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Based on record review, observations, and interview, the hospital failed to protect and promote the rights of patients in 8 of 30 patient records reviewed (Patient 14, 15, 19, 20, 22, 23, 24, 31) and in 2 of 2 psychiatric units observed (offsite child/adolescent psych unit, inpatient adult psych unit).

Findings include:

-Staff failed to ensure the Important Message from Medicare informing Medicare recipients of their discharge appeal rights was given to eligible patients within 48 hours of admission and/or discharge. See A117

-Staff failed to ensure that patient/patient representatives without advanced directives were offered or given information about formulation of an advanced directive. See A132

-Staff failed to ensure a safe environment for the mental health patient population mitigating ligature risks. See A144

-Staff failed to ensure the use of physical restraints on patients was addressed in nursing care plans. See A166

-Staff failed to ensure standing orders were not used for the initiation and continuation of patient restraints and to limit continuous restraint orders to a maximum of 24 hours as per policy. See A169

- Staff failed to ensure a face-to-face evaluation was completed by trained staff within 1 hour after applying restraints. See A178

The cumulative effects of these violations of patient's rights resulted in the hospital's inability to promote the health, safety and welfare of its patients.

Based on record review and interview, staff failed to ensure the Important Message from Medicare informing Medicare recipients of their discharge appeal rights was given to eligible patients within 48 hours of admission and/or discharge in 3 of 3 Medicare eligible medical records reviewed in a total sample of 30 (Patient 14, 20, 31).

Findings include:

Per review of facility policy titled Medicare Forms Delivery, #26, dated 3/2018 revealed, "II. Implementation A. Important Message from Medicare (IMM) 1. Hospitals must notify Medicare beneficiaries who are hospital inpatients about their hospital discharge appeal rights. Hospitals will use the Important Message from Medicare (IMM) a statutorily-required notice, to explain the beneficiary's rights as a hospital patient, including discharge appeal rights. Hospital must issue the IMM within 2 calendar days of admission, must obtain the signature of the beneficiary or his or her representative and provide a copy at that time. Hospitals will also deliver a copy of the signed notice as far in advance of discharge as possible, but not more than 2 calendar days before discharge.

Review of Patient #20's medical record on 3/20/2018 at 1:25 PM revealed Patient #20 was admitted to the hospital on 12/15/2017 and was discharged on 12/19/2017. However contained no documented evidence of staff providing the first and second copy of the Important Message from Medicare.

Per interview with Director of Care Coordination V on 3/21/2018 beginning at 10:30 AM, V stated "I cannot find any documentation that either copy of the IMM was given to the patient."

Review of Patient #31's medical record on 3/21/2018 at 9:00 AM revealed Patient #31 was admitted on 12/21/2017 and discharged on 12/24/2017. However contained no documented evidence of staff providing the second copy of the Important Message from Medicare.

Per interview with Director of Care Coordination V on 3/21/2018 beginning at 10:30 AM, V stated "I cannot find any documentation that the second copy of the IMM was given to the patient."



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Review of Patient 14's medical record on 3/20/2018 at 10:42 AM revealed Patient 14 was admitted to the hospital on 11/18/2017 and was discharged on 11/22/2017. However contained no documented evidence of staff providing the first copy of the Important Message from Medicare.

Per interview with Director of Nursing Services U, at the time of the medical record review, U stated, "I don't see that it was done".

Based on record review and interview, staff failed to address and formulate patient's advanced directives in 5 of 30 medical records reviewed (Patient #3, 14, 22, 23, 24).

Findings include:

Review of policy titled, "Advance Directive," #500, dated 11/2017 revealed, "Patients without an advance directive are provided with information about how to develop one...[hospital name] outpatients are asked about having an advance directive appropriate to the care, treatment and services provided."

A medical record review was conducted on Patient #22's open surgical record accompanied by Registered Nurse VVV who confirmed the following finding: Advanced Directive documentation in the medical record revealed Patient #22 did not have an advanced directive and there was no documentation indicating that information was offered.

A medical record review was conducted on Patient #23's open surgical record accompanied by Registered Nurse VVV who confirmed the following finding: Advanced Directive documentation in the medical record revealed that Patient #23 did not have an advanced directive and there is no documentation indicating that information was offered.

Per interview with Manager of Pre-operative, Post-operative, and Digestive Health II on 3/20/2018 at 1:09 PM regarding the advanced directive, Manager II stated, "There is no documentation that information was offered."

A medical record review was conducted on Patient #24's open outpatient procedure record on accompanied by Manager II who confirmed the following finding: Advanced Directive documentation in Patient #24's medical record revealed that Patient #24 was not asked about advanced directives on admission.


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Review Patient #3's medical record revealed Patient #3 was admitted on 3/14/18 and was currently an inpatient. Patient #3 did not have an advanced directive documented and there was no documentation indicating information was offered. Findings were confirmed during interview on 3/19/18 at 1:35 PM with Interim Nurse Manager O who stated, "It does not look like the service was provided".

Review of Patient #14's medical record revealed Patient #14 was admitted to the hospital on 11/18/2017 and was discharged on 11/22/2017. Patient #14 did not have an advanced directive documented and there is no documentation indicating that information was offered. Findings were confirmed during interview on 3/20/18 at 10:42 AM with Interim Nurse Manager O who stated, "It does not look like the service was provided".

Based on observation, record review, and interview staff failed to ensure a safe environment for the mental health patient population mitigating ligature risks in 2 of 2 psychiatric units observed (off-site children/adolescent unit and main hospital adult unit).

Findings Include:

Per review on 3/21/2018 at 11:30 AM, Environmental Safety Manager BB provided documentation of "Safety and Security Education, Ligature Risks for Behavioral Health Units" the form was not dated, revealed, "This communication is to inform you of what ligature risks are, how to identify them, and what you should do to ensure the safety of patients at UPH-Meriter. What is a ligature risk? A ligature-point risk is a point from which a suicidal patient may attach a sheet, rope or other flexible material for the purpose of strangulation; the flexible material itself is the ligature. Both the material and the attachment point are considered risks. Some examples include: Door handles...patient bed frames..."

During tour of offsite Child and Adolescent Psychiatry Unit on 3/20/2018 10:40 AM with Nurse Manager YY, observed a total of 20 rooms on the Adolescent and children units. Observations of patient rooms revealed the following safety risks:

-Door handle housing unit (approximately 3 feet off the ground) on the inside and outside of patient's bedroom protrudes approximately 1 and 1/2 inches off the door at a 90 degree angle, allowing for a ligature to stay in place and aid in potential harm for patients with self injurious behaviors and/or suicide risk.

-Wooden platforms used for bed frames which are moveable and could aid in potential harm for patients with self injurious behaviors and/or suicide risk.

Per interview with Nurse Manager YY on 3/20/2018 at 10:45 AM, Nurse Manager YY stated "We have identified that the door handles on the door can cause a ligature risk...and we have also identified risks with the wooden platform bed...".


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Per observations on 3/21/18 at 10:30 a.m. of the Adult psychiatric services 16 bed unit, in the main hospital, revealed rooms #157 and #158 did not have ligature resistant hand towel and soap dispensers.

During interview with Unit Manager JJJJ and Safety Manager BB on 3/21/18, confirmed the hospital had not conducted testing for non-break-away room curtains (that had gaps between upper curtain binding and the wall frame), or non-break-away shower curtains (that had gaps between upper shower curtain binding and the wall frame) to determine whether they should sustain weight for suicide by hanging risk. JJJJ and BB confirmed during interview that the break-away clothing hooks had never been tested to ensure their safety and functionality.

Based on record review and interview staff failed to ensure the use of physical restraints on patients was addressed in nursing care plans in 2 of 3 restraint records reviewed (Patient 15, 19) in a total sample of 30 records.

Findings include:

Review of facility policy titled, "Restraint And Seclusion For Violent And Self-destructive Patients" last reviewed 6/2016 revealed the following:
-The use of seclusion or restraint is in accordance with written modification to the patient's treatment plan. All aspects of the seclusion or restraint episode, including the behaviors and events leading up to it, a medical evaluation, the release from seclusion or restraint, and the patient debriefing that follows are recorded in the clinical record."

Review of Patient #15's medical record revealed Patient #15 was admitted on 1/22/18 after an intentional drug overdose attempt. Per emergency department progress notes dated 1/22/18 at 8:02 PM left and right soft wrist restraints were placed due to "Interference with Medical Treatment" related to Patient #15 pulling at tubes and lines. Per review of "Non-Violent Flowsheet" soft wrist restraints were started on 1/22/18 at 11:00 PM until 1/23/18 at 3:00 AM. Review of "Shift Summary/Events" dated 1/23/18 at 2:23 PM, revealed no documented evidence of staff addressing the use of physical restraints as an active care plan problem.

Per review of Patient #19's medical record revealed Patient 19 was admitted on 3/8/18 from a local rehabilitation hospital for tachypnea (abnormal rapid breathing), agitation and gross hematuria (blood in urine) septicemia (infection of the blood stream) and required multiple blood transfusions. Restraints (bilateral soft wrist) were ordered on 3/8/18 at 4:39 PM for "Interference with Medical Treatment". Per review of Patient 19's "Non-Violent Flowsheet", right and left wrist restraints were used on 3/11/18 from 11:00 PM - 3/14/18 at 6:00 PM. Review of "Shift Summary/Events" revealed no documented evidence of staff addressing the use of physical restraints as an active care plan problem.

Per interview with Director of Nursing Services U on 3/21/18 at 10:00 AM, U stated, "If the restraint is being used it should be documented on the care plan".

Based on record review and interview staff failed to ensure standing orders were not used for the initiation and continuation of patient restraints and to limit continuous restraint orders to a maximum of 24 hours as per policy in 3 of 3 restraint charts reviewed (Patient #14, 15, 19) in a total sample of 30 records.

Findings include:

Per review of policy titled "RESTRAINT AND SECLUSION FOR VIOLENT AND SELF-DESTRUCTIVE PATIENTS" # POL #161, last reviewed 6/2016 revealed the following:
-Continuation of the Order for Restraint or Seclusion for 24 or More Hours. 1. If restraint or seclusion needs to continue for 24 or more hours, the physician primarily responsible for the patient's ongoing care sees and evaluates the patient every 24 hours before writing a new order for restraint or seclusion. 2. When restraint or seclusion is discontinued before the time-limited order expires, that original order can be used to reapply restraint or seclusion if the patient is at imminent risk of harming himself or herself or others, and non-physical interventions are determined to be ineffective. However, a new order is obtained from the physician as soon as possible, but no longer than ONE (1) hour after reinitiating of restraint or seclusion. E #3. When restraint or seclusion is continued, the physician gives a written order for continuation of restraint or seclusion within the time limits for a maximum of 24 consecutive hours."

Review of Patient #14's medical record revealed Patient #14 was admitted on 11/18/17 for weakness and decreased appetite from a Memory Care unit and had a cystoscopy with left urethral stent placed under general anesthesia on 11/18/17. On 11/19/17 at 8:54 PM physician wrote an order for a left hand mitt with a restraint reason of "Interference with Medical Treatment" related to Patient #14 having pulled out multiple intravenous lines. The electronic physician order revealed under "Standing order interval: CONTINUOUS X 36 HOURS" with "Expected date: & Expiration date:" blank.

Review of Patient #15's medical record revealed Patient #15 was admitted on 1/22/18 after an intentional drug overdose attempt. On 1/22/18 at 8:02 PM left and right soft wrist restraints were placed in the emergency room for "Interference with Medical Treatment" related to Patient #15 pulling at tubes and lines. The electronic physician order revealed under "Standing order interval: CONTINUOUS X 36 HOURS" with "Expected date: & Expiration date:" blank.

Review of Patient #19's medical record revealed Patient #19 was admitted on 3/8/18 from a local rehabilitation hospital for tachypnea (abnormal rapid breathing), agitation and gross hematuria (blood in urine), septicemia (infection of the blood stream) and required multiple blood transfusions. Restraints (bilateral soft wrist) were ordered initially on 3/9/18 at 4:39 PM for "Interference with Medical Treatment". The electronic physician order under "Standing order interval: CONTINUOUS X 36 HOURS" with "Expected date: & Expiration date:" revealed the following:
-Restraint order started on 3/9/18 at 4:39 PM had an "END" date of 3/11/18 at 5:38 AM (greater than 24 hours),
-Restraint order started on 3/10/18 at 1:25 PM had an "END" date of 3/12/18 at 2:25 AM (>24 hours),
-Restraint order started on 3/11/18 at 4:26 PM had an "END" date of 3/13/18 at 4:14 AM (>24 hours),
-Restraint order started on 3/14/18 at 6:34 PM had an "END" date of 3/16/18 at 1:44 AM (>24 hours),
-Restraint order started on 3/15/18 at 1:45 PM had an "END" date of 3/17/18 at 1:44 AM (>24 hours),
-Restraint order started on 3/18/18 at 6:14 AM had an "END" date of 3/19/18 at 6:13 PM (>24 hours),
-Restraint order started on 3/19/18 at 4:28 AM had an "END" date of 3/20/18 at 4:28 PM (>24 hours),
-Restraint order started on 3/20/18 at 6:03 AM had an "END" date of 3/21/18 at 5:59 PM (>24 hours),
-Restraint order started on 3/21/18 at 7:05 AM had an "END" date of 3/22/18 at 7:04 PM (>24 hours).

Per interview with Director of Nursing Services U on 3/21/18 at 10:00 AM, U confirmed that electronic restraint orders were written with 36 hour time frame. Per interview with Clinical Practice Leader-ER JJJ during the same time, JJJ stated "I agree with you it should be 24 hours".

Based on record review and interview staff failed to complete a face-to-face evaluation by trained staff within 1 hour after applying restraints in 3 of 3 restraint records reviewed (Patient #14, 15, 19) in a total sample of 30.

Findings include:

The facility policy titled "RESTRAINT AND SECLUSION FOR VIOLENT AND SELF-DESTRUCTIVE PATIENTS" # POL #161, last reviewed 6/2016 revealed the following:
-"Initial Evaluation of the Patient in Restraint or Seclusion" "1. Within ONE (1) HOUR of the initiation of restraint or seclusion, the physician or RN trained in seclusion and restraint evaluates the patient in person and collaboratively with the treatment staff assesses the situation and determines whether the restraint or seclusion is to continue. 2. This assessment includes: a. The patient's immediate situation, including medical and behavioral condition, and risks associated with he intervention. b. The triggers of the event. c. Less restrictive measures utilized...e. The need to continue to terminate seclusion or restraint f. The patient's reaction to the intervention."

Review of Patient #14's medical record revealed Patient #14 was admitted on 11/18/17 for weakness and decreased appetite from a Memory Care unit and had a cystoscopy with left urethral stent placed under general anesthesia on 11/18/17. On 11/19/17 at 8:54 PM physician wrote an order for a left hand mitt with a restraint reason of "Interference with Medical Treatment" related to Patient #14 having pulled out multiple intravenous lines. There was no documentation of a face to face being completed by a physician or physician's assistant within one hour of restraint placement per hospital policy.

Review of Patient #15's medical record revealed Patient #15 was admitted on 1/22/18 after an intentional drug overdose attempt. On 1/22/18 at 8:02 PM left and right soft wrist restraints were placed in the emergency room for "Interference with Medical Treatment" related to Patient #15 pulling at tubes and lines. Per "Registered Nurse Plan of Care" dated 1/23/18 at 8:23 AM restraints were removed at 3:00 AM. There was no documentation of a face to face being completed by a physician or physician's assistant within one hour of restraint placement per hospital policy.

Review of Patient #19's medical record revealed Patient #19 was admitted on 3/8/18 from a local rehabilitation hospital for tachypnea (abnormal rapid breathing), agitation and gross hematuria (blood in urine) became septic (infection of the blood stream) and required multiple blood transfusions. Restraints (bilateral soft wrist) were ordered initially on 3/9/18 at 4:39 PM for "Interference with Medical Treatment". There was no documentation of a face to face being completed within one hour of restraint placement by a physician or physician's assistant when restraint's were ordered to continue every 24 hours (3/21/18 at 7:05 AM, 3/20/18 at 1:46 PM, 3/19/18 at 4:29 AM, 3/18/18 at 6:14 AM, 3/16/18 at 11:07 AM, 3/15/18 at 1:44 AM, 3/14/18 at 6:34 AM, 3/13/18 at 7:08 AM, 3/13/18 at 11:59 AM, 3/11/18 at 4:14 AM, and 3/10/18 at 2:25 AM).

An interview was conducted with Director of Nursing Services U and Clinical Practice Leader JJJ on 3/21/18 at 10:00 AM who confirmed that face to face evaluations are not being completed by physicians and/or physician's assistants an hour after restraint placement and nursing staff are not trained to perform face to face.

Based on record review and interview, the hospital failed to ensure that patient care plans were developed based on patient's needs, in 7 of 30 patients reviewed (1, 2, 4, 7, 8, 25, 32).

Finding include:

Review of hospital policy "Assessment, Care and Treatment, revised 11/2017" revealed under C. Care Planning... 2. The care plan, based on the identified needs obtained from the assessments, information from the medical record and the patient/family, and other interdisciplinary communication, is further developed and established, including the identification of goals, within 24 hours of admission... 7. The goals and plans for care, treatment, and services are revised when necessary based on the patient reassessments that occur throughout the patient's encounter as outlined in the patient care standards."

Review of Patient #8's admission psychiatric H &P (history and physical) dated 3/15/18 at 12:12 PM revealed under "Physical Issues:..that patient has multiple lacerations on arms and legs-have been treated supportively and patient is being given antibiotic ointment for now; we'll continue to monitor".

Review of Patient #8's multidisciplinary problems, active problems revealed no nursing care plan for the healing of self-inflicted lacerations.

Review of Patient #7's admission psychiatric H &P (history and physical) dated 3/6/18 at 4:49 PM revealed under "History leading to Admission...presents to the ED (emergency department) with suicidal thoughts, cut self on arm...blood sugars were in the 300's, hasn't been taking medications regularly at home, is on insulin for Type 2 Diabetes."

Review of Patient #7's multidisciplinary problems, active problems revealed no nursing care plan for the healing of self-inflicted lacerations or the nursing management/education of unstable diabetes and medication non-compliance.


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Review of Patient #25's open surgical medical record with Operating Room Nurse Manager RRR and the 9th floor Surgical/Orthopedic Nurse Manager D confirmed the following finding: Patient #25 had an exploratory laparotomy for a small bowel obstruction on 3/14/2018. There was no problem or goal related to the surgery or incision on Patient #25's care plan.

Per interview with Manager D on 3/20/2018 at 2:15 PM, Manager D stated, "s/he should probably have that."


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Review of patient #32 care plan revealed Patient #32 was admitted on 12/19/2017 with a diagnosis of cellulitis. Care plan was initiated with a problem for risk of impaired skin integrity, an intervention listed on the care plan included a consult to dietitian. Review of Patient #32's medical record revealed no evidence of a dietitian consult being completed.

Per interview with Director of Care Coordination on 3/21/2018 at 10:00 AM, V stated, "Once a problem is initiated on the care plan, interventions are canned and listed automatically, if the nurse does not complete the intervention or does not feel the patient needs the interventions it needs to be removed from the interventions to individualize the care plan for that specific patient, and it looks like the nurse did not remove that intervention".

Review of Patient 32's physician orders revealed Intake and Output order was written on 12/19/2017, per review of intake documentation for Patient #32 there was no documentation of meal intake for 12/20/2018 for lunch or supper, 12/21/2017 for breakfast, 12/22/2017 for supper, or 12/23/2017 for supper.

Director of Care Coordination V confirmed the findings and stated on 3/21/2017 at 10:30 AM, "The staff should be documenting intake for all the meals per physician order".


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Review of Patient #1's medical record revealed Patient #1 was a 77 year old insulin dependent diabetic admitted on 3/5/18 for Clostridium Difficile Bacteria (infectious diarrhea) and was currently an inpatient. Care plan was initiated with a problem list for impaired gas exchange, risk of falls, impaired risk of skin integrity, and discharge planning. There was no documented nursing care plan problem for diabetic management, diarrhea, and Patient #1 being on isolation related to C-diff (Clostridium Difficile Bacteria). This was confirmed during an interview on 3/19/18 at 2:00 PM with Interim Nurse Manager O.

Review of Patient #2's medical record revealed Patient #2 was a 89 year old admitted for exacerbation of Congestive Heart Failure, rule out pneumonia and hypoxia (low oxygen level) on 3/12/18 and was currently an inpatient. There was no documented nursing care plan problem for low pulse oximetry, use of oxygen, infectious process receiving antibiotics. Per Interim Nurse Manager O during interview on 3/19/18 at 1:48 PM, "The staff pick out what problems they think are most important and document on those."

Review of Patient #4's medical record revealed Patient #4 was a 44 year old alcoholic admitted on 3/17/18 for vomiting blood and having black stools and was currently an inpatient. There was no documented nursing care plan problem for post procedure (endoscopy), monitoring of stools and/or vomit for blood, and addiction assistance. This was confirmed during an interview on 3/20/18 at 2:40 PM with Interim Nurse Manager O.

Based on record review, observation, and interview, nursing staff at this facility failed to label intravenous solutions after removing the plastic overwrap and inserting the intravenous tubing in 1 of 2 pre-operative areas observed (Surgical pre-operative area).

Findings include:

On 3/20/2018 between 7:20 AM-8:45 AM observations in the surgical pre-operative area were conducted accompanied by Nurse Manager of Pre-operative, Post-operative, and Digestive Health II, Assistant Manager of Pre-operative and Post-operative E, and Director of Peri-operative services C.

On 3/20/2018 at 7:20 AM 7 bags of lactated ringers intravenous solution were observed hanging on an intravenous pole in a pre-operative unit medication room without the protective overwrap and had intravenous tubing attached. 5 of the bags had an orange tag on the attached tubing that said "Change Tues [Tuesday]." 2 of the bags had yellow tags on the tubing that said, "Change Sat [Saturday]." All of the labels had spaces for date, time and initials for who prepared the intravenous bags, however none of the bags had dates and times on the labels.

Per interview with Manager II on 3/20/2018 at 7:20 AM regarding when the intravenous bags were prepared and by who, Manager II stated they would have been prepared that morning but was unable to state who prepared them, and stated, "That was missed then."

Per review of facility policy titled, "Medication Administration," #101, dated 11/2016, reviewed on 3/20/2018 at 5:50 PM, the policy revealed in part, "Any time one or more medications or solutions are prepared but not administered immediately, the medication container (syringe, bottle, box, medicine cup, basin, or plastic bag) must be labeled. Generic labels are available in all medication storage areas and include space to write in the medication name, strength, date, and time."

Based on record review, observation, and interview staff at this facility failed to ensure that protected patient information is secured from access of unauthorized persons in 2 of 18 departments observed (9th floor Surgical/Orthopedic floor, Ultrasound) involving 3 of 3 patients (Patient #28, 29, 37).

Findings include:

Review of facility policy titled "Protection of Information Guidelines, 1.AD.04 effective 3/17, revealed under Background "All information, regardless of where it is handled or stored (e.g. in computers, file cabinets, desks, fax machines, voice-mail, etc.) must be protected from unauthorized access, modification, disclosure, and /or destruction...Security Standards Computers/Work Stations...Prior to leaving a workstation unattended, take reasonable steps to safeguard access to information (e.g., log out, enact password-protected screensaver, or other measures)..."

During a tour of the 9th floor Surgical/Orthopedic floor on 3/19/2018 at 12:00 PM, accompanied by Nurse Manager D and Director of Perioperative Services C, the following items were observed to be in a small refrigerator in a family lounge which is accessible by visitors, patients, and staff not authorized to access patient information: 2 cans of half and half lemonade/ice tea for Patient #28 and 1 bottle of Ensure for Patient #29. Patient #28 was admitted on 1/27/2018. Patient #29 was admitted on 1/29/2018. These items were labeled with patient name, medical record number, and date of birth.

Per interview with Manager D on 3/19/2018 at 12:00 PM regarding who is responsible for maintaining the refrigerator and checking the contents, Manager D stated that kitchen staff are responsible.

Manager D stated that anyone in the lounge (which is unsecured) could have access to the information on the patient labels and agreed that the items should not have been in that refrigerator. Manager D also stated that neither Patient #28 nor #29 were still in the facility.


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Per observation on 3/19/18 at 12:23 PM Ultrasound Diagnostic Clinic room #2 had the ultrasound machine left on with Patient #37's name and birth date along with ultrasound pictures. There was no one in the room at the time of discovery. This deficiency was confirmed in interview at time of discovery on 3/19/18 at 12:23 PM with Manager I, who agreed staff should have logged off the ultrasound machine before leaving the room.

Based on observation, record review and interview the facility failed to ensure all medications are secure and not available for unauthorized access, in 3 of 18 departments observed (Birth Center, Neonatal Intensive Care Unit, Women's Clinic)

Findings include:

Review of facility policy titled "Medication Delivery and Storage", revised 1/15, revealed under II. B. "Secure storage with restricted access: All areas need to ensure that drugs and biologicals are securely stored with access restricted to authorized personnel only; these location include:..2. General Patient Care Areas including patient rooms, clinic exam and procedure rooms...4. Carts-medications stored in carts within departments or units need to be appropriately secured.

Per observation on 3/19/18 at 11:50 AM on the Birth Center Triage Floor #2, Room 6 had a saline syringe in a drawer that was unsecured. This was confirmed in interview on 3/19/18 at 11:50 AM with Manager J who agreed the drawer should be locked.

On 3/19/18 at 12:10 PM in the Women's Clinic Floor 2, the following was observed:
Room 1 had 8 Sodium tubes and 6 Nitrate (fixative) vials unsecured,
Room 2 had 6 Sodium tubes and 6 Nitrate vials unsecured,
Room 3 had 7 Sodium tubes unsecured,
Room 4 had 8 Sodium tubes and 5 Nitrate vials unsecured,
Room 5 had 7 Sodium tubes and 5 Nitrate vials unsecured,
Room 6 had 8 Sodium tubes and 6 Nitrate vials unsecured,
and Room 7 had 6 Sodium tubes and 6 Nitrate vials unsecured.

The above deficiencies were confirmed in interview on 3/19/18 at 12:10 PM with Manager I, who was unaware the medications should be secure.

Per observation on 3/19/18 at 1:00 PM in the Neonatal Intensive Care unit on Floor 3 there was an unsecured crash cart with a breakaway tag in Room 24. The cart was not in view of the nursing station. This observation was confirmed on 3/19/18 at 1:00 PM with Manager IIII.

Per observation on 3/20/18 at 2:00 PM Neonatal Intensive Care unit Room #1 had 2 sterile saline syringes in an unlock medication drawer. This was confirmed in interview on 3/20/18 at 2:00 PM with Manager IIII who agreed the drawer should have been locked.

Based on observation and interview, the hospital failed to maintain food and clean items used for food preparation in a manner in to prevent food-borne illness, in 1 of 1 hospital kitchens (main) and 2 of 4 total hospital kitchenettes observed (9th floor Surgical/Orthopedic family lounge refrigerator and kitchenette and 9th floor Atrium kitchenette).

Findings include:

1) Observations of the main hospital kitchen on 3/19/18 from 4 p.m. through 6 p.m. revealed the following:

a) The 4 of 4 metal racks holding "clean" pots and pans were dust-covered and had food debris (crumbs) along their outer surfaces in the main kitchen food preparation area..

b) One of 2 cooking utensil drawers had debris scattered under the utensils in the main kitchen food preparation area.

c) In the "clean" dish storage room, there was dust and debris on the floor. The door (in this room) opened to a public coridor and was open at the time of observation. Debris from the public coridor was blowing into the "clean" dish room.

d) Test tray temperatures of food prepared in the main kitchen and taken on adult psychiatric unit at 5:50 p.m. revealed carton of milk to be 43.7 degrees Fahrenheit (according to FDA Food Code 2017 should be at 40 degrees or colder).

e) Observations of the tray line revealed that holding tempertures of hot food were not being monitored after initial placement temperature (immediately after cooking). The hospital had no system of periodic temperature testing to ensure that hot and cold foods remained at safe temperatures while being processed for patients delivery.

During interview with Kitchen Manager KKKK, at time and date of observation, KKKK stated that "we do not have a routine cleaning schedule for the clean dish storage...". KKKK confirmed that the milk temperature was more than 40 degrees fahrenheit.


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2) Observations of the 9th floor Surgical/Orthopedic floor on 3/19/2018 at 12:00 PM, while accompanied by Nurse Manager D and Director of Perioperative Services C, revealed a boxed lunch indicating it contained chicken salad was in the refrigerator in the family lounge with a label revealing it was "best used by 2/22" (28 days after the best used by date).

Per interview with Manager D on 3/19/2018 at 12:00 PM regarding who is responsible for maintaining the refrigerators and checking the contents, Manager D stated that kitchen staff are responsible, "They check them daily."

In the kitchenette on the 9th floor Surgical/Orthopedic floor on 3/19/2018 at 12:10 PM there was an opened loaf of bread in the refrigerator that expired March 17, 2018.

3) In the kitchenette on 9th floor Atrium on 3/19/2018 at 12:05 PM, while accompanied by Nurse Manager D and Director of Perioperative Services C, there was one opened loaf of bread that was not marked with an expiration date and a drawer that contained bins of cellophane sealed crackers were dirty with crumbs and debris.

Per interview with Manager D regarding the debris in the drawer on 3/19/2018 at 12:15 PM, Manager D stated, "Yes, there are bits and crumbs." Manager D stated that kitchen staff are responsible for cleaning the kitchenettes.

Per observation on 3/19/18 at 12:38 PM in the family room refrigerator on Birth Center Floor 3, there were 4 sandwiches with out labels of contents or expiration dates, a salad dated 3/18, and an unlabeled container with unknown substance. This was confirmed in interview on 3/19/18 at 12:38 PM with Manager J who confirmed all items should have a patient name and dates.

Per observation on 3/19/18 at 1:25 PM in the Birth Center Floor 4 nutrition center refrigerators, there were 8 sandwiches without labels of contents or expiration dates, a pack of cauliflower expired 3/16, and a bag of salad expired 3/15. This was confirmed in interview on 3/19/18 at 1:25 PM with Manager J who confirmed all items should have patient names and dates.

Based on observation, staff interviews, and review of maintenance records between March 19 and March 20, 2018, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

482.41 Condition of Participation: Physical Environment is NOT MET

Findings include:

The facility was found to contain the following deficiencies.
Hospital

K 161 Building Construction
K 222 Egress Doors
K 223 Doors with Self Closing Devices
K 293 Exit Signage
K 321 Hazardous Areas
K 323 Anesthetizing Locations
K 324 Cooking Facilities
K 351 Sprinkler System - Installation
K 353 Sprinklers Systems- Testing and Maintenance
K 374 Subdivision of Building Spaces
K 754 Soiled Linen And Trash Containers
K 911 Electrical Systems - Other
K 915 Essential Electrical Systems - Other
K 916 Essential Electrical Systems - Other
K 918 Essential Electrical Systems - Other
K 920 Electrical Equipment Power Cords

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, record review and interview, the facility failed to ensure all rooms containing biohazard materials are secured and have biohazard signage outside the room, in 6 of 18 areas observed (Birth Center, Neonatal Intensive Care, Women's Clinic, Ultrasound Diagnostic Clinic, Heart and Vascular unit)

Findings include:

Per observation on 3/19/18 at 11:50 AM the soiled room on Birth Center floor #2 contained biohazards. There was no sign outside the room to indicate the presence of biohazards. This deficiency was confirmed in interview at time of discovery with Manager J on 3/19/18 at 11:50 AM, who was unaware a sign should be outside the room.

Per observation on 3/19/18 at 12:10 PM the soiled room, and the Special Processing Room, on in the Women's Clinic on Floor 2 contained biohazards. There was no sign outside the room to indicate the presence of biohazards. This deficiency was confirmed in interview at time of discovery with Manager I at time of discovery on 3/19/18 at 12:10 PM, who was unaware a sign should be outside the room.

Per observation on 3/19/18 at 12:23 PM the soiled room on in the Ultrasound Diagnostic Clinic on Floor 2 contained biohazards. There was no sign outside the room to indicate the presence of biohazards. There was no sign outside the room to indicate the presence of biohazards. This deficiency was confirmed in interview at time of discovery with Manager I at time of discovery on 3/19/18 at 12:23 PM, who was unaware a sign should be outside the room.

Per observation on 3/19/18 at 12:38 PM the soiled room on in the Birth Center Floor 3 contained biohazards. There was no sign outside the room to indicate the presence of biohazards. This deficiency was confirmed in interview at time of discovery with Manager J on 3/19/18 at 12:38 PM, who was unaware a sign should be outside the room.

Per observation on 3/19/18 at 1:25 PM the soiled room on in the Birth Center Floor 4 contained biohazards. There was no sign outside the room to indicate the presence of biohazards. This deficiency was confirmed in interview at time of discovery with Manager J on 3/19/18 at 1:45 PM, who was unaware a sign should be outside the room.

Per observation on 3/20/18 at 7:23 AM the soiled room on in the Birth Center Floor 5 contained biohazards. There was no sign outside the room to indicate the presence of biohazards. This deficiency was confirmed in interview at time of discovery with Director K on 3/19/18 at 1:45 PM, who was unaware a sign should be outside the room.

Per observation on 3/22/18 at 2:00 PM the soiled room on in the Neonatal Intensive Care Unit Floor 7 contained biohazards. There was no sign outside the room to indicate the presence of biohazards. This deficiency was confirmed in interview at time of discovery with Manager IIII on 3/19/18 at 2:00 PM, who was unaware a sign should be outside the room.


29963


Per observation on 3/19/2018 at 11:50 AM of Floor 11 Heart and Vascular Unit noted 3 rooms labeled soiled utility room A, B, and C. The rooms were unlocked and stored biohazard containers. Soiled Utility Room A also contained a bottle of spray enzyme. Soiled Utility Room C also contained a gallon of bleach. There was no sign outside the room indicating biohazard supplies were stored in the room.

Per observation on 3/19/2018 at 12:40 PM of Floor 10 Heart and Vascular Short Stay Unit noted soiled utility room that was unlocked and stored biohazard containers. There was no sign outside the room indicating biohazard supplies were stored in the room. Tours of floor 10 and 11 were completed with Director of Care Coordination V and findings were confirmed with V at time of tour.

Based on observation, staff interviews, and review of maintenance records between March 19 and March 20, 2018, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
Hospital

K 161 Building Construction
K 222 Egress Doors
K 223 Doors with Self Closing Devices
K 293 Exit Signage
K 321 Hazardous Areas
K 323 Anesthetizing Locations
K 324 Cooking Facilities
K 351 Sprinkler System - Installation
K 353 Sprinklers Systems- Testing and Maintenance
K 374 Subdivision of Building Spaces
K 754 Soiled Linen And Trash Containers
K 911 Electrical Systems - Other
K 915 Essential Electrical Systems - Other
K 916 Essential Electrical Systems - Other
K 918 Essential Electrical Systems - Other
K 920 Electrical Equipment Power Cords

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation and interview, staff at this facility failed to ensure that all surfaces are intact and in good repair in order to be disinfected in 1 of 18 departments observed (Infusion clinic), failed to ensure there is a separation of clean and dirty for textiles in 1 of 1 onsite laundry facilities, and failed to ensure that sharps and syringes are secured in 1 of 18 departments (Radiology).

Findings include:

Equipment repair
On a tour of the Infusion clinic on 3/19/2018 at 12:20 PM, accompanied by the Director of Perioperative Services C, a chair in room 225 was observed to be missing a piece of laminate on the patient tray table. This missing laminate exposed porous wood underneath which is unable to be effectively cleaned. Per interview with Director C on 3/19/2018 at 12:20 PM regarding the laminate missing, Director C stated, "I understand."

Separation of Clean and Dirty
Per interview with the Director of Facility Operations G and Manager of Logistics (which includes linens) H on 3/19/2018 at 1:50 PM, Director G stated that the facility launders patient room curtains on-site, all other laundry is contracted out.

On a tour of the onsite laundry facilities on 3/19/2018 at 2:00 PM accompanied by the Director of Facility Operations G and Manager of Logistics H, it was observed that there is one door for the room that houses dirty and clean curtains. The dirty curtains are bagged and placed on the floor, then put into the wash machine, moved to the dryer, folded and stored until needed. When removed from this room the clean curtains, which are not covered, have to cross over the dirty section to go through the door for disbursement.

Per interview with the Director of Facility Operations G and Infection Preventionist XXX on 3/21/2018 at 8:50 AM regarding the flow of laundry and separation of clean and dirty, Director G stated, "I understand what you are saying."

Unsecured Needles and Syringes
A tour of the Radiology department was conducted on 3/21/2018 at 8:30 AM. A cart in a radiology room was found to be unlocked and contained unsecured needles and syringes with no radiology staff present. This finding was discussed with and confirmed per interview by the Manager of Interventional Radiology and Computerized Tomography AAAA.

Based on observations, record reviews, and interviews, the hospital failed to ensure a system for controlling potential transmission of infections and communicable diseases, in 9 of 18 areas reviewed (Surgery, Birthing Center, Dialysis, Cath Lab, Medical/Surgical floors, Digestive Health, Environmental Services, Ultrasound Diagnostic Clinic, Neonatal Intensive Care Unit).

Findings include:

Per interview with Infection Preventionist XXX and Director of Per-operative Services C on 2//19/2018 at 2:15 PM regarding standards of practice for this facility, Preventionist XXX stated, "APIC [association for professionals in infection control and epidemiology], CDC [Centers for Disease Control], AORN [Association of peri-Operative Registered Nurses], and AAMI [Association for Advancement in Medical Instrumentation] to name a few."

Infection Preventionist XXX stated that hand hygiene expectations are upon entry and exit to patient care areas and also the WHO [World Health Organization] 5 moments of hand hygiene.

Infection Preventionist XXX and Director C both stated that all policies are up to date with current standards of practice.

Per the Centers for Disease control, March 1, 2011, (http://www.cdc.gov/injectionsafety/providers/provider) "A needle or other device should never be left inserted into a medication vial septum for multiple uses. This provides a direct route for microorganisms to enter the vial and contaminate the fluid."

The facility's policy titled, "Central Venous Catheter, Short-Term (not PICC [peripherally inserted central catheter]): Insertion, Care & Maintenance, Adult," #134, dated 4/2015, was reviewed on 3/21/2018 at 10:30 AM. The policy revealed in part, "Management of IV [intravenous] injection ports and administration sets 1. b. Alcohol pledget: Scrub the hub with friction for a total of 15 seconds. Allow to dry."

The facility's policy titled, "Pre-Operative Patient Preparation (Adult)," #135, dated 2/2016, was reviewed on 3/21/2018 at 10:40 AM. The policy revealed in part, "If necessary, hair is removed by clipping based on the type of surgery. Hair removal should occur as close to the surgery time as possible and preferably outside of the operating room (OR ) setting."

APIC (Association for Professionals in Infection Control and Epidemiology) Position Paper: Safe Injection, Infusion, And Medication Vial Practices in Health Care (2016) under Medication Vials "Disinfect the rubber septum on all vials prior to each entry, even after initially removing the cap of a new, unused vial."

The facility's policy titled, "Hand Hygiene and Surgical Hand Antisepsis," #539, dated 11/2017, was reviewed on 3/20/2018 at 6:55 PM. The policy revealed in part, "All staff, providers, volunteers, and contracted individuals will perform hand hygiene upon every entry and exit of any occupied patient room. Hand hygiene is also performed in accordance with the World Health Organizations's (WHO) five 'moments' for hand hygiene: 1. Before contact with a patient, 2. Before performing a clean or aseptic procedure, 3. After exposure to body fluids, 4. After contact with a patient, 5. After contact with patient's environment."

Review of facility policy titled "Food Handling and Storage in Patient Care Areas", dated 10/17, revealed under B.2.c.1) "Patient food stored in unit refrigerators is labeled with a patient label and dated. 2) Patient food placed in unit patient refrigerators not labeled, dated, or older than 3 days is disposed of. d. Unopened packaged food is disposed of after the stated manufacturer's expiration date or after 3 days of receipt if there is no manufacturer's expiration date..."

Review of facility policy titled "Basic Aseptic Technique, revised 11/15, revealed under II.E.6. "The gown back is considered nonsterile because it cannot be constantly monitored...J. Sterile field is maintained and monitored constantly monitored (sic) for contamination. 1. Sterility of an open sterile field is event related and requires continuous visual observation."

Ultrasound Diagnostic Clinic Observations:

Review of facility policy titled "Cleaning, Disinfection, and Care of the Environment and Equipment-Meriter Hospital Medical Imaging" reviewed 3/11/16, revealed under II. Frequency, The ultrasound machine and transducers must be cleaned and disinfected after each patient use..."

On 3/19/18 at 12:23 PM in the Ultrasound Diagnostic Clinic Floor 2, the following was observed:
Room 1's ultra sound gel cup contained ultrasound gel residue,
Room 2's ultra sound gel cup contained ultrasound gel residue,
Room 3's ultra sound gel cup contained ultrasound gel residue,
Room 4's ultra sound gel cup contained ultrasound gel residue,
Room 5's ultra sound gel cup contained ultrasound gel residue,
and Room 6's ultra sound gel cup contained ultrasound gel residue.

The above deficiencies were confirmed in interview on 3/19/18 at 12:23 PM with Manager I, who agreed there should be no gel residue.

Environmental Services Observations:

Review of facility policy titled "Discharge Cleaning and Bedmaking", dated 3/18/2016, revealed under #8 "...First, clan the top of the overbed table; then clean the pillow and lay it on the clean table surface...Clean the upper half of the mattress, first the top and then the bottom, the upper half of the bed frame, and the side rail...next clean the lower half of the mattress, first the top then the bottom, the lower half of the bed frame and then the lower part of the side rail...11.C. Be sure to clean the knobs and push plates on both the patient room and bathroom doors and all other high touch points in the room."

Per observation on 3/19/18 at 1:45 PM Housekeeper 2 L had long hair, unsecured that would fall on cleaned surfaces as s/he would wipe down the delivery bed and sleeper sofa. Housekeeper L wiped down the top of the mattress, and under the top 2/3's of the mattress, then placed clean items on top of the mattress and did not clean completely under the bottom third. Housekeeper wiped one side of the blood pressure cuff while resting it on his/her knee, flipped it over and placed it on his/her knee to wipe the other side. Housekeeper L placed a pillow on an unwashed table, wiped one side clean, flipped the pillow over and placed it back on the table to wipe the other side; this technique was repeated with 3 additional pillows. Housekeeper L, did not wipe down any handles on drawers or cupboards when cleaning the room. Housekeeper L wearing gloves used with cleaning, removed the glove boxes from the plastic holder on the wall reaching inside touching gloves inside the boxes, to clean the holder. Housekeeper L wiped down the anesthesia cart and did not remove stickers and tape that were on the top edge of the cart.

The above deficiencies were discussed in interview with Director K on 3/19/18 at 7:50 AM who agreed the housekeeper's hair should be contained, and items should be cleaned in an aseptic manner.

Per interview with the Director of Facility Operations G on 3/19/2018 at 1:37 PM regarding cleaning products used for general cleaning in patient care areas, Director G stated that Virex 256, a pre-mixed and ready to use product was used and that the system was calibrated to automatically dilute the product with water when put into a bucket/container for cleaning purposes. Director G stated that housekeeping staff change the bottles as needed and check that the system was functioning correctly on a periodic basis, but this was not recorded and there was no data to indicate that the system was properly mixing. Per the manufacturer recommendations for dilution testing, reviewed on 3/20/2018 at 4:20 PM, there are specific concentration levels to stay within when testing for the product to be effective.

Birthing Center Observations:

Per observation on 3/19/18 at 11:46 AM in the Birth Center Triage unit Floor 2, in rooms 1 and 4 there was ultrasound gel on the ultrasound paddles (to monitor fetal heart tones).

Per observation on 3/19/18 at 1:38 PM on Birth Center Floor 4, Rooms 473, 474 and 479, had ultrasound paddles for fetal heart tones that were cracked.

The above deficiencies were confirmed in interview on 3/19/18 beginning at 11:46 AM with Manager J, who confirmed the paddles should be replaced.

Per observation on 3/20/18 at 8:40 AM, Registered Nurse LL drew up lidocaine for an intravenous line insertion on Patient #12 prior to a scheduled caesarean section. Nurse L removed the cap on the vial of lidocaine and inserted the needle without cleaning the septum. Nurse LL held the intravenous start kit in his/her right hand, that contained the syringe with the newly drawn lidocaine, removed the glove from his/her right hand, entered data on the computer and donned a new glove without performing hand hygiene. Nurse LL proceeded to perform the intravenous line insertion.

The following was observed on 3/20/18 between 9:45 AM and 10:20 AM following Patient #12 from preoperative stage in The Birth Center Triage floor through cesarean section procedure in the Birth Center Operating Room:

At 9:45 AM in the Operating Room, the following staff and interpreter had ears, head hair and/or facial hair exposed: Interpreter XX, Surgical Technician TT, Medical Student NN, Medical Resident OO, Resident PP, Surgeon RR, Anesthesiologist QQ, Medical Resident SS, Nurse LL, Nurse MM, Doctor UU, Doctor VV and Doctor WW. This deficiency was confirmed in interview on 3/22/18 at 10:20 AM with Registered Nurse MM, who stated they should have their hair and ears covered.

At 10:02 AM Surgical Technician T had his/her back to the open sterile instrument table.

At 10:05 AM Nurse LL applied skin preparation Chlorhexidine to Patient #12's abdomen prior to a cesarean section surgery. Upon completion, Nurse LL removed the glove on his/her right hand went to the baby warmer set a timer, for the prep dry time, without performing hand hygiene.

At 10:10 AM Anesthesiologist QQ and Resident PP's lower strings on the their masks were loosely tied so that the mask was not close under their chins.

The above deficiencies were discussed in interview with Director K on 3/21/19 at 7:45 AM who confirmed staff should be cleaning items between use, performing hand hygiene after removing gloves and have ears and all hair should be contained in the Operating Room.

Neonatal Intensive Care Unit Observations:

Review of "AirLife TM" manufacturer's instructions (n.d.) revealed under Caution: "Store unit in moisture barrier overpouch at room temperature until ready for use."

Per observation on 3/20/18 at 2:00 PM there are 10 ventilator units with Sterile Inhalation solution, 2 liter bags, manufactured by AirLife TM, that were out of the moisture barrier overpouch. This deficiency was confirmed at time of discovery on 3/20/18 at 2:00 PM with Manager IIII, who was unable to say how long they had been out of their wrapper.


26711


Surgery Department Observations:

Operating Room:

On 3/20/2018 between 8:50 AM and 10:30 AM observations were conducted in the operating room with Director C and Manager RRR.

At 9:15 AM on 3/20/2018 Doctor QQQ was observed removing the plastic cap from vials of Lidocaine, Succinylcholine (anesthetizing agent), Propofol (anesthetizing agent) and Cefazolin (antibiotic) without disinfecting the rubber septum prior to entering the vials with needles to remove the solutions. This finding was discussed with and confirmed per interview by Director C and Manager RRR on 3/20/2018 at 10:16 AM.

At 9:22 AM on 3/20/2018 Patient #23 arrived in the operating room and Doctor QQQ was observed to apply gloves without performing hand hygiene, and then accessed Patient #23's intravenous port on 2 occasions, without cleansing the port site with alcohol. This finding was discussed with and confirmed per interview by Director C and Manager RRR on 3/20/2018 at 10:16 AM.

At 10:12 AM on 3/20/2018 Operating Room Technician SSS was observed removing gloves during a post-operative room cleaning and apply new gloves without performing hand hygiene. This finding was discussed with and confirmed per interview by Director C and Manager RRR on 3/20/2018 at 10:16 AM.

Digestive Health observations
On 3/20/2018 between 10:30 AM and 11:30 AM observations in the Digestive Health Center were conducted accompanied by Director C and Manager II.

At 11:04 AM on 3/20/2018 Registered Nurse TTT was observed drawing up normal saline and contrast media into syringes for Patient #24's ERCP (endoscopic retrograde cholangiopancreatography) procedure. Nurse TTT removed the protective plastic caps from the vials and did not cleanse the septums with alcohol prior to inserting the needles to remove the solution on 3 occasions. This finding was confirmed during interview with Director C and Manager II on 3/20/2018 at 11:32 AM.

At 11:25 AM on 3/20/2018 Endoscopy Technician UUU was observed removing a pair of gray gloves, not performing hand hygiene, and then applied a pair of purple gloves. This finding was discussed with and confirmed per interview by Director C and Manager II on 3/20/2018 at 11:32 AM.

The facility's policy titled, "Surgical Attire," #24, dated 2/2016, was reviewed on 3/20/2018 at 5:46 PM. The policy revealed in part, "Personnel cover head and facial hair, including sideburns and necklines, when in the semi-restricted and restricted areas of the surgical suite." This policy does not address that staff's ears are to be covered with the surgical head cover.

Review of Association for peri-Operative Registered Nurses, Publish Date: May 30, 2017 "A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn."

Operating Room observations
On 3/20/2018 between 8:50 AM and 10:30 AM observations were conducted in the operating room accompanied by Director C and Manager RRR.

At 8:53 AM on 3/20/2018 Registered Nurse PPP was observed opening sterile packs for Patient #23's total shoulder replacement. Nurse PPP was wearing a surgical bonnet that was tucked behind PPP's ears (exposing them to an area where sterile supplies were being opened) and exposed the sides of PPP's hair along the temple line and the back of the head. This finding was discussed with and confirmed per interview by Director C and Manager RRR on 3/20/2018 at 10:16 AM.

At 9:15 AM on 3/20/2018 Doctor QQQ was observed entering the operating room with a surgical bonnet that was tucked behind QQQ's ears and a surgical mask on that did not cover a light beard that extended along both sides of QQQ's face to the hair line in front of the ears. This finding was discussed with and confirmed per interview by Director C and Manager RRR on 3/20/2018 at 10:16 AM.

At 9:35 AM on 3/20/2018 Doctor LLL was observed entering the operating room with a surgical bonnet that was tucked behind LLL's ears. This finding was discussed with and confirmed per interview by Director C and Manager RRR on 3/20/2018 at 10:16 AM.

At 9:40 AM Resident NNN was observed entering the operating room with a surgical bonnet that was tucked behind NNN's ears. This finding was discussed with and confirmed per interview by Director C and Manager RRR on 3/20/2018 at 10:16 AM.

At 10:00 AM Vendor OOO was observed entering the operating room with a surgical bonnet that was tucked behind OOO's ears. This finding was discussed with and confirmed per interview by Director C and Manager RRR on 3/20/2018 at 10:16 AM.

Per interview with Director C on 3/20/2018 at 10:25 AM regarding the practice of wearing either laundered cloth surgical hats or blue surgical bonnets and tucking them behind the ears so that the ears are exposed in the operating room and other sterile areas, Director C stated that C was familiar with AORN's recommended practice of covering ears and all hair and stated, "It's a staff compliance issue."


29963


Dialysis observations:

Per review on 3/21/2018 at 10:45 AM of policy titled Infection Control Practices, Hemodialysis, #7, dated 9/15, revealed G.4. Employees must wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station. Employees must remove gloves and wash hands between each patient or station.

Per observation on 3/21/2018 at 8:00 AM of Registered Nurse EEEE providing dialysis to patient #33, Registered Nurse EEEE was observed touching the dialysis machine without the use of gloves at station #1. At 8:20 AM, Registered Nurse EEEE was observed initiating dialysis on patient #33 per central venous catheter, Registered Nurse EEEE used a syringe to draw back blood from the catheter of patient #33, removed syringes and disposed of in the sharps container, removed gloves and grabbed gauze out of the central supply cart; EEEE did not performing hand hygiene after removing gloves and before obtaining clean supplies. Findings were observed by Director of Nursing FFFF who stated, "gloves should be worn when touching the dialysis station and hand hygiene needs to be completed every time gloves are removed".

Cath Lab observation:

Per observation on 3/19/2018 at 12:55 PM of Registered Nurse X assisting in a procedure in the cath lab on patient #5. Registered Nurse X placed Electrocardiography patches on patient #5's chest, removed gloves, grabbed more patches out of the supply drawer, and continued placing patches on patient #5 body; Registered Nurse X did not perform hand hygiene after removing gloves and before obtaining clean supplies.


37420


Medical/Surgical floor Observations:

At 8:30 AM on 3/20/2018 Registered Nurse DDD was observed putting on a pair of clean gloves, administered insulin, returned to computer keyboard to document administration without removing gloves and performing hand hygiene and continued on to administer oral medications. This finding was confirmed during interview with Director of Nursing Services U and Interim Nurse Manager O on 3/20/2018 at 8:35 AM who stated "dirty gloves should have been removed and hand hygiene performed before using computer keyboard."

At 9:00 AM on 3/20/2018 observed Registered Nurse KKK remove a pair of gloves, perform hand hygiene, then donned a new pair of gloves obtained from scrub top pocket. This finding was confirmed during interview with Director of Nursing Services U and Interim Nurse Manager O on 3/20/2018 at 9:05 AM who stated, "gloves should not be kept in pockets."

Based on record review and interview the facility failed to ensure operative reports are immediately documented in the medical record post procedure in 1 of 7 surgical records reviewed (Patient #12) in a total 30 Medical Records reviewed.

Findings include:

Review of facility "Medical Staff By-laws", adopted January 2018, revealed on page 47, Required Elements-Operative/Procedure Report "...When a full operative or invasive procedure report cannot be entered immediately into the patient's medical record after the operation or procedure, a post operative progress note is entered in the medical record before the patient is transferred to the next level of care that will include: Name of the primary surgeon and his/her assistants, Procedure performed, Description of each procedure finding, Estimated blood loss, if applicable, Specimens removed, if applicable, Post-op diagnosis"

Patient #12's medical record review on 3/20/18 at 3:55 PM revealed the immediate Operative Report dated 3/20/18 at 3:13 PM does not include the following: Surgeon RR, and assistants Medical Student NN, Medical Resident OO; Procedure findings including sex, weight and APGAR scores of baby (baby's color, heart rate, reflexes, muscle tone and respiratory effort); Estimated blood loss and Postoperative Diagnosis. This was confirmed in interview on 3/20/18 at 3:55 PM with Manager JJJJ, who agreed it was an incomplete post operative note.

Based on record review and interview, anesthesiology staff failed to document completion of a pre-anesthesia evaluation prior to a surgical procedure in 1 of 7 surgical records reviewed (Patient #25) in a total of 30 medical records reviewed.

Findings include:

Patient #25's open surgical medical record was reviewed on 3/20/2018 at 1:48 PM with Nurse Manager RRR and Nurse Manager D who confirmed the following finding: Patient #25's surgical event time line revealed that Patient #25's abdominal surgery with general anesthesia on 3/14/2018 started at 2:32 PM and ended at 3:18 PM. The pre-anesthesia evaluation was completed at 2:37 PM on 3/14/2018, 5 minutes after surgery started, when Patient #25 would have been under anesthesia. Per interview with Manager RRR on 3/20/2018 at 1:55 PM regarding this finding, Manager RRR stated, "Yes, it was documented as being done after surgery started."

Review of policy titled, "Anesthesia Care," #172, dated 7/2015 revealed, "An Anesthesiologist discusses the risks, benefits, and alternatives of the anesthetic with the patient or person legally authorized to give consent prior to administration of anesthesia and documents this information in the patient record."