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Based on medical record review and staff interview the facility staff failed to ensure Patient #4 was discharged in a safe manner.

The findings included:

A review of Patient #4's medical record revealed the patient had an intravenous (IV) line placed in his right forearm on 03/24/2011. Patient #4's medical record indicated the nursing staff assessed the patient's IV access every shift from 03/24/2011 through discharge on 03/27/2011. The documentation in Patient #4's chart did not reveal the IV access had been removed prior to Patient #4's discharge from the hospital on 03/27/2011.

An interview was conducted on 05/11/2011 from 2:08 p.m. through 2:25 p.m. with Staff #33, Registered Nurse (RN), Nurse Manager, Staff #32 RN Assistant Nurse Manager and Staff #77, RN Assistant Nurse Manager. In response to the question when an IV access would be removed; Staff #77 reported IV access lines were automatically removed unless there was a physician's order to leave the line in related to the patient's follow-up care by a home health service or the patient was being discharged to a rehabilitation hospital. Staff #32 and Staff #77 reported if the unit became busy and a patient needed to be discharged the Assistant Nurse Manager or the unit Charge Nurse might assist. Staff #32 stated, "We might help with the paperwork or teaching. However, the primary nurse would be the one performing the discharge assessment. They should know if a patient has an access that needs to be removed." Staff #32 stated, "We had a patient leave against medical advice, just walked out of the hospital purposely with an IV access. We called the police to bring the patient back, because of the safety issues of him being in the community with an IV access."

An interview was conducted on 05/12/2011 at 8:59 a.m. with Staff # 73, RN Assistant Nurse Manager. Staff #33 joined the interview process after it had started. Staff #73 reviewed Patient #4's medical record and verified the patient's IV access had been assessed during the hospital stay. Staff #73 identified from the medical record that Staff #75, RN had assisted in the discharge documentation. Staff #73 reported that Staff #75 had not been Patient #4's primary nurse. Staff #75 reported that the primary nurse; Staff #74 had performed the discharge assessment and should have known Patient #4 had an IV access. Staff #75 reviewed Patient #4's medical record and reported the record did not document the physician wanted the patient to have an IV access post discharge from the hospital. Staff #75 stated, "The IV access should have been removed." Staff #75 reported the nurse leaving an IV access in a patient was not safe for the patient related to the possibility of infection and the direct access to the blood stream.

Based on medical record review, facility document review and staff interview the facility failed to follow acceptable professional nursing standards by discharging a patient without removing the intravenous (IV) access. (Patient #4)

The findings included:

A review of Patient #4's medical record revealed the patient had an intravenous (IV) line placed in his right forearm on 03/24/2011. Patient #4's medical record indicated the nursing staff assessed the patient's IV access every shift from 03/24/2011 through discharge on 03/27/2011. The documentation in Patient #4's chart did not reveal the IV access had been removed prior to Patient #4's discharge from the hospital on 03/27/2011.

Review of the facility's investigation of the event revealed nursing staff had not followed acceptable hospital and professional nursing standards. The investigation documented the expectations of the facility related to "... patient discharge to include patient assessment, removal of invasive lines and tubes, appropriate documentation and actions to be taken in the event a patient leaves without IV access removed ..."

Review of the facility's policy titled "IV (Peripheral) Insertion, Care & Maintenance" did not contain rationale associated with the removal of an IV access. the "Objective" for the policy read: "All intravenous (IV) sites require monitoring as they are at risk of becoming infected, infiltrated and/or developing phlebitis ..." [Phlebitis is the inflammation of a vein.]

An interview was conducted on 05/11/2011 from 2:08 p.m. through 2:25 p.m. with Staff #33, Registered Nurse (RN), Nurse Manager, Staff #32 RN Assistant Nurse Manager and Staff #77, RN Assistant Nurse Manager. Staff #32 and Staff #77 explained the discharge process. Staff #32 stated, "You gather your paperwork in the chart the discharge instructions, the discharge medication reconciliation and the summary to review. Then you take that to the patient's room to review the information with the patient to make sure they understand. The patient signs the discharge instructions and the follow-up plan of care. The assessment is performed in the computer before the patient is discharged." In response to the question when an IV access would be removed; Staff #77 stated, "Once you know their ride is there. Sometimes you find out at 8:00 in the morning that the patient will be discharged but their ride will not arrive until 4:00 p.m. or 5:00 p.m. I don't take their access out in the morning, in case they have medications that need to be administered by IV." Staff #32 stated, "The discharge assessment should be done in the room with the patient. The information has to be documented in order to discharge the patient." Staff #77 reported IV access lines were automatically removed unless there was a physician's order to leave the line in related to the patient's follow-up care by a home health service or the patient was discharged to a rehabilitation hospital. Staff #32 and Staff #77 reported if the unit became busy and a patient needed to be discharged the Assistant Nurse Manager or the unit Charge Nurse might assist. Staff #32 stated, "We might help with the paperwork or teaching. However the primary nurse would be the one performing the discharge assessment. They should know if a patient has an access that needs to be removed."

An interview was conducted on 05/12/2011 at 8:59 a.m. with Staff # 73, RN Assistant Nurse Manager. Staff #33 joined the interview process after it had started. When asked if a patient had left the unit with an IV access in place that should have been removed; Staff #73 stated, "I heard about it. I was not present. I heard a family had called and stated [the patient's name] had left with the IV access in place. Whatever steps were taken the manager previous to me handled the situation." Staff #73 reviewed Patient #4's medical record and verified the patient's IV access had been assessed during the hospital stay. Staff #73 identified from the medical record that Staff #75, RN had assisted in the discharge documentation. Staff #73 reported that Staff #75 had not been Patient #4's primary nurse. Staff #75 reported that the primary nurse Staff #74 had performed the discharge assessment and should have known Patient #4 had an IV access. Staff #75 reviewed Patient #4's medical record and reported the record did not document the physician wanted the patient to have an IV access post discharge from the hospital. Staff #75 stated, "The IV access should have been removed." Staff #75 reported the nurse leaving an IV access in a patient was not safe for the patient related to the possibility of infection and the direct access to the blood stream.

An interview was conducted on 05/12/2011 at 1:55 p.m. with Staff #4, the Vice President of Nursing Services. Staff #4 provided the facility's policy on IV care. Staff #4 stated, "The policy does not offer a standard for the removal of IV access at the time of discharge." Staff #4 reported the nurses did not have a physician's orders for the patient to keep the access. Staff #4 reported the nurses involved should have assessed Patient #4 and removed his IV access prior to discharge per the hospital's standards.

Based on the observations and interviews it was determined that the Leadership of the hospital failed to maintain the physical environment to protect the Staff.

The findings included:

1. Observations during the tour of the hospital on 5/9/11, at 13:05 PM, in room 5052 revealed a quarter sized tear in the vinyl sitting chair which revealed the foam under the vinyl. The Case Manger for 5 South verified that this tear has the potential to harbor infections and viruses. This interview occurred at 13:07 PM, on 5/9/11 in the hall way of 5 South. Observations on the floor of 4 South , at 14:30 PM, on 5/9/11 revealed that the floor had a grayish brown coating that made the floor appear unclean. The Janitor's closet had brown stains dripping from the walls. The Nurse Manger verified that the Janitor's closet wall needing cleaning. This interview occurred in the hallway of 4 South on 5/9/11, at 14:30 PM.

2. Observations during a tour of the hospital found the floor of the End Stage Renal Disease unit (ESRD) to have floors with brownish gray coating that looked unclean. The ESRD Nurse Manager verified during interview that the hospital was responsible for the housekeeping and maintenance of the dialysis unit. This interview occurred on 5/9/11 at 2:20 PM, in the Dialysis unit. The ESRD patients are immunity compromised and are extremely susceptible to any disease

3. Observations of the Staff Garage on 5/12/11, at 1315, revealed a debris and an upswept garage, with bird feces on the floor.. Two bird nests were observed in the corner of the Garage. The Environment Control Director stated during interview that Pest Control had come on 5/9/11, to remove a dead bird in the Staff Garage. The birds may carry diseases and has the potential to put the Staff at risk, if the birds deposit feces on the Staff members. Interview from the Environment Control Director verified that the physical environment "strives to be clean and that he and members of his team were working on it 24/7".

Based on observation and staff interview, the facility staff failed to maintain infection control policies and programs.

The findings included:

1. Observations during the tour of the hospital on 5/9/11, at 13:05 PM, in room 5052 revealed a quarter sized tear in the vinyl sitting chair which revealed the foam under the vinyl. The Case Manger for 5 South verified that this tear has the potential to harbor infections and viruses. This interview occurred at 13:07 PM, on 5/9/11 in the hall way of 5 South. Observations on the floor of 4 South , at 14:30 PM, on 5/9/11 revealed that the floor had a grayish brown coating that made the floor appear unclean. The Janitor's closet had brown stains dripping from the walls. The Nurse Manger verified that the Janitor's closet wall needing cleaning. This interview occurred in the hallway of 4 South on 5/9/11, at 14:30 PM.

2. Observations during a tour of the hospital found the floor of the End Stage Renal Disease unit (ESRD) to have floors with brownish gray coating that looked unclean. The ESRD Nurse Manager verified during interview that the hospital was responsible for the housekeeping and maintenance of the dialysis unit. This interview occurred on 5/9/11 at 2:20 PM, in the Dialysis unit. The ESRD patients are immunity compromised and are extremely susceptible to any disease.

3. The Manager of Infection Control verified that isolation carts have not been available in the peak times of inpatients during the winter, which resulted in the staff having to use overbed tables to place isolation supplies on. This interview occurred on 5/9/11, at 8:29 AM. The failure to have consistent isolation carts has the potential for patients not to notice that a patient is on isolation and to break the hospital's protocol.

4. The Vice President of Clinical Support Services, who accompanied the Surveyor on the tour verified the findings of the observations at 3:00 PM, on 5/9/11.

5. An observation was conducted on 05/10/2011 from 10:16 a.m. through 10:43 a.m. of eight nourishment rooms. The observation was conducted with Staff #4, the Vice President of Nursing Services, Staff #52, an Engineer and the nurse managers of the units. The observations revealed six of eight ice machines failed to have an air gap to prevent the backflow of waste water or other contaminates from entering the ice machine drain line:
? Labor and Delivery- The ice machine drain was in direct contact with the floor waste water drain system.
? Mother and Baby Nourishment Room #1-The ice machine drain was in direct contact with the hand washing sink.
? 2 South- The ice machine drain was in direct contact with the floor waste water drain system.
? 2 North- The ice machine drain was in direct contact with the floor waste water drain system.
? 3 North-The ice machine drain was in direct contact with the floor waste water drain system.
? Medical Intensive Care Unit- Then ice machine drain had been directly attached to the sink drain line above the U-joint. The ice machine drain line came in contact with any waste fluids poured into the sink.

An interview was conducted during the tour and observations on 05/10/2011 with Staff #4 and Staff #52. Staff #52 stated, "An air gap is needed to prevent the backflow from the [waste water] drain into the ice machine." Staff #52 verbally acknowledged without an air gap contaminates of bacteria in the waste drain system could enter the ice drain line and contaminate the ice machine system.



6. Observations of the Staff Garage on 5/12/11, at 1315, revealed a debris and an upswept garage, with bird feces on the floor.. Two bird nests were observed in the corner of the Garage. The Environment Control Director stated during interview that Pest Control had come on 5/9/11, to remove a dead bird in the Staff Garage. The birds may carry diseases and has the potential to put the Staff at risk, if the birds deposit feces on the Staff members. Interview from the Environment Control Director verified that the physical environment "strives to be clean and that he and members of his team were working on it 24/7".

Based on interviews with the Case Managers and observations during tours it was determined that the hospital's Governing Body failed to ensure adequate infection control measures to prevent potential infection to staff and patients.

The findings included:

1. Observations during the tour of the hospital on 5/9/11, at 13:05 PM, in room 5052 revealed a quarter sized tear in the vinyl sitting chair which revealed the foam under the vinyl. The Case Manger for 5 South verified that this tear has the potential to harbor infections and viruses. This interview occurred at 13:07 PM, on 5/9/11 in the hall way of 5 South. Observations on the floor of 4 South , at 14:30 PM, on 5/9/11 revealed that the floor had a grayish brown coating that made the floor appear unclean. The Janitor's closet had brown stains dripping from the walls. The Nurse Manger verified that the Janitor's closet wall needing cleaning. This interview occurred in the hallway of 4 South on 5/9/11, at 14:30 PM.

2. The Infection Control Manger verified during interview, that the hospital had an outbreak of Respiratory Syncytial Virus (RSV) in the Nursery Intensive Care Unit, on 3/30/11, at 12:00 PM, involving three patients. Three cases were identified, with no cause found for the outbreak. This interview occurred in the agency's conference room, on 5/12/11, at, 8:26 AM. This virus has the potential to cause a serious lower respiratory tract in infants and may live for up 4 to 7 hours on hard surfaces and up to 30 minutes on the hand.

3. Observations during a tour of the hospital found the floor of the End Stage Renal Disease unit (ESRD) to have floors with brownish gray coating that looked unclean. The ESRD Nurse Manager verified during interview that the hospital was responsible for the housekeeping and maintenance of the dialysis unit. This interview occurred on 5/9/11 at 2:20 PM, in the Dialysis unit. The ESRD patients are immunity compromised and are extremely susceptible to any disease.

4. The Manager of Infection Control verified that isolation carts have not been available in the peak times of inpatients during the winter, which resulted in the staff having to use overbed tables to place isolation supplies on. This interview occurred on 5/9/11, at 8:29 AM. The failure to have consistent isolation carts has the potential for patients not to notice that a patient is on isolation and to break the hospital's protocol.

5. The Vice President of Clinical Support Services, who accompanied the Surveyor on the tour verified the findings of the observations at 3:00 PM, on 5/9/11.