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Based on record review and interview, the facility failed to document interventions put in place for identified Performance Improvement (PI) and failed to develop new interventions when success was not achieved or sustained for 1 of 3 PI plans assessed.

Findings include:

Record review of the facility's Performance Improvement (PI) meeting minutes revealed a PI for the Medical Records Department dated April 2014 for Medical Record Delinquency Rate equaled 97%. The Compliance Threshold was set at less than 50% of monthly discharges. There was no Action Plan attached to this PI. There was a notation as follows:
"Physicians: Medical Records have 25 days of paper charts to analyze. Physicians need to come to medical records to work on the paper charts."

Further review of the PIs for Medical Records Department for Medical Record Delinquency rates revealed the following:
· May 2014 - 139%
· June 2014 - 219%
· July 2014 - 67%
· August 2014 - 37%
· September 2014 - 28%
· October 2014 - 199%
· November 2014 - 223%
· December 2014 - 196%
· January 2015 - 284%
· February 2015 - 104%

There were no action plans attached to any of the above PI reports.

Record review of the facility's MEC (Medical Executive Committee) meeting minutes from May 2014 to February 2015 revealed the same information was presented as in the PI meeting minutes. There were no action plans attached to any of the reports.

Record review of the facility's Governing Body meeting minutes from May 2014 to March 2015 reveal only one mention of the Medical Records delinquency by the facility's Medical Director, Staff Q. In the February 2015 meeting he reported there was a high delinquency rate for physician's medical records, but the physicians "continue to work on this area."

During an interview on 5/19/15 at 2:00 p.m. with the Director of Medical Records, Staff N, she said the Medical Records Delinquency Rate was for discharge summaries not completed in 30 days and the Psychiatric Assessment not being signed by the facility psychiatric physicians within 60 hours from the time the patient was admitted. She said there were four psychiatric physicians and only one of them was current with dictating the Discharge Summaries and signing the Psychiatric Assessments. She said her Action Plan was to email her spread sheet bi-weekly to the delinquent physician with the number of records that needed to be completed. She said she started that Action Plan in April 2014 when the electronic records system was put in effect. She said from that time until present she had spoken with Administrator, Staff O, about the delinquencies and the Administrator had spoken to the physicians. She said Medical Director, Staff Q, was one of the physicians who was delinquent.

Staff N said around the time the rates dropped below 50% was when a RN (Registered Nurse) was hired to dictate the Discharge Summary for one of the physician's with the most outstanding records not completed. She said in the March 2015 Medical Executive Committee meeting she was told the facility may hire another RN to dictate the Discharge Summaries in order to get the rates below 50%.

Staff N said she did not write an action plan and she had no record of when she spoke to the Administrator about the high delinquency rates. She agreed the delinquent records had been going on for a long time without any changes being made in what the facility was doing.

Interview on 5/20/15 at 8:50 a.m. with the Administrator, Staff O, when he was informed that the Medical Records PI project did not have any documentation for why it was chosen or any documentation for why there was no improvement, said the Governing Board was responsible for the Performance Improvement process. He said he felt the facility was doing what needed to be done, but was not documenting what was being done. He said they were not giving themselves credit for what they were doing. He said he would correct that immediately.

Record review of the facility's Policy and Procedure for Performance Improvement Plan number 781.100.33 dated 7/14 revealed the following on page 9 of 12:

"Plan the Improvement and Continued Data Collection
· During the planning step, the causes of variation are prioritized, solutions are designed, an implementation strategy is developed and indicators to measure the effectiveness of the improvement are created...

Do Improvement, Data Collection and Analysis
· Implementation strategies are outlined in an action plan that identifies the plan for improvement, the persons responsible, the target dates for implementation, identification of any dependencies (required for implementation) and any comments related to the actual implementation...
· Educate staff, management and Medical Staff on changes.

Check and Study the Results through Data Collection to Analyze the Plan
· As action plans are implemented, indicators identified in the plan are monitored and tracked so that actual performance improvement occurs.
· Ongoing tracking of indicators insures stability of the process.

Act to Hold the Gain and to Continue to Improve the Process
· When performance improvement is not sustained the FOCUS-PDCA cycle continues as the new process and causes of variation are re-assessed."

Page 12 of 12

"Evaluation

The effectiveness of the PI Plan is evaluated by the PI Committee and reported annually to the Medical Staff Executive Committee. This evaluation is based on comparisons of annual goals and objectives with program activities and achievements."

Record review of the Policy and Procedure for Performance Improvement Program number 781.100.30 dated 7/14 on page 8 of 8 revealed the following:

"9. Data analysis should lead to documented improvement actions and evaluation of actions taken. Issues that have been identified are monitored through Performance Improvement Council minutes so that progress toward solution is made in a timely manner. Performance Improvement reports summarize issues and actions."

Based on record review and interview, the facility failed to ensure the Performance Improvement (PI) program implemented preventative actions in 1 of 1 adverse event assessed to establish clear expectations for patient safety.

Findings include:


Record review of the RCA (Root Cause Analysis) dated 12/12/14 revealed that on 11/27/14 at 6:30 p.m. a 13 year old female on the adolescent unit set fire to a pair of pants in the closet in her room. The 13 year old stated she got a lighter from a peer on the unit. The RCA noted the incident happened because "A cigarette lighter was taken to the floor because a proper search was not done in intake. The action plan was to provide in-service training for staff regarding contraband and the new search process by 3/30/15.

Record review of the facility's Risk Management Committee meeting minutes for 2014 and 2015 under Contraband Issues revealed the following:
· 12/2014 - 3 occurrences in November. A cigarette lighter found on the adolescent unit and one on the adult unit along with a cell phone on the adult unit.
· 1/2015 - 4 occurrences in December. Three adults had cell phone and one of the three adults also had a wallet and keys. A fourth adult had a crack pipe.
· 2/2015 - 1 occurrence in January. One adult was admitted to the unit with shoelaces, a belt and a sweatshirt with strings in it. Under Trends, Actions and Recommendations was a recommendation "that we train staff on the new search procedure within 30 days."
· 3/2015 - 5 occurrences in February. A lighter was found under a cafeteria table, a lighter was found in a patients room when staff smelled smoke in the room, a lighter was taken from a patient when smoke was smelled in the room, matches were confiscated from a patient when smoke was smelled in the room, and property taken from the patient was brought back the next day and given to the patient. Under Trends, Actions and Recommendations was a recommendation "that we train staff who perform searches on the new search procedure.
· 4/2015 - 2 occurrences in March. A plastic bag with psychotropic medication was found on the third floor in the dayroom and a discharging patient was found to have shoestrings and a belt in the bottom of the bag that had been in his possession.

The action plan for the RCA for 12/2014 was not attached to the reports. There was no documentation that an in-service had occurred and with what staff.

Interview on 5/19/15 at 10:00 a.m. with the Director of Risk/PI, Staff M, she said the Safety Committee did not report to the Risk Committee and the Risk Committee did not report to the PI committee. She said she reported to the MEC (Medical Executive Committee). She was asked if she was in charge of the PI committee. She said she facilitated the meeting and reported on Patient Satisfaction in that committee.

Interview on 5/19/15 at 11:15 a.m. with Administrator, Staff O, he said the Governing Body met monthly. He said they sometimes met for special meeting between the monthly meetings. He said he set the agenda for the meetings. He said the Department Directors rotated through about every 6 months to discuss their departments. That was when "special issues" could be brought up for discussion.

Record review of the MEC and Governing Board meeting minutes from April 2014 to March 2015 revealed nothing reported in the meetings about contraband.

Interview on 5/20/15 at 10:45 a.m. with Risk/PI Manager, Staff M, she said the facility only had one adverse event in 2014 to present that resulted in a Root Cause Analysis (RCA). She said the action plan for the adverse event on 11/27/14 was to give an in-service to the intake staff and the other staff who had been trained to perform searches. She said not every staff could perform a search. She said the in-service was given on 3/18/15. She was asked why it took so long to give the in-service. She said they were given 90 days from the RCA. She was asked if she did anything different when contraband was still being found each month after the RCA. She said she contacted the Intake Director and he investigated who did the search and then counseled that employee. She said a second in-service was given in April 2015 that included all the staff.

Staff M was asked what new search process was taught at the in-service. She was asked if she had any documentation of what the Intake Director did and who he counseled. She said she would have to ask the Intake Director. After a phone call to the Intake Director, she said he did not actually have a new process, but re-taught what they had been doing. She said he did not document his investigations or who he counseled. She said she did not report the contraband to the MEC or Governing Board.

Record review of the facility's Policy and Procedure for Performance Improvement Program number 781.100.33 revealed the following on pages 2, 3, :

"GOVERNANCE AND LEADERSHIP:

The hospital's Governing Body is responsible and accountable for the quality of all services delivered by (the facility). The Governing Body's authority and accountability is delegated to the hospital Administrator and the Medical staff for developing, implementing and maintaining a viable performance improvement program....

MEDICAL STAFF EXECUTIVE COMMITTEE:

Oversight and approval of the PI Plan is further delegated by the Administrator to the Medical staff Executive committee, which has responsibilities for oversight of the quality of medical care rendered to (facility) patients....

The Medical Staff Executive Committee is responsible for:
· Assisting and participating in the development, implementation and evaluation of the ongoing performance improvement program....

PERFORMANCE IMPROVEMENT COMMITTEE:...

The Performance Improvement Committee has responsibilities for:...
5. Reporting to the hospital's Governing Body on performance improvement initiative, goals and significant issues.
6. Establishing organization-wide PI measures that are strategically aligned....
8. Reviewing and providing oversight for sentinel event root cause analyses.

Record review of the facility's Policy and Procedure for Patient and Belongings Searches revealed it was revised in 7/2014. The Procedure noted "All direct patient care staff shall receive training on the correct procedures for performing contraband checks and searches."

Interview on 5/20/15 at 12:50 p.m. with DON (Director of Nursing) Staff P, she said the policy was for volunteer patients to have their belongings checked for contraband in Intake. If the patient was admitted under a warrant, then the floor nurse and staff would check the belongings for contraband. When she was asked about the facility's Policy and Procedure (P&P), she said only certain staff were trained to perform searches, but that on hire, all staff were trained on searches in orientation. She agreed the P&P needed to be updated to show more specifically how searches were performed in the facility.

Based on record review and interview, the facility failed to document the reasons for conducting Performance Improvement (PI) projects and the measurable progress achieved on 1 of 3 projects reviewed.

Findings include:

Record review of the facility's Policy and Procedure for Performance Improvement Plan dated 7/14 revealed the following on page 7 of 12:

PERFORMANCE IMPROVEMENT METHODOLOGY:

(The Facility's) approach to PI is based upon The Joint Commission cycle for improving performance: design, monitoring performance through data collection, analyzing performance and improving and sustaining improved performance...

Find a process to improve

The first step is to find opportunities for improvements. This often requires baseline data collection to determine whether a problem actually exists. Data may come from variances from established standards/thresholds, patient or physician complaints, risk management issues, aggregate outcome measures/benchmarking, satisfaction questionnaires, clinical department meetings, staff meetings, hospital or medical staff department meetings and quality monitoring activities...."

Record review of the facility's Performance Improvement (PI) meeting minutes revealed a PI for the Medical Records Department dated April 2014 for Medical Record Delinquency Rate equaled 97%. The Compliance Threshold was set at less than 50% of monthly discharges. There was no Action Plan attached to this PI or reason for why it was being conducted.

Further review of the PIs for Medical Records Department for Medical Record Delinquency rates revealed the following:
· May 2014 - 139%
· June 2014 - 219%
· July 2014 - 67%
· August 2014 - 37%
· September 2014 - 28%
· October 2014 - 199%
· November 2014 - 223%
· December 2014 - 196%
· January 2015 - 284%
· February 2015 - 104%

There were no action plans attached to any of the above PI reports or reason for why it was being conducted. There was no notation of any measurable progress achieved.

Record review of the facility's MEC (Medical Executive Committee) meeting minutes from May 2014 to February 2015 revealed the same information was presented as in the PI meeting minutes. There were no documentation of why the PI was chosen or any measurable progress achieved.

Record review of the facility's Governing Body meeting minutes from May 2014 to March 2015 reveal only one mention of the Medical Records delinquency by the facility's Medical Director, Staff Q. In the February 2015 meeting he reported there was a high delinquency rate for physician's medical records, but the physicians were working on the problem.

During an interview on 5/19/15 at 2:00 p.m. with the Director of Medical Records, Staff N, she said the Medical Records Delinquency Rate was for discharge summaries not completed in 30 days and the Psychiatric Assessment not being signed by the facility psychiatric physicians within 60 hours from the time the patient was admitted. Staff N said she did not write an action plan and there was no documentation for why the PI was chosen. She said there had not been any improvement except for two months when a RN (Registered Nurse) was hired to write discharge summaries for one of the physicians.

Interview on 5/20/15 at 8:50 a.m. with the Administrator, Staff O, when he was informed that the Medical Records PI project did not have any documentation for why it was chosen or any documentation for why there was no improvement, said the Governing Board was responsible for the Performance Improvement process. He said he felt the facility was doing what needed to be done, but was not documenting what was being done. He said they were not giving themselves credit for what they were doing. He said he would correct that immediately.

Based on record review and interview, the facility failed to ensure the governing body, medical staff and administrative officials:
· Determined the number of distinct improvement projects to be conducted annually
· Evaluated Performance Improvement (PI) projects to ensure they were improving quality of care and patient safety by actively reviewing results of data collection, analyses, and activities
· To revise PI projects that were not producing results or meeting goals

Findings include:

PI Project #1

Record review of the facility's Performance Improvement (PI) meeting minutes revealed a PI for the Medical Records Department dated April 2014 for Medical Record Delinquency Rate equaled 97%. The Compliance Threshold was set at less than 50% of monthly discharges. There was no Action Plan attached to this PI. There was a notation as follows:
"Physicians: Medical Records have 25 days of paper charts to analyze. Physicians need to come to medical records to work on the paper charts."

Further review of the PIs for Medical Records Department for Medical Record Delinquency rates revealed the following:
· May 2014 - 139%
· June 2014 - 219%
· July 2014 - 67%
· August 2014 - 37%
· September 2014 - 28%
· October 2014 - 199%
· November 2014 - 223%
· December 2014 - 196%
· January 2015 - 284%
· February 2015 - 104%

There were no action plans attached to any of the above PI reports.

Record review of the facility's MEC (Medical Executive Committee) meeting minutes from May 2014 to February 2015 revealed the same information was presented as in the PI meeting minutes. There were no action plans attached to any of the reports. No recommendations were presented.

Record review of the facility's Governing Body meeting minutes from May 2014 to March 2015 reveal only one mention of the Medical Records delinquency by the facility's Medical Director, Staff Q. In the February 2015 meeting he reported there was a high delinquency rate for physician's medical records, but the physicians "continue to work on this area."

During an interview on 5/19/15 at 2:00 p.m. with the Director of Medical Records, Staff N, she said the Medical Records Delinquency Rate was for discharge summaries not completed in 30 days and the Psychiatric Assessment not being signed by the facility psychiatric physicians within 60 hours from the time the patient was admitted. She said there were four psychiatric physicians and only one of them was current with dictating the Discharge Summaries and signing the Psychiatric Assessments. She said her Action Plan was to email her spread sheet bi-weekly to the delinquent physician with the number of records that needed to be completed. She said she started that Action Plan in April 2014 when the electronic records system was put in effect. She said from that time until present she had spoken with Administrator, Staff O, about the delinquencies and the Administrator had spoken to the physicians. She said Medical Director, Staff Q, was one of the physicians who was delinquent.

Staff N said around the time the rates dropped below 50% was when a RN (Registered Nurse) was hired to dictate the Discharge Summary for one of the physician's with the most outstanding records not completed. She said in the March 2015 Medical Executive Committee meeting she was told the facility may hire another RN to dictate the Discharge Summaries in order to get the rates below 50%.

Staff N said she did not write an action plan and she had no record of when she spoke to the Administrator about the high delinquency rates. She agreed the delinquent records had been going on for a long time without any changes being made in what the facility was doing.

PI Project #2

Record review of the RCA (Root Cause Analysis) dated 12/12/14 revealed that on 11/27/14 at 6:30 p.m. a 13 year old female on the adolescent unit set fire to a pair of pants in the closet in her room. The 13 year old stated she got a lighter from a peer on the unit. The RCA noted the incident happened because "A cigarette lighter was taken to the floor because a proper search was not done in intake. The action plan was to provide in-service training for staff regarding contraband and the new search process by 3/30/15.

Record review of the facility's Risk Management Committee meeting minutes for 2014 and 2015 under Contraband Issues revealed the following:
· 12/2014 - 3 occurrences in November. A cigarette lighter found on the adolescent unit and one on the adult unit along with a cell phone on the adult unit.
· 1/2015 - 4 occurrences in December. Three adults had cell phone and one of the three adults also had a wallet and keys. A fourth adult had a crack pipe.
· 2/2015 - 1 occurrence in January. One adult was admitted to the unit with shoelaces, a belt and a sweatshirt with strings in it. Under Trends, Actions and Recommendations was a recommendation "that we train staff on the new search procedure within 30 days."
· 3/2015 - 5 occurrences in February. A lighter was found under a cafeteria table, a lighter was found in a patients room when staff smelled smoke in the room, a lighter was taken from a patient when smoke was smelled in the room, matches were confiscated from a patient when smoke was smelled in the room, and property taken from the patient was brought back the next day and given to the patient. Under Trends, Actions and Recommendations was a recommendation "that we train staff who perform searches on the new search procedure.
· 4/2015 - 2 occurrences in March. A plastic bag with psychotropic medication was found on the third floor in the dayroom and a discharging patient was found to have shoestrings and a belt in the bottom of the bag that had been in his possession.

The action plan for the RCA for 12/2014 was not attached to the reports. There was no documentation that an in-service had occurred and with what staff.

Record review of the MEC and Governing Board meeting minutes from April 2014 to March 2015 revealed nothing reported in the meetings about contraband.

Interview on 5/19/15 at 10:00 a.m. with the Director of Risk/PI, Staff M, she said the Safety Committee did not report to the Risk Committee and the Risk Committee did not report to the PI committee. She said she reported to the MEC (Medical Executive Committee). She was asked if she was in charge of the PI committee. She said she facilitated the meeting and reported on Patient Satisfaction in that committee.

Interview on 5/20/15 at 10:45 a.m. with Risk/PI Manager, Staff M, she said the facility only had one adverse event in 2014 to present that resulted in a Root Cause Analysis (RCA). She said the action plan for the adverse event on 11/27/14 was to give an in-service to the intake staff and the other staff who had been trained to perform searches. She said not every staff could perform a search. She said the in-service was given on 3/18/15. She was asked why it took so long to give the in-service. She said they were given 90 days from the RCA. She was asked if she did anything different when contraband was still being found each month after the RCA. She said she contacted the Intake Director and he investigated who did the search and then counseled that employee. She said a second in-service was given in April 2015 that included all the staff.

Staff M was asked what new search process was taught at the in-service. She was asked if she had any documentation of what the Intake Director did and who he counseled. She said she would have to ask the Intake Director. After a phone call to the Intake Director, she said he did not actually have a new process, but re-taught what they had been doing. She said he did not document his investigations or who he counseled. She said she did not report the contraband to the MEC or Governing Board.

Interview on 5/19/15 at 10:10 a.m. with DON (Director of Nursing) Staff P, she said each department head set their own Performance Improvement project. She said most of the PI plans were on-going projects and there was no set meeting each year where they discussed which PI projects they were going to do for the year. She said as needs arose and were identified, a PI project would be started to take care of the problem.

Interview on 5/19/15 at 11:15 a.m. with Administrator, Staff O, he said the Governing Body (GB) met monthly, but sometime had special meetings called between the monthly meetings. He said the Department Directors rotated through about every 6 months to discuss their departments. "Special issues" could be brought up for discussion at that time. Staff O said the PI indicators and special projects were not discussed in the GB before being developed and implemented. He said Board Members were on the PI, Risk and Safety committees. He said once or twice a year the PI indicators from the previous 5 to 7 months were brought to the GB. He stated there had not been a routine schedule for this procedure. He could not provide documentation that the GB had oversight of the PI projects. He stated there was a lack of documentation in this area that would be corrected immediately.

Record review of the facility's Policy and Procedure for Performance Improvement Program number 781.100.33 revealed the following on pages 2, 3 & 4:

"GOVERNANCE AND LEADERSHIP:

The hospital's Governing Body is responsible and accountable for the quality of all services delivered by (the facility). The Governing Body's authority and accountability is delegated to the hospital Administrator and the Medical staff for developing, implementing and maintaining a viable performance improvement program....

MEDICAL STAFF EXECUTIVE COMMITTEE:

Oversight and approval of the PI Plan is further delegated by the Administrator to the Medical staff Executive committee, which has responsibilities for oversight of the quality of medical care rendered to (facility) patients....

The Medical Staff Executive Committee is responsible for:
· Assisting and participating in the development, implementation and evaluation of the ongoing performance improvement program....

PERFORMANCE IMPROVEMENT COMMITTEE:...

The Performance Improvement Committee has responsibilities for:...
5. Reporting to the hospital's Governing Body on performance improvement initiative, goals and significant issues.
6. Establishing organization-wide PI measures that are strategically aligned....
8. Reviewing and providing oversight for sentinel event root cause analyses...

The PI Committee is responsible for:...
9. Evaluating the PI program annually and making recommendations for organization-wide PI indicators..."

Based on interview and record review the Facility's staff failed to provide discharge instructions related to a follow up care in 1 of 7 discharged patients record reviewed . Patient #4

Findings include:

Patient #4

Reviewed Consultation records of Patient #4 on 05/19/2015 revealed on 05/09/2015 that she was admitted on this date "due to Psychosis with history and Impression of STD (Sexually Transmitted Disease), Review of Systems under Genitoreproductive: yellow vaginal discharge, itching, hx(history) of G&C (Gonorrhea and Chlamydia). Physician (R)'s recommendation said : Follow up with obgyn after discharge ..."

Patient #4
During an interview on 05/19/2015 at 12:25 p.m. with the assigned Nurse (D) for patient #4, the Surveyor asked the Registered Nurse for documentation that this patient had discharge instructions to see a gynecologist for follow up after discharge, and he said "She just left a while ago, and went home. I did not mention about referring her to a gynecologist because I do not know. Usually if we miss it, the outpatient facility where she will see the Psychotherapist, they will refer our patients to appropriate doctor. "

He presented to the Surveyor the Patient's written discharge instructions given prior to discharge; There was no referral order to a gynecologist upon discharge.

During an interview on 05/19/2015 at 1:30 p.m. with Physician (E) that wrote the discharge orders for Patient #4, the Surveyor told her that there was no referral to a Gynecologist prior to sending home as written from the Consultation Notes upon admission this Patient. She reviewed the medical records of the Patient via computer, and said "We will sure to call the patient, she has the contact number in the chart, and we can add it on notify her about this referral."

Review of the Facility's policy about "Admit, Discharge, Transfer and Re-admit" on page 4 item 3.b said "Discharge summary will include #2 i.e. Health care needs that did not get resolved that require referral for continued care or treatment at a different setting."

Based on observation, interview and record review, the Facility's staff failed to implement the Facility Policy and Procedure to wash/sanitize hands after direct contact with contaminated supplies or patients and failed to implement its policy and procedure when handling sharp items in 3 random staff observed .

Findings:

Staff (A)
Observation on 05/19/2015 at 9:10 a.m during tour of the facility's community kitchen, revealed Dietary Assistant (A) was observed in the dirty dish room. The Dietary Aide was cleaning/ scraping left over food supplies from Patients' utensils into the dirty sink. Observation revealed the Dietary Aide scraped the leftover food into the dirty sink using her hand, wiped her hands on her apron then proceeded to the dish washing machine and retrieved clean / sanitized trays from the dishwashing machine. The Dietary Aide did not wash/sanitize her contaminated hands when moving from the dirty area of the kitchen to touching the clean trays.

Staff (B)
On 05/19 /2015 at 9:35 a.m Licensed Vocational Nurse (B) was observed at station 2's nursing station. The Licensed Nurse was applying topical cream to Patient #1's arms.
Observation revealed Licensed Vocational Nurse (B) donned a pair of gloves, applied topical cream from a tube of Mometasome cream to the patient's both arms. After applying the cream the Licensed Nurse removed her contaminated gloves and placed then on the desk adjacent to the Medication Administration Record, entered information in the Medication Administration Record with her contaminated hands, picked up the keys for the medication room and the tube of topical cream and entered the medication room with her contaminated hands.
The Licensed Nurse did not wash/ sanitize her contaminated hands after removing the pair of gloves used to apply topical cream to the Patient's arms.

During an interview on 05/19/2015 at 9:37 a.m with Licensed Vocational Nurse (B), the Surveyor inquired of the Licensed Nurse why was the patient having the topical cream applied to his arms. The Licensed Nurse said the Patient was getting the cream for Eczema.
The Surveyor then informed her that she did not wash/sanitize her contaminated hands after she had applied the topical cream to the patient's arms and removed her contaminated gloves.

The Licensed Nurse said " I am sorry. "
Review on 05/19/2015 of Patient # 2's medical record revealed an order dated 05/15/2015 for " Mometasome Furoate Ointment , apply thin layer to face, elbow, ankles, buttocks, back of neck fingers and other affected areas."


Review of the Facility's current Policy and Procedure #760.800.16 directs staff as follows: " Needles and sharps are to be handled in such a manner that accidental cuts and puncture wounds will be prevented. To the extent possible all needles will be safely engineered to reduce needle stick related injuries. Needles, syringes and other sharps must be discarded in a safe and rigid container.

Used needles , syringes and sharps will be discarded intact immediately after use into an impervious needle disposable container which is readily accessible. If a sharps container is not readily accessible, a small portable sharps container must be brought to the site where the injection will be give. "

Patient # 10
On 05/20/2015 at 11:35 a.m Registered Nurse (L) was observed at the nurses' station on the third floor of the Facility. The Registered Nurse was observed testing for blood glucose of the Patient (#10) by finger stick method.
Observation revealed Registered Nurse (L) washed her hands donned a pair of gloves, and pricked the Patient's finger with a lancet. She then placed the lancet and alcohol swab in a disposable cup, and read the glucose value using a Contour Glucometer. She then wiped the contour meter with an alcohol swab and returned it to the holder. She then removed her gloves and sanitized her hands.
The Licensed Nurse then applied an alcohol swab to the Patient's puncture site, wiped the blood from the puncture site, and applied a band aide to the Patient's puncture site. She then removed one hand of her contaminated gloves, picked up the cup containing the lancet and swab in her right hand . She then used her left hand which she had removed the contaminated glove to pick up clean glove from the box of clean gloves stored on the nurses' station.
She then entered the nurses' charting room , retrieved the used lancet from the cup with her gloved hands and placed it in the sharp container on the wall. Retrieving the used Lancet placed the staff at risk for the potential of needle stick.
The Licensed Nurse did now wash/sanitize her contaminated hands after she had removed the contaminated alcohol swab from the Patient's puncture site.

Review of the Facility's current Policy and Procedure on Infection control # 760-800.09 dated 08/14 direct staff as follows: " Gloves must be worn for any procedures when hand contact can be reasonably anticipated with infectious materials such as blood, mucous membrane or non- intact skin, items of surface visibly soiled with blood or fluid."
"Disposable gloves are issued and should never be washed or disinfected for re-use. Gloves should immediately be replaced if torn. Hands are to be washed following CDC guidelines when gloves are removed. "

Review of the Facility's Policy and Procedure on Infection Control Hand washing:
" Employees will wash hands: when coming on duty, before and after using the restrooms or completing personal hygiene or grooming functions, before applying and handling supplies, when hands are obviously soiled, between handling of individual patients, prior to giving care to patients or handling his/or her belongings/equipment, before and after handling any body secretions, Following sneezing coughing blowing or wiping the nose and/or mouth, before and after handling used specimen containers and soiled equipment /linen, before and after eating when going off duty. "

Review of the Facility's current Policy and Procedure #760.800.16 directs staff as follows: " Needles and sharps are to be handled in such a manner that accidental cuts and puncture wounds will be prevented. To the extent possible all needles will be safely engineered to reduce needle stick related injuries. Needles, syringes and other sharps must be discarded in a safe and rigid container.

Used needles, syringes and sharps will be discarded intact immediately after use into an impervious needle disposable container which is readily accessible. If a sharps container is not readily accessible, a small portable sharps container must be brought to the site where the injection will be give. "

Based on an interview, the Facility's governing body failed to ensure its discharge planning process tracks readmission to the Facility in its Quality Assessment and Performance Improvement activities.


Findings include:

During an interview on 05/20/2015 at 1:15 p.m. with the Director of Social Services (F), the Surveyor asked if there was a tracking and review of hospital readmission as part of Quality Assessment and Performance Improvement, she said "I only share my audit about the compliance of the staff in completing their initial admission and discharge plan within 72 hours every time we have our quality meetings, but not the hospital readmission."
Subsequent interview on 05/20/2015 at 1:20 p.m. was made with the Director of Nursing (P), the Surveyor asked if there was a process of tracking and reviewing the hospital readmission as part of Quality Assessment and Performance Improvement, she said "No, we do not have that. We are thinking now on how to do it next time ..."