HospitalInspections.org

Based on staff interview and review of credentials files and hospital policies, it was determined the governing body failed to ensure 4 of 6 non-physician members of the medical staff (Non-physician practitioners A, B, C, and D) had been appointed to the medical staff and had been granted privileges to practice at the hospital. This resulted in a lack of oversight of these practitioners by the governing body. Findings include:

The credentials files for 6 non-physician practitioners were reviewed. Four of the credentials files did not contain documentation that they had been appointed to the medical staff and had been granted privileges to practice at the hospital. Examples include:

a. Non-physician practitioner A, an NP, practiced on the Mental Health Unit. His credentials file documented he was an employee of the hospital who was hired on 6/07/10. Documentation that he had been granted privileges to practice and had been appointed to the medical staff was not present.

b. Non-physician practitioner B, an NP, practiced on the Mental Health Unit. Her credentials file documented she was an employee of the hospital who was hired on 10/31/11. Documentation that she had been granted privileges to practice and had been appointed to the medical staff was not present.

c. Non-physician practitioner C, an NP, practiced on the Mental Health Unit. Her credentials file documented she was an employee of the hospital who was hired on 1/03/12. Documentation that she had been granted privileges to practice and had been appointed to the medical staff was not present.

d. Non-physician practitioner D, an RN, practiced in the operating room and served as a first assistant to surgeons who practiced at the hospital. She was a hospital employee who was hired in August 2005. Her "POSITION DESCRIPTION & ANALYSIS [job description]," revised 10/04, stated she was responsible for duties such as clamping blood vessels, suturing, and coagulating bleeding points. Documentation that she had been granted privileges to practice and had been appointed to the medical staff was not present.

The Medical Staff Coordinator reviewed the files with the surveyor on 2/09/12 beginning at 10:30 AM. She confirmed the above practitioners had not been appointed to the medical staff and had not been granted privileges to practice at the hospital.

The hospital did not appoint non-physician practitioners to the medical staff and did not grant them privileges.

Based on record review and staff interview it was determined the hospital failed to ensure each patient was given patient rights information in advance of care for 1 of 2 patients in isolation (#5) whose records were reviewed. This had the potential to interfere with awareness and understanding of patient rights. Findings include:

Patient #5 was a 55 year old male who was admitted to the hospital on 2/04/12 for fever and chills. There was an undated, unsigned copy of a form titled "Notification of Patient Rights and Responsibilities" present in Patient #5's record. The word "Isolation" was hand written in the area of the form designated for a patient's signature. There was no nursing documentation in Patient #5's record to indicate the information on the form had been discussed with Patient #5 or that the form had been given to him for review.

The Director of the Medical/Surgical Department was interviewed on 2/06/12 at 2:30 PM. She reviewed Patient #5's record and explained it was not the hospital's practice to get signatures on documents from patients who were in contact isolation, such as Patient #5, to reduce the risk of infection transmission. She confirmed there was no evidence of nursing documentation to validate patient rights information had been discussed with or distributed to Patient #5. A policy that addressed this process was requested. The Director of the Medical/Surgical Department stated the process was not addressed in hospital policy but probably should be addressed in the isolation policy.

A system was not in place to assure patients in isolation were informed of their rights.

Based on observation, staff interview, and review of medical records, it was determined the hospital failed to ensure care was provided in a safe setting for 2 of 3 patients on the Mental Health Unit (#7 and #15) whose records were reviewed. This resulted in increased opportunities for patients to harm themselves. Findings include:

1. Patient #15's medical record documented a 47 year old male who was admitted to the hospital on 1/27/12. He had been treated on a medical floor for alcohol withdrawal and then had been transferred to the Mental Health Unit on 1/30/12. He was currently a patient as of 2/08/12. His "IP PSYCH INTAKE REPORT," written by a psychiatrist and dated 1/30/12, stated he was found by police in a state park on 1/27/12. It said his plan was "to drink until he could drive himself into the water and commit suicide." When Patient #15 was asked about suicide during the examination, the psychiatrist documented Patient #15 stated he would not think about it, he would just do it. The psychiatrist documented Patient #15 "conveys a strong picture of emotional devastation." The intake also stated his "Insight and judgement [sic] appear clearly affected by severe depression."

A tour of the Mental Health Unit was conducted by the Unit Director on 2/07/12 beginning at 10:45 AM. All of the rooms were constructed with special door knobs, sinks, curtain rods, etc. that were designed so patients could not attach anything to surfaces in an attempt to hang themselves. Most of the rooms had beds built with a wooden frame with no springs or attachable surfaces. However, Patient #15's room, 504, contained a hospital bed with a metal frame and springs. It was a manual bed which could be raised or lowered. In addition, the head and foot of the bed could manually be raised or lowered. A pair of shoes was present with the shoelaces removed, but clothing could easily be tied to the bed in an attempt to harm himself.

During the tour, the Unit Director identified 5 rooms that contained hospital beds. These rooms included 501, 503, 504, 505, and 506. He said no policy was in place regarding the use of hospital beds or medical equipment on the Mental Health Unit. He said no assessment of patients for suitability and risk of the use of hospital beds was conducted prior to placing patients in rooms with hospital beds.

The hospital placed Patient #15 in a room with a hospital bed which increased his risk of self harm.

2. Patient #7's medical record documented a 52 year old female who was admitted to the hospital on 1/27/12 with diagnoses of mood disorder and personality disorder. She was currently a patient as of 2/08/12. Her medical record did not contain an assessment of the risk for using a hospital bed.

Her room, 503, was observed with the Unit Director on 2/07/12 beginning at 10:45 AM. Her room contained a hospital bed. He confirmed an assessment for suitability and risk of the use of hospital beds had not been conducted for Patient #7.

The hospital had not ensured patients on the Mental Health Unit were treated in a safe environment.

Based on observation and interview it was determined the facility failed to ensure patient's medical information remained confidential. The potential for patients/family members to view other patients' information was witnessed in 2 of 4 observations where patient information was accessed from the electronic medical record in patients' rooms. Failure to ensure patient confidentiality had the potential to result in disclosure of private information to unauthorized individuals. Findings include:

1. On 2/07/12 at 8:30 AM, an RN in the ICU was observed during a medication administration. She explained the medication administration record was electronic and demonstrated how to document the administration of a medication. She began by selecting the patient from her list of two patients being cared for on 2/07/12. For several seconds the full names of both patients were available to view on the screen. The family member of one of the listed patients was seated in a position that allowed for visualization of the computer screen. It was possible for this individual to read information related to the RN's other patient.

The ICU RN observed during a medication administration on 2/07/12 was interviewed on 2/09/12 at 1:30 PM. She confirmed that a screen containing the full names of her patients was accessed and potentially available to be viewed by unauthorized individuals. She stated she tried to remember to turn the screen away from patients/family members to limit inappropriate visualization of patient information.

2. On 2/08/12 at 9:10 AM, an RN was observed to complete a preoperative evaluation of a patient in the Outpatient Surgery Department. The patient was lying in the hospital bed and the patient's spouse was seated in the room. The RN was observed to select the patient's name from a list of full names of patients scheduled for surgery on 2/08/12. The names were available to be viewed from the spouse's position.

On 2/08/12 at 2:10 PM, the Charge Nurse for the Outpatient Surgery Department was interviewed. She confirmed that at times during the admission and discharge process screens with a list of patient's full names were accessed. She stated staff attempted to move through these screens quickly to limit the possibility of unauthorized visualization of personal patient information.

An RN who worked in the PCU was interviewed on 2/09/12 at 2:00 PM. She demonstrated the process of accessing medication administration screens in the computer. She stated a "status board" was compiled by each RN which contained only the patient's cared for by that RN. She stated the "status board" was accessed when the RN entered documentation into the computer. She accessed her "status board." The list of patients included the patient's first and last name, diagnosis, age, diet, physician, and code status. She stated she was aware this information was potentially available for view when the "status board" was accessed in patients' rooms. She stated she attempted to position the screen in such a way as to not be viewed by unauthorized individuals.

The facility failed to ensure that personal information was not available to unauthorized individuals.

Based on record review, policy review, and staff interview, it was determined the hospital failed to ensure restraint orders were complete and in accordance with physician orders for 2 of 5 restrained patients (#16 and #27) whose records were reviewed. This resulted in patients being restrained without clear authorization or direction as to type of restraints. Findings include:

A hospital policy, "RESTRAINTS," dated 3/01/11, stated "restraints require an order by the physician responsible for the patient." Restraint orders were incomplete or missing as follows:

1. Patient #27 was a 72 year old male who was admitted to the hospital on 12/11/11 after a motor vehicle accident. Nursing documentation indicated Patient #27 had bilateral soft wrist restraints 12/12/11 through 12/18/11.

The restraint orders on 12/15/11, 12/16/11, and 12/17/11 did not state the type of restraints. There was no order for restraints present in Patient #27's record for 12/18/11.

The Director of Nursing Operations and the Vice President of Patient Care Services were interviewed together on 2/08/12 at 3:45 PM. After review of Patient #27's record, the Director of Nursing Operations confirmed the restraint order for 12/18/11 was missing from the record. The Vice President for Patient Care Services confirmed the type of restraint was not stated on the physician orders for 12/15/11, 12/16/11, and 12/17/11. She explained there was a flaw in the form that led to the incomplete orders.

The use of restraints was not in accordance with complete physician orders.

2. Patient #16 was a 61 year old male who was admitted to the hospital on 1/07/12 for care related to confusion and a fall. Physician restraint orders, dated 1/09/12, 1/10/12, 1/11/12, and 1/16/12, did not specify the type of restraints. Nursing documentation indicated Patient #16 had soft restraints on both wrists during the dates referenced above.

The Vice President of Patient Care Services was interviewed on 2/08/12 at 2:35 PM. She reviewed Patient #16's record and confirmed the restraint orders did not include the type of restraints, including the initial order on 1/09/12.

Restraint orders were incomplete, not specifying the type of restraints.

Based on record review and staff interview, it was determined the hospital failed to ensure nursing staff developed or kept current nursing care plans for 7 of 31 patients (#5, #7, #9, #10, #11, #31 and #38) whose care plans were reviewed. This had the potential to result in unmet patient needs. Findings include:

1. Patient #10 was an 88 year old male who was admitted to the Medical/Oncology Unit of the hospital on 2/05/12 for care primarily related to chronic obstructive pulmonary disease, pneumonia, and diabetes.

The initial RN assessment, dated 2/05/12 at 10:06 AM, included the following information:
Patient #10 reported being "basically blind" and being incontinent of urine and using pads for his incontinence. The nursing care plan, dated 2/06/12 did not include nursing diagnoses or goals to address either issue.

A staff RN from the Medical/Oncology Unit was interviewed on 2/07/12 at 3:20 PM. He reviewed Patient #10's record and stated the care plan should have included a diagnosis to address the urinary incontinence. He stated he did not realize Patient #10 was blind and it should have been addressed in the care plan.

Patient #10's nursing care plan was incomplete.

2. Patient #11 was a 62 year old male who was admitted to the hospital on 2/06/12 for a course of chemotherapy. The initial RN assessment, dated 2/06/12 at 5:44 PM, documented "Diarrhea: Y [yes]" and "Constipation: N [no]." It also described Patient #11 as "calm" and "relaxed."

The nursing care plan, dated 2/05/12 (the date may have been a documentation error since the admission date was 2/06/12), included a nursing diagnoses of "Bowel: Constipation" and "Anxiety/Fear." The nursing diagnoses did not say "Potential for Constipation" or "Potential for Anxiety/Fear" or address diarrhea.

The Director of the Medical/Surgical Department was interviewed on 2/07/12 at 10:00 AM. She explained the nursing diagnosis of "Bowel: Constipation" automatically populated for every patient admitted to the Medical - Oncology unit, where Patient #11 was receiving care. She also stated that the nursing diagnosis of "Anxiety/Fear" automatically populated for patients on chemotherapy because of the potential for anxiety and fear.

A staff RN on the Medical/Oncology Unit was interviewed on 2/07/12 at 10:20 AM. She stated it was possible for nursing staff to change some of the information after it auto-populated. They could delete a nursing diagnosis by marking it as "complete" and then enter another nursing diagnosis that was determined to be more relevant or accurate.

Patient #11's nursing care plan did not accurately reflect his nursing assessment data.

3. Patient #38 was a 64 year old female who was admitted to the hospital on 12/23/11 after a motor vehicle accident. A nursing care plan, dated 12/25/11 included restraints as an intervention. Physician orders for a left soft wrist restraint, dated 12/24/11, 12/25/11, 12/26/11, and 12/27/11, were present in Patient #38's record. There were gaps in nursing documentation of restraints between 7:00 PM and 8:00 AM the following morning on 12/26/11, 12/27/11, and 12/28/11.

On 2/09/12 at 8:15 AM, the staff RN who provided care to Patient #38 on the night shifts for 12/26/11, 12/27/11, and 12/28/11 was interviewed. He stated Patient #38's restraints had been removed on 12/25/11 at 6:00 PM by another nurse. He explained at the time restraints were removed, the care plan was changed to "prn [as needed]" in the computer instead of being "completed" as it should have been. He stated that when a restraint care plan changes to "prn," then the cues disappear that remind nurses to monitor restrained patients hourly. When restraints were restarted on 12/26/11 at 8:00 AM, the care plan was not updated to reflect the active use of restraints. He stated he thought the lack of appropriate updating of the care plan may have contributed to him not charting on restraints during his shifts on 12/26/11, 12/27/11, and 12/28/11. He stated he could not remember whether Patient #38 was in restraints during those shifts and he didn't remember whether he removed the restraints. He acknowledged he did not document either scenario and it would have been one or the other.

Patient #38's nursing care plan was not updated to reflect the change in restraint status.

4. Patient #5 was a 55 year old male who was admitted to the hospital on 2/04/12 for fever and chills. The nursing care plan, dated 2/05/12, included a nursing diagnosis of "Bowel, Constipation." RN documentation, dated 2/06/12 at 11:50 AM stated Patient #5 was "having loose stools" and refused lactulose and stool softener (treatments for constipation). The nursing care plan was not updated to reflect the change in bowel status from constipation to diarrhea.

The Director of Nursing Operations was interviewed on 2/08/12 at 11:00 AM. She explained a group of professionals in the hospital determined pre-set nursing diagnoses as they related to medical diagnoses. The Meditech computer system was programmed to automatically bring up nursing diagnoses linked to medical diagnoses. She stated, for example, "Bowel: Constipation," was a pre-set nursing diagnoses for patients who were admitted to the Medical-Oncology Unit because most patients were prescribed pain medication that could have a constipating effect. When asked if nursing staff could change the nursing diagnosis to: "Potential for Constipation," to more accurately reflect actual health status when the patient was not constipated, she stated the professional group made a decision to leave out the words "Potential for" because the additional words took up too many spaces and Meditech was limited. When asked if nursing staff could delete the pre-selected diagnoses and enter more individualized diagnoses, such as delete "Bowel: Constipation" and enter "Bowel: Diarrhea," she stated that was an option.

Patient #5's care plan did not accurately reflect the findings of his nursing assessment.

5. Patient #9 was an 80 year old female who was admitted to the Medical/Oncology Unit of the hospital on 2/03/12 for care primarily related to pneumonia and a urinary tract infection. The initial RN assessment, dated 2/03/12 at 10:10 AM, stated Patient #9 had normal bowel sounds and denied having constipation or diarrhea.

A nursing care plan, dated 2/06/12, included a nursing diagnosis of "Bowel: Constipation" and a corresponding goal for Patient #9's bowel pattern to "return to acceptable normal level." There was no evidence Patient #9 was constipated.

A staff RN from the Medical/Oncology Unit was interviewed on 2/07/12 at 3:05 PM. He explained that nurses could not select "Potential for Constipation" in their computer system. He acknowledged that would have been more accurate.

Patient #9's care plan did not accurately reflect the findings of his nursing assessment.

6. Patient #31 was a 21 year old female who was admitted to the hospital on 2/07/12, in labor with her second baby. Patient #31's record included a social worker note dated 1/23/11 which stated she had adopted out her first baby, had financial difficulties, needed a car seat, and suffered from depression. The note further stated Patient #31 was physically abused by the father of her baby and had recently left him to live with her parents. Patient #31's History and Physical, dated 2/07/12 at 10:05 PM, stated she had a significant medical history for a blood clot in her brain that developed three weeks after her first baby was delivered. The physician stated in her note she had started Patient #31 on anticoagulant therapy before the delivery, and the therapy would continue through this hospitalization and into her post partum period.

A nursing care plan, dated 2/08/12 for Patient #31 did not address the history of domestic violence, financial concerns, the adoption of her first baby, depression, or anticoagulant therapy.

In an interview on 2/09/12 at 1:55 PM, the Patient Care Coordinator reviewed Patient #31's record and confirmed no care plans had been developed to address the history of domestic violence, financial concerns, coping related to adopting out her first baby, depression and anticoagulant therapy. She stated the plan of care for Patient #31 was inadequate and should have been more specific for the patient.

The nursing care plan was not updated to reflect the unique and individual physical and psychological needs of Patient #31.



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7. Patient #7's medical record documented a 52 year old female who was admitted to the hospital on 1/27/12 with diagnoses of mood disorder and personality disorder. She was currently a patient as of 2/08/12. Her "IP PSYCH INTAKE," dated 1/28/12, stated she had a history of methamphetamine and cocaine use and had been hospitalized in 2006 for physical symptoms related to their use. It stated Patient #7 had a long history of methamphetamine dependence and said she was currently on opiates (oral morphine) for a back injury. The intake also stated Patient #7 had been hospitalized on the Mental Health Unit from 1/20/12 to 1/25/12. It said following discharge, she was arrested in a nearby town, on 1/26/12, for driving under the influence. She was readmitted to the Mental Health Unit on 1/27/12.

Patient #7's "Treatment Plan Report," dated 1/30/12, listed amphetamine dependence and "Sedative, Hypnotic, or Anxiolitic Dependence" as diagnoses. (Anxiolitics are drugs used to reduce anxiety.) The treatment plan, which included the nursing care plan, listed 1 problem-"Altered mood -depressed with psychotic features ..." The plan did not address addiction or pain.

The Nurse Manager for the Mental Health Unit was interviewed on 2/07/12 beginning at 9:00 AM. She confirmed Patient #7's treatment plan did not address addiction or pain.

Patient #7's nursing care plan was not complete.

Based on observation, review of kitchen logs and hospital policies, and staff interviews, it was determined the hospital failed to ensure 1 of 1 kitchen evaluated for environmental issues was maintained in such a manner as to ensure the safety and well-being of patients. Failure to maintain a clean food storage and preparation environment had the potential to negatively impact the well-being of all patients receiving care in the hospital. Findings include:

1. During a tour of the hospital's kitchen, on 2/07/12 beginning at 2:00 PM, with the Dietary Manager and the Dietitian, the following concerns were noted:

a. In the walk-in freezer the following food was observed to be undated and/or expired:

i. An opened package of sausage crumbles, label dated 4/01/11. There was no clarification on the package if the date was the open date or expiration date.

ii. An opened bag of sliced pepperoni, labeled with an expiration date of 11/11.

iii. An opened bag of zucchini, label dated 2/27 but no year was included on the label.

iv. An opened package of pie shells, no open date or expiration date.

v. An opened box with pieces of chocolate cake, expiration date of 1/30/12.

b. In the walk in refrigerator the following food was observed to be undated or expired:

i. A package of beef tips, opened and undated.

ii. An unopened package of flour tortillas, dated 11/15/11.

iii. A container of custard, undated.

A policy titled "PRODUCTION, PURCHASING, STORAGE," dated 5/95 and revised 1/12, addressed food and supply storage procedures. The policy stated foods were to be dated when opened, and food would be discarded past the use-by or expiration date. The policy did not define time frame from package opening to discard date.

The Dietary Manager, who was present during the tour, discarded the foods upon discovery of missing or expired labels.

c. The triple sink for pot and utensil sanitizing was observed to be in use by a kitchen worker cleaning utensils. Upon surveyor request, the kitchen worker tested the sanitizer side of the triple sink and the result was greater than 400 ppm (parts per million). The Dietary Manager stated the results should have been 200 ppm, and the water was too warm and instructed the worker to change the water and retest for appropriate level of sanitizer.

d. The pot and utensil washing sinks had a form titled "POT SINK TEMP & SANITIZER LOG" posted which indicated the wash water, rinse water, and sanitizer was to be refilled and quality checked each meal time. The log had columns to include the quat (sanitizer) reading, water temperature of the wash and rinse sinks, and the temperature of the sanitizer sink. The log for February 2012 was missing entries for the following dates:

-2/01/12 breakfast and lunch meals
-2/02/12 breakfast, lunch and dinner meals
-2/03/12 dinner meal
-2/06/12 breakfast and dinner meals
-2/07/12 breakfast meal.

During the tour on 2/07/12 the Dietary Manager confirmed the log was not completed and stated the system of measuring the sanitizer level was a new practice for their kitchen staff.

e. The Dietary Manager stated the kitchen staff cleaned work areas with a sanitizing solution that was in red buckets throughout the kitchen. He tested a bucket in the dirty dish handler area. The test indicated the sanitizing solution was less than 100 ppm. The Dietary Manager stated the worker had left for the day, and should have discarded the sanitizing solution before leaving.

A policy titled "SANITATION AND INFECTION CONTROL," dated 5/95, and reviewed 3/11, addressed cleaning of work areas and the use of sanitizer solutions. The policy stated the sanitizer in red buckets was to be replaced every 2-4 hours. The policy did not define the parameters for acceptable levels of sanitizer concentration.

According to the FDA (Food and Drug Administration) 2009 food safety standards, the sanitizing solution must be 200 ppm. If the concentration is too weak, it can result in an inadequate reduction of harmful microorganisms, and too much may be toxic. In addition, the water temperature for chemical sanitizers work best in water that is between 55 and 120 degrees.

f. The floors behind the grills and oven unit and behind the vending machines contained dust and food items. The debris was verified by the Dietary Manager during the tour. He stated housekeeping was responsible for cleaning the department after the kitchen was closed. The nightly cleaning included scrubbing and moping the floors and behind the equipment.

The physical environment of the dietary department was not adequately maintained to ensure the safety and well-being of patients.

Based on staff interview, observation, and review of facility policy and procedures, it was determined the hospital failed to ensure an infection control surveillance program for Laboratory, Radiology and Nutritional Services was developed. The failure to develop a program to monitor these departments had the potential to expose hospital patients and staff to infection. Findings include:

1. During a tour of the Laboratory with the Chief Scientist on 2/07/12 beginning at 11:00 AM, the following infection control concerns were noted:

a. The room in which biological specimens were received and logged in had one sink that was designated as a "dirty" sink with a red sign on the wall above the sink. A "dirty" sink is a sink which is used for biohazardous chemicals or specimens, and cannot be used for hand washing. However, a paper towel dispenser, soap dispenser, and three bottles of hand moisturizer (two of which were commercial hand lotions without antibacterial properties) were noted on back portion of the sink beside the faucet. The presence of the above items indicated the sink was used as a hand washing area.

The Chief Scientist was present during the tour and confirmed the sink was designated as a dirty sink and immediately removed the items from the sink area. She stated the sink was not to be used as a hand washing area, and confirmed there was no clean sink in the specimen receiving room.

The main lab area had multiple sinks, designated as "dirty" sinks with red signs posted above them. The Chief Scientist pointed out the one sink in the entire laboratory facility that was designated as a "clean" sink for staff hand washing. The identified sink was close to the entrance and exit and traffic flow area for the staff. The Chief Scientist stated the entire staff would use the sink at the beginning of the shift, when going to breaks and lunch, and at the end of the shift.

The laboratory lacked sufficient access to designated "clean" sinks for staff to perform appropriate hand hygiene.

b. The process of obtaining a blood specimen by venipuncture was observed four times. Blood draws were not completed in a clean manner as follows:

On 2/07/12 at 10:00 AM, a phlebotomist was observed to attempt a blood draw on a patient in the ICU. She donned gloves and wiped the area on the patient's arm down with an alcohol pad. She then palpated the area with her gloved finger prior to inserting the needle, but was unable to withdraw any blood. At 10:15 AM, a second phlebotomist arrived to complete the blood draw. She was observed to don gloves, wipe an area of the patient's arm with alcohol and then palpate with her gloved finger over the cleaned area prior to inserting the needle.

On 2/08/12 at 8:50 AM, during a tour of the laboratory, a third phlebotomist was noted to cleanse the site on a patient's arm then palpate the vein just prior to venipuncture without re-cleansing the site, thus contaminating the site.

A Clinical and Laboratory Standards Institute publication, dated 5/27/11, states after cleansing the venipuncture site, if the phlebotomist needs to palpate the vein, the site will need to be decontaminated again.

During an interview directly after the tour, the Laboratory General Manager stated the phlebotomy staff was directly observed for technique as part of the orientation process. He stated the staff would then be permitted to draw patient specimens on the hospital units and in the outpatient areas. The General Manager stated gloves were used as protection of the phlebotomist, and that he did not think the palpation of the site was contaminating the specimen.

c. During observation of venipuncture by phlebotomy staff on 2/07/12 at 8:50 AM and at 9:30 AM in the laboratory outpatient area, it was noted staff wore gloves during data entry on the computer, and when using writing utensils after obtaining the specimen. The computer and writing utensils were not cleaned after the patient was dismissed from the room. One phlebotomist was noted to have artificial nails. The Chief Scientist was unaware of the staff with artificial nails, and stated there was no policy regarding staff with artificial nails.

A hospital policy titled "INFECTION CONTROL Artificial Nails," dated 6/13/02, stated "Individuals who are employed and assigned to roles which include delivery of direct patient care are not allowed to wear artificial fingernails or long natural fingernails."

The laboratory did not monitor venipuncture practice, cleansing of work areas, and hand hygiene/artificial nails.

2. During a tour of the hospital's kitchen with the Dietary Manager and Dietician, on 2/07/12 beginning at 2:00 PM, the following infection control concerns were noted in the kitchen:

a. The triple sink for pot and utensil sanitizing was observed to be in use by a kitchen worker cleaning utensils. Upon surveyor request, the kitchen worker tested the sanitizer side of the triple sink and the result was greater than 400 ppm (parts per million). The Dietary Manager stated the results should have been 200 ppm, and the water was too warm and instructed the worker to change the water and retest for appropriate level of sanitizer.

b. The pot and utensil washing sinks had a form titled "POT SINK TEMP & SANITIZER LOG" posted which indicated the wash water, rinse water, and sanitizer was to be refilled and quality checked each meal time. The log had columns to include the quat (sanitizer) reading, water temperature of the wash and rinse sinks and the temperature of the sanitizer sink. The log for February 2012 was missing entries for the following dates:

-2/01/12 breakfast and lunch meals
-2/02/12 breakfast, lunch and dinner meals
-2/03/12 dinner meal
-2/06/12 breakfast and dinner meals
-2/07/12 breakfast meal.

During the tour on 2/07/12 the Dietary Manager confirmed the log was not completed and stated the system of measuring the sanitizer level was a new practice for their kitchen staff.

c. The Dietary Manager stated the kitchen staff cleaned work areas with a sanitizing solution that was in red buckets throughout the kitchen. He tested a bucket in the dirty dish handler area. The test indicated the sanitizing solution was less than 100 ppm. The Dietary Manager stated the worker had left for the day, and should have discarded the sanitizing solution before leaving.

A policy titled "SANITATION AND INFECTION CONTROL," dated 5/95, and reviewed 3/11, addressed cleaning of work areas and the use of sanitizer solutions. The policy stated the sanitizer in red buckets was to be replaced every 2-4 hours. The policy did not define the parameters for acceptable levels of sanitizer concentration.

According to the FDA (Food and Drug Administration) 2009 food safety standards, the sanitizing solution must be 200 ppm. If the concentration is too weak, it can result in an inadequate reduction of harmful microorganisms, and too much may be toxic. In addition, the water temperature for chemical sanitizers work best in water that is between 55 and 120 degrees.

d. Food and debris was noted on the floor behind the grills, oven unit, and vending machines. The debris was verified by the Dietary Manager during the tour. He stated housekeeping was responsible for cleaning the department after the kitchen was closed. The nightly cleaning included scrubbing and mopping the floors and behind the equipment.

Infection control practices in the dietary area of the hospital were not effectively monitored.

3. During a tour of the Diagnostic Imaging Department with the Manager and the Chief Radiological Technician on 2/07/12 beginning at 9:45 AM, the following infection control concerns were noted:

a. The Chief Radiological Technician stated the lead aprons and other non-critical patient care equipment were cleaned on a weekly and "as needed" basis. She was not able to produce a schedule for the equipment cleaning. The Chief Radiological Technician described the cleaning solution used to clean the equipment. She stated the concentrated cleaning solution was diluted with tap water, and then dispensed into the refillable bottles. The Chief Radiological Technician provided a bottle of the diluted cleaning solution. The label was faded, and it was not clear when the mixture had been replenished or when it expired.

The Director of Nursing Operations was present during the tour of Diagnostic Imaging on 2/07/12 beginning at 9:45 AM. After the tour she stated she had placed a call to the manufacturer of the product. She stated the representative she spoke with had instructed her that sterile or distilled water was to be used for dilution, and the expiration date of the cleaning solution was seven days after dilution. The representative also told the Director of Nursing Operations the cleaning solution was to be used for hard surfaces only, therefore the lead aprons would require a different cleaning agent.

The CDC "Guideline for Disinfection and Sterilization in Healthcare Facilities," dated 2008, describes noncritical items as patient items that come in contact with intact skin. Examples of noncritical patient-care items are blood pressure cuffs, lead aprons, and computers. The article stated the noncritical reusable items should be cleaned after each use with a low level disinfectant.

Patient care equipment in the diagnostic imaging department was not sufficiently disinfected.

Based on record review and staff interview, it was determined the hospital failed to ensure nursing staff developed or kept current nursing care plans for 7 of 31 patients (#5, #7, #9, #10, #11, #31 and #38) whose care plans were reviewed. This had the potential to result in unmet patient needs. Findings include:

1. Patient #10 was an 88 year old male who was admitted to the Medical/Oncology Unit of the hospital on 2/05/12 for care primarily related to chronic obstructive pulmonary disease, pneumonia, and diabetes.

The initial RN assessment, dated 2/05/12 at 10:06 AM, included the following information:
Patient #10 reported being "basically blind" and being incontinent of urine and using pads for his incontinence. The nursing care plan, dated 2/06/12 did not include nursing diagnoses or goals to address either issue.

A staff RN from the Medical/Oncology Unit was interviewed on 2/07/12 at 3:20 PM. He reviewed Patient #10's record and stated the care plan should have included a diagnosis to address the urinary incontinence. He stated he did not realize Patient #10 was blind and it should have been addressed in the care plan.

Patient #10's nursing care plan was incomplete.

2. Patient #11 was a 62 year old male who was admitted to the hospital on 2/06/12 for a course of chemotherapy. The initial RN assessment, dated 2/06/12 at 5:44 PM, documented "Diarrhea: Y [yes]" and "Constipation: N [no]." It also described Patient #11 as "calm" and "relaxed."

The nursing care plan, dated 2/05/12 (the date may have been a documentation error since the admission date was 2/06/12), included a nursing diagnoses of "Bowel: Constipation" and "Anxiety/Fear." The nursing diagnoses did not say "Potential for Constipation" or "Potential for Anxiety/Fear" or address diarrhea.

The Director of the Medical/Surgical Department was interviewed on 2/07/12 at 10:00 AM. She explained the nursing diagnosis of "Bowel: Constipation" automatically populated for every patient admitted to the Medical - Oncology unit, where Patient #11 was receiving care. She also stated that the nursing diagnosis of "Anxiety/Fear" automatically populated for patients on chemotherapy because of the potential for anxiety and fear.

A staff RN on the Medical/Oncology Unit was interviewed on 2/07/12 at 10:20 AM. She stated it was possible for nursing staff to change some of the information after it auto-populated. They could delete a nursing diagnosis by marking it as "complete" and then enter another nursing diagnosis that was determined to be more relevant or accurate.

Patient #11's nursing care plan did not accurately reflect his nursing assessment data.

3. Patient #38 was a 64 year old female who was admitted to the hospital on 12/23/11 after a motor vehicle accident. A nursing care plan, dated 12/25/11 included restraints as an intervention. Physician orders for a left soft wrist restraint, dated 12/24/11, 12/25/11, 12/26/11, and 12/27/11, were present in Patient #38's record. There were gaps in nursing documentation of restraints between 7:00 PM and 8:00 AM the following morning on 12/26/11, 12/27/11, and 12/28/11.

On 2/09/12 at 8:15 AM, the staff RN who provided care to Patient #38 on the night shifts for 12/26/11, 12/27/11, and 12/28/11 was interviewed. He stated Patient #38's restraints had been removed on 12/25/11 at 6:00 PM by another nurse. He explained at the time restraints were removed, the care plan was changed to "prn [as needed]" in the computer instead of being "completed" as it should have been. He stated that when a restraint care plan changes to "prn," then the cues disappear that remind nurses to monitor restrained patients hourly. When restraints were restarted on 12/26/11 at 8:00 AM, the care plan was not updated to reflect the active use of restraints. He stated he thought the lack of appropriate updating of the care plan may have contributed to him not charting on restraints during his shifts on 12/26/11, 12/27/11, and 12/28/11. He stated he could not remember whether Patient #38 was in restraints during those shifts and he didn't remember whether he removed the restraints. He acknowledged he did not document either scenario and it would have been one or the other.

Patient #38's nursing care plan was not updated to reflect the change in restraint status.

4. Patient #5 was a 55 year old male who was admitted to the hospital on 2/04/12 for fever and chills. The nursing care plan, dated 2/05/12, included a nursing diagnosis of "Bowel, Constipation." RN documentation, dated 2/06/12 at 11:50 AM stated Patient #5 was "having loose stools" and refused lactulose and stool softener (treatments for constipation). The nursing care plan was not updated to reflect the change in bowel status from constipation to diarrhea.

The Director of Nursing Operations was interviewed on 2/08/12 at 11:00 AM. She explained a group of professionals in the hospital determined pre-set nursing diagnoses as they related to medical diagnoses. The Meditech computer system was programmed to automatically bring up nursing diagnoses linked to medical diagnoses. She stated, for example, "Bowel: Constipation," was a pre-set nursing diagnoses for patients who were admitted to the Medical-Oncology Unit because most patients were prescribed pain medication that could have a constipating effect. When asked if nursing staff could change the nursing diagnosis to: "Potential for Constipation," to more accurately reflect actual health status when the patient was not constipated, she stated the professional group made a decision to leave out the words "Potential for" because the additional words took up too many spaces and Meditech was limited. When asked if nursing staff could delete the pre-selected diagnoses and enter more individualized diagnoses, such as delete "Bowel: Constipation" and enter "Bowel: Diarrhea," she stated that was an option.

Patient #5's care plan did not accurately reflect the findings of his nursing assessment.

5. Patient #9 was an 80 year old female who was admitted to the Medical/Oncology Unit of the hospital on 2/03/12 for care primarily related to pneumonia and a urinary tract infection. The initial RN assessment, dated 2/03/12 at 10:10 AM, stated Patient #9 had normal bowel sounds and denied having constipation or diarrhea.

A nursing care plan, dated 2/06/12, included a nursing diagnosis of "Bowel: Constipation" and a corresponding goal for Patient #9's bowel pattern to "return to acceptable normal level." There was no evidence Patient #9 was constipated.

A staff RN from the Medical/Oncology Unit was interviewed on 2/07/12 at 3:05 PM. He explained that nurses could not select "Potential for Constipation" in their computer system. He acknowledged that would have been more accurate.

Patient #9's care plan did not accurately reflect the findings of his nursing assessment.

6. Patient #31 was a 21 year old female who was admitted to the hospital on 2/07/12, in labor with her second baby. Patient #31's record included a social worker note dated 1/23/11 which stated she had adopted out her first baby, had financial difficulties, needed a car seat, and suffered from depression. The note further stated Patient #31 was physically abused by the father of her baby and had recently left him to live with her parents. Patient #31's History and Physical, dated 2/07/12 at 10:05 PM, stated she had a significant medical history for a blood clot in her brain that developed three weeks after her first baby was delivered. The physician stated in her note she had started Patient #31 on anticoagulant therapy before the delivery, and the therapy would continue through this hospitalization and into her post partum period.

A nursing care plan, dated 2/08/12 for Patient #31 did not address the history of domestic violence, financial concerns, the adoption of her first baby, depression, or anticoagulant therapy.

In an interview on 2/09/12 at 1:55 PM, the Patient Care Coordinator reviewed Patient #31's record and confirmed no care plans had been developed to address the history of domestic violence, financial concerns, coping related to adopti

Based on staff interview, observation, and review of facility policy and procedures, it was determined the hospital failed to ensure an infection control surveillance program for Laboratory, Radiology and Nutritional Services was developed. The failure to develop a program to monitor these departments had the potential to expose hospital patients and staff to infection. Findings include:

1. During a tour of the Laboratory with the Chief Scientist on 2/07/12 beginning at 11:00 AM, the following infection control concerns were noted:

a. The room in which biological specimens were received and logged in had one sink that was designated as a "dirty" sink with a red sign on the wall above the sink. A "dirty" sink is a sink which is used for biohazardous chemicals or specimens, and cannot be used for hand washing. However, a paper towel dispenser, soap dispenser, and three bottles of hand moisturizer (two of which were commercial hand lotions without antibacterial properties) were noted on back portion of the sink beside the faucet. The presence of the above items indicated the sink was used as a hand washing area.

The Chief Scientist was present during the tour and confirmed the sink was designated as a dirty sink and immediately removed the items from the sink area. She stated the sink was not to be used as a hand washing area, and confirmed there was no clean sink in the specimen receiving room.

The main lab area had multiple sinks, designated as "dirty" sinks with red signs posted above them. The Chief Scientist pointed out the one sink in the entire laboratory facility that was designated as a "clean" sink for staff hand washing. The identified sink was close to the entrance and exit and traffic flow area for the staff. The Chief Scientist stated the entire staff would use the sink at the beginning of the shift, when going to breaks and lunch, and at the end of the shift.

The laboratory lacked sufficient access to designated "clean" sinks for staff to perform appropriate hand hygiene.

b. The process of obtaining a blood specimen by venipuncture was observed four times. Blood draws were not completed in a clean manner as follows:

On 2/07/12 at 10:00 AM, a phlebotomist was observed to attempt a blood draw on a patient in the ICU. She donned gloves and wiped the area on the patient's arm down with an alcohol pad. She then palpated the area with her gloved finger prior to inserting the needle, but was unable to withdraw any blood. At 10:15 AM, a second phlebotomist arrived to complete the blood draw. She was observed to don gloves, wipe an area of the patient's arm with alcohol and then palpate with her gloved finger over the cleaned area prior to inserting the needle.

On 2/08/12 at 8:50 AM, during a tour of the laboratory, a third phlebotomist was noted to cleanse the site on a patient's arm then palpate the vein just prior to venipuncture without re-cleansing the site, thus contaminating the site.

A Clinical and Laboratory Standards Institute publication, dated 5/27/11, states after cleansing the venipuncture site, if the phlebotomist needs to palpate the vein, the site will need to be decontaminated again.

During an interview directly after the tour, the Laboratory General Manager stated the phlebotomy staff was directly observed for technique as part of the orientation process. He stated the staff would then be permitted to draw patient specimens on the hospital units and in the outpatient areas. The General Manager stated gloves were used as protection of the phlebotomist, and that he did not think the palpation of the site was contaminating the specimen.

c. During observation of venipuncture by phlebotomy staff on 2/07/12 at 8:50 AM and at 9:30 AM in the laboratory outpatient area, it was noted staff wore gloves during data entry on the computer, and when using writing utensils after obtaining the specimen. The computer and writing utensils were not cleaned after the patient was dismissed from the room. One phlebotomist was noted to have artificial nails. The Chief Scientist was unaware of the staff with artificial nails, and stated there was no policy regarding staff with artificial nails.

A hospital policy titled "INFECTION CONTROL Artificial Nails," dated 6/13/02, stated "Individuals who are employed and assigned to roles which include delivery of direct patient care are not allowed to wear artificial fingernails or long natural fingernails."

The laboratory did not monitor venipuncture practice, cleansing of work areas, and hand hygiene/artificial nails.

2. During a tour of the hospital's kitchen with the Dietary Manager and Dietician, on 2/07/12 beginning at 2:00 PM, the following infection control concerns were noted in the kitchen:

a. The triple sink for pot and utensil sanitizing was observed to be in use by a kitchen worker cleaning utensils. Upon surveyor request, the kitchen worker tested the sanitizer side of the triple sink and the result was greater than 400 ppm (parts per million). The Dietary Manager stated the results should have been 200 ppm, and the water was too warm and instructed the worker to change the water and retest for appropriate level of sanitizer.

b. The pot and utensil washing sinks had a form titled "POT SINK TEMP & SANITIZER LOG" posted which indicated the wash water, rinse water, and sanitizer was to be refilled and quality checked each meal time. The log had columns to include the quat (sanitizer) reading, water temperature of the wash and rinse sinks and the temperature of the sanitizer sink. The log for February 2012 was missing entries for the following dates:

-2/01/12 breakfast and lunch meals
-2/02/12 breakfast, lunch and dinner meals
-2/03/12 dinner meal
-2/06/12 breakfast and dinner meals
-2/07/12 breakfast meal.

During the tour on 2/07/12 the Dietary Manager confirmed the log was not completed and stated the system of measuring the sanitizer level was a new practice for their kitchen staff.

c. The Dietary Manager stated the kitchen staff cleaned work areas with a sanitizing solution that was in red buckets throughout the kitchen. He tested a bucket in the dirty dish handler area. The test indicated the sanitizing solution was less than 100 ppm. The Dietary Manager stated the worker had left for the day, and should have discarded the sanitizing solution before leaving.

A policy titled "SANITATION AND INFECTION CONTROL," dated 5/95, and reviewed 3/11, addressed cleaning of work areas and the use of sanitizer solutions. The policy stated the sanitizer in red buckets was to be replaced every 2-4 hours. The policy did not define the parameters for acceptable levels of sanitizer concentration.

According to the FDA (Food and Drug Administration) 2009 food safety standards, the sanitizing solution must be 200 ppm. If the concentration is too weak, it can result in an inadequate reduction of harmful microorganisms, and too much may be toxic. In addition, the water temperature for chemical sanitizers work best in water that is between 55 and 120 degrees.

d. Food and debris was noted on the floor behind the grills, oven unit, and vending machines. The debris was verified by the Dietary Manager during the tour. He stated housekeeping was responsible for cleaning the department after the kitchen was closed. The nightly cleaning included scrubbing and mopping the floors and behind the equipment.

Infection control practices in the dietary area of the hospital were not effectively monitored.

3. During a tour of the Diagnostic Imaging Department with the Manager and the Chief Radiological Technician on 2/07/12 beginning at 9:45 AM, the following infection control concerns were noted:

a. The Chief Radiological Technician stated the lead aprons and other non-critical patient care equipment were cleaned on a weekly and "as needed" basis. She was not able to produce a schedule for the equipment cleaning. The Chief Radiological Technician described the cleaning solution used to clean the equipment. She stated the concentrated cleaning solution was diluted with tap water, and then dispensed into the refillable bottles. The Chief Radiolo