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

A. Ensure the dialysate pH and conductivity was checked with an independent meter, verified by witness, and documented prior to treatment initiation on 2 of 2 (Patient #5, #7) dialysis patients observed.

B. Provide a safe environment in 20 out of 20 (# 106, 108, 109, 202, 203, 229, 230, 228, 201, 232, 226, 225, 220, 221, 218, 219, 222, 303, 304, and 305) patient bathrooms, bedrooms, and the adult day room. The facility failed to ensure that the patients shower areas were equipped with break away rods and curtains. The facility failed to have cords, hoses, and supplies out of reach of patients The alarm system for the adolescent unit was inoperable leaving staff with no security system. The wardrobe furniture was not secured to prevent patient injuries.
REFER to A-144
It was determined this deficient practice created an Immediate Jeopardy situration and placed patients at risk of potential harm, serious injury, and subsequent death. These failed practices had the potential to affect all patients admitted to the facility.

Based on chart reviews and interview, it was determined that the facility failed to follow its own policy and procedure concerning patient rights in 3 ( #11, 12, 59) of 10 (#11, 12, 24, 53, 54, 55, 56, 57, 58, 59) patient charts reviewed.
Findings:
A review of the facilities policy and procedures titled "Patient Rights: General Guidelines, Process Standards" revealed the following:"G. If, owing to the patient's condition upon admission and later, the patient does not appear to understand the context of the rights document or the explanation of the rights document, the staff should give the patient another copy of the "Patient's Bill of Rights" and should attempt to provide an explanation daily until understanding is reached or until discharge. The necessity of repeating the rights communication process should be documented in the computer documentation system under Patient/Family Education."
During a chart review on 2/27/2013, patient #11 refused to sign consent upon admission on 2/23/2013. One entry was found in the electronic medical record (EMR) for 2/26/2013 at 7:59PM. The entry reported, that the patient was instructed on rights and medications. The documented patient response stated,"Fair or able to repeat half of information." No further documentation was noted of attempts to obtain the patient's complete understanding of his rights.
During a chart review on 2/27/2013, patient #12 was admitted on 2/18/2013 to present (2/27/2013). Documentation found on (2/19/2013, 20, 21, 22, 24, and 25th) for teaching on patient rights. Documentation reports that patient #12 had poor or no understanding. There was no documentation for 2/23/2013.
During a chart review on 2/27/2013, patient #59 was hospitalized from 2/2/2013-2/8/2013. Documentation was found on (2/03/2013, 4, 6, 7, 8th) for teaching on patient rights. Documentation reports that patient #59 had poor or no understanding. There was no documentation for 2/5/2013.
An interview with staff #58 on 2/27/2013 at 4:30PM confirmed that documentation was not present for patient #59.

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

A. Ensure the dialysate pH and conductivity was checked with an independent meter, verified by witness, and documented prior to treatment initiation on 2 of 2 (Patient #5, #7) dialysis patients observed. This deficient practice had the potential to adversely impact the health and safety of all patients receiving dialysis at the facility.

While touring the dialysis unit on 2/26/2013 at 10:00 am the following observation was made: While observing dialysis treatment initiation for patient #5 and patient #7 noted that the pH and conductivity of the dialysate was not checked with an independent meter prior to initiation of patient treatment.

Review of the manufacture's instructions regarding dialysate conductivity and to measure approximate pH with an independent meter revealed the following:
Final Set-up Procedure for 2008K Machine:
1. Rotate dialyzer to the correct position (arterial inlet up).
2. Connect dialysate lines to dialyzer by matching the color of the quick connector to the color of the blood tube fitting. When done correctly, the red arterial blood tubing connector and the red quick connector of the dialysate line should be connected to the corresponding ports at the top of the dialyzer. This is to create a counter-current flow (blood flowing from top to bottom, dialysate flowing from bottom to top) inside the dialyzer to maximize clearance.
3. Reconnect arterial and venous monitor lines to their respective ports. Unclamp the lines.
4. After priming the extracorporeal blood circuit, press RESET to clear all alarms. Start the blood pump and begin recirculating the saline through the circuit.
5. Press the (down) key on the level detector to lower the fluid level in the drip chamber. Verify that the blood pump stops and the venous clamp occludes.
6. Press the (up) key on the level detector to raise the fluid level in the drip chamber to an acceptable level.
7. Check blood tubing to ensure that there are no kinks, especially between the blood pump and the dialyzer.
8. Replace saline bag with a fresh bag if necessary.
WARNING! Check the conductivity and approximate pH of the dialysate solution using an independent device.
9. Check for a normal dialysate flow by observing the rise and fall of the external flow indicator located on the dialyzer supply line. The float should drop four times in about 15 seconds for a 500-ml/min flow, or four time in 10 seconds for an 800-ml/min flow.
10. Open the shunt door and verify that the machine goes into bypass mode. In bypass mode, an audible alarm may sound, the bypass light on the control panel should light, and float in the flow indicator of the dialyzer supply line should drop and remain at the bottom of the indicator.

Interview with staff #23 on 2/26/2013 at 10:30 am revealed the following.
"We were not aware that we were suppose to check the pH and conductivity of the dialysate prior to initiation of the dialysate treatment with an independent meter. We check the machine readings prior to initiation of the patient treatment, but don't double check with independent meter."


32143


B. Provide a safe environment in 20 out of 20 (# 106, 108, 109, 202, 203, 229, 230, 228, 201, 232, 226, 225, 220, 221, 218, 219, 222, 303, 304, and 305) patient bathrooms, bedrooms, and the adult day room. The facility failed to ensure that the patients shower areas were equipped with break away rods and curtains. The facility failed to have cords, hoses, and supplies out of reach of patients The alarm system for the adolescent unit was inoperable leaving staff with no security system. The wardrobe furniture was not secured to prevent patient injuries. This deficient practice had the potential to adversely impact the safety of all patients receiving mental health care at the facility.
Findings Included:
1). A tour of the Behavioral Health Unit on 2/25/2013 at 1:30 PM, revealed an electric clipper with a cord. The clippers were in an unlocked cabinet in the adult dayroom.
An interview with staff # 30 on 2/25/2013 confirmed the clippers were in an unlocked location accessible to patients.
2). On the Senior Care Unit, the clean supply room was found open and unattended.
During an interview on 2/25/2013 at 4:15, staff # 32 confirmed the clean supply room is not locked when the staff is away from the desk.
3). A tour of the Behavioral Health Unit on 2/25/2013 at 1:30 PM, revealed the shower area in the Emergency Room had a three foot hose attached to the shower head.
An interview with staff #1 on 2/25/2013 at 1:35 PM, reported that the patients are never left alone in the shower area. He did confirm that the hose could potentially be used as a weapon against the staff.
4). A tour of patient rooms at the Behavioral Health unit on 2/25/2013 at 2:00 PM revealed the shower curtain rods and shower curtains in the patient bathrooms were not made of a break away material to provide anti-ligature safety. Twenty (20) patients rooms (#106, 108, 109, 202, 203, 229, 230, 228, 201, 232, 226, 225, 220, 221, 218, 219, 222, 303, 304, and 305) shower curtain rods were made of PVC pipe. When surveyor's full weight was applied to the curtain rod, the rod did not break away.
An interview with staff # 1, 5, and 57 on 2/25/2013 at 2:30 PM, confirmed that the shower rods and curtains were a non break away material. Staff # 57 confirmed that she was not aware that the rods and curtains were not break away materials. Staff # 57 reported that a work order had been submitted over a year ago and she was under the impression it had been corrected. Staff #5 reported that the work order was "dropped" concerning the replacement of rods and curtains. Staff #5 confirmed that the communication was a problem and the staff needs to take on the responsibilities to correct these issues. Staff #5 stated, "We have break away rods and curtains here. We are going to have to look around and find them. I will get them replaced immediately."
5). A tour of patient rooms at the Behavioral Health Unit on 2/27/2013 at 10:30 AM revealed the shower curtain rods and shower curtains in the patient bathrooms had not been replaced with break away materials for anti- ligature safety. Instead, the PVC pipe used for the shower curtain rods had slits cut into the pipe in several places, to weaken the rod, to cause it to break away when weight was applied. On observation of the curtain rod breaking away, it was observed that the brackets in the wall, holding the shower rod in place,were pulling out of the sheet rock. The screws were lose or had fallen out of the brackets onto the floor. The screws were now identified as another safety hazard with the potential to cause harm to all patients receiving care.
An interview on 2/28/2013 at 2:30 PM, staff #5 stated,"We have sawed the pipes in places to make it weak. It should break easily." Weight of the surveyor was applied causing the pipe to break in sharp pieces. Staff #5 confirmed that the broken pipe and screws could be used to cause serious injury to the patients or staff.
6). A tour of the Behavioral Health Unit on 2/28/2013 at 3:30 PM, revealed an alarm system at the nurses' station on the Child and Adolescent Unit, used to detect movement in the hallways after bedtime. No PM sticker was found on the device. Staff #64 turned the system on to demonstrate its use. The alarm system did not alarm when the surveyor walked up and down the hall. There was no prevention maintenance verification of safety inspection on the device.
An interview with staff #64 on 2/28/2013 at 3:40 PM, reported that the alarm system is turned on at night and she was unaware it was not working. Staff #57 stated, "I don't know what it is. I don't know how it works." Staff #5 confirmed the system was not operable.
7). A tour of the Behavioral Health Unit on 2/28/2013 at 3:30 PM, revealed patient rooms 301, 303, 304, 305, and 310 had 6 ft wardrobe furniture that was not secured to the wall or floor. The furniture was light weight and could be pulled over easily with one hand.
An interview with staff #1 and #5 on 2/28/2013 at 3:50 PM, confirmed that the wardrobes were unsecured. Staff #1 stated, "I didn't think they needed to be secured."

Based on observation, interview and document review the facility failed to implement the least restrictive restraint for 1 of 6 patient's observed.

On 2/28/2013 during a tour of the Intensive Care Unit (ICU) patient #2 was observed in a private room with ventilator assisted respirations. He was on Versed per hospital protocol for sedation. Pt #2 was also observed to have bilateral mittens applied. The mittens were tied per hospital policy to a non moving part of the bed.

During this observation, staff nurse #17, who was assigned to care for pt #2, indicated the physician had ordered both the Versed and the mittens because pt #2 would sometimes override the Versed, awake and quickly pull at his tubing. She feared he would extubate himself.

During this observation time pt #2 underwent deep suction performed by a respiratory staff member. Pt #2 winced his eye lids. He did not otherwise move. Afterwards a staff member entered the room spoke loudly to pt #2 and touched him mid chest in an attempt to arouse him. After this observation the question was presented as to why was it necessary for pt #2 to have both medication and mechanical types of restraint. Again the above description of rapidly awakening and pulling tubing was given.

Following a request to remove the mittens, pt #2 was observed for 20 minutes. At no time did he demonstrate behavior indicating he was awake or able to pull at his tubing. Pt #2 did not move his arms. After this trial period, the mittens were not replaced and the versed was titrated down.

Further conversation with staff #9 reflected daily monitoring of charts for patient who were restrained. Review of pt #2 Medical Record (MR) revealed documentation that indicated least restrictive interventions had been attempted and were not successful leading up to the requested removal of the mittens. The question was posed, as to how could staff evaluate, if a less restrictive measure was effective, if the patient was medically sedated and unable to move. Staff #9 indicated she understood the question and recognized the dilemma.

The documented nursing assessment was inaccurate in reflecting less restrictive restraint measures had been attempted. Pt #2 was subjected to both medical sedation and mechanical restraint with the application of mittens. Both were used simultaneously.

Based on observation, interview and document review the facility failed to include patient safety issues in the Quality Assessment Process Improvement of the Sleep Disorders Center evidenced by toxic liquids identified in two (2) bedrooms, trash receptacles that had not been emptied in two (2) bedrooms and five (5) pillows improperly stored.

On 2/25/2013 at 10:30 Am during the initial tour of the sleep disorder center two bedrooms were observed. Each bed was remade and the room appeared ready for a new patient. Each bed room was observed with a one (1) gallon container of bleach stored in the patient's wardrobe cabinet. Each bed room also was observed to have a one (1) quart bottle of 70%alcohol stored in the patient wardrobe cabinet. The trash receptacle in each bed room had not been emptied and oxygen tubing was visible in the receptacles.

Further observed during this department tour revealed five (5) pillows stored on the floor in a corner beside a cabinet.

On 2/25/2013 during the department tour the manager was interviewed and confirmed the bleach and 70% alcohol was being stored in the bedroom areas due to a lack of space and proper storage. She also confirmed the 5 pillows should not be stored on the floor, but again there was so little storage space.

Further interview with the manager of the department revealed the Quality Assessment Process Improvement (QAPI) followed by the department did not include safety for the patient from toxic liquids, sanitary rooms or contaminated linen.

Based on interview and record review the facility failed to ensure vital signs were assessed during and after blood transfusions in 1 of 3 (# 40) charts reviewed for blood transfusions.
This deficient practice could potentially cause harm in all patients receiving blood products in the hospital.
Findings include:
Review of the facility's "Blood or Blood Component Therapy/Management of Transfusion Reaction" policy dated 11/2012 revealed the following:
"Take and record the patient's vital signs, including temperature prior to administration of blood or components, and after the first 50 mls of blood has infused, and then hourly for the duration of the transfusion.
Baseline vital signs are used for later comparisons, to determine possible transfusion reaction.
The most common clinical events accompanying a severe transfusion reaction in order of frequency are:
a. Fever, with or without chills
b. Lumbar, extremity, or chest pain
c. Change of pulse, temperature or blood pressure (hypotension)
d. nausea
e. nausea, flushing of the face
f. dyspnea
g. bleeding "

Review of nurses' notes revealed Patient #40 was a 21 year old female admitted on 02/11/13 with a diagnosis of acute sickle cell crisis.
Review of physician orders dated 02/12/13 revealed the following:
Type and Cross, 3 units of PRBCs (packed red blood cells).
Transfuse 2 units when ready.
Review of a physician order dated 02/14/13 revealed staff was to transfuse one more unit of PRBCs.
Review of "BHSET Blood and Blood Component Flow Sheet" revealed Patient #40 received the following blood transfusions:
* Unit #1 was started on 02/12/13 at 9:25 a.m. and completed at 12:10 p.m. A temperature of 98.6 degrees Fahrenheit was taken at 9:25 a.m... There were no other documented temperatures listed on the form during the transfusion process.
*Unit #2 was started on 02/12/13 at 1:20 p.m. and completed at 3: 55 p.m... An increased temperature of 99.5 degrees Fahrenheit was taken at 1:20 p.m... There were no other documented temperatures listed on the form during the transfusion process.
*Unit #3 was started on 02/13/13 and there were no start time or completion time written on the form. There were no listed temperatures or respirations documented during the process.
During an interview on 02/27/13 at 2:40p.m., Staff #27 confirmed the vital signs were missing and should have been documented in the information on the blood transfusion form.

Based on observation, document review and interview the facility failed to provide preventative maintenance as required by established policy and procedures. The facility also failed to ensure supplies and equipment were inventoried for the purpose of removing expired items from the imaging department.
The review of policy numbered PE.07.06.0001 reads, "Subject: Medical Equipment Preventive Maintenance Plan, Policy: It is responsibility of the Clinical Engineering staff to keep the Preventive Maintenance Program up to date, accurate and ongoing ....."
The review of policy numbered PE.07.03.0002 reads, "Subject: Medical Equipment Inspection, Procedure: It shall be the responsibility of the Clinical Engineering Department to routinely inspect all pertinent facility equipment and devices to determine their safe operation, If deficiencies are found, the head of the department will be notified and corrective measures will be implemented."
The review of policy numbered PE.07.03.0001 reads, "Subject: Medical Equipment Risk Assessment , Purpose: Equipment utilized in patient care supports that care in varying levels of performance, reliability and safety, As a result, all patient care equipment need not be managed the same, but, rather at a level commensurate with its importance to the quality of patient care ..... "
While touring the Outpatient PACU (Post Anesthesia Care Unit) on 2/26/2013 at 1PM with staff #7 a pulse oxemiter, identification number 117-02054, was observed with the last preventive maintenance (PM) date of 3/28/2011. On follow up of the overdue preventive maintenance date, the surveyor was provided with a document that contained a hand written note, "When can't locate, move to the next cycle."
An interview with staff #7 in the Blue Bonnet Room on 2/26/2013 at approximately 3PM, confirmed it was the practice the Clinical Engineering Department to bump unfound equipment to the next cycle for preventative maintenance. Staff #7 confirmed it was not the policy of the facility to bump unfound equipment to the next cycle for preventative maintenance.
Staff #7 was asked to provide the surveyor a list of equipment, overdue for PMs and was bumped to the nest PM cycle. Staff #7 provided the surveyor a list containing 87 pieces of equipment overdue for PMs and was bumped to the next PM cycle.




32143

During a tour of the Behavioral Health Unit 2/26/2013 at 8:53 AM, revealed three suction machines with no preventive maintenance (PM) stickers. A suction machine in the emergency department (ED) was placed on top of the emergency cart. It had no canisters or tubing. Two suction machines were found on the Senior Care Unit. One machine was on the emergency cart and the other was in use in the patient room 104. The three suction machines were not found in the maintenance log. In addition, two nebulizer machines and a K-pad were found on the adult unit with no PM stickers.
Interview with staff #5 and #65 on 2/26/2013 at 8:53 AM, confirmed there is no regular maintenance on the three suction machines, nebulizers, or K-Pad found on the behavioral units. Staff #5 reported that all suction machines are on crash carts and checked daily by the nursing staff. Staff #5 confirmed that the staff of behavioral health unit has not been testing the equipment. Staff #65 stated, "These are non- essential items and they fall onto the lower level of inspection." Staff # 65 confirmed he was not aware these items were on this unit. Staff # 65 was unable to locate the suction machines in his equipment inventory. The items were later found to be rentals.
During a tour of the Behavioral Health Unit 2/25/2013 at 1:30 PM, revealed expired items at multiple locations.
-Four expired 1 liter bags of normal saline in the emergency carts.
-The ED medication room had two bottles of unmarked, opened Betadine bottles, and twelve expired insulin syringes dated, "Exp. 2010."
- Wound care dressings, a package of Kerlix dressing, a multipack of 4 x 4 gauze, and plastic cup lids, found opened in a plastic tub in the adult medication room.
- In the adult exam room items were found expired or opened. Two packages of IV tubing "Exp. 2011", 8 GYN cultures "Exp. 2010", and 7- 23 gauge needles "Exp. 2012" and 2 packages of Kerlix opened.
- In the adult unit supply room 2 Foley catheters and 6 mini locks found expired "EXP 2012" 2 nebulizer adapters had dried pieces of a rubber like substance in the bottom of the package with no expiration dates.
Interview with staff #57 on 2/25/2013 at 3:30 PM, confirmed the findings listed above. Staff #57 reported that the facility did have personnel that were responsible for checking on expired items.








10135

During a tour of the imaging department on 02/27/13 the following expired items were found stored on shelves/or in drawers:
*At 9:13 a.m.
Two transducer covers expired on 1/2013.
*At 9:24 a.m.
Six percutaneous sheet inducer sets expired 06/2012.
One percutaneous thrombolytic device expired 01/2012.
Eighteen Glow and tell tape expired 07/2011.
*At 9:40 a.m.
Seven Introducer sheaths with Radiopaque Markers expired 10/2012
Four Groshung catheters expired 09/2010.
One angiographic catheter expired 11/2011.
Six angiographic catheters expired 04/2012.
Two angiographic catheters expired 06/2012.
One angiographic catheter expired 07/2012.
During an interview on 02/27/13, Staff #28 confirmed the equipment was expired.

Based on observation, interviews, and policy reviews the facility had failed to maintain repairs, maintenance, and an appropriate housekeeping schedule to provide a sanitary environment in 20 out of 20 (# 106, 108, 109, 202, 203, 229, 230, 228, 201, 232, 226, 225, 220, 221, 218, 219, 222, 303, 304, and 305) patient rooms and throughout the behavioral unit. The facility also failed to ensure the proper cleaning of equipment in the emergency department to prevent cross contamination. The facility also failed to ensure the use of standard precautions to prevent transmission of infection by contact in the hemo-dialysis unit.
Findings include:
A tour of the Behavioral Health Unit 2/25/2013 at 1:30 PM, revealed shipping boxes in the clean supply rooms on the geriatric and adult units.
- A refrigerator and microwave was found in the clean supply room on the geriatric unit. The refrigerator had spilled liquid substances in the door and shelves. Molded foods in containers were found and out dated condiments. The microwave had spillage and dried substance inside and was dusty on the outside.
Interview with staff #5 and #57 on 2/26/2013 at 8:30 AM, confirmed that the staff was using the clean supply as a break room. Staff #5 confirmed that the refrigerator and microwave was dirty and the shipping boxes should not be in the clean supply room.
- 20 out of 20 (# 106, 108, 109, 202, 203, 229, 230, 228, 201, 232, 226, 225, 220, 221, 218, 219, 222, 303, 304, and 305) patient bedrooms had stained mattresses that smelled of urine and/or torn. The floors were dirty with dust, hair, and stains. A buildup of dirt and hair was found around all the wardrobes and baseboards.
- The Senior Care Unit seclusion room was found to have a dirty stained mattress and a strong smell of urine. Dirty wash cloths and towels were found behind the bed. Dirt and dust was found on the floor and around the base boards. The bathroom in the seclusion area was found dirty with towels and wash cloths lying on floor and the sink. The trash can was over flowing to the floor with trash.
- The Senior Care Unit bathroom/shower room had mildew around the shower ledge area. Dirty towels were found on the floor, trash debris, and dirt/hair was found on the floor. The rolling PVC shower chair was turned upside down by the surveyor. The chair had caked on dirt, soap scum, and green mold growing and hanging down.
- The clean linen room floor had dust, debris, and linen found under the cart. A section of the floor had rust stains that extended along the wall.
- Patient rooms 104, 108, and 111 had black mold and mildew on the window blinds. Paint and plaster was missing in multiple areas on the bedroom walls and bathrooms.
- The adult soiled linen room was filled with bags of trash. The surveyor was unable to open the door completely due to bags of trash falling out into the hallway.
- The adult exam room table had multiple tears and was covered in dust.
An interview with staff #57 and #1 on 2/25/2013 at 2:00 PM confirmed the above findings. Staff # 57 reported that the nursing staff and housekeeping were responsible to keep the shower area clean. Staff #57 stated, "They pick up the trash in the morning and the evenings. I am sure they picked up the trash this morning."
A tour of the Behavioral Health Unit with staff #57, 1, 5, 6, 58, 51 and 62 on 2/26/2013 at 8:30 AM, revealed the above findings were found the following day. The Senior Adult Unit shower chair had been cleaned of the mold and mildew but still had a buildup of dirt/ soap scum. The trash had been removed from the soiled linen rooms.
An interview with staff #5, and #6 on 2/26/2013 at 9:00 AM confirmed the above findings. Staff #6 stated that the housekeepers perform a 10 step cleaning process. No one had been scheduled to buff the floors on the units. Staff #6 reported that he makes regular rounds to check on housekeeping and feels he has good communication with the behavioral unit. Staff #6 denied having any staffing issues. Staff #5 reported that the safety committee (including infection control) had made rounds of this unit on 7/13/2012, 8/31/2012, and 12/7/2012. Staff #51 reported being aware of these finding and had reported them to the safety committee.
A tour of the Behavioral Health Unit with staff #57, 1, 5, 6, 58, 51 and 62 on 2/27/2013 at 11:00 AM, revealed the following;
- Patient room 232 had a dirty soiled linen cart with a plastic laundry bag in a clean room.
- Adult seclusion room windows were dirty with dried, dripping substance down glass. The inside screen/grate had mold and mildew.
- Adult patient room 222 had dirty tiles in the bathroom. A brown dried substance was on the bottom tiles and mildew in shower. The door frame was missing paint causing it to have heavy rust.
- Adolescent rooms 301, 303, 304, 305 had dirty windows, shoe molding laid over on the floor, and paint/plaster missing from areas on the walls in the rooms.
- Toilets overflowed when flushed in rooms 301 and 305.
- Soap dispenser and toilet paper holder was broken in rooms 301 and 305.
During an interview with staff #60 and #61 on 2/27/2013 at 11:30 AM, reported that only one staff member picks up all the trash in the entire hospital and over at the behavioral health unit on the weekends. Staff #61 reported that he had been off for the weekend and 2/25/2013 for jury duty. No one had picked up the trash at the behavioral unit for three days. Staff #60 reported that two house keepers are working during the day and one at night. If census goes down they are pulled to the main hospital to clean rooms frequently.


10135

During an observation on 02/26/13 at 1:10 p.m., ED triage Room #2 was found to have a glucometer for patient use. During an interview on 02/26/13 at 1:10 p.m., Staff #29 reported they cleaned the glucometer every couple of weeks with alcohol pads.
According to the website " http:www.cdc.gov/injectionsafety/blood-glucose-monitoring.html " , ran 03/07/13 revealed the following:
The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration.
CDC is alerting all persons who assist others with blood glucose monitoring and /or insulin administration of the following infection control requirements:
Whenever possible, blood glucose meters should not be shared. If shared, the device must be cleaned and disinfected after every use per manufacturer ' s instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared.
Review of the " Blood Glucose Monitoring: Lifescan Surestep Flexx " facility policy dated 08/2009 revealed the following cautions:
Potential Biohazard:
Wear gloves
Do not use alcohol, Windex or other glass cleaners, or any cleansers with abrasives, phenol or ammonia to clean the test area. A 10% bleach solution is the disinfectant of choice.
.) During an observation on 02/26/13 at 3:24 p.m., 20 plus boxes of laboratory supplies were stored in packing boxes on shelves.
.) During an observation on 02/27/13 at 10:48 a.m., boxes of supplies used in radiology procedures were stored on shelves in packing boxes.




27558

While touring the acute dialysis unit treatment area on 2/26/2013 at 10:00 am the following observations were noted:
a. Staff member #23 took a roll of tape to the patient station to initiate dialysis treatment on patient # 5. The roll of tape was put on the patient table beside patient bedside in preparation to initiate treatment.
b. Staff member #24 came to patient #5 beside table and retrieved roll of tape and took it to patient # 7 for use on patient treatment initiation. The roll of tape was put on the patient beside table beside patient bedside in preparation to initiate treatment
c. Staff member #24 took package of 2x2's to patient #7, removed 4 2x2's for patient use and returned the package of unused 2x2's back to cabinet where clean and sterile supplies were stored.
d. During set up of patient machines observed staff #24 and staff # 26 were not using gloves during set up and application of blood tubing. After completing machine set up, the staff then went to 2 other machines to begin set up without hand hygiene and/or application of gloves prior to initiating set-up.
Review of "An APIC Guide 2010"
"Guide to the Elimination of Infections in Hemodialysis" revealed the following:
Standard Precautions
Standard Precautions (formerly Universal Precautions) refers to the practices that are designed to prevent transmission of infection by contact with bodily fluids. The concept of Standard Precautions is based on the principle that ALL blood, body fluids, secretions, and excretions of all patients may contain transmissible infectious agents, and involves the use of PPE such as masks, face shields, gowns, and gloves. In HD settings, in addition to Standard Precautions, more stringent measure are recommended because of the increased potential for contact with blood and bloodborne pathogens including HIV, HBV, and HCV. The risk of exposure is increased because accessing the bloodstream is required during the dialysis session, there is close proximity of patients, and staff have frequent contact with numerous patients and equipment. Exposure to blood and potentially items can be routinely expected during the process of HD. As a result, dialysis healthcare personnel must take more rigorous steps to protect their patients as well as themselves, as follows.
*Uses Dedicated equipment: A risk of transferring infectious material between patients is created when moving equipment or disposables from patient station to station. Any single-use disposable item must be used for only one patient and the discarded. Items such as adhesive tape should be dedicated for use on a single patient and discarded. Blood pressure cuffs should be made or covered with a material that can be cleaned and disinfected between patients uses. Items such as pillows and blankets are sometimes supplied by the facility and sometimes the patient. Patients bringing items from home to the unit for each treatment must take them home afterwards to prevent use by other patients. Unused medications or supplies (e.g., syringes, alcohol swabs) taken to the patient's station should not be returned to a common clean area or used on other patients.
*Prohibit use of shared mobile supply or medication carts.
*Gloves must always be worn for any contact with the patient or the patient's equipment.
*Isolation of HbsAG-positive patients (see HBV/Precautions)
PPE Guidelines for Standard Precaution in HD Settings
Patients:
1. Wear a mask during initiation and discontinuation of dialysis treatment if vascular access is a catheter.
2. Wear a mask in a HD facility when experiencing symptoms of an upper respiratory illness.
Employees:
1. Lab-style cover coats:
* Regular cotton, non-fluid resistant lab coats are not considered PPE and should be removed or worn under an isolation or fluid resistant gown when needed.
* Fluid resistant lab coats are considered PPE.
* Either type of lab coat must be removed if it becomes soiled or wet.
* Either type of lab coat must be removed prior to leaving the unit and for breaks and lunch.
2. Full isolation or fluid resistant gowns should:
* Be worn when caring for an isolation patient with HBV.
* Cover arms and be closed in front.
* Be worn when there is likelihood of blood contact, especially when initiating and removing patients from dialysis.
* Be worn when there is a likelihood of body fluid contact especially with diarrhea illnesses, uncontrolled secretions, draining wounds, stool incontinence, and ostomy tubes and bags.
* Be worn during reprocessing of dialyzer's.
3. Gloves should be:
* Worn whenever caring for a patient.
* Worn when touching the patient's medical equipment or handling lab specimens or used dialyzer's.
* Changed whenever moving from a dirty to a clean site/task on the same patient (i.e., new gloves should be donned after touching the HD machine, prior to touching the same patient's vascular access).
* Changed after cannulation.
* Removal of gloves should always be followed with hand hygiene.
4. Mask should be:
* Worn if experiencing mold cold or cough illness in order to protect patients and other employees.
5. Face protection (mask with eye protection {goggles, face shield}) should be:
*Worn during initiation and discontinuation of dialysis
* Worn during reprocessing of dialyzer's or cleaning equipment in a sink.
* Worn when within 6 feet of an unmasked coughing patient.
* Discarded between patients or if reusable, cleaned and disinfected between uses as indicated.
HBV Isolation/Precautions
Introduction
In addition to Standard Precautions, isolation (separate room) for HBsAg positive patients is standard of practice in HD facilities, for several reasons:
1. Environmental stability: HBV can persist on surfaces and equipment and remain infectious at ambient room temperature for up to 7 days. HBsAg has been detected on clamps, machine control surfaces, doorknobs, and other surfaces in dialysis facilities. These blood-contaminated surfaces can serve as a reservoir for HBV transmission, creating the potential for contamination of healthcare personnel hands, equipment, and supplies.
2. High viral titer: Persons with HBV infection tend to have high concentrations of virus in their blood. This, along with its environmental stability, makes the risk of HBV transmission from blood contaminated items in this setting greater than would be expected for other common bloodborne viruses.
While HCV and HIV also pose potential infection risk to employees and patients, the risk is significantly less than that related to HBV.
* HIV infection from an exposure occurs at a rate of 0.2%-0.4%.
*HCV infection from an exposure occurs at a rate of less that 1%.
* HBV infection from an exposure occurs at a rate of up to 30%.
HBV Isolation/Precautions
*Patients are placed in a private room or segregated area.
* Dedicated dialysis machine is used for HBV-positive patients.
* Dialyzers are discarded in biomedical waste after treatment.
* Dialyzers can not be reprocessed/reused.
* Gown and gloves are requited for each entry into room.
* Mask with eye protection is required for cannulation and decannulation.
* Staff caring for HBV patients cannot care for HBV susceptible patients at the same time.
* Staff caring for HBV patients should be HBV-immune.
* Required when the surface antigen is positive and not required when the surface antigen is not detectable."
Interview with staff # 23 confirmed the findings.

Based on observation, interview and policy review the hospital failed to maintain a sanitary environment for the preparation of raw chicken and the storage of tuna salad observed in the facilities dietary department.

On 2/27/2013 at 10:00 AM an initial tour of the dietary department was conducted with the Executive Chef for the facility. During the tour a food service staff was observed cutting raw chicken at a work station. Upon investigation a large volume of raw chicken was observed in a deep sink. There was no ice water in the deep sink to cover and chill the raw chicken and only a small stream of water was running directly over one chicken part. The United States Department of Agriculture (USDA) recommends raw chicken secured in plastic bags, may be maintained in cold ice water for thawing and preparation. The cold water should be changed every thirty (30) minutes.

The food service staff was observed, cutting the chicken at the joint and placing the two parts into a smaller deep pan. There was no ice beneath the smaller pan to chill the chicken and maintain it at a safe temperature while preparation was on-going.
During the tour this was brought to the attention of the Executive Chef, who indicated the chicken was being prepped for the next days use and yes, she should have some cold water on the chicken. However, the Executive Chef did not correct the unsanitary method of preparing and storing the raw chicken observed in the dietary staff.

Also during the department tour the walk in refrigerator was observed to have chilled raw vegetables on one side and thawed raw meat still in plastic on the other side. Staff #11 was questioned why raw vegetables and thawed packaged meat was being stored together. He responded "We just got this walk-in, you should have seen it before, when we only had one walk-in". Three (3) large plastic sacks of thawed chicken was observed. There was no use by date identified on the soft thawed chicken. Also there was a large plastic sack of soft thawed beef. There was no use by date identified on the beef. These observations were confirmed by staff #10 and staff #11.

Also during this tour a white plastic container was observed in the refrigerator. The container seal had been broken and part of the content had been removed. The label of the container read Tuna Salad. There was no date opened or used by date identified on the open container. This was verified by staff #10, who questioned why a date opened was needed if the manufactures use by date was visible.
The foodsafety.gov web cite recommends Tuna salad be used within 3-5 days once the manufacture's container has been opened. Without the date opened identified, staff #10 could not determine the number of days the tuna salad had been in use.

On 2/27/2013 at 11:00 AM in the manager office, staff #10 was asked if there was a policy for labeling opened containers of food. He indicated "no there was not". When asked if there was a policy for the safe storage of raw chick while being prepped for menu usage he indicated "no there was not". When he was asked if there was a policy for the thawing and storage of meat in general he indicated "no there was not".

Based on chart reviews, and interview the facility failed to verify a safe discharge, document notification of discharge to the legal guardian, complete a discharge plan, or discharge instructions on 1 (#54) of 5 (#53, 54, 56, 12, and 59) patient charts.
2.) Review of patient # 54's medical record revealed patient was a 17 year old female voluntarily admitted on 11/19/2012 with a diagnosis of adjustment disorder/ rule out depression. Review of the physicians discharge summary revealed Patient #54 sent a text to a friend complaining of family problems and thoughts of suicide with no viable plan. She has a strained relationship with her mother and has been in Child Protective Services (CPS) involvement due to emotional and physical abuse. Patient #54 denied suicidal thoughts and had plans to move to Austin as soon as she completes high school in three weeks. Patient was discharged in her grandmother's care according to physician discharge summary. Physician order dated 11/10/2012 documented to please call mother, grandmother, and CPS to confirm the patients history. In the nursing notes dated 11/9/2012 at 4:21 PM the patient reported that she had been in a drug raid at her grandmothers home but she was not arrested. The nuring notes dated 11/11/2012 stated, "Spoke to doctor, he feels that she is ready to go home. Physician instructed me to contact grandmother to see if she is ok with discharge. The Grandmother and Aunt stated that they are ok with her going home today. Pt. gathering things for discharge." There was no clear documentation on where the patient was discharged or with whom. There was no documentation of patient's mother (legal guardian) being notified of discharge. Patient had no discharge planning or discharge instructions in the medical record.
Interview with staff #57 on 2/28/2012 reported that all patients should have a discharge plan and instructions at time of discharge. Staff #57 confirmed that patient #54 had no discharge planning or instructions.

Based on chart reviews, and interview the facility failed to follow its policy and procedures in reevaluating the needs of the patients on an ongoing basis and prior to discharge in 3 (#53, 54, 56) of 5 (#53, 54, 56, 12, and 59) patient charts.
Review of the policy# 3.5.3 titled "Discharge Process" section D stated, "Discharge planning needs are identified which focus both on current needs and anticipated needs based on reason for hospitalization, discharge planning needs may change and may require additional resources to promote by timely discharge and continuity of care."
1.) Review of patient # 53's medical record revealed patient was an 83 year old female involuntarily admitted on 11/19/2012 with a diagnosis of dementia with behavioral disturbance and Cardiovascular Accident (CVA). The emergency detention warrant reported patient #53 was confused and wanted to shoot her daughter, son-in-law, and herself. The chart revealed patient #53 lived alone in her own home and handled her own financial affairs with her extended family and grandchildren's assistance. Documentation in the record revealed Patient #53 commented multiple times that she did not make the alleged comments and her daughter is lying. Patient #53 also accused the daughter of taking money out of her account without asking her. The physician had written an order on 11/22/2012 for Adult Protective Services (APS) to be contacted. APS is to follow up with the patient at discharge. Review of the discharge planning forms revealed the "Master Treatment Plan Discharge Planning" form was initiated on 11/20/2012. The first section addresses living arrangements and placement. Independent living arrangements was checked with no comments. The second column was for referrals/recommendations with "psychiatrist" checked. The following comment stated, "Will need referral and 11/30 apt made with psychiatrist for 12/5 at PM." The chart revealed that the APS referral was made on 11/28/2012 at 1350. There was documentation that the APS referral was ever addressed on the care plan or discharge plan. There was no documentation of caregiver assistance on discharge teaching sheet or master discharge plan.
2.) Review of patient # 54's medical record revealed patient was a 17 year old female voluntarily admitted on 11/19/2012 with a diagnosis of adjustment disorder/ rule out depression. Review of the physicians discharge summary revealed Patient #54 sent a text to a friend complaining of family problems and thoughts of suicide with no viable plan. She has a strained relationship with her mother and has been in Child Protective Services (CPS) involvement due to emotional and physical abuse. Patient #54 denied suicidal thoughts and had plans to move to Austin as soon as she completes high school in three weeks. The patient was discharged in her grandmother's care according to physician discharge summary. The physician order dated 11/10/2012 reports to please call mother, grandmother, and CPS to confirm the patients history. In the nursing notes dated 11/9/2012 at 4:21 PM the patient reported that she had been in a drug raid at her grandmothers home but she was not arrested. Nursing notes dated 11/11/2012 states, "Spoke to doctor, he feels that she is ready to go home. Physician instructed me to contact grandmother to see if she is ok with discharge. Grandmother and Aunt stated that they are ok with her going home today. Pt. gathering things for discharge." No clear documentation on where or whom the patient was discharged. No documentation of patients mother (legal guardian) notified of discharge. Patient had no discharge planning or discharge instructions in chart.
Interview with staff #57 on 2/28/2012 reported that all patients should have a discharge plan and instructions at time of discharge. Staff #57 confirmed that patient #54 had no discharge planning or instructions.
3.) Review of patient # 56's medical record revealed patient was a 57 year old female involuntarily admitted on 10/24/2012 with a diagnosis of bipolar disorder, psychotic features, and cocaine dependence; Patient # 56 also had medical co morbidities of hypertension, asthma, and migraine headaches. The patient was treated in the facility for a urinary tract infection and a sexually transmitted disease (STD). Patient #56 arrived at the facility, where she was obtained from jail, on an emergency detention warrant and later an order of protective custody. The medical record revealed that patient #56 rambles and has flight of ideas. Documentation revealed that patient #56 continued to claim she was sodomized by six men on her front porch. The physician discharge summary stated, "Prognosis guarded to poor because of the patients noncompliance with medication, appointments, and also drug dependence." Review of the master treatment plan discharge planning revealed no comments for discharge planning. One referral was made for patient to go to the local mental health authority, an appointment was made to see psychiatrist 11/13/2012 at 2:00 PM, and to an outpatient substance abuse program with no address and an incomplete phone number. No updated information on patient #56's discharge treatment plan was noted.