HospitalInspections.org

Based on observations during tour, policy and procedure review, medical record review, and staff interview, the facility's nursing staff failed to supervise and evaluate patient care by failing to ensure medications were maintained in a safe and secure location for 1 of 3 observed medication passes (Patient #22), and by failing to ensure an isolation assessment was completed every shift for 1 of 2 sampled patients (Patient #17).

The findings include:

A. Review of Hospital Policy titled "Medication Administration, PC-69" Last Revised 02/2015, revealed "...Drug Dispensing and Security...2. All medications are kept in a secure location within the department ..."

Review of open medical record for Patient #22 revealed a 46 year old female admitted on 09/06/2016 at 1903 with a diagnosis of CVA (stroke) and history of seizures. Review of the MAR (Medication Administration Record) revealed RN # 7 (Registered Nurse) administered Furosemide (fluid pill) 80 mg (milligrams) po (by mouth), ASA (Aspirin) 325 mg po, Plavix (blood thinner) 75 mg po, Nexium (heartburn) 40 mg po and Zonisamide (seizures) 100 mg po at 1259.

Observation on 09/07/2016 at 1410 on the progressive care unit revealed a medication drawer sitting in window sill of Pt #22's semi-private room. Continued observation revealed the medication drawer had opened packages of Furosemide, ASA, Plavix, Nexium and Zonisamide. Further observation revealed 3 unopened packages of Zonisamide 100 mg tablets in the drawer. The observation revealed Pt #17 was in the bed closest to the window sill. The observation revealed the patient in the other bed (closest to the door) had 5 visitors in the room.

Interview on 09/07/2016 at 1410 with AS #9 (Administrative Staff) during the observation revealed the staff should not leave medications in a patient's room. The interview confirmed the nursing staff failed to follow hospital policy for securing medications. The interview confirmed the findings.

Interview on 09/07/2016 at 1430 with RN #7 revealed "I gave the medications to the patient. I was interrupted by the wound care nurse and forgot to remove the medication drawer from the room."

B. Review of Hospital Policy titled "Patient Assessment and Reassessment, PC-41" Last Revised 04/2016 revealed "...PROCEDURE...2. Reassessment a. The patient will be reassessed: ...Minimally every shift and at unit specified intervals related to the care setting and course of treatment ..."

Review of open medical record for Patient #17 revealed a 61 year old male admitted on 09/02/2016 at 1131 with a diagnosis of severe hypokalemia. Further review revealed documentation dated 09/03/2016 at 1129 of a positive c-diff (clostridium difficile - a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon.) stool specimen result. Review of the nursing flowsheet revealed documentation of contact enteric isolation precautions for Pt #17 on 09/03/2016 at 1223 and 2026, on 09/05/2016 at 0720, 1400, and 1918, on 09/06/2016 at 0710, 0810, 1410, and 1828 and on 09/08/2016 at 0735. Further review of nursing flowsheet revealed no available documentation of contact enteric isolation precautions documented on 09/04/2016, 09/06/2016 from 7p-7a and on 09/07/2016.

Interview on 09/08/2016 at 1130 with AS #10 (Administrative Staff) revealed the nursing staff were expected to document isolation precautions every shift or every 12 hours. The interview confirmed the findings.

Based on hospital policy and procedure review, observations during tour and staff interview, the hospital's infection control officer failed to ensure infection prevention guidelines were implemented by the hospital's staff by failing to perform hand hygiene during glove changes in 5 of 14 observed staff administering patient care (MD #1, RN #2, RN #3, LPN #4, RN #7, Patient #14, #15, #16, & #22), by failing to don appropriate personal protective equipment for a 2 of 2 observed nursing staff providing care of a patient on contact enteric isolation precautions (RN #5, CNA #6, Pt #17), and by failing to clean/disinfect a hemodialysis machine prior to placing clean supplies/solutions for 1 of 1 observed hemodialysis nurses (RN #8) performing routine exterior cleaning of a dialysis machine between patients.

The findings include:

A. Review of the hospital's policy and procedure "Hand Hygiene Policy & Procedure, IC-109 PC-112" Approved 08/2015, revealed "...Effective hand hygiene decreases the risk of cross contamination from patients, patient care equipment, and the environment. Hand Hygiene is the single most important strategy to reduce the risk of transmitting organisms from one person to another or from one site to another on the same patient. Cleaning hands promptly and thoroughly between patient contact with blood, body fluids, secretions, excretions, equipment and potentially contaminated surfaces is an important strategy for preventing infections."

1. Observation on 09/06/2016 at 1115 in the hospital's intensive care unit revealed RN #2 (Registered Nurse) administered medications to patient #14 (Pt). The observation revealed RN #2 washed her hands with soap and water, donned gloves and then documented on a shared computer in Pt #14 ' s room. Continued observation revealed RN #2 scanned the patient ' s armband and without hand hygiene or removing gloves proceeded with medication administration through a central intravenous catheter. Further observation revealed RN #2 removed gloves and pulled her work telephone from her uniform pocket and answered an incoming call. Continued observation revealed RN #2, while still talking on the telephone, washed her hands, placed the telephone back into her uniform pocket and without hand hygiene donned disposable gloves. Continued observation revealed RN #2 continued with medication administration through the central line catheter. Further observation revealed RN #2 cleaned the central lumen (line) port with an alcohol pad, then placed open port on the patient's chest and bed linens while she removed a lumen port cap (cover for line tip) from a bag hanging from the IV (Intravenous) pole. Continued observation revealed RN #2 placed the lumen port cap on the lumen tip without further cleaning. Further observation revealed RN #2 removed IV tubing from a previously used antibiotic bag, cleaned the spike (inserts directly into fluid bag) on the end of the tubing with an alcohol pad and then placed the spike into a new antibiotic bag lying on a table/cart at patient's bedside without cleaning the port.

Interview on 09/06/2016 at 1115 with AS #9 (Administrative Staff) during the observation revealed the staff should have performed hand hygiene after removing gloves and before touching shared equipment The interview confirmed the nurse did not follow the hospital's hand hygiene policy. The interview confirmed the finding.

2. Observation on 09/06/2016 at 1125 in the hospital's intensive care unit revealed MD #1 (Medical Doctor) cleaned hands with foam and turned to speak with a nurse in hallway, placing cleaned hands on the back of her jacket and then proceeded into Pt #14's room without hand hygiene. Continued observation revealed MD #1 went to the patient's bedside, touching rails on bed, bed linens and patient without further hand hygiene and without gloves. Further observation revealed MD #1 moved from bedside, donned disposable gloves (right hand fully gloved, left hand gloved half way up hand with thumb exposed) without hand hygiene. Continued observation revealed a sink with soap and water was present in the room beside the glove boxes. Further observation revealed MD #1 removed the left hand glove and answered his cell phone. Continued observation revealed MD #1 exited Pt #14's room into the hallway with phone in his left hand and the removed left hand glove in right gloved hand. Continued observation revealed MD #1 hung up telephone, removed right hand glove and threw in hallway trashcan without further hand hygiene. Further observation revealed MD #1 proceeded into another patient's room and begin patient care without hand hygiene or donning gloves.

Interview on 09/06/2016 at 1125 with AS #9 (Administrative Staff) during the observation revealed the staff should have performed hand hygiene after removing gloves, before touching shared equipment and before entering another patient's room. The interview confirmed the physician did not follow the hospital's hand hygiene policy. The interview confirmed the finding.

3. Observation on 09/06/2016 at 1135 in the hospital's intensive care unit revealed RN #3 sitting at Pt #15's bedside donned in an isolation gown with no gloves using her personal cell phone, while monitoring the patient's hemodialysis treatment. The observation revealed RN #3, while still holding phone, checked IV lines, hemodialysis lines and documented on patient's chart without performing hand hygiene before or after equipment contact and without donning gloves.

Interview on 09/06/2016 at 1135 with AS #9 (Administrative Staff) during the observation revealed the staff should have performed hand hygiene before and after touching shared equipment The interview confirmed the nurse did not follow the hospital's hand hygiene policy. The interview confirmed the finding.

4. Observation on 09/06/2016 at 1215 in the hospital's progressive care unit revealed LPN #4 (Licensed Practical Nurse) administered medications to Pt #16. Observation revealed LPN #4 cleaned hands with foam and donned disposable gloves. Continued observation revealed LPN #4 documented on a shared computer in Pt #16's room and without removing gloves or further hand hygiene, cleaned the hub on an IV saline lock and flushed with sterile solution.
Interview on 09/06/2016 at 1215 with AS #9 (Administrative Staff) during the observation revealed the staff should have performed hand hygiene before and after touching shared equipment The interview confirmed the nurse did not follow the hospital's hand hygiene policy. The interview confirmed the finding.
5. Observation on 09/07/2016 at 1445 in the hospital's progressive care unit revealed RN #7 threw a label with Patient #22's demographic and medication information in the trashcan in the medication/clean supply room. Continued observation revealed RN #7 digging through the trashcan, throwing trash out onto the medication/clean supply room floor without gloves. The observation revealed RN #7 removed the trashcan liner and dumped the remaining contents of the trashcan on the medication/clean supply room floor.
Interview on 09/07/2016 at 1445 with AS #9 (Administrative Staff) during the observation revealed staff should not go through the trash and should wear gloves when handling any type of trash. The interview confirmed the finding.

B. Review of the hospital's Contact Isolation and Enteric Precautions signage revealed "CONTACT PRECAUTIONS ENTERIC PRECAUTIONS Perform hand hygiene before entering room or cubicle and wash hands with SOAP AND WATER for 15 seconds before leaving the room. (Written in English and Spanish language) Gloves when entering the room. Gown for direct patient care or whenever clothing may contact surfaces in the room."

Observation on 09/06/2016 at 1230 in the hospital's progressive care unit revealed RN #5 cleaned hands with foam, donned an isolation gown and entered Pt #17's room. Continued observation revealed a Contact Isolation Enteric Precautions sign posted on Pt #17's room door which read "Gloves when entering the room." The observation revealed RN #5 entered Pt #17's room without gloves. Further observation revealed CNA #6 (Certified Nursing Assistant), donned with gloves only, carrying dirty supplies to the in-room bathroom and walking back behind the curtain to the patient care area without hand hygiene.

Interview on 09/06/2016 at 1245 with AS#9 during the observation revealed the staff should have worn gloves and isolation gowns during any contact with a patient on contact enteric isolation precautions and should have washed hands with soap and water after touching contaminated supplies/equipment.

C. Review of Contract Hemodialysis Policy and Procedure Titled "Termination of dialysis with all dialyzer types..." revised March 2015, revealed "...Clean exterior surface of dialysis deliver system ..."

Observation on 09/07/2016 at 1545 revealed RN #8 cleaned a hemodialysis machine with a Clorox/water combination and washcloth between patients. The observation revealed RN #8 picked up the dialysis bath solutions from the machine and wiped/cleaned underneath them. Observation revealed the bath solutions had a hand-written date/time of 09/07/2016 at 1507.

Interview on 09/07/2016 at 1545 with RN #8 during the observation revealed "I put new bath solutions on the machine for the next patient. I document on the new bottles the date and time they were opened."

Interview on 09/08/2016 at 1255 with NM #10 (Nurse Manager) revealed the staff should not place clean supplies or new solutions on the machines until after they have been cleaned and wiped down with an appropriate disinfectant. Interview confirmed the staff did not follow company policy for cleaning a dialysis machine.