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Based on interview and record review, the facility failed to ensure a properly executed informed consent was obtained for one sampled patient (Patient 16 - a confused patient). The nurse failed to ensure the physician had spoken with the family regarding a left heart cardiac catheterization procedure, prior to obtaining a phone consent from the family for the procedure. This placed Patient 16 at risk for having a procedure without an informed consent.

Cardiac catheterization is an invasive medical procedure used to diagnose and treat heart conditions. A long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin,or neck and threaded into the heart. Through the catheter, the physician is able to perform diagnostic tests and treatments.

Findings:

On December 9, 2015, at 2:45 p.m., Registered Nurse (RN) 6 was interviewed. RN 6 stated he was working on December 5, 2015. RN 6 stated RN 7 called him with concerns about whether Patient 16 had a cardiac procedure ordered. RN 7 told him Patient 16 was confused and she did not have an informed consent in the record. RN 6 told her to call the family to get the informed consent. RN 6 stated he assumed Physician 5 had already spoken with the family in order to obtain an informed consent, but did not verify with the physician if he did.

On December 10, 2015, at 8:45 a.m., RN 7 was interviewed. RN 7 stated RN 6 informed her Patient 16 had an order for a left heart catheterization procedure. RN 7 said she told RN 6 there was no informed consent obtained. RN 7 stated RN 6 told her to call the family to get one. RN 7 stated RN 6 told her the physician already talked to the family. RN 7 stated she called Patient 16's cousin (listed on the face sheet as emergency contact) to inform her of the heart catheterization procedure the physician had ordered, and if she would consent to Patient 16 having the procedure. RN 7 stated she did not ask the cousin if the physician had called her to explain the procedure and to explain the risks and benefits of the procedure. RN 7 stated the cousin gave verbal consent for Patient 16 to have the procedure.

The medical record for Patient 16 was reviewed with RN 7. There was no evidence in the medical record that Physician 5 obtained informed consent from Patient 16's family. The informed consent that RN 7 signed based on her conversation with Patient 16's cousin, was not in the record. RN 7 did not know what happened to the informed consent that she signed. RN 7 stated Patient 16 did not have the procedure because it was ordered for the wrong patient.

The policy and procedure titled, "Informed Consent," was reviewed. The policy indicated, "... Specifically, informed consent must be obtained for all procedures performed in the operating room, cardiac catheterization laboratory,... The physician is responsible to engage in an interactive process to provide the patient or an incompetent patient's surrogate with the information that is necessary to allow an informed decision to be made... The physician is responsible for obtaining the informed consent and for documenting this discussion in the medical record...The hospital is responsible to obtain a signed attestation from the patient verifying that the physician has completed the informed consent..."

Based on interview and record review, the facility failed to ensure one patient (Patient 16) was cared for in a safe setting. Patient 16 was mistakenly transported to the Cardiac Catheterization Lab (CCL) for a left heart (cardiac) catheterization procedure that was ordered for another patient. This placed Patient 16 at risk for undergoing an unnecessary and invasive heart procedure.

Cardiac catheterization is an invasive medical procedure used to diagnose and treat heart conditions. A long, thin, flexible tube called a catheter is put into a blood vessel in the arm, groin,or neck and threaded into the heart. Through the catheter, the physician can conducted diagnostic tests and treatments.

Findings:

The record for Patient 16 was reviewed. Patient 16 was admitted to the facility on October 23, 2015. Patient 16, a 70 year old male, was admitted for a dislodged suprapubic catheter (A flexible rubber tube that is placed directly into the bladder, through a surgical incision in the abdomen).

There was an order by Physician 5, dated December 5, 2015, at 10:23 a.m., for a left heart catheterization procedure. The order was entered by the CCL Registered Nurse (RN) 6, and canceled the same day at 11:31 a.m.

A late entry nursing note dated December 7, 2015, by RN 7, indicated on December 5, 2015, at 9:30 a.m., she notified RN 6 that she was unaware of any heart procedure to be done for Patient 16. At that time, RN 7 also requested that RN 6 verify the order with Physician 5 because Patient 16 was not his patient. At 10:30 a.m., RN 6 verified with RN 7 that Patient 16 was "the right patient."

A progress note by Physician 6, dated December 5, 2015, indicated Patient 16 had numerous problems including confusion. The progress note revealed, "To make things worse, he was taken for cardiac catheterization today that was not ordered. He (the patient) became very anxious and upset..."

On December 9, 2015, at 2:45 p.m., RN 6 was interviewed. RN 6 stated he was working on December 5, 2015. RN 6 remembered that he saw Patient 16's name on the board in the procedure exam room. He stated the board included the Patient 16's name, room number, physician name, procedure, and scheduled time. RN 6 stated that when they were ready to start the heart catheterization on Patient 16, he looked in the computer and saw there was no order.

RN 6 further stated he entered the order as a verbal order based on the information written on the board. He did not verify the name with Physician 5 prior to entering the order into the computer. RN 6 stated when RN 7 called him with her concerns about whether Patient 16 had a cardiac procedure ordered, he reassured her that it was the right patient, based on the information written on the board. When RN 7 explained to him there was no consent in the record, he told her to call the family to get the informed consent. RN 6 stated he assumed Physician 5 had already spoken with Patient 16's family.

RN 6 then stated Patient 16 was transported to the CCL, and was placed on the table in one of the procedure rooms. RN 6 stated, when Physician 5 came into the room to start the left heart catheterization procedure, the physician said, "That is not my patient." RN 6 stated the procedure should have been ordered for Patient 35 not Patient 16.

On December 10, 2015, at 9:35 a.m., the CCL Secretary (CCLS) was interviewed. The CCLS stated she had written the procedure in the schedule book as well as on the board for Patient 16's procedure. The CCLS stated Physician 5 called her on December 4, 2015 and requested to add a patient from 3 East, Room 317 A, to the schedule for a left heart catheterization for the morning of December 5, 2015. The CCLS stated Physician 5 did not give a name, only a room number. The CCLS stated she checked the computer to see what patient was in Room 317 A, and added that patient (Patient 16) to the schedule. She further stated the normal process was for the physician to state the patient's name and room number when scheduling a procedure.

The unit census for 3 East, dated December 4, 2015, was reviewed. The census indicated Patient 16 was in Room 2317 A, and Patient 35 was in Room 2317 B.

On December 10, 2015, at 1 p.m., the CCL Manager (CCLM) was interviewed. The CCLM stated when a physician called the unit to put a patient on the schedule, it was not appropriate to give only a room number. The CCLM stated the Secretary taking the call from Physician 5, should have asked for a patient name.

Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met by failing;


1. To ensure a properly executed informed consent was obtained for one sampled patient, (Patient 16-a confused patient) (A131);

2. To ensure one patient, (Patient 16) was cared for in a safe setting, as the patient was mistakenly transported to the Cardiac Catheterization Laboratory (area where invasive cardiac procedures are conducted) for a procedure that was ordered for another patient placing the patient at risk for undergoing an unnecessary procedure (A144);

3. To ensure Patient 1, who was on telemetry monitoring (continuous cardiac monitoring per physician's order) was maintained on telemetry during transportation to a Magnetic Resonance Imaging procedure (a type of x-ray) during the actual procedure, and was accompanied by a Registered Nurse per facility protocols (A395);

4. To ensure the Dialysis for Patient 6 (system where blood is filtered to remove toxins) was provided in a timely manner and post dialysis weights were documented (A395);

5. To ensure a propofol drip order (medication used for sedation) for Patient 21 was clarified with the physician and the medication was titrated to the level of sedation expected per the physician according to the RASS scale (RASS - Richmond Agitation Sedation Scale, a validated and reliable method to assess patients' level of sedation) (A405), and;

6. To ensure for one patient, Patient 30, undergoing a gastric procedure in the outpatient area the rubber stoppers on medication vials were wiped with an alcohol swab prior to administering the medication intravenously (into a vein) (A405, A749).


The cumulative effect of these systemic practices resulted in the failure of the facility to deliver statutorily mandated compliance with the Federal regulations for the Condition of Participation: Nursing Services to ensure the delivery of quality healthcare in a safe environment.

Based on observation, interview and record review, the facility failed;

1. For one patient, Patient 1, who was on telemetry monitoring (continuous cardiac monitoring per physician's order), to ensure the patient was maintained on telemetry during transportation to a Magnetic Resonance Imaging procedure (MRI-a type of x-ray), during the actual procedure, and was accompanied by a Registered Nurse (RN) per facility protocols, and;

2. For one patient, Patient 6, on dialysis, to ensure dialysis (system where blood is filtered to remove toxins) was provided in a timely manner and post dialysis weights were documented.

Together, these failures impacted the overall provision of medical care, and in the case of Patient 1 may have contributed to the patient's death.

Findings:

1. A review of Patient 1's record was conducted. On October 6, 2015, at 2:57 p.m., the paramedic ambulance responded to Patient 1's home where he was found on the floor. At that time the patient's vital sign monitor indicated he was experiencing atrial fibrillation (an irregular heart rhythm). Patient 1 arrived at the facility and was admitted on October 6, 2015, at 3 p.m.

The initial history and physical indicated to admit Patient 1 for telemetry monitoring, serial electrocardiograms (ECG-monitoring of the hearts electrical rhythms) and laboratory tests to monitor cardiac enzymes (an indicator of a heart attack).

On October 6, 2015, at 4:16 p.m., Patient 1 had an ECG conducted. The result indicated, "Abnormal Rhythm ECG."

On October 7, 2015, at 12:24 a.m. and at 6:03 a.m., two ECGS were conducted. The results both indicated, "Abnormal ECG."

A review of Patient 1's cardiac rhythm analysis dated October 7, 2015, at 6 a.m., indicated the patient had an irregular heart rhythm.

A review of the nurses note dated October 7, 2015, at 7:30 p.m., indicated Patient 1 had an irregular atrial cardiac rhythm.

A review of a nurses note dated October 8, 2015, at 1 a.m., five 1/2 hours after the initial ECG was done indicated Patient 1 was taken off telemetry monitoring to be transported for a MRI of the head. Documentation failed to show that the patient's physician was consulted, or an order to disconnect the telemetry monitoring in order to transport the patient for the MRI was documented.

An interview was conducted with the Clinical Manager, (CM) 1 for the telemetry unit on December 8, 2015, at 2 p.m. CM 1 stated Patient 1 did not have a normal ECG when he was taken off of the telemetry monitor to be transported for an MRI. CM 1 further stated the patient (Patient 1) should have been monitored and accompanied by a registered nurse.

An interview was conducted with the Radiology Manager on December 9, 2015, at 8:30 a.m. The Radiology Manager stated if a patient is sent for an MRI without a telemetry monitor and a nurse accompanying the patient the radiology staff would not monitor the patient.

An interview was conducted with the MRI Technologist (MRT) on December 8, 2015, at 6 p.m. The MRT stated Patient 1 did not have an R.N. (Registered Nurse) with him and was not connected to a telemetry monitor when the patient was brought to the MRI area by the transporter staff.

The MRT stated he then moved the MRI table into the hallway and assisted Patient 1 from his bed onto the MRI table and into the MRI area.

The MRT further stated when Patient 1 was initially advanced into the MRI the patient asked to be brought out, and stated he was short of breath. The MRT then pulled the patient out of the MRI, sat the patient up and placed high flow oxygen on him. The MRT further stated after speaking with the patient he agreed to attempt the procedure again, so the MRT advanced him into the MRI for the second time, but again the patient asked to be pulled out. Patient 1 was not undergoing cardiac monitoring at this time.

At that point the MRT stated he told Patient 1 that he wouldn't continue the procedure at that time. The MRT stated he rolled the patient back out into the hall and as he was assisting the patient onto his bed the patient became non responsive. The MRT stated he called the operator and used the overhead system to call a code blue (cardiac arrest), the crisis team responded quickly, began life saving procedures, but Patient 1 died.

A review of the discharge summary indicated Patient 1 was declared dead at 1:52 a.m., on October 8, 2015. The report of the emergency room physician dictated on October 8, 2015, at 2:29 a.m., indicated Patient 1's diagnosis as, "Cardiac arrest."

A review of the facility policy, "Protocol: Transport of Monitored Patients (Last Revised: 8/5/14)," was conducted. The protocol indicated parameters for those telemetry patients who must be escorted by an R.N., and those who do not require escort by an RN during transportation for tests. The protocol indicated those patients who would require escort with an RN, included patients with arrhythmia changes (irregular heartbeat).

An interview was conducted with the Chief of Staff on December 10, 2015, at 2:05 p.m. The Chief of Staff stated if a patient was on telemetry, the patient's physician should be consulted when the patient was to be transported for testing in order to determine if telemetry monitoring should or should not be continued during that time.

2. During a tour of the facility on December 9, 2015, at 9 a.m., Patient 6 was observed in his bed. The patient was alert and oriented and stated he received dialysis at the facility and was planning on receiving a dialysis treatment today before he was discharged home.

A review of Patient 6's record was conducted. Patient 6 was admitted to the facility on November 29, 2015, with a bone infection (osteomyelitis) of the right great toe. The patient had a history of acute kidney failure, and was on dialysis.

A review of the physician orders for Patient 6 was conducted. The dialysis orders were as follows;
"Dialysis Procedure 11/29/15 (9:43 p.m.) Routine." The next order indicated,"Dialysis Procedure 11/30/15 (5:17 p.m.) Routine."

Further record review failed to show that Patient 6 received dialysis on November 29 or 30, 2015, per the physician orders. The first dialysis treatment Patient 6 received was on December 1, 2015, from 12:45 a.m., through 3:45 a.m., 27 hours after the initial physician's order for dialysis was documented.

Patient 6 subsequently received dialysis daily. A review of the dialysis flow sheets failed to show a post dialysis weight on December 4, and 7, 2015.

An interview was conducted the Clinical Manager (CM) 2 on December 9, 2015, at 11 a.m. CM 2 stated a routine dialysis order indicates dialysis had to be done within a six hour range. CM 2 further stated post dialysis weights must be done by the dialysis nurses.

Based on observation, interview and record review, the facility failed to ensure:

1. A propofol drip (medication used for sedation) order for Patient 21, was clarified with the physician and the medication was titrated to the level of sedation (RASS - Richmond Agitation Sedation Scale-a validated and reliable method to assess patients' level of sedation), as ordered by the physician. This failure placed the patient at risk for under or over sedation; and,

2. Nursing staff administering intravenous (directly into a vein) medication, cleaned the rubber seal (diaphragm) before drawing up medication, intended for patient use. This failure placed the patient at risk for infection.

Findings:

1. During an interview with Intensive Care Unit (ICU) Registered Nurse (RN) 1, on December 8, 2015, at 9:55 a.m., the RN stated patients' sedation levels were assessed against the RASS Scale or a Ramsey scale, depending upon the physician's order.

ICU RN 1 demonstrated the documentation of sedation titration and RASS Scores using a patient's electronic medical record. A reference tool, available through each patient's electronic record, indicated the following:

"Richmond Agitation Sedation Scale (RASS)
Short Term Description

+4 - Combative overtly combative, violent, immediate danger to staff;

+3 - Very agitated pulls or removes tube (s) or catheter (s); aggressive;

+2 - Agitated frequent non-purposeful movement, fights ventilator;

+1 - Restless anxious but movements not aggressive vigorous;

0 - Alert and Calm;

-1 - Drowsy not fully alert, but has sustained awakening (eye opening/eye contact) to voice (>10 seconds);

-2 - Light Sedation briefly wakens with eye contact to voice (< 10 seconds);

-3 - Moderate Sedation movement or eye opening to voice (but no eye contact);

-4 - Deep Sedation no response to voice, but movement or eye opening to physical stimulation; and,

-5 - Unarousable No response to voice or physical stimulation."

On December 8, 2015, at 1:25 p.m., Patient 21 was observed in a bed in the facility's Intensive Care Unit (ICU). Patient 21 was orally intubated (tube placed in his throat) and mechanically ventilated (machine breathing for the patient). Patient 21's eyes were closed, he was not moving and he was receiving an intravenous sedation (medication infused directly into the patient's veins). Patient 21's RASS score was documented as -3 (minus three).

Patient 21's record was reviewed. Patient 21 was transferred from another general acute care hospital on December 5, 2015, for a higher level of medical care. According to the "Emergency Reports," Patent 21 was intubated on December 5, 2015, at 3:29 a.m., and placed on a "propofol drip."

A review of the physician's orders dated December 5, 2015, at 3:29 a.m., indicated Patient 21's propofol drip for sedation was to be titrated (changed) every 10 minutes for a RASS score of "3 (3=Very agitated pulls or removes tubes)." (There was no specification in the record indicating the score should be minus three.) There was no documentation in the record that nursing staff contacted the physician to clarify the goal for titrating the medication to the RASS score.

Patient 21's electronic medication record (eMAR) was reviewed. According to the eMAR, Patient 21's propofol dose was adjusted on December 5, 2015, at 4:06 a.m., 5:18 a.m., 5:30 a.m., and 5:49 a.m.

On December 8, 2015, at 1:30 p.m., Patient 21's record was reviewed with the Emergency Department Clinical Manager (ED CM). The ED CM was unable to find Patient 21's RASS score documented in the record on December 5, 2015, at 4:06 a.m., 5:18 a.m., 5:30 a.m., and 5:49 a.m. The ED CM stated there was documentation of adjustments to the propofol, and staff should be changing the dose according to the physician's order. During further review, the CM stated staff documented the dose (i.e. 40 milligram / kilogram, but failed to document the rate. The CM agreed a RASS score of three would not produce the sedation wanted by the physician.

There was no documentation in the record that nursing staff used a RASS score to adjust the dose of the propofol.

The facility policy and procedure titled "Protocol: Titrated Medications (Adults)," with a last revised date of May 29, 2015, was reviewed. The policy indicated its purpose was to ensure safe medication practices for medications which were titrated to patient parameters.

The policy indicated medications ordered for titration require, starting dose, incremental dose, interval time for adjustment, assessment parameters and target or goal endpoint. The policy also indicated if assessment parameters were not specified, then standardized parameters were used. The policy contained standardized parameters for propofol that indicated a Ramsey target goal (not a RASS).



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2. On December 8, 2015, at 1:50 p.m., an observation in the outpatient GI (gastrointestinal) lab was conducted with the Clinical Quality Improvement Specialist (CQIS).

Registered Nurse (RN) 4 was observed drawing up medication from three vials, into three different syringes. Two of the medications were used for sedation during a colonoscopy procedure, and were administered via an intravenous line. As the vials were unopened, the RN removed the dust cover (plastic cap) and immediately inserted a syringe through the diaphragm (rubber stopper) into the vial.

The RN did not wipe the stopper with an alcohol swab, prior to the nurse inserting the needle and aspirating the medication.

During an interview conducted with RN 4, on December 8, 2015, at 2:20 p.m., RN 4 stated she did not wipe the rubber caps off before she drew up the three medications.

During a concurrent interview with the CQIS, the CQIS stated, "Nurses are supposed to wipe the rubber stopper prior to any medication draw and especially with any multi-dose vial."

The facility policy and procedure titled,"Multi-dose Vial & Product Expiration," dated March 24, 2014, indicated, "...Use aseptic technique when entering a multi-dose vial or bag used for injection and/or sterile application. For all injectable products, remove the dust cap and disinfect the rubber seal by scrubbing vigorously with an alcohol swab."

The Institute for Safe Medication Practices (ISMP) indicated safe practice guidelines for intravenous medications included using aseptic technique (free of contaminants). Aseptic technique included disinfection of the medication access diaphragm on a vial prior to accessing the medication or solution.

Based on observation, interview, and record review, the facility failed to maintain a system for controlling sources of infections in accordance with facility policies and procedures when:

1. The laundry room floor had open trash and eight wet dirty towels on the floor laying next to containers of clean mop heads;

2. The laundry room dryer had lint in the vent trap;

3. No hand washing sink and/or available hand sanitizer was found near the hospital's main trash disposal area. Hand hygiene was not available to the environmental services staff as per facility policy;

4. Two dirty beds were observed in the basement hallway;

5. For one Environmental Services Employee (EVS) 1, the annual N95 Respirator Training and Fit test was not completed for four years;

6. For one patient, Patient 30, in the outpatient Gastric Procedure room, alcohol swabs were not used to wipe the rubber stopper before the nurse drew up and administered medications;

7. During an observation of a colonoscopy procedure, a medical staff member was observed without appropriate personal protective equipment, and;

8. After the pre-cleaning of a gastric scope, the technician touched the wall with the dirty scope and the staff did not clean the porous wall between procedures.

Findings:

1. On December 9, 2015, at 11:00 a.m., an observation of the laundry room was conducted.

The laundry room had eight wet dirty cleaning towels on the floor and a full open trash bag lying next to the clean mop head containers lined up against the wall.

During a concurrent interview with the Director of Environmental Services (DES), he stated the facility had a washer and dryer used for laundering mop heads which were used to clean the floors. The laundered mop heads were then placed in clean bins in the same room.

The DES stated the wet towels on the floor were used to clean contaminated surfaces and should have been bagged and sent out to the contracted laundry service. The DES stated the trash should have been discarded in the trash disposal area down the hall.

The facility policy and procedure titled, "General Procedures relevant to Infection Prevention and Precautionary Measures," revised July 2014, indicated, "Standard precautions are a set of basic infection prevention practices intended to prevent transmission of infectious diseases from one person to another...Standard Precautions include:...All linen should be placed in a impervious laundry bag. Linen is decontaminated by a contracted linen processing company...Dressings (trash) without blood or other infectious material may go in the regular trash."


2. During an observation of the dryer lint trap on December 9, 2015 at 11:15 a.m., with the DES present, the dryer trap was observed with a large amount of lint.

During an interview with the DES on December 9, 2015, at 11:10 a.m., the DES stated the laundry room was not kept clean and the lint trap should have been cleaned to prevent risk of fire. The DES stated the facility did not keep a current log to indicate who was responsible for keeping the laundry area clean and the emptying of the lint trap.

The facility procedure titled, "Monthly Laundry Equipment Safety & Maintenance Checklist," revised 2008, indicated,..."Inspect all lint traps for wear and/or improper filtration...Check dryer for build-up (of lint)."

3. An observation of the facility's main trash disposal compacting area was conducted on December 9, 2015, at 11:35 a.m., with the Director of Environmental Services (DES). An Environmental Services Floor Technician (EVSFT) was observed pushing a large gray plastic bin with ungloved hands towards the trash entrance gate. The EVSFT used his hands to enter a key code to open the gate. The EVSFT then used his hands to push a button to unload the trash bin into the automatic trash compactor. The EVSFT then entered the key code again to exit the gated trash compactor area.

During the observation, it was noted there was no hand washing sink available in the immediate area nor was there any hand disinfectant. An observation was made of a dispenser hanger plate (used to hang the hand sanitizer) on the inside and outside of the gate.

An interview was conducted with EVSFT on December 9, 2015, at 11:35 a.m., with the DES present. The EVSFT stated he had to go down the hall (approximately 50 feet away) to wash his hands and/or to use the hand sanitizer. The EVSFT stated there were hand sanitizers located in the trash disposal area a week ago but he did not remember when the hand disinfectant dispensers were no longer available on the wall.

A concurrent interview was conducted with the DES. The DES stated he did not know the hand disinfecting dispensers were missing. The DES stated, "The workers should have told me and/or placed a request for maintenance to repair the missing dispensers."

An interview was conducted with the Director of Facilities Management (DFM) on December 9, 2015, at 11:45 a.m., with the DES present. The DFM stated, "As of November 24, 2015, no work order was placed regarding the missing hand sanitizers."

The DFM and the DES acknowledged multiple workers for over 15 days had been dumping trash without the use of readily available hand sanitizer.

The facility undated policy titled, "Hazard Communications/Right to Know," indicated, ..."Reporting unsafe conditions,...It is the employee's responsibility to report any known unsafe condition/broken (missing) equipment to management in a timely manner."

The facility policy and procedure titled, "General Procedures Relevant to Infection Prevention and Precautionary Measures," revised July 16, 2014, indicated, "Standard precautions include: Hand Hygiene: cleaning hands with soap and water or an alcohol-based hand rub to prevent infection."

4. An observation of the basement hallway was conducted with the Clinical Quality Improvement Specialist (CQIS) and the Director of Materials Management (DMM) on December 9, 2015, at 12:20 p.m.

Four beds were observed in the basement hallway kept next to a wall. Multiple workers from different departments were observed walking through the hallway. In addition, dietary trays were observed being transported through the hallway.

During an observation, one patient bed had a sheet of paper taped to it with the word "Dirty" on it. Another patient bed was observed with trash at the foot of the bed which included gloves, a white infusion cap, and a crumpled paper towel.

During an interview with the DMM, on December 9, 2015, at 12:20 p.m., the DMM stated, both beds were dirty and dirty beds should not be in the hallway.

During an interview with the CQIS conducted on December 9, 2015, at 12:30 p.m., the CQIS stated the beds were to be cleaned prior to being placed in the hallway for temporary storage. The CQIS stated dirty beds should not be in a hallway that multiple staff including dietary personnel transporting dietary carts used.

The facility policy and procedure titled, "Environmental Cleaning," revised October 18, 2014, indicated, "The environmental services department cleans equipment, furniture, and floors, with designated disinfectant agent daily."

5. An interview was conducted with EVS 1 on December 9, 2015, at 11 a.m. EVS 1 was asked what mask she would use to enter Patient 34's room. EVS stated and pointed to the regular sized mask (1860-regular mask) located on the isolation cart. EVS 1 stated, "I never check the size, they never told me what size (to wear). EVS 1 was assigned to clean Patient 34's room.

Record review indicated Patient 34 was admitted on November 11, 2015, with pneumonia and hemoptysis (coughing up blood). Patient 34 had a physician's order dated November 11, 2015, 4:56 p.m.,which indicated, "Continuous Airborne Precautions."

Airborne Precautions are precautions taken to prevent the spread of disease which included donning a fit tested N-95 mask prior to entering the patient's room.

On December 10, 2015, the employee file for EVS 1 was reviewed. EVS 1 was hired on August 26, 2010.

Record review indicated EVS 1's annual N95 fit test and respiratory training was last completed on August 16, 2011. EVS 1's employee file indicated she was fit tested (mandatory yearly test defined by the Occupational Health and Safety Administration (OSHA)-for proper fit of a mask for airborne disease prevention) for the 3M1860S- size small mask. EVS 1 indicated she was going to use the regular size mask for entering an airborne precautions room.

There was no indication the annual N95 fit test and respiratory training was completed for 2012, 2013, 2014, and 2015.

During an interview with the Director of Environmental Services (DES) conducted on December 9, 2015, at 11 a.m., the DES stated all EVS workers should be fit tested and educated on a yearly basis. The DES stated she (EVS 1) should have known which mask was her correct size as per the FIT test.

During an interview with the Chief Human Resources Officer (CHRO), on December, 10, 2015, at 1:30 p.m., the CHRO reviewed the employee file and was unable to find documentation of the N95 fit testing and the respiratory training since August 16, 2011. The CHRO stated EVS 1 should have completed the annual training and should have been Fit tested for 2012, 2013, 2014, and 2015.

The facility policy, "Annual Health Review," dated June 23, 2014, indicated, "Respirator N95 fit test...training is due 12 months from last completed...Reports: at the end of the month a compliance report will be sent to the Directors for follow-up with their employees. If employees are not complete by the end of the month of hire, a report is sent to Human Resources advising them to suspend these employees until compliance is met...If the employee remains noncompliant at 60 days, the matter will be referred to Human Resources for appropriate action which may include suspension until completed or termination."

6. On December 8, 2015, at 1:50 p.m., Registered Nurse (RN) 4, was observed preparing three medications for Patient 30. The three medications were drawn up (removed from the vial) in separate syringes by RN 4 which included:

Versed (a relaxant) 5 milligrams;

Benadryl (promotes drowsiness) 50 milligrams; and

India ink (marks excised polyp site within the colon) 1 milliliter drawn up from a mutidose vial.

All three vials had a rubber stopper. All three vials were not wiped off with an alcohol swab prior to RN 4 drawing up and administering the medication into intravenously (into a vein).

During an interview conducted with RN 4 on December 8, 2015, at 2:20 p.m., RN 4 stated she did not wipe the rubber caps off before she drew up the three medications."

During a concurrent interview with the Clinical Quality Improvement Specialist (CQIS), the CQIS stated, Nurses are to wipe the rubber stopper prior to any medication draw and especially with any multi-dose vial.

The facility policy and procedure titled,"Multi-dose Vial & Product Expiration," dated March 24, 2014, indicated, "...Use aseptic technique when entering a multi-dose vial or bag used for injection and/or sterile application. For all injectable products, remove the dust cap and disinfect the rubber seal by scrubbing vigorously with an alcohol swab."

7. An observation of a colonoscopy performed on Patient 30 was conducted on December 8, 2015, at 1:50 p.m., with the Clinical Quality Improvement Specialist (CQIS). Patient 30's procedure was conducted in the outpatient department.

A colonoscopy is a procedure that allows a physician to look at the inner lining of the colon and rectum by using a flexible tube.

During the observation of the procedure, MD 2 was observed performing the entire procedure without a face shield on. MD 2 remained in the same room during the pre-cleaning of the used flexible tube.

During a concurrent interview with the CQIS, the CQIS stated the physician should have worn the required personal protective equipment (which included a face shield) during and after the procedure.

The facility policy and procedure, "General Procedures Relevant to Infection Prevention and Precautionary Measures," dated, July 16, 2014, indicated, "Personal Protective Equipment (PPE): certain types of clothing or equipment that a person wears to protect his or her body from infectious agents or bodily fluids, types of PPE include: face mask/face shield/eye protection (goggles) should be worn when contact with blood or body fluids to the face can be expected, especially during suctioning or intubation."

8. On December 8, 2015, at 1:50 an observation of a colonoscopy performed for Patient 30, was conducted with the Clinical Quality Improvement Specialist (CQIS). Patient 30's procedure was conducted in the outpatient department.

During the observation of the pre-cleaning of the used (dirty) gastric scope, the technician touched the wall with the used scope. The wall was not observed to be cleaned prior to the next procedure.

During an interview with Registered Nurse (RN 5) on December 8, 2015, at 2 p.m., RN 5 stated the technician should not have bumped the scope against the wall. RN 5 stated the wall was to be wiped down during terminal cleaning at the end of the day.

During a concurrent interview with the CQIS, the CQIS stated she observed the dirty scope hitting the wall. The CQIS stated there was no cleaning of the wall prior to the next procedure in which a clean scope would be placed next to the wall.

The facility policy, "Cleaning and Decontamination Spills of Blood or other Body Fluids," dated May 8, 2013, indicated, "If a spill is small, it can be cleaned and decontaminated with the hospital EPA (Environmental Protection Agency) registered disinfectant in one step..."