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29354

Based on Program Staffing Models and Minimum Staffing schedule review, interview, and policy review, the provider failed to maintain registered nurse (RN) coverage at all times for six of six psychiatric treatment units (Birch One, Birch Two, Cedar One, Cedar Two, Oak One, and Oak Two). Findings include:

1. Review of the provider's 4/13/18 Program Staffing Models and Minimum Staffing policy revealed there should have been a minimum of one RN on all the units at all times.

Interview on 6/26/18 at 2:45 p.m. with RN F regarding licensed nurse staffing on each of the above units revealed:
*She was the charge nurse for the acute evening shifts.
*There was always an RN on each unit each shift.
*They utilized a float RN.
*The float RN would go between units and assist with licensed nurse coverage.
*If an RN needed to be replaced for example illness then the float RN was the first nurse to be used for that replacement.
*If the float nurse was utilized as a unit nurse they would not have a float nurse.
*Sometimes she had to fill in as a unit RN if someone was ill.

Interview on 6/26/18 at 1:15 p.m. with the director of nursing (DON) regarding licensed nurse/RN coverage on each of the above units revealed:
*They had two RNs who were scheduled on the day shift Monday through Friday on each unit.
*They had one RN on each unit on the evening, night, and weekend (day, evening, and night) shifts.
*There had been times during a code green emergency or a code blue emergency a unit had not been covered by an RN if they had been assigned to be the code responder.
*If the RN assigned to be the code responder left the unit then the unit was typically covered by the next door or "sister unit", but there would not be an RN physically on that unit.
*They did not have a policy for RN coverage for each unit.
*They had staffing "minimums."
*Her expectations would be to have each unit covered twenty-four hours per day everyday by two RNs.
*During the past four months they had left a unit unattended by an RN during a code response, but no adverse occurrences had occurred.
*Due to the acuity on the units they had times when an RN had been assigned as the code responder but had not been able to respond per their facility policy.
-Nothing significant or harmful had occurred to the patient but had put the code responders and patients at risk.
*During the day the charge nurse would cover for lunch breaks for their "sister units."
*During the evening, night, or weekend the RN could leave the unit depending on the acuity of the unit and if the "sister unit" was okay with it, but they always had an RN available.
*There were currently twenty-six RN vacancies.

Surveyor: 18559
Interview on 6/27/18 at 9:20 a.m. with the youth treatment supervisor C revealed:
*They had one nurse cover on Oak One, Oak Two, and Birch Two at night.
*A cover nurse position had been created to cover nurses if they had to leave the unit, but the cover nurse for Oak One and Oak Two was currently not filled.
*If the nurse for Oak One, Oak Two, or Birch Two would have to leave the unit for an emergency the nurse on the other unit would have to cover both units.

Surveyor: 29354
Interview on 6/28/18 at 7:40 a.m. with the director of clinical services regarding the licensed nurse coverage on the above units revealed:
*Each of the following unit bed capacities included:
-Birch One/acute adult: fifteen beds.
-Birch Two/acute adolescent: fifteen beds.
-Cedar One/acute adult: twenty-three beds.
-Cedar Two/one-half adolescent and one-half adult: fourteen beds.
-Oak One/acute adolescent: twenty beds.
-Oak Two/adolescent: sixteen beds.
*His expectations for licensed nurse coverage on each of the units included:
-Licensed nurses had emergency responsibilities.
-He would defer nursing responsibilities to the DON.

Review of the provider's undated Nursing Services, Nursing Administration, Chapter 5, revealed: "Hours of Service: Registered Nurses are on site to meet patient care needs 24 hours per day, 7 days per week."

Review of the provider's 6/5/18 Nursing Administration/Patient Care policy revealed:
*"Policy: A Code blue is called and procedures shall be initiated in the event that a victim experiences an obstructed airway, respiratory arrest, cardiac arrest, and/or a potentially life threatening event. A victim may be a patient, trusty, visitor, or staff.
*Purpose: To ensure emergency equipment, medication, supplies, and trained team are available in cases of airway obstruction, respiratory arrest, cardiac arrest, and/or a potentially life threatening event.
*Responsible Parties:
-Nurse Manager/House supervisor.
-RNs/LPNs.
*Equipment:
-Code Blue Team wears beepers and responds to code Blue Calls:
--IV [intravenous] RN.
--Recording RN.
*The first available RN shall be the coordinator of the Code Blue Scene:
-Ensure an RN to record; until arrival of assigned Recording RN.
-Ensure an RN to be in charge of suctioning.
-Ensure an RN to start the Patient Transfer Form.
-Ensure an RN/staff to perform CPR [cardiopulmonary resuscitation] as needed."

Review of the provider's 6/5/18 Code Green policy revealed:
*"Policy: A Code Green shall be initiated when there is a risk that a patient may become harmful to self or others and additional assistance is required to maintain safety.
*Purpose:
-To provide a mechanism for assistance and intervention in order to protect patient(s) when a patient(s) behavior is likely to become harmful to self or others.
-To maintain a safe and therapeutic environment.
*Responsible Parties: code Green Response Team members.
*Treatment Unit Staff:
-Staff assigned on treatment units who have the responsibility of patient care during an assigned period of time.
-Treatment unit staff may include registered nurses.
*Code Green Response Team members:
-Assigned staff from designated areas which will include Birch 1, Birch 2, Cedar 1, Oak 1, and Oak 2.
-One staff and one back up staff from each area shall be assigned each shift.
*Procedure:
-V. Code Green Area.
--A. the nurse in charge of the unit, or Nurse Manager/House supervisor in areas other than patient care units, shall:---1. Designate a staff member who is familiar with the patient to directing staff including the Code Green Response Team members.
--B. The person directing the Code Green shall be present at all times.
--C. If the attending physician is unable to respond to the Code, an RN shall contact the on-call physician for further orders, if needed."

A. Based on observation, record review, interview, and policy review, the provider failed to ensure one of one steam sterilizer had been monitored for temperature, pressure, and sterilization cycle. Findings include:

1. Observation on 6/27/18 at 4:00 p.m. of a steam sterilizer located in the central supply room revealed:
*A log book was kept to monitor weekly biological tests.
*Sterilization pouches with chemical indicators.
*A notebook contained a log of the equipment sterilized.

Review of the provider's notebook log to monitor the sterilizer from 4/6/18 to 6/26/18 revealed:
*The pieces of equipment processed for each day were documented.
*The weekly biological test was documented.
*The temperature, pressure, and sterilization cycle had not been documented for each load.

Interview on 6/27/18 at 4:00 p.m. and on 6/28/18 at 8:45 a.m. with radiologic technologist A revealed:
*She was responsible for sterilizing equipment with the steam sterilizer.
*She had been trained by the previous central supply person.
*The following equipment were sterilized in the steam sterilizer:
-Bite blocks for the electroconvulsive therapy department.
-Hemostats.
-Knife blade handles.
-Pick-ups.
-Bandage scissors.
*She kept a log of where the equipment went, but had not monitored temperature, pressure, or what cycle each equipment load had been processed with.
*She had been monitoring the steam sterilizer according to how she had been trained.
*The hospital's infection control policies were written in accordance with the Centers for Disease Control and Prevention (CDC) and the Association for Professionals in Infection Control and Epidemiology (APIC).

Interview on 6/28/18 at 1:40 p.m. with infection control coordinator B revealed:
*She received the monthly biological test results from the sterilizer but no information concerning temperature, pressure, or sterilization cycles.
*Radiologic technologist A had been trained by the previous central supply director.
*The infection control policies had been modeled after the CDC and APIC.

Review of the 11/22/11 Installation and Operation Guide for the M9 Self-Contained Steam Sterilizer revealed:
*The recommended steam sterilization monitoring program should have included physical monitors and process monitors.
*Physical monitors included temperature and pressure.
*Process monitors included biological and chemical indicators.
*The printer accessory should have been kept to create a record of the load's actual cycle time, temperature, and pressure.

Review of the provider's undated Sterilization and Storage of Reusable Items Dispensed From Central Service policy revealed no mention of a program to monitor the steam sterilizer.

Review of the 2008 CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities revealed:
*Sterilization procedure should have been monitored for mechanical, chemical, and biological indicators.
*The mechanical monitors for steam sterilization included the daily assessment of cycle time and temperature and an assessment of the pressure.
*"Ensuring consistency of sterilization practices requires a comprehensive program that ensures operator competence and proper methods of cleaning and wrapping instruments, loading the sterilizer, operating the sterilizer, and monitoring of the entire process."

Review of the 2009 APIC TEXT of Infection Control and Epidemiology, page 55-10, revealed "The staff should document each sterilizer load number, date, time, contents of load, outcomes of chemical indicators and integrators, outcomes of biological indicators, outcomes of mechanical indicators (e.g. time, temperature, and pressure), and the operator's name or initials."



29354

B. Based on observation, interview, policy review, and contract review, the provider failed to ensure one of one certified registered nurse anesthetist (CRNA) (D) contracted worker maintained appropriate infection control technique during three of three observed sampled patients (9, 14, and 31) electroconvulsive therapy (ECT) treatments. Findings include:

1. Observation on 6/27/18 at 7:15 a.m. in the ECT Suite revealed:
*In the procedure area was CRNA D, registered nurse (RN) E, and the medical director.
*Patient 9 was laying on a gurney.
*Following the ECT procedure CRNA D:
-Removed the blood pressure (BP) cuff from the patient's left arm.
-The BP cuff dropped onto the floor.
-He then picked the BP cuff up and placed it over the hook on the cart.
*Patient 9 was transferred on the gurney to a recovery area.

2. Observation on 6/27/18 at 7:32 a.m. in the same above ECT Suite procedure room revealed:
*Patient 31 was brought into the area on a gurney.
*CRNA D removed the gloves he had been wearing during the observation of patient 9 at 7:15 a.m. Without performing hand hygiene CRNA D:
-Placed an intravenous (IV) bag of Lactater's Ringer (LR) on the IV pole.
-Opened the IV tubing.
-The top end of the IV tubing touched the floor.
-Picked up the tubing, removed the cap of the IV tubing, and inserted it into the IV bag.
-Without performing hand hygiene put on a new pair of gloves.
-Took the patient's left hand and laid it on top of the covers.
-Opened the IV start kit and laid the items on top of the patient's covers without first laying down a clean barrier.
-Attempted to start the IV.
-Went to the other side of the bed.
-Took the patient's right hand and laid it on top of the covers.
-Checked for an IV site.
-Cleaned the IV site and inserted the IV needle.
-Removed the inner cannula to the IV needle and placed it on top of the patient's covers.
-Removed the supplies from the bed covers and discarded them.
-Removed his gloves and without performing hand hygiene put on a new pair of gloves.
-Removed a clean syringe and a vial of Robinal, drew up the medication, and administered it into the IV line.
*During that time RN E took the BP cuff that had been used on patient 9 and without cleaning or disinfecting it placed it on patient 31's left upper arm.
*CRNA D applied the oxygen mask to patient 31 and inserted a mouth guard or "bite block."
*Following the ECT procedure CRNA D:
-Removed the BP cuff from his left arm.
-The BP cuff fell onto the floor.
-Picked the BP cuff up and placed it over the hook on the cart.
-Removed the oxygen mask and mouth guard.
*At 7:52 a.m. CRNA D with the same pair of gloves on left the procedure area and went across the room to the recovery area with patient 31.

3. Observation on 6/27/18 at 7:55 a.m. CRNA D left the recovery area and returned to the same above ECT Suite procedure area wearing the same pair of gloves. He then removed his gloves and without performing hand hygiene:
*Identified patient 14 who was in the procedure room.
-Hung a new bag of LR IV solution.
-Opened a new package of IV tubing.
-The IV tubing touched the floor.
-Removed the capped end of the IV tubing and inserted it into the LR bag.
-Without performing hand hygiene he put on a new pair of gloves.
-Without creating a clean barrier he laid the IV start supplies on top of the covers.
-Inserted the IV into patient 14's right hand.
-Administered medications through the IV line.
-Without cleaning or disinfecting the BP cuff that had been used on patients 9 and 31 he applied it to patient 14's left arm.
-Applied a clean oxygen mask and inserted a mouth guard into patient 14.
*Following the ECT procedure he removed his gloves and without performing hand hygiene he:
-Left the procedure area.
-Went across the room to the recovery area.
-Entered the area where patient 31 was and without performing hand hygiene began to view the medical chart.

4. Interview on 6/27/18 at 8:20 a.m. with CRNA D regarding the above observations revealed:
*He agreed he had not changed his gloves or performed hand hygiene.
*He probably should have done hand hygiene.
*He should have done hand hygiene between each patient.
*The IV tubing was covered when it had touched the floor, but he should have noticed when it had.

Interview on 6/27/18 at 1:30 p.m. with the director of nursing (DON) regarding the above observations revealed:
*Her expectations would have been for CRNA D to follow the policies and procedures for hand washing and universal precautions.
*CRNA D was a contracted worker.

Interview on 6/27/18 at 2:50 p.m. with RN/ECT nurse coordinator E regarding the above observations revealed:
*They did not typically put down a barrier for IV starts.
*Her expectations would have been to do hand hygiene after removal of gloves and between patient contact.

Interview on 6/27/18 at 4:05 p.m. with the DON regarding the above observations revealed:
*They did not have a job description for CRNA contracted workers.
*There had not been any competencies for infection control completed for CRNA D.
*CRNA D was not an employee of the hospital.
*Her expectations would have been to have CRNA D follow their policies.

Interview on 6/28/18 at 8:30 a.m. with infection control coordinator B regarding the above observations revealed:
*Her expectations were to have all employees and contracted workers follow proper protocols regarding performing appropriate hand hygiene.
*There should have been:
-A barrier laid down prior to the IV starts.
-An overbed table used instead of the top of the covers to do the IV starts.
*Items should not have been laid directly on top of the patient.
*The IV tubing should have been discarded after touching the floor.

Review of the provider's 3/27/18 Handwashing Technique and Use of Hand Sanitizers policy revealed:
*Purpose:
-"To prevent spread of infection."
-"NOTE: Handwashing and the use of hand sanitizers are the most effective techniques for preventing the spread of infection."
-"Cleanse hands before:
--Preparing medication.
--Caring for a patient.
-Cleanse hands after:
--Giving care to patient or handling his equipment.
--Preparing and passing medication.
--Following the removal of gloves.
--Following exposure to any blood or other potentially infectious material even if gloves have been worn."

Review of the provider's 6/5/18 Intravenous Insertion policy revealed:
*"Aseptic technique and standard universal precautions and protective equipment will be used."
*Procedure: "Wash your hands and put on gloves and/or protective clothing or equipment."

Review of CRNA D's contract with the provider with a period of performance as of 6/1/18 through 5/31/19 revealed:
*"B. The Provider agrees to perform the following services:
-5. To observe and abide by the hospital policies and by-laws."

Review of the APIC Text of Infection Control and Epidemiology, 3rd Edition, 2009, pages 19-3, 20-1, and 21-4 through 21-5 revealed:
*Page 19-3: Indications for Hand Hygiene:
-"Before and after direct patient contact.
-Before inserting invasive devices.
-After contact with patient's intact skin (e.g., taking pulse or blood pressure).
-After removing gloves.
-After contact with objects and equipment in the patient's immediate vicinity.
-When moving from a contaminated body site to a clean body site during patient care"
*Page 20-1: Aseptic technique involves using barriers "To prevent transferring microorganisms from the environment to the patient during the procedure being performed."
*Page 21-4 through 21-5: "Noncritical items are those items that contact intact skin but not mucous membranes. Examples are blood pressure cuffs, linens. These items could potentially contribute to secondary transmission by contaminating hands of healthcare workers or by contact with medical equipment that will subsequently come in contact with patients."