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Based on record review, interviews, and observations, the hospital failed to ensure that the RN supervised and evaluated the nursing care of each patient as evidenced by:

1) Failing to ensure that a patient on a Dopamine drip was receiving the correct dosage as ordered by the physician and
2) Failing to ensure that vital signs for a patient on a Dopamine drip was monitored frequently for 1 of 1 patients on a Dopamine drip (#12) in a total sample of 25.
Findings:

Review of the medical record for Patient #12 revealed an admit date of 05/12/17 with diagnoses including myocardial infarction and hypotension. Review of admit physician orders dated 05/12/17 (no time) revealed orders for a Dopamine drip (used to treat low blood pressure) at 5mcg/kg/hr - titrate to keep blood pressure between 90-100. Further review of the orders revealed to obtain vital signs every 4 hours. The patients weight was documented as 213 pounds (96.82 kg).

Review of the nurses notes dated 05/12/17 at 8:20 p.m. revealed Dopamine was infusing at 5mcg/kg/hr, 6.4 mL/hr. According to the patient's weight, the Dopamine should have been infusing at 18.15 mL/hr.

Review of the record revealed that vital signs, including blood pressure, were obtained on the following dates:
05/12/17 at 10:15 p.m. - B/P 98/56
05/12/17 at 12:00 a.m. - B/P 98/45

05/13/17 at 2:15 a.m. - B/P 97/47
05/13/17 at 8:00 a.m. - B/P 85/53
05/13/17 at 9:00 a.m. - B/P 102/64
05/13/17 at 12:00 p.m. - B/P 108/58
05/13/17 at 8:00 p.m. - B/P 93/44
05/13/17 at 12:00 a.m. - B/P 96/52

05/14/17 at 8:00 a.m. - B/P 103/53
05/14/17 at 12:00 p.m. - B/P 105/55
05/14/17 at 4:00 p.m. - B/P 110/66
05/14/17 at 5:40 p.m. - B/P 101/88
05/14/17 at 8:00 p.m. - B/P 101/88
05/14/17 at 12:00 a.m. - B/P 110/56

05/15/17 at 4:00 a.m. - B/P 112/62
05/15/17 at 8:00 a.m. - B/P 140/72

There was no more documented evidence in the record that that the patient's blood pressure was monitored more frequently than the above times while he was on Dopamine drip at 5mcg/kg/hr.

Further review of the record revealed that the patient's Dopamine drip was titrated to 4mcg/kg/hr on 05/15/17 at 8:09 a.m. Following this titration, the patient's vital signs were obtained at 9:00 a.m., 11:00 a.m., 12:30 p.m. and 3:56 p.m.

The patient's Dopamine drip was further titrated on 05/15/17 at 3:56 p.m. to 3mcg/kg/hr with vital signs obtained at 4:00 p.m., 6:00 p.m., 8:00 p.m. and 11:00 p.m. There was no documented of any more frequent vital signs during the titration of the Dopamine.

The nurses notes on 05/15/17 at 11:00 p.m. revealed the Dopamine drip was lowered to 2mcg/kg/hr, running at 2.5mL/hr and on 05/16/17 at 4:34 a.m., was lowered to 1mg/kg/hr (1.3mL/hr). The drip was discontinued on 05/16/17 at 5:35 a.m.

On 05/16/17 at 2:00 p.m., a copy of the hospital's policy and procedure related to Dopamine drips was requested. At 2:30 p.m., S1DON provided a copy of a paper titled Critical Care Infusions. Review of this paper revealed it provided the formula for figuring the correct infusion rates of Dopamine and examples of calculations. The form did not address the monitoring of patients who were on Dopamine drips. Interview with S1DON at that time confirmed there was no policy and procedure that addressed Dopamine drips. S1DON further stated that the vital signs for patients on Dopamine drips should be assessed at least every hour.

On 05/16/17 at 3:00 p.m., interview with S3Pharmacy Director revealed that the nursing staff should not have to calculate the correct infusion rate of Dopamine drips because the IV pumps calculate for them. She stated that the nurses input the correct dosage and weight and the pump figures the infusion rate. At that time, S3Pharmacy Director was asked to calculate the correct infusion rate for Patient #12, who had an order for Dopamine 5mcg/kg/hr and weighed 213 pounds. She calculated the infusion rate to be 18.15 mL/hr. At that time, she reviewed the patient's nurses note dated 05/12/17 at 8:20 p.m. and confirmed that the rate the patient received was incorrect. She further stated that she was unsure how that happened.

On 05/16/17 at 3:50 p.m., further interview with S1DON revealed that the IV pumps should be calcuating the correct infusion rates for Dopamine. After reviewing Patient #12's record, she confirmed that the documented infusion rates were incorrect, and was unsure how that happened. She also confirmed that there was no documented evidence that the patient's vital signs were assessed at least every hour while on the Dopamine drip.

Based on personnel records review and interview, the hospital failed to ensure the nursing staff remained competent to provide nursing care assigned as evidenced by failing to conduct annual competency skills evaluations of the nursing staff for 3 of 3 RN's whose personnel files were reviewed (S4RN, S5RN, S6RN).
Findings:

Review of the personnel files of S4RN, S5RN, and S6RN revealed all had been employed more than one year. Further review revealed no documented evidence that an annual competency skills evaluation had been conducted during the last year.

On 05/17/17 at 10:30AM, an interview with S1DON revealed she was responsible for ensuring that the competency skills evaluations of staff were conducted, and confirmed that she had not conducted the competency evaluations of the staff.

Based on record review and interview, the hospital failed to ensure the infection control officer was qualified based on education, training, or certification as evidenced by appointing an infection control officer with lack of evidence of education, training or a certification in infection control.
Findings:

Review of the personnel file of S1DON revealed she was the current Director of Nurses and Infection Control Officer. Further review of her personnel record revealed she had no former experience as an Infection Control Officer and no certification as having been trained as an Infection Control Officer.

An interview was conducted with S1DON on 05/17/17 at 9:15 a.m. She reported that she was appointed the Director of Nurses and the Infection Control Officer in 2016. She further reported that she had no formal infection control training or experience.

Based on observation, record review, and interview, the hospital failed to ensure the infection control officer developed a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. This deficient practice was evidenced by:

1) Failing to ensure infection control practices were followed during medication pass;
2) Failing to ensure that medication carts were free from spills, build-up of dirt/debris and old pill pieces;
3) Failing to ensure the glucometer was disinfected after patient use; and
4) Failing to maintain a sanitary hospital environment
Findings:

1) Failing to ensure infection control practices were followed during medication pass:
On 05/17/17 at 9:30 a.m., observation revealed S10LPN on the hall passing medications from the medication cart. Further observations revealed the medication cart had a drawer for each patient, and the patients' medications were in plastic zipper bags. Observations during this time revealed S10LPN was removing the patients' pills from the plastic bags with her bare fingers. S11LPN was observed to touch the medication cart, her name badge and scratch her face during the pass. She was not observed to clean her hands at any time.

2) Failing to ensure that medication carts were free from spills, build up of debris and old pill pieces:
On 05/17/17 at 9:30 a.m., observation revealed S10LPN was in the hall preparing medications to administer to a patient. Interview with S10LPN, at that time, revealed that the medication cart is pushed into each patient's room when medications are administered. When asked how often the medication cart is cleaned/disinfected, she stated once a day, by the night shift nurse. Observation of the medication cart at that time revealed multiple white spills down the front and sides of the cart, a thick build-up of dirt and grime on the bottom drawers of the cart and small pill pieces on top of the cart where she was currently preparing medications. At that time, S10LPN confirmed that the medication cart was not clean and it was going in and out of each patient's room during medication pass.

On 05/17/17 at 9:45 a.m., observation of two medication carts in the medication room revealed that they had old spills and a build-up of dirt and grime by the bottom drawers. S11LPN was observed to be preparing medications at one these carts and a black hair was observed on the top of the preparation area. When asked how often the carts were cleaned/disinfected, she stated they were cleaned/disinfected nightly by the night shift nurses.

Review of the policy and procedure titled, Medication Administration Carts, presented as current by S1DON revealed that medication carts are to be wiped down with alcohol based wipes daily, on night shift.

3) Failing to ensure the glucometer was disinfected after patient use:
On 05/17/17 at 9:30 a.m., when S10LPN was asked how often the glucometer on the medication cart was disinfected, she stated daily. When further asked if she disinfected the glucometer after using it on each patient, she stated no. She further stated that the patients do not touch the glucometer.

On 05/17/17 at 9:45 a.m., when S11LPN was asked how often the glucomenter on the medication cart was disinfected, she stated daily.

On 05/17/17 at 10:00 a.m., interview with S1DON, who was also the Infection Control Officer, confirmed that the glucometers are cleaned once per day and not after use on each patient.

4) Failing to maintain a sanitary hospital environment:
On 05/15/17 at 1:15PM, an initial tour was conducted, which revealed the following observations:

Shower room a - There were three open, used bars of soap sitting in the shower stall with black hairs noted on them and four open bottles of shampoo.
Shower room i - There was used soap in the shower stall
The blood pressure monitor in the hallway near room b was dirty and had multiple brown drips on the base.
The blood pressure monitor at the end of the hallway near room f had dirt and grime on the handles and there were holes in the velcro areas of both arm cuffs.
The blood pressure monitor in the hallway near room g had old pieces of tape stuck to it and was sticky with old tape residue.
There were several strips of clear plastic tape stuck to the blood pressure monitor located between the hallways near room h.
The EKG machine located between the hallways near room h had dirt, dust and trash particles in the bins and on the base of the machine with a sticky substance on the lead wires.
The scales located between the hallway near room b had brown residue on top and a thick buildup of dust and grime on the bottom, with the nonstick surface curling up.
The whirlpool room had a brown substance on the tile wall.

The following patient rooms had labels on the outside of the door which stated "Room cleaned and ready for patient use":
Room c - The IV pump base was coated with hair and a dark substance; there was a brown substance on the top of the pump. Strands of hair were noted on the top of the bedspread. The call bell had a brown substance on it. The mirrored tray on the overbed table had spills on the inside and a black substance on the outside.
Room d - The ante room had a trash can filled with trash; the sink in the ante room contained dark brown clumps of an unknown substance; the side of the overbed table was coated with dried, red substance.
Room e, bed a - Black hair and a thick layer of dust was noted on the electrical panel above bed; the trash can was full with gloves and food; the side rail was coated with drips of yellow substance. Bed b - a syringe containing 3cc of normal saline was sitting on top of the shelf over the bed.
Room f, bed a - The trash was full with food wrappers and newspapers; there was hair noted on the top of the bedspread; the IV pole had old, dark red, dried substance on the base; there was a thick buildup of dust on the top of the panel over the bed. Bed b - There was dirt, grime and hair on the IV pump; crumbs were in the tray of the overbed table; thick dust was on the top of the panel above the bed. The bathroom had a large spiderweb with a live spider in it, and brown substance was at the base of the commode.
Room h - IV pump had old tape stuck to it; the bedside table drawer had hair on it; trash and spills were in the bottom drawers of the bedside table
Room j - Old, dried, red substance was on the call bell.
Room k - A dead bug was on the floor by the chair; trash was in the window sill; a plastic needle covering was on the floor under the bed
Room l - A piece of gauze with blood on it was under the bed; a dead bug was in the room.

On 05/15/17 at 2:50PM, the above infection control issues were shared and observed with S1DON. She confirmed the areas were in need of housekeeping.




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