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Based on record review and interview, the facility failed to follow physicians' orders to Type and Cross match a patient's blood , monitor an insulin dependent patient's blood glucose level, post-surgical procedure and ensure a patient used Incentive Spirometer prescribed by the physician in 3 of 16 current sampled patients: Patient #s 3, 8, 14

Findings
Patient #3
Review on 02/16/206 of Patient #3's clinical record revealed a physician's order dated 02/15/2016 for " Type and cross match patient. "
Review of Patient #3's clinical records revealed laboratory values which indicted the following values: 02/2016, Patient's Hemoglobin 13.2 g/dl and 10.7 g/dl. 02/16/2016 Hemoglobin 11.7 g/dl
Review of the patient's clinical record revealed no evidence that samples were drawn for Type and crossmatch.

Interview on 02/16/2016 at 10:15 a.m. with the Registered Nurse assigned to Patient #3 revealed the patient has being passing large amount blood in his urine since admission. She stated that she had called the blood bank but there was no evidence that the samples were sent for Patient #3 to have blood typed and cross matched.

Interview on 02/16/2016 at 10:20 a.m. with the unit's Nurse Manager revealed he spoke to the Nurse who had transcribed the physician's order on patient #3. He said the order was not carried out because she had a number of admissions and she had forgotten to send the sample.
The facility was not aware that the sample was not sent until the Surveyor informed staff of the omission.


Patient #8
Patient #8 was observed on 02/17/2016 at 8:35 a.m. in pod 9 of the post anesthesia care unit. The Patient was alert and oriented to person place and time.
Interview with the Patient at that time revealed she was in the hospital because she had an injection in her spine.

Review on 02/17/2016 of a post discharge clinical record of patient #8 from the post anesthesia care unit revealed a physician's order dated 02/17/2016 for " Finger stick blood glucose for all diabetic in Pre-op for Insulin Dependent Diabetics recheck Blood Glucose prior to discharge from PACU "

Review of Patient # 8's clinical record (Home Reconciliation Order Form) dated 02/17/2016 revealed a physician's order for Humalog 10 units Sub. Q3 times per day, NovoLOG Flexpen 10 units Sub- Q every day, Reason for taking (diabetes,) Bydureon Pen Injector 2 milligrams Sub-Q every week. Reason for taking (diabetes).

Review of the Patient's clinical record revealed no indication/ documentation that Patient #8's blood glucose was monitored post operatively as ordered by the physician.

Interview on 02/17/2016 at 9:05 a.m. with Registered Nurse ( O), Registered Nurse assigned to Patient #8 post operatively , the Surveyor requested evidence that the patient's blood glucose was monitored post operatively. The Registered Nurse said he said he did not do a blood glucose check post operatively on Patient #8 because the patient did not have general anesthesia during the procedure.

Patient 14.
Review of Patient #14's clinical record revealed a physician's order dated 02/17/2016 for " Cough, deep breathe, Incentive Spirometer Q1 hour while awake. "
Review of Patient #14's clinical record revealed documentation in the patient teaching record which indicated that the patient had teaching on Incentive Spirometer on 02/17/2016 at 16:32 p.m.

Review of Patient #14's clinical record (nursing notes and records in the computer) revealed no indication/ documentation that Patient #14 coughed, deep breathe and used the Incentive Spirometer every hour while awake as ordered by the Physician.

Patient #14 was observed in his room on 02/18/2016 at 10:45 a.m. The Patient was alert and oriented to person place and time.

Interview on 02/18/2016 at 10:45 a.m. in the presence of the Registered Nurse Director of Informatics and the Patient's spouse, The Surveyor asked the patient if he had used an Incentive Spirometer and described it as a clear plastic apparatus that he uses by inhaling and exhaling. Patient #14 said he is aware of the device and have used it before but he cannot recall using this device since he was admitted to the facility. The Patient said he has a CPAP machine that he uses while in the facility.
Observation revealed there was no evidence of an Incentive Spirometer in the Patient's room or in his possession.

Interview with Registered Nurse (N) on 02/18/2016 at 10:50 a.m., revealed Patients generally comes from PACU with the Incentive Spirometer that she generally document in the daily nurses notes about the teaching and remind the patient to use it when she enters the patient's room but she did not document when the Incentive Spirometer is used.

Based on observation, interview and record review the facility failed to ensure staff sanitize their hands after glove changes;

Failed to ensure staff wear PPE(Personal Protective Equipment ) when cleaning and disinfecting used patient equipment and when handling soiled linen and used IV (Intravenous) apparatus.

Failed to ensure staff handle prepared food in a manner to prevent food bourne illness.
This failed practice had the potential for adverse infection control outcomes that could affect all patients and staff.

Citing random observations in the Dietary suite, the operating room, In Patient Unit and outpatient surgical suite.

Findings:

Dietary suite

Observation on 2/17/2016 at 10:35 am in the dietary suite at the hospital revealed the following information:

Observation revealed the three (3) compartment sink was used for ware washing and also used for food thawing and food preparation.

Observation revealed two (2) packages of cooked frozen turkey slices were immersed in hot water in the ware washing sink.

Observation revealed the temperature measuring device on the heat sanitizing dishwashing machine in the dietary suite was not easily readable.

The temperature dial was on the base of the dishwasher at ground level. Staff had to go down on their knees onto the floor to be able to see the temperature on the dial in order to determine if the temperature was reaching the required degree to sanitize dishes.

Staff observed reading the temperature during the dishwashing process stated it was difficult to go down on the floor to read the temperature.

This hardship for staff had the potential for errors in determining if the dishes were washed and sanitize at the correct temperature.

During an interview with Staff (#R) Dietary Manager stated the meat in the sink was being thawed and will be used for sandwiches.

Staff (R) stated the sink was also used for ware washing and food preparation.

Review of the facility's Dietary policies presented for review revealed there were no instructions for cleaning the sink before and after being used to prepare or thaw food.
The policy instructed staff to :

'Thaw food in the refrigerator (most preferred method).

Thaw under cool, running potable water to flow out from the food.

Defrosting in microwave with cooking immediately following thawing as part of the cooking process- for small items only'.

In Patient Unit
Observation on 2/16/2016 at 9:50 am in room 107 revealed a dirty patient gown on the floor in the patient ' s room. There was a visible blood stain on the gown.
Staff (T) Patient Care Technician picked up the gown from the floor without wearing gloves.
Observation on 2/16/2016 at 10:25 am in room 102 revealed an empty infusion bag with connected intravenous tubing label normal saline with additive of Gentamycin (antibiotic) was hanging from an IV(Intravenous) pole.
Staff (S) Registered Nurse removed the used IV bag and tubing from the pole without wearing gloves.
The Surveyor questioned the practice of handling used patient intravenous apparatus without wearing gloves and Staff (S) stated she was not aware she should have worn gloves when handling the used IV apparatus.

Review of medical record for Patient (# 17) who was the patient being cared for in room 107 , it was revealed the patient was receiving her intravenous antibiotics to treat Urinary Tract Infection.

Observation on 2/17/2016 at 9:25 am in the operation room (OR)revealed Staff (P) Registered Nurse(RN) was preparing a patient for surgery.
During the skin preparation Staff (P) changed gloves multiple times, twice changing a used gloves for sterile gloves. The staff never sanitized her hands at any time between glove changes.
Observation revealed there was a hand antiseptic cleaner accessible in the operating room.
During an interview on 2/17/2016 at 9:45 am with Staff( W), OR RN Manager she stated staff are instructed to wash their hands after each glove change.




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Review on 02/17/2016 of the Facility's current policy and Procedure on Hand Hygiene, Policy # 1626551, approved 10/2015 direct staff as follows: " Hand Hygiene shall be practiced before and after each patient contact, ( even if gloves are worn. ) All employees are required to wash, rinse and dry their hands or apply alcohol hand rub before beginning work, after using rest room and prior to leaving work.
Gloves shall be worn when exposure to blood or any other body fluids excretions or secretions is likely. "

Observation on 02/17/2015 at 8:50 a.m. revealed Patient Care Technician (F) was observed terminally cleaning Pod # 9 in the PACU. (Post Anesthesia Care Unit), after it was utilized by a patient post operatively. The Patient Care Technician donned a pair of clean gloves, removed soiled linen from Pod #9, cleaned the unit with Sani cloth wipes , walked over to Pod #3 removed the soiled linen with his gloved hands, then walked to the nurses station and removed- clean Sani-cloth from the container of Sani- cloth. The Patient Care Technician touched the Sani- cloth container stored at the nurses ' station with his contaminated gloved hands. Patient Care Technician (F) did not remove his contaminated gloves and wash/ sanitize his contaminated hands after touching contaminated linen.

During an interview on 02/17/2016 at 9:05 a.m. the Surveyor notified Patient Care Technician (F) of her observation of him not removing gloves and washing or sanitizing his contaminated hands. He responded " I am sorry. "

RN (G )
Observation on 02/17/2016 at 8:55 a.m. revealed Registered Nurse (G) was observed terminally cleaning pod #3 in the Post Anesthesia Care Unit of the facility. Observation revealed Registered Nurse (G) picked up the soiled linen that was used by the previous patient post operatively. Registered Nurse (G) was not wearing a pair of gloves when she touched the contaminated linen and gown used by the patient. After discarding the soiled linen in the soiled linen container, Registered Nurse (G) returned to Pod #3 and removed clean gloves from a packet of gloves with her contaminated hands. Registered Nurse , (G) did not wash/ sanitize her contaminated hands before removing clean gloves from the box of gloves.

During an Interview on 02/17/2016 at 9:00 a.m., the Surveyor notified Registered Nurse (G) that she did not wear gloves when touching contaminated linen and that she did not wash or sanitize her hands after touching the soiled linen. She stated " Oh yes "


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Findings:

Expired Hand Sanitizers

On 02/16/2016 at 1:55 p.m. the Physical Therapy rehabilitation services had 1 hand foam sanitizer manufactured by Symmetry Skin 550 milliliters with expiration date October 2015, Product # 90050050 located on the clean sink in the middle of the therapy room. On 02/16/2016, 2 hand foam sanitizers manufactured by Symmetry Skin with expiration date October 2015 and January 2014 with same Product # 90050050; 1 was located in the Patient Registration and 1 was at the clean sink back of the therapy room.


Interview on 02/17/2016 at 1:20 p.m. with the Unit Clerk (I), the Surveyor verified with her who uses the hand foam sanitizer in front of her that is expired, she said "Us here at the Registration either the staff or the patients." The Surveyor showed to her the expiration date in that bottle, and she said "Yes, it is expired. Alright, I will get a new one."

Interview on 02/17/2016 at 1:45 p.m. with Physical Therapist (E), the Surveyor showed to her an expired bottle of hand foam sanitizer at the back of the therapy room on top of the clean sink, she said "I will throw it away, we just started last year those sanitizers on the wall, but we did not throw it yet away." The Surveyor showed to her the other hand foam sanitizers one that was located in the Patient Registration and the other on the clean sink in front of the therapy room.


Hand washing


On 02/16/2016 at 1:48 p.m. Patient #6 was lying on the first big low mat performing exercise using a big, red ball under his feet and rolling it with his shoes on. Physical Therapist (D) was observed providing a strengthening exercise to Patient #6. He completed this exercise at 1:55 p.m., while Physical Therapist (D) placed the big, red ball on the floor without disinfecting it, and then Patient #6 left the Rehabilitation Room. Physical Therapist (D) worn a glove on her left hand, cleaned the first big low mat with no gloves on the right hand. She did not wash her hands after cleaning the big low mat, touched a red folder, and called the next patient for treatment.



Interview on 02/16/2016 at 1:55 p.m. with Physical Therapist (D), the Surveyor notified her that she returned back the ball without cleaning it after used by a patient, she used only a glove for disinfecting the mat, and did not perform hand hygiene after wiping the low mat, and she said "We clean all our equipment every night. Yes, I should have washed my hands after wiping it."

Based on interview the facility's governing body failed to appoint a director to oversee the respiratory services.


Findings:


Interview on 02/17/2016 at 9:20 a.m. with the facility's Chief Nursing Officer (T), the Surveyor verified with her if the facility provides a respiratory service and who directs it, she said "Yes, we provide respiratory service for our patients, we only have 1 respiratory therapist that acts as a technician, because the staff that perform mainly the respiratory services are the registered nurses, along with the anesthesia services. We do not currently have a director for the Respiratory since the Anesthesia department oversees that."