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Based on records reviewed, and staff interview, the Hospital failed to ensure an authorized representative, as allowed by State law, signed informed consent for invasive procedures in two of two incapacitated patients (Patient #6 and #7) in a total sample of ten patients. The Health Care Proxy was not activated by the attending physician in the medical record as required by Hospsital policies and procedures.

Findings include:

The Hospital policy titled Health Care Proxies and Living Wills, dated August 2013, indicated the attending physician makes the determination that a patient lacks the capacity to make healthcare decisions. The attending physician must document the determination of incapacity and the surrogate decision maker in the patient's medical record.

The medical record for Patient #6 indicated he/she had respiratory failure, was ventilator dependent and sedated. Informed consent forms for Patient #6 indicated the Health Care Proxy signed the informed consents for bronchoscopy (a medical test to view the airways and lungs) and the placement of an arterial line (a thin catheter inserted into an artery.) The medical record did not indicate the Health Care Proxy was activated by the attending physician as required by Hospital policy.

The medical record for Patient #7 indicated he/she had dementia. The informed consent form for Patient #7 indicated the Health Care Proxy signed the informed consent for a tracheostomy (a surgical procedure to create an opening through the neck.) Review of Patient #7's informed consent form indicated Patient #7's Health Care Proxy signed the informed consent for the tracheostomy procedure. The medical record did not indicate the Health Care Proxy was activated by the attending physician as required by Hospital policy.

The Surveyor interviewed the Medical Director of the Medical Intensive Care Unit (MICU) at 1:00 P.M. on 1/14/15. The Medical Director of the MICU said that the Attending Physician is required to enter a note into the Progress Notes when a Health Care Proxy is activated.

Based on record review and interview, the Hospital failed to ensure that the Medical Staff adhered to the Hospital's Guidelines for the Prevention of Intravascular Catheter Related Infections for one of ten sampled patients (Patient #4).

Findings include:

1) The Hospital's Infection Control Policy titled Guidelines for Prevention of Intravascular Catheter Related Infections, approved 10/12/11, indicated that a Peripherally Inserted Central Catheter (a PICC is an intravenous access that can be used for a prolonged period of time) was to be removed if there was clinical evidence of a catheter infection.

The Nurses Notes dated, 10/7/14 at 5:00 A.M., indicated Patient #4 experienced rigors (a sudden feeling of cold with shivering) and malaise (a condition of general bodily weakness).

The Interdisciplinary Progress Note, dated 10/7/14 and signed by Patient #4's Attending Physician, indicated Patient #4 had an increase in white blood cells (WBC s) from 7000 to 11,000 (normal is 4500 to 10,000; an increase may indicate infection) and reported chills. The Attending Physician Note indicated a concern for PICC line infection and that the PICC line would likely need to come out.

The Physician Orders, at 8:15 A.M. on 10/7/14, indicated Vancomycin (an antibiotic) 1000 milligrams (mg) to be administered every twelve hours (no duration indicated in the order) for Patient #4. The medication administration record indicated Vancomycin 1000 mg was administered to Patient #4 beginning at 8:48 A.M. on 10/7/14.

The Physician Progress Note, dated 10/8/14 at 3:20 A.M., indicated Patient #4 had a temperature of 100.8 degrees Fahrenheit (normal is 97.8 to 99 Fahrenheit) and had a low blood pressure.

The Surveyor interviewed Hospital Physician #1 at 7:20 A.M. on 1/20/15. Hospital Physician #1 said Patient #4's PICC line was not discontinued. Hospital Physician #1 said he believed there was a team discussion about asking for an Infectious Disease consult, but Hospital Physician #1 did not believe this happened. Hospital Physician #1 said it was decided that Patient #4's symptoms of infection were related to the series of injections into his/her knees.

Patient #4's medical record entries from 10/7/14 through 10/25/14 did not indicate the knee injections as a possible cause for the symptoms of chills, malaise, fever or increase in WBC count.

The Hospital policy Guidelines for Prevention of Intravascular Catheter Related Infections, a patient with a PICC line and clinical signs of infection i.e. rigors, malaise, temperature and elevated WBCs would require careful assessment of the insertion site for erythema (redness), induration (swelling) or purulence (pus). The Guideline also indicated the biopatch and transparent dressing were to be changed every 7 days or when the dressing became loosened or soiled.

The Nurses Notes, dated 10/8/14, indicated Patient #4 was due for a PICC line dressing change. The Nurses Notes indicated, Patient #4 postponed the dressing change and no evidence of an insertion site assessment was present in Patient 4's medical record through 10/25/14.

The Physician Orders, dated 10/7/14 at 8:15 A.M., indicated Patient #4's PICC line dressing was to be changed by Registered Nurse #7 and it was " ok to go longer than seven days." This was contradictory to the PICC catheter dressing change policy and accepted standards of care.

The Surveyor interviewed Registered Nurse #7 at 3:00 P.M. on 1/14/15. Registered Nurse #7 was named in the Physician Order dated 10/8/14 as the Registered Nurse that Patient #4 would allow to change his/her PICC line dressing. Registered Nurse #7 said Patient #4 was fixated on something happening to the PICC line and would not allow just any Registered Nurse to change the dressing.

Based on record review and staff interview, for one of ten sampled patients (Patient #4), the Hospital failed to ensure that nursing staff documented from 6/6/14 to 12/19/14 that Patient #4's routine daily medications were self-administered and 2) reported to nursing leadership that personal private staff were practicing nursing by accessing a peripherally inserted central catheter (PICC).

Findings include:

The Hospital's policies and procedures related to Nursing Medication Administration indicated that only a registered nurse, licensed practical nurse or student nurse will administer medications to ensure safe medication administration practices. Hospital policies and procedures related to Patient Self-Administration of Medications indicated that the physician will write an order for a patient to store medication at the bedside and to self-administer the medication. The policy indicated the nurse will assess the patient's ability to self-administer the ordered medications and the nurse will record the medication as self-administered.

The Hospital policy and procedure titled Private Duty Nursing Personnel indicated that private duty personnel may assist in the care of patients and the care is limited to the provisions of activities of daily living and companionship measures.

The Physician Order, dated 6/7/14 at 3:53 P.M., indicated that it was okay for the medications to be administered by Patient #4's personal staff according to their schedule. The Order was contrary to Hospital policy and procedure because private duty nurses may not administer medications to patients. The Physician's Order was transcribed by a hospital registered nurse.

The Physician Order, dated 6/9/14 at 5:37 P.M., indicated that Patient #4 may self-administer routine medications, but all controlled substances must be administered by Hospital nurses.

The Surveyor interviewed Registered Nurse #1 at 9:45 A.M. on 1/13/15. Registered Nurse #1 said 3 of Patient #4's personal staff identified themselves as nurses.

The Surveyor interviewed Registered Nurse #3 at 11:10 A.M. on 1/13/15. Registered Nurse #3 said Patient #4's personal staff identified themselves as nurses. Registered Nurse #3 said that Patient #4's personal staff administered oral, non-controlled medications. Registered Nurse #3 said that Patient #4's personal staff would then hand her a piece of paper with the date and time Patient #4 took his/her routine daily medications. Registered Nurse #3 said she would then enter the information into Patient #4's electronic medication administration record (eMAR).

The Surveyor interviewed Registered Nurse #4 at 7:45 A.M. on 1/14/15. Registered Nurse #4 said she never witnessed Patient #4 taking his routine medications. Registered Nurse #4 said Patient #4's personal staff provided her with a piece of paper that indicated the date and time Patient #4 took his/her medications. Registered Nurse #4 said she would then enter the administration into Patient #4's eMAR.

The Surveyor interviewed Registered Nurse #5 at 8:00 A.M. on 1/15/15. Registered Nurse #5 said Patient #4's personal staff told her when Patient #4 received routine medications. Registered Nurse #5 said she would then enter the information into Patient #4's eMAR.

The Surveyor interviewed Registered Nurse #6 at 9:00 A.M. on 1/20/15. Registered Nurse #6 said she never saw Patient #4 take his/her routine daily medications. Registered Nurse #6 said Patient #4's personal staff would give Patient #4 his/her routine daily medications. Registered Nurse #6 said Patient #4's personal staff told her when Patient #4 received his/her medications and Registered Nurse #6 would enter the information in the eMAR.

Random review of eMARs, dated 6/6/14 to 12/19/14, indicated Registered Nurse #1, Registered Nurse #3, Registered Nurse #4, Registered Nurse #5 and Registered Nurse #6 documented that they administered routine daily medications to Patient #4. The eMARs did not indicate the medications were self-administered by Patient #4 or his/her personal staff.

Registered Nurse #1 said Patient #4's personal staff flushed Patient #4's PICC following fentanyl administration by Hospital registered nurses.

Registered Nurse #3 said she observed Patient #4's personal staff flushing Patient #4's PICC.

Registered Nurse #4 said Patient #4's personal staff flushed Patient #4's PICC. Registered Nurse #4 said she never provided the flush medication to the personal staff because the personal staff had their own supply.

The Surveyor interviewed Hospital Physician #1 at 7:30 A.M. on 1/21/15. Physician #1 said he saw Patient #4's personal staff flush Patient #4's PICC.

The Surveyor interviewed Nursing Director #1 at 12:50 P.M. on 1/12/15. Nurse Director #1 said she did not think she reported to executive nursing leadership that nursing staff were recording medications administered by Patient #4's personal staff or that Patient #4's private staff were accessing Patient #4's PICC.

The Surveyor interviewed Associate Chief Nurse #1 at 10:00 A.M. on 1/13/15. Associate Chief Nurse #1 said Patient #4's visitors, guests and personal staff were not authorized to practice nursing in the Hospital.

The Surveyor interviewed Associate Chief Nurse #2 at 10:30 A.M. on 1/14/15. Associate Chief Nurse #2 said she was not aware the Hospital nursing staff were documenting the administration of Patient #4's routine daily medications based on information provided by Patient #4's personal staff or that Patient #4's personal staff were accessing Patient #4's PICC.

Based on interview and record review, the Hospital failed to ensure that medications for self-administration were kept secure in a patient room, as required by Hospital policies and procedures, for one of ten sampled patients (Patient #4).

Findings include:

The Hospital's policies and procedures related to Nursing Medication Administration and Patient Self-Administration of Medications indicated the medications ordered for self-administration will be stored in a lockable storage container at the bedside.

The Surveyor interviewed Registered Nurse #1 at 9:45 A.M. on 1/13/15. Registered Nurse #1 said Patient #4's routine medications were not kept in a locked place in Patient #4's room.

The Surveyor interviewed Registered Nurse #3 at 11:10 A.M. on 1/13/15. Registered Nurse #3 said Patient #4's routine medications were kept in Patient #4's room and Patient #4 took his/her own medications. Registered Nurse #3 said she had nothing to do with the medications ordered for self-administration.

The Surveyor interviewed Registered Nurse #5 at 8:00 A.M. on 1/15/15. Registered Nurse #5 said she did not know where in Patient #4's room his/her routine daily medications were kept.

Associate Chief Nurse #1 was interviewed at 12:00 P.M. on 1/14/15. Associate Chief Nurse #1 said the bedside tables on Patient #4's nursing unit, unlike the bedside tables on the other nursing units, did not contain a drawer with a lock to secure medications ordered for self-administration.

Based on record review and interview, for 6 of 6 sampled employees (Registered Nurse #3, #4, #7, #8, #9 and Hospital Physician #1) the Hospital failed to ensure that staff consistently adhered to Infection Control practices including Hospital policies for precautions and respiratory protection requirements.

Findings include:

1.) The Hospital policy titled Contact Precaution Fact Sheet, dated 8/2013, indicated multi-drug resistant organisms required Contact Precautions. The Hospital policy indicated clean non-sterile isolation gowns must be worn upon entering the room of a patient who is on Contact Precautions.

Patient #4's Progress Note, dated 6/10/14, indicated he/she was diagnosed with a multi-drug resistant organism and placed on Contact Precautions.

The Surveyor interviewed Nurse Director #1 at 12:50 P.M. on 1/12/15. Nurse Director #1 said the use of precaution gowns by staff was interpreted by Patient #4 as if he/she was dirty. Nurse Director #1 said staff were expected to adhere to the use of personal protective equipment.

The Surveyor interviewed Registered Nurse #3 at 11:10 A.M. on 1/13/15. Registered Nurse #3 said she did not wear personal protective equipment when entering Patient #4's room because Patient #4 requested that it not be worn. Registered Nurse #3 said she did not observe other caregivers using personal protective equipment when caring for Patient #4.

The Surveyor interviewed Registered Nurse #4 at 7:45 A.M. on 1/14/15. Registered Nurse #4 said Patient #4 was adamant about staff not using isolation gowns. Registered Nurse #4 said she did not wear isolation gowns when caring for Patient #4.

The Surveyor interviewed Registered Nurse #7 at 3:00 P.M. on 1/14/15. Registered Nurse #7 said she often changed Patient #4's Peripherally Inserted Central Catheter (a PICC is an intravenous access that can be used for a prolonged period of time) dressing and was not aware Patient #4 was on Contact Precautions. Registered Nurse #7 said she did not remember any signage indicating precautions and she did not wear an isolation gown when caring for Patient #4.

The Surveyor interviewed Physician #1 at 7:20 A.M. on 1/20/15. Physician #1 said he visited Patient #4 five to seven times weekly. Physician #1 said he did not wear an isolation gown because Patient #4 found it offensive.

The Surveyor interviewed the Infection Preventionist assigned to monitor Patient #4's unit 1:30 P.M. on 1/14/15. The Infection Preventionist said she had no knowledge of personal protective equipment not being used according to the Hospital policy and staff had not approached her about Patient #4.

The Surveyor interviewed Nurse Director #1 at 12:50 P.M. on 1/12/15. The Nurse Director said Patient #4 traveled with a private cook, a personal physician, approximately six (6) attendant staff persons, and a cleaner/helper. The Nurse Director said Patient #4's staff were continuously in attendance of Patient #4's for his/her six (6) month hospitalization. The Nurse Director #1 said Patient #4 referred to his/her personal staff as nurses and the staff would participate in the direct care of Patient #4.

The Surveyor interviewed Registered Nurse #1 at 9:45 A.M. on 1/13/15. Registered Nurse #1 said Patient #4's personal staff would assist with activities of daily living care.

The Surveyor interviewed Registered Nurse #3 at 10:35 A.M. on 1/13/15. Registered Nurse #3 said Patient #4's personal staff provided all of Patient #4's care including routine medication administration.

The Surveyor interviewed the Infection Prevention Team (Hospital Epidemiologist, Infectious Disease Physician, Infection Preventionists and Occupational Health Director) at 1:30 P.M. on 1/14/15. The Hospital Epidemiologist said the Hospital did not have any policies or procedures in place relating to infection control or immunization that addressed these personal staff.

3.) The Occupational Health Director said the Hospital policy follows the requirements for annual fit testing of Hospital staff who wear an N-95 (a tight-fitting facepiece respirator).

The Surveyor interviewed Registered Nurse #8 and #9 at approximately 11:00 A.M. on 1/15/15. Registered Nurses #8 and #9 said they could care for a patient requiring them to use an N-95 respirator.

The Surveyor reviewed the health files of Registered Nurse #8 and #9 on 1/20/15. Registered Nurse #8 and #9, who said they would be able to immediately don an N-95 particulate respirator as needed, did not undergo fit testing since 2000 and not annually as required the Hospital policy.