HospitalInspections.org

On the days of the hospital validation survey based on record review and interview, the hospital failed to ensure updates to the patient's plan of care that included restraint information for 1 of 28 patient charts reviewed for restraints. ( Patient 3)

The findings include:

On 5/13/2014 at 3:40 p.m., review of Patient 3's medical record revealed the patient was placed in physical restraints on 5/08/2014 but the patient's plan of care was not updated to include restraints until 5/13/2014. On 5/13/2014 at 3:45 p.m., the finding was verified with Registered Nurse 1.

On the days of the hospital validation survey based on record review, interview, the hospital failed to ensure its staff documented every 2 hours for 1 of 28 charts reviewed for care of patients in restraints. (Patient 2)

The findings are:

On 05/13/14 at 2:55 p.m., review of Patient 2's chart revealed the patient was in two point and lap belt restraints on 05/05/14 at 06:00 a.m.. The next recorded nursing documentation was at 03:30 a.m. on 05/06/14 which showed the patient was still in two point and lap belt restraints. The next nursing documentation on 5/06/14 at 06:30 a.m. showed the patient was in a lap belt restraint only. There was no documentation every 2 hours and there was no documentation when the two point restraint was removed. The findings were verified on 05/13/14 at 3:30 p.m. by Clinical Nurse Specialist 1.

On the days of the hospital validation survey based on record review, interview, and review of hospital policies and procedures, the hospital failed to ensure all patient plans of care was updated every 24 hours per hospital policy for 1 of 28 inpatient charts reviewed (Patient 3) and documentation maintained for 1 of 28 patient charts reviewed (Patient 5).

The findings include:

On 5/13/2014 at 12:30 p.m., review of Patient 4's open medical record showed the patient was a 36 year old admitted with a diagnosis of Acute and Chronic Pancreatitis 1 week ago. Review of the patient's medical record revealed there was no evidence that the patient's plan of care was updated every 24 hours since 5/07/14.

Review of hospital policy, titled, Assessment and Reassessment of Patients, states, "...The plan of care will be reviewed by an Registered Nurse, at least, every 24 hours in consultation with appropriate members of the health care team and the patient/family. The plan of care will be revised as appropriate to the patient's condition and ongoing assessment / reassessment process.

On 05/13/14 at 1:40 p.m., review of Patient 5's chart revealed the patient was admitted on 05/06/14. Review of the patient's chart revealed the patient had been on two other patient units (5th tower and 8th tower) prior to transferring to this unit. Review of the patient's plan of care revealed there was no documentation from the patient's stay on the previous two units. On 05/13/14 at 2:00 p.m., during an interview with nursing staff from the 5th and 8th towers, staff revealed that all documentation is transferred with the patient. On 05/13/14 at 2:25 p.m., the finding was verified by Clinical Nurse Specialist 1.

On the days of the hospital validation survey based on review of hospital personnel files, interview, and review of hospital policy and procedures, the hospital failed to ensure 3 of 3 dialysis employees (Technician 3, Registered Nurse (RN) 18, and Nurse Manager (NM) 6) had documentation of required annual education.

The findings are:

On 5/15/14 at 2:00 p.m., review of hospital personnel files revealed Technician 3, RN 18, and NM 6 had no annual water training completed for 2014. Technician 3: No annual water training in personnel file. Annual Water Check Off was to be completed by 2/28/14. RN 18: last annual water training was completed 2/21/13. Annual Water Check Off was to completed by 2/28/14. NM 6: last annual water training was completed 3/11/13. Annual Water Check Off was to completed by 2/28/14. The findings were verified in an interview with the Director 1 on 5/15/14 at 4:15 PM.

Hospital Policy, titled, 7-02-03, Teammate Qualifications, reads, ".... 3. Teammate records will include at a minimum: ....Annual skills certification/ competencies....". Revision Date: September 2013.

On the days of the hospital validation survey based on observations, interview, and review of hospital policy and procedures, 1 of 18 Registered Nurses (RN) failed to minimize the potential transmission of infections during a procedure. (RN 14)

The findings are:

On 05/12/14 at 2:00 p.m., random observations of RN 14 in the Emergency Department revealed RN 14 obtained saline from a Normal Saline 1000 cc(cubic centimeter) bag via aseptic technique to use as a flush to check for intravenous (IV) patency. RN 14 failed to disinfect the IV port prior to connecting the syringe to ensure IV patency. On 05/12/14 at 2:10 p.m., RN 14 verified that the IV port should have been cleaned prior to connecting syringe.

Hospital Policy, titled, "Section: Nursing Administration; Subject: IV Therapy", reads, "....Aseptic technique is mandatory in the administration of IV fluids....".

On the days of the hospital validation survey based on chart review, interview, and review of the hospital policy and procedures, the hospital failed to ensure that documents for 2 of 28 inpatient charts (Patient 17 and 18) and 1 of 6 outpatient charts (Patient 19) were authenticated by the physician.

The findings are:

On 05/13/14 at 12:00 p.m., review of the hospital's outpatient charts showed Patient 19's outpatient chart revealed there was no date and time documented on the anesthesiologist consent and no time documented on the anesthesiologist pre-evaluation form by the anesthesiologist.






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On 5/14/14 at 1:10 p.m., review of Patient 17's open medical record revealed the anesthesia pre-evaluation note was completed on 5/12/14 but had no time that the evaluation was completed by the anesthesiologist.
The findings were verified with the Director 12 on 5/14/14 at 2:40 p.m..

On 5/14/14 at 3:30p.m., review of Patient 18's open medical record revealed the anesthesia pre-evaluation note was completed on 5/12/14 but has no time that the evaluation was completed by the anesthesiologist.
The finding was verified with Director 12 on 5/14/14 at 3:50 p.m..

Hospital policy, titled, "Medical Staff Rules and Regulations", reads, "....All clinical entries in the patient's medical record shall be accurately dated and authenticated....".

On the days of the hospital validation survey based on record review, interview, review of hospital policy and procedures and other submitted material, the hospital staff failed to acquire order clarification for 3 of 4 patient charts reviewed for blood flow rates (BFR) and dialysate flow rate (DFR) orders (Patient 2, 5 and 22), failed to acquire discharge order for 1 of 6 outpatient charts reviewed (Patient 3), and failed to obtain orders for oxygen for 1 of 28 inpatient charts reviewed (Patient 8).

The findings are:

On 05/12/14 at 1:50 p.m., observation revealed Patient 8 with a nasal cannula in nares with oxygen rate of 2 liters per min (lpm). Further review of Patient 8's chart revealed there was no physician orders for oxygen at 2 lpm. On 05/12/14 at 2:10 p.m., RN 14 revealed that the order for oxygen was in the respiratory protocol for the Emergency Department. Further review of Patient 8's physician orders revealed there was no protocol for respiratory ordered. The finding was verified by RN 14 on 5/12/14 at 2:10 p.m..

On 05/13/14 at 12:00 p.m., review of Patient 3's outpatient chart showed the patient was admitted on 05/13/14 at 6:17 a.m. for outpatient surgery and discharged on 05/13/14 at 9:45 a.m. Review of Patient 3's chart revealed there was no physician order for discharge. The finding was verified on 5/13/14 at 12:00 p. m. by RN 12.

On 05/13/14 at 1:40 p.m., review of Patient 5's chart revealed physician orders dated 05/09/14 for "BFR 250 ml (milliliters/min (minute), may adjust BFR to maintain adequate AP (arterial pressure) & (and) VP (venous pressure) dialysate 600 ml/min". Review of the patient's dialysis treatment sheet dated 5/09/14 revealed the BFR ran at 350 and the DFR ran at 500 for a perma catheter.

On 05/13/14 at 2:55 p.m., review of Patient 2's chart revealed physician orders dated 05/04/14 for "BFR 250 ml (milliliters/min (minute), may adjust BFR to maintain adequate AP (arterial pressure) & VP (venous pressure) dialysate 600 ml/min". Review of the patient's dialysis treatment sheet dated 05/04/14 revealed the DFR ran at 500. Review of physician orders dated 05/05/14 showed a physician order for "BFR 200 ml/min to 500 ml/min, may adjust BFR to maintain adequate AP & VP and DFR 600-800 ml/min". Review of the patient's dialysis treatment sheet dated 5/5/14 revealed the patient's BFR ran at 300 ml/min and the DFR ran at 500 ml/min. Review of physician orders dated 05/06/14 showed an open physician order for "BFR 200 ml/min to 500 ml/min, may adjust BFR to maintain adequate AP & VP and DFR 600-800 ml/min". Review of the patient's dialysis treatment sheet dated 5/6/14 revealed the patient's BFR ran at 300 ml/min and DFR ran at 400 ml/min. Review of physician orders dated 05/07/14 showed an open physician order for "BFR 200 ml/min to 500 ml/min, may adjust BFR to maintain adequate AP & VP and DFR 600-800 ml/min". Review of the patient's dialysis treatment sheet dated 5/7/14 revealed the patient's BFR ran at 400 ml/min and the DFR ran at 600 ml/min. Review of the physician orders dated 05/09/14 showed an open physician order for "BFR 200 ml/min to 500 ml/min, may adjust BFR to maintain adequate AP & VP and DFR 600-800 ml/min". Review of the patient's dialysis treatment sheet dated 5/9/14 revealed the patient's BFR ran at 400 ml/min and DFR ran at 600 ml/min. Review of physician orders dated 05/13/14 showed an open physician order for "BFR 200 ml/min to 500 ml/min, may adjust BFR to maintain adequate AP & VP and DFR 600-800 ml/min". Review of the patient's dialysis treatment sheet dated 5/13/14 revealed the patient's BFR ran at 375 ml/min and the DFR ran at 600 ml/min.

On 05/14/14 at 11:55 a.m., review of Patient 22's chart revealed open physician orders dated 05/09/14 for "BFR 250 ml (milliliters/min (minute), may adjust BFR to maintain adequate AP (arterial pressure) & VP (venous pressure) dialysate 600 ml/min". Review of the patient's dialysis treatment sheet dated 5/09/14 revealed a BFR of 400 ml/min and a DFR of 600 ml/min. Review of physician orders dated 05/12/14 showed an open physician order for "BFR 200 ml/min to 500 ml/min, may adjust BFR to maintain adequate AP & VP and DFR 600-800 ml/min". Review of the patient's dialysis treatment sheet dated 05/12/14 revealed the patient's BFR of 450 ml/min and DFR 700 ml/min. On 05/14/14 at 12:40 p.m., interview with Nurse Manager 6, he/she reported, "these are the standing orders for the patient and it can run anywhere from 200 to 500". When Nurse Manager 6 was asked if that apply for grafts/fistulas/catheters, he/she stated, "well, we know to run catheters at 400".

Hospital policy, titled, "Administrative Manual: Grouped Orders", reads, "....the use of order protocols must be documented as an order in the patient's medical record and authenticated by the prescriber responsible for the care of the patient....".

Hospital "Medical Staff Rules and Regulations", reads, "....Patients shall be discharged only on a written order of the attending practitioner....".

Hospital policy, titled, "Orders for Patient Care, Policy: 3-02-03, reads, "1. A physician....provides orders for patient care activities in one of the following ways:....c. Approves by signature patient specific standing orders....5. Standing orders are distinguished from protocols. A standing order is an order that directs an intervention until a new order replaces the order....".

On the days of the hospital validation survey based on observations, interview, and review of hospital policies, the hospital failed to inspect patient-specific and floor stock medications and biologicals to identify expired, mislabeled, or unusable available for patient use.

The findings are:

On 5/13/14 at 11:10 a.m., observations in the Post Anesthesia Care Unit (PACU) in the Hyperthermia cart revealed two (2) vials of Procainamide Hydrochloride 1 gram (gm)/ 2 milliliters (ml) that expired on 5/1/14.
The findings were verified with Director 5 and Nurse Manager 2 on 5/13/14 at 11:12 a.m.. On 5/13/14 at 11:29 a.m., observations in the Endoscopy Medication Area revealed 41 HP Fast tests that expired 4/14. The findings were verified with Director 5 and Endoscopy Supervisor 1.
On 5/13/14 at 12:03 p.m., observations in Operating Room (OR) 1- Cysto Room revealed 1-opened 100 ml bottle of Forane, liquid for inhalation, not labeled when opened. On 5/13/14 at 12:08 p.m., observations in OR 4 revealed 1 bottle of Serofurone 250 ml that was not labeled when opened.
On 5/13/14 at 12:15 p.m., observations in the anesthesia processing room revealed (2) opened 16 ounce bottles of 70% alcohol that were not labeled when opened and (1) opened 8 ounce bottle of Hydrogen Peroxide that was not labeled when opened. The findings were verified with Director 5, Quality Manager 4, and Anesthesia Manager 1 upon the observations.

Hospital policy number,titled, QSP-PHRM-0028, Inspections of Patient Care Areas and Clinics, reads, "....1. Patient care areas and clinics that store medications are inspected each month by a pharmacist or qualified designee for expired, damaged or unusable medications. 2. These medications are removed from pharmacy stock and patient care areas....".

On the days of the hospital validation survey based on observations and interview, the hospital failed to ensure the safety of patients by placing electrical outlet covers in the patient rooms and examination rooms on the pediatric unit, cracked peeling paint in the dialysis unit's water treatment area, and a large hole in the wall in the biohazard room in the operating room.

The findings include:

On 05/12/2014 at 1240, an observational tour of the second floor pediatric unit showed there were no outlet covers over the electrical outlets in any of the patient rooms or the patient examination rooms on the unit. The hospital's main group lead stated, "as far as he knew no outlet covers had ever been used on the pediatric unit in the 7 years he had been employed at the hospital." The finding was verified on 05/12/2014 at 1340 with the hospital's main group lead.




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On 05/13/14 at 11:00 a.m., random observations of the dialysis unit revealed cracked peeling paint around the edges of the wall behind carbon tank 1, carbon tank 2, water softener tank and the reverse osmosis machine. On 05/13/14 at 11:10 a.m., the findings were verified by Director 1.


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On 5/13/14 at 11:39 a.m., observations in the biohazard room in the operating room (OR) front hall revealed a large hole in the wall behind the door. During an interview with Director 5 on 5/13/14 at 11:39 a.m., he/she revealed, "That has been fixed before. They take those big carts and just ram them into the wall."

On the days of the hospital validation survey based on observations and interview, the hospital failed to ensure equipment was maintained to ensure an acceptable level of safety and quality.

The findings are:

On 5/131/4 at 12:22 p.m., observations in the anesthesia workroom showed an anesthesia cart with a Medfusion 3500 Infusion Pump that was last inspected on 5/24/12. During an interview with Anesthesia Technician 1, he/she revealed, "all of the equipment must be inspected at least annually. This one obviously hasn't been and we do still use it."

On the days of the hospital validation survey based on observations, interview, and review of the hospital's temperature logs, the hospital failed to ensure safety of all food by way of out of acceptable ranges for freezer temperatures in the dietary area greater than zero degrees, failure to label trays of food with date and time prepared, and out of date ranch dressing packets on the shelves.

The findings include:

On 5/12/2013 from 12:30 p.m.-3:00 p.m., random observations of the dietary area revealed the main freezer had a temperature of 15 degrees Fahrenheit(F). On 5/12/2014 at 1:00 p.m., during an interview with the Executive Chef, he/she verified the temperature was usually 10 degrees (F) but at the moment, the freezer was defrosting. On 5/12/2014 at 2:00 p.m., review of the logs for the freezer dated 2/10/2014 to 5/12/2014 revealed the freezer temperature was 10 - 12 degrees(F) on all recordings. The guidelines for the temperature for the freezer is -10 (F). On 5/13/2014 at 09:30 a.m., during an interview with the Director of the dietary department, he/she revealed " I was not aware the temperature was set this high and he/she was aware the food placed in the freezer was to be kept at 0 degrees (F).

On 5/12/2014 at 12:40 p.m., observations of the dry storage area revealed a box of ranch dressing had a label on the side dated 7/2013. It was found that the dressing had a shelf life of 6 months and was therefore expired.

On 5/12/2014 at 1:15 p.m., observations of the refrigerated area of the dietary department revealed 5 trays of cut up potatoes without a day of preparation label and 4 trays of pizzas without a day of preparation label. On 5/12/2014 at 1:20 p.m., a half bag of prunes unlabeled. On 5/12/2014 at 1:15 p.m., the findings were verified with the Chief Chef.

On the days of the hospital's validation survey based on review of employee files and interview, the hospital failed to ensure the Infection Preventionist had been appointed by the governing body.

The findings include:

On 05/12/2014 at 1:30 p.m., a review of the Infection Preventionist employee file revealed there was no evidence of board appointment to the position of Infection Preventionist or Infection Control Office in the file. The Infection Preventionist had been employed in the position since 10/19/2003, and the Vice President of Professional Services stated the Infection Preventionist transferred into a vacant position and did not have a board appointment. On 05/12/2014 at 1:35 p.m., the finding was verified with the Vice President of Professional Services.

On the days of the hospital validation survey based on observations, interviews, and review of hospital policy and procedures, the hospital failed to ensure its staff used acceptable principles of infection control to minimize the potential transmission of infectious agents throughout the hospital in the Emergency Department: (Emergency Department Technician1, Registered Nurse(RN) 5, Registered Nurse 6, Transporter 1, ED Technician 2, Multidisciplianry Technician 1, RN 9, 10, 11, and 12, Pharm D, Lab Technician 1, Respiratory Technician (RRT 5); in the Dialysis Unit: Clinical Certified Hemodialysis Technician (CCHT)3, Venipuncture Technician 2, Dietary Aide 2; in the Medical - Surgical Unit: Registered Nurse 3, RN 2, and RN 4, RN 17, and RN 16; in the Dietary Department: Tray Aide 1; in the Intensive Care Unit: Physician 1; in the 7-Tower Room: RRT 2 through appropriate hand hygiene, use of personal protective equipment (Family Member - Dialysis Unit) through lack of appropriate disinfection and/or cleaning of patient equipment, through opened unlabeled foods in refrigerators in the ambulatory care center, and through the opened Yankeur suction devices in the Post Anesthesia Care Unit (16, 17, 18, 21, 9, 10, 15, 14, 13, 5, 6, 1, 2, and 3) and Operating Rooms 3 and 4.

The findings are:

On 05/12/14 at 12:50 p.m., random observations of emergency department's triage area revealed Emergency Department (ED) Technician 1 had his/her fingers on the patient's left wrist with no gloves. ED Technician 1 exited the triage room, retrieved a wheelchair, and transported the patient to the room assigned. ED Technician 1 failed to clean the patient equipment (wheel chair) after patient transport. ED Technician 1 failed to don gloves or perform hand hygiene prior to touching the patient and failed to perform hand hygiene prior to exiting the triage room.

On 05/12/14 at 1253 p.m., random observations of the ED triage area revealed RN 5 escorted a patient from the waiting room to the triage room, placed the patient in a chair, placed a used disposable blood pressure cuff on the patient's arm, and obtained an oral temperature. RN 5 failed to dispose of the disposable patient equipment and failed to clean the non disposable patient equipment prior to and post patient use.

On 05/12/14 at 1:00 p.m., random observations of the ED triage area revealed ED Technician 1 escorted a patient from waiting room into triage room, placed the patient on a used disposable blood pressure cuff, pulse oximetry and obtained an oral temperature. ED Technician 1 failed to dispose of disposable patient equipment and failed to clean non disposable patient equipment prior and post patient use. On 05/12/14 at 1:03 p.m., ED Technician 1 revealed the equipment get wiped down with approved wipes, the staff wear gloves or use hand sanitizer between patient use, and in the triage area, disposable blood pressure cuffs are reused until soiled.

On 05/12/14 at 1:03 p.m., RN 5 revealed, "We just use our common sense" when asked about the hospital policy on disposable patient items or equipment. On 05/12/14 at 1:04 p.m., Director 9 could not recall the hospital policy for disposable patient items or equipment.

On 05/12/14 at 1:35 p.m., random observations revealed RN 6 entered a patient's room, scanned the patient's bracelet, labeled a blood tube with without gloves, and exited the patient's room. RN 6 failed to perform hand hygiene before and after exiting the patient's room and failed to don gloves when handling possible contaminated specimens.

On 05/12/14 at 1:45 p.m., random observations of hospital Transporter 1 revealed Transporter 1 entered and exited patient room 30 without performing hand hygiene.

On 05/12/14 at 1:48 p.m., random observations of ED Technician 2 revealed ED Technician 2 cleaned the counter top of ED room 30, exited ED room 30, and stated that cleaning of the ED 30 was completed. Observations showed ED Technician 2 failed to clean the patient call light, monitor screen, and cable wires. On 05/12/14 at 1:49 p.m., ED Technician 2 stated that he/she did know to clean all patient equipment between patient use, but he/she was in a hurry to move the hallway patient into the room.

On 05/12/14 at 3:15 p.m., random observations of Multidisciplinary Technician 1 revealed Multidisciplinary Technician 1 escorted a patient in the ED waiting room to the X-ray room, placed a lead apron on the patient, failed to clean the apron, and after completion of the radiograph, returned the patient to the ED room via wheelchair. At 3:25 p.m., Radiologist Technician 1 escorted a patient into the X-ray room and placed the same lead apron on the patient without cleaning the apron. On 05/12/14 at 3:30 p.m., Radiologist Technician 1 stated that the equipment is suppose be cleaned after every patient. On 05/12/14 at 3:31 p.m., Multidisciplinary Technician 1 stated, "I was coming back to clean it, but the patient was brought in to quick."

On 05/14/15 from 11:28 a.m. until 11:50 a.m., random observations of a "Code Blue" revealed Respiratory Technician 5 failed to perform hand hygiene when exiting the patient's room. RN 10 failed to perform hand hygiene when exiting the patient's room. RN 11 removed soiled gloves and failed to perform hand hygiene prior to exiting the patient's room. Lab Technician 1 entered and exited the patient's room several times wearing the same gloves. Lab Technician 1 failed to remove soiled gloves prior to and after entering and exiting the patient's room. RN 9 failed to perform hand hygiene after removing soiled gloves and prior to donning clean gloves. Pharm D 1 failed to perform hand hygiene prior to exiting the patient's room and re-entering the patient's room with medication. RN 12 exited the patient's room wearing the soiled gloves.

On 05/14/12 at 11:53 a.m., Director 10 and Clinical Nurse Specialist 1 revealed that it is expected staff members will perform infection control measurers but also to provide the patient with care.

Hospital policy, titled, "Reuse of Disposable Supplies", reads, "all supplies designated as "disposable " or "one time use only" are discarded after their initial use....".

Hospital policy, titled, "Hand Hygiene", reads, "....cleanse hands: before and after contact with a patient's intact skin (i.e. taking pulse/blood pressure, or lifting a patient)...."Wash in-Wash out" principle may be used when entering and leaving the patient's room to assure hand hygiene before and after patient contact....Alcohol-base hand rub: place a quarter size of gel into one palm and rub hands together, covering all of the surfaces of the hands and fingers until hands are dry or about 30 seconds....Soap and water: wet hands with warm water, apply 3-5 ml of soap to hands, rub vigorously for at least 15 seconds, covering all surfaces of hands and fingers....".

Hospital policy, titled, "Electronic Equipment Cleaning and Disinfection", reads, "...complex items or those requiring frequent cleaning and disinfection (i.e. between patients) are the responsibility of the department...".




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On 05/14/14 at 08:57 a.m., random observation of the dialysis unit revealed Venipuncture Technician 2 in room 7 during a blood draw by Technician 3 without personal protective equipment (PPE).

On 05/14/14 at 08:58 a.m., random observations of the dialysis unit revealed Clinical Certified Hemodialysis Technician (CCHT) 3 placed paper tape strips to the patient's bedside rail and used on the patient's access site after dialysis.

On 05/14/14 at 09:02 a.m., random observations of the dialysis unit revealed the label maker was removed from Patient Room 6 and placed on the nurse's counter without disinfection after use.

On 05/14/14 from 11:30 a.m. to 12:00 p.m., random observations of the dialysis unit revealed a patient's family member in Room 7 without PPE during the patient's dialysis treatment and left the unit without performing hand hygiene prior to exiting.

On 05/14/14 from 12:10 p.m. to 12:30 p.m., random observations of the dialysis unit revealed CCHT 3 de-accessed the needles from the patient's left upper arm and applied a clamp to the upper fistula site and the removed the clamp. After removal of the clamp, Technician 3 removed all PPE and carried the clamp with bare hands to a container with bleach water.

On 05/14/14 at 12:12 p.m., random observations of the dialysis unit revealed Dietary Aide 2 entered the dialysis unit, carried a meal tray into Room 3 and exited the patient's room and the dialysis unit without performing hand hygiene.

Hospital policy, titled, "Infection Control For Dialysis Facilities, Policy: 12-07-01,....16." reads, "Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces....PPE is to be removed prior to leaving the treatment area....25. Non-disposable items....are not to be shared unless disinfected between patients....".




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On 5/13/2014 at 10:30 a.m., random observations in the dietary area revealed Tray Aide 1 removed gloves, donned a new pair gloves without performing hand hygiene to set up food trays. On 5/13/2014 at 10:45 a.m., the finding was verified with Tray Aide 1.

On 5/13/2014 at 11:30, observations of Registered Nurse 3 administering a medication by mouth revealed the RN 3 entered the patient's room with the computer, introduced self, verified name and date of birth, checked the patient's name bracelet, scanned the medication, gave education regarding the medication, and donned gloves, but RN 3 failed to sanitize hands prior to donning gloves. On 5/13/2014 at 11:40, the finding was verified with RN 3.

On 5/13/2014 at 12:30 p.m., observations of RN 2 administering medications revealed RN 2 entered the patient's room, checked the patient's blood pressure (BP) with a manual BP cuff, then placed the BP cuff back on the medication cart without cloeaning the blood pressure cuff. On 5/13/2014 at 12:40 p.m., interview with RN 2, reveal he/she did not know what to use to clean the BP cuff, and this was not a usual practice.

On 5/13/2014 at 2:45 p.m., observation of RN 4 administering medications revealed RN 2 entered the patient's room, performed hand hygiene, introduced self, informed the patient, scanned the patient's bracelet, scanned the medication label, asked the patient for date of birth and name, removed the gloves and donned a new pair of gloves and hung an intravenous medication without performing hand hygiene between gloving. On 5/13/2014 at 2:50 p.m., the finding was verified with RN 4.




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On 5/12/14 at 1:48 p.m., observations in the Intensive Care Unit (ICU) Room 106 revealed Physician 1 failed to perform hand hygiene prior to entering or exiting the patient rooms. The findings were verified with Assistant Director 1 on 5/12/14 at 1:48 p.m..

On 5/12/14 at 2:42 p.m., observations on 7-Tower Room 719 revealed RRT 2 failed to disinfect the dynamap machine when using it between patients and placing the machine back into a clean area. On 5/12/14 at 3:38 p.m., observations on 7-Tower Room 709 revealed RRT 2 failed to disinfect his/her stethoscope after patient assessment. The findings were verified with RRT 2 after the observations at 2:42 p.m. and 3:38 p.m.

On 5/13/14 at 10:40 a.m., observations in the patient nourishment refrigerator in the Ambulatory Care Center (ACC) revealed (1) half pint of 1% lowfat chocolate milk and (1) half pint of 2% reduced fat milk was opened in the side door of the refrigerator with no date when opened.
The findings were verified with Director 5 on 5/13/14 at 10:40 a.m..

On 5/13/14 from 11:05 a.m. and 11:09 a.m., observations in the Post Anesthesia Care Unit (PACU) revealed opened Yankauer suction devices in PACU Rooms 16, 17, 18, 21, 9, 10, 15, 14, 13, 5, 6, 1, 2, and 3. The findings were verified with Director 5 and Manager 2 from 11:05 a.m. to 11:09 a.m. upon the observations. On 5/13/14 at 11:41 a.m., observations in Operating Room (OR) 3 revealed an opened Yankauer suction device laying across the suction canister. On 5/13/14 at 12:08 p.m., an observation in OR 4 revealed an opened Yankauer suction device laying across the suction canister. The findings were verified with Director 5 and Anesthesia Manager 1 upon the observations at 11:41 a.m. and 12:08 p.m..








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On 05/13/2014 at 11:35 a.m., observation of RN 17 performing a wound dressing change on the third floor joint unit showed RN 17 donned a clean pair of gloves, performed the dressing change to the patient's surgical wound incision, removed the soiled gloves, performed hand hygiene for less than 5 seconds. After documenting on the computer and before leaving the patient's room, RN 17 performed hand hygiene using soap and water for less than 10 seconds. On 05/13/2014 at 11:55 a. m., the findings were verified with RN 17.

On 05/13/2014 at 2:40 p.m., observations of RN 16 administering medications on the surgical fourth floor showed RN 16 performed hand hygiene with soap and water for less than 15 seconds. On 05/13/2014 at 2:24 p.m., the finding was verified with RN 16.

Review of hospital policy and procedures, titled, "...SECTION: HAND HYGIENE...NUMBER: QOP-IC-HH-0001...REVISED 09/2002...Policy/Procedures:" reads, " ...4. Technique A. Alcohol-based hand rub 1) Place a quarter size of gel into one palm and rub hands together, covering all of the surfaces of the hands and fingers until hands are dry or about 30 seconds. Pay attention to the area under and around the nails. B. Soap and water: 1) Wet hand with warm water 2) Apply 3-5 ml (milliliters) of soap to hands 3) Rub vigorously for at least 15 seconds, covering all surfaces of hands and fingers 4) Rinse with warm water 5) Dry thoroughly with a disposable towel 6) Use towel to turn off faucet...".

Guidelines and standard nursing practice in the health care setting set forth in the Recommendation and Reports for the Centers for Disease Control, reads, "Morbidity and Mortality Weekly Report Recommendations and Reports October 25, 2002/Vol 51/No. RR-16 Guideline for Hand Hygiene in Health-Care Settings...2. Hand-Hygiene technique...B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacture to hands and rub together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (lB) (90-92,94,411)...". Guidelines and standard nursing practice in the health care setting set forth by the Centers for Disease Control, reads, "...Hand Hygiene Guidelines Fact Sheet...When using an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry...".

On the days of the hospital validation survey based on record review, interview, and review of hospital policy and procedures, the hospital failed to ensure the medical staff updated the patient's history and physical (H&P) for 1 of 6 patient records reviewed. (Patient 18)

The findings are:

On 5/14/14 at 3:30 p.m., review of Patient 18's open chart revealed there was no updated H&P completed for the day of surgery. The findings were verified with Director 5 on 5/15/14 at 4:10 p.m..

Hospital policy, titled, Medical Records 1.1, reads, "....c.. When the history and physical examination are not recorded before an operation or any potentially hazardous diagnostic procedure, the procedure shall be canceled, unless the attending practitioner states in writing that such delay would be detrimental to the patient....".