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Based on record review and interview, the hospital failed to ensure that a registered nurse supervised and evaluated nursing care needs of one of one adolescent patient (Patient #6) who suffered from a chronic condition that reduced the blood flow to her heart and caused fluctuations in blood pressure. Hospital nursing staff did not evaluate the patient's vital signs or notify emergency services for at least 79 minutes while the patient experienced fainting episodes.

Refer to A0395

Based on record review and interview, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care according to patient needs for one of one patient (Patient #6) who suffered from a chronic medical condition that caused reduced blood return to the heart and fainting episodes. Nursing failed to assess Patient #6's blood pressure and heart rate for at least ninety minutes during incidents of the patient's temporary loss of consciousness.

Findings included:


Patient #6's Intake Assessment dated 08/21/16 at 1957 reflected admitting diagnoses that included Disruptive Mood Dysregulation Disorder and POTS (Postural Orthostatic Tachycardia Syndrome).


Nursing Admission Assessment dated "08/23[22]/16" at 0010 reflected Patient #6's vital signs and neurological symptoms which included migraine headaches, vertigo, loss of consciousness, and fainting.


Nursing Progress Notes dated 08/22/16, time not legible, reflected Patient #6 was in the consult room for a nurse interview. The patient "suddenly lost consciousness....secured safely from falling on floor...complained of having a headache and some chest pain..." There was no documented evidence of Patient #6's blood pressure or heart rate.


Nursing Progress Notes dated 08/22/16 at 0129 reflected that Patient #6 still had "syncopal [fainting] episodes and 911 called for assist in medical care..." There was no documented evidence of Patient #6's blood pressure or heart rate until 0145 on 08/22/16.


During an interview on 08/31/16 at 1440, Personnel #5 acknowledged the above findings.


Personnel #25 stated on 09/02/16 at 1535 that she was trying to maintain Patient #6's airway during the fainting episodes. The patient was not medically stable and needed to go to the medical hospital.



The National Institute of Neurological Disorders and Stroke (NINDS) noted that patients with POTS may have symptoms of "excessively reduced volume of blood returns to the heart ...can have fluctuation of blood pressure in either direction..." (http://www.ninds.nih.gov/disorders/postural_tachycardia_syndrome/postural_tachycardia_syndrome.htm).

Based on record review and interview, the hospital's nursing administration failed to ensure adequate evaluation of non-employee nursing personnel. Two of two non-employee registered nurses (Agency Personnel #25, and #36) did not receive hospital orientation prior to working at the hospital. Agency Personnel #36 worked more than 700 hours in patient care, and Agency Personnel #25 worked at least 90 hours before completing tests that evaluated the nurses' knowledge regarding patient care and safety issues.

Findings included:

Hospital records reflected Agency Nurse #36 worked 106 shifts of seven hours or more per shift between 02/13/16 and 08/25/16. Written tests regarding patient confidentiality (HIPAA), patient rights, patient abuse and neglect, safety in the environment of care, and infection control were dated 09/01/16, more than six months later. There was no documented evidence of emergency management of behavior and/or restraint and seclusion training.

Record review of hospital records reflected Agency Nurse #25 worked at least twelve shifts between 08/06/16 and 08/25/16.

Record review of Agency Personnel #25's file reflected the agency nurse had a completed a test regarding patient rights which was dated 09/02/16. Additional tests regarding patient confidentiality (HIPAA), abuse and neglect, and infection control were dated 09/01/16 and carried the agency nurse's signature only. There was no evidence of a hospital appointed instructor's signature.

Agency Personnel #25 denied during an interview on 09/02/16 at 1535 that she had received hospital orientation.

During an interview on 09/02/16 at 1040, Personnel #1 acknowledged the above findings.

Based on record review, interview, and observation the hospital's infection control officer failed to develop an efficient system for the prevention, control, and investigation of infections.

1) Items and surfaces difficult to disinfect and/or potentially harboring microorganisms were observed in patient care areas and included soiled and dusty floors, missing floor boards, peeled off wall paint, and ripped mattresses,
2) Paper towels were not available in patient bathrooms leaving patients to use toilet paper after hand hygiene, and
3) The hospital's infection control program expected hand hygiene compliance only from half of their employees. Infection surveillance failed to test all employees for tuberculosis.

Findings included:


1) Observations on 08/31/16 at 1540 in the hospital's dining room reflected four condiment bins with grainy white substance. A dried red substance was observed on the floor close to the exit to the conference room. Dried substance of a light gray color was observed in front of the tray return window. Two rolled up fabric rolls were observed on the floor in front of the hot bar. Personnel #5 identified the fabric rolls as "noodles" and stated he did not know why they were there.


Observations on the Adult Unit I Exam Room on 08/31/16 at 1600 reflected a broken piece of plastic in the overhead cabinet. The cabinet under the sink had two rolled up towels identified by Personnel #5 as not clean. A dark colored dried up spilled fluid was noted on the bottom of the cabinet.



Observations on the Adult Unit I on 08/31/16 at 1610 reflected peeled off wall paint in the bathroom connecting Rooms 101 and 102, leaving underlying wall material difficult to disinfect. Dust particles were observed on the floor between the window and the bed in Room 102. The mattress next to the window in room 102 had a large rip. Personnel #49 acknowledged the findings at that time.

Observations on Adult Unit II on 08/31/16 at 1635 reflected peeled off blue wall paint and dust next to the window in Room 111.


Ripped mattresses were observed on the hospital's Pediatric Unit on 09/01/16 at 1045 in Rooms 203 Bed A and 206 Bed B.


Observations on the hospital's Geriatric Unit on 09/01/16 at 1101 revealed the floor board in Room 117 was missing in two places. An unidentified staff member stated the missing floor boards had been identified with a work order. The surveyor requested copy of the work order. It was not provided.


The American Journal of Infection Control (June 2016) noted "growing evidence that demonstrates a clean environment is instrumental to the prevention of hospital acquired infections (HAI's). Environmental surfaces are a means of transmission of multi drug resistant organisms (MDRO's). MDRO's can survive on surfaces for extended periods of time" (http://dx.doi.org.ezp.waldenulibrary.org/10.1016/j.ajic.2016.04.082).


2) Observations on the Adult Unit I on 08/31/16 at 1615 reflected two rolls of toilet paper next to the sink adjacent to Room 105. There were no paper towels observed in the bathroom.


Observations on the hospital's Pediatric Unit on 09/01/16 at 1040 reflected no paper towels were available in patient bathrooms for Rooms 201, 204, and 206. Rolls of toilet paper were observed next to the sink. An unidentified patient stated there were no paper towels available for use after hand washing.


Observations on the hospital's Adolescent Girls Unit on 09/01/16 at 1055 reflected toilet paper at the sink in the bathroom for Room 210. There were no paper towels. Personnel #51 was asked about the patient use of paper towels and stated that patients "sometimes" used toilet paper to dry their hands after washing because the only paper towel dispenser were "out on the unit." There was nothing else visible or available for patients to dry their hands after washing.

The Centers for Disease Control (2016) recommended to "dry hands using a clean towel...to avoid getting sick and spreading germs to others."


3) The hospital's 2016 Infection Control and Employee Health Project/Performance Report reflected the hospital's benchmark for hand hygiene rate was set at 50 percent. The 2016 employee hand washing compliance rate was less than 85 percent.


The hospital's 2016 Infection Control and Employee Health Project/Performance Report reflected that the compliance rate with employee tuberculosis screening was less than 88 percent leaving one out of ten employees unscreened for symptoms of tuberculosis.


Personnel #1 and Personnel #49 acknowledged the above findings during an interview on 09/02/16 at 1345.


The hospital's Infection Control Program Policy IC 400.00 dated 09/01/16 reflected the purpose to evaluate, assess, and improve the hospital's Infection Control Program through surveillance, prevention, and control of infections.