HospitalInspections.org

Based on observations and interviews it was determined the facility failed to ensure the patients were in a safe environment in the Geropsych Unit. This had the potential to negatively affect all patients being served by this Geropsych Unit.

Findings include:

An intial tour was conducted on the Geropsych Unit on 7/2/12 at 12:30 PM. The surveyor noted 9 of the 10 patient rooms had call light cords that measured 3 to 4 feet in length. The hospital beds were electric with electric cords that measured 3 to 4 feet. The cords looped around and banded together with pull ties.

An interview was conducted on 7/2/12 at 1:30 PM with Employee Identifier (EI) # 1, the Nurse Manager for the Geropsych Unit who verified the cords were 3 to 4 feet long.

An interview was conducted on 7/4/12 at 11:00 AM with EI # 2, the Program Director who verified the cords could be unsafe for the patients.

Based on the review of the medical records, observation and interviews, it was determined the nursing staff failed to ensure patients' medications were administered according to the physician's orders. This negatively affected Medical Record (MR) # 2 and had the potential to negatively affect all patients served by this facility.

Findings include:

An observation of medication administration for MR # 2 was conducted 7/3/12 at 8:00 AM. After the observation of medication administration, the surveyor reviewed the physician orders for MR # 2.

Review of the Medication Reconciliation Order Form dated 6/22/12 revealed orders to continue Klor-Con (potassium) 10 meq. (milliequivalents) 2 tabs twice a day.

Review of the physician's orders revealed a 24 hour chart check on 6/22/12.

Review of the potassium level collected 6/22/12 at 11:00 AM revealed a level of 2.9 (normal 3.5 to 5.10).

Review of the physician's order dated 6/22/12 or 6/23/12 (date difficult to read) revealed orders for the patient to receive KCL (potassium) 40 meq daily for 4 days. This order was noted by the nursing staff on 6/23/12 at 1:00 PM.

Review of the physician's orders revealed a 24 hour chart check on 6/23/12, 6/24/12, 6/25/12, 6/27/12, 6/28/12, 6/29/12, 6/30/12, and 7/1/12.

Review of the Medication Administration Record (MAR) revealed the patient received the following:

Micro K (potassium cl) 2 -10 meq tabs on:
6/22/12 at 7:51 PM
6/23/12 at 9:11 AM
6/23/12 at 8:16 PM
6/24/12 at 7:59 AM

Micro K 20 meq tab on 6/24/12 at 11:14 AM

Micro K (4 tablets) - 10 meq tabs on:
6/25/12 at 8:17 AM
6/26/12 at 8:01 AM
6/27/12 at 8:10 AM

There was no documentation the patient received any potassium after 6/27/12 or the 40 meq daily for 4 days.

An interview was conducted with Employee Identifier (EI) # 1, Nurse Manager for the Geropsych unit on 7/3/12 at 8:30 AM. The surveyor asked why the nurse did not administer the Micro K 2-10 meq tabs that AM. EI # 1 called the pharmacist and asked what happened to the Micro K 2-10 meq tabs twice a day order written on 6/22/12. After the phone call ended EI # 1 said the pharmacist told her when the potassium order written on 6/22/12 or 6/23/12 automatically stopped the first order. The surveyor asked was the physician contacted and the response was," no".

Review of the MR # 2 on 7/3/12 at 3:00 PM revealed a potassium level obtained on 7/3/12 at 11:30 AM which read 2.6 (lower than the 2.9 on 6/22/12). A physician's order was received on 7/3/12 at 1:45 PM for the patient to receive Klor-Con 40 meq twice a day with a potassium level every other day.

An interview was conducted on 7/4/12 at 2:00 PM with EI # 7, the Director of Nurse. The surveyor asked if the 24 hour chart checks indicated the staff reviewed the physician's orders and the MAR included all physician medication orders and the response was, "yes".

Based on review of medical records, polices and procedures and interview, it was determined in 2 of 3 Geri-psych Unit records reviewed the treatment plans did not include therapeutic interventions for the nursing and physician needs of the patient, nor that the physician attended the Interdisciplinary Treatment Plan and Review. The interventions were not updated when the patients' condition did not improved. This affected Medical Record (MR) # 1, and # 2 and had the potential to affect all patients served on the Geropsych Unit.

Findings include:

Facility Policy: Treatment Planning Process # 05.002

1.0 Purpose:

To ensure plans for care, treatment, and service are individualized to meet the patient's unique needs and circumstances

2.0 Policy

A. Each patient admitted to the Program has an individualized written treatment plan that is based on interdisciplinary clinical assessments. The treatment planning process is continuous and dynamic, beginning at the time of admission and continuing through discharge. Patients and families are actively involved in the treatment planning process...

4.0 Problem Identification and Interdisciplinary Team Meeting

D. Interdisciplinary Team Meetings

The initial treatment team meeting is held no later than three days after admission at which time the Interdisciplinary Treatment Plan is reviewed and revised. Each team member is responsible for having completed their assessment and to, present a summary in the team meeting. The treatment team meetings are directed by the Attending Psychiatrist...

5.0 Procedure for Completing Interdisciplinary Treatment Plan

I. The Treatment Team Participant Signature section should be completed by each person involved in the Interdisciplinary Treatment Plan.


P. Define specific interventions which comprise the treatment that will be utilized to help patient achieve short- and long-term goals on the Individual Treatment Plans. Include the frequency of each activity, (example: process group 1 hour five times a week to identify contributors to depression) which discipline will be responsible for implementation, focus of intervention, and when possible the name of person responsible...

7.0 Interventions

A. Interventions are the action each discipline will take to assist the patient in meeting the short-term goals. Each discipline lists interventions related to the problem and short-term goals.

1. Interventions are discipline specific.

2. Interventions are specific and should be concise and clearly defined.

3. Interventions list the frequency, the action/focus, and the person responsible for completion.

Facility Policy: Treatment Team Protocol # 05.004

1.0 Purpose

To develop a coordinated consistent and well-focused approach to treating the patient.

4.0 Subsequent Team Reviews

C. Format

1. The program facilitates the review with the Attending Physician.

4. The Treatment Plan review will identify and a brief descriptive, measurable summary of patients' progress or lack thereof for each short-term goal. The Individual treatment plan will reflect change in target date, interventions and/or short-term goals to enable patient to achieve their treatment goals.


1. MR # 2 was admitted to the facility on 6/22/12 with diagnoses including Paranoid Schizophrenia.

Review of the Interdisciplinary Treatment Plan dated 6/22/12 revealed no documentation the physician participated in the treatment plan, nor was there documentation of the date the nurse signed the document.

Review of the problem titled Psychotic Symptoms revealed no documentation of a patient's name and listed the following goals:

A. Patient will be able to verbalize needs and wants without agitation within 6 days. Target date was 6/28/12.

B. Patient will understand and be compliant with medication regime within 6 days. Target date was 6/28/12.

C. Patient will be able to sleep through out the night by day 6. Target date was 6/28/12.

Page 2 of the problem titled Psychotic Symptoms revealed no documentation of a patient's name and listed the Team interventions:

Physician: Assess 5 times per week regarding: presence of a ________ (this area was blank). There was no documentation the physician reviewed this intervention, nor was there documentation of any other therapeutic interventions to reach the above stated goals.

Nursing: Assess for agitation. There was no documentation of a date the nurse reviewed this intervention, nor was there documentation of any other therapeutic interventions to reach the above stated goals.

Review of the Interdisciplinary Treatment Plan Review dated 6/27/12 revealed goal A. was unchanged with no documentation of a revision of the interventions to help the patient meet this goal. There was no documentation the physician attended the Interdisciplinary Treatment Plan Review.

An interview was conducted with Employee Identifier (EI) # 1, the Nurse Manager for the Geropsych Unit on 7/2/12 at 1:00 PM who verified the above.


2. MR # 1 was admitted to the facility on 6/14/12 with diagnoses including Psychosis.

Review of the Interdisciplinary Treatment Plan dated 6/15/12 revealed no documentation of the date the nurse signed the document.

Review of the problem titled Psychotic Symptoms revealed the following goals:

A. Patient will be able to communicate needs without becoming aggressive or agitated by day 7. Target date was 6/22/12.

B. Patient take medication as prescribed and understand within 5 days. Target date was 6/20/12.

C. Patient will have no agitated episodes to increase psychotic symptoms within 7 days. Target date 6/22/12.

Physician: Assess 5 times per week regarding: presence of psychosis. There was no documentation of any other therapeutic interventions to reach the above stated goals.

Nursing: Assess for aggressive, confusion and agitated state. There was no documentation of any other therapeutic interventions to reach the above stated goals.

Review of the Interdisciplinary Treatment Plan Review dated 6/20/12 revealed goal A, B and C was unchanged with no documentation of a revision of the target date or interventions to help the patient meet this goal.

Review of the Interdisciplinary Treatment Plan Review dated 6/27/12 revealed goal A was unchanged with no documentation of a revision of the interventions to help the patient meet this goal.

An interview was conducted with EI # 1 on 7/2/12 at 2:00 PM who verified the above.

Based on the review of the medical records, observation, and interviews, it was determined the pharmacist failed to ensure patients' medications were administered according to the physician's orders. This negatively affected Medical Record (MR) # 2 and had the potential to negatively affect all patients served by this facility.

Findings include:

An observation of medication administration for MR # 2 was conducted 7/3/12 at 8:00 AM. After the observation of medication administration, the surveyor reviewed the physician orders for MR # 2.

Review of the Medication Reconciliation Order Form dated 6/22/12 revealed orders to continue KlorCon (potassium) 10 meq. (milliequivalents) 2 tabs twice a day.

Review of the potassium level collected 6/22/12 at 11:00 AM revealed a level of 2.9 (normal 3.5 to 5.10).

Review of the physician's order dated 6/22/12 or 6/23/12 (date difficult to read) revealed orders for the patient to receive KCL (potassium) 40 meq daily for 4 days.

Review of the Medication Administration record revealed the patient received the following:

Micro K (potassium cl) 2 -10 meq tabs on:
6/22/12 at 7:51 PM
6/23/12 at 9:11 AM
6/23/12 at 8:16 PM
6/24/12 at 7:59 AM

Micro K 20 meq tab on 6/24/12 at 11:14 AM

Micro K 4 - 10 meq tabs on:
6/25/12 at 8:17 AM
6/26/12 at 8:01 AM
6/27/12 at 8:10 AM

The surveyor reviewed the medical record on 7/3/12, which revealed no documentation the patient received any potassium after 6/27/12 or the patient received the 40 meq daily for 4 days.

An interview was conducted with Employee Identifier (EI) # 1, Nurse Manager for the Geropsych unit on 7/3/12 at 8:30 AM. The surveyor asked why the nurse did not administer the Micro K 2-10 meq tabs that AM. EI # 1 called the pharmacist and asked what happened to the Micro K 2-10 meq tabs twice a day order written on 6/22/12. After the phone call ended EI # 1 said the pharmacist told her when the potassium order written on 6/22/12 or 6/23/12 automatically stopped the first order. The surveyor asked was the physician contacted and the response was," no".

Review of the MR # 2 on 7/3/12 at 3:00 PM revealed a potassium level obtained on 7/3/12 at 11:30 AM which read 2.6 (lower then the 2.9 on 6/22/12). A physician's order was received on 7/3/12 at 1:45 PM for the patient to receive Klor-Con 40 meq twice a day with a potassium level every other day.

Based on observations, review of policy and interview, it was determined the facility failed to ensure:

1. All supplies/medications available for patient use were not expired.

2. Multi dose medications were labeled when opened.

This had the potential to negatively affect all patients served at the facility.


Findings include:

Facility Policy
Subject: Emergency Crash-Carts/Emergency Boxes

Policy/Procedure:
... Crash cart and emergency box medications will be checked monthly by Pharmacy for expiring medications and fluids needing replacement...


Facility Policy and Procedure manual
Number: 350
Section 050

Medication Selection, Procurement and Storage

Outdated Drug Control

Extreme care must be exercised that no outdated drugs are dispensed for patient use or allowed to remain in the dispensing area of the pharmacy or in patient care areas.

Procedures

1. The pharmacy personnel will check all medications stored in the pharmacy and outside the pharmacy each month and remove all outdated drugs from their storage location.

2. All outdated drugs stored outside the pharmacy will be returned to the pharmacy department for proper handling/disposal...


Facility Policy
Subject: Infection Control

Medications/Intravenous Fluids:
... Multidose vials will only be used for the treatment of a single patient.

Multidose vials are to be dated when opened, stored appropriately and disposed of in 28 days or per manufacturers expiration date and/or pharmacy recommendations...


An initial tour of the Emergency Department was conducted on 7/2/12 at 10:30 AM. During the tour, the surveyor observed the following drugs in the Crash Cart:

1 - Dopamine Hcl 400 mg (milligrams) in 250 ml (milliliters) of 5% Dextrose which expired 6/1/12

1 - Lidocaine 4 mg/ml 250 ml in 5% Dextrose which expired 10/1/10.

2 - 5 % Dextrose 500 ml which expired 7/1/11

1 - Dobutamine 250 mg/20 ml which expired 7/1/12


An initial tour of the Outpatient Procedure area was conducted on 7/2/12 at 11:10 AM. During this tour, the surveyor observed located in Procedure Rooms # 4 and # 5 each had a bottle of Lidocaine 1%, which were opened and both labeled 3/27/12.

An interview was conducted on 7/2/12 at 11:10 AM with Employee Identifier (EI) # 6, Surgery Manager concerning the above opened bottles. EI # 6 stated the opened bottles were only to be kept 30 days.


An intial tour for the Medical/Surgical Floor was conducted on 7/2/12 at 12:30 PM. Observed located in the Crash cart were the following expired medications:
Dopamine HCL (Hydrochloride) 1600 mcg/ml (micrograms/milliliter) 250 ml - expiration date 1 June 2012
Dextrose 5% - 500 ml bag - expiration date 1 July 2011

Located in the refrigerator in the medication preparation room were the following opened medications with the names of patients who were discharged from the facility:
2 bottles of Magnesium Citrate - one dated 5/28/12 (Patient's Name) and the second with a different patient's name
Golytely (Patient's Name)

An interview was conducted on 7/2/12 at 12:30 PM with EI # 9, Charge Nurse, who verified the above medications were expired and the medications in the refrigerator should have been removed upon patients' discharge.


An initial tour of the Intensive Care Unit (ICU) was conducted on 7/2/12 at 1:05 PM. Observed located in the Crash cart were the following expired intravenous fluids:
Sodium Chloride 0.9% - 500 ml - expiration date 1 September 2011
Sodium Chloride 0.9% - 500 ml - expiration date 1 August 2011

An interview was conducted on 7/2/12 at 1:05 PM with EI # 10, ICU Charge Nurse, who verified the above intravenous fluids were expired.


A tour of the Radiology Department was conducted on 7/3/12 at 12:35 PM. During this tour, the surveyor observed located in the Commuted Tomography (CT) room an open bottle of Bacteriostatic Normal Saline - 30 ml bottle, which was unlabeled. Also located in the CT room was an Emergency Box which contained the following expired medications:
Benadryl 50 mg/ml (2 bottles) - expiration date 4/12
Epinephrine 1:1000 (2 bottles) - expiration date 1 December 2011
Calcium Chloride 10% - expiration date 1 June 2012
Atropine 10 ml (quantity 2) - expiration date 1 January 2012
Lidocaine 2% (quantity 2) - expiration dated 1 December 2011
Epinephrine 1:10,000 - expiration dated 1 April 2012

On 7/3/12 at 12:35 PM an interview was conducted with EI # 11, radiology Director, who verified the above medications were expired.



17650

A tour of the Outpatient Rehabilitation was conducted on 7/3/12 at 12:40 PM. During the tour, the surveyor observed the following drugs:

3 - Lidocaine 1% 10 mg/ml 20 ml bottles which expired 9/1/09.

An initial tour of the Sleep Laboratory was conducted on 7/4/12 at 8:40 AM. During the tour, the surveyor observed the following drugs in the Crash Cart:

1 - Naloxone Hcl 1 ml which expired 4/1/12

1 - Epinephrine 1:10,000 10 ml which expired 4/1/12

1 - 500 ml 5 % Dextrose which expired March 1, 2012

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served.

Findings include:

Refer to Life Safety Code violations.

Based on facility policy, observations and interviews with facility staff, it was determined the facility failed to ensure:

1. Kitchen area was clean from excessive grease and dust.

2. Expired supplies were not available for patient use.

3. Equipment used for patient care was safe.

4. Crash-carts were monitored each shift according to the facility policy.


Findings include:

An initial tour of the Kitchen/food preparation area was conducted on 7/2/12 at 1:35 PM. During this tour, the surveyor observed excessive grease and dust buildup on the hood and vents. The surveyor observed dust tags located on the fire suppression systems located over the baking ovens, convection ovens, boiler pots, flat top grills, stove and fryer area, air conditioning vents and light fixtures. The surveyor also observed a blackened area on the wall above the hood vent over the stove/flat top grill area.


Facility Policy
Subject: Emergency Crash-Carts/Emergency Boxes

Policy/Procedure:
... Crash cart and emergency box medications will be checked monthly by Pharmacy for expiring medications and fluids needing replacement...

The nursing department personnel will be responsible for the restocking and monthly check of other non-medication and non-respiratory therapy equipment. Respiratory therapy department personnel will be responsible for restocking and monthly check of all respiratory equipment and supplies...

Specific to Surgical and Sleep Lab: The crash-cart is checked daily during operational hours excluding days that the Department is closed.

Daily checks of crash cart:
The Charge Nurse will assign a licensed staff member to complete the crash-cart check daily on each shift...

The Manager for each area is responsible for monitoring compliance to the crash-cart checks.


A tour of the Medical/Surgical Floor was conducted on 7/2/12 at 12:30 PM. The surveyor observed outdated medications located in the crash cart. During this tour, Employee Identifier (EI) # 9 verified the crash cart was only checked during a code (cardiac arrest).

A tour of the Intensive Care Unit was conducted on 7/2/12 at 1:05 PM. The surveyor observed outdated intravenous fluids located in the crash cart. During this tour, EI # 10 verified the crash cart was only checked during a code.



17650

A tour of the Emergency Department was conducted on 7/2/12 at 10:30 AM. During the tour, the surveyor observed the following expired supplies in the Crash Cart:

5 - 22 gauge Jelco expired March 2012

5 - 18 gauge Jelco expired November 2011

1 - 18 gauge Jelco expired March 2010

6 - 20 gauge Jelco expired November 2011

2 - blue top lab tubes expired 08/2009

2 - green top lab tubes expired 03/2010

2 - purple top lab tubes expired 06/2010

A review of the ER (Emergency Room) crash cart audit form revealed no documentation the crash cart was checked for the following dates and shifts:
4/1/12 - 7 PM to 7 AM
4/2/12 - 7 AM to 7 PM
4/3/12, 4/8/12, 4/14/12, 4/15/12, 4/16/12, 4/17/12, 4/22/12 - 7 PM to 7 AM
4/28/12 - both shifts
The only documented date for the crash cart check for the week of 5/9/12 was 5/9/12
5/13/12, 5/14/12 - 7 PM to 7 AM
5/15/15 - 7 AM to 7 PM
5/25/12, 5/26/12, 5/27/12, 6/2/12 - 7 PM to 7 AM
No documentation of the dates after 6/7/12 for the week of 6/3/12.
6/10/12 - 7 AM to 7 PM
6/14/12, 6/18/12 - 7 PM to 7 AM
Saturday for the week of 6/17/12 - both shifts
6/24/12 - both shifts
6/29/12 - 7 PM to 7 AM
6/30/12 - both shifts


A tour of the Outpatient Rehabilitation Center was conducted 7/3/12 at 12:40 PM. The surveyor noted an Anadonye Therapy Unit, Radio, Ultrasound and Electrial Stimulus Machine and Patient Lift at the pool side not labeled as safe for patient use.

An interview was conducted with EI # 15, the Physical Therapy Director on 7/3/12 at 12:55 PM who verified the above.


A tour of the Sleep Laboratory was conducted on 7/4/12 at 8:40 AM. During the tour, the surveyor observed the following expired supplies in the Crash Cart:

2 - 22 gauge Jelco expired 08/2008

2 - 18 gauge Jelco expired 08/2008

2 - 20 gauge Jelco expired 09/2008

2 - blue top lab tubes expired 12/2006

2 - green top lab tubes expired 09/2007

2 - purple top lab tubes expired 08/2006

2 - red top lab tubes expired 01/2008

2 - 2x2 gauze packages expired 12/2009

1 - nasopharyngeal airway 24 french expired 12/2011

1 - Endotube 7.0 expired 05/2011

The surveyor found the following equipment not labeled safe for patient use: CPAP (Continuous Positive Airway Pressure)machine, BiPAP (Bilevel Positive Airways Pressure) machine, and 2 header boxes.

Review of the crash cart log for the Sleep Lab revealed no documentation of a check since 4/28/09.

An interview with EI # 16, the Sleep Lab Supervisor was conducted on 7/4/12 at 9:45 AM who verified the above.

A tour of the Geri-psychiatric Unit was conducted on 7/2/12 at 12:30 PM. During the tour, the surveyor observed the following expired supplies in the Crash Cart:
2 - 22 gauge Jelco which expired 12/2010

1 - 22 gauge Jelco which expired 5/2009

3 - 22 gauge Jelco which expired 3/2012

3 - 20 gauge Jelco expired 5/2012

3 - 18 gauge Jelco expired 11/2011

1 - 18 Jelco expired 7/2008

2 - purple top lab tubes expired 12/2010

2 - red top lab tubes expired 12/2010

2 - green top lab tubes expired 1/2011

2 - blue top lab tubes expired 7/2010

A review of the Geri-psychiatric Unit crash cart checklist forms dated 6/4/12, 6/8/12, 6/11/12, 6/14/12, 6/18/12, 6/19/12, 6/22/12, 6/23/12, 6/24/12, 6/29/12 and 6/30/12 - 7 PM to 7 AM revealed no documentation the crash cart was checked.

Based on review of the facility policies, directions for use on the Sanizene bottle, observations, interviews and review of the whirlpool culture reports, it was determined the facility failed to ensure the staff followed the acceptable standards of practice for wound care, hand hygiene, cleaning the whirlpool and the use of hair coverings in food preparation areas. This had the potential to negatively affect all patients served by this facility.

Findings include:

Refer to A 748

Based on review of the facility policies, directions for use on the Sanizene bottle, observations, interviews and review of the whirlpool culture reports, it was determined the facility failed to ensure the staff followed the acceptable standards of practice for wound care, hand hygiene, cleaning the whirlpool and the use of hair coverings in food preparation areas. This affected Medical Record (MR) # 13 and # 17 and had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Hand Hygiene # 4002

Purpose:

To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs and infections.


Policy:

All personnel will use the hand-hygiene techniques, as set forth in the following procedure...

Before each patient encounter...

After coming in contact with body fluids, dressings, mucous membranes, etc., and hands are not visibly soiled (i.e., handling sputum containers, bedpans, urinals, catheters)...

After contact with medical equipment/supplies in patient areas

Always after removing gloves...

Notes:

Always follow Standard Precautions.

Gloves are to be worn when contact with blood, bodily fluids, mucous membranes, dressings, non-intact skin, etc., is anticipated...

Change gloves when moving from a contaminated body site to a clean body site on the same patient.

An observation of wound care with the Employee Identifier (EI) # 8, the Licensed Physical Therapist Assistant (LPTA) using the whirlpool, was conducted on 7/3/12 at 9:30 AM. EI # 8 washed his/her hands with soap and water and donned a pair of gloves. EI # 8 used a pair of scissors to remove the dressing from MR # 13's left leg. Using the same pair of gloves and scissors, EI # 8 removed the dressing from the patient's right leg. There was a moderate amount of yellow drainage on both dressings.

EI # 8 then obtained gauze and removed the excess silvadene from the patient's left and right leg wearing the same gloves used to remove the dressings.

EI # 8 then placed both of the patient's legs in the whirlpool simultaneously.

The surveyor asked EI # 8 what was in the whirlpool. EI # 8 showed the surveyor a package of Chlorazene 8 gram bag and stated 64 gallons of water.

EI # 8 removed the patient from the whirlpool at 10:00 AM and donned a pair of gloves after hand hygiene. EI # 8 then began a fluff debridement on the left leg and then the right leg without changing gloves.

On 7/3/12 at 10:25 AM the surveyor observed EI # 8 clean the whirlpool room. The surveyor asked what EI # 8 cleaned the whirlpool with and the response was, "Sanizene." The surveyor asked how much was used to clean the whirlpool and the response was, "1/2 to 1 cup to the whirlpool." Review of the instruction on the bottle of Sanizene revealed instruction to use 1 ounce per gallon which would have equaled 8 cups for the 64 gallons of water in the whirlpool.

Review of the whirlpool cultures revealed the following positive results:

January 10, 2012

Extremity Tub Agitator - Pseudomonas

January 16, 2012

Extremity Tub Agitator after cleaning - Gram positive cocci - Coagulase Negative staph.

January 20, 2012

Extremity Tub Agitator after 2nd cleaning - no growth @ 72 hours

April 3, 2012

Extremity Tub Agitator - Gram Positive Cocci

Extremity Tub Drain - Gram Negative Rod (pseudomonas)

April 18, 2012

Extremity Tub Drain - Gram Negative Rod (pseudomonas)

An observation of wound care for MR # 13 was conducted on 7/3/12 at 10:45 AM with EI # 13, the Licensed Practical Nurse (LPN). EI # 13 used the same pair of scissors to remove the gauze from the left leg and the right leg without cleaning. EI # 13 used tape that was located on the LPN's personal stethoscope to secure the dressing. After EI # 13 completed the wound care and left the room she/he placed the stethoscope around her/his neck and went down the hall on the nursing unit.

An observation of wound care was conducted 7/3/12 at 3:05 PM with EI # 14, an LPN. The LPN removed tape from her/his pocket to secure the dressing to both legs. After the wound care was complete the surveyor followed EI # 14 to the nurses station and asked where the tape was she/he used on the wound care and EI # 14 pulled the tape from his/her pocket.

An interview was conducted with the Infection Control Officer on 7/4/12 at 1:20 PM. The surveyor asked if the hospital expected the staff to use different gloves and scissors for each wound and the response was, "yes". The surveyor asked if tape should be used on multiple patients and the response was, "the tape should be left in the patients' room."



20228

On 7/3/12 at 7:55 AM, the surveyor observed EI # 4, Physician and EI # 5, Certified Registered Nurse Practitioner exit Procedure room # 5 after having performed a colonoscopy and then entered Procedure room # 4 without washing their hands or performing hand hygiene.

Observations were conducted on 7/4/12 from 11:02 AM to 12:00 PM in the Kitchen. During this observation time, the surveyor observed EI # 17, Dining room Cashier enter and exit the kitchen/food preparation area multiple times without a hair net or covering. On 7/4/12 at 11:30 AM, the surveyor observed EI # 7, Director of Nurses entered the kitchen/food preparation area without a hair net or covering.

Based on observation and staff interviews, it was determined the facility failed to assure the operating rooms were monitored for safe parameters of humidity and temperature for 2 of 2 operating rooms. This had the potential to negatively affect all patients who had surgical procedures performed at the facility.


Findings include:


A tour of the Surgery Department was conducted on 7/2/12 at 10:25 AM. The surveyor observed 2 surgical suites in the surgery department.

An interview was conducted on 7/3/12 at 7:40 AM with Employee Identifier (EI) # 6, Surgery Manager. The surveyor asked EI # 6 how the temperature and humidity was monitored for the two surgical suites. EI # 6 stated there were monitors on the walls outside each of the surgical suites. EI # 6 verified they were not recording temperatures or humidity for either suite.

Based on a review of medical records and an interview with staff members, it was determined the hospital failed to assure there was an ongoing activity program for their swing bed patients. This affected Medical Record (MR) # 12 and had the potential to affect all patients admitted to a swing bed.


Findings include:

A review of MR # 12 revealed the patient was admitted to swing bed on 3/28/11. A review of the medical record revealed no documentation of activities.

An interview with the Employee Identifier # 18, the Activities Director on 7/4/12 at 11:50 AM verified there was no documentation in the swingbed medical record of activities for MR # 12.