HospitalInspections.org

Based on observation, interview, and document review, the hospital failed to ensure that the Condition of Participation for Provision of Services was met when:

1. Failed to identify and label the enteral nutrition (tube feeding) for one of four patients (Patient 42). This failure had the potential for not identifying the correct patient, the correct physicians' order for enteral feeding. (Cross Reference C0271).

2. Failed to provide a functional and sanitary environment when infection control practices were not implemented in accordance with hospital policy and nationally recognized standards. Staff did not change gloves and wash hands between medication administrations, when providing patient care for one of four patients (Patient 42) in contact isolation. This failure could have resulted in cross contaminations and a wide spread of infections among patients. (Cross Reference C0278).

The cumulative effect of these systemic problems had the potential to endanger patients' health and safety and had the potential to transmit infectious microorganisms to patients and increased the risk of infections to all patients who received care in the facility. The facility failed to deliver care in a safe setting in order to be in compliance with the Condition of Participation for Provision of Services - § 485.635.






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Based on observation, interview and document review, the hospital failed to identify and label the enteral nutrition (enteral nutrition generally refers to any method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements, the use of liquid supplements or delivery of part or all of the daily requirements by use of a tube (tube feeding)) for one of four patients (Patient 42). This failure had the potential for not identifying the correct patient, the correct physicians' order for enteral feeding.

Findings:

During a concurrent observation on 12/8/16 beginning at 8:25 a.m., Licensed Staff SS was conducting the medication administrations for Patient 42. Observed in one corner of the room was a pole with a half emptied bag of enteral feeding and tubing. The enteral feeding was not currently being administered to Patient 42, it was turned off and disconnected from Patient 42. The front of the enteral feeding was labeled 150 Source Cal and there was approximately 500 milliliters (mls) left in the bag. On the back of the enteral feeding (bag) was a pre-affixed patient label. The label had an area to complete with the patient name, patient identification, date of administration, time of administration, the tube feeding order; the label was left blank.

Licensed Staff SS concurred there was no patient identifiable information placed on the enteral feeding.

During a concurrent interview and document review on 12/8/16 at 10:45 a.m., Licensed Staff F concurred the enteral feeding was administered on 12/7/16 at 11:00 p.m. and discontinued on 12/8/16 at 3:00 a.m., by Licensed Staff TT per physician order.

Review of the policy and procedure titled, "ENTERAL FEEDINGS" last revised 10/16, indicated "...Label container, tubing and syringe with the date and time..."


During an interview on 12/8/16 at 12:10 p.m., the Director of Pharmacy (DOP) indicated the hospital had not begun medication administration observation audits. DOP stated the hospital had a tool to use to observe nursing staff administer medications and stated she planned to begin the audits January 2017.

During an interview on 12/8/16 at 1:40 p.m., Chief Nursing Officer (CNO) indicated the hospital had not begun medication administration observation audits.

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Based on observation, interview and record review, the hospital failed to provide a functional and sanitary environment when infection control practices were not implemented in accordance with hospital policy and nationally recognized standards. Staff did not change gloves and wash hands between medication administrations, when providing patient care for one of four patients (Patient 42) in contact isolation for urinary tract infection cultured for Extended Spectrum Beta-Lactamases (ESBL). This failure could have resulted in cross contaminations and a wide spread of infections among patients.
Note: ESBLs are enzymes produced by bacteria such as Escherichia coli (E.coli) and Klebsiella. These are mainly bacteria that are found normally in the human bowel, but can cause serious illness. ESBLs can be resistance to a range of frequently used antibiotics including penicillin's and cephalosporins. As a result, infections caused by these bacteria can be difficult to treat and the prevalence of these bacteria and infections caused by them are becoming more common in both community and healthcare settings. The most common bacteria that produce these enzymes are E. coli and Klebsiella which are bacteria that can live in your bowel without you being unwell or showing any signs or symptoms of infection (this is referred to as colonization). These bacteria cause infection if they get into an area of the body where they are not normally found, such as the urinary tract. Urine infection is the most commonly diagnosed infection, but infection in the lungs (chest), wounds and in the blood can also occur. Infections caused by ESBL-producing bacteria can be more difficult to treat because of antibiotic resistance, as there are fewer effective antibiotics to use.

Findings:

During an observations on 12/8/16 from 8:50 a.m. through 10:10 a.m., Licensed Staff SS donned personal protective equipment (PPE) (a face shield, gown and gloves) to enter Patient 42's room. Patient 42 was on contact precautions (contact precautions are designed to reduce the risk of transmission of microorganisms by direct or indirect contact). During the medication administration observation, Patient 42 was to be administered one subcutaneous injection (heparin, a blood thinner), five oral medications (metoprolol -for high blood pressure; amlodipine - for high blood pressure; levetiracetam - an anticonvulsant; docusate sodium - for constipation; bisacodyl - for constipation), and eye drops (neomycin-polymyxin-dexameth).

During the observation in the medication room, Licensed Staff SS gathered the medications for Patient 42 from the Omnicell (a medication dispensing cabinet) and a medication cart. No hand hygiene was observed prior to obtaining the medications. No hand sanitizer was observed in the medication room. The counter where the medications were laid down was not observed wiped down with a germicidal solvant and there was no barrier placed on the counter. Licensed Staff SS placed two normal saline flush syringes containing 10 milliliters (mls) in his left leg pocket along with the zip-locked bio-hazard labeled bag containing the neomycin eye drops. After obtaining the medications, Licensed Staff SS left the medication room to enter Patient 42's room. There was no hand hygiene performed prior to donning gloves and entering the room.

Licensed Staff SS obtained vital signs and verified the patients identity. The g-tube (a gastric tube placed in the abdomen) was located and aspirated for residual and the first medication (metoprolol) was crushed and administered through the g-tube. The next medication administered were the eye drops (neomycin-polymyxin-dexameth) to Patient 42's left eye. Licensed Staff SS did not change gloves or wash his hands between the administration of medication (metoprolol) via g-tube and the administration of eye drops (neomycin-polymyxin-dexameth). Licensed Staff SS continued with the next g-tube medication administration. There was no hand hygiene performed after the administration of eye drops to the next medication to be crushed and administered via g-tube. At the completion of the g-tube medication administration there was no removal of gloves and hand hygiene performed. Licensed Staff SS proceeded to administer the subcutaneous injection without changing the gloves and performing hand hygiene. Licensed Staff SS concurred he had not changed gloves between the g-tube medication administrations, the eye drop medication administration and the subcutaneous heparin injection.

During an interview on 12/8/16 at 12:00 p.m., Chief Nursing Officer (CNO) stated the hospital uses the general standards of the Lippincott Manual of Nursing Practice if the hospital did not have a specific best practice policy.

Review of the policy and procedure titled "STANDARDS OF PRACTICE/CLINICAL REFERENCE" last reviewed 10/16, indicated "...The Medical/Surgical Unit of ...Hospital will provide for the essential nursing care of the acutely ill patient. The personnel of this unit will provide nursing care using the general standards of the Lippincott Manual of Nursing Practice, current edition..."

Review of the Lippincott procedure guidelines "Installation of Eye Medications" Tenth Edition, indicated "...Preparatory phase...Wash hands before instilling medication..."

Review of the policy and procedure titled "HAND HYGIENE & GLOVE USE" revised 10/16, indicated "PURPOSE: The spread of microorganisms from person to person, person to environment or environment to person often occurs through transient carriage on the hands. Hand washing and hand hygiene are key components of infection prevention and control...A. Perform hand hygiene before and after routine patient care activities, including entering and exiting the patient care environment and after hand-contaminating activities. B. Perform hand hygiene before handling medications...C. Wear gloves for contact with moist body substances and remove them immediately after completing the specific task they were used for. After glove removal, clean hands with either soap and water or alcohol-based hand rub..."

During an interview on 12/8/16 at 12:10 p.m., DOP indicated the hospital had not begun medication administration observation audits. DOP stated the hospital had a tool to use to observe nursing staff administer medications and stated she planned to begin the audits January 2017.

During an interview on 12/8/16 at 1:40 p.m., CNO indicated the hospital had not begun medication administration observation audits.