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On the days of the hospital validation survey based on review of patient charts and interview, the hospital failed to ensure staff followed the physician's orders or obtain physician orders in the provision of care for 5 of 47 open patient charts reviewed for care and services. (Patient #5, #8, #32, #6, #34)


The findings are:


On 8/27/13 at 1526, review of Patient #5's chart revealed the patient was admitted from the hospital's emergency department on 8/19/13 at 1720 to the Sixth Medical South Tower with a diagnosis of Altered Mental Status and an intravenous catheter. Review of the nurse notes from 8/19/13 through 8/27/2013 revealed the patient had an intravenous catheter inserted on 8/22/13 at 1721 that was discontinued on 8/27/13 1026. Review of the patient's physician orders from 8/19/2013 through 8/27/2013 showed there was no physician order for the intravenous catheter. The findings were verified on 8/27/13 at 1540 with the Clinical Outcomes Coordinator.

On 8/28/13 at 1214, review of the physician's orders on Patient #8's chart revealed a physician order dated 8/9/13 for percutaneous endoscopic gastrostomy (peg)(tube that carries liquid nutrients into the patient's stomach)care each shift, but there was no documentation by nursing staff that the peg care was provided on 8/12/13, 8/14/13, and 8/22/13. The findings were verified with the Clinical Outcomes Coordinator upon review.

On 8/28/13 at 1148, review of Patient #6's chart (medication administration records and nursing notes)revealed the patient received Dilaudid 3 milligrams (mg) intravenous (IV) for pain on 8/28/13 at 0953, but there was no follow up evaluation of the effectiveness of the pain medication documented.







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On 8/28/2013 at 1530, review of Patient #32's chart showed the patient was admitted on 8/08/2013 with Aspiration Pneumonia and Thrombocytopenia (related to chemotherapy administration). Review of the patient's chart showed the patient's oxygen saturation levels ranged from 96-100%(percent) on 1-2 liters oxygen via nasal canula (tube for the flow of oxygen). Then, on 8/27/2013 at 0545, documentation showed the patient's oxygen saturation level dropped to 76-87%, and staff increased the patient's oxygen flow rate to 6 liters (55% oxygen administration). The patient's oxygen saturation level rose to 91% (percent) initially, but then, the patient's oxygenation level declined to 86%. Respiratory staff suctioned the patient, and replaced the patient's nasal cannula with an oxygen mask at a flow rate of 15 liters. Review of the patient's chart revealed there was no documentation by either nursing staff or respiratory staff that the patient's physician was notified of the patient's change of condition (respiratory status). On 8/28/13 at 1530, Outcomes Coordinator #1 verified the findings.

On 8/29/13 at 1000, the Oncology Nurse Manager, stated, "...We have protocols to change oxygen administration to whatever we need to to keep oxygen saturation up to keep from calling the physicians all the time...". On 8/29/2013 at 1030, the Respiratory Therapy Director, revealed, "...When the therapist went over 50% oxygen administration for this patient, the physician should have been notified."

Hospital policy, titled, Respiratory Care Protocol, reads, "...I. In the event of any acute onset of increased work of breathing, increased cardiac work, evidence of hypoxia, or evidence of decreased cardiac output, the physician or designee will be contacted for instructions/orders...".






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On 08/28/2013 at 1020, review of Patient #34's chart revealed the patient was admitted to the hospital's medical intensive care unit on 08/25/2013 with a diagnosis of Emphysema (chronic) with questionable sepsis(severe infection in the blood). Review of the patient's chart (medication administration and nurse notes) revealed the patient received pain medication on 08/26/2013 at 2349 and 08/27/2013 at 0228, but there were no documentation of an evaluation of the patient's pain level after the administration of pain medications from 08/26/13 at 1900 to 08/27/2013 at 0700. On 08/28/2013 at 1040, the Nurse Manager verified the finding.

Hospital policy and procedure, titled, "...SUBJECT: Pain assessment/Management...REVIEWED: 06/12 REVISED: 08/12, reads, "...Guidelines: 1. In the inpatient setting, a full pain assessment will be obtained at least once during every 8-hour shift to include location, intensity, quality, and patient satisfaction with pain management regimen. An additional pain score will be documented within the same 8-hour period and may include post intervention assessment as indicated by the patient's condition...".

On the days of the hospital validation survey based on observations, record reviews, interviews, and review of hospital policy and procedures, the hospital failed to ensure the patient's initial nursing assessment was completed in the required time frame for 1 of 47 patient charts reviewed for care and services (Patient #12), and lack of physician orders for the dialysis prescription for 4 of 7 patients receiving hemodialysis. (Patient #16, #19, #42, and #39)


The findings include:


On 8/27/13 at 1100, review of Patient #12's chart revealed the patient was admitted on 8/12/13 with Sickle Cell Crisis. Review of the patient's initial/admission nursing assessment revealed the nursing assessment was not completed until 8/15/13 which was three days after admission. The finding was verified with Quality Management Team Member on 8/27/13 at 1130.
Hospital policy, titled, "Plan for Providing Patient Care Services", revised 7/12, states, "...INPATIENTS... 2. The Registered Nurse (RN) analyzes the assessment data and identifies priority patient needs and initiates a preliminary plan of care within 8 hours of admission. Within 24 hours of admission, the RN completes the remainder of the admission assessment and initiates a plan of care consistent with the medical plan of care...".






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Review of the hospital's Hemodialysis Standing Orders, revealed, "When a new start hemodialysis patient is to initiate treatment, the physician must write orders for the first four days. On the the fifth day, the order may then be written to continue day four's order three times a week....".

On 8/27/13 at 1050, review of Patient #19's chart revealed the patient was admitted to the hospital on 8/22/13 and received dialysis treatments. On 8/26/13 from 1225 to 1325, observations showed the patient received a hemodialysis treatment. On 8/26/2013 at 1330, a review of the patient's chart revealed the physician order read, "New Hemodialysis Patient" but had no prescription for the patient's dialysis treatment. Review of the patient's chart revealed the hemodialysis treatment dated 8/26/13 was the patient's second hemodialysis treatment since admission. The findings were verified by Registered Nurse(RN) #31 on 8/27/13 at 1215.

On 8/27/13 at 1510, review of Patient #16's chart revealed the patient was admitted to the hospital on 8/22/13 and received hemodialysis treatments. On 8/26/13, observations showed the patient in the hemodialysis treatment room dialyzing. Review of the patient's chart revealed there were no physician orders for the dialysis prescription for the patient's hemodialysis treatment dated 8/26/13 The findings were verified by RN #32 on 8/27/13 at 1540.

On 8/29/13 at 1130, review of Patient #39's chart revealed the patient was admitted to the hospital and received hemodialysis treatments. Review of the patient's chart revealed the patient received Continuous Renal Replacement Therapy during the current hospitalization as well as hemodialysis treatments. Review of the Hemodialysis Inpatient Order on the patient's chart stated the frequency of the treatment for "once" and the duration for "1 occurrence". Further review of the chart revealed the patient received a dialysis treatment dated 8/20/13, but there was no physician order for the dialysis prescription for the hemodialysis treatment. The findings were verified by RN #32 on 8/29/13 at 1550.

On 8/29/13 at 1200, review of Patient #42's chart revealed the patient was admitted to the hospital on 8/24/13 and received hemodialysis. Review of the patient's chart revealed the patient received hemodialysis treatments on 8/24/13 and 8/27/13, but there was no physician order for the dialysis prescription for the hemodialysis received on 8/27/13. The findings were verified by RN #32 on 8/29/13 at 1550.

On the days of the hospital validation survey based on record review and interview, 1 of 47 patient care plans developed by nursing had not been updated every 24 hours. (Patient #8)

The findings are:

On 8/28/13 at 1214, review of Patient #8's plan of care developed by nursing revealed the patient's nursing care plan had not been updated by nursing every 24 hours on 8/9/13 and 8/17/13. On 8/28/13 at 1230, the findings were verified with the Clinical Outcomes Coordinator.

On the days of the hospital validation survey based on record review and interview, the hospital failed to ensure the patient's consent form had the type of the operation/procedure documented on the consent form for 1 of 47 open patient charts reviewed. (Patient #19)

The findings are:

On 8/26/13 at 1220, observations revealed Patient #19 received a hemodialysis treatment from 1220-1320 in the hospital's dialysis treatment room. On 8/26/13 at 1320, review of Patient #19's chart revealed the patient was admitted on 8/22/13 and had a "Consent to Operation or Procedure" form with the patient's signature and a Registered Nurse's (RN) signature as witness dated 8/22/13 at 2210, but the type of the operation/ procedure was not on the consent form. On 8/27/13 at 1215, Registered Nurse #31 verified the finding and reported there was no other consent form on the patient's chart that identified the procedure/operation.

On the days of the hospital validation survey based on observations and interviews, the dietary department staff failed to ensure all opened food items in the kitchen were labeled.


The findings are:


On 8/26/2013 from 1225 to 1400, random observations in the hospital's kitchen revealed staff placed their personal lunch bag in the cooler located in the dry storage area, chocolate fudge icing labeled as opened 9/11/2010 had no expiration date, dark corn syrup and light corn syrup in the dry storage area had no label identifying when the containers were opened, an unlabeled package that appeared to be meat lying on shelf in the main freezer, and an unlabeled clear bag containing a white substance located in the dry storage area that was identified by the Dietary Director as coconut. On 8/26/2013 at 1400, the Dietary Director reported, "...All of the items opened should have a label on them so that we know when food has been opened and when it is to be discarded...".

On the days of the hospital's validation survey based on observations, interviews, and review of hospital policies and procedures, hospital staff failed to adhere to the hospital's own infection control policies and procedures to minimize potential cross contamination and transmission of infectious agents in the hospital's catheter lab, emergency department, operating suites, medical surgical units, cardiac rehabilitation unit, intensive care units, and the computerized tomography control room.

The findings include:

On 8/26/13 at 1430, observations in the Cardiac Rehabilitation area showed Registered Nurse(RN) #18 failed to clean/disinfect the stethoscope used between multiple patients during the check in process. The finding was verified by A Quality Management Team Member on 8/26/13 at 1430.

On 08/28/2013 at 1505, observations revealed Registered Nurse #11 during the performance of wound care revealed the RN donned clean gloves, turned the patient to the left side, removed the old dressing from the pressure ulcer on the sacrum, and removed the gloves. RN #11 used an alcohol hand sanitizer to clean the hands for less than 2 seconds, but not thoroughly cleaning all surfaces of the hands and fingers until dry. Then, RN #11 donned gloves and performed the dressing change to the patient's sacral ulcer. Then, RN #11 removed the soiled gloves and used an alcohol hand sanitizer to clean his/her hands for less than 2 seconds, but not thoroughly cleaning all surfaces of the hands and fingers until dry. RN #11 donned clean gloves, changed the patient's bed linen, used wipes to cleaned the patient's rectal area, repositioned the patient, and removed the soiled gloves. RN #11 used an alcohol hand sanitizer to clean his/her hands for less than 5 seconds, but not thoroughly cleaning all surfaces of the hands and fingers until dry. RN #11 donned gloves, put a new gown on the patient, positioned the patient, covered the patient with a sheet and blanket, and removed the soiled gloves. RN #11 used an alcohol hand sanitizer to clean his/her hands for less than 2 seconds, but not thoroughly cleaning all surfaces of the hands and fingers until dry. On 08/28/2013 at 1530, RN #11 verified the findings.

Patient #38 was admitted to the surgical intensive care unit on 08/26/2013 with a diagnosis Post Surgical Open Heart. On 08/28/2013 at 0940, observations revealed Registered Nurse #10 administered the patient's medications, and then used an alcohol hand sanitizer to clean his/her hands for less than 5 seconds, but not thoroughly cleaning all surfaces of the hands and fingers until dry. On 08/28/2013 at 1000, RN #10 verified the findings.

Hospital policy and procedure, titled, "...INFECTION CONTROL POLICY AND PROCEDURE SUBJECT", reads, ": Hand Hygiene Reviewed 12/12... PROCEDURE:...When using a alcohol-based hand rub a. Apply product to palm of one hand. b. Rub hands together, covering all surfaces of hands and fingers, until hands are dry...".

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






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On 8/28/2013 at 1130, observation of Registered Nurse (RN) #8 revealed the nurse obtained the Glucometer (portable machine for checking blood sugars on patients in their room), performed a fingerstick blood sugar on the patient, laid the Glucometer on the patient's bed, failed to sanitize the Glucometer after patient use, and then, returned the Glucometer to its base location. On 8/28/2013 at 1200, RN #8 verified the Glucometer had not been cleaned prior to or after use on the patient.

Hospital policy, titled, CLEANING DISINFECTION AND STERILIZATION OF PATIENT CARE EQUIPMENT, reads, "...4. On inpatient units, patient care equipment that is taken from one patient room to another should be cleaned immediately before use, in between each patient use, and after use...High touch area on this equipment should be wiped with a disinfection wipe..."




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On 8/26/13 at 1315, observations on the hemodialysis unit revealed a hospital employee entered the dialysis treatment room without washing or sanitizing their hands upon entrance. Observations showed the visitor proceeded into the contact isolation precaution room without donning personal protective equipment (PPE) prior to entrance. After leaving the contact isolation precaution room, the visitor did not wash or sanitize his/her hands.

On 8/26/13 at 1320, observations of the dialysis unit revealed a hospital employee entered the hemodialysis treatment area without washing or sanitizing the hands. Observations revealed Certified Clinical Hemodialysis Technician (CCHT) #1 de-accessed the patient's catheter in Bay 4 as the hospital employee walked past the patient's bed. The hospital employee, who had worn no ppe, exited the hemodialysis treatment area without washing or sanitizing the hands.

On 8/26/13 at 1430, observations in the hemodialysis treatment room revealed Certified Clinical Hemodialysis Technician #1 failed to change gloves after palpation of the patient's access site, failed to perform hand hygiene, or to don clean gloves prior to cannulation of the patient's access site in Bay 3.

On 8/26/13 from 1425 to 1435, observations on the dialysis treatment room revealed torn strips of tape hanging from the dialysis machine in the
contact isolation precaution room. Observations revealed the RN de-accessed the patient's needles from the right upper arm site and applied the strips of tape hanging from the dialysis machine to the patient's access site. On 8/26/13 at 1458, RN #31 reported tape is supposed to be torn and "placed on a clean area prior to applying to the patient. RN #31 stated, "I did place the tape on the machine and that wasn't right".

On 8/28/13 at 1150, observations in OR(Operating Room) Suite #5 revealed Certified Registered Nurse Anesthetist (CRNA) #1 had visible hair strands located around the edges of the bonnet that he/she wore in the surgical suite. On 8/28/13 at 1213, observations in OR Suite #4 revealed Medical Doctor (MD) #4 had visible strands of hair around the back of the surgical cap, and Surgical Technician (ST) #1 had visible hair strands around the edges of the bonnet he/she wore in the surgical suite. On 8/28/13 at 1600, RN #33 revealed, "I know they wear their hair out but their not supposed to". On 8/29/13 at 0940, observations of MD #3 in the 7th North Tower revealed the MD wore the shoe covers that had been used in the OR. On 8/29/13 at 0940, RN #34 revealed MD #3 had "just performed surgery and was on the floor".

Hospital policy, titled, "Dress code, Procedure/Protocol:" reads, "....4. All head and facial hair is to be covered; bouffant caps are the preferred head attire....".
Hospital policy, titled, "Cleaning and Disinfection, FMS-CS-IC-II-155-110A", reads, "Cleaning the Dialysis Machine, Externally disinfect the dialysis machine with 1:100 (1 to 100) bleach solutions after each dialysis treatment....".
Hospital policy, titled, "FMS Inpatient Services Visitor's Policy, FMS-CS-IS-I-500-060A", reads, "Having visitor's in the inpatient treatment area while initiating and terminating treatment can increase the risk of potential cross contamination for both the patient and visitor. These restrictions are necessary to ensure the accurate preparation of the equipment and the safe and effective delivery of care to the patient, to maintain infection control, and to prevent any accidental exposure of the visitor to bloodborne pathogens during the time the visitor is present in the treatment area....".







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On 08/26/13 at 1230, observations in the emergency department revealed Technician #1 failed to clean the Blood pressure cuff, pulse oximeter, and the vital sign machine after use on a patient and prior to use on another patient. On 08/26/13 at 1300, Technician #1 revealed that they(staff) clean patient equipment before and after use on a patient with Sani-wipes.

On 08/26/13 at 1413, observations in the emergency department revealed RN #2 administered medications, exited the patient's room with the computer, entered another patient's room, but failed to perform hand hygiene prior to or immediately after exiting the patient rooms. On 08/26/13 at 1415, the RN revealed, "I should perform hand hygiene before and after I see the patients. I didn't use it after I left that room."

On 08/26/13 at 1540, observations in the hospital's emergency department revealed RN #17 initiated an IV(intravenous catheter), removed the soiled gloves, donned new gloves to transport blood to the lab, but failed to perform hand hygiene between glove changes.

On 08/27/13 at 1400, observations on Seven (7) North Tower revealed RN #3 and RN #4 completed a patient's dressing change with gloved hands, removed the soiled gloves, donned clean gloves, and performed another task without performing hand hygiene between glove changes. On 08/27/13 at 1450, RN #4 revealed, "we should have washed our hands after removing the gloves".

On 08/28/13 at 0938, observations of RN #9 on the Six (6) Floor North Tower revealed the RN failed to perform hand hygiene after he/she dropped the patient's medication packet containing the medication on the floor. Observation showed RN #9 picked up the medication packet, opened the medication packet, placed the medication in the cup, and handed the cup to the patient.

On 08/28/13 at 1040, observations on Fifth Floor (5) North Tower revealed Lab Technician #3 performed hand hygiene, donned gloves, applied tourniquet, palpated the site, cleaned the site, then palpated the site again, and inserted the needle, but failed to change the soiled gloves after palpating the site for the second time and prior to inserting the needle. On 08/28/13 at 1053, Lab Technician #3 revealed, "I don't change glove during the process, I only don gloves one time per room visit".

On 08/26/13 at 1440, random observations of Registered Nurse #2 in the emergency department preparing medications for administration revealed the Registered Nurse failed to disinfect the septums of the patient's intravenous (IV) port prior to administering Zofran, and failed to disinfect the septum of the Toradol and Demerol vials prior to withdrawing the medications.

On 8/26/13 at 1505, random observations on the dialysis treatment room floor revealed Registered Nurse #31 opened a vial of Heparin, but failed to clean the medication septum prior to the withdrawal of the medication from the vial and administering the medication.

On 08/29/13 at 1535, the Director revealed Lexington Medical Center uses Nurses' Guide to Clinical Procedures 6th edition, 2009 for the hospital's policy for nursing practices.

Review of the section, titled, "Primary Procedure References", reads, "Nursing Services at Lexington Medical Center has adopted Smith-Temple, J. &Johnson, J. Young. Nurses' Guide to Clinical Procedures, 6th edition, 2009 , J.B. Lippincott Company as the primary source of reference for procedures and protocols....".

Facility Policy, titled, "Proper Venipuncture Procedure and Technique", reads, "....8. Clean the venipuncture site. ....DO NOT TOUCH THE VEIN SITE AFTER CLEANING IT...."

Hospital policy, titled, "Infection Control, Isolation: Standard, Droplet, Airborne and Contact", reads, "1....Wash hands before donning gloves and immediately after gloves are removed, between patient contacts....change gloves between tasks and procedures on the same patient after contact....".




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On 8/27/13 from 0955 to 1015, observations in a patient room on 6 South Medical Tower revealed Registered Nurse #27 performing percutaneous endoscopic gastrostomy (peg) care. Observations showed RN #27 failed to remove the soiled gloves used when performing the patient's peg care and failed to perform hand hygiene after performing the peg care. Wearing the soiled gloves, RN #27 tore Hypafix tape from a clean roll of tape with the soiled gloves, and placed the roll of tape into the patient's clean supplies.

On 8/27/13 at 1105, observations on the 6 South Medical Tower revealed the Assistant Discharge Planner #1 walked into a contact isolation patient's room without donning any type of Personal Protective Equipment (PPE), had the patient sign a piece of paper, and then exited the room without performing hand hygiene. The findings were verified with the 6 Medical Nurse Manager on 8/27/13 at 1105. On 8/27/13 at 1115, Assistant Discharge Planner #1 stated,"I didn't realize the patient was an isolation patient."

On 8/28/13 from 0935 to 1005, observations from the catheter lab control room revealed MD #1 performed a left and right heart cath in cath lab procedure room #1 without wearing a face mask. The findings were verified with the Cardiac Cath Lab Director on 8/28/13 at 1005.
On 8/28/13 at 1008, observations from the Cardiac Cath Lab control room revealed MD #1 failed to wash or sanitize his/her hands after removing soiled gloves.

On 8/28/13 from 0935 to 1015, observations from the catheter lab control room revealed MD #2 performed a left heart cath in catheter lab procedure room 2 without wearing a face mask. The findings were verified with the Cardiac Catheter Lab Director on 8/28/13 at 1015.

On 8/28/13 at 1515, observations in the CT control room revealed Lab Technician #3 failed to wash or sanitize his/her hands after transferring the blood from a patient's bone marrow aspiration into the blood tubes. The findings were verified with the Clinical Outcomes Coordinator. On 8/28/13 at 1520, Lab Technician #3 revealed, " I didn't wash my hands because my cart is dirty. I would have washed them later."

On 8/28/13 at 1037, observations in the catheter lab procedure room revealed Registered Nurse #13 failed to disinfect the septums on the Saline and Versed vials prior to withdrawing the medication. At 1039 on 8/28/13, observation showed Registered Nurse #13 failed to disinfect the injection port of the patient's intravenous line prior to administering medication.

On the days of the hospital validation survey based on observations, interview, and review of hospital policy and procedures, the hospital failed to ensure its own policies and procedures for timeout in the operating room was followed for 3 of 3 pre-surgery timeout observed. (Operating Suite(OR) #5, #4, and #12)


The findings are:


Hospital policy, titled, "Surgical Procedural Verifications Site Marking and Time Out Process, Current Revision 1.5", reads, "....II. TIME-OUT....B. During the time-out all other activities are suspended to the extent possible without compromising patient safety.....".

On 8/28/13 at 1150, observations of the Timeout procedure in Operating Room (OR) Suite #5 revealed as each practitioner delivered their individual statement of procedure and agreement, other members of the surgical team engaged in other activities such as walking around the surgical suite and/or moving various pieces of equipment required for the surgery during the remainder of the Timeout process.

On 8/28/13 at 1213, observations of the Timeout procedure in OR Suite #4 revealed as each practitioner delivered their individual statement of procedure and agreement, other members of the surgical team engaged in other activities such as walking around the surgical suite and/or moving various pieces of equipment required for the surgery during the remainder of the Timeout process.

On 8/28/13 at 1230, observations of the Timeout procedure in OR Suite # 12 revealed as each practitioner delivered their individual statement of procedure and agreement, other members of the surgical team engaged in other activities such as walking around the surgical suite and/or moving various pieces of equipment required for the surgery during the remainder of the Timeout process.

On 8/28/13 at 1600, Registered Nurse #33 revealed that acceptable practice for the OR Timeout is for staff to address the hospital's guidelines for Time Out. We use reminder boards in the OR rooms as a part of the timeout process.