HospitalInspections.org

Based on record review and interview, the facility failed to evaluate the need for corrective action plans for all parts of the hospital in 1 of 3 significant adverse events reviewed (Case #1).

Findings include:

Adverse event case #1, reviewed on 5/6/2015 at 10:00 AM, involved an inpatient elopement that had occured on 10/10/2014 at the ASLMC campus. Dir K stated at the time of the review that preventive actions had been implemented at all inpatient units at the ASLMC campus. Dir K stated the ASLSS and ASMC campuses of the hospital were not evaluated for being at similar risk for patient elopement to occur. Dir K stated ASLSS and ASMC campuses included inpatient care and could be at similar risk, Dir K stated preventive actions as a result of this adverse event had not been implemented at the ASLSS and ASMC campuses of the hospital.

Based on record review and interview, the facility staff failed to evaluate pharmacological pain effectiveness in 6 of 40 patients (Pt. #5, 14, 21, 22, 24 and 46) medical records reviewed after the administration of pain medications per policy. This deficiency has the potential to affect all patients treated for pain management at this facility.

Findings include:

Per review on 5/4/15 at 4:10 PM of facility policy titled Pain Management, #2006, dated 10/11, stated in part "VII. 2. To evaluate the pharmacological pain interventions, the following guidelines for reassessment are recommended: a. Reevaluate pain intensity/behavior within 30-60 minutes of administering an oral pain medication."

Per review on 5/5/15 at 10:00 AM of Pt. #14's medication administration record, Pt. #14 received a Tylenol on 5/5/15 at 8:08 AM, a re-assessment was not completed yet as of 10:00 AM.

Per review on 5/6/15 at 10:06 AM of Pt. #21's medication administration record, Pt. #21 received a Tylenol on 4/22/15 at 8:17 PM, a re-assessment was not completed until 12:00 PM.

Per review on 5/6/15 at 10:30 AM of Pt. #22's medication administration record, Pt. #22 received a Norco on 4/15/15 at 1:06 PM, a re-assessment was not completed until 8:00 PM.

Per review on 5/6/15 at 11:15 AM of Pt. #24's medication administration record, Pt. #24 received a Norco on 4/29/15 at 7:11 PM, a re-assessment was not completed until 8:41 PM.

Per interview with CNS LL on 5/5/15 at 10:15 AM. CNS LL stated staff are expected to complete and document a follow up pain assessment within an hour of a pain medication being given.




18816

Pt #5's MR review on 5/5/15 at 10:20 AM reveal Pt #5 arrived in the ED on 1/30/15 at 5:19 PM with complaint of hip pain rated 8 out of 10. Pt #5 was admitted to the hospital at 9:24 PM, there is no documentation of pain medication being administered to Pt #5 until 0:46 PM there is documentation of oxycodone (pain med) given with additional oxycodone given at 10:30 PM. On 1/31/15 Pt #5 is given oxycodone at 8:56 PM, there is no assessment related to effectiveness of the medication. On 2/1/15 at 7:34 PM, Pt #5 is given oxycodone, there is no documented assessment of the effectiveness of the medication until 9:14 PM when another dose is given. There is no reassessment of effectivness of the medication until 12:02 AM on 2/2/15.

This is confirmed in interview during MR review with RN Informatics TTTT during record review stating the reassessment should be done per policy.



29972

Per review on 5/5/15 at 3:30 PM of facility policy titled, "Pain Management" last revised 10/11, staff should reevaluate pain intensity and behavior within 15-30 minutes of an IV pain medication.

Review of Pt. #46's MR on 5/5/25 beginning at 2:40 PM revealed Pt. #46 was seen in the ED on 5/3/15 for complaints of pain with urination and flank pain. At 2:54 PM, Pt. #46 was given 4 mg of Morphine via IV line and then was discharged home ambulatory at 2:57 PM (3 minutes later).

Per interview during MR review with CNS KKKK, KKKK stated staff should have done pain reassessment as per policy before discharging Pt. #46 home from the ED.

Based on medical record review and interview the facility failed to develop nursing care plans based on patient needs for 2 of 35 inpatients (#8 and #35).

Findings include:

Facility policy "Nursing Documentation" #1008 dated 4/2015 states in part: "5.2 Documentation requirements for patient's nursing plan of care...C. Nursing plans of care are initiated based on patient needs, medical diagnosis, nursing diagnosis..."



18816

Pt #8's MR reviewed on 5/6/15 at 2:30 PM revealed Pt #8 had knee surgery on 5/5/15. The nursing care plan includes under Pain, Verbalized understanding and effective use of Patient Controlled Analgesia (PCA). Pt #8 does not have a PCA pump. This is confirmed in interview with Informatic JJJ during MR review, acknowledging the plan for PCA should not have been initiated.



29972

Review of Pt. #45's MR on 5/5/15 beginning at 10:30 AM showed on 4/25/15 Pt. #45 was admitted to the hospital for 5 days due to weakness and exacerbation of COPD (Chronic Obstructive Pulmonary Disease). Review of Pt. #45's Plan of Care shows no evidence of staffing developing of plan of care for COPD including setting measurable goals, interventions, and evaluations of outcomes. Per interview with CNS GGGG during Pt. #45's MR review, GGGG stated staff should have implemented a care plan related to Pt. #45's ineffective breathing pattern. GGGG was unable to find any evidence in Pt. #45's MR of staff implementing a care plan addressing Pt. #45's admitting diagnosis of COPD.

Based on record review, observation and interview, the facility staff failed to administer and document medication per policy in 1 of 1 staff (RN QQQQ) observed administering oral medication and failed to label and transport IV medications per policy in 1 of 1 surgical departments observed (OR). This deficiency could potentially affect all the patients at this facility.

Findings include:

Per review on 5/4/15 at 4:10 PM of facility policy titled Medication Administration, #2022, dated 12/14, stated in part under 4.13: "Caregivers will document the medication given after the actual administration has occurred, not prior to administration." Under Appendix B 6. "Make sure the patient has received the entire dose of medication according to the directions for administration and route." The policy goes on to state: "Prior to giving the patient the medication, the caregiver will verify the medication and...right patient, right drug, right dose..." The policy goes on to state: "Medications must not be removed for more than one patient nor should medications be carried around/stored in anticipation of future use..."

Per observation on 5/4/15 at 11:05 AM of RN QQQQ administering medications to Pt. #49. RN QQQQ mixed Miralax in a cup of juice and placed on the bed side table. Pt. #49 did not touch the medication mixed in juice. RN QQQQ documented medication being given at 11:06 AM, prior to leaving pt. room. RN QQQQ did not observe Pt. #49 take medication prior to documenting in medication administration record. Director of Advanced Practice Nurses (DAPN) D were present during the medication administration.

Per interview with DAPN D and Vice President of Nursing RR on 5/6/15 at 3:10 PM, DAPN D stated the nurses are expected to stay with the patients until medication is taken and then the nurse should document that the medication was administered.




18816

Per observation on 5/4/15 at 2:55 PM in the Outpatient Surgical Area OR 1 there are one syringe each of Cefazolin (antibiotic) and Lidocaine (numbing agent) that have no Pt name, date drawn, or initials of who drew up the medications. Per interview with RN SSSS at time of observation, the medications were drawn up at 1:30 PM in preparation for a case. Per interview with Mgr P, medication should not be drawn up more than an hour before a procedure.

Per observation on 5/5/15 at 9:15 AM Anesth AA removed two syringes from his/her scrub pocket in preparation to sedate Pt #4 in OR 2.

Based on record review and interview, the facility failed to properly retain medical records for the consent of forensic exam and acknowledgement of medical information pertaining to sexual assault in 2 of 2 sexual assault patients receiving sexual assault forensic exam (#42 and #43).

Findings include:

Facility protocol "Sexual Assault Treatment Center Medication Protocol" dated 1/2015, states in part: "Emergency Contraception: Patient must sign form stating that she has been given verbal and written information."

Per Pt. #42's MR, reviewed on 5/5/2015 at 3:05 PM, Pt. #42 presented to the ED on 9/6/2014 at 10:43 PM with a chief complaint of sexual assault. A sexual assault exam was performed. The MR does not contain a consent for exam or evidence that medical information about emergency contracteption was provided to the patient.

Pt. #43's MR, reviewed on 5/5/2015 at 3:20 PM, reveals Pt. #43 presented to the ED on 5/12/2014 at 1:20 PM with a chief complaint of sexual assault. A sexual assault exam was performed. The MR does not contain a consent for exam or evidence that medical information about emergency contracteption was provided to the patient.

During an interview with RN UUUU on 5/6/2015 at 10:50 AM, RN UUUU stated patients are given information sheet about emergency contraception and sign the form, but "we have had issues scanning records."

Dir K stated on 5/6/2015 at 2:10 PM the forms that Pts. #42 and #43 would have signed pertaining to sexual assault and emergency contraception had not been scanned into the electronic health record and the original copies had been "thrown away" by the MR department.

Based on observation and interview, the facility failed to ensure patient records are secure and protected from unauthorized access in 1 of 1 areas in which medical records are stored (storage room). This deficiency has the potential to affect all patients who receive treatment at this facility.

Findings include:

Per tour at ASLSS on 5/5/15 at 9:30 AM of the medical records storage area, accompanied by Manager of Health Information (MHI) MM noted films and paper files containing patient information.

Per interview with MHI MM on 5/5/15 at 9:35 AM, MHI MM stated EVS is responsible for cleaning the room but not sure when or how often it is done. MHI MM then stated the area does not get cleaned when staff is present.

Per interview on 5/5/15 at 9:45 AM, Administrator OO stated EVS cleans the department in the evening when HIM staff "are not present."

Based on record review and interview the facility failed to complete treatment plans per protocol for 2 of 5 BH patients (#12 and #13) and failed to authenticate consent forms in 4 of 49 patient medical records reviewed (#26, 27, 28, 29).

Findings include:

A MR review was conducted on Pt. #12's closed BH MR on 5/6/2015 at 11:00 AM accompanied by RN Mgr CCC, BH RN DDD, RN CNO EEE and MSW GGG who confirmed the following findings at the time of discovery:

Pt. #12 was discharged from BH on 4/20/2015. There is no documentation of treatment planning being completed in the "Doc Flow Sheets (the Doc Flow sheet is a section in the computer)."

In an interview with BH RN DDD on 5/6/2015 at 11:30 AM regarding "treatment planning" and this facility, RN DDD stated that treatment planning is a multi-disciplinary group meeting where discharge planning is discussed/determined and the expectation is that the information is then documented in the computer in the Doc Flow sheet section. The Doc Flow sheet is completed by the RN, social worker, or occupational therapist then the RN produces a progress note in the computer where the care plan gets pulled in which will indicate if outcomes were met or still need to be addressed. According to BH RN DDD, a paper form titled "BH Treatment Plan Acknowledgement," is meant to be the attestation that the treatment planning session took place and is signed by the patient and all staff members present. This form is then signed electronically by the MD.

Pt. #12's BH Treatment Plan Acknowledgement form was signed by Pt. #12 on 4/18/2015, the nurse case manager and the MSW signed the form indicating the date they completed the session was on 4/20/2015, two days after Pt. #12 signed the form.
There are two more lines for staff signatures that also have the date of 4/20/2015 but no corresponding signatures.

A MR review was conducted on Pt. #13's closed BH MR on 5/6/2015 at 11:00 AM accompanied by RN Mgr CCC, BH RN DDD, and RN CNO EEE, and MSW GGG who confirmed the following findings at the time of discovery:

Pt. #13 was discharged from BH on 4/21/2015. There is no documentation of treatment planning being completed in the Doc Flow Sheets.

A MR review was conducted on Pt. #26's closed OB MR on 5/5/2015 at 2:39 PM accompanied by CI RN BBB, Quality Dir WW, and MHU Mgr XX who confirmed the following findings at the time of discovery:

Pt. #26's AD information was incomplete upon admission and Pt. #26's Consent for Treatment agreement does not have the signature date or time a hospital representative offered information on privacy practices, payment policy, or patient rights.

In an interview with Mgr XX at 3:00 PM regarding who is responsible for ensuring these forms are completed, Mgr XX stated registration staff is unless the Pt. is a direct admit to the unit and then unit staff are responsible for offering this information and completing the consent form.

A MR review was conducted on Pt. #27's open MR on 5/5/2015 at 3:27 PM accompanied by CI RN BBB, Quality Dir WW, and MHU Mgr XX who confirmed the following findings at the time of discovery:

Pt. #27's Consent for Treatment agreement does not indicate a time the patient/hospital representative signed the form.

A MR review was conducted on Pt. #28's open MR on 5/5/2015 at 2:17 PM accompanied by CI RN BBB, Quality Dir WW, and MHU Mgr XX who confirmed the following findings at the time of discovery:

Pt. #28's Consent for Treatment agreement does not indicate a time the patients family member/hospital representative signed the form.

A MR review was conducted on Pt. #29's closed MR on 5/5/2015 at 3:03 PM accompanied by CI RN BBB, Quality Dir WW, and MHU Mgr XX who confirmed the following findings at the time of discovery:

Pt. #29's Consent for Treatment agreement does not indicate a time or date the patients family member/hospital representative signed the form and is not signed by a hospital representative.

Based on observation and interview, the facility failed to ensure medications are only accessible to authorized staff members in 2 of 21 patient care departments observed (OR and inpatient unit 3CD).

Findings include:



18816

On 5/4/15 between 2:10 PM and 2:58 PM in the Medical Building Outpatient Surgical Area the following was observed:

At 2:10 PM the crash cart in the Pre/Post Op area has a breakaway lock that will not prevent access when unattended. The area is unattended at night per interview with Sup. P at the time of the observation.

At 2:30 PM in OR 2 the following medications are unsecured: Precedux 400 mcg/ml (IV sedative), 2 vials of Tetracaine (numbing agent), 2 vials of irrigation solution.

At 2:58 PM while walking through the sterile corridor, there is a table with multiple basins containing medications. Per interview during observation, with Mgr P, the medications are pulled the night before for the next days cases. Per Mgr P the OR is locked, but housekeeping has access at night for cleaning.

On 5/5/15 at 1:39 PM in there is a breakaway lock on the crash cart by OR 12, allowing for unauthorized access.

On 5/5/15 at 2 PM there is a crash cart with a breakaway lock in the Day Surgery area, allowing for unauthorized access.

The above was discussed in interview with Dir M on 5/5/15 at 3:30 PM, acknowledging the carts should be locked.


29963


Per tour on 5/4/15 at 11:10 AM of Surgical Unit 3CD at ASLMC, observed a code cart secured with a plastic break away lock containing medications, being stored in an unlocked room labeled the clean utility room. This cart is stored in an area that can not be in view of staff. Findings were shared and discussed with Director of Advanced Practice Nurses (DAPN) E. DAPN E stated in an interview "while the cart is stored in an unlocked room, the door to the clean utility room is close to the nurses station". The code cart contains medication such as: Atropine, Epinephrine, Lidocaine, Dopamine, and other medications.

Based on observation and interview, the facility staff failed to discard an open, single use vial of medication 1 of 1 surgical departments (OR).

Findings include:

On 5/5/15 at 1:35 PM in the Main OR Anesthesia Supply Room, there is an open bottle of topical Lidocaine Hydrochloride (numbing agent) with no date. Per interview with Surg RN KK, on 5/5/15 at 3:30 PM the Lidocaine is a single use dose and should have been tossed.

Based on observation, interview and review of record documents the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for hospital services appropriate to the needs of the community. These deficiencies occur in all of the 215 smoke compartments and would affect all inpatients, outpatients, staff, and visitors within the facility.

Findings include:

A-700: The facility failed to maintain a safe environment from fire based on the following twenty-four (24) K-tags:
K-11 (building separation barrier);
K-17 (corridor wall assembly);
K-18 (corridor door openings);
K-20 (vertical opening or shaft);
K-22 (exit signs);
K-25 (smoke barrier assembly);
K-27 (smoke barrier doors);
K-29 (hazardous spaces);
K-32 (number of exits);
K-38 (exit access);
K-39 (width of aisles or corridors serving as exit access);
K-50 (fire drill requirements);
K-51 (fire alarm system with approved components, devices or equip. installed);
K-56 (installation of automatic sprinkler system);
K-62 (maintenance of automatic sprinkler system);
K-64 (maintenance of portable fire extinguishers);
K-74 (portable fire extinguishers);
K-77 (medical gas equipment);
K-130 (miscellaneous means of egress findings);
K-144 (emergency power system inspection and testing);
K-147 (electrical wiring, identification & equipment);
K-154 (automatic fire sprinkler system out-of-service for 4+ hours/24-hours);
K-155 (fire alarm system out-of-service for 4+hours/24-hours); and
K-211 (Alcohol Based Hand Rub (ABHR) dispensers).

Based on the cumulative effects of the above deficiencies, 42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET.

Please refer to the K-tags found later in this report for the specific findings.

Based on observation, interview and review of record documents the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for hospital services appropriate to the needs of the community. These deficiencies in all of the 215 smoke compartments and would affect all inpatients, outpatients, staff, and visitors within the facility.

Findings include:

A-700: The facility failed to maintain a safe environment from fire based on the following twenty-four (24) K-tags:
K-11 (building separation barrier);
K-17 (corridor wall assembly);
K-18 (corridor door openings);
K-20 (vertical opening or shaft);
K-22 (exit signs);
K-25 (smoke barrier assembly);
K-27 (smoke barrier doors);
K-29 (hazardous spaces);
K-32 (number of exits);
K-38 (exit access);
K-39 (width of aisles or corridors serving as exit access);
K-50 (fire drill requirements);
K-51 (fire alarm system with approved components, devices or equip. installed);
K-56 (installation of automatic sprinkler system);
K-62 (maintenance of automatic sprinkler system);
K-64 (maintenance of portable fire extinguishers);
K-74 (portable fire extinguishers);
K-77 (medical gas equipment);
K-130 (miscellaneous means of egress findings);
K-144 (emergency power system inspection and testing);
K-147 (electrical wiring, identification & equipment);
K-154 (automatic fire sprinkler system out-of-service for 4+ hours/24-hours);
K-155 (fire alarm system out-of-service for 4+hours/24-hours); and
K-211 (Alcohol Based Hand Rub (ABHR) dispensers).

Based on the cumulative effects of the above deficiencies, 42 CFR 482.41(b) Standard for Life Safety From Fire was NOT MET.

Please refer to the K-tags found later in this report for the specific findings.

Based on observation, record review and interview, this facility failed to maintain an environment that ensures the integrity of the structure, patient equipment and safety of supplies for patients and staff in 6 out of 23 departments observed (kitchen, maternal health, post partum, newborn intensive care unit, behavioral health and OR).

Findings include:

Kitchen observations:
A tour of the kitchen was conducted on 5/4/2015 at 10:34 AM accompanied by Food and Nutrition Dir SS, VPO TT. The following observations were made and confirmed by SS and TT at the time of discovery:

In the Juice cooler there were sections on the tile floor that appeared to have damaged/broken tiles. These surfaces were porous, not smooth, and therefore uncleanable. Per interview with Dir SS on 5/4/2015 at 3:20 PM regarding this finding, Dir SS stated those areas are where a non-skid surface had been placed but the surface was now wore away revealing the porous material.

Maternal Health unit observations:
A review of the facility's policy titled, "Sterile Packaging Integrity," dated 4/2015, was conducted on 5/5/2015 at 12:30 PM. The policy states in part, "Rotation of supplies is important to insure previously processed items are used before those more recently processed."

A tour of the MHU was conducted on 5/5/2015 at 9:00 AM accompanied by MHU Mgr XX and Quality Dir WW. The following observations were made and confirmed by XX and WW at the time of discovery:

In the clean utility room there were numerous packages of sterile supply packs with various sizes of forceps, Delee suction apparatus, and retractors that were dated anywhere between 2006 through 2013 underneath sterile packs dated 2014 and 2015. These items had not been rotated for use in a first in first out manner.

In the bathroom of room K241 the porcelain tub has a small chip of porcelain missing creating a rough surface rendering that area not cleanable for all microorganisms.

Post Partum unit observations:
A tour of the Post Partum unit was conducted on 5/5/2015 at 10:55 AM accompanied by MHU Mgr XX and Quality Dir WW. The following observations were made and confirmed by XX and WW at the time of discovery:

In room L205 there were numerous chips/holes in the porcelain tile of the shower wall. Mgr XX stated that there used to be a bench attached to the wall there and it was removed and the holes must have never been filled in or repaired.

NICU observations:
A tour of the MHU was conducted on 5/5/2015 at 9:45 AM accompanied by NICU Mgr ZZ and Quality Dir WW. The following observations were made and confirmed by ZZ and WW at the time of discovery:

Three 250cc bottles of sterile water were in the cabinet of the RT dirty utility room and all 3 had expired 1/2013.

Behavioral Health unit observations:
A tour of the BH unit was conducted on 5/6/2015 at 11:00 AM accompanied by RN Mgr CCC, BH RN DDD, and RN CNO EEE who confirmed the following findings at the time of discovery:

All of the rooms (with the exception of the Quiet room) along the hallway with the room numbers starting with 4204 have tears in the wallpaper exposing the porous drywall underneath which is uncleanable and therefore may harbor microorganisms. This constitutes seven patient rooms numbered from 4204-4211.

Also in these rooms, in the bathrooms, there is a series of breaches in the tile on the walls by the sinks. These areas do not have smooth surfaces that can be effectively cleaned and could potentially harbor microorganisms. There are also some rooms down the hallway starting with room 4103 that have these exposed areas. Room 4208 also has holes in the drywalled walls where it appears something was removed and the holes not repaired.




18816

OR unit observations:
Per observation on 5/5/15 at 9:47 AM, there is cracked grout in the lower left corner of the observation window in OR 2. Per interview with Dir M on 5/5/15 at 3:30 PM, Dir M acknowledged the need for washable surfaces in the OR.

Based on observation and Staff interview, the facility did not provide adequate ventilation due to lack of positive pressure in one Operating room, and one clean supply room of the main hospital in accordance with CDC and AIA guidelines. This deficient practice had a potential of contaminating air in clean spaces with undesirable contaminants, and causing possible infection in 2 of the 139 smoke compartments, and had the potential to affect all patients, staff and visitors within these smoke compartments.
The CDC guidelines can be found in the website

Findings include:
1. On 05/06/15 at 10:15 am, surveyor observed on the 3rd floor in OR number 8 that air was going into the operating room from the adjacent inner core space. The OR was actively engaged in a surgical procedure. The 2006 Guidelines for Design and Construction of Health Care Facilities requires Operating rooms to have positive pressure with relationship to other zones.
2. On 05/04/15 at 2:25 pm, surveyor observed on the 6th floor in clean supply room 6 LM that air was going into the room from the adjacent corridor. The 2006 Guidelines for Design and Construction of Health Care Facilities requires clean supply rooms to have positive pressure with relationship to other zones.
These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff LLL, staff MMM, staff NNN, staff OOO, staff PPP, staff QQQ, and staff RRR.

Based on observation, record review and interview the facility failed to maintain an environment to maximize infection prevention in 14 of 23 departments observed (kitchen, EVS, MHU, 3CD, 4EF, 4KLM, 11S, ICU, OR, Inpatient Rehab, CICU, Outpatient Rehab, Dialysis, ED). This has the potential to affect all patients receiving care at this facility.

Findings include:


26711

Kitchen at ASLMC:

A tour of the kitchen was conducted on 5/4/2015 at 10:34 AM accompanied by Food and Nutrition Dir SS, VP of OPs TT. The following observations were made and confirmed by SS and TT at the time of discovery:

In the Bakery freezer there were 3-4 pieces of icicles about 1 1/2-2 inches in diameter and approximately 2-4 inches in length on a box with food products and on the floor, and marks where water had dripped down onto cardboard boxes that contained food products from some pipes that came from the fans directly above it. Dir SS was unsure if this had been noticed by staff.

At a handwashing sink in the kitchen/food preparation area the only trash receptacle in the vicinity was a large bin with a cover that had to be lifted that was not next to the handwashing sink. There is a potential for re-contamination of hands if the cover is lifted. Dir SS asked a kitchen staff member what trash receptacle is used for that particular sink and the staff member confirmed it was the large bin with the lift up cover. Dir SS stated there should be a dedicated trash receptacle at all handwashing sinks.

Environmental Services at ASLMC:

A tour of the facility's housekeeping storage area was conducted on 5/4/2015 at 2:13 PM accompanied by Dir of EVS UU and DON VV. The following observations were made and confirmed by UU and VV at the time of discovery:

In an EVS storeage area where bins are dedicated for dirty mop heads there were 4 soiled/wet blue towels and one soiled mop head laying on the floor strewn about. Dir UU stated UU does not know why those would be on the floor.

A tour of the janitor closets on the 11th floor revealed one closet to have an open can of V8 juice and a water bottle and another closet to have a bottle of soda, a muffin in plastic wrap, and a coffee (travel type) cup. Dir UU confirmed that there should be no food or drink in the housekeeping closets.

Review of a staff training document provided on 5/6/2015 at 1:54 PM indicated EVS staff were trained on February 22, 2012 that no food or drink items are to be in the housekeeping closet.

An observation of Hskpr KKK was made at 2:30 PM performing a terminal clean of a discharged patient's room. A mop head used on a previous patient room remained on the mop when Hskpr KKK brought it into the cleaned room to do the floor. Dir UU confirmed that the mop head should have been removed after cleaning the previous room before moving on to the next room.

Maternal Health Unit at ASMC:

A review of the facility's policy titled, "Operating Room Attire," dated 10/8/2012, was reviewed on 5/5/2015 at 7:53 PM. The policy states in part, "Protective eyewear (i.e.: goggles or glasses with side shields) should be worn whenever activities could place personnel at risk for a splashing or spraying."

A tour of the MHU was conducted on 5/5/2015 at 9:00 AM accompanied by MHU Mgr XX and Quality Dir WW. The following observations were made and confirmed by XX and WW at the time of discovery:

In the kitchenette on the labor and delivery side of the unit there was a build up of debris (dust and packets of sugar). Mgr XX stated that EVS is responsible for cleaning the kitchenette.

In the MHU OR, RN YY was observed at 9:35 AM to have the surgical bonnet tucked behind the ears and the sleeves of the long sleeve cover jacket pushed up to the elbows. Mgr XX verbalized understanding that the potential for skin cell/bacteria shedding is increased with surgical apparel worn this way.

At 11:35 AM an observation of first year resident AAA was observed doing a circumcision on Pt. #30. Resident AAA had no eye protection and had the surgical bonnet tucked behind the ears.


29963

Surgical Inpatient Unit (3CD) at ASLMC:

Observation of RN D completing a surgical wound dressing change on Pt. #1 was completed on 5/4/15 at 10:20 AM, during the dressing change RN D used a cloth pad which was placed on the bed under the left foot. After dressing change was completed the cloth pad along with garbage and unused supplies was placed on the counter of the back wall ledge. RN D finish assisting Pt. #1, grabbed cloth pad off counter of back wall ledge and disposed of linen and garbage. RN D left room without disinfecting area which was contaminated from the cloth pad. CNS RRRR was present during observation of dressing change.

Observations were discussed with CNS RRRR and DAPN D after completion of dressing change on pt.#1 on 5/4/15 at 10:30 AM, CNS RRRR and DAPN D agreed area should have been disinfected with a cavi-wipe.

Per review on 5/6/15 at 2:50 PM of facility policy titled Ancillary Areas, procedure #12, undated, stated in part under note: Ancillary areas may include, but not limited to, corridors, kitchens, utility rooms...2. Damp dust and dry the following: all flat surfaces..."

Per tour of 3CD kitchenette on 5/4/15 at 11:10 AM, drawers had plastic containers filled with packets of salt/pepper, hot chocolate, and crackers. Plastic containers had remnant of open packets of salt/pepper, hot chocolate and cracker crumbs mixed with closed packets of items. Ice/Water machine had white film surrounding the spout.

Per interview with System Director Environmental Services (SDES) UU on 5/6/15 at 2:50 PM, SDES UU stated the "EVS department is responsible for cleaning the kitchenettes and aware that policy does not state how often the staff are expected to clean the kitchenettes".

Medical Telemetry Unit (4EF) at ASLMC:

Per tour of 4EF kitchenette on 5/4/15 at 11:45 AM, drawers had plastic containers with remnants of open packets of saltine crackers mixed with closed individually wrapped crackers. Ice/Water machine had white film surrounding the spout. Brown stains noted on the metal cupboards housing condiments.

Medical Telemetry Unit (4KLM) at ASLMC:

Per tour of 4KLM storage room noted the following on the floor: 8 plastic bags filled with pillows, a bag of empty aluminum cans and 2 harnesses used for machine to assist patients with transfers.

Per tour of 4KLM kitchenette on 5/4/15 at 11:55 AM, drawers had plastic containers with remnants of open packets of splenda and salt mixed with closed individually packaged condiments. Ice/Water machine had white film surrounding the spout.

Orthopaedic Spine Inpatient Unit (11S) at ASLMC:

Per review on 5/4/15 at 4:10 PM of facility policy titled Intravenous Catheter Care: Peripheral and Central, policy #1007, dated 2/15, stated in part under Table 1, page page 11 under 2. "For CVC (central venous catheter) dressing changes: CVC dressing changes will be completed using sterile supplies and aseptic technique including wearing a mask to reduce the transfer of microorganisms."

Observation of RN G completing a Peripherally Inserted Central Catheter (PICC) dressing change on Pt. #2 was completed on 5/4/15 at 3:20 PM, during the dressing change, RN G removed the old dressing and disposed in garbage with gloves. RN G donned sterile gloves without performing hand hygiene. During procedure RN G wore a mask covering only her mouth, RN G's nose was uncovered throughout entire procedure. DON H was present during dressing change and stated during an interview that "RN G should have completed hand hygiene before applying sterile gloves and mask should have been worn covering nose during dressing change."

Per interview with DAPN E on 5/6/15 at 3:10 PM, DAPN E stated "staff has been educated that masks should be worn to cover nose during during dressing changes."

Intensive Care Unit at ASLSS:

Per review on 5/4/15 at 4:10 PM of facility policy titled Hand Hygiene, policy #183, dated 5/15 stated in part under 4.5 Hand Hygiene (b) Hand rub viii After removing gloves.

Observation of RN NN completing a blood draw from an intravenous line from pt. #19 was completed on 5/5/15 at 11:20 AM, after the blood was collected in a tube, RN NN left the patient room, with same gloves used to collect blood, took tube of blood to centralized area near nurses station to analyze blood. Administrator OO was present during the blood draw procedure. Per interview with DAPN E on 5/6/15 at 3:12 PM, DAPN E stated "the nurse should have changed gloves and performed hand hygiene prior to leaving the room."

Per tour of 3rd floor at SSMC kitchenette on 5/6/15 at 12:05 PM, drawers had remnants of open packets of salt/pepper mixed with closed individually packaged condiments. Inpatient Services (IS) PP confirmed findins in kitchenette.

Per review on 5/6/15 at 8:00 AM of facility policy titled Standard and Transmission Based Precautions "Isolation" Policy, #2051, dated 10/14, stated in part under 6.3 Droplet Precautions- Personal Protective Equipment (PPE) required for entry into patient room: surgical mask or procedural mask.

Observation of RN QQ on 5/6/15 at 11:55 AM in pt. room #3113 was completed, accompanied by CNS LL. Signage on door indicated patient in room was on droplet precautions requiring masks to be put on prior to entering room. RN QQ completed hand hygiene, put on gloves and a mask, and entered room. Observed a visitor sitting in the room without a mask. After observation was completed, CNS LL was asked if visitors are expected to follow Personal Protective Equipment (PPE) requirements, CNS LL stated, "yes, the visitor should have been wearing a mask."


18816

Surgical Services at ASLMC:

Per interview with Sup P on 5/4/15 at 2:25 PM, the facility follows AORN (Association of Peri-Operative Registered Nurses) and APIC (Association for Professionals in Infection Control and Epidemiology) guidelines for the surgery departments.

Per review on 5/5/15 at 8:00 PM of AORN 2015 Edition Guidelines under Aseptic Practice Patient Skin Asepsis Recommendation IV.e "The antiseptic should be allowed to dry for the full time recommended...before sterile drapes are applied". Under Sterile Technic Recommendation VII Sterile fields should be constantly monitored. Under Aseptic Surgical Attire Recommendation I.c. "When in the restricted areas, all nonscrubbed personnel should completely cover their arms with a long-sleeved scrub top or jacket", and III "Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears, and facial hair". Under Aseptic Technique Environmental Cleaning Recommendation III.c.4 "Items that are used during a surgical or invasive procedure should be cleaned and disinfected...", and Sterilization and Disinfection Instrument Cleaning Recommendation XI.g.3. "Compressed air forced through the lumen eliminates moisture that can serve as a medium for microbial growth." Under Patient and Worker Safety, Environment of Care Part 2 Recommendation II.b. Semi-restricted area is defined as the peripheral support areas of the surgical suite including "...storage areas, work areas for process instruments; sterilization processing rooms, corridors leading from the unrestricted area to the restricted area of the surgical suite..."

Per review on 5/5/15 at 12:00 PM of Alcon Betadine 5% skin prep for eyes it states under Dosage and Administration "5. After the Betadine %5 Sterile Ophthalmic Prep Solution has been left in contact for two minutes, sterile saline solution in a bulb syringe should be used to flush the residual prep solution form the cornea, conjunctiva and palpebral fornices." (entire eye)

Per review on 5/6/15 at 6:00 PM of facility policy titled Surgical Attire, revised 11/13, it states under Policy: "All persons entering the semi-restricted and restricted areas of the surgical department are expected to be dressed in appropriate attired (sic) as follows: 1. Scrubs (shirt, pants, dress, jackets)...4. Hair Covering a) Personnel should cover head and facial hair when in the semi-restricted and restricted areas of the surgical suite."

Per review on 5/6/15 at 6:00 PM of facility policy titled Establishing a Surgical Sterile Field, reviewed 3/14, it states under 5.5 (b) "Sterile fields are prepared as close as possible to the time of use."

Per review on 5/6/15 at 6:00 PM of facility policy titled Hand Hygiene/Surgical Hand Antisepsis, reviewed 5/15, it states under Hand Hygiene 4.5 (b) Hand rub (alcohol-based waterless hand sanitizer)...iii Before and after patient contact...Before preparing and administering medication...viii After removing gloves..."

On 5/4/15 in the Medical Building Outpatient Surgical Area between 2:00 PM and 3:30 PM the following was observed:

At 2:15 PM there are baggies containing unlabeled cereal type foods and a hot chocolate mix with an expiration date of 1/29/2009. This is confirmed in interview at time of discovery with Sup P.

At 2:25 PM while in the semi-restricted corridor, Scribe Q who has a goatee, and Dir M who has a mustache are not wearing a mask to cover their facial hair. Dir M agreed in interview during observation, facial hair needs to be covered in the restricted and semi restricted areas.

At 2:35 PM during tour of the Outpatient Surgical Suite, viewing the sterile corridor through a window, SA R is observed turning away from an table with open instruments, while waiting for a case to finish in OR 2. SA R is observed grabbing own's upper arms with his/her fingers touching the backs of his/her arms, breaking sterility of own's gloves. This was confirmed in interview with Sup P during the observation.

At 2:50 PM RN S and SA T are observed with hair and ears not contained in a bonnet. SA T turned back to open sterile instruments. This is confirmed in interview with Sup P and Dir M during observation.

At 3:00 PM SPT U did not wash hands between glove changes when going from cleaning instruments to removing clean instruments from the washer. This is confirmed with Dir M in interview with Dir M at 3:30 PM.

At 3:15 PM SPT U while cleaning the table to hold instruments, did not ensure all surfaces were wiped down and wet with disinfectant. When drying instruments to prepare for wrapping and sterilizing, SPT U did not ensure tubing was completely dry after blowing air through, and did not ensure the irrigator was dry. This is confirmed with Dir M in interview with Dir M at 3:30 PM.

On 5/5/15 in the Medical Building Outpatient Surgical Area between 7:30 AM and 11:20 PM the following was observed:

At 8:10 AM during the IV start for Pt #4, RN Y removed the left glove, palpated the IV size, donned the same glove without the benefit of hand hygiene.

At 8:19 AM when administering eye drops to Pt #4, dabbed Pt #4's eye with a tissue, placed the tissue on a unwashable cloth chair.

At 8:34 AM MD Z did not perform hand hygiene when entering or leaving Pt #4's Pre-Op room.

At 9:00 AM MD AA did not perform hand hygiene after leaving Pt #4's Pre-Op room.

At 9:15 AM RN BB applied Betadine 5% Ophthalmic Prep to Pt #4's right eye, using a saturated gauze four times. RN BB immediately rinsed the eye with a syringe of sterile water, followed with wiping the eye dry with gauze, rather than allowing the prep to dry two minutes prior to rinsing. The manufacturer's instructions do not state to wipe the eye dry.

At 9:15 AM ST DD did not have all hair encased in a bonnet.

At 10:05 AM, Anesth Assistant EE did not place used clamps and scissors with other surgical instruments to be sterilized, rather wiped them with a disinfectant, did not open them to clean all surfaces, and placed them on the Anesthesia Cart for the next Pt case. EE did not wipe down the sides of the Anesthesia Cart or all surfaces of the Anesthesia Medication Cart. EE wiped the heart monitor wires as a group rather than individually to ensure all surfaces are clean.

During cleaning of the OR at 10:14 AM, Housekeeping staff FF and GG cleaned horizontal surfaces of equipment used, and did not clean all areas of the surgical microscope, light handles, Phago machine, all of stools and chairs that were used by staff, the wrist rest "halo" that goes around the Pt's head, did not wipe down computer keyboards, or the anesthesia chair.

During set up for the following eye surgery at 10:24 AM ST HH reached over the sterile table, when not gowned, to grab a sterile gown.

At 11:20 AM, Housekeeper FF while cleaning the Pre/post-op room after Pt #4 left, removed the three cushions at the head of the bed, wipe all side, and replaced them with out cleaning the bed where they attach.

On 5/5/14 during tour and observation of the Main OR and GI area the following was observed between 1:30 PM and 3:30 PM:

At 1:30 PM MD V is observed during a procedure in OR 11 wearing a skull cap, rather than a bonnet and regular eyeglasses, rather than eye protection.

At 1:40 PM ST W is observed in OR 18 with his/her back to two sterile tables with open instruments. Radiology Tech JJ does not have on a jacket.

At 3:02 PM MD X in OR 4 does not have on a jacket.

The above observations were shared with Dir M during interview on 5/5/15 at 3:30 PM who agreed proper PPE should be worn, the sterile field must be maintained, prep should be applied per manufacturer's instructions and cleaning of the OR should include all surfaces of all equipment used.


26390

Inpatient Rehabilitation ASLMC:

On 5-4-2015 at 12:10 the clean utility room was observed with VP Operations A and QMC B. The room contained 19 pillows in open plastic bags stored on the floor.

CICU Unit ASLMC:

On 5-4-2015 at 5:00 pm a review of the policy #2051, titled Standard and Transmission Based Precautions, effective 1/2014 was completed. The policy states in part, "Non critical equipment grid - Responsibility RT, movable equipment, stethoscope personal, cleaning solution - Cavi wipe, after each patient use."

On 5-4-2015 at 2:31 pm on the CICU floor, RT HHH was observed with pt. #3 performing a suction treatment. RT HHH auscultated pt. #3's lungs as part of the treatment, placing the used stethoscope around neck. When finished, RT HHH left pt. #3's room without cleaning the stethoscope. Outside pt. #3's room RT HHH was asked, when should the stethoscope be cleaned. RT HHH explained, it should have been cleaned after it was used and a Cavi wipe should have been used.

Rehabilitation Offsite location:

On 5-5-2015 at 8:25 am a observation of the storage room with Supervisor III and QMC B was made. The room contained dirty linens and stored clean linen along with clean supplies. The room had no clear separation of dirty and clean supplies.


29972

Dialysis Unit at ASLMC:
Review on 5/5/15 beginning at 12:00 PM of facility policy titled, "Standard and Transmission-based Precautions Isolation Policy" last revised 10/14 states the following: "Hand hygiene is performed before putting on gloves and after removal of gloves; Gloves must be worn whenever caregiver handles or touches visibly or potentially contaminated patient care equipment and environmental surfaces; Gowns are to be tied at the neck and waist and not hang loose on individuals."
On 5/4/15 beginning at 1:30 PM observed PCT MMMM initiating dialysis treatment on Pt. #47. Per interview with dialysis manager LLLL at the time of observation, LLLL stated Pt. #47 was in contact isolation for MRSA (Methicillin Resistant Staph Aureus). Per observation of MMMM, while preparing Pt. #47's CVC for dialysis treatment, MMMM's isolation gown was hanging off shoulders and not completely tied around neck and back and MMMM's hair braids (waist length) hung outside the front of MMMM's isolation gown allowing for potential exposure of clothes and hair to infectious contaminates. During observation, MMMM removed gloves after drawing blood off Pt. #47's CVC, then squirted sanitizer into left hand while obtaining gloves with right hand and then proceeded to rub in sanitizer with both hands, MMMM did not perform hand hygiene prior to obtaining clean gloves out of glove box; this allowed for potential contamination of clean supplies. During observation of Pt. #47 in contact isolation, observed PCT OOOO documenting on top of computer station within the contact isolation area without donning gloves and isolation gown. Per interview with LLLL during observation staff should don isolation gown and gloves when behind the curtains of dialysis station of a patient in contact isolation. LLLL stated when a patient is in contact isolation, all equipment within the dialysis station behind the curtains is considered "dirty" and staff should be wearing isolation gown and gloves.
On 5/4/15 beginning at 1:30 PM observed 3 garbage cans overflowing with packaging material and used supplies on the Dialysis unit. Per interview with LLLL at the time of observation, the garbage cans should have been emptied by staff and should not be overflowing.
Emergency Department at ASMC:
Per ED observations on 5/5/15 beginning at 2:20 PM, Pt. #48 came into the ED with a gunshot wound to the head. Observed RN IIII with gloved hands attempt to place an IV in Pt. #48's arm. RN IIII had visible blood on gloves and then proceeded to open supply cart drawers and obtain saline syringe with visibly soiled gloves potentially contaminating cart and clean supplies. After the emergency code was complete, RN IIII removed clean supply cart from room and locked cart. RN IIII failed to clean all areas of the cart including sides of carts and handles. RN IIII did not discard any of the potentially contaminated supplies in this supply cart. Observed RN IIII with soiled gloves enter code on the keypad to enter the "Laboratory" room in the ED potentially contaminating the keypad and exposing other staff to infectious contaminates. Confirmed findings during observation with CNS KKKK, per interview with KKKK at the time of observation, staff should not go into clean supplies with gloves on and gloves should be removed and hand hygiene performed before entering codes on keypads to enter secured rooms.
On 5/4/15 at 3:15 PM, observed a hand sanitizer dispenser outside of conference meeting room E and F soiled with a red residue on dispenser handle. Confirmed findings with Staff "B" at the time of observation.

Based on record review and interview, the facility failed to ensure Post Anesthesia Evaluations are conducted after Pts have recovered from the anesthesia received in 2 of 4 surgical MRs where general anesthesia was administered, out of a total 5 surgical records reviewed.

Findings include:

Per interview with RN O on 5/5/15 at 1:45 PM anesthesia staff does not always see Pts after delivering to the PACU post surgery.

Pt #5's MR review on 5/6/15 at 10:20 AM revealed Pt #5 had hip surgery on 2/1/15 under general anesthesia. Pt #5 is documented as arriving in PACU at 10:27 AM, the Final Anesthesia Post-Op Assessment is timed 10:37 AM, there is no additional notation by an Anesthesiologist indicating full recovery from general anesthesia. This is confirmed during MR review with RN Informatic TTTT acknowledging the Post-op note is 10 minutes post surgery, not allowing for full recovery from general anesthesia.

Pt #7's MR review on 5/6/15 at 2:00 PM revealed Pt #7 had hip surgery on 4/8/15 under general anesthesia. Pt #7 is documented as arriving in PACU at 10:43 AM, the Final Anesthesia Post-Op Assessment is timed 10:49 AM, there is no additional notation by an Anesthesiologist indicating full recovery from general anesthesia. This is confirmed during MR review with RN Informatic JJJ acknowledging the Post-op note is 6 minutes post surgery, not allowing for full recovery from general anesthesia.

Based on record review and interview, the facility staff failed to evaluate pharmacological pain effectiveness in 6 of 40 patients (Pt. #5, 14, 21, 22, 24 and 46) medical records reviewed after the administration of pain medications per policy. This deficiency has the potential to affect all patients treated for pain management at this facility.

Findings include:

Per review on 5/4/15 at 4:10 PM of facility policy titled Pain Management, #2006, dated 10/11, stated in part "VII. 2. To evaluate the pharmacological pain interventions, the following guidelines for reassessment are recommended: a. Reevaluate pain intensity/behavior within 30-60 minutes of administering an oral pain medication."

Per review on 5/5/15 at 10:00 AM of Pt. #14's medication administration record, Pt. #14 received a Tylenol on 5/5/15 at 8:08 AM, a re-assessment was not completed yet as of 10:00 AM.

Per review on 5/6/15 at 10:06 AM of Pt. #21's medication administration record, Pt. #21 received a Tylenol on 4/22/15 at 8:17 PM, a re-assessment was not completed until 12:00 PM.

Per review on 5/6/15 at 10:30 AM of Pt. #22's medication administration record, Pt. #22 received a Norco on 4/15/15 at 1:06 PM, a re-assessment was not completed until 8:00 PM.

Per review on 5/6/15 at 11:15 AM of Pt. #24's medication administration record, Pt. #24 received a Norco on 4/29/15 at 7:11 PM, a re-assessment was not completed until 8:41 PM.

Per interview with CNS LL on 5/5/15 at 10:15 AM. CNS LL stated staff are expected to complete and document a follow up pain assessment within an hour of a pain medication being given.




18816

Pt #5's MR review on 5/5/15 at 10:20 AM reveal Pt #5 arrived in the ED on 1/30/15 at 5:19 PM with complaint of hip pain rated 8 out of 10. Pt #5 was admitted to the hospital at 9:24 PM, there is no documentation of pain medication being administered to Pt #5 until 0:46 PM there is documentation of oxycodone (pain med) given with additional oxycodone given at 10:30 PM. On 1/31/15 Pt #5 is given oxycodone at 8:56 PM, there is no assessment related to effectiveness of the medication. On 2/1/15 at 7:34 PM, Pt #5 is given oxycodone, there is no documented assessment of the effectiveness of the medication until 9:14 PM when another dose is given. There is no reassessment of effectivness of the medication until 12:02 AM on 2/2/15.

This is confirmed in interview during MR review with RN Informatics TTTT during record review stating the reassessment should be done per policy.



29972

Per review on 5/5/15 at 3:30 PM of facility policy titled, "Pain Management" last revised 10/11, staff should reevaluate pain intensity and behavior within 15-30 minutes of an IV pain medication.

Review of Pt. #46's MR on 5/5/25 beginning at 2:40 PM revealed Pt. #46 was seen in the ED on 5/3/15 for complaints of pain with urination and flank pain. At 2:54 PM, Pt. #46 was given 4 mg of Morphine via IV line and then was discharged home ambulatory at 2:57 PM (3 minutes later).

Per interview during MR review with CNS KKKK, KKKK stated staff should have done pain reassessment as per policy before discharging Pt. #46 home from the ED.

Based on medical record review and interview the facility failed to develop nursing care plans based on patient needs for 2 of 35 inpatients (#8 and #35).

Findings include:

Facility policy "Nursing Documentation" #1008 dated 4/2015 states in part: "5.2 Documentation requirements for patient's nursing plan of care...C. Nursing plans of care are initiated based on patient needs, medical diagnosis, nursing diagnosis..."



18816

Pt #8's MR reviewed on 5/6/15 at 2:30 PM revealed Pt #8 had knee surgery on 5/5/15. The nursing care plan includes under Pain, Verbalized understanding and effective use of Patient Controlled Analgesia (PCA). Pt #8 does not have a PCA pump. This is confirmed in interview with Informatic JJJ during MR review, acknowledging the plan for PCA should not have been initiated.



29972

Review of Pt. #45's MR on 5/5/15 beginning at 10:30 AM showed on 4/25/15 Pt. #45 was admitted to the hospital for 5 days due to weakness and exacerbation of COPD (Chronic Obstructive Pulmonary Disease). Review of Pt. #45's Plan of Care shows no evidence of staffing developing of plan of care for COPD including setting measurable goals, interventions, and evaluations of outcomes. Per interview with CNS GGGG during Pt. #45's MR review, GGGG stated staff should have implemented a care plan related to Pt. #45's ineffective breathing pattern. GGGG was unable to find any evidence in Pt. #45's MR of staff implementing a care plan addressing Pt. #45's admitting diagnosis of COPD.

Based on record review, observation and interview, the facility staff failed to administer and document medication per policy in 1 of 1 staff (RN QQQQ) observed administering oral medication and failed to label and transport IV medications per policy in 1 of 1 surgical departments observed (OR). This deficiency could potentially affect all the patients at this facility.

Findings include:

Per review on 5/4/15 at 4:10 PM of facility policy titled Medication Administration, #2022, dated 12/14, stated in part under 4.13: "Caregivers will document the medication given after the actual administration has occurred, not prior to administration." Under Appendix B 6. "Make sure the patient has received the entire dose of medication according to the directions for administration and route." The policy goes on to state: "Prior to giving the patient the medication, the caregiver will verify the medication and...right patient, right drug, right dose..." The policy goes on to state: "Medications must not be removed for more than one patient nor should medications be carried around/stored in anticipation of future use..."

Per observation on 5/4/15 at 11:05 AM of RN QQQQ administering medications to Pt. #49. RN QQQQ mixed Miralax in a cup of juice and placed on the bed side table. Pt. #49 did not touch the medication mixed in juice. RN QQQQ documented medication being given at 11:06 AM, prior to leaving pt. room. RN QQQQ did not observe Pt. #49 take medication prior to documenting in medication administration record. Director of Advanced Practice Nurses (DAPN) D were present during the medication administration.

Per interview with DAPN D and Vice President of Nursing RR on 5/6/15 at 3:10 PM, DAPN D stated the nurses are expected to stay with the patients until medication is taken and then the nurse should document that the medication was administered.




18816

Per observation on 5/4/15 at 2:55 PM in the Outpatient Surgical Area OR 1 there are one syringe each of Cefazolin (antibiotic) and Lidocaine (numbing agent) that have no Pt name, date drawn, or initials of who drew up the medications. Per interview with RN SSSS at time of observation, the medications were drawn up at 1:30 PM in preparation for a case. Per interview with Mgr P, medication should not be drawn up more than an hour before a procedure.

Per observation on 5/5/15 at 9:15 AM Anesth AA removed two syringes from his/her scrub pocket in preparation to sedate Pt #4 in OR 2.

Based on observation and interview, the facility failed to ensure medications are only accessible to authorized staff members in 2 of 21 patient care departments observed (OR and inpatient unit 3CD).

Findings include:



18816

On 5/4/15 between 2:10 PM and 2:58 PM in the Medical Building Outpatient Surgical Area the following was observed:

At 2:10 PM the crash cart in the Pre/Post Op area has a breakaway lock that will not prevent access when unattended. The area is unattended at night per interview with Sup. P at the time of the observation.

At 2:30 PM in OR 2 the following medications are unsecured: Precedux 400 mcg/ml (IV sedative), 2 vials of Tetracaine (numbing agent), 2 vials of irrigation solution.

At 2:58 PM while walking through the sterile corridor, there is a table with multiple basins containing medications. Per interview during observation, with Mgr P, the medications are pulled the night before for the next days cases. Per Mgr P the OR is locked, but housekeeping has access at night for cleaning.

On 5/5/15 at 1:39 PM in there is a breakaway lock on the crash cart by OR 12, allowing for unauthorized access.

On 5/5/15 at 2 PM there is a crash cart with a breakaway lock in the Day Surgery area, allowing for unauthorized access.

The above was discussed in interview with Dir M on 5/5/15 at 3:30 PM, acknowledging the carts should be locked.


29963


Per tour on 5/4/15 at 11:10 AM of Surgical Unit 3CD at ASLMC, observed a code cart secured with a plastic break away lock containing medications, being stored in an unlocked room labeled the clean utility room. This cart is stored in an area that can not be in view of staff. Findings were shared and discussed with Director of Advanced Practice Nurses (DAPN) E. DAPN E stated in an interview "while the cart is stored in an unlocked room, the door to the clean utility room is close to the nurses station". The code cart contains medication such as: Atropine, Epinephrine, Lidocaine, Dopamine, and other medications.

Based on observation, record review and interview, this facility failed to maintain an environment that ensures the integrity of the structure, patient equipment and safety of supplies for patients and staff in 6 out of 23 departments observed (kitchen, maternal health, post partum, newborn intensive care unit, behavioral health and OR).

Findings include:

Kitchen observations:
A tour of the kitchen was conducted on 5/4/2015 at 10:34 AM accompanied by Food and Nutrition Dir SS, VPO TT. The following observations were made and confirmed by SS and TT at the time of discovery:

In the Juice cooler there were sections on the tile floor that appeared to have damaged/broken tiles. These surfaces were porous, not smooth, and therefore uncleanable. Per interview with Dir SS on 5/4/2015 at 3:20 PM regarding this finding, Dir SS stated those areas are where a non-skid surface had been placed but the surface was now wore away revealing the porous material.

Maternal Health unit observations:
A review of the facility's policy titled, "Sterile Packaging Integrity," dated 4/2015, was conducted on 5/5/2015 at 12:30 PM. The policy states in part, "Rotation of supplies is important to insure previously processed items are used before those more recently processed."

A tour of the MHU was conducted on 5/5/2015 at 9:00 AM accompanied by MHU Mgr XX and Quality Dir WW. The following observations were made and confirmed by XX and WW at the time of discovery:

In the clean utility room there were numerous packages of sterile supply packs with various sizes of forceps, Delee suction apparatus, and retractors that were dated anywhere between 2006 through 2013 underneath sterile packs dated 2014 and 2015. These items had not been rotated for use in a first in first out manner.

In the bathroom of room K241 the porcelain tub has a small chip of porcelain missing creating a rough surface rendering that area not cleanable for all microorganisms.

Post Partum unit observations:
A tour of the Post Partum unit was conducted on 5/5/2015 at 10:55 AM accompanied by MHU Mgr XX and Quality Dir WW. The following observations were made and confirmed by XX and WW at the time of discovery:

In room L205 there were numerous chips/holes in the porcelain tile of the shower wall. Mgr XX stated that there used to be a bench attached to the wall there and it was removed and the holes must have never been filled in or repaired.

NICU observations:
A tour of the MHU was conducted on 5/5/2015 at 9:45 AM accompanied by NICU Mgr ZZ and Quality Dir WW. The following observations were made and confirmed by ZZ and WW at the time of discovery:

Three 250cc bottles of sterile water were in the cabinet of the RT dirty utility room and all 3 had expired 1/2013.

Behavioral Health unit observations:
A tour of the BH unit was conducted on 5/6/2015 at 11:00 AM accompanied by RN Mgr CCC, BH RN DDD, and RN CNO EEE who confirmed the following findings at the time of discovery:

All of the rooms (with the exception of the Quiet room) along the hallway with the room numbers starting with 4204 have tears in the wallpaper exposing the porous drywall underneath which is uncleanable and therefore may harbor microorganisms. This constitutes seven patient rooms numbered from 4204-4211.

Also in these rooms, in the bathrooms, there is a series of breaches in the tile on the walls by the sinks. These areas do not have smooth surfaces that can be effectively cleaned and could potentially harbor microorganisms. There are also some rooms down the hallway starting with room 4103 that have these exposed areas. Room 4208 also has holes in the drywalled walls where it appears something was removed and the holes not repaired.




18816

OR unit observations:
Per observation on 5/5/15 at 9:47 AM, there is cracked grout in the lower left corner of the observation window in OR 2. Per interview with Dir M on 5/5/15 at 3:30 PM, Dir M acknowledged the need for washable surfaces in the OR.

Based on observation, record review and interview the facility failed to maintain an environment to maximize infection prevention in 14 of 23 departments observed (kitchen, EVS, MHU, 3CD, 4EF, 4KLM, 11S, ICU, OR, Inpatient Rehab, CICU, Outpatient Rehab, Dialysis, ED). This has the potential to affect all patients receiving care at this facility.

Findings include:


26711

Kitchen at ASLMC:

A tour of the kitchen was conducted on 5/4/2015 at 10:34 AM accompanied by Food and Nutrition Dir SS, VP of OPs TT. The following observations were made and confirmed by SS and TT at the time of discovery:

In the Bakery freezer there were 3-4 pieces of icicles about 1 1/2-2 inches in diameter and approximately 2-4 inches in length on a box with food products and on the floor, and marks where water had dripped down onto cardboard boxes that contained food products from some pipes that came from the fans directly above it. Dir SS was unsure if this had been noticed by staff.

At a handwashing sink in the kitchen/food preparation area the only trash receptacle in the vicinity was a large bin with a cover that had to be lifted that was not next to the handwashing sink. There is a potential for re-contamination of hands if the cover is lifted. Dir SS asked a kitchen staff member what trash receptacle is used for that particular sink and the staff member confirmed it was the large bin with the lift up cover. Dir SS stated there should be a dedicated trash receptacle at all handwashing sinks.

Environmental Services at ASLMC:

A tour of the facility's housekeeping storage area was conducted on 5/4/2015 at 2:13 PM accompanied by Dir of EVS UU and DON VV. The following observations were made and confirmed by UU and VV at the time of discovery:

In an EVS storeage area where bins are dedicated for dirty mop heads there were 4 soiled/wet blue towels and one soiled mop head laying on the floor strewn about. Dir UU stated UU does not know why those would be on the floor.

A tour of the janitor closets on the 11th floor revealed one closet to have an open can of V8 juice and a water bottle and another closet to have a bottle of soda, a muffin in plastic wrap, and a coffee (travel type) cup. Dir UU confirmed that there should be no food or drink in the housekeeping closets.

Review of a staff training document provided on 5/6/2015 at 1:54 PM indicated EVS staff were trained on February 22, 2012 that no food or drink items are to be in the housekeeping closet.

An observation of Hskpr KKK was made at 2:30 PM performing a terminal clean of a discharged patient's room. A mop head used on a previous patient room remained on the mop when Hskpr KKK brought it into the cleaned room to do the floor. Dir UU confirmed that the mop head should have been removed after cleaning the previous room before moving on to the next room.

Maternal Health Unit at ASMC:

A review of the facility's policy titled, "Operating Room Attire," dated 10/8/2012, was reviewed on 5/5/2015 at 7:53 PM. The policy states in part, "Protective eyewear (i.e.: goggles or glasses with side shields) should be worn whenever activities could place personnel at risk for a splashing or spraying."

A tour of the MHU was conducted on 5/5/2015 at 9:00 AM accompanied by MHU Mgr XX and Quality Dir WW. The following observations were made and confirmed by XX and WW at the time of discovery:

In the kitchenette on the labor and delivery side of the unit there was a build up of debris (dust and packets of sugar). Mgr XX stated that EVS is responsible for cleaning the kitchenette.

In the MHU OR, RN YY was observed at 9:35 AM to have the surgical bonnet tucked behind the ears and the sleeves of the long sleeve cover jacket pushed up to the elbows. Mgr XX verbalized understanding that the potential for skin cell/bacteria shedding is increased with surgical apparel worn this way.

At 11:35 AM an observation of first year resident AAA was observed doing a circumcision on Pt. #30. Resident AAA had no eye protection and had the surgical bonnet tucked behind the ears.


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Surgical Inpatient Unit (3CD) at ASLMC:

Observation of RN D completing a surgical wound dressing change on Pt. #1 was completed on 5/4/15 at 10:20 AM, during the dressing change RN D used a cloth pad which was placed on the bed under the left foot. After dressing change was completed the cloth pad along with garbage and unused supplies was placed on the counter of the back wall ledge. RN D finish assisting Pt. #1, grabbed cloth pad off counter of back wall ledge and disposed of linen and garbage. RN D left room without disinfecting area which was contaminated from the cloth pad. CNS RRRR was present during observation of dressing change.

Observations were discussed with CNS RRRR and DAPN D after completion of dressing change on pt.#1 on 5/4/15 at 10:30 AM, CNS RRRR and DAPN D agreed area should have been disinfected with a cavi-wipe.

Per review on 5/6/15 at 2:50 PM of facility policy titled Ancillary Areas, procedure #12, undated, stated in part under note: Ancillary areas may include, but not limited to, corridors, kitchens, utility rooms...2. Damp dust and dry the following: all flat surfaces..."

Per tour of 3CD kitchenette on 5/4/15 at 11:10 AM, drawers had plastic containers filled with packets of salt/pepper, hot chocolate, and crackers. Plastic containers had remnant of open packets of salt/pepper, hot chocolate and cracker crumbs mixed with closed packets of items. Ice/Water machine had white film surrounding the spout.

Per interview with System Director Environmental Services (SDES) UU on 5/6/15 at 2:50 PM, SDES UU stated the "EVS department is responsible for cleaning the kitchenettes and aware that policy does not state how often the staff are expected to clean the kitchenettes".

Medical Telemetry Unit (4EF) at ASLMC:

Per tour of 4EF kitchenette on 5/4/15 at 11:45 AM, drawers had plastic containers with remnants of open packets of saltine crackers mixed with closed individually wrapped crackers. Ice/Water machine had white film surrounding the spout. Brown stains noted on the metal cupboards housing condiments.

Medical Telemetry Unit (4KLM) at ASLMC:

Per tour of 4KLM storage room noted the following on the floor: 8 plastic bags filled with pillows, a bag of empty aluminum cans and 2 harnesses used for machine to assist patients with transfers.

Per tour of 4KLM kitchenette on 5/4/15 at 11:55 AM, drawers had plastic containers with remnants of open packets of splenda and salt mixed with closed individually packaged condiments. Ice/Water machine had white film surrounding the spout.

Orthopaedic Spine Inpatient Unit (11S) at ASLMC:

Per review on 5/4/15 at 4:10 PM of facility policy titled Intravenous Catheter Care: Peripheral and Central, policy #1007, dated 2/15, stated in part under Table 1, page page 11 under 2. "For CVC (central venous catheter) dressing changes: CVC dressing changes will be completed using sterile supplies and aseptic technique including wearing a mask to reduce the transfer of microorganisms."

Observation of RN G completing a Peripherally Inserted Central Catheter (PICC) dressing change on Pt. #2 was completed on 5/4/15 at 3:20 PM, during the dressing change, RN G removed the old dressing and disposed in garbage with gloves. RN G donned sterile gloves without performing hand hygiene. During procedure RN G wore a mask covering only her mouth, RN G's nose was uncovered throughout entire procedure. DON H was present during dressing change and stated during an interview that "RN G should have completed hand hygiene before applying sterile gloves and mask should have been worn covering nose during dressing change."

Per interview with DAPN E on 5/6/15 at 3:10 PM, DAPN E stated "staff has been educated that masks should be worn to cover nose during during dressing changes."

Intensive Care Unit at ASLSS:

Per review on 5/4/15 at 4:10 PM of facility policy titled Hand Hygiene, policy #183, dated 5/15 stated in part under 4.5 Hand Hygiene (b) Hand rub viii After removing gloves.

Observation of RN NN completing a blood draw from an intravenous line from pt. #19 was completed on 5/5/15 at 11: