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Based on observation, interview and record review, the facility failed to ensure patients received care in a private setting while in emergency room. Patients assigned to rooms 13A, 13B, 13C, 13D and 14B in emergency department west received care in chairs in the hallway where they were in clear view of other patients. This deficient practice violated the patients' right to personal privacy.

Findings:

During initial tour, on 2/24/14 at 9:30 am in the Emergency Department (ED), triage assessment of a patient could be visualized from the waiting area. The triage area was not in an enclosed room, and the triage exam questions and patient answers could be heard from the hallway behind the triage section in the ED where patients were sitting in chairs against the wall.

At 10 am on 2/24/14 while touring ED west there were patients sitting in chairs against the hallway receiving treatment, in assigned patient chair 13A, and 13C. There was no physical partition separating the patients sitting in the chairs in the hallway. Patients had no privacy during their treatments.

During an interview with the ED medical director (MD2), during a tour of ED west, where patients with low level of acuity are treated, he stated, when busy, the ED gets 50 to 60 patients for a space with 17 beds, the hallway chairs are used to treat patients with minor injuries , and alleviate prolonged patient wait time for treatment. Patients assigned to 13 and 14 are treated in chairs in the hallway with their consent to be treated in the chairs. MD 2 further stated by using the chairs for treatment, the ED is able to care for more patients in a timely manner and alleviate long wait times.

During an interview with the VP on 2/27/2014 at 8:45 am, she presented a document titled "Emergency Department Renovation Design and Construction Status". She explained that there are plans underway to remodel the ED triage area into rooms with privacy, and the hallway chair treatment areas will be replaced by actual rooms by expanding the patient care area.

Based on interviews and record reviews, the facility failed to ensure the Registered Nurse (RN) assessed the patient care needs, health status, and the patient's response to the intervention for 6 of 41 sampled patients (Patient 20, 21, 27, 28, 29 and 17). For Patients 20, 28 and 29, the staff failed to assess the pain level, to reassess the patients' pain level after administration of pain relief medication. For Patient 27, who had undergone abdominal surgery, the nursing staff did not enquire about her pain level after she had received pain relief medication. This deficient practice had the potential to result in inadequate pain management. For Patient 21, who had infectious diarrhea, the patient had to wait an hour after turning on the call light. For Patient 17, the RNs failed to assess the vital signs, oxygen saturations (the amount of oxygen carrying hemoglobin in the blood), and pain levels were not assessed as indicated in the patient controlled analgesia (PCA) order. This deficient practice had the potential to miss possible side effects of the medication on Patient 17.

Findings:

1. On February 25, 2014, at 8 a.m., during the initial tour of the unit, Patient 20 was observed lying in bed, with a chest tube in placed. The patient was awake, alert, oriented and able to communicate his needs.

According to Patient Demographic, Patient 20 was admitted to the facility on February 23, 2014 due to a stab wound to the abdomen.

A review of the physician order revealed the following orders:

a. Morphine 2 milligrams per milliliter (mg/ml) intravenous (IV) every two (2) hours for pain.

b. Morphine 4 mg/ml 3 mg = 0.75 ml IV every two (2) hours for pain. This medication was administered on February 24, 2014 at 10 a.m. for a pain level of 7/10. However, there was no written evidence the pain level was reassessed after administration of the medication.

c. Toradol 30 mg IV every 6 hours x 48 hours. This medication was administered on February 24, 2014 at 2:20 p.m., 9 p.m., and 6 a.m. There was no written evidence of an assessment of the level of pain and/or reassessment of the pain level after medication administration.

d. Five percent (5%) Lidoderm Patch 12 hours on 12 hours off daily over upper abdomen. This was applied on February 24, 2014 at 1 p.m. and was off at 1 a.m. There was no written evidence of an assessment of the level of pain and/or reassessment of pain level after application of the patch.

During a concurrent interview with RN 5 while reviewing the clinical record, RN 5 was not able to find the Pain Flow Sheet from February 24, 2014 which would indicate the pain was assessed prior to administration of medication and re-assessed after administration of medication.

2. On February 25, 2014, at 8:30 a.m., Patient 21 was observed lying in bed. The patient was awake, alert and oriented. During a concurrent interview with the patient, she stated that last weekend on the day shift she had to use the bathroom and needed assistance due to having diarrhea. She further stated she had to wait for an hour after she turned on the call light .

On February 27, 2014, at 1:45 p.m., during an interview with RN 8, she acknowledged the patient informed her of the one hour wait and the patient had a bowel accident in bed. She indicated the call light should have been answered by facility staff who happens to be in the hallway whether the patient was assigned to the staff or not.

According to the Patient Demographics Patient 21 was admitted to the facility on February 16, 2014, with diagnoses that included severe sepsis and infectious diarrhea.


3. On February 27, 2014, at 10:50 a.m., Patient 28's closed medical record was reviewed.

According to the Patient Demographics, Patient 28 was admitted to the facility on August 12, 2012 due to complained of pain to the top of the head which was described as constant. There was no recent head injury.

On admission, at 5:57 a.m., the patient was assessed as having pain of 8 out of 10 scale and did not indicate location and pain characteristic.

At 8:54 a.m.,(three hours later) the patient was administered Vicodin (5mg-500 mg) 1 tab by mouth. At 10:08 a.m., an hour after the pain level was reassessed and indicated it was unchanged and physician notified.

At 10:06 a.m., the patient was having pain of 7 out of 10 on a pain scale
but did not indicate the location and other pain characteristic. At 10:51 a.m., the patient was administered Vicodin (5mg-500mg) 1 tab. At 11:20 the patient was re-assessed for the effectiveness of the medication. It was documented pain is decreased. There was no pain scale used to determine how much the pain has decreased.

4. On February 28, 2014, at 7:05 a.m., Patient 29's closed medical record was reviewed.

According to the Patient Demographics, Patient 29 was admitted to the facility on September 17, 2013, with diagnoses of swelling of both upper extremities, marked pulmonary edema and urinary tract infection.

On admission, at 6:30 p.m., the patient was assessed as having pain of 6 out 10 scale but did not indicate the site and pain characteristic.

After an hour at 7:32 p.m., the patient was administered Fentanyl (titrate low dose intravenous (IV) 25 micrograms (mcg) via the left ankle. At 7:52 p.m., the pain level was assessed and the documentation indicated the pain is decreased but did not use the pain scale to indicate the level of pain.

At 9:07 p.m., the patient was assessed as having pain of 6 out of 10 scale but did not indicate the site and pain characteristic. There was no written evidence the patient was administered medication or any intervention to address the pain.

On February 28, 2014, at 9:30 a.m., during an interview with RN 10, she stated the pain should be re-assessed within 60 minutes after administration of medication to check on the effectiveness of the medication. She also stated the pain scale should be used in assessing patient pain level.



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5. On February 24, 2014 at 11:25 a.m., during a tour of the Post Anesthesia Care Unit (PACU), Patient 27 was observed lying on a gurney, with her eyes closed. The patient had an indwelling urinary catheter, which was connected to a urinary drainage bag, and was receiving intravenous (IV) fluid. The patient's abdominal surgical dressing, was dry and intact. During the observation, when the nurse asked the patient what her pain level was, the patient indicated eight out of 10 severity.

A review of Patient 27's clinical record, conducted on February 26, 2014, revealed the patient was admitted to the facility on February 24, 2014 for exploratory laparotomy (abdominal surgery), and bilateral ovarian cystectomies (removal of cysts on the ovaries).

A review of the History and Physical document, dated February 22, 2014, indicated the patient was alert and oriented, and able to make her needs known.

Review of the Medication Administration Record (MAR), dated February 24, 2014, indicated an order for Tylenol #3 300 mg two tablets orally every four hours as necessary for moderate (5-7 on pain scale of 0-10) pain level.

A review of the Pain Assessment/Management Flow Sheet document for February 24-February 27, revealed the patient's postoperative pre-medication pain intensity was assessed as "seven to nine" over 10, with average post medication pain level reassessment documentation of "zero to two" over 10. The sedation level was documented as "S" (sleepy) following pain medication administration on February 24 at 3:45 p.m., and 7:20 p.m., and February 25 at 1 a.m., and as "one" (awake and alert) post pain medication administration, on February 26, 2014 at 9:10 a.m., 1:10 p.m., and 7:30 p.m.

On February 26, 2014 at 11:10 a.m., during observation and interview, Patient 27 was alert and oriented, and sitting up in bed. When queried as to whether the staff had questioned her regarding pain level post pain medication administration, the patient replied that, except for her current assigned nurse, the staff had not returned to ask if her pain was relieved.
At 3:10 p.m. the same day, during an interview with RN 6, she stated a patient's pain level was to be assessed at the start of the shift, then every four hours. She further indicated if pain medication was administered, the nurse was to return to the room 30 minutes later in order to reassess the pain level.

A review of the facility policy titled, "Pain Management Guidelines", revised July 2013, stipulated to monitor pain frequently in patients having pain, especially after a pain management intervention, and to reassess pain within one hour of intervention.


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6. The clinical record for Patient 17 was reviewed on February 26, 2014, at 9:55 a.m. Patient 17 was admitted to the facility on February 23, 2014 for colorectal cancer and peri-anal abscess.

The "Adult Patient Controlled Analgesia (PCA) Pre-Printed Physician Orders" form dated February 24, 2014, at 4 p.m., indicated an order to start Dilaudid infusion via the PCA pump. The pre-printed form indicated "4. Check and record vital signs, pain score, and mental status prior to initiating PCA and q (every) 15 minutes x 2 after starting PCA or after any increasing dosage changes to PCA. Monitor vital signs, pain score, and mental status Q 1 hour x 4 hours, then Q 2 hours x 4 hours, then at least every four hours while PCA is in use. 5. Patient must have intermittent pulse oximetry (a machine that reads the oxygen saturation level) q 4 hours for the first 24 hours. Record total volume of medication infused on the Pain Flow Sheet or Medication Administration Record every 4 hours."

The electronic "Anesthesia Record" dated February 24, 2014 indicated the following entry: "17:00 (5 p.m.) - PCA Setup Dilaudid 0.3 Mg (milligrams) basal; 0.2 Mg q 15 min. Pt Ed (patient education) given, PCA not yet begun.."

The "Pain Assessment/Management Flow Sheet" indicated an entry on February 24, 2014, at 2 p.m. for "PCA Dilaudid 0.3 mg/hr (milligrams per hour) (bolus) demand 0.2 mg/15 min". The vital signs, pain intensity, and sedation were not recorded for the time the PCA pump was started. The sets of vital signs, pain intensity, and sedation documented on the form were for 8:30 p.m. of the same day, on February 25, 2014, at 5 a.m., 9 a.m., 11 a.m., 1 p.m., 3 p.m., and 5 p.m.

The "Graphic Record" indicated the vital signs and oxygen saturations were recorded on: February 24, 2014, at 8:30 p.m., February 25, 2014, at 4 a.m., 8 a.m., and 8 p.m., and February 26, 2014, at 5 a.m. and 8 a.m. There were no documentation that the physician order was followed to check and record vital signs, pain score, mental status, and pulse oximetry prior to initiating PCA and q 15 minutes x 2 after starting the pump, Q 1 hour x 4 hours, then Q 2 hours x 4 hours, then at least every four hours while PCA is in use.

The Pain Assessment/Management Flow Sheet indicated the total amount of medication that infused. The flow sheet indicated an entry for February 24, 2014, at 8 p.m. that the PCA was started. The next entry was for February 25, 2014, at 5 a.m. for PCA injection number 1 with a cumulative dose of "5.4". There was no documentation the order to record the total volume of medication infused on the Pain Flow Sheet or Medication Administration Record every 4 hours was done from February 24, 2014, at 8 p.m. to February 25, 2014, at 5 a.m. was followed.

The facility policy titled "Patient Controlled Analgesia" revised August 2013 indicated "8. At the start of the PCA therapy, evaluate and document on the Pain Flow Sheet, the patient's vital signs, pain control, and mental status initially and with the first dose given then Q 1 hour x 4 hours, then Q 2 hours x 4 hours, then every 4 hours until pump disconnected. 9. Chart the total volume of medication infused on the Pain Assessment/Management Flow sheet Q4H (every 4 hours)."

Based on interview and record review, the facility failed to develop the care plan was comprehensive, and addressed the specific care issues, for one of 41 sampled patients (27). The plan of care for Patient 27, who was postoperative abdominal surgery, failed to address the care issues of bowel elimination and potential for infection. This deficient practice had potential to result in inadequate delivery of care, and postoperative complications for the patient.

Findings:

A review of Patient 27's clinical record, conducted on February 27, 2014, at 11 a.m., indicated the patient was admitted to the facility on February 24, 2014 for exploratory laparotomy (abdominal surgery), and bilateral ovarian cystectomies (removal of cysts on the ovaries).

A review of the History and Physical document, dated February 22, 2014, indicated the patient was alert and oriented, and able to make her needs known.

A review of the Interdisciplinary Plan of Care, dated February 24, 2014, failed to include the care plan for "Alteration in bowel elimination", which addressed potential concerns such as constipation and diarrhea, expected outcomes and goals, and interventions.

There was no care plan which addressed potential for infection and possible interventions/approaches i.e. monitoring of vital signs and lab values.

During an interview with RN 5 at 11:10 a.m. the same day, she stated the care plan should have addressed bowel elimination, including potential side effects of pain medication, and that infection control should also have been addressed, due to patient's postoperative status.

Based on observation, record review and interview, the facility failed to ensure the patient's medication was not left at the bedside unless there was a physician order and medication prepared for a patient was kept secure and accessible only to the authorized licensed nurse from preparation to administration in accordance with Federal and State laws for 2 of 41 sampled patients (Patient 21 and Patient 6). For Patient 21, a vial of Nystatin powder was left at the patient's bedside without a physician's order. For Patient 6, RN 30 left the patient's intravenous antibiotic on top of cart outside the patient's room when she carried a meal tray away and available. This deficient practice has the potential for the medications being available for use and accessible to unauthorized person.

Findings:

1. On February 25, 2014, at 8 a.m., during the initial tour of the unit with RN 6, it was observed in Room 4229 that a vial of Nystatin powder medication was left at Patient 21's bedside.

A review of the Patient Demographic indicated Patient 21 was admitted to the facility on February 16, 2014, with diagnoses that included sepsis and infectious diarrhea. The Initial Wound Notification/Physician Attestation Wound Order dated February 17, 2014 indicated the patient had moisture associated skin damage on bilateral groin.

A physician order dated February 20, 2014, indicated to apply Nystatin Powder to groin and buttocks area twice a day (BID) and as needed. The Medication Administration Record (MAR) dated February 24, 2014 indicated treatment for the bilateral groins was performed at 2 p.m. and 10 p.m.

During a concurrent interview with RN 6, she stated the medication Nystatin should not be left at the bedside unless there's a physician order for it to be left at bedside.

A review of the facility's policy titled, Medication Administration indicated the following medications may be kept at the patient's bedside with physician order such as topical skin medications.



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2. On 2/25/2014, at 10:10 a.m., during a medication pass observation, on the Pediatric Nursing Unit, a registered nurse (RN 30) was observed preparing Patient 6's medications. The patient was in isolation, for clostridium difficile (C-diff/a bacteria that causes diarrhea). After preparing Zosyn, an intravenous (IV) antibiotic, RN 30 noticed a meal tray on top of a cart just outside of the patient's room. Inside the cart was Personal Protective Equipment (PPE), gowns and gloves used to protect staff, visitors, and other patients from contracting or spreading the infection. RN 30 placed the medication Zosyn on top of the cart, picked up and walked away with the meal tray. The medication was left behind out of view of RN 30. RN 30 returned, put on a gown and gloves, and picked up the Zosyn medication and entered the isolation room and proceeded to administer the medication to Patient 6.

During a concurrent interview, RN 30 stated she should not have left the medication (Zosyn) behind when she carried away Patient 6's meal tray.

On 2/25/2014, at 3:20 p.m., during an interview, the Director of Pharmacy (DOP) stated, "Once the medication for the patient (Patient 6) was prepared it should have been kept with the RN (30) until administered to the patient (Patient 6). The DOP further stated medication should not be out of the view of the nurse prior to administration to the patient.

According to the California Code of Regulation, title 22, section 70263(l), " Medications shall not be left at the patient's bedside unless the prescriber so orders. "

According to the California Code of Regulation, title 22, section 70263(q)(8), " Drugs shall be accessible only to responsible personnel designated by the hospital, or to the patient as provided in 70263(l) above. "

Based on interviews, and document review, the facility failed to ensure that medications removed from non-profiled Automatic Dispensing Cabinets (ADCs) were appropriate and medications ordered by the physician were administered as prescribed; and override medications were reviewed by the pharmacy to ensure safe and consistent medication administration for Patient 33. This deficient practice has the potential to result in medication error.

Findings:

On 2/24/2014, at 10 a.m., during a discussion of the medication use monitoring of the non-profile Automatic Dispensing Cabinets (ADC) that were being used in the departments, the director of pharmacy (DOP) stated there are three non-profiled ADCs in the Emergency Department (ED) 1, ED 2 West Side, and ED Trauma. During a concurrent interview, a registered nurse (RN 32) stated the flu season is the EDs busiest time and usually receives about 213 patient visits a day.

During an interview, on 2/26/2014, at 11:30 a.m., RN 28 stated if there was a reasonable period of time between the first and second dose of medication then the medication orders should be sent to the pharmacy. RN 28 stated immediacy of drug and interval between the first and second dose dictates the need for a medication override.

On 2/26/2014, at 2:20 p.m., Pharmacist 5 stated she looks at the report of medications removed from the ADCs in the ED more than one dose dispensed for billing. The evaluator randomly selected patients (Patient 42 and 33) from Pharmacist 5's report.

A review of Patient 42's clinical record indicated the ED physician ordered an antibiotic, Macrodantin 100 milligram (mg) oral tablet for one dose on 2/24/2014 at 12:43 p.m. It was documented as administered to the patient over 1 hour and 15 minutes later at 2:05 p.m.

During a concurrent interview, Pharmacist 4 stated, "ED is not a profile unit, we do not retrospectively review each medication dispensed to a patient, only random sampling.

During a concurrent interview Pharmacist 2 stated, " Reconciliation is only partially done in the ED. That is a potential problem that we do not confirm medication to an actual order to look at appropriateness of dose in the ED. The pharmacists do not have access to the ED computer system in which the physician enters patient's medication orders.

On 2/26/2014, at 2:50 p.m., Pharmacist 4 stated manpower is a concern; we would like to have a pharmacist in the ED to review medication orders.

On 2/26/2014, at 2:55 p.m., the clinical record of Patient 33 indicated the patient was first seen in the ED and later admitted to the facility's Intensive Care Unit (ICU) where albuterol (A medication for breathing) was overridden over 25 times by different respiratory therapists and administered to Patient 33 for five days between 2/19/2014 through 2/24/2014, without a pharmacist review.

During a concurrent interview, Pharmacist 2 stated if a medication order is missing the nurse or respiratory therapist should notify the pharmacy. Pharmacist 2 further stated, "It is our policy to notify pharmacy in 24 hours when a respiratory or nursing staff discovers a missing medication, and the albuterol overrides should have been caught through the override report."

On 2/27/2014, at 2:15 p.m., the DOP stated the facility generally do not have oral medication overrides, because oral medications can take 30 to 45 minutes to be absorbed and the pharmacist had time to review Patient 42 Macrodantin medication order. The DOP stated we missed the order, but the respiratory therapist should have notified the pharmacy to enter the albuterol medication order into the system. The DOP stated the pharmacists are supposed to review overrides line by line.

On 2/27/2014, at 3:30 p.m., the Respiratory Therapy (RT) Director stated the albuterol overrides for Patient 33 should not have happened; the respiratory therapist should have followed policy and procedure by notifying the pharmacist.

A review of the facility's policy and procedure titled, "Pharmaceutical Services - Automated Medication Dispensing System (Omnicell) - Override Medications," dated 6/2013, indicated, "Override medications are medications on Profiled Units that can be accessed by nursing staff, respiratory staff, or physicians before review of the physician's order by the pharmacist. Review of the physician's order by the pharmacist is an important step in ensuring rational, safe, and effective drug therapy. Overriding of medications should be limited to critical clinical situations.

According to a nationally recognized professional association, American Society of Health-System Pharmacists (ASHP, which published numerous authoritative guidelines in pharmacy practice referred by the industry as the standard of practices), the guideline titled, "Minimum Standard for Pharmacies in Hospitals " dated 4/13/2012, indicated all medication orders shall be prospectively reviewed by a pharmacist and assessed in relation to pertinent patient and clinical information before the first dose is administered or made available in an automated dispensing device, except in emergent situations ... There shall be a procedure for retrospective review of these orders. The guideline further suggested the use of [ADC] shall be structured so as to not hinder the pharmacist's review of (and opportunity to intervene in) medication orders before the administration of first doses ...

Based on observation, interview, and document review, the facility failed to control medications by failing to:

1. Ensure sterile pharmaceutical (medication) preparation areas, that uses the laminar flow hood ([hood] to protect the working environment from dust and other airborne contaminants), was cleaned and appropriately documented as so. This deficient practice has the potential to result in contaminating medication with dust and airborne contaminants during preparation.


2. Maintain the temperature in the facility's medication refrigerators in accordance with hospital policy, to ensure stability, potency and safety of the refrigerated medications, for three of eight refrigerators observed (neonatal intensive care unit [NICU], 3G Satellite Pharmacy and 3 FARR Satellite Pharmacy). This deficient practice has the potential to result in inappropriate medications storage temperature.


Findings:

1. On 2/25/2014, at 10:40 a.m., during a tour of the 3G Satellite Pharmacy, with the Director of Pharmacy (DOP), attached to the outside glass of the laminar flow hood was a signature log titled, "(Facility) Department of Pharmacy Hood Cleaning/Quality Control." There were initials on the signature log, under columns labeled, Pharm (pharmacy)/Tech (technician). The initials were for the morning (AM) and afternoon (PM), to indicate the hood was cleaned that day (2/25/2014) in the morning and in the evening. However, at the time of inspection it was 10:40 a.m., on 2/25/2014.

During a concurrent interview, the DOP acknowledge the initials were of the pharmacy technician (Pharm Tech 3) and indicated the hood was cleaned both in the morning, and the evening on 2/25/2014. The DOP stated the Pharm Tech 3 should not have signed the hood cleaning log in the morning indicating the hood was cleaned in the evening ahead of time.

At 10:55 a.m., on 2/25/2014, during an interview, Pharm Tech 3 stated, "I routinely initial that I have cleaned (the Hood) in the morning and the evening when I first come into work."

A review of the facility's policy and procedure titled, "Compounded Sterile Pharmaceutical Preparation," dated 2/2014, indicated, " ...clean the laminar flow hood(s) exposed work surfaces (counter and walls). They must be cleaned daily at the beginning and end of each compounding shift and after any spill."

2. On 2/24/2014 at 10 a.m., during observation of the facility's refrigerators, the DOP stated the temperature of the refrigerators should be maintained between 36 degrees Fahrenheit (F) to 46 degrees F.

At 11:35 a.m., on 2/24/2014, two refrigerators (Refrigerator 1 and 2) were observed in the medication storage room on the NICU Nursing Unit. Refrigerator 2's temperature was monitored by the Omnicell (an automatic medication dispensing unit) with a refrigerator temperature sensor that indicated the temperature was 48 degrees F. The DOP adjusted Refrigerator 2, in an attempt to bring the temperature back into an acceptable range between 36 degrees F and 46 degrees F. The Omnicell temperature for Refrigerator 2 was checked at 11:50 a.m., 15 minutes later, and Refrigerator 2's temperature had increased to 50 degrees F.

On 2/25/2014 at 10:50 a.m., during an observation of the medication storage area, located in the 3G Satellite pharmacy, the refrigerator had two thermometers inside. One thermometer indicated a temperature of 47 degrees F and the second thermometer indicated a temperature of 40 degrees F. The DOP acknowledged there was a discrepancy in the refrigerator temperature and was unable to verify which thermometer was accurate to ensure appropriate medication storage temperatures.

On 2/25/2014 at 11:10 a.m., during an observation of the facility's refrigerator located in the 3 FARR satellite pharmacy; Pharm Tech 4 stated in the presence of the DOP that the digital temperature located on the outside of the refrigerator indicated 40 degrees F. However, there was also a thermometer located inside the refrigerator, and Pharm Tech 4 stated that thermometer indicated the refrigerator temperature was 52 degrees F. The DOP and the Pharm Tech 4 could not explain the discrepancy in the refrigerator temperatures.

A review of the facility's Refrigerator Temperature Log indicated the normal temperature range should be between 36 to 46 degrees F.

Based on observation, interview and record review, the facility failed to implement its policies and procedures titled, "Linen, Waste and Senso-Tech Room Temperature Monitoring".

Findings:

1. During a tour of the facility on February 4, 2014, at 10:40 a.m., in the pediatric unit clean utility room, the linen cart had a torn plastic cover exposing the clean linens on the shelves.
At the same time, during an interview, the safety officer, who accompanied the evaluator during the tour, stated the torn linen cart cover needed to be changed.
A review of the sign posted on the wall outside the room indicated that linen cart/shelves must be covered.

A review of the facility policy and procedure entitled Linen reviewed and approved on February, 2013 indicated clean linen is stored in the clean linen room and in the clean linen closets on the units/departments. Linen is either wrapped in clear plastic or covered with a linen cart cover.

2. During a tour of the facility on February 24, 2014, at 10:50 a.m., in the medical surgical unit in the G Tower, in the soiled utility room, there were two large plastic bags of trash on the floor. The bags of trash came from isolation rooms.
At the same time, during an interview, the safety officer stated the bags of trash should not be on the floor.

A review of the facility policy and procedure entitled Waste reviewed and approved on February, 2013 indicated trash will be collected from the soiled holding areas on patient units a minimum of three times daily.

3. During a tour of the facility on February 25, 2014, at 7:55 a.m., in the rehab unit the following were observed:
a. In the soiled linen closet, there was a soiled sock and soiled face towel on the floor. There was a towel hanging outside the soiled linen cart.
b. In the tub room, there were gown and towels piled up on the floor. There was a container of body wash and shampoo on top of the grab bar.
A review of the signs posted indicated "Please remove linen and toiletries after use." Another sign indicated "Please place used linen in hamper."
c. In the shower room for ambulatory patients, there was a container of body wash.

4. During a tour of the facility on February 25, 2014, at 8:48 a.m., in the telemetry unit soiled utility room, there was a red barrel left open with yellow gowns.
At the same time, during an interview, the registered nurse supervisor could not explain why the yellow gowns were in the red barrel. The nurse supervisor stated the barrel should be covered and the yellow gowns were disposed of in the isolation patients' room.

In room 3418, the trash was full and part of the yellow gown and tie was hanging outside the trash receptacle.

5. During a tour of the facility on February 26, 2014, at 7 a.m., in the coronary care unit soiled utility room, the trash barrel was overflowing. There were 4 large bags of trash above the rim of the trash barrel. There were three bags of soiled linen on top of the soiled linen barrel.
During an interview on February 26, 2014, at 7:18 a.m., the environmental services manager stated there was a 3 p.m.-11:30 pm. staff assigned to the whole hospital.
At 7:32 a.m., in room 2218, in the pediatric intensive care unit, the trash receptacle was full.

6. A review of the temperature/humidity monitoring logs for January and February, 2014 indicated the following areas were monitored: operating rooms, cardiac catheterization labs, obstetric procedure rooms and recovery room.
There was no documentation of temperature/humidity monitoring for the intensive care units.

During an interview on February 26, 2014, at 8:45 a.m., the facilities manager stated the intensive care units were not monitored for temperature and humidity.

A review of the facility's policy and procedure titled, "Senso-Tech Room Temperature Monitoring" reviewed and approved on November, 2013 indicated operating room humidity shall be maintained between 35-60% and temperature control should be maintained between 68-73 degrees.

The temperature/humidity is primarily monitored through the Senso Tech system which is controlled and maintained by Materials Management Department.

Based on observations, interview, and record review, the facility failed to ensure the infection control policies were practiced by the staff, visitors and contractors.
1. During an observation of care of a patient in contact isolation (Patient 34), the Registered Nurse (RN) and the Certified Nurse Assistant (CNA) were observed not performing hand hygiene after removing gloves and touching clean supply/equipment. This failure had the potential to spread infection to other patients.
2. During the observation of the facility photography contractor taking the photograph of an infant, the photographer was observed combining clean and used linen on the shelf of the photography infant bed. This failure had the potential to spread infection to other patients.
3. Patient 20, 34 and Patient 39 had intravenous (IV) heparin locks (HL) that were not labeled of the date and time of insertion. Patient 21 had a HL with dressing labeled nine days ago. This failure had the potential for infection at the insertion site if the HL was left for an extended period of time.
4. There were thawed expressed breast milk (EBM) bottles found in the refrigerator in the Neonatal Intensive Care Unit (NICU) that were not labeled with the date and time of when the EBM were thawed. This failure had the potential to feed the babies with expired EBM.
5. Patient 40 was receiving IV fluids and the IV bag solution was not labeled.
6. RN 9 did not follow infection control practice during wound care of Patient 19.
7. A visitor was observed without personal protective equipment (PPE) while visiting a patient in contact isolation.
8. An RN and CNA failed to remove soiled gloves and practice hand washing before continuing with the care of Patient 9.
9. Medical staff members failed to provide current TB status .

Findings:

1. During the tour of 4G Medical/Surgical floor with the RN 5, Nurse Manager of 4G Medical/Surgical floor, on February 25, 2014, at 8:30 a.m., a sign indicating "Isolation" was observed posted on the door of Room 4211. RN 5 stated Patient 34 is on isolation for a positive methicillin resistant staphylococcus aureus (MRSA) infection in the nares.

During the observation of care for Patient 34 on February 25, 2014, at 8:50 a.m., RN 2 and CNA 1 were observed performing peri-care, changing the external urinary catheter, and changing the linens for Patient 34. RN 2 and CNA 1 were observed removing their gloves and reach for linens from the clean linen cart without performing hand hygiene immediately after removing gloves. RN 2 was also observed answering the cordless phone several times without sanitizing her hands prior to answering the phone. After using the phone, RN 2 did not perform hand hygiene prior to donning new gloves and resuming care for Patient 34.

During the interview with RN 2 at 9:03 a.m., RN 2 stated she should use the sanitizer after removing gloves "so we don't spread infection."

The facility policy titled "Hand hygiene, Cough, and Respiratory Etiquette" dated May 2013 indicated "Thorough hand washing is the most important factor in infection control; it must be faithfully practiced without exception." The policy indicated hand-washing is performed after contact with body fluids or excretions, mucous membranes, and wound dressings, if hands are visible soiled. "Decontaminate hands after removing gloves."

2. During an interview with the patient in Room 5414 on February 24, 2014, at 9:35 a.m., the photographer was taking infant pictures of the patient's baby. The baby was laying on top a pink furry. The pink furry blanket was on top of a black cloth used as a backdrop. The photographer was observed pulling out a rolled baby blanket from under the black cloth. Under the black cloth, the rolled baby blanket was resting directly on top of the mattress of the portable infant warmer. The photographer placed the rolled baby blanket on the first shelf of the infant warmer, touching other rolled blankets on the shelf. The photographer rolled the portable infant warmer from the room. At 9:52 a.m., the pink furry blanket was observed folded on the first shelf of the portable infant warmer next to the rolled baby blankets.

During the concurrent interview with the photographer, she stated the pink furry blanket is a back-up blanket she uses when an infant's parents forget to bring their own blanket to use in the infant's picture. The photographer stated the rolled blanket does not touch the infant. The rolled blanket goes under the black blanket, used as a positioning aid. The photographer stated she places the used rolled blanket on the left side of the top shelf and the clean ones on the right side. When the surveyor informed the photographer she placed the used rolled blanket on the right side of the shelf, the photographer stated she was in a hurry so she just placed it in the shelf. The photographer stated she did not even realize she placed the used rolled blanket on the right side of the shelf. RN 7, Director of Children's Services, explained to the photographer that once something touched the bed (for example, linen), it is considered dirty and needs to be placed in the dirty linen cart.
The facility policy titled "Linen" dated February 2013 indicated soiled linen is kept separate from clean linen at all times.

3. During the tour of the facility on February 25, 2014, at 8:20 a.m., Patient 39 was observed with an IV HL on her left antecubital (region of the arm in front of the elbow). However, the left antecubital HL transparent dressing was not dated and timed of the IV HL insertion. Patient 39 stated the HL was inserted the evening of February 23, 2014.
RN 2 was asked to Patient 39's bedside at 9 a.m. RN 2 looked at Patient 39's left antecubital HL and stated "It does not have date, time and initials of when it was inserted."

4. During the observation of cares for Patient 34 on February 25, 2014, at 8:56 a.m., Patient 34 was observed to have a HL on his right antecubital. The transparent dressing was not dated and timed of the IV HL insertion.
During the concurrent interview with RN 2, RN 2 stated "It does not have date, time, and initials. It needs to have date, time, and initials."

The facility policy titled "Prevention of IV Associated Infection" dated May 2013 indicated "Procedures accompanying insertion ...5. Record the date, time, and initials on label at IV site ...F.d. Dressings are changed every 96 hours (with site change)."

5. During the tour of the NICU on February 24, 2014, at 10:28 a.m., there was 1 bottle of expressed breast milk (EBM) found without a label of the date and time the breast milk was thawed. There were 2 bottles of breast milk not labeled of when the mother had pumped the breast milk, or when the EBM was thawed.

During the concurrent interview with RN 1, while RN 1 looked at the three (3) bottles, she stated the bottles need to be dated with the date and time of when the nurse started thawing the EBM. RN 1 stated the mother need to write the date and time of when she pumped the EBM. RN 1 also stated "Once the breast milk was defrosted, it is good for 24 hours; then, it is thrown out."

The facility policy titled "Breast Milk: Collection, and Storage, Use in NICU" dated December 2013 indicated the purpose of the policy is to provide for the safe collection of and storage of breast milk in a manner that minimizes the risk of breast milk contamination. The policy indicated "Only breast milk, which is properly collected, labeled, and stored, will be used." All breast milk shall be labeled with name of infant, medical record number, date, and time of collection." "Thawed breast milk may be refrigerated for 24 hours then discarded." "Frozen breast milk must be dated and timed before it is placed in a refrigerator to thaw. This milk may be refrigerated for 24 hour. Care should be taken to thaw only the amount needed to feed the infant for a 24 hour period."


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6. On February 25, 2014, at 8 a.m., during the initial tour of the unit with RN 6, the following were observed:
a. In Room 4232, the C-Pap/Bipap circuit tubing was noted hanging by the machine, exposed to the element. The mask and tubing for respiratory treatment was noted to be in a plastic bag hanging by the flowmeter.

On February 26, 2014, at 1:20 p.m., during an interview with RCP, he stated the C-pap/Bi-Pap circuit/tubing when not in use is customary for the RCP to put them in a plastic to protect it from being touched and exposed from elements. He further stated the facility's policy did not address the storing of the tubing/circuit when not use.
b. In Room 4229, Patient 21 was noted to have a heplock/saline lock on the left arm and the dressing was labeled February 16, 2014. During a concurrent interview with RN 6. she stated the heplock/saline lock should have been removed/changed after 4 days of being placed.

The facility policy titled, "Intravenous Therapy" indicated, "All peripheral intravenous sites, tubing, and dressings will be changed every 4 days for adult patients."
c. In Room 4228, Patient 20 was noted to have a heplock/saline lock on the left hand and there was no label as to when it was placed. The right hand had a heplock/saline lock dated February 24, 2014.

The chest drainage system and tubing was noted to be on the floor. The facility reference book indicated adjust tubing to hang in straight line from chest tube to drainage chamber to promote drainage and prevents fluid or blood from accumulating in pleural cavity.
d. In Room 4223, Patient 40 was noted receiving 0.9 % normal saline via right heplock/saline lock. Upon closer observation the IV bag solution was not labeled.
According to facility policy titled "Intravenous Therapy" indicated, "Intravenous containers without additives will be labeled with patient name, date and time hung, initials of the person hanging."
e. In Room 4220, there was a basin that contained bottles of 0.9% of Sodium Chloride and Wound Cleanser which was opened and undated. There was a packet of Xerofoam (Petroleum Dressing) which was opened and almost dried. There were four (4) packets of antibiotic.

During an interview with RN 9, she stated the contents in the basin was used for wound care treatment for the patient.

7. On February 25, 2014, at 9:55 a.m., during an observation of the right arm wound for Patient 19, RN 9 was assisted by a nursing student to prepare the equipment and supplies. The gauzes, bottle of normal saline and container of wound cleanser were placed on top of the pillow by the right side. The RN started to take off the splint on the right arm and placed on the chair beside the trash can. The RN put on pair of gloves and started to remove the soiled dressing from the right arm. The soiled dressing was not discarded instead it was placed on the pillow where Patient 19's right arm rested. The RN lifted the arm and sprayed wound cleanser and placed back the arm on the soiled dressing. The RN then poured normal saline on the wound while resting on top of the soiled linen. The student nurse started cutting pieces of tapes and placed them on the bed siderails. The RN put on a new pair of gloves, lifted the arm, applied xerofoam dressing, wrapped the arm with kerlix and discard the soiled dressing. The splint was then applied and wrapped with ace bandage.

A review of the Patient Demographic indicated Patient 19 was admitted to the facility on February 10, 2014 due to a gunshot wound to the hip and right upper extremity. There was a physician order dated February 19, 2014 on the right upper arm to change dressing daily and as needed (PRN). To cleanse site with normal saline, cover with xerofoam gauze and apply ABD kling.

A review of the facility's procedure on Dressings, Bandages and Binders obtained from Clinical Nursing Skills and Techniques 8th edition by Perry, Potter and Ostendorf indicated:
Place disposable waterproof bag within reach of work area (to ensure easy disposal of soiled linen).
With gloved hand remove dressing and inspect wound for appearance, color, size, drainage or odor. Fold dressings with drainage contained inside and remove gloves inside out. Dispose of gloves and soiled dressing . Cover wound lightly with sterile gauze and perform hand hygiene.
Create sterile field with sterile dressing tray or individually wrapped sterile supplies on over-bed table. Our any prescribed solution into sterile basin.
Cleanse wound, perform hand hygiene and apply clean gloves. Use gauze or cotton ball moistened in saline or antiseptic swab or spray wound surface with wound cleanser. Use sterile gauze to blot in to the wound.
Apply dressing.

During a concurrent interview with RN 9, she concurred that she failed to follow the infection control practices during wound care.


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8. On 2/24/2014, at 10:10 a.m., during an observation of a medication pass, a registered nurse (RN 30) on the Pediatric Nursing Unit, RN 30 stated Patient 6 was on isolation for clostridium difficile (C-diff), a bacteria that causes diarrhea. RN 30 was observed putting on Personal Protective Equipment (PPE), a gown and gloves, which is used to protect staff, visitors, and other patients from contracting or spreading an infection. However, an adult female was observed asleep in Patient 6's room not wearing PPE. RN 30 stated the adult female was a family member of Patient 6.

During an interview, on 2/26/2014, at 10:20 a.m., the Quality Assurance Director (QA Director), stated, visitors must adhere to the facility's contact isolation policy which requires the visitors to wear PPE while in the patient's room. The QA Director further stated the facility's policy also requires overnight visitors to wear PPE.

On 2/27/2014, at 3:05 p.m., during an interview, RN 29 stated, Patient 6 was under contact isolation for clostridium difficile and head lice. RN 29 stated one family member can sleep with the patient; however, the family was still required to wear PPE. She stated, "(Patient 6's) family member was not wearing PPE on 2/24/2014 and should have been." RN 29 further stated, "Another family member is here today and is wearing the PPE now."

A review of the facility's policy and procedure titled, "Infection Control, Isolation: Empiric Application of Transmission-Based Precautions," revised 5/2013, indicated, " ...Explain to the patient and family the need for Transmission-Based Precautions for staff, family and visitors ...Instruct family and visitors on Personal Protective Equipment (PPE)."

A review of another facility's policy and procedure titled, "Infection Control, Isolation Precautions," revised 5/13, indicated, " ... wear clean non-sterile gloves when entering the room ...Remove gloves before leaving the patient's room and wash hands immediately with an antimicrobial agent ...ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room to avoid transfer of microorganisms to other patients or environment ...Wear a clean non-sterile gown when entering the room. Remove the gown before leaving the patient's room...ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients or environment."



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9. During a tour of the Medical/Surgical ward on 2/25/14,CNA and RN were observed changing Patient 9's soiled linen and clothing. The RN and CNA changed their visibly soiled gloves without washing their hands, then continued to care for the patient.

10. During a review of the medical staff credentialing file, only four of the ten medical doctors had current tuberculosis tests.

The Facility policy and procedure titled "Bylaw language related to TB testing"' stated "beginning January 1, 2014 all new medical staff would submit annual TB screening tests and existing staff have until April 1, 2014 to submit annual TB test."