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Based on observation and interview it was determined the facility failed to implement infection control procedures between endoscopy procedures in the operating room for one observed procedure and failed to perform hand washing between changing gloves.

The findings include:

The facility did not provide a policy for cleaning the endoscopy equipment between cases.

Observation of an endoscopy procedure on 04/05/11 at 10:50am revealed the Registered Nurse (RN) #1, who was the circulating nurse for the procedure, did not disinfect the adapter that connects the scope to the machine nor the water bottle tubing after completion of the procedures. Upon completion of the EGD (esophagastroduodenoscopy) and Colonoscopy on Patient #2, the scrub technician disconnected the colon scope from the adapter and water bottle with contaminated gloves. After the patient was removed from the operating suite, RN #1, with gloved hands, disconnected the dirty suction tubing and placed it in the trash. The nurse then placed the solidifier in the suction cannister which contained liquid stool and discarded it in the trash. The dirty towel was removed from the top of the cart which contained a dirty biopsy forcep. The dirty gloves were exchanged for clean gloves. However, the nurse did not wash nor disinfect her hands between changing gloves. She/he then proceeded to disinfect the machine and top of the cart but did not clean the adapter nor the water bottle tubing.

Interview with RN #1 on 04/05/11 at 11:00am revealed she did not clean the adapter nor the water bottle tubing. The nurse stated the staff is responsible for cleaning the equipment and everyone helps. RN #1 agreed she/he should have wiped the adapter and the water bottle tubing after the procedure. The nurse also acknowledged she/he did not perform hand washing between changing gloves.

Interview with the Nurse Manager of the Operating Room on 04/06/11 at 10:40am revealed the circulating nurse and the scrub technician help each other with cleaning and preparing the OR room for the next procedure. She/he would expect the adapter to be disinfected and the nurse should have washed her/his hands between changing gloves.

Interview with the Chief Nursing Officer/Infection Control Nurse, on 04/06/11 at 9:45am revealed there is no specific policy on who is responsible for cleaning the endoscopy equipment between cases. She/he stated there is a limited amount of staff in the operating room and that is why no one is specifically assigned to clean the equipment. The nurse stated it was the expectation that equipment be cleaned between procedures and the nurse should have disinfected her hands between contaminated and clean glove changes.

Based on observation, record review and interview, it was determined the facility failed to have medication orders signed (in accordance with Federal and State laws regarding written and signed orders, and accepted standards of practice) by the physician, prior to administration, for one (1) out of ten (10) sampled patients.

The findings include the following:

The facility policy on physician orders dated 04/08/07, with a revision date of 04/08, states the nurse utilizing the medication reconciliation form, will obtain a list of medications and doses from the patient. The nurse will clarify all home medications and dosages with the ordering physician. The medication reconciliation form becomes an order sheet for the medications. The orders must be dated, timed and signed by the clinician upon receipt.

Record review of Patient #3, admitted on 04/01/11 with a diagnosis of a Right Fractured Hip, revealed the medication reconciliation sheet dated 04/01/11, was not signed by a physician. The admission orders dated 04/01/11 did not include any medication orders. The medication administration record (MAR) revealed the following medication were administered to the resident:
Celexa 20mg daily- given 04/02, 04/03, 04/04, 04/05
Vitamin D 1000mg daily- given 04/02, 04/03, 04/04, 04/05
Lovaza 1 tablet three times per day- given 04/01, 04/02, 04/03, 04/04, 04/05
Pradaxa 150mg twice per day- given 04/01, 04/02, 04/03, 04/04, 04/05
Plavix 75mg daily given- 04/02, 04/03, 04/04, 04/05
Atenolol 25mg twice per day given- 04/01, 04/02, 04/03, 04/04, 04/05
Cordarone 200mg every twelve hours given- 04/01, 04/02, 04/03, 04/04, 04/05
Lisinopril 10mg daily given- 04/02, 04/03, 04/04, 04/05

Interview with the Unit Manager on 04/06/11 at 8:30am revealed Resident #3 came from another facility. Per policy, the nurse copies the medications onto the medication reconciliation form. It is not the usual practice to obtain a verbal order for the medications if the physician is not present to sign the orders. The unit manager admitted there is potential problem giving medications without a physician signature on the form.

Interview with the Physician on 04/06/11 at 9:15am revealed medication reconciliation forms are not required because the resident came from acute care. He/she stated the orders do not have to be signed for seventy two hours after a resident is admitted. The physician stated there was no harm to the resident from receiving the medications on the medication reconciliation form.

Interview with the Chief Nursing Officer on 04/06/11 at 9:25am revealed the same medication reconciliation policy applies to both acute care and swing beds. The physician circles a C continue or DC to discontinue the medication. She/he stated the physician must have circled the C to continue the medications on Resident #3 but forgot to sign the form.

Interview with the Pharmacist on 04/06/11 at 9:00am revealed the process for stocking the medication carts is as follows:
a) the nurse takes off the order
b) the order is faxed to the pharmacy
c) the pharmacist reviews the order on the computer and the medication carts are stocked
The Pharmacist admitted the medications for Resident #3 should not have been provided to the nursing staff without a signed physician order.

Based on record review and interview, the facility failed to have criminal background checks for six (6) of ten (10) sampled physician credentialing/personnel files and failed to have abuse registry checks for four (4) of ten (10) sampled physician credentialing/personnel files.

The findings include:

Review of credentialing/personnel files for ten (10) physicians, either employed directly by the facility or per contracted service on 04/06/11, revealed six (6) of those files did not contain a criminal background check on the physicians and four (4) of those files did not contain an abuse registry check for the physicians.

Interview with the Administrative Assistant responsible for credentialing the facility physicians, on 04/06/11 at 1:45pm, revealed criminal background checks and abuse registry checks were performed for the physicians employed by the facility, but not for the physicians providing contracted services.

Interview with RN #4 on 04/06/11 at 2:00pm revealed the facility does not have a policy regarding credentialing of physician staff. She also indicated the facility does get criminal background checks and abuse registry checks on the physicians who are employees of the hospital; however, the facility does not require proof of these checks by the physician contracting agencies, nor do they themselves obtain these reports on the contracted physicians.