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Based on interview and review of the facility's policies and documents, it was determined the facility failed to ensure every patient was given information on admission, or at any time during the hospitalization, on how to file a grievance with the State Survey Agency (SSA) without going through the facility's grievance process.

The findings include:

Review of the facility's policy titled, "Individual Rights Inquiries and Complaints (i.e., Patient Grievance Process)", revised January 2014, revealed at registration the patient and/or representative would receive the "Patient Grievance Process Notice". Review of the notice in Appendix B, revealed there was a space devoted to the SSA's contact information; however, the contact information area was blank, without any information listed.

Review of the facility's, "Patient Admission Booklet", section on "Patient Grievance Process Notice" revealed the patient was told if he/she felt any of his/her patient rights had been violated, a formal grievance could be initiated by contacting the Chief Executive Officer (CEO) in writing with address given, or by telephoning the Director of Nursing (DON) with telephone number given. Further review revealed the patient was instructed a facility representative would contact him/her upon receipt of the grievance, investigate the grievance allegation(s), and provide him/her with the name of the contact person for any further correspondence.

Interview with the CEO on 06/04/14 at 12:28 PM, revealed on admission each patient was given the "Patient Grievance Process Notice" without the State Survey Agency's contact information. The CEO stated this was done so all the facilities in their healthcare system could use the form as the SSA address might be different for facilities located in different areas. She stated the SSA contact information would be filled in and given to a patient who filed a grievance with the facility. However, the CEO reported there was no facility process in place for giving this information to a patient who wanted to file a grievance with the SSA, without filing with the facility or filing anonymously, and each patient had the right to do so.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure nursing care plans were developed and current based on each patient's nursing care needs as evidenced by no documented evidence nursing care plans were developed and current for thirty-one (31) of thirty-two (32) sampled patients.

The findings include:

Review of the facility's, "Patient Plan of Care" Policy, revised 04/2014, revealed each patient's plan of care was based on prioritization of patient care needs identified through analyzing data obtained from the Admission History and Nursing Assessment during the initial assessment. The plan of care was to be revised as indicated by subsequent assessment/observations. Policy review revealed the Registered Nurse (RN) was responsible for the identification of nursing interventions which would facilitate the achievement of specific outcomes, and for the follow up with the Physician or other ancillary staff related to specific interventions/outcomes. Continued review of the policy revealed problems and goals were to be identified for each body system as appropriate. Review of the policy revealed RNs were to initiate the care plans applicable to the patient's condition within eight (8) hours after admission and were to review the assessments, goals and outcomes and make changes as necessary to individualize the care plan based on the patient's specific needs. The policy stated each patient's care plan would be reviewed and updated by a RN or licensed clinician every twenty-four (24) hours or more frequently as indicated by the patient's condition. Further review of the policy revealed a new care plan could be initiated at any time per nursing judgment and patient specific needs.

Review of thirty-one (31) of thirty-two (32) sampled patients' records revealed no documented evidence care plans were developed as per the facility policy.

Interview, on 06/04/14 at 3:45 PM, with RN #1 revealed care plans should have been developed upon admission to address the needs of patients. RN #1 stated for example, if a patient was receiving wound care the nurse should develop a care plan to address the patient's wound. Further interview revealed the care plans should have been audited and should have addressed Physician's Orders and contained measured outcomes and goals.

Interview, on 06/04/14 at 4:00 PM, with RN #3 revealed care plans should have been initiated upon patients' admission to the facility. RN #3 stated the care plans should have addressed active diagnoses and been updated with any changes. RN #3 indicated however, this had not been done.

Interview, on 06/04/15 at 4:10 PM, with RN #2 revealed care plans should have been initiated upon patients' admission to the facility, and should have addressed the patients' active problems. Further interview revealed RN #2 indicated this had not been done however.

Interview, on 06/04/14 at 3:59 PM, with the RN Unit Manager revealed nursing staff should have developed and revised nursing care plans for each patient upon admission to the facility. She stated the facility had developed patient care plans on paper until approximately one (1) year ago, when use of the new computer system was started. She stated the facility's computer system gave suggestions for nursing care plans based on the care a patient needed and received; however, the nurses could determine whether or not to use those care plans. Continued interview revealed the facility's policy stated nursing care plans were to be developed upon admission and revised as needed. She stated she expected the nursing staff to follow the facility's policy.

Interview, on 06/04/14 at 4:20 PM, with the Director of Nursing (DON) revealed according to the facility's policy, care plans were to be developed within eight (8) hours of a patient's admission to the facility, and revised every twenty-four (24) hours and as needed. She stated she expected nurses to follow the facility's policy. Continued interview revealed the facility started using a new computer system, approximately one (1) year ago, which made suggestions for nursing care plans; however the nurses were not used to the system and use of the care plans. She stated she did not expect the nurses to develop nursing care plans using all of the computer suggestions, but expected the nurses to prioritize and address the top three (3) care plans based on each patient's needs.

Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to ensure staff followed infection control precautions as evidenced by observations of three (3) dietary workers who failed to follow Contact Precautions, posted on nine (9) patients' room doors, when they delivered meal trays to those patients.

Additionally, the facility failed to ensure staff were following acceptable hand hygiene techniques to prevent transmission of healthcare-associated infections, as evidenced by the failure of the facility's Wound Care Nurse to perform hand hygiene during a Wound Vac (special suction device) dressing change.

The findings include:

1. Review of the facility's policy titled, "Isolation: Standard and Transmission-Based Precautions", with an approval date of February 2014, revealed hand hygiene, using soap and water or alcohol foam cleaner, was the single most important method of reducing the transmission of microorganisms. Continued review of the policy revealed contact precautions, including contact containment and contact-spores, were used for specific patients known or suspected to be infected or colonized with microorganisms which could be transmitted by direct contact with the patient or indirect contact with environmental surfaces or patient care items in the patient's environment. Additional review revealed signs would be placed when transmission-based precautions were in place and education provided to all health care workers regarding standard and transmission-based precautions. Further review of the policy revealed the facility would ensure health care workers followed standard and transmission-based precautions recommended practices.

Review of the facility's, "Isolation Tray Service" Policy, with approved date of February 2014, revealed the Nutritional Services Department and personnel were trained in appropriate standard precaution procedures as part of new employee orientation, as well as, with an annual in-service review. The policy revealed if a staff member was responsible for serving trays, he/she followed the hospital policy and procedure for entering the patient's room when in isolation.

Observation, on 06/03/14 at 11:35 AM, revealed Dietary Worker #1 arrived on the unit with the food cart for tray delivery. At 11:38 AM, Dietary Worker #1 removed a tray from the food cart and entered room 505 without following the contact precautions posted on the room door, which included sanitizing hands upon entry into room, donning gloves while in the room, then, after removing gloves, sanitizing hands upon exit of the room. Record review revealed the patient in room 505 was on contact precautions due to a history of Methicillin-Resistant Staphylococcus Aureus (MRSA) and Vancomycin-Resistant Enterococci (VRE), which were antibiotic resistant infections.

Continued observation revealed after exiting room 505, Dietary Worker #1 went back to the food cart and without sanitizing his/her hands removed another tray and entered room 504 at 11:40 AM, again without following the posted contact precautions. Record review revealed the patient in room 504 was on contact precautions due to a history of MRSA and VRE infections.

Observation revealed upon exiting room 504, Dietary Worker #1 did not sanitized his/her hands, returned to the cart and picked up another tray and delivered it to room 508, at 11:41 AM, without following the posted contact precautions on the door. Record review revealed the patient in room 508 was on contact precautions due to Chronic Skin Ulcers.

Observation at 11:42 AM revealed Dietary Worker #1 did not sanitize his/her hands, went back to food cart, picked up another tray and delivered it to room 506 without practicing the contact precautions posted on the room door. Record review revealed the patient in room 506 was on contact precautions due to Osteomyelitis (a bone infection).

Additional observation revealed Dietary Worker #1 again did not sanitize his/her hands, returned to the food cart, pushed the cart onto the other side of the unit and delivered a tray at 11:45 AM, to room 534 without practicing the contact precautions posted on the room door. Record review revealed the patient in room 534 was on contact precautions due to Osteomyelitis.

Further observation revealed Dietary Worker #1 did not sanitize his/her hands, returned to the food cart and delivered a tray to room 530, at 11:47 AM, without following the contact precautions posted on the door. Record review revealed the patient in room 530 was on contact precautions due to Acute Respiratory Failure.

Interview with Dietary Worker #1 on 06/03/14 at 11:50 AM, revealed dietary workers did not enter patient rooms who were on contact with containment precautions. However, the dietary staff were able to go in and out of rooms with just contact precautions without having to put on gloves and gowns.

Observation on 06/03/14 at 5:20 PM, revealed Dietary Worker #2 obtained a meal tray off the food cart and went in and out of room 505 without practicing the posted contact precautions. Observation revealed Dietary Worker #2 did not sanitize her hands, went back to the food cart, made a note on a piece of paper, then took a tray to room 504 at 5:23 PM, and handed the tray to the nurse who was standing in the doorway. Continued observation revealed Dietary Worker #2 returned to the food cart without sanitizing her hands, pushed the food cart into the other hallway and removed a food tray which she delivered to room 530 at 5:25 PM and once again failed to follow the posted contact precautions upon entering the room. However, observation revealed Dietary Worker #2 did sanitize her hands upon exiting of the room.

Interview with Dietary Worker #2 on 06/03/14 at 5:30 PM, revealed she had training on the facility's infection control practices. Dietary Worker #2 stated she "sometimes" used hand sanitizer "when going into a" patient room. She stated however dietary workers did not have to follow the precautions posted because they did not enter the "yellow" (contact with containment precautions) patient rooms.

Interview with a Housekeeper on 06/04/14 at 7:50 AM, revealed all staff should be following the precautions listed on the door of the patients' rooms.

Observation on 06/04/14 at 11:25 AM, revealed the food cart arrived on the 4 South Unit. Dietary Worker #3 was observed to sanitize his hands then pushed the food cart down the hallway and stopped outside room 492 which had contact precautions posted on the room door. At 11:27 AM, Dietary Worker #3 was observed to enter and exit room 492 without following the posted contact precautions. Record review revealed the patient in room 492 was on contact precautions due to Osteomyelitis.

Continued observation revealed Dietary Worker #3 returned to the food cart, picked up another food tray and entered room 487, at 11:28 AM, without following the posted contact precautions on the room door. Record review revealed the patient in room 487 was on contact precautions due to Acute Respiratory Failure.

2. Review of the facility's Hand Hygiene Policy, revised October 2012, revealed the purpose of the policy was to provide guidelines for hand hygiene for healthcare providers based on the Center for Disease Control (CDC) Guideline for Hand Hygiene in Healthcare Settings Recommendations, to ensure appropriate healthcare providers completed hand hygiene to prevent the transmission of healthcare associated infections and communicable diseases or conditions. Continued review revealed hand hygiene must be performed after contact with the patient environment or equipment, when moving from a dirty patient care task to a clean task, and before and after gloves were used. Further review revealed gloves should be changed and hand hygiene performed during patient care if moving from a contaminated body site to a clean body site.

Record review revealed Patient #1 was admitted on 4/21/14 with Diagnoses which included Diabetes with Right Foot Diabetic Ulcer, Osteomyelitis (bone infection) of Right Calcaneus (heel bone), Bacteremia with Sepsis (a bacterial infection in the blood), Deep Debridement (removal of dead, damaged or infected tissue) and Fever. The patient was admitted for long-term Intravenous (IV) antibiotics and wound care.

Observation, on 06/03/14 at 3:30 PM, revealed the facility's Wound Care Nurse (WOCN) performed a Wound Vac dressing change on Patient #1. She only removed one (1) glove after she removing the old dressing from the resident, and she did not sanitize her hands prior to donning a clean glove. Continued observation revealed the nurse dropped a sealed package containing a pair of scissors on the floor, picked the package up and placed it on a chair with the other dressing supplies. Further observation revealed the nurse cleaned the wound with Normal Saline (NS) with the same gloves she was wearing when she picked the scissor package up off the floor with. She then removed those gloves and donned clean gloves without sanitizing her hands. Observation revealed the nurse measured the wound, opened the scissor package which had been on the floor, removed the scissors, cut the transparent dressing into strips and applied the strips to the periwound (area around the wound) area, while wearing the same gloves. The nurse continued wearing the same gloves while she cut the foam to the size of the wound, placed the foam in the wound bed and covered the foam with a transparent dressing. The nurse cut a hole in the transparent dressing, placed the tubing over the hole and turned the Wound Vac on, all without changing her gloves or sanitizing her hands.

Interview, on 06/03/14 at 4:15, with the WOCN revealed she "guessed" she should have removed both gloves after removing the contaminated dressing, and sanitized her hands prior to donning clean gloves. She stated she should have removed her gloves and sanitized her hands after she picked the scissor package up off the floor; however, stated she did not even remember picking the package up off the floor. Continued interview revealed she should have sanitized her hands each time she removed her gloves. She revealed she should have removed her gloves, sanitized her hands and donned clean gloves after she opened the scissor package, prior to touching the scissors. Further interview revealed she had "really messed up" and had not kept her mind on what she was doing. She stated her failure to sanitize and change gloves were Infection Control issues, and the facility's policy was to wash or sanitize hands when going from clean to dirty and after removal of gloves.

Interview, on 06/04/14 at 4:20 PM, with the Director of Nursing (DON) revealed the facility's Hand Hygiene Policy stated to wash or sanitize hands when going from dirty to clean and after removing gloves. She stated the Wound Nurse should have removed both her gloves and not just the one (1). The DON stated the Wound Nurse should have also washed or sanitized her hands: after she removed the dressing; after she picked up the scissor package from off the floor; after she opened the scissor package which had been on the floor; and every time she removed her gloves.




31409

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to provide meals to meet the nutritional needs of the patients for four (4) of thirty-two (32) sampled patients (Patients #7, #10, #11 and #27) as evidenced by the patients stating meal temperatures were not satisfactory and they did not receive what they ordered.

The findings include:

Review of the facility's policy, "Isolation: Standard and Transmission-Based Precautions", with approval date of February 2014, revealed contact precautions were used for patients known or suspected to be infected or colonized with microorganisms which could be transmitted by direct contact with the patient or indirect contact with the patient's environment or care items. Further review of the policy revealed airborne precautions, used for patients with suspected or diagnosed with infections which could be transmitted by air and droplet precautions, used for patients known or suspected to have infections transmitted by large particle droplets, were to have meals served on disposable dietary service items.

Review of the facility's policy, "Meal Delivery System", with approval date of February 2014, revealed the purpose of the policy was to ensure prompt and accurate delivery of meals to all patients and to provide the highest quality of service possible in a hospital setting.

1. Interview with Patient #10 on 06/02/14 at 2:10 PM, revealed his/her dissatisfaction of the meals served to him/her by the facility. Patient #10 stated the meals were usually cold and he/she did not always receive what was originally ordered.

2. Interview with Patient #7 on 06/03/14 at 09:25 AM, revealed he/she did not receive the food he/she ordered.

3. Interview with Patient #27 on 6/03/14 at 9:35 AM, revealed he/she disliked the food served. Patient #27 stated the food usually arrived cold and he/she did not receive the food items ordered.

4. Interview with Patient #11 on 06/02/14 at 2:20 PM, revealed the food was always cold on every meal served to him/her. Resident #11 stated he/she usually did not receive the food he/she ordered. According to Resident #11, the meals usually arrived in Styrofoam containers which did not retain heat.

Observation on 06/03/14 at 11:55 AM, revealed a sign posted on Patient #11's room door indicating he/she was on contact containment precautions. Continued observation revealed Patient #11's lunch meal arrived with each food item in a separate Styrofoam container. Interview with Patient #11, at the time of observation, revealed the food was "lukewarm".

Interviews with the Director of Risk and Quality Management and with the Quality Management Specialist on 06/04/14 at 1:40 PM, revealed in regards to patients on contact containment precautions and contact-spores precautions, all meals were served in disposable containers to help with infection control practices.

Interview with Registered Nurse (RN) #1 on 06/04/14 at 3:45 PM, revealed nursing staff had received complaints about the disposable container food, served to some patients, being cold or not tasting good. RN #1 stated she usually called Dietary and tried to get those patients another meal.

Interview with RN #3 on 06/04/14 at 4:00 PM, revealed the patients who were on contact containment and contact-spores precautions usually complained of their food tasting cold, even after staff attempted to microwave the food. RN #3 stated she would call Dietary and have another tray sent up.

Interview with RN #2 on 06/04/14 at 4:10 PM, revealed all the containment precaution patients complained of their food being cold. RN #2 further stated she had informed the Director of Nursing of these complaints.

Interview with Certified Nursing Assistant (CNA) #1 on 06/04/14 at 4:15 PM, revealed the patients in the containment precaution rooms usually mentioned their food being cold and not tasting good.

Interview with CNA #2 on 06/04/14 at 4:20 PM, revealed the patients in the containment precaution rooms complained "all the time" about their food being cold. CNA #2 further stated she would try to heat the food up; however, it did not reheat very well due to being in the disposable containers.

Interview with the Clinical Nutrition Director (CND) on 06/04/14 at 4:30 PM, revealed nursing required all contact containment and contact-spores precaution patients to have their meals served in disposable containers. The CND stated these patients were dependent on the nursing staff to deliver the meals trays in a timely manner to ensure the food temperature was appropriate. The CND further stated it was difficult to keep food warm in disposable containers.

Interviews with the Director of Nursing (DON) and the Administrator on 06/04/14 at 5:15 PM, revealed they were aware of the complaints of cold food by the patients who were on contact containment and contact-spores precaution rooms. The DON stated the food was served in disposable containers to help prevent cross contamination of microorganisms.