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Based on record review and interview, the facility failed to have a system in place to identify problems with physician on-call procedures for 1 of 1 patient requiring specialty consult in the Emergency Department (Patient #10).

Findings include:

Review of facility policy "Physician and Midlevel Coverage in the Emergency Department" dated 9/12/2017 revealed "Specialty consultation is available to respond to the hospital within 30 minutes. Call schedules maintained by the Registration Department in the AMION (am I on) system are used to determine which physician is on call... II. Assignment of Primary and Specialty Physicians/Dentists/Podiatrists to On-Call Schedules: A. Physician Coverage: Each primary and specialty physician/dentist/podiatrist who is assigned to a call schedule provided there is more than one physician practicing in that specialty."

Per medical record review, Patient #10 presented to the Emergency Department on 3/3/2018 at 2:17 PM with complaints of abdominal pain and blood in stool. Review of the Emergency Department Provider report revealed "I placed a consult in to [Physician EE], GI [gastrointestinal] doctor. Several attempts were made to page and contact the on-call GI doctor. Due to the acuity of this patient I felt it necessary to contact the GI specialist in [receiving facility city]." Review of Patient #10's certification for transfer revealed "[Transferring Facility] does not have the capability of providing appropriate services for this patient. Describe below: 'GI intervention, could not contact on-call GI doc" (physician).

The facility's AMION on-call schedule for 3/3/2018, reviewed on 3/6/2018 at 11:45 AM, revealed "Service: Gastroenterology [telephone number]. Time: 8A-8A. Name: [Physician EE]." This was followed by contact information. During an interview at the time of the review, Registered Nurse X stated "[Physician EE] is our only GI doctor, but [EE] is almost always on call." When asked how specialty services are contacted for consult, Registered Nurse X stated "we follow what the list [AMION] says, it would tell us if someone isn't on call or not available."

During an interview on 3/6/2018 at 4:00 PM, Chief Medical Officer DD stated "[Physician EE] would say [EE] is always on call."

During an interview on 3/7/2018 at 10:55 AM, Chief Medical Officer DD stated "our policy states if we only have one provider, they don't have to be on-call all the time. Since we only have one [GI provider], [EE] doesn't have to be on call all the time." Per DD, "if [EE] isn't available, [EE] calls the switchboard and let's them know if not available or available by telephone only...they enter it on the AMION software." When asked about the procedure when a physician is on call per the AMION system and doesn't respond, Chief Medical Officer DD stated "non-response should always be relayed to the supervisor so we can look into it. When I talked to [Physician EE], [EE] hadn't not been available for calls in a couple of months and did not know of any pages that hadn't been answered or responded to." DD stated they weren't sure why there was no response. Per DD, "it could have been a technical or system error, if it [the page] didn't go through we need to be notified."

Based on record review and interview, staff at this facility failed to ensure that the Important Message from Medicare informing Medicare recipients of their discharge appeal rights was given to eligible patients within 48 hours of admission and/or discharge in 3 out of 4 Medicare eligible medical records reviewed out of a total of 32 records reviewed (Patient #27, #20 and #22).

Findings include:

The facility policy titled, "An Important Message from Medicare-Discharge Appeal Process," #1400102, dated 11/25/14, was reviewed on 3/7/2018 at 11:30 AM. The policy revealed, "Registration staff will obtain the signature of all Medicare and managed Medicare beneficiaries or their representative...on the IM [important message] at the time of registration...Discharge Procedures (Follow-up Copy IM) Delivery should be no more than 2 days before the planned date of discharge and at least 4 hours before discharge. The Case Manager will provide one copy of the IM to the beneficiary and request their signature on the backside of the form with the date and time under "Additional Information" indicating the receipt of the notice."

A medical record review was conducted on Patient #27's closed medical record with Surgical Services Supervisor M, Registered Nurse C, and Chief Nursing Officer B who confirmed the following finding during an interview: The medical record revealed that Patient #27, a Medicare recipient, was admitted on 2/13/2018 and discharged on 2/17/2018. There was no second signature on the Medicare Discharge Appeal form indicating Patient #27 received this information prior to discharge.





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Patient #20's closed medical record was reviewed and revealed that Patient #20 was admitted on 9/4/17 and discharged on 9/8/17. There was no second signature on the Medicare Discharge Appeal form indicating Patient #20 received this information prior to discharge.

Patient #22's closed medical record was reviewed and revealed that Patient #22 was admitted on 12/19/17 and discharged on 12/30/17. There was no second signature on the Medicare Discharge Appeal form indicating Patient #20 received this information prior to discharge

Per interview with Patient Relations Coordinator HH on 3/5/2018 at 2:15 PM regarding the Medicare Discharge Appeal form, Coordinator HH stated, "Case management staff manage that and the patient gets one on admission and prior to discharge."

Based on record review and interview the hospital failed to appropritely monitor safety of patients in restraints per their policy in 2 of 2 patient restraint records reviewed (Patient # 1 and #2).

Review of policy titled "Restraints (System Wide)" #15400 effective 5/07/2017 under IV. Non-Behavioral (Medical Management)Restraint Protocol d. Monitor i. revealed "Assessment - At initiation, every four (4) hours minimally".

Review of Patient #1's medical record, patient assessment care plan titled "Restraint Asmt (Assessment) Level 2 MedMgmt" (medical management) with Director Medical/Surgical Unit N revealed Patient #1's wrist restraints were applied 2/26/18 at 2:20 PM and discontinued on 3/03/18 at 4 PM. 4 hour nursing assessments for wrist restraints were missing on Patient #1, once on 3/01/18 (between 3:39 AM and 9 AM) and twice on 3/02/18 (between 1 AM and 5:15 AM and 7:31 AM and 12 PM) for a total of 3 of 30 minimum four hour wrist restraint checks required per hospital's policy.

Review of Patient #2's medical record, patient assessment care plan titled "Restraint Asmt (Assessment) Level 2 MedMgmt" (medical management) with Director Medical/Surgical Unit N revealed Patient #2's wrist restraints were applied 2/28/18 at 6:47 AM and discontinued on 3/06/18 at 8:50 AM. 4 hour nursing assessments for wrist restraints were missing on Patient #2, 3 times on 2/28/18 (between 6:47 AM and 11:31 AM, 11:31 AM and 6:12 PM, and 6:12 PM and 3/01/18 at 12:42 AM), 3 times on 3/01/18 (between 12:42 AM and 6:17 AM, 6:17 AM and 10:44 AM, 10:44 AM and 4:44 PM), 4 times on 3/02/18 (between 12 AM and 4:10 AM, 8 AM and 12:21 PM, 3:30 PM and 7:43 PM, 7:43 PM and 3/03/18 at 12 AM), twice on 3/03/18 (between 3:47 AM and 7:55 AM, 7:55 AM and 12:35 PM), 3 times on 3/04/18 (between 7:54 AM and 2:39 PM, 3:50 PM and 7:52 PM, 11:34 PM and 3/05/18 at 4:30 AM), 3 times on 3/05/18 3 (between 7:57 AM and 12:10 PM, 3:54 PM and 7:41 PM, 7:41 PM and 3/06/18 at 1 AM) and once on 3/06/18 (between 4:13 AM and 1:12 PM) for a total of 19 of 37 minimum four hour wrist restraint checks required per policy.

During interview with Manager of Med/Surg N on 3/06/18 between 12 PM and 1:34 PM, N confirmed there were missing 4 hour nursing assessments for Patient #1 and #2.

Based on record review and interview, facility staff failed to monitor 1 of 3 Emergency Department patients per policy (Patient #10).

Findings include:

Review of facility policy "Normal Assessment Standard on the ESD Patient" revealed "The protocol will be utilized to assess all patients in Emergency Services. ...Assessment needs to be completed upon admission to the ESD [Emergency Services Department]. Subsequent abnormal findings are reassessed as follows: ...Class III VS/reassess every 1-2 hours..."

Per medical record review, Patient #10 presented to the Emergency Department on 3/3/2018 at 2:17 PM with complaints of abdominal pain and blood in stool. Patient #10 was triaged at a level III (3) at 2:36 PM. Patient #10's vital signs were documented on 3/3/2018 at 2:36 PM and then not again until 8:12 PM, more than 5 hours later. Patient #10 was transferred out of the Emergency Department on 3/4/2018 at 2:03 AM. Patient #10's initial nursing assessment was documented on 3/3/2018 at 4:06 PM, the next documented assessment was on 3/4/2018 at 2:10 AM, more than 10 hours later.

During an interview on 3/6/2018 at 11:30 AM, Emergency Department Director W stated staff are expected to document assessments and vital signs per the policy, every 1 to 2 hours.

Based on record review and interview facility staff failed to provide timely interventions and document progress toward nursing care plan goals for 5 of 32 patients reviewed (Patient #5, Patient #7, Patient #16, #31 and #32) and failed to provide instructions to 1 of 1 patients leaving against medical advice (Patient #5).

Findings include:

Review of facility document "Medical/Surgical/Pediatric Unit Scope of Services" dated 10/2017 revealed "Care Planning: Care plans and nursing interventions are regularly updated or revised based on physician orders or a change in patient condition. ...Education on disease management and new skills are incorporated in the plan of care as the patient prepares to transition home."

Review of facility policy "Safety of Patients Who Leave Against Medical Advice (AMA) and Patient Elopement" dated 7/13/2016 revealed "1. If a competent/decisional patient wishes to leave the health care facility against medical advice (AMA)... d. Appropriate discharge instructions will be provided and documented."

Review of medical record for Patient #5 revealed Patient #5 was admitted to the facility on 3/5/2018 at 3:00 AM for seizures and alcohol detox (removal of toxins, poisons or harmful substances from the body). A care plan for "Ineffective Coping" was initiated on 3/5/2018 with a goal "Patient will be informed of support and or treatment opportunities for alcoholism." Interventions initiated include "Provide information: -Community classes; -Provide patient with alcohol/drug rehabilitation contact numbers; -[County Services]." Patient #5 was discharged from the facility against medical advice on 3/6/2018 at approximately 3:00 PM, 36 hours after admission. There was no evidence in Patient #5's medical record that interventions had been performed to help Patient #5 meet the care plan goal.

Review of Patient #7's medical record revealed Patient #7 was admitted to the facility on 3/2/2018 for hypoxemia (low oxygen saturations). A care plan for "Knowledge Deficit: COPD [Chronic Obstructive Pulmonary Disease]" was initiated on 3/2/2018 with a goal "Patient will demonstrate increased understanding of disease process." Interventions initiated include "Instruct on COPD; Instruct on Respiratory Anatomy; Instruct on Nutrition needs for COPD; Instruct on complication of COPD; Instruct on emotional concerns in COPD; Instruct in Community resources for patient with COPD." At the time of Patient #7's medical record review on 3/7/2018 at 10:30 AM, Patient #7 had not received any education or interventions pertaining to the Knowledge Deficit care plan.

Review of Patient #16's medical record revealed Patient #16 was admitted to the facility on 3/5/2018 for nausea and electrolyte imbalance. A care plan for "Knowledge Deficit: CHF [Congestive Heart Failure]" was initiated on 3/5/2018 with a goal "Patient/Significant Other will verbalize understanding of the etiology of CHF and future prevention of CHF." Interventions initiated include "CHF Education and Knowledge Assessment." At the time of Patient #16's medical record review on 3/7/2018 at 11:00 AM, Patient #16 had not received an education or knowledge assessment.

Review of Patient #31's closed medical record with the Director of Family Birth Place O revealed Patient #31, a newborn, was born on 2/22/2018. On the care plan under the problem "Potential for complications" the goal revealed, "The patient will remain free of complications." The goal did not indicate what complications Patient #31 was to remain free from.

Review of Patient #32's closed medical record with the Director of Family Birth Place O revealed Patient #32, a newborn, was born on 2/22/2018. On the care plan under the problem "Potential for complications" the goal revealed, "The patient will remain free of complications." The goal did not indicate what complications Patient #32 was to remain free from.

Per interview with Director O on 3/7/2018 at 10:30 AM regarding standardized computer care plans, Director O stated that nursing staff does have the ability to go in to the care plan and individualize the goals.

During an interview on 3/7/2018 at 11:15 AM, Critical Care Director P stated "I think a lot of the education components are left until the last day."

During an interview on 3/7/2018 at 11:50 AM, when asked how progress toward goals is documented, Director of Nursing N stated "there are limitations with the EHR [electronic health system], if the interventions are completed then the goal is automatically met."




26711

Based on record review and interview, facility staff failed to obtain an agreement for services for each Emergency Department visit in 1 of 3 emergency department patients reviewed (Patient #8), failed to ensure that medical record documentation was legible in 1 of 1 cesarean section anesthesia record (Patient #30), and failed to have complete documentation on 1 of 2 newborn identification records (Patient #32) in 32 patient records reviewed.

Findings include:

Review of facility policy "Agreement for Services" dated 11/6/2017 revealed "In the hospital setting, after explanation, the Agreement for Services shall be signed every time the patient is registered for a service, such as: Inpatient, Outpatient, Observation, and Emergency Services."

Per medical record review, Patient #8 presented to the Emergency Department on 2/27/2018. Patient #8's Agreement for Services is scanned in the record dated 2/27/2018, the scanned form was signed and dated 10/23/2017. Review of Patient #8's historical visits to the Emergency Department include dates of service on 2/25/2018, 1/24/2018, 11/1/2017, and 10/23/2017. 4 of the 5 ER visits all contained the same scanned Agreement for Services, signed and dated 10/23/2017.

During an interview on 3/6/2018 at 10:30 AM, Registered Nurse X stated "I'm not sure why they are all the same. Registration usually has them [patients] sign every time they come in I think." Review of medical staff rules and regulations did not contain the expectation of legibility of medical records for the medical staff.


26711


Review of Patient #30's closed medical record with Director of Family Birth Place O revealed on the anesthesia record for Patient #30's cesarean section, in the remarks section, several entries were illegible. During interview with Director O on 3/7/2018 at 10:31 AM regarding the illegible entries, Director O stated, "Looks like 'went to room'," and was unable to decipher another illegible entry.

Per interview with Certified Registered Nurse Anesthetist I on 3/7/2018 at 11:00 AM, who wrote the remarks, one entry was "report to RN [Registered Nurse] (not went to room) and the other illegible entry was "supine with left uterine displacement."

Review of Patient #32's closed medical record with Director O revealed, on the Newborn Identification form, in the last paragraph that certifies that at the time of discharge the identification number on baby and mom's bracelets both match, the line where the identification number was to be written in, was blank.

Per interview with Director O on 3/7/2018 at 11:15 AM regarding this blank line, Director O stated, "They are supposed to write the number in."

Based on record review and interview, staff at this facility failed to obtain physician authentication for verbal orders in 1 of 2 maternity records reviewed (Patient #30).

Findings include:

Review of The Medical Staff Rules and Regulations, dated October 19, 2017, on 3/7/2018 at 12:30 PM revealed, "The responsible practitioner shall record and promptly authenticate (sign, time, and date) all orders within 48 hours."

Patient #30's closed medical record was reviewed on 3/7/2018 at 10:29 AM with the Director of Family Birth Place O. There was a verbal order dated 2/22/2018 at 11:30 AM that was not signed by a physician and had an electronic entry next to it that revealed, "To be Electronically singed by [physician's name]."

An interview was conducted with Chief Nursing Officer B on 3/7/2018 12:30 PM regarding this order, Chief Nursing Officer B stated that B contacted the medical record department regarding the electronic signature and the order remains unsigned.

Based on observation, record review, and interview, the hospital failed to ensure that 7 of 8 kitchen staff observed (BB, CC, KK, LL, MM, NN, OO,) prepared food with proper hair restraints in the kitchen.

Findings include:

Facility policy titled "Infection Control - Hospital Food and Nutrition Services" dated 9/9/16 was reviewed on 3/6/17 at 12:00 PM. This policy revealed "Hair should be clean, simply styled, off the collar, and covered by a hair net."

During observation on 3/6/17 at 11:30 AM in the kitchen, observed Director of Food Services BB, Food services supervisor CC, Cook KK, Dietary Aide LL, Diet Associate MM, Dietary Aide NN, and Cook OO, who prepared food and patient food trays with one to two inches of exposed hair at the front of the head.

An interview was conducted with Director of Food Services BB on 3/6/17 at 11:50 AM, Director of Food Services BB stated they have not enforced the need to cover all hair.

Based on observation, staff interviews, and review of maintenance records between March 5 and March 6, 2018, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
Hospital

K 131 Multiple Occupancies -Occupancy Separation
K 161 Building Construction Type and Height
K 222 Egress Doors
K 271 Discharge From Exits
K 293 Exit Signage
K 300 Protection Other-Sprinkler Maintenance and Sprinkler Installation
K 321 Hazardous Areas
K 324 Cooking Facilities
K 341 Fire Alarm System - Installation
K 345 Fire Alarm Systems - Testing and Maintenance
K 351 Sprinkler Syustem - Installation
K 353 Sprinklers Systems- Testing and Maintenance
K 363 Corridor - Doors
K 511 Utilities- Gas and Electric
K 915 Electrical Systems - Other
K 920 Electrical Equipment - Power Cords and Extensions
K 922 Gas Equipment - Cylinder and Storage

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, staff interviews, and review of maintenance records between March 5 and March 6, 2018, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
Hospital

K 131 Multiple Occupancies -Occupancy Separation
K 161 Building Construction Type and Height
K 222 Egress Doors
K 271 Discharge From Exits
K 293 Exit Signage
K 300 Protection Other-Sprinkler Maintenance and Sprinkler Installation
K 321 Hazardous Areas
K 324 Cooking Facilities
K 341 Fire Alarm System - Installation
K 345 Fire Alarm Systems - Testing and Maintenance
K 351 Sprinkler Syustem - Installation
K 353 Sprinklers Systems- Testing and Maintenance
K 363 Corridor - Doors
K 511 Utilities- Gas and Electric
K 915 Electrical Systems - Other
K 920 Electrical Equipment - Power Cords and Extensions
K 922 Gas Equipment - Cylinder and Storage
Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation and interview, staff at this facility failed to ensure that all surfaces are intact and in good repair in order to be disinfected in 2 of 6 departments (family birth place, medical/surgical floor) and failed to ensure that sharps and syringes are secured in in 7 of 7 rooms in the family birth place department..

Findings include

A tour of the Labor, Delivery, Recovery, and Postpartum rooms was conducted on 3/5/2018 at 12:00 PM with Chief Nursing Officer B and Director of the Family Birth Place O. In 7 out of 7 rooms, needles and syringes were observed in an unlocked drawer. Per interview with Director O on 3/5/2018 at 12:05 PM regarding the drawers where the needles were located, Director O stated that if there are medications that go in those drawers when there are patients in those rooms, then the drawers are locked, otherwise they are not and could be opened/accessed by whoever might be in the room.

On 3/5/2018 at 12:30 PM an observation in the Cesarean Section surgical room revealed that the laminate on the inside of the entry door was significantly gouged/scraped revealing a porous wood underside that would not be able to be disinfected. This finding was confirmed with Chief Nursing Officer B and Director O at the time of the observation in an interview.

A tour of the Medical/Surgical unit was conducted on 3/5/2018 at 1:00 PM accompanied by Chief Nursing Officer B and the Director of Medical/Surgical N. A supply cart in a clean utility/supply room was observed to be missing a section of laminate revealing a porous wood underside that would not be able to be disinfected. Chief Nursing Officer B confirmed this finding at the time of the observation in an interview.

Per interview with the Director of Facilities and Support Services U and Chief Nursing Officer B on 3/7/2018 at 8:10 AM regarding policies for the equipment repair related to missing laminate Director U stated, "We have nothing that would speak to this." Regarding the security of needles/sharps and syringes, Director U stated, "We do not have something specific to security of needles and syringes. We do look for not locked needles during environmental rounds."

Based on observation, record review, and interview, this facility failed to develop, implement, and maintain an active, hospital-wide program for the prevention of infections and communicable diseases by failing to develop policies and procedures to follow standards of practice for infection prevention while gowning surgical attire in 5 of 5 observations of 1 of 1 surgical patient (Patient #3); failing to perform hand hygiene per policy in 2 of 2 observations (Post Anesthesia & Gastro-Intestinal Rooms), in 1 of 1 central line dressing change (Patient #6), in 1 of 1 epidural injection observation (Patient #34), 1 of 2 blood glucose checks (Patient #33), in 4 of 4 medication administrations in 3 patients (Patient #5, #4 and #3) and 1 of 1 observation (Patient #6); and by failing to mitigate risks contributing to healthcare-associated infections in 1 of 1 (dirt utility room), 1 of 1 procedure room (Gastro-intestinal), 1 of 2 isolation patients observed (Patient #1), and 1 of 1 chemical dispensing systems.

Findings include:

The facility failed to develop policies and procedures to follow standards of practice for infection prevention while gowning surgical attire. (See Tag A-748)

The facility facility staff failed to perform hand hygiene per policy, and failed to mitigate risks contributing to healthcare-associated infections. (See Tag A-749)

The cumulative effect of these systemic problems result in the hospital's inability to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Based on observation, record review, and interview, the facility failed to develop policies and procedures to follow standards of practice for infection prevention while gowning surgical attire in 5 of 5 observations of 1 of 1 surgical patient (Patient #3).

Findings include:

Per interview with Surgical Supervisor M on 3/6/2018 at 8:20 AM regarding standards of practice for the surgery department, Supervisor M stated, "AORN (Association of peri-Operative Registered Nurses) for up here and AAMI (Association for Advancement in Medical Instrumentation) for sterile processing."

Review of Association for peri-Operative Registered Nurses, Publish Date: May 30, 2017 "A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn."

Review of 2014 edition of AORN Perioperative Standards and Recommended Practices. "The recommendation for non-scrubbed personnel to wear long-sleeved jackets in the OR (Operating Room) or invasive procedure room is not a new recommendation. It has been a part of the AORN 'Recommended practices for surgical attire' since 1994. Wearing long-sleeved attire helps contain skin squames shed from bare arms."

Review of policy titled, "Infection Control-Surgery and Outpatients Procedures/Sterile Processing," #0700509, dated 3/21/2017, lists as a reference 2017 AORN Guidelines for Perioperative Practice, section regarding surgical attire. This policy does not address covering of arms, hair, or ears in the surgical suite per AORN standards.

During observation in the Operating Room on 3/6/2018 between 9:15 AM and 10:39 AM, during Patient #3's surgical procedure, Certified Registered Nurse Anesthetist I was observed wearing a blue disposable surgical bouffant which was tucked behind the ears, exposing both ears. These findings were confirmed during interview with Infection Preventionist L and Surgical Supervisor M on 3/6/2018 at 11:30 AM.

During observation in the Operating Room on 3/6/2018 between 9:20 AM and 10:39 AM the following staff were observed to be wearing cloth surgical hats that did not cover all of the hair (in the back of the head) or the ears during the set up of the sterile field: Registered Nurses G and H and Surgical Technician F, during Patient #3's surgical procedure (surgical insertion of a port-a-cath, implanted device for medication administration). These findings were confirmed during interview with Infection Preventionist L and Surgical Supervisor M on 3/6/2018 at 11:30 AM.

During observation on 3/06/18 at 10:10 AM, Doctor J was observed to enter the operating room where sterile instruments were opened and the surgeon had just begun Patient #3's sterile procedure, without a cover jacket to cover arm hair, and wearing a skull cap which exposed both ears and approximately 1 1/2-2 inches of hair at the back of the head. During interview on 3/06/2018 at 11:30 AM with Infection Preventionist L and Surgical Supervisor M, Supervisor M stated that they would get push back from some doctors about the skull caps, "They want evidenced based data that says they can't wear them."

During observation on 3/06/18 at 10:17 AM, Radiology Technician K entered the operating room to operate the C-arm (x-ray machine) and wore a cloth surgical bonnet that did not contain all the hair or the ears. This finding was confirmed during interview with Infection Preventionist L and Surgical Supervisor M on 3/6/2018 at 11:30 AM.




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Based on observation, record review and interview, facility staff failed to perform hand hygiene per policy in 2 of 2 observations (Post Anesthesia & Gastro-Intestinal Rooms), in 1 of 1 central line dressing change (Patient #6), in 1 of 1 epidural injection observation (Patient #34), 1 of 2 blood glucose checks (Patient #33), in 4 of 4 medication administrations in 3 patients (Patient #5, #4 and #3) and 1 of 1 observation (Patient #6); and the facility failed to mitigate risks contributing to healthcare-associated infections in 1 of 1 (dirt utility room), 1 of 1 procedure room (gastro-intestinal), 1 of 2 isolation patients observed (Patient #1), and 1 of 1 chemical dispensing systems.

Findings include:

Per interview with Infection Preventionist L on 3/6/2018 at 11:45 AM regarding the standards of practice for infection prevention and hand hygiene at this facility, Infection Preventionist L stated, "APIC (Association of Professionals for Infection Control and Epidemiology), CDC (Centers for Disease Control), and the 5 moments of hand hygiene from WHO (World Health Organization)."

Hand Hygiene

Review of Centers for Disease Control Hand Hygiene Recommendations, Date last modified: October 12, 2007
IV.A. Hand Hygiene
IV.A.3.b. After contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings.
IV.A.3.c. After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient).
IV.A.3.d. If hands will be moving from a contaminated-body site to a clean-body site during patient care.
IV.A.3.e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient .
IV.A.3.f. After removing gloves.

Review of facility policy "Hand Hygiene" dated 5/24/2017 revealed "B. Use an alcohol-based hand rub in all other recommended situations, as follows, unless hands are visibly soiled: 1. Before and after direct patient contact. 2. Before donning sterile gloves. ...4. After contact with a patient's intact skin. ...6. After removing gloves. 7. When moving from a contaminated body site to a clean body site during patient care."

The facility's policy titled, "Infection Control-Surgery and Outpatients Procedures/Sterile Processing," #0700509, dated 3/21/2017, was reviewed on 3/7/2018 at 5:07 AM. The policy revealed, "Hand wash is to be performed upon reporting for duty, between patient contact and whenever gloves are removed."

Per interview with Chief Nursing Officer B on 3/6/2018 at 8:45 AM regarding if the surgical department follows the same hand hygiene guidelines as the rest of the hospital, Chief Nursing Officer B replied, "I believe so."

During observation on 3/6/2018 at 7:53 AM, Registered Nurse C was observed performing hand hygiene at a sink in the Post Anesthesia Care Unit. Without using a paper towel, Nurse C shut off the faucet potentially recontaminating C's hands. This finding was confirmed during interview on 3/06/18 at 11:30 AM with Infection Preventionist L and Surgical Supervisor M.

During observation on 3/6/2018 at 9:01 AM and 9:03 AM Registered Nurse E was observed performing hand hygiene at a sink in the Gastro-Intestinal Procedure room. Without using a paper towel, Nurse E shut off the faucet potentially recontaminating E's hands on both occasions. This finding was confirmed during interview on 3/06/18 at 11:30 AM with Infection Preventionist L and Surgical Supervisor M.

During observation of Patient #6's central line dressing change on 3/6/2018 at 8:10 AM, Registered Nurse Y donned gloves to remove Patient #6's dressing. Registered Nurse Y then removed the gloves and donned a pair of sterile gloves without performing hand hygiene to disinfect the catheter exit site and apply a new dressing. During an interview on 3/7/2018 at 11:45 AM, Director of Nursing N stated "hand hygiene is expected when moving from dirty to clean tasks."

During observation on 3/06/18 at 9:35 AM of an epidural injection at L4-L5 was performed in the Radiology Department, Room 3, by Physician JJ. Physician JJ did not do hand hygiene prior to donning sterile gloves at the start of the procedure and did not do hand hygiene after gloves were removed after the procedure. During interview after the procedure on 3/06/18 at 10:48 AM with X-ray Tech II, II confirmed Physician JJ should have performed hand hygiene before and after the procedure. During interview on 3/07/18 at 11:50 AM, Director of Nursing N confirmed staff should be performing hand hygiene before applying gloves pre-procedure and after removing their gloves post procedure.

During observation on 3/7/2018 at 11:30 AM, Registered Nurse FF donned gloves to perform Patient #33's blood glucose check. After checking Patient #33's blood glucose, Registered Nurse FF wore the same pair of gloves to write on the white board in the room and handle Patient #33's call light, telephone, and menu at bedside without first removing gloves or performing hand hygiene. During an interview on 3/7/2018 at 11:55 AM, Director of Nursing N stated FF "should have removed the gloves and performed hand hygiene" after the procedure, before touching multiple other items in the room.

On 3/6/2018 between 8:55 AM and 9:18 AM in the Gastro-Intestinal Procedure room, Registered Nurse D was observed to have gloves on. Wearing the same gloves Nurse D was observed to touch Patient #4 to assist to reposition, document on the computer, enter pocket for an unknown supply, give intravenous medications, handle a specimen cup for the physician to deposit a tissue sample from the colonoscope, document on the computer again, and enter scrub pocket again. Glove changes and/or hand hygiene were not performed between any of these tasks. During interview on 3/6/2018 at 11:30 AM with Infection Preventionist L and Surgical Supervisor M, Infection Preventionist L stated "they" [staff] should not be putting their hands in their pockets."

Medication Administration

The facility's procedure titled, "Administration of Medication: Administering Medications via IV [intravenous] Bolus or IV Push," published by Cinhal Information Systems (company that publishes nursing and allied health literature), dated 2018, was reviewed on 3/7/2018 at 11:30 AM. The procedure revealed in part, "What You Need to Know Before Administering Medications via I.V. Bolus or I.V. Push...Use correct aseptic technique, which includes, at minimum, hand hygiene before and after preparation and administration of medication/solution...disinfection of the I.V. access port, needleless connection, or other vascular access device prior to administration of the medication/solution."

During observation on 3/6/2017 at 8:25 AM, Registered Nurse Z removed Patient #5's nicotine patch without gloves, opened a new patch and applied to Patient #5's skin without gloves. Registered Nurse Z then donned gloves without performing hand hygiene and administered a subcutaneous injection to Patient #5. Registered Nurse Z removed the gloves and proceeded to administer Patient #5's oral medications without performing hand hygiene. During interview on 3/7/2018 at 11:50 AM, Director of Nursing N stated staff should be performing hand hygiene "after taking off gloves."

During observation on 3/6/2018 in the Gastro-Intestinal Procedure room, Registered Nurse D was observed accessing Patient #4's intravenous port without cleansing the port with alcohol at the following times: 9:00 AM, 9:02 AM, 9:04 AM, and 9:06 AM. These findings were confirmed during interview on 3/06/18 at 11:30 AM with Infection Preventionist L and Surgical Supervisor M.

During observation in the Operating Room on 3/6/2018 at 10:28 AM, Certified Registered Nurse Anesthetist I was observed to remove gloves, not perform hand hygiene, then obtain medications from the Pyxis machine and apply new gloves and continue anesthesia support for Patient #3. This finding was confirmed during interview on 3/06/18 at 11:30 AM with Infection Preventionist L and Surgical Supervisor M.

During observation in the Operating Room on 3/6/2018 at 10:37 AM, Certified Registered Nurse Anesthetist I was observed to remove gloves, not perform hand hygiene, administer intravenous medication to Patient #3 before performing hand hygiene, and then did hand hygiene. This finding was confirmed during interview on 3/06/18 at 11:30 AM with Infection Preventionist L and Surgical Supervisor M.

Storage

During a tour of the Critical Care Unit on 3/5/2018 at 12:40 PM with the Director of Critical Care P and Chief Nursing Officer B, several stacks of informational pamphlets were observed in a drawer in a dirty utility room. During an interview at the same time, Director P stated that these pamphlets were intended for patients and families and should not be stored in the dirty utility room.

Review of AORN Guidelines for Processing Flexible Endoscopes, Recommendation IX, aornstandards.org Jan 2018:
"Flexible endoscopes and endoscope accessories should be stored in a manner that minimizes contamination and protects the device or item from damage...IX.a. Cabinets used for storage of flexible endoscopes should be situated in a secure location in the clean workroom of the endoscopy processing room in a two-room design or in a separate clean area close to, but not within, the endoscopy procedure room."

On 3/6/2018 at 8:55 AM in the Gastro-Intestinal Procedure room, observation revealed clean endoscopes were being stored in a vented cabinet in the same room that colonoscopies are being performed. During interview on 3/06/18 at 9 AM with Surgical Supervisor M, M stated, "That was not an issue for [accrediting organization]."

Isolation Procedures

Patient #1 was in contact and droplet isolation precautions on 3/6/2018. During observation of care on 3/6/2018 at 8:45 AM, while in Patient #1's room to perform an assessment, Registered Nurse AA left the room to obtain a stethoscope. Registered Nurse AA stated "there should be one [stethoscope] in here. I wonder if someone forgot and brought it out with them."

During an interview on 3/7/2018 at 11:50 AM, Director of Nursing N stated "there should be dedicated equipment" in isolation rooms.

Cleaning

Per review of the manufacturer's recommendations for use for the 3M products used at this facility, dated July 2017, the recommendations revealed, "We recommend that end users check their disinfectant and/or sanitizer active concentration levels to help ensure dilution and active ingredient accuracy. This can be accomplished through the use of test strips, titration kits, and/or analytical methods."

Per interview with the Director of Facilities and Support Services U on 3/7/2018 at 8:05 AM regarding checking the concentration of chemicals after changing a container on the automated chemical dispensing system used by housekeeping staff for cleaning, Director U stated that to U's knowledge there are no routine checks of the concentration. Director U stated that the vendor will check the concentration if staff at the facility suspect something is not right, but to U's knowledge, there are no logs of this.





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Based on observation, record review and interview, the facility failed to accurately post emergency response information in 1 of 2 offsite locations toured (Rehabilitation Clinic).

Findings include: Review of the facility's "Special Situation Plans -- EMERGENCY" guide dated 8/2017 revealed "Emergency - Dial #282; Offsite Locations - Dial 9-911."

During an interview on 3/7/2018 at 8:40 AM, Rehabilitation Director GG stated "We call 9-911 for medical emergencies."

During observation of the offsite, outpatient rehabilitation clinic on 3/7/2018 at 8:50 AM, all the phones had on them a sticker labeled "Emergency -- Dial #282." Rehabilitation Director GG stated at the time of the observation, "the stickers were brought over from the hospital, we should replace those" to match the facility's emergency response plan to call 9-911.