 10/21/16, revealed the Resident experienced weakness and needed assistance with ADLs. In addition, the Resident had recently experienced the significant loss of a loved one.

Review of the comprehensive care plan revealed the Resident was care planned for fall prevention and dementia. There were no other problems, goals, and interventions identified for the Resident's other concerns. The level of care needed to provide ADL assistance was not addressed.

Resident #10

Record review on 10/26-27/16 revealed Resident #10 was admitted to SB status on 10/13/16 with a diagnosis that included post CVA (stroke). Review of the SB nurse admission evaluation note, dated 10/13/16, revealed the Resident wore dentures, glasses, and an eye patch. In addition, the Resident had a history of dizziness, dysphagia (difficulty swallowing), and chronic pain.

Review of the Resident's comprehensive care plan revealed not all of the Resident's problems had been addressed.

During an interview on 10/26/16 at 9:12 am, when asked about the resident care plans, Medical Doctor #1 stated staff learned about the residents by rounding and discussing how the residents are doing.

During an interview on 10/26/16 at 9:30 am, when asked how the nurses wrote the care plans, Registered Nurse #3 stated they chose information from the computer and they utilized a care plan book located on the shelf.

During an interview on 10/26/16 at 11:05 am when asked how staff knew what care needed to be provided to the SB residents, Certified Nursing Assistant (CNA) #1 stated staff utilized an assignment sheet and the patient information card located at the nurses desk. In addition, the CNA stated the staff received verbal instructions during staff rounding. The CNA explained how Resident #5 needed "set up help" to complete his cares.

Review of the assignment sheet, dated 10/26/16, listed general information about the residents that included fall precautions; code status; diet; flu vaccine status; blood glucose needs; allergies; and a diagnosis. There was no information about the problems identified in the nursing assessments.

Review of the patient information cards revealed needed vital signs, diet, intake and output needs, weights, and rehabilitation therapy needs. There was no information about problems, goals and interventions for the concerns identified during the assessments.

During the Interdisciplinary Team Meeting on 10/27/16 at 10:05 am -11:00 am, the team discussed:


· Resident #3's behavior towards roommates and the Resident's skin issues;


· During the discussion about Resident #5, facility staff discussed the potential discharge goal for the Resident; and


· During the discussion about Resident #10, the MD told nursing staff they needed to discuss the plan for the medication changes with the Resident. The team also identified the Resident had a "huge anxiety component" and she "needs an endpoint." During the review the MD stated the Resident "has no goal" several times.

Review of the facility policy "Swing Bed Patient Assessment and Provision of Care", revised 9/28/16, revealed "Information regarding resident care requirements is obtained from patient care orders, through the reports of other staff members, and other pertinent data sources."
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Based on observation and interview the facility failed to ensure signage that notified patients seeking treatment in the Emergency Department (ED) their right to a medical screening exam in all patient treatment areas. This failed practice placed patients at risk for not being aware of their right to a medical screening exam. Findings:

During a tour of the ED on 10/24/16 at 1:15 pm the EMTALA (emergency medical treatment and labor act) signage was noted on the door leading into the ER. There was no signage observed in any of the 4 patient treatment areas noted within the ED.

When asked about the lack of signage in the patient treatment areas, the ED Manager stated the sign located out front was the only one she'd seen. The ED Manager confirmed all the patients enter the ED through the 1 door where the signage was posted, but there were no EMTALA postings in any of the ED patient treatment areas.
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