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Based on review of clinical records and interview, it was determined the facility failed to assure nursing staff followed physician orders for seven (#23, #25-#30) of ten (#21-30) surgical patients. Failure to follow physician orders did not assure patients received medications and/or treatment determined appropriate by their physician and was likely to affect all patients in the facility. Findings follow:

A. Review of the clinical record for Patient #23 revealed an order dated 12/02/14 for IV (intravenous) LR (Lactated Ringers) 100 cc (cubic centimeters) per hour. Review of Pre-Op (operative) IV Medications/Infusions revealed an IV of LR was documented with a rate of KVO (keep vein open) which did not match the physician's order for a rate of 100 cc per hour.
B. Review of the clinical record for Patient #25 revealed an order dated 12/04/14 for Zantac 150 mg (milligram) PO (by mouth) or IV as required, an order for Reglan 10 mg PO (or IV if required) and an order for Robinul 1 mg PO. Review of Pre-Op Medications revealed no evidence Zantac, Reglan or Robinul were administered and at 0605, Tessalon Pearl 20 mg PO was administered. Review of Physician Orders revealed no evidence of an order for Tessalon Pearl.
C. Review of the clinical record for Patient #26 revealed Alphagan 4 gtts (drops), Akten Ointment and Aktrol Ointment was documented as administered in the Operating Room Nurse's Notes. Review of Physician Orders revealed no evidence of orders for Alphagan, Akten or Aktrol to be administered intra-operatively. Review of Pre-Operative Orders dated 12/04/14 revealed orders for Zantac 150 mg PO, Reglan 10 mg PO and Robinul 1 mg PO. Review of Pre-Op Medications revealed no evidence Zantac, Reglan or Robinul was administered.
D. Review of the clinical record for Patient #27 revealed Pre-Operative orders dated 12/04/14 for Zantac 150 mg PO, Reglan 10 mg PO and Robinul 1 mg PO. Review of Pre-Op Medications revealed no evidence Zantac, Reglan or Robinul was administered. Review of Operating Room Nurse's Notes revealed Akten Ointment, Alphagan drops and Aktrol Oinment were administered. Review of Physician Orders revealed no evidence Akten, Alphagan or Aktrol were ordered to be given intraoperatively.
E. Review of the clinical record for Patient #28 revealed Pre-Operative orders dated 12/04/14 for Zantac 150 mg PO, Reglan 10 mg PO and Robinul 1 mg PO. Review of Pre-Op Medications revealed no evidence Zantac, Reglan or Robinul were administered. Review of Pre-Op Medications revealed Tessalon Pearl 200 mg were administered. Review of Physician Orders revealed no evidence Tessalon Pearl was ordered. Review of Operating Room Nurse's Notes revealed Akten, Lidocaine, Alphagan and Maxitrol were administered. Review of Physician Orders revealed no evidence Akten, Lidocaine, Alphagan or Maxitrol were ordered to be given intraoperatively.
F. Review of the clinical record for Patient #29 revealed Xanax 0.5mg was administered pre-operatively on 12/14/14. Review of Physician Orders revealed no evidence Xanax was ordered.
G. Review of the clinical record for Patient #30 revealed Preoperative Orders dated 12/05/14 for Zantac 150 mg PO, Reglan 10 mg PO and Robinul 1 mg PO were ordered. Review of Pre-Op Medications revealed no evidence Zantac, Reglan or Robinul was administered.
H. Findings identified above as A-G were verified with the Director of Medical Records during interview on 12/18/14 at 1300.


31039

Based on observation, review of policies and the crash cart supply list, it was determined the nursing staff failed to ensure oxygen was available on four (1 in Surgical Services and 3 in Emergency Department) of eight (1 in Surgical Services, 3 in Emergency Department, 1 in Obstetrics, 2 in Medical/Surgical and 1 in ICU) crash carts observed. By not having oxygen readily available on the cart, the facility could not assure they were ready for an emergency. The failed practice had the likelihood to affect all patients that needed emergency response care. Findings follow:

A. During a tour of the facility on 12/16/14 from 0930 until 1115, observation revealed the following crash carts without oxygen:
1) One adult crash cart in Surgical Services;
2) One adult crash cart in the Cardiac Room in the Emergency Department;
3) One adult crash cart in the Trauma Room in the Emergency Department; and
4) One pediatric crash cart in the Trauma Room in the Emergency Department.
B. Review of policy titled Crash Carts on 12/16/14 stated "1) An itemized list is attached to each cart, stating the name, strength, quantity, and location of each medication on the cart. These lists must remain attached at all times for quick reference." "2) Each cart is standardized to match the other exactly, thus familiarization with one will also include the other."
C. Review of policy titled Crash Cart and Defibrillator Checklist Instructions on 12/16/14 stated "1. The charge nurse or her appointee must perform crash cart/ defibrillator checks for accurate supplies, meds(medications), and appropriate working order once, every shift."
D. Review of crash cart supplies list on 12/16/14 revealed "Right side of cart O2 tank with regulator ...(1)".
E. During an interview on 12/16/14 at 1115, the Chief Nursing Officer (CNO) verified the 4 crash carts did not have oxygen on them. The CNO stated it was an oversight. The facility received new carts and they never put the oxygen back on them.

Based on clinical record review, review of policies and procedures and interview, it was determined staff failed to follow their policy to document patient response following blood transfusion for one of one (#1) Swing-Bed patient. Failure to document blood transfusion according to policy did not assure the patient remained stable during and after receiving blood or that the patient received the ordered amount. The failed practice was likely to affect all patients receiving blood in the facility. Finding follow:

A. Review of policy, "Blood Transfusions" revealed "start blood at 120 ml(milliliter)/hr (hour) for 15 minutes. RN (Registered Nurse) must observe patient constantly for the first 15 minutes. If no reaction occurs, increase rate to 225 ml/hr and document the increase. If condition permits, run blood in 2-3 hours. Observe 5 minutes response and chart, observe 15 minutes response and record, observe closely for signs and symptoms of chills and fever, rash, back aches. Complete blood transfusion. Flush line with normal saline. Document stop time and one hour post VS (vital signs) on Blood Administration Form."
B. Review of the Blood Administrtion Form for Swing-Bed Patient #1 revealed he began receiving blood on 10/27/14 at 1215. There was no evidence the blood flow rate was documented; there was no evidence of RN (registered nurse) observations for the first 15 minutes of transfusion; there was no evidence of the time the blood ran (i.e. 2-3 hours); there was no evidence the patient was observed closely for signs and symptoms of chills/fever, rash, back ache; there was no evidence the line was flushed with saline; and there was no evidence post transfusion vital signs were taken and no evidence of the amount of blood administered.
C. Findings listed above as B were verified with the Director of Medical Records during interview on 12/18/14 at 1300.

Based on review of clinical records and interview, it was determined the facility failed to document patient consent or refusal to administer or withhold blood products in six (#23, #25-#28 and #30) of seven (#23, #25-#30) surgical patients. Failure to document patient consent or refusal to administer or withhold blood products did not assure the record was complete and did not assure patients' wishes were upheld. The failed practice was likely to affect all surgical patients admitted to the facility. Findings follow:

A. Review of the Consent for Anesthesia Services for Patients #23, #25-#28 and #30 revealed, three check boxes for a Blood Transfusion as follows: 1) give consent to receive blood or blood products as determined by my anesthetist and doctor to be necessary for my well-being; 2) give consent to receive blood or blood products only as an emergency life-saving measure; and 3) do not want to receive blood or blood products under any circumstance. The check boxes were blank which did not indicate the patient's choice to receive blood or not to receive blood.
B. Findings identified above as A were verified with the Director of Medical Records during interview on 12/18/14 at 1300.


30634


Based on Medical Staff Rules and Regulations review, clinical record review and interview, it was determined the facility failed to ensure the physician signed, dated, and authenticated verbal orders within 24 hours as stated in the Medical Staff Rules and Regulations for seven (#1, #4-#9) of 10 (#1-#10) in-patients. Failure of the physician to sign the orders did not ensure physician had reviewed the orders to determine they were carried out as desired; failure to date and time the signature did not ensure the physician authenticated the order within the time frame of 24 hours as stated in the Medical Staff Rules and Regulations. The failed practice created the potential to affect any patient in the facility. Findings follow.

A. Review of Medical Staff Rules and Regulations Medical Records Requirement Summary revealed verbal/telephone orders were to be signed, dated, and authenticated within 24 hours of the order.
B. Review of clinical records revealed the following orders were not completed within the 24 hour time frame:
1) Patient #1-from 10/01-03/14-seven of seven verbal orders were not dated and timed.
2) Patient #4-from 12/12-15/14-five of five verbal orders were not dated and timed and two of five were not signed.
3) Patient #5-from 12/12-15/14-four of four verbal orders were not dated and timed and two of four not signed.
4) Patient #6-from 12/10-15/14-27 of 27 verbal orders were not dated, timed, or signed.
5) Patient #7-from 12/12-15/14-three of three verbal orders were not dated and timed and one of three was not signed.
6) Patient #8-from 12/14-16/14-four of four verbal orders were not dated, timed, or signed.
7) Patient #9-from 12/09-12/14-eight of eight verbal orders were not dated and timed and seven of eight were not signed.
C. During an interview with the Director of Medical Records on 12/18/14 at 1300, the lack of time, date, and authentication of orders was confirmed.

Based on review of clinical records and interview, it was determined the facility failed to assure a history and physical examination as performed within 30 days prior to surgery for three (#26-#28) of ten (#21-#30) patients. Failure to assure a history and physical examination was performed within 30 days prior to surgery did not assure any changes in the patient's condition prior to surgery were taken into consideration and was likely to affect all surgical patients admitted to the facility. Findings follow:

A. Review of the clinical record for Patients #26-#28 revealed the history and physical examinations were performed on 10/13/14. Patients #26-#28 underwent ophthalmological procedures on 12/04/14 which was greater than 30 days post the history and physical examinations.
B. Findings identified in A were verified with the Director of Medical Records during interview on 12/18/14 at 1300.

Based on review of monthly medication storage area inspections, review of policy and interview, it was determined the facility failed to inspect medication areas on a monthly basis for four of four (Emergency Department (ED), Obstetrics, Medical/Surgical (Med/Surg) and Intensive Care Unit (ICU)) areas reviewed. By not inspecting the medication storage areas monthly (per policy) the facility could not assure all floor stocks were controlled. The failed practice had the likelihood to affect all patients who received medication from these areas. Findings follow:

A. Review of monthly medication storage area inspections on 12/16/14 for the previous 12 months (December 2013 through November 2014) revealed the following missing inspections:
1) ED was missing May, July, August and September 2014;
2) Obstetrics was missing May, July, August and September 2014;
3) Med/Surg was missing May, July, August and September 2014; and
4) ICU was missing April, May, July, August, September, and October 2014.
B. Review of policy titled Drug Storage-Pharmacy Inspections of Medication Areas on 12/16/14 stated "Each month a pharmacist, or a pharmacy technician under the direct supervision of a pharmacist as allowed by Federal, State or Local regulations, inspects all medication storage, preparation and dispensing areas."
C. During an interview on 12/16/14 at 0925, the Director of Pharmacy verified there were missing inspections of medication storage areas.

Based on observation, review of package inserts, review of policy, and interview, it was determined the facility failed to date Succinylcholine and Rocuronium Bromide when removed from refrigeration to ensure it was not available for patient use past manufacturers recommendation in two of two anesthesia medication trays observed. By not dating the medication when it was removed from refrigeration, the facility could not assure the medication would not be used beyond the manufacturer's recommendation and therefore would not be able to assure the safety, efficacy and/ or potency. The failed practice had the likelihood to affect all patients admitted into surgical services. Findings follow:

A. During a tour of the facility on 12/16/14 from 0930 to 1115, observation revealed the following:
1) Anesthesia cart in Operating Room #1:
a) Two Succinylcholine 200mg (milligram)/10 ml(milliliter) vials for injection not dated as to when they were moved from refrigeration storage to room temperature; and
b) One Rocuronium Bromide 10mg/5ml vial for injection not dated as to when it was moved from refrigeration storage to room temperature.
2) Anesthesia cart in Operating Room #2:
a) One Succinylcholine 200mg (milligram)/10 ml(milliliter) vial for injection not dated as to when it was moved from refrigeration storage to room temperature; and
b) Two Rocuronium Bromide 10mg/5ml vials for injection not dated as to when they were moved from refrigeration storage to room temperature.
B. Review of package insert for Succinylcholine stated "Store in refrigerator ...The multi-dose vials are stable for 14 days at room temperature without significant loss of potency."
C. Review of package insert for Rocuronium Bromide stated "Upon removal from refrigeration to room temperature storage conditions (25 C/77F), use Rocuronium Bromide injection within 60 days."
D. Review of policy titled Anectine (Succinylcholine Bromide) /Nimbex/Zemuron (Rocuronium Bromide) Protocol stated "Anectine/Nimbex/Zemuron will be dated when removed from refrigeration. Anectine will be discarded 14 days after removal from refrigeration. Zemuron is dated with a 60 day expiration date when removed from the refrigerator. Upon expiration, the Zemuron is discarded."
E. During an interview on 12/16/14 at 1015, Certified Registered Nurse Anesthetist #2 verified the Succinylcholine and Rocuronium Bromide were not dated with the date they were removed from refrigeration.

Based on interview, the facility failed to have policies and procedures in place to ensure annual re-certification of Intravenous (IV) Admixture technique for all personnel trained to compound medications in the Laminar Flow Hood (per United States Pharmacopeia Chapter 797, 2008). By not evaluating the competencies of the personnel, the facility could not assure the sterility or accuracy of the medications compounded. The failed practice had the likelihood to affect all patients who received medications compounded in the Laminar Flow Hood. Findings follow:

A. IV Admixture competencies were requested at the entrance conference on 12/15/14 at 1015 and Surveyor #1 did not receive any.
B. During an interview on 12/17/14 at 0925, the Director of Pharmacy verified they did not have competencies, or policies procedures for annual competencies (ie: media fill tests or take samples of finished products and have them tested for sterility) of the personnel trained to compound medications in the Laminar Flow Hood.

Based on observation, review of policy and interview, it was determined the facility failed to ensure floor stock was properly controlled in one of one Procedure Room in Surgical Services toured in that Prescription Solutions were unsecured and accessible to unlicensed personnel. By not controlling floor stock, the facility could not assure the safety, integrity or efficacy of the uncontrolled medications. The failed practice had the potential to affect all patients that were admitted into the facility for procedures. Findings follow:

A. A tour of the facility on 12/16/14 between 0930 and 1115 revealed the following solutions unsecured in the Procedure Room:
1) Ten bottles of Balanced Salt Solution 500 ml (milliliter); and
2) 72 Single Dose bottles of Balanced Salt Solution 15 ml.
B. Review of policy titled Drug Storage-Pharmacy Inspections of Medication Areas stated "Medications will be accessible only to authorized personnel."
C. During an interview on 12/16/14 at 0940, the Operating Room Director verified the solutions in the Procedure Room were unsecured.

Based on observation, review of policy and interview, it was determined the facility failed to ensure outdated medications and an opened half full Single Dose Vial (SDV) were not available for patient use in three (Surgical Services, Intensive Care Unit (ICU) and Obstetrics) of five (Surgical Services, Intensive Care Unit (ICU), Obstetrics, Emergency Department(ED) and Medical/Surgical) areas toured. By not removing outdated medications/ an opened, half full single use vial, the facility could not assure the integrity, safety and efficacy of the medications. The failed practice had the likelihood to affect all patients who receive medications. Findings follow:

A. During a tour of the facility on 12/16/14 from 0930 to 1115, observation revealed expired medications and an opened, half full SDV available for patient use:
1) Surgical Services
a) One Ondansetron 4 mg (milligram)/2 ml (milliliter), opened, half empty, still available for patient use on an anesthesia tray; and
b) One Esmolol 10mg/1 ml SDV for injection expired 10/14.
2) ICU
a) Two Atropine Prefilled Syringes 1mg/10 ml for injection, one expired 09/14 and on 10/14;
b) One Magnesium Sulfate 10 grams/20 ml vial for injection expired 11/14;
c) Two Vasopressin 20 units/1ml expired 11/14; and
d) One Dextrose 5% in water 500ml fluids for injection expired 09/14.
3) Obstetrics
a) Two Epinephrine Prefilled Syringes 1:10,000 10 ml for injection expired 12/1/14.
B. Review of policy titled Drug Storage-Pharmacy Inspections of Medication Areas stated "Monthly inspections shall be documented and detailed enough to ensure at least the following ...Expired, unusable, and improperly labeled medications are removed and returned to the pharmacy."
C. During an interview on 12/16/14 at 1115, the Chief Nursing Officer verified the availability of the expired medications available for patient use.
D. During an interview on 12/16/14 at 1020, Certified Registered Nurse Anesthetist #2 verified the availability of the opened, half full SDV still available for patient use.

Based on review of Adverse Drug Incident Reports, Dispensing Alert Notifications, policy and interview, it was determined the facility failed to report and review adverse drug reactions in that 12 of 18 adverse drug reactions were not reported according to policy. By not reporting and reviewing adverse drug reactions, the facility could not assure medication management and patient safety. The failed practice had the likelihood to affect all patients who receive medication. Findings follow:

A. Review of Adverse Drug Incident Reports on 12/17/14 revealed 12 of 18 Adverse Drug Reaction Forms were not completed for medications dispensed to treat adverse drug reactions for the previous 11 months (01/14 through 11/14). The following medications were dispensed and a Dispensing Alert Notification was printed and when asked if they were for an allergic reaction the answer was "yes", but there was no Adverse Drug Reaction Incident Report filled out:
1) Diphenhydramine 50 mg(milligram)/1ml(milliliter) on 01/15/14;
2) Diphenhydramine 50 mg/1ml on 01/17/14;
3) Diphenhydramine 50 mg/1ml on 01/17/14;
4) Diphenhydramine 50 mg/1ml on 01/19/14;
5) Diphenhydramine 50 mg/1ml on 01/21/14;
6) Diphenhydramine 50 mg/1ml on 01/26/14;
7) Diphenhydramine 50 mg/1ml on 01/27/14;
8) Diphenhydramine 50 mg/1ml on 02/13/14;
9) Diphenhydramine 50 mg/1ml on 02/15/14;
10) Diphenhydramine 50 mg/1ml on 08/18/14;
11) Ranitidine 25mg/1ml on 08/21/14; and
12) Diphenhydramine 50 mg/1ml on 01/17/14.
B. Review of Dispensing Alert Notifications on 12/17/14 revealed the following question: "Is this medication being administered for an ADVERSE DRUG EVENT/ REACTION? If answered YES, Please complete an ADVERSE DRUG REACTION form as required by P & P (policy and procedure)."
C. Review of policy titled Reactions: Adverse Drug Reactions (ADRs) stated "Adverse (untoward) drug reactions shall be reported and reviewed in accordance with this policy in order to continuously improve the medication management system and patient safety ...8. A written report of the reaction shall be made on in Adverse Reaction Report Form. This report shall include the patient's drug history, the reaction observed, and the action taken. ADR reports shall be forwarded to the director of Pharmacy."
D. During an interview on 12/17/14 at 0955, the Director of Pharmacy verified the Dispensing Alert Notifications should have had an Adverse Drug Reaction Report Form filled out for each medication dispensed due to an allergic reaction.

Based on observation, line isolation monitor testing documentation review, and interview, it was determined the facility did not meet Life Safety Code requirements related to the sealing of smoke barrier wall penetrations, monthly testing of line isolation monitor alarms, storage of combustible materials, and display of combustible decorations in egress corridors. The failed practices had the potential to affect all patients,staff and visitors. See CMS 2567, K-25, K-29, K73, and K-130.

Based of observation, review of policies and procedures, and interview, it was determined the Infection Control Nurse failed to assure a sanitary environment for patient care in that there was an accumulation of dust on equipment, tape with sticky residue on equipment, sterile supplies stored with unsterile supplies and torn/cracked upholstry in five (Surgical Services Department, Emergency Department, Obstetrics Department, Medical Surgical Department, and Intensive Care Unit) of five areas observed. Failure to maintain a sanitary environment did not assure patients, visitors and staff were not exposed to contaminants and was likely to affect all persons in the facility. Findings follow:

A. A tour of the facility on 12/16/14 from 0935 to 1130 with the Chief Nursing Officer and the Infection Control Nurse revealed:
1) In the Out-Patient/Pre-Operative area, dust was on the vital signs monitors, suction regulators, and suction canisters in Rooms 1-5 which did not assure they were sanitary;
2) In Operating Room #3 tape, which had a sticky residue and could not be sanitized, was used to secure a suction tube to a gray plastic funnel. When asked what the device was used for, the Operating Room Director explained it was used under the drapes to provide oxygen to patients undergoing cataract procedures since nasal cannulas "got in the way" during the procedure. Tape was also securing a vacuum line to a suction canister stand. A computer keyboard located on a mobile computer stand had heavy layers of dust between the keys which did not assure it was sanitary;
3) In Operating Room 1, dust was between the keys of the computer keyboard which did not assure it was sanitary;
4) In Operating Room 2, dust was between the keys of the computer keyboard which did not assure it was sanitary;
5) In the Cardiac Room in the Emergency Department, tape was on the handles of the cabinet drawers, dust was on the vital signs monitor bracket, the crash cart, the defibrillator, the Phillips vital signs monitor and on the workstation on wheels (WOW) keyboard and base which did not assure they were sanitary;
6) In the hallway outside the Cardiac Room in the Emergency Department there were: two WOWs which had heavy layers of dust on both, one 12 lead EKG (electrocardiogram) machine which was dusty, one hand sanitizer dispenser which had dust on the top. The dust on the equipment did not assure they were sanitary;
7) In the Clean Workroom in the Obstetrics Department, dust was on the towel dispenser, the soap dispenser and along the inside edges of the ice machine which did not assure they were sanitary. There was no assurance ice used for patients was not contaminated with dust;
8) In the Janitor Closet in the Obstetrics Department, a fan was stored in a hopper sink. The fan had heavy layers of dust in the fan blades cover which did not assure it was sanitary;
9) In the hallway across from the Nurse's Station, a cart which held patient supplies had heavy layers of dust on the shelves which did not assure they were sanitary. Two blue plastic "caddies/totes" which held patient supplies, had heavy layers of dust in the compartments which did not assure they were sanitary. The crash cart and defibrillator were located beside the cart. The crash cart and defibrillator had heavy layers of dust which did not assure they were sanitary;
10) On the Medical/Surgical Unit, a WOW and Dynamap vital signs monitor were located outside Room 1405. The WOW and Dynamap monitor both were dusty which did not assure they were sanitary;
11) Outside Room 1409, a WOW and vital signs monitor were dusty which did not assure they were sanitary;
12) Outside Room 1207, a WOW and 12 lead EKG machine were dusty which did not assure they were sanitary;
13) In the pass through hallway on the Medical Surgical Unit, a Vera II patient lift device had heavy layers of dust on the base and next to it, a crash cart and defibrillator that had heavy layers of dust which did not assure they were sanitary;
14) In the Intensive Care Unit (ICU), four black vinyl chairs had cracks/cuts in the vinyl covering exposing the padding underneath which is absorbent and cannot be sanitized;
15) In the ICU three WOWs located at the Nurses' station had heavy layers of dust on their bases as well as dust between the keys of the keyboards which did not assure they were sanitary;
16) In ICU Rooms 1, 2, 4, 5, and 7 sterile gloves were stored in the second drawer of the bedside cabinets. Along with the sterile gloves (sterile), monitor cords (non-sterile) were placed on top of the sterile gloves which did not assure sterile supplies were not stored with non-sterile supplies. The brackets holding vital signs monitors in these same rooms had heavy layers of dust which did not assure they were sanitary.
B. Review of Policy, "Infection Preventionist" presented by the Director of Nursing on 12/16/14 at 1415 revealed, "Inspects the hospital environment and observes personnel activities or work practices for the purpose of detecting possible infection hazards and to evaluate compliance with standards set by the Infection Prevention Committee".
C. During interview with the Infection Control Nurse on 12/17/14 at 1350, she stated, "We recently changed Environmental Services personnel and they don't clean medical equipment." When asked if surveillance activities were conducted, she stated she had "secret shoppers" who observed hand hygiene practices.

Based on observation, review of Infection Control Committee Meeting Minutes, review of Hand Hygiene Detailed Observation Tools, review of policies and procedures and interview, it was determined the Infection Control Nurse failed to assure surveillance of patient care practices was conducted throughout the facility to assure aseptic techniques were followed. Failure to conduct surveillance did not assure breaks in aseptic technique were addressed or reported and failed to assure contamination did not occur. This failed practice was likely to affect all patients in the facility. Findings follow:

A. On observation 12/17/14 at 0940 in the Out-Patient/Pre-Operative area, Registered Nurse #1 opened a new vial of medication and drew the contents into a syringe. She did not disinfect the vial prior to drawing the medication into the syringe.
B. On observation 12/17/14 at 0853, Operating Room Technician #1 entered the Cesarean Section (C-Section) Operating Room to set up for a C-Section procedure. She was wearing a cloth skull cap which did not completely cover her hair, exposing 3-4 inch strands of hair down her neck.
C. On observation 12/17/14 at 0900 in the C-Section Operating Room, Certified Registered Nurse Anesthetist (CRNA) #1 prepped the back of the patient and began a sterile spinal anesthesia procedure. He did not wash his hands or use hand sanitizer prior to donning sterile gloves. He did not remove his gloves until 0927. From 0900 to 0927, CRNA #1 adjusted the intravenous (IV) and piggy-back lines for the patient, placed an oxygen nasal cannula on the patient's face, placed electrocardiogram pads on the patient ' s chest, secured the sterile drapes to two IV poles, and documented in the patient's record all while wearing betadine stained gloves used for the spinal anesthesia conducted at 0900. He did not wash his hands or use hand sanitizer after removing his gloves.
D. On observation 12/17/14 at 0905, the Operating Room Director donned sterile gloves to place a Foley catheter. She did not wash her hands or use hand sanitizer prior to donning sterile gloves or after removing her gloves.
E. On observation 12/17/14 at 0912, the Director of Respiratory Therapy entered the C-Section room wearing a surgical mask which was tied at the top, but not at the bottom. By not tying the bottom of the mask respiratory secretions had the potential to contaminate sterile supplies used in the procedure.
F. On observation 12/17/14 at 0925, the Operating Room Director donned green exam gloves and took blood samples out of the room. She did not wash her hands or use hand sanitizer prior to donning gloves. At 0927, the Operating Room Director returned to the room wearing green exam gloves, removed them and did not perform hand hygiene.
G. On observation 12/17/14 at 1320 in the Medical/Surgical Medication Room, Licensed Practical Nurse #1 opened a new vial of medication and drew the contents into a syringe. She did not disinfect the vial prior to drawing the medication into the syringe.
H. On observation 12/17/14 at 1335, Respiratory Therapist #1 took a pulse oximeter (oxygen measuring device) out of her jacket pocket, placed it on Patient #31's finger, measured his oxygen concentration level and then placed the device back into her pocket without disinfecting it. She then listened to Patient #31's lungs and did not disinfect her stethoscope prior to hanging it around her neck and leaving the room.
I. Review of 13 (04/30/14, 05/22/14, 05/22/14, 06/27/14, 07/22/14, 07/22/14, 08/27/14, 09/25/14, 11/05/14, 11/05/14, 11/17/14, 12/08/14, and 12/08/14) of 22 (04/30/14, 04/30/14, 05/22/14, 05/22/14, 06/27/14, 6/27/14, 07/22/14, 07/22/14, 08/06/14, 08/06/14, 08/27/14, 08/27/14, 09/25/14, 09/25/14, 10/17/14, 10/17/14, 11/05/14, 11/05/14, 11/17/14, 11/17/14, 12/08/14, 12/08/14) Hand Hygiene Detailed Observation Tools revealed staff did not wash hands prior to exiting the patient's room. During interview with the Infection Control Nurse on 12/18/14 at 0925 when asked who she reported the findings from the surveillance to, she stated she reported the information to the Infection Control Committee.
J. Review of five of five (01/30/14, 03/31/14, 05/30/14, 07/30/14, and 09/30/14) Infection Control Committee Meeting Minutes revealed no evidence patient care practices, to include hand hygiene, were reported. By not reporting results to the Committee, a plan to improve compliance was not documented as being discussed and/or implemented.
K. Review of policy, "Handwashing Practices" revealed When to Wash Your Hands ...before and after each patient contact, before and after glove use, after touching contaminated surfaces."
L. Review of policy "Foley Catheter Insertion and Removal" revealed "wash hands thoroughly."
M. Findings identified above as A-F were confirmed with the Operating Room Director on during interview 12/17/14 at 0940.
N. Findings identified above as G-J were confirmed with the Infection Control Nurse during interview on 12/18/14 at 0925.

Based on review of operative reports and interview, it was determined the facility failed to assure the time of operation was included in seven (#23, #25-#30) of ten (#21-#30) operative reports. Failure to include the time of operation did not assure an accurate time line of events was documented and was likely to affect all surgical patients admitted to the facility. Findings follow:

A. Review of the operative report dated 12/02/14 for Patient #23 revealed no evidence the time of operation was documented.
B. Review of the operative reports dated 12/04/14 for Patients #25-#29 revealed no evidence the time of operation was documented.
C. Review of the operative report dated 12/05/14 for Patient #30 revealed no evidence the time of operation was documented.
D. Findings identified above as A, B, and C were verified with the Director of Medical Records during interview on 12/18/14 at 1300.

Based on review of Contracted Therapists files, review of contract and interview, it was determined the facility failed to ensure 2 (Speech/Language Pathologist(SLP) #1 and Certified Occupational Therapy Assistant (COTA) #1) of 10 (Physical Therapists (PT) #1-3, Physical Therapy Assistant (PTA) #1 & 2, Occupational Therapist (OT) #1 & 2, COTA #1 & 2, and SLP #1) rehabilitative staff maintained certification in Cardiopulmonary Resuscitation (CPR) per contract. By not ensuring all persons with direct patient care responsibilities maintain certification in CPR, the Facility could not assure a prompt and efficient response in the event of an emergency. The failed practice had the likelihood to affect all patients who received Rehabilitation services. Findings follow:

A. Review of employee files on 12/15/14 revealed SLP #1 did not have CPR certification and COTA #1 had an online CPR course renewal but no evidence of the skills portion being renewed.
B. Review of Rehabilitation Services Agreement on 12/15/14 revealed the following: "TherEX will maintain on file and make available to Hospital upon request verification of the qualifications of individual staff, including the following ...evidence of CPR certification."
C. During an interview on 12/16/14 at 1400, the Director of Rehabilitation verified SLP #1 did not have CPR certification and COTA #1 did not have the skills portion of CPR certification.