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Based on interview, record review, and policy review, the facility's Governing Body failed to ensure that the facility wide Quality Assessment and Performance Improvement (QAPI) Plan for 2014, 2015 and 2016 was approved and included quality measures based on high risk, high volume and problem prone areas including all clinical contractual services. The Governing Body failed to ensure that the contracted services of the Hemodialysis (a medical procedure to remove fluid and waste products from the blood) Unit and the Organ, Tissue and Eye Procurement Program (organ, tissue or eye cornea, the clear front part of the eye, transplant) were in substantial compliance. This failure had the potential to cause inadequate patient care monitoring and poor patient outcomes. The adult facility census was 300 and the pediatric facility census was 149.

Findings included:

1. Record review of the facility's policy titled, "Performance Improvement and Patient Safety (PIPS) Plan - 2016," dated 11/2015, showed that the program required collaborative participation from appropriate services, clinical and non-clinical, including services provided by contractors. The Board of Directors (Board) was responsible and accountable for annual approval of the PIPS Plan.

2. During an interview on 05/19/16 at 8:50 AM, Staff V, Patient Safety Quality (PSQ) Coordinator, stated that the 2016 PIPS plan was not scheduled to be reviewed by the Board of Directors until 07/2016.

During an interview on 05/19/16 at approximately 2:00 PM, Staff T, Regional Director of PSQ, stated that the PSQ Plan for 2016, including contractual services, had not been approved by the Board of Directors.

During an interview on 05/25/16 at 10:00 AM, Staff B, System Manager of Clinical Excellence and Patient Safety, stated that the Annual QAPI Plans for the last three years (2014, 2015 and 2016) had not been approved by the Governing Board.









27029

Based on observation, interview, record review and policy review, the facility failed to identify opportunities for Quality Assessment and Performance Improvement (QAPI) and to implement changes that would lead to improvement in the high volume, high risk, and problem prone areas of:
- The Dialysis (Hemodialysis is a medical procedure to remove fluid and waste products from the blood) Unit, a contracted clinical service;
- The Organ, Tissue and Eye (an organ, tissue or eye cornea, the clear front part of the eye, transplant) Procurement program, a contracted service; and
- The Important Message From Medicare, a document required for all patients receiving Medicare services.
These failures could potentially lead to worsened medical conditions, death or violation of patients' rights.
The adult facility census was 300 and the pediatric facility census was 149.

Findings included:

1. Record review of the undated Dialysis Unit document titled, "Year 2015 Trend for Acute Treatments," showed the total number of patients dialyzed for the year was 3,297. The high volume unit is necessary to provide Dialysis treatments for inpatients diagnosed with renal (kidney) failure or chronic kidney disease. Patients required to undergo Dialysis often have been hospitalized for other reasons.

2. Record review of the document from Medscape, a health professional network, titled, "Starting Dialysis is dangerous," dated 05/31/16, stated that one of the highest risks to patients receiving dialysis is, "Risks of all forms of infection are many times higher once the patient is started on dialysis. Patients on dialysis are 100-fold more likely to develop methicillin-resistant Staphylococcus aureus septicemia (MRSA is a bacteria that is resistant to many antibiotics. Staph and MRSA can cause a variety of problems ranging from skin infections and sepsis to pneumonia to bloodstream infections) than the general population and 800-fold more likely than if not dialyzed with a native arteriovenous fistula (Hemodialysis fistulas are surgically created access ports between the native artery and vein in an extremity). Exposure to hospital-acquired infection is often just a component of the myriad of dangers associated with the increased amount of in-patient care. Others (risks) might include exacerbation (worsening) of malnutrition, hypostatic pneumonia (congestion due to the stagnation of blood in the dependent portions of the lungs in old persons or in those who are ill and lie in the same position for long periods), falls, and venous thromboembolism (blood clot) risk."

3. Observations on 05/16/16 at 3:15 PM showed four patients (#3, #45, #46 and #47) in the Dialysis Unit in the Dialysis treatment process. The Dialysis unit is one large room and the patients are within close proximity to each other and the nursing staff. There were curtains that could be pulled around the beds but no curtains were pulled between or around the beds. There were also no real (walls or private rooms) or 'perceived' barriers (such as tape on the floor to define an area) to identify each patients space.

4. Observation on 05/16/16 at 3:15 PM showed Patient #45 in bed one, Patient #46 in bed three, Patient #47 in bed four, and Patient #3 in bed two. The sign at the end of the bed for Patient #3, stated that she was in CONTACT ISOLATION (used to prevent the spread of diseases that can be spread through contact with open wounds).

5. Record review of the History & Physical (H&P) for Patient #46 and Patient #47 showed they both had wounds on their lower legs and/or feet.

6. Record review of Patient #3's H&P showed she was diagnosed with Resistant Acinetobacter baumannii (referred to as ACB, is an opportunistic pathogen, which is an agent that causes infection, affecting people with compromised immune systems, and is becoming increasingly important as a hospital-derived infection). The H&P also showed Patient #3 had wounds on her feet.

During an interview on 05/16/16 at 3:50 PM, Staff AA, Director of Clinical Services and Dialysis stated that a patient with Resistant ACB should not be in the Dialysis Unit and should have been dialyzed in her room. He stated that the facility had no means to alert staff what pathogen a patient had and there was no signage in use to alert visitors, staff or other patients that the patient had a highly infectious condition.

During an interview on 05/18/16 at 10:00 AM, Staff AA stated that the QAPI project for the Dialysis Unit was improved hand hygiene. He stated that he observed staff and monitored the hand hygiene and glove use. He stated that the current hand hygiene compliance was 80 percent. He stated that hand hygiene performance had not been reported to the QAPI Committee in 2016.

The facility failed to focus on the risk of possible exposure to an infectious disease for all patients with compromised immune systems, in the dialysis unit. The facility also failed to use collected data of hand hygiene to identify opportunities to implement changes that could lead to improvement in the high volume, high risk, and problem prone area of Dialysis.

7. Record review of the facility's policy titled, "Organ and Tissue Donation," revised 08/2013, showed the following:
- The Organ Procurement Organization (OPO, non-profit organization that is responsible for the evaluation and procurement of deceased-donor organs for organ transplantation) will determine suitability based on established criteria.
- An OPO representative will speak with the family about organ donation.
- Contact with the family, by the OPO, should be documented by facility staff in the medical record with donation eligibility noted.

8. Record review of the facility's document titled,"Organ and Tissue Recovery Agreement," dated 01/15/15, showed the following:
- The donor hospital will provide timely organ referrals to the OPO of all imminent deaths by notifying the donor hotline.
- Timely notification of referrals to the OPO is defined by the facility/vendor agreement as within one (1) hour of the imminent death, cardiac death, and prior to withdrawal of mechanical support.
- Referrals are made timely so that an on-site evaluation can be conducted by the OPO to determine the medical, legal and behavioral suitability of the referral.
- Donor hospitals' staff shall not rule out any patients as potential donors.

9. Record review of the US Department of Health & Human Services document titled, "Organ Procurement and Transplantation Network (OPTN)," dated 05/31/16, showed the number of waiting list candidates for Organ, Tissue and/or Eye donations are currently 120,693.

10. Record review of the facility's document titled, "Death to Referral Time," dated 2016 showed the following percentage of cases reported in under the required 60 minutes:
- January 62%;
- February 65%;
- March 75%; and
- April 86%.

During an interview on 05/18/16 at 10:10 AM, Staff B, System Manager of Clinical Excellence and Patient Safety, stated that the percentages for cases reported in a timely manner had improved for the year.

During an interview on 05/18/16 at 2:00 PM, Staff V, Patient Safety and Quality (PSQ) Coordinator, stated that she was not aware of any activities for improvement of the OPO timely referrals. She stated that it was the responsibility of someone else and that the current compliance percentages had not been reported to the Board of Directors in 2016.

The facility failed to use the collected data to identify opportunities to implement changes that could lead to improvement in the notification of referrals to the OPO.

11. Medical record review of the Important Message from Medicare Letters (IMM- notice to patients that described their discharge rights), from 05/16/16 to 05/18/16 showed that Patients #23, #24, #45, and #46 had a note written on the Patient or Representative signature line that indicated, "patient was unable to sign due to condition," and Patients #20 and #27 indicated, "verbal consent," on their signature line.

12. Record review of the facility document titled, "Delivery of the IMM," dated 09/03/2013 showed that:
- The IMM must be delivered to the enrollee in person;
- Registration must deliver the IMM to the patient at or near the time of admission; and
- If a patient is unable or refuses to sign the IMM, registration will note this.

During an interview on 05/18/16 at 2:20 PM, Staff CC, Manager of Patient Access (Registration), stated that he was not concerned that there were many admissions where the patient was not able to sign or gave verbal consent that they understood the IMM. Staff CC stated that there was not a process to follow up to determine if a patient could sign the document after the initial "unable to sign/verbal consent" comments were entered. Staff CC stated that he did not monitor for trends to determine if some registration staff had disproportionate numbers of "unable to sign" than others. Staff CC stated that there were "corporate" audits done for each registration staff members on the IMM. Staff CC stated that the auditors checked ten records a month for every registration staff member and he received a copy of those reports.

13. Record review of facility's undated policy titled, "Registration Policy Review," showed a list of items that will be audited for registration staff that included, "Patient Rights- IMM for Medicare and Medicare HMO's," (Health Maintenance Organizations- a type of medical insurance). The policy showed that five random registrations per user, per month would be audited. If the user has done less than five registrations that month, 100% of their work would be audited.

During an interview on 05/18/16 at 4:15 PM, Staff CC stated that he was not able to print the audit reports but he had his laptop with the electronic files of the audits. Staff CC opened the file and clicked on 12 random names of his registration staff files in succession. Each file showed N/A (Not Applicable) on the line item, "Patient Rights-IMM for Medicare." Staff CC stated, "I guess we're not auditing them anymore." Staff CC stated that he had 66 registration staff members.

The facility failed to collect IMM data, for this high volume area, to identify opportunities to implement changes that could lead to improvement for Medicare recipients regarding discharge rights.





29511

Based on interview, record review and policy review, the facility failed to ensure that Quality Assessment Performance Improvement (QAPI) projects (assessment conducted of a patient care problem through peer analysis, intervention, resolution of the problem, and follow-up) reflected the complexity and scope of services provided, including those provided by contract. This failure had the potential to affect all patients and prevent the facility from having an effective QAPI Program. The adult facility census was 300 and the pediatric facility census was 149.

Findings included:

1. Record review of the facility's policy titled, "Performance Improvement and Patient Safety (PIPS) Plan - 2016," dated 11/2015 showed:
- Annually the entity (facility) determined the number and scope of distinct quality and safety improvement priorities and projects.
- The projects were documented, including the reason for conducting them and the measurable progress achieved. The frequency and detail of data collection was approved by the Board of Directors (Board)
- The entity set priorities for its performance improvement activities that focus on high risk, high volume, and problem prone areas.

2. During an interview on 05/18/16 at 10:00 AM, Staff AA, Director of Clinical Services and Dialysis, stated that the Performance Improvement (PI) project for the Dialysis Unit was improved hand hygiene. He stated that he observed staff and monitored the hand hygiene and glove use. He stated that the current hand hygiene compliance was 80 percent. He stated that hand hygiene performance had not been reported to the QAPI Committee in 2016.

3. Record review of the undated document titled, "2016 Department Plan," for the Dialysis Unit showed that 10 hand hygiene observations per month were completed in 2016 with a compliance percentage of 80 percent.

The facility performed 1123 dialysis procedures from 01/01/16 to 04/30/16 which averages approximately 281 dialysis treatments per month. The 10 hand hygiene QAPI observations are not representative of the scope and complexity of the unit.

During an interview on 05/19/16 at 8:50 AM, Staff V, Patient Safety and Quality Coordinator, stated that she could not provide a list of 2016 Board approved PI projects for clinical services.

After several requests to submit documentation to verify substantial compliance for the facility-wide QAPI Program and the scope and services provided to patients, verification could not be provided by the facility. The Annual QAPI Plan had not been approved by the Board, therefore the number of distinct improvement projects were not approved by the Board.














27029

Based on observations, interviews, record reviews and policy and procedure reviews the facility failed to have a systemic practice in place to prevent the following:
- A patient with known colonization (carrier of a germ but not showing signs and symptoms) with Resistant Acinetobacter baumannii (referred to as ACB, an opportunistic pathogen, which is an agent that causes infection), affecting people with compromised immune systems, and becoming increasingly important as a hospital-derived infection) was improperly transported and dialyzed in the Dialysis (Hemodialysis, a medical procedure to remove fluid and waste products from the blood) Unit. This failure was a breach of facility policy and procedure and exposed other patients, staff and visitors to the infectious agent. (A-0756).
The facility also failed to ensure staff:
- Properly wore surgical masks with visors when vascular access (a surgically created vein used to remove and return blood during Hemodialysis) lines were removed after a dialysis treatment (A-0749).
- Performed hand hygiene (wash hands with soap and water or use hand sanitizer) before putting on gloves or between glove changes (A-0749).
- Performed hand hygiene and changed gloves after touching a contaminated inanimate object and prior to touching the patient's bed linens, medications and cell phones during medication administration (A-0749).
-Properly followed sterile technique for a Central Venous Catheter (a catheter placed into a large vein) dressing change (A-0749).
The adult facility census was 300 and the pediatric facility census was 149.

The severity and cumulative effect of these systemic practices resulted in the facility being out of compliance with 42 CFR 482.42 Condition of Participation: Infection Control. The facility was culpable (accountable and responsible) in that it had identified 28 patients with Resistant ACB in 2016 and failed to report the safety issues to administrative leadership, educate staff or to put procedures in place to prevent transmission.

Subsequently the situation constituted a condition of Immediate Jeopardy (IJ) which placed all patients of the facility at risk. The facility provided an acceptable plan of correction (POC) and implemented corrective actions to abate the IJ on 05/25/16 to prevent further risk to patients. The POC included:
- Notification to the treating nephrologist (physician who specializes in kidney care and treating diseases of the kidneys) of the patients that were exposed in the Dialysis Unit;
- Development and immediate approval of a new policy and procedure for the management of actual and/or potential infectious disease exposures.
- Development and implementation of new signage so patients with actual and/or potential infectious disease are immediately identifiable as to isolation and transport requirements.
- Staff Education beginning 05/25/16 for all staff in all departments before their next scheduled shift as to the new policy, new signage, modified hall passes, electronic health record and personal protective equipment (PPE), hand hygiene and glove use. Education will continue until 100% of all employees are educated before their next scheduled shift.
- Daily surveillance by Infection Control prevention;
- Daily drills by Department Directors or designee; and
- All corrective actions will be documented with the Interim Vice President of Nursing as the responsible person.

Based on observation, interview, and policy review the facility failed to ensure that staff followed infection control policies and procedures when they failed to:
- Properly wear surgical masks with visors when vascular access (a surgically created vein used to remove and return blood during Hemodialysis) lines were removed after a Dialysis (Hemodialysis is a medical procedure to remove fluid and waste products from the blood) treatment for one patient (#47) of one patient observed.
- Perform hand hygiene (wash hands with soap and water or use hand sanitizer) before putting on gloves or between glove changes for one patient (#47) of one patient observed.
- Perform hand hygiene and change gloves after touching a contaminated inanimate object and prior to touching the patient's bed linens, medications and cell phones during medication administration for two patients (#22 and #48) of two patients observed.
-Properly follow sterile technique for a Central Venous Catheter (a catheter placed in to a large vein) dressing change for one patient (#40) of one patient observed.
The adult facility census was 300 and the pediatric facility census was 149.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene," dated 03/2013, showed Hand Hygiene was the most important means for preventing the transmission of infectious organisms, and directed staff to perform hand hygiene:
- Before and after each patient contact;
- After handling patient equipment;
- After removing gloves;
- Before performing any invasive procedure;
- Before and after contact with wounds; and
- When moving from a contaminated body site to a clean body site during patient care.

Record review of the facility's policy titled, "Standard Precautions," dated 04/2014, showed Standard Precautions were based on the principles that all blood, body fluids, secretions, excretions, non-intact skin and mucous membranes may contain transmissible infectious agents; and directed staff to perform hand hygiene between patient contacts and after glove removal; and utilize appropriate barriers to protect themselves from possible exposure to bloodborne pathogens (infectious microorganisms in blood that can cause disease in humans) and other potentially infectious materials.

2. Record review of the Centers for Disease Control and Prevention (CDC) instructions titled, "Sequence for Donning Personal Protective Equipment (PPE), dated 2009, showed the following sequence:
- Mask - secure ties or elastic bands at middle of head and neck;
- Fit flexible band to nose bridge;
- Fit snug to face and below chin; and
- Face shield, place over face and eyes and adjust to fit.

3. Observation on 05/16/16 at 3:50 PM showed Staff C, Patient Care Technician (PCT), and Staff DD, Registered Nurse (RN), putting on a gown, surgical mask with visor and gloves to remove vascular access lines from Patient #47. Staff DD failed to properly place and wear the surgical mask that was meant to protect her in case of a blood splash. Staff DD placed the flexible soft 'mask' part of the shield at the bottom of her chin rather than covering her nose and mouth as described in the CDC recommendations. The rigid plastic 'shield' of the PPE started at the chin line and would not have protected her eyes. Staff C failed to wash his hands before putting on or between glove changes. Observation also showed Staff C removed his gloves and put on another pair of gloves without performing hand hygiene while caring for Patient #47.

During an interview on 05/16/16 at 3:50 PM, Staff AA, Director of Clinical Services and Dialysis, stated that he observed the Dialysis Unit almost daily to detect breeches in infection control. He shrugged his shoulders and failed to acknowledge that the mask was worn improperly.

4. Observation on 05/17/16 at 9:30 AM showed Staff N, RN, prepared to administer medications to Patient #22. Staff N typed on the computer keyboard, scanned five medications and picked up a piece of paper off the floor. Without performing hand hygiene, she administered the five medications, straightened up the patient's bed linens, removed her phone from her pocket and replaced it back in her pocket. Staff N used her contaminated hands to administer medications to the patient and contaminated her cell phone without cleaning it.

During an interview on 05/17/16 at 9:45 AM, Staff N stated that she didn't realize that she had contaminated her hands or she would have performed hand hygiene.

5. Observation on 05/17/16 at 10:15 AM showed Staff CCC, RN, prepared to administer medications to Patient #48. She dropped her cell phone on the floor, then picked it up off of the floor and put it back into her pocket without wiping it off or performing hand hygiene. She administered the two medications to the patient while the urinal containing urine sat on the bedside table with the medications. She changed the intravenous (IV, within the vein) line but did not perform hand hygiene or remove the urinal from the bedside table.

During an interview on 05/17/16 at 10:30 AM, Staff CCC, when asked about her actions that contaminated her hands, the medications, IV line and cell phone, she stated, "Yeah, ok, thanks".

6. Record review of the facility's policy titled, "Central Venous Catheters: Short Term Catheter Care and Management," dated 08/2013, showed that transparent Central Venous Catheter dressings are changed every seven days, unless they are noted to be soiled or loose, and they are sterile dressing changes to be done under aseptic (free from contamination caused by harmful bacteria, viruses, or other microorganisms) conditions.

7. Observation on 05/18/16 at 2:25 PM of Patient #40, showed a sterile dressing change being completed for a Peripherally Inserted Central Venous Catheter (PICC) in the left arm. Staff GG, RN, was the primary nurse for the patient and completed the dressing change, while Staff FF, Charge RN, assisted. After the dressing was removed, Staff GG put on sterile gloves, and proceeded to use her gloved right hand at multiple times to grasp the patients arm. Staff GG then utilized her right hand to hold items while changing the dressing which included the chlorhexidine (an antibacterial compound used as an antiseptic and disinfectant) swab and also the chlorhexidine impregnated disk (a small circular device that fits around the catheter at the point of its entry in to the body). Staff GG also touched the catheter itself numerous times throughout the procedure as she attempted to clean and place the dressing. At no time after the sterile gloves were put on, did Staff GG remove gloves, clean hands, or obtain new sterile gloves.

During a concurrent interview on 05/18/16 at 2:40 PM, Staff EE, Director of Critical Care and Staff FF, Charge RN. Staff EE confirmed that the PICC line dressing change was a sterile procedure. Staff FF also confirmed that she observed Staff GG touch the patients arm and catheter, and not maintain sterile precautions which was the expectation.




36474

Based on observation, interview and record review, the facility failed to include the administrative leadership or have current facility-wide activities, inservices and training that addressed problems identified through the infection prevention and control program for one patient (#3) of one patient observed with Resistant Acinetobacter baumannii (referred to as ACB, which is an opportunistic agent that causes infection), affecting people with compromised immune systems, (and becoming increasingly important as a hospital-derived infection). This failure had the potential to negatively affect all patients, staff and visitors in the facility by exposing them to infectious disease and substandard quality care. The adult facility census was 300 and the pediatric facility census was 149.

Findings included:

1. Record review of the facility's Policy and Procedure titled, "Patient Care Policy, Isolation Guidelines," dated 05/2014, showed that a patient on Contact Isolation can be transported under the following procedures designed to reduce the risk of infection to others by direct or indirect contact with items in the patient's environment:
- Patients infected or colonized (no active symptoms) with resistant organisms are included in this category.
- Patients may be transported to other departments but ensure the receiving department is notified of precautions.
- Except Dialysis: Dialysis will occur in the patient room for patients with ACB.
- Consider limiting transport if the patient has diarrhea, a colostomy, uncontained wound/skin lesions.
- Cover wheelchair/stretcher with barriers-patient should be placed in a clean gown and instructed to wash hands before leaving room.

2. Observation on 05/16/16 at 3:15 PM showed Patient #3 in the Dialysis (Hemodialysis is a medical procedure to remove fluid and waste products from the blood) Unit. She was in the process of the treatment and had a sign on the end of her bed that read, "CONTACT PRECAUTIONS".

During an interview on 05/16/16 at 3:30 PM, Staff DD, Registered Nurse (RN)/Dialysis, stated that the patient had Resistant ACB.

Record review showed that Patient #3 had been transported from room #133 on the first floor using the elevator to the sixth floor to the location of the Dialysis Unit. The number of staff, visitors and other patients that could have been exposed to this pathogen cannot be determined.

During an interview on 05/16/16 at 3:30 PM, Staff AA, Director of Clinical Services and Dialysis, stated he wasn't familiar with the pathogen and would have to look it up.

Record review of the History & Physical's for the patients in the Dialysis Unit showed that three patients (#3, #46 and #47) of four patients had wounds on their lower legs and/or feet.

3. Record review of the facility's infection control undated document titled, "Patients with CRE (carbapeamase resistant organisms are bacteria resistant to medications) &/or Resistant Acinetobacter 01/01/16 - 05/23/16,"showed that the facility had 28 patients with Resistant ACB from 01/04/16 through 05/20/16. The record showed that nine of the 28 patients required Dialysis treatments. The record showed that Patient #3 was the only patient transported to the Dialysis Unit for treatment.

During an interview on 05/17/16 at 3:00 PM, Staff R, Administrative Supervisor of Dialysis, stated that he didn't know if it was staff convenience or lack of staff that prompted staff to transport Patient #3 to the Dialysis Unit.

During an interview on 05/18/16 at 10:00 AM Staff AA stated that he reviewed quality issues with the Quality Director but he had not reported any of his data or quality issues to the infection control committee or the Board of Directors in 2016. He stated that currently there was no procedure or method to alert staff or visitors that a patient is infected or colonized with Resistant ACB.

During an interview on 05/19/16 at 3:10 PM, Staff II, Infection Preventionist; Staff JJ, Infection Preventionist; Staff KK, Director of Infection Prevention for Facility Systems; Staff MM, Infection Preventionist, stated that they were aware of the incident with Patient #3 being transported to the Dialysis Unit. They stated that it shouldn't have happened, "And we don't know why".

During an interview on 05/23/16 at 2:50 PM, Staff AA stated that all Leaders and Directors had been made aware of the situation with Resistant ACB and the Dialysis Unit, and that there had been Huddles (meetings with all staff members working on the unit prior to the shift beginning that discuss important information regarding patients on the floor, new education, or updates from leadership) with staff on the nursing units.

During an interview on 05/23/16 at 3:50 PM, Staff BBB, Infection Control Physician, stated that Resistant ACB lives longer and is more resistant than other known resistant pathogens, which it why it is such a problem. He stated that the pathogen has the ability to infect when it becomes dry and can live on a surface for an extended period.

During an interview on 05/24/16 at 9:05 AM Staff ZZ, RN, stated that she had been Patient #3's primary nurse who sent her to the Dialysis Unit. She did not know what the facility policy and procedure was for isolation guidelines and had not been educated on that. She stated that there was no mechanism to alert the nursing staff as to specific pathogens. She stated that a normal patient assignment was five patients per nurse and that she would have to go into each clinical record to find out each patient's pathogen. She stated that she had worked 05/27/16, 05/28/16 and 05/29/16. When she was asked if she had received any education in the huddles about the incident or the pathogen, she stated, "No ma'am". When Staff ZZ was asked to describe the pathogen she stated, "Honestly, I would have to look it up".