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Based on observation, record review and interview, the facility failed to ensure 4 of 7 Patients (#20, #22, #14, and #12,) received proper nursing care as evidenced by:

-RN FF did not disinfect a glucometer she used on Patient #20 before she put the machine in her pocket.
-RN JJ performed a dressing change for Patient #22 with contaminated scissors.
-CNA KK did not perform catheter care for Patient #14 per policy and procedure and standard of care with RN LL present.
-Patient's #12, #14 and #20 had IV sites that were not dated.


Findings include:


Patient Care

Observation on 2/23/15 at 11:30 a.m. revealed RN FF was preparing to get a FSBS (fingerstick blood sugar) from Patient #20 before lunch. After getting the result, RN FF put the glucometer in her pocket before disinfecting it. She took the glucometer to the nurses' desk, took it out of her pocket and then used a germicidal wipe to disinfect it.

Record review of the facility's Policy and Procedure for Cleaning Community Equipment reviewed on 7/2015 revealed the following:

"Procedure:
Any item of community equipment utilized by a patient is to be disinfected between patient usages with recommended disinfectant wipes. Equipment includes but is not limited to:
-Glucometer meters ... "


Observation on 2/23/16 at 12:15 p.m. with DON D revealed Wound Care RN JJ was preparing to provide wound care to Patient #22. RN JJ opened a single sterile package with bandage scissors onto her clean field. She used the scissors to cut the dirty bandages off both feet. She put the scissors back on her clean field without disinfecting them. When RN JJ was applying the new dressing on both feet, she used the contaminated bandage scissors to cut the clean dressings.

During an interview at this time with RN JJ, after the patient left, she was asked about the scissors. She said she knew better, but just did not think to clean them in between the dirty to the clean site.



Observation on 2/23/16 at 1:45 p.m. with RN LL revealed CNA KK was preparing to provided indwelling catheter care for Patient #14. She started by wiping the patient's groin areas, the pubic area and then the penis. She then wiped the meatus (opening) and then the catheter tubing from the meatus out. She did not retract the patient's foreskin to fully clean around the meatus.


Interview at this time outside the patient's room with RN LL, she said CNA (certified nurses' aide) KK should have wiped the catheter first, then the meatus, penis and then outward.


During an interview at this time outside the patient's room with CNA KK, she was asked how she was taught to provide catheter care. She said she was taught in CNA school. She said she had worked at the facility for 1 year and was taught to clean from the groin to the penis.

Record review of the facility's Policy and Procedure for Indwelling Urinary Catheter Insertion, Care, Specimen Collection Procedure reviewed on 7/2015 revealed the following:

"CATHETER CARE ...
6. Catheter Care - Male ...
b. Gently grasp shaft of penis. If patient is uncircumcised, retract foreskin ...
c. Wash tip of penis at urethral meatus. First. Using circular motion, cleanse from meatus outward. Discard cloth, and repeat with clean cloth until penis is clean. Rinse and dry gently.
d. Return foreskin to its natural position.
e. Gently cleans shaft of penis and scrotum. Pay attention to underlying surface of penis. Lift scrotum carefully and wash underlying skinfolds. Rinse and dry thoroughly ....
8. Using clean cloth, wipe in a circular motion along length of catheter for about 10 cm (4 inches)..."


Observations on 2/23/16 at 2:10 p.m. with DON D of patients' IV (Intravenous) sites revealed they were not dated for Patients #12, #14, and #20.

Interview at this time with DON D, he said the IV sites should be dated and changed every 72 hours.

Based on observation, interview and record review, the facility failed to ensure there was a system for identifying, reporting, and investigating infections as evidenced by:

-Multiple areas of the facility had thick layers of dust; pre-operative area, ED (Emergency Department), and Operating Suite.
-Surgical instruments were not processed in an open position
-Laryngoscope blades and instruments were not stored in a manner to show they had been reprocessed after use.
-The kitchen staff did no ensure the proper concentration of sanitizing solution was being used in the three compartment sink and sanitizing bucket.


Findings include:


Environment


Observation on 2/22/16 at 8:50 a.m. in the pre-operative area of the surgical suite with DON (Director of Nursing) D revealed a layer of dust on the table of the medication dispensing unit. There was a layer of dust on the monitor in bay 6 and a thick layer of dust under the beds in bay 7 and bay 9.


Interview at this time with DON D, he said the facility used to use an outside agency to provided housekeeping services, but recently change to having housekeeping services done by in-house employees. He said they feel the environment is much cleaner and more sanitary than before.


Observation on 2/23/15 at 8:30 a.m. of the ED with DON D revealed a layer of dust on the top of the blanket/fluid warmer in the Trauma room. The top of the crash cart had a layer of dust. There was a thick layer of dust under the stretchers in exam rooms 2, 4 and 5.


Observation on 2/23/15 at 9:55 a.m. with DON D revealed a stretcher outside Procedure room 1 had a thick layer of dust underneath. There was dust layer on top of a bassinet outside OR 1.


Surgical instruments


Observation on 2/22/16 at 10:05 a.m. with DON D in the Obstetrical (OB) Suite revealed multiple single packaged hinged instruments in the closed position. Laryngoscope blades, Magill forceps and a straight hemostat were in the crash cart, not in any type of packaging.


Interview at this time with OB Manager, RN K, she was asked about the single packaged hinged instruments and she said they came from sterile processing that way. She was asked how she knew the laryngoscope blades and instruments in the crash cart were disinfected. She said when they were used they went to Respiratory Therapy for processing. She said she did not know what they did with them.


Interview on 2/22/16 at 2:00 p.m. with Respiratory Therapist (RT) NN, she said they used to reprocess the laryngoscopes, but stopped about two years ago. She said the RT department went to disposable laryngoscopes. She said the non-disposable blades go to Sterile Processing to be disinfected.


Observation on 2/22/16 at 1:00 p.m. with DON D and Surgery Manager RN F of the Sterile Processing storage area revealed multiple single packaged hinged instruments were in the open position.


Interview at this time with RN F, she said she would make sure the instruments were reprocessed in the open position. She said she would have to figure out what to use to keep them open with some of the instruments.


Record review of the facility's Policy and Procedure for Sterilization and Handling of Sterile Instruments and Supplies revised on 8/2014 revealed the following:

"PROCEDURE:

-Open all clamps and disassemble instruments that are designed to be taken apart for sterilization.

Record review of the facility's Policy and Procedure for Initial Decontamination of Instruments for Outlying Departments revised on 7/31/14 revealed the following:

"RESPONSIBILITY:
It is the responsibility of each team member to ensure instruments are sent to Central Sterile for proper cleaning between patients. Each instrument must be processed before used on any other patient. This refers to each and every department at (facility) which includes but is not limited to the following departments _ ...OB.


Kitchen


Observation on 2/24/16 at 8:40 a.m. of the Kitchen with DON D revealed a three compartment sink that was filled in each section. Pots and pans were upside down draining next to the sanitizing sink.


Interview at this time with Dietary Manager (DM) PP, she said they had already cleaned pots and pans from breakfast. DM PP said they used quaternary ammonia (quat.) as the sanitizer in the third sink. She was asked to check the level of sanitizer in the sink. The level was below 100 ppm (parts per million). She was asked what the level should be and she said 200 ppm. DM PP emptied the sink and refilled it with water and sanitizer. The sanitizing level was at 200 ppm. DM said whoever filled the sink must not have let the sanitizer finish its cycle or the sanitizer was blocked.


Record review of the log revealed no documentation of the amount of sanitizer when the pots and pans were processed.


Observation at this time of a sanitizing red bucket with Dietitian OO, revealed the level was below 100 ppm.


Record review of the Sanitizing bucket log for 2/24/16 revealed at 6 a.m. the level was 400 ppm and at 8 a.m. it was 250 ppm.


Interview at this time with Dietitian OO, she was asked if quat. normally degraded that fast. She said not unless someone added more water. The Dietitian was asked for the Policy and Procedures for three-compartment sink and sanitizing buckets.


Record review of the facility's Policy and Procedure for Dishwashing revised on 11/2010 revealed the following:

"PROCEDURES: ...

6. Pots and pans will be washed in a three-compartment sink or dishwasher.
7. Pots and pans will be washed using an approved detergent in recommended dilution, rinsed in clear water, and then sanitized with approved agent ....
11. Pot and pan sanitizing solutions will be monitored and recorded. "


Record review of the facility's Policy and Procedure for Food Preparation and Handling revised on 06/2013 revealed the following:

" PROCEDURE: ...
7. Cleaning cloths are stored in a sanitizing solution. Cleaning clothes are not used once soiled. Sanitizing solutions are changed once soiled or when solution is not at the correct calibration. "


Interview at this time with Dietitian OO, she was asked if she felt the policies were specific enough for what the PPM should be and which sanitizing solution was to be used. She said the policies needed to be more specific and she would be revising them.

Based on observation, record review and interview the facility failed to assure Surgical Services achieved and maintained a high standard of medical practice and patient care as evidenced by:

- "Time Out" was not performed for endoscopy procedure which is done as a patient safety practice.


Findings include:


Observation on 2/22/16 at 12:00 a.m. in procedure room #1 with DON D revealed Patient #1 was being prepared for endoscopy procedures. Patient #1 was put to sleep and the procedure was started without Dr. G, RN (Registered Nurse) Q or CRNA (Certified Registered Nurse Anesthetist) P requesting a "Time Out".


During an interview on 2/22/16 at 3:20 p.m. with OR Manager, RN F, she was asked why a "Time Out" was not done before the endoscopies were started. She said "Time Outs" were not done for endoscopies when they were initiated 8 years ago, so they did not do them. She said she had not heard if they needed to do them now for endoscopies.


Record review of the facility's Policy and Procedure for Procedural/Surgical Site Verification Policy reviewed on 03/2013 revealed the following:

" POLICY: To promote patient safety by providing guidelines for verification of correct site, correct procedure, and correct patient for invasive/surgical procedures ...

PROCEDURE: ...
9. Once the patient has been prepped and draped and the site mark is visible, a 'time out' or pause will be performed prior to the incision to validate correct patient, correct site, correct procedure, correct position, correct radiological exams, and correct implants/instruments. This 'time out' must be done in the location where the procedure is to be performed, immediately before the start of the procedure or the incision is made. Perioperative verification and 'time out' will be performed for all cases, including those not involving a site mark, except in an emergency if the risks outweigh the benefits ...
11 ....Documentation is required".


Record review of The Joint Commission on-line article on The Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery (No date) revealed Under Perform a time-out the following:
" Conduct a time-out immediately before starting the invasive procedure or making the incision ...
-Document the completion of the time-out ... "

Based on observation, record review, and interview, the facility failed to follow policy and procedure for delivery of respiratory care as evidenced by:

-A ventilator calibration was not logged as failed when last used in November 2015 and there was no documentation if the ventilator was checked out. The ventilator was still in service.


Findings include:


Observation on 2/24/16 at 9:15 a.m. with DON D of the Respiratory Therapy (RT) Department revealed Director of RT NN was asked to check the calibration of a ventilator. She said she would check the one she liked to use. When the machine was turned on the last calibration was in November 2015 and showed the PAW (measurement of airway pressure) transducer check "failed." RT NN said the machines are checked after they are cleaned so they will be ready when they are needed. She ran a calibration and the PAW transducer showed "failed" again. RT NN made adjustments and ran the calibration again. All areas showed "passed" on the second try. RT NN was asked for the calibration logs. She said there were no logs kept for the machines. She was asked for the Policy and Procedure for checking the calibration on ventilators.


Record review of the facility's Policy and Procedure for RT Procedure-Mechanical Ventilation & Protocol revised on 06/2013 revealed the following:


"Procedure: ...
Ventilator Initiation ...
3. Assure the ventilator's calibration has been verified prior to use. A sticker or some type of documentation will be attached to the equipment with the date and initials of who calibrated the ventilator .... "

Based on record review and interview, the facility failed to ensure 3 of 3 patients (#5, #28 and #29) in Swing Beds were informed both orally and in writing of their rights and all rules and regulations governing resident conduct and responsibilities with acknowledgment in writing.


Findings include:


Record review of electronic records on 2/24/16 at 1:00 p.m. with RN QQ revealed the following:

Patient #5 was admitted to a swing bed on 2/17/16 for pneumonia. There was no documentation that the patient had been education about Patient Rights either orally or in writing or any acknowledgment by the patient in writing.


Patient #28 was admitted to a swing bed on 12/22/15 for pneumonia. There was no documentation that the patient had been education about Patient Rights either orally or in writing or any acknowledgment in writing by the patient.


Patient #29 was admitted to a swing bed on 12/4/15 for acute renal failure. There was no documentation that the patient had been education about Patient Rights either orally or in writing or any acknowledgment by the patient in writing.


Interview at this time with RN QQ, she said she could not find anywhere in the patients' records where any education was done on Patient Rights or any patient acknowledgment. She did not offer anyone who might know where that information was kept.

Based on record review and interview, the facility failed to ensure 3 of 3 patients (#5, #28 and #29) in Swing Beds were provided an ongoing program of activities designed to meet their interests and physical, mental and psychosocial well-being.


Findings include:


Record review of electronic records on 2/24/16 at 1:00 p.m. with RN QQ revealed the following:

Patient #5 was admitted to a swing bed on 2/17/16 for pneumonia. There was no documentation that the patient had been provided any assessments for activities or any activities.


Patient #28 was admitted to a swing bed on 12/22/15 for pneumonia. There was no documentation that the patient had been provided any assessments for activities or any activities.


Patient #29 was admitted to a swing bed on 12/4/15 for acute renal failure. There was no documentation that the patient had been provided any assessments for activities or any activities.


Interview at this time with Medical/Surgical Unit Manager RN GG, she said she had an activity schedule for February 2016. She said she did not document if the patients participated or declined the activities or if they were offered other activities.


Record review of the Activity Schedule for February 2016 revealed the following types of activities were offered two on each day in different combinations:
Memory game, dominos, newspaper, cards, word search, trivia, current events, crosswords, puzzles, and devotions/cards.