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Based on observation, facility policy and interview, it was determined the facility failed to ensure patients, visitors and staff on the Senior Behavioral Care (SBC) Unit were in a safe environment. This had the potential to affect all patients served by this facility, visitors and staff.

Findings include:

Policy: 11.001- Environmental Safety Checks

Effective Date: 03/2012

1.0 Purpose

To ensure a safe physical environment for patients, staff and visitors.

3.0 Procedure

A. A general surveillance of each room is made daily...

8. Observed room for glass items, cords...remove from room..."


A tour of the SBC Unit was performed on 8/18/15 at 11:05 AM with Employee Identifier (EI) # 1, Chief Nursing Officer.

A bed with an electric plug in-cord 96 inches or approximately 8 feet long was observed in patient room, 2602 W.

An interview conducted on 8/18/15 at 11:10 AM with EI # 1 confirmed the bed cord was not secured and the length was in excess of 18 inches.

Based on review of facility policy and procedure, medical record (MR) and interviews, it was determined the facility failed to ensure Senior Behavioral Care (SBC) unit patients who required the use of seclusion received care according to facility policy. This did affect MR # 7, 1 of 1 SBC Unit patients reviewed requiring seclusion. This had the potential to affect all patients served by the SBC unit.

The findings include:

North Baldwin Infirmary Inpatient Policies and Procedures

Policy No. 09.001-Restraint and Seclusion

Effective Date: 03/2012

2.0 Purpose

To establish guidelines for the safe, effective use of seclusion...in accordance with state, CMS (Centers for Medicare and Medicaid Service)...regulations. To ensure the protections of the patient's rights, dignity, physical, and psychological well being of individuals requiring restraint and/or seclusion.

3.0 Definitions

C. Seclusion is the involuntary confinement of a person alone in a room or an area where the person is physically prevented from leaving...used for the management of violent or self destructive behavior.

4.0 Policy

A...Seclusion is limited...with oversight reflective of its high-risk potential...it is governed by organizational policies that provide clear guidance to staff to support their use...

5.0 Procedure

Behavioral Health Restraint and Seclusion (Violent or self-destructive behavior)

11. Continuous, in-person observation:

Monitoring of patients in restraint or seclusion is done through continuous in-person observation by a competent staff member...

12. Monitoring and Care:

c. The monitoring and assessment shall include the following...for the type restraint or seclusion employed.

1. Signs of any injury associated with...seclusion
2. Nutrition and hydration
5. Vital signs and interpreting their relevance to the physical safety of the patient in...seclusion
6. Hygiene and elimination
7. Physical and psychological status and comfort...

f. Monitoring and care are implemented and documented on the Restraint/Seclusion Flowsheet by trained and competent staff.


13. Release from Restraint

c. Staff must take appropriate actions to facilitate the individual's reentry into the milieu following release from...seclusion, including, but not limited to:

i. Providing an opportunity to discuss the experience privately within 24 hours following the release: (debriefing)

2. Debriefing:

a. The patient and, if appropriate, the patient's family, participate with staff who were involved in the episode...to meet in a debriefing about each episode of restraint or seclusion.

b. The debriefing is documented and placed in the patient's medical record:

i. Identify what led to the incident and what could have been handled differently; ascertain that the patient's physical well-being psychological comfort, and right to privacy were addressed; encourage identification of triggers, including those related to staff, peers, external stressors, and the environment..."

MR # 7 was admitted to the facility 5/20/15 with diagnoses including Schizoaffective Disorder, Bipolar and Anxiety.

Record review revealed a physician's order dated 5/26/15 at 11:15 AM for the following: " Seclusion for aggressive, violent behavior and threats to peers and staff, not to exceed 4 hours. Release when calm and no longer a danger to others".

Further medical review revealed a document titled, "15 Minute Checks/1-1 Observation Check Sheet" that included documentation on 5/26/15 at 11:15 AM MR # 7 was in seclusion, 1-1 observations in place.

Review of the 5/26/15 "15 Minute Checks/1-1 Observation Check Sheet" documentation revealed MR # 7 was in the seclusion room from 11:15 AM to 3:15 PM. On 5/26/15 at 3:15 PM nursing documentation revealed the seclusion room door was open, patient is now asleep, allowed to sleep in the room with door open and 1:1 staff present.

The record failed to include required monitoring and care, provided by staff documented on the Restraint/Seclusion Flowsheet. There was no
Restraint/Seclusion Flowsheet in the record.

Review of the 4:46 PM nursing documentation and "15 Minute Checks/1-1 Observation Check Sheet" revealed the patient was awake, remains delusional, requested a snack, provided while MR # 7 was sitting on bed in the seclusion room.

Review of the 6:15 PM nursing documentation revealed the following: MR # 7 was awake, alert and oriented to person, place and time, sitting on the bedside, quiet with labile mood and affect.

Review of the 5/26/15 nursing documentation from 8:15 PM to 5/27/15 at 1:00 AM revealed MR # 7 was in bed, resting and asleep.

Review of the 5/27/15 3:00 AM nursing documentation revealed the patient was awake, requested a shower, calm, speaking in a normal tone, cooperative with care during shower assist.

Review of the 5/27/15 6:51 AM nursing documentation revealed the "...patient was calm and cooperative with organized thoughts, compliant with his 1:1 staff...provided therapeutic communication and encouraged verbalization of feelings/thoughts..."

Nursing documentation revealed the patient was discharged on 5/27/15 at 11:15 AM.

There was no documentation staff completed and documented a patient debriefing as required per facility policy.

In an interview on 8/20/15 at 2:50 PM with Employee Identifier # 3, Senior Behavioral Unit Program Manager, confirmed the staff failed to complete the Restraint/Seclusion Flowsheet and the patient debriefing as required per policy.

Based on review of the facility's policies and procedures, medical records (MR) and interviews, it was determined the facility failed to ensure the staff:

1) Followed their own policy for wound assessment and documentation. This affected MR's # 13, # 18 and # 14, 3 of 3 records reviewed with wounds.

2) Performed blood glucose testing as ordered. This affected MR # 8, 1 of 1 Senior Behavioral Care Unit patients reviewed that required blood glucose testing.

3). Documented the anatomical location of medication injection sites. This affected MR # 7, 1 of 1 Senior Behavorial Care Unit patients reviewed who received injectible medications.

This had the potential to negatively affect all patient served by this facility.


Findings include:

Skin Assessment and Care

Purpose: To establish guidelines for skin assessment and pressure ulcer prevention and treatment

Policy: The nurse shall assess and document the condition of the skin upon admission to the unit, every shift during hospitalization, and prior to discharge.

The nurse may implement approved skin care guidelines as indicated.

The nurse shall assess changes in existing dermal lesions or pressure ulcers at the time of each treatment or dressing change.
...
"Stage III or IV pressure ulcer-...Begin wet to moist saline dressings and change twice daily...

Documentation:

Assessment of wound appearance should be done twice daily and as needed with findings documented in the nursing notes.

Documentation of wound appearance should include (if applicable) but not limited to:
Location
Size, including depth
Shape
Tunneling/undermining/margins
Description of surrounding tissue
Description of exudates
Wound care provided including dressing, if indicated
Patient's tolerance to procedure


Policy and Procedure:
Title: Medication Administration
Date Revised: 3/15

Purpose:
To establish guidelines for safe medication administration

Policy

"...Each medication order should include:
3. Route of administration

Administration
...Patient Safety

Prior to Administration of Medication:
C...Scan medication, administer medication, document date, time and site the medication was administered..."


1. MR # 13 was admitted to the facility 1/16/14 at 5:23 PM with diagnoses including Sacral Decubitus, Urinary Track Infection, Hypotension and Altered Mental Status.

Review of the skilled nurse (SN) notes documentation dated 1/16/14 at 5:23 PM revealed the following: "noted old large decub (decubitus) to coccyx area, stage 4 with brownish drainage and foul odor..."

Review of the initial critical care assessment dated 1/16/14 revealed the skin integrity had a "lesion/ulcer".

There was no documentation of the wound appearance to include size, shape, tunneling/undermining/margins, description of surrounding tissue, or if wound care was provided and patient's tolerance to the procedure.

Review of documentation by the SN on 1/16/14 at 10:35 PM contained the following: "Wound pink and tunneling noted. Site cleansed with saline and redressed with 4 by 4's and ABD (abdominal) pad"...

There was no order written for the wound care provided. There was no documentation of the size, shape, undermining/margins, description of surrounding tissue, or patient's tolerance to the procedure.

There were no measurements to include length, width, depth of the wound or tunneling measurements.

Review of documentation by the SN on 1/18/14 at 2:38 PM contained the following: "Large pink area approximately 4 inches diameter with dime sized stage 4 to rt (right) of sacrum. Wet to dry drsg (dressing) change done. Patient tolerated well".

There was no written order for the above documentation of the wound care. There was no measurements to include width, length, depth, and tunneling/undermining. There was no description of the surrounding tissue and exudate.

Physical Therapy saw the patient on 1/18/14 for assessment of the wound and debridement per consult dated 1/18/14. Documentation revealed the patient had a sacral decubitus ulcer with the following measurements: "... 14 inferior undermining 3.0 cm (centimeters) Lateral undermining 2.5 cm, Superior undermining 1.8 cm. Medial undermining 4.0. Depth of wound base= 1.4 cm. No odor or drainage noted. Wound red in color".
Wound care was documented by the Physical Therapist.

An interview conducted 8/20/15 at 10:45 AM with Employee Identifier (EI)# 9, Nurse Manager, verified the above documentation and agreed the wound assessment was not completed on the initial nursing assessment.

2. MR # 18 was admitted to the facility 8/17/15 with diagnosis of Osteomyelitis of the Right Middle Toe.

Review of the initial assessment dated 8/17/15 at 11:00 PM revealed no assessment of the patient's right middle toe wound.

An interview conducted 8/20/15 at 11:05 AM with EI # 9, confirmed the above findings and agreed the wound assessment was not completed on the initial nursing assessment.




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3. MR # 14 was admitted to the facility on 6/6/15 with diagnoses including Altered Mental Status, Hypotension and Urinary Tract Infection.

Review of the 6/6/15 10:53 PM physician's Emergency Department physical exam documentation revealed MR # 14 had a (an) infected wound on his/her right [left] lower extremity, receiving intravenous antibiotics at home.

Review of the 6/7/15 1:40 AM nursing documentation revealed the patient was "admitted to Intensive Care Unit...left heel dsg (dressing)intact...Protective boots intact, heels elevated on pillows. Orders noted."

Review of the 6/7/15 2:07 AM nursing assessment documentation revealed the presence of a "partial thickness wound to the left heel". The initial nurse assessment did not include documentation of the wound size, including depth, shape, presence or absence of tunneling/undermining/margins, description of surrounding tissue and a description of exudates as required per facility policy.

Review of the 6/7/15 7:00 AM nursing wound flowsheet documentation revealed the presence of a left heel pressure ulcer and a "water based" dressing change performed." Review of the record failed to reveal a physician's order for a water base dressing to the left heel wound.

Review of the 6/7/15 9:27 AM physician's Admission History and Physical revealed assessment of a 2 cm (centimeter) wound healing left posterior heel wound.

There was no additional nursing assessment documentation for the left heel wound on 6/7/15.

Further review revealed a 6/8/15 4:15 PM physician inpatient progress note revealed documentation home antibiotics as well as wound care would be continued. The physician's physical exam documentation revealed the following: left heel with stage III small (0.5 cm x [by] 0.5 cm) wound.

There was no 6/8/15 nursing wound assessment documentation completed.

Written questions were provided to EI # 1, Chief Nursing Officer on 8/19/15 at 3:30 PM. On 8/20/15 at 11:20 AM, EI # 1 confirmed staff failed to perform and document wound assessments according to facility policy. There was no physician's order for the 6/7/15 wound care performed.

4. MR # 8 was admitted to the facility on 8/12/15 with diagnoses including Major Neurocognitive Disorder, likely Alzheimer's Type with Disturbance of Behavior.

Review of 8/18/15 11:57 AM physician's progress note documentation revealed the presence of ketone/proteinuria secondary to Malnourishment. Check blood glucose.

Record review revealed nursing orders dated 8/18/15 at 5:00 PM for blood glucose fingerstick 4 times daily before meals and at bedtime.

Further review revealed no blood glucose testing documented prior to dinner on 8/18/15, at bedtime on 8/18/15 or before breakfast or lunch on 8/19/15. There had been no blood glucose testing completed as ordered.

In an interview on 8/20/15 at 11:35 AM with EI # 1, the aforementioned was confirmed.

5. MR # 7 was admitted to the facility 5/20/15 with diagnoses including Schizoaffective Disorder, Bipolar and Anxiety.

Record review revealed the Registered Nurse (RN) administered Geodon 20 mg (milligrams) IM (intramuscular) and Ativan 2 mg IM on 5/26/15 at 6:46 AM. There was no documented anatomical location of the medication injection sites.


Record review revealed the RN administered Prolixin 10 mg IM and Benadryl 50 mg IM on 5/26/15 at 7:44 AM. There was no documented anatomical location of the medication injection sites.


Record review revealed the RN administered Prolixin10 mg IM and Ativan 2 mg IM on 5/26/15 at 10:47 AM. There was no documented anatomical location of the medication injection sites.

In an interview on 8/20/15 at 2:50 PM with EI # 1, confirmed the staff did not complete the required documentation of IM injection sites.

Based on observations, review of the policy and procedures and interviews with the staff it was determined the dietary department failed to follow their own policies for:

1. Removal of expired products

2. Proper labeling of all opened food items

3. Proper labeling of freezer items

4. Storage of a bowl of hard boiled eggs in the middle compartment of the 3 compartment sink.

5. Proper plating of patient food

This had the potential to negatively affect all patients, visitors and staff served by the facility.

Findings include

Policy: Food and Supply Storage Procedures
Policy Number: B0006
Revised date 1/15

Policy:

All food, on-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption.

Procedures:

"...Cover, label and date unused portions and open packages...

Dry Storage:

...Remove from storage any items for which the expiration date has expired...

...Foods that must be opened must be stored in NSF (National Sanitation Foundation) approved containers that have tight-fitting lids. Label both the bin and the lid. Hang scoop. Scoops may be stored in bins on a scoop holder. The food level must be no closer that one-inch below the handle of the scoop...

Frozen Storage:

Store bulk materials in NSF approved containers that have tight fitting lids. Label both the bin and the lid...

Date and rotate items; first in, first out (FIFO)...

Policy:

Storage of Pots, Dishes, Flatware, Utensils
Policy Number F017
Revised date 1/14

Policies:

Pots, dishes, and flatware are stored in such a way as to prevent contamination by splash, dust, pests, or other means.

Procedure:

Air dry all food contact surfaces, including pots, dishes, flatware, and utensils before storage, or store in a self-draining position. Do not stack or store when wet...

1. A tour was conducted of the Dietary Department on 8/19/15 at 12:50 PM with Employee Identifier (EI) # 10, Infection Control Officer/ Registered Nurse (RN) Manager. During the tour, observations were conducted in multiple areas of the Dietary Department.

Observations conducted at the Cooler area revealed the following items were opened and not labeled with the date it was opened.

Cattleman's Bar B Que Sauce 1 gallon jug
Teriyaki Sauce 1 gallon
Mustard 128 ounce jar
A-1 steak sauce 2 bottles

Observations of the dry food shelves revealed the following food products were open with no label documented for the date the product was opened:

Quaker Oats 42 ounces 2 boxes
Olive Oil 1 gallon
Farina Cream of Wheat 28 ounce also expired 4/29/15
Croutons large bag
French's Fried onions 24 ounce bag

Observation of the Freezer revealed the following food products without labels to indicate what the food was:

Several large bags in a bin on the freezer shelf. EI # 11, Dietary Manager, was asked what was in the sealed bags. EI # 11 replied Taco meat.

An observation of the dry food bins revealed the flour container and the rice container had scoops lying on top of the food product. The scoops were not hanging up or in a food scoop holder in the bin at the proper level as per hospital policy.

An observation conducted at the 3 compartment sink revealed the first compartment of the sink contained dirty pots and pans with food residue. The middle compartment contained a large bowl with water and approximately 6 hard boiled eggs. The third compartment contained clean pots and pans stacked on top of one another.


2. An observation was conducted on 8/19/15 at 12:15 PM in the Dietary Department to observe the plating of food for the patients.

During the observation, EI # 12, Dietary Aide, was observed plating food. During the observation EI # 12 walked to the freezer and obtained a container of Parsley for the plates. EI # 12 returned to the plating line and began plating the patients food. EI # 12 failed to remove gloves after touching the contaminated cooler and container, sanitize hands and don clean gloves.

During an observation of food plating EI # 12 was also observed using a paper towel to wipe off spills on the patient plate, place the paper towel on the counter, then reuse the same paper towel for the next patient plate, thus causing contamination of each plate prepared.

During the plating process, EI # 11 was observed removing the patient plates from the line and placing on the food cart. EI # 11 then walked to the cooler removed food products and placed on the patient trays. EI # 11 failed to sanitize hands and don gloves prior to removing the plates from the line and placing items on the patient trays and failed to sanitize hands and don gloves after opening the cooler.

An interview conducted on 8/19/15 at 1:30 PM with EI # 11 confirmed the above mentioned findings.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to the Life Safety Code survey report.

Based on observations, review of facility policies and procedures, manufactures directions for use for Virex Tb and interviews, it was determined staff failed to:

1) Perform hand hygiene according to facility policy.

2) Clean and disinfect reusable equipment according to facility policy and manufactures directions for use.

3) Ensure policy for single dose and multi dose vial medication was followed.

4) Use disinfectant products per manufacturers directions and perform patient room cleaning according to facility policy and procedure.

This included observations in the gastrointestinal (GI) room, labor and delivery, Senior Behavioral Care (SBC) Unit, housekeeping and nursing unit and the Intensive Care Unit (ICU). This affected Medical Record (MR) # 1 and had the potential to negatively affect all patients served by the facility, staff and visitors.

The findings include:

Policy and Procedure:

Subject: General Department Infection Control Policy

Revised Date: 06/15

I. Policy:

A. Purpose to provide guidelines for all departments and employees for the prevention and control of infection.

II. Hand Hygiene

"Hand Hygiene is the most effective technique for preventing the spread of infection. Employees...follow established policies for hand hygiene...

A. Infirmary Health System follows CDC (Centers for Disease Control) handwashing guidelines and recommendations including:

1. Indications for hand washing...

Before having direct contact with patients.

4. After contact with body fluids, excretions...non-intact skin and wound dressings.

6. After contact with inanimate objects, (including medical equipment), in the vicinity of the patient.

7. After removing gloves...

F. Use of Gloves

1. The use of gloves does not replace the need for hand cleansing by either hand rubbing or hand washing.

XI. Cleaning of Reusable Equipment

A. Patient care equipment should be cleaned between each patient use...

1. Most equipment can be cleaned with the hospital approved disinfectant wipe/liquid disinfectant...

Terms used to understand the different types of germicides/disinfectants used in the hospital:

...Disinfection-Killing or destroying most disease-producing microorganisms

Disinfectant-Used on inanimate objects...

Classification of Equipment:

c. Non-critical: Objects that come in contact with intact skin, but not mucous membranes...examples of non-critical items...blood pressure cuffs, bedside tables, furniture...

Equipment Policy:

...Disinfectants should be used in the dilution and manner recommended by the manufacturer.

...Perform low-level disinfection for non-critical patient-care surfaces...and equipment (e.g. blood pressure cuff) that touch intact skin when visibly soiled and in between patient use..."


Medline Industries
Virex Tb
Ready-To-Use Disinfectant Cleaner

"Use Overview

Virex Tb is a one-step cleaner and disinfectant for spray-and-wipe cleaning...Spray area until it is covered with the solution. Allow product to penetrate and remain wet: three minutes for all bacteria..."

Policy and Procedure: Cleaning a Patient Room After Discharge
Subject: HP-020
Date Revised: 7/17/12

"Purpose: To establish the proper method of cleaning rooms after a patient has been discharged, to ensure a safe and clean environment to the next patient in the room...

Procedure: In order to properly clean a room after discharge the following items will be needed:

E. Germicidal cleaner solution...
K. Glass cleaner

The following steps should be taken when cleaning the room:

D. Using the germicidal cleaner wipe down any equipment left in the room such as IV (intravenous) pumps, and poles...compression devices...

G. Using the germicidal solution clean the bed side table...bed controls, the window sills...and mirrors.

H. Using germicidal solution...wipe the sink, shower, water fixtures...and mirrors..."

Policy and Procedure:
Subject: Vials: Single Dose and Multi Dose
Depart. Responsibility: Infection Prevention and Pharmacy
Date Reviewed: 3/15

Purpose: To provide guidelines for the safe injection practices and the prevention of misuse of vials.

Policy: Staff should follow safe injection and infection control practices as outlined below, in addition to preventing misuse of vials thereby preventing the spread of infection.

Procedure:..."The rubber septum should be disinfected by wiping with a sterile alcohol pad before entry"...


Subject: Anesthesia Safety

Departmental Responsibility: Anesthesia

Purpose: To establish procedures designed to insure the sagely of patients undergoing anesthesia

Policy: To safeguard the welfare of all patients during anesthesia

Guidelines:..."Label all syringes, bottles and bags containing drugs"...


1. On 8/19/15 at 8:30 AM, a medication pass was observed and performed in ICU 5. Upon entering ICU 5, the surveyor observed the Respiratory Technician, EI # 7 completing a nebulizer treatment. While MR # 1 was completing the nebulizer treatment, EI # 7 removed the stethoscope from around his/her neck, placed the stethoscope over MR # 1's lungs and auscultated front and back.

EI # 7 then returned the stethoscope to his/her neck and placed the tubing and stethoscope bell in the front pocket of his/her uniform. EI # 7 did not disinfect the stethoscope bell and tubing prior to placing it in the uniform pocket.

With gloves on, EI # 6, ICU, Registered Nurse (RN) administered an injection to MR # 1's peri-umbilical area of the abdomen. EI # 6 discarded the needle into the sharps container, then documented using the computer keyboard. EI # 6 removed and discarded gloves, donned a clean pair of gloves before administering MR # 1's oral medications. EI # 6 failed to perform hand hygiene immediately following glove removal.

EI # 6 completed the oral medication administration then began set up and administration of intravenous Rocephin. EI # 6 removed and discarded gloves, returned to the computer and documented on the keyboard. EI # 6 failed to perform hand hygiene after glove removal.

In an interview on 8/21/15 at 9:30 AM, EI # 1, Chief Nursing Officer confirmed staff failed to follow facility infection control policy.

2. On 8/19/15 at 10:55 AM in the SBC Unit, the surveyor observed an unsampled patient sitting at the table in the dining room. The patient had a large bandaid type dressing on his/her left elbow. There was bleeding from the elbow observed and blood on the dining table. The blood was cleaned from the dining table with a disinfectant wipe by another SBC Unit staff member.

EI # 4, Registered Nurse entered the dining room, wearing gloves and carrying a large bandaid. EI # 4 applied a large bandaid type dressing to the bleeding elbow.

EI # 4 then removed the gloves, wadded the gloves up in his/her hands and exited the dining room. EI # 4 walked to the end of the hallway, opened the door and entered the nurses station.

EI # 4 did not perform hand hygiene after the wound dressing application and removal of gloves. There was a sink, water, soap and paper towels in the dining room available for hand hygiene following glove removal.

In an interview on 8/21/15 at 9:30 AM, EI # 1 confirmed staff failed to follow its own policy for hand hygiene after glove removal.

3. On 8/20/15 at 8:45 AM, the surveyor observed EI # 8, Housekeeper complete cleaning a patient room after use. EI # 8 removed and discarded his/her gloves numerous times during the procedure. On two occasions EI # 8 changed gloves when the gloves developed holes in the finger and palm area. EI # 8 failed to perform hand hygiene following glove removal numerous times during the cleaning.

EI # 8 used the disinfectant cleaning product, Virex Tb to clean and disinfect the room including the hospital bed and furniture, and the IV infusion pump and antiembolism compression pump.

EI # 8 sprayed Virex Tb on the cleaning rag and immediately wiped down the surfaces of the IV infusion pump and antiembolism compression pump.

EI # 8 failed to follow the manufacturers instructions for use, spray the equipment until covered with solution and allow to penetrate and remain wet for 3 minutes.

EI # 8 cleaned the bathroom toilet with a bottle labeled Neutral Na, a germicidal and disinfectant product. EI # 8 then sprayed the bathroom mirror with a bottle labeled Spic and Span glass cleaner, then wiped the mirror with paper towels. EI # 8 continued to wipe the bathroom sink faucets and sink bowl with Spic and Span glass cleaner and paper towels.

EI # 8 confirmed the solution was "windex cleaner" (glass cleaner) after wiping the bathroom faucets and sink bowl.

In an interview following the observations on 8/20/15 at 10:10 AM, EI # 8 and EI # 1, Chief Nursing Officer confirmed staff failed to utilize the appropriate germicidal and disinfectant products during the patient room cleaning.




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4. An observation conducted on 8/19/15 at 8:30 AM of EI # 10, Anesthesiologist, drawing up medication in a syringe from a multi dose vial. EI # 10 failed to clean the septum with an alcohol prep before entry with the needle. EI # 10 placed the medication into a red box after the procedure was over. The syringe did not have a label to identify the name of the medication, amount or the time the medication was drawn up.

EI # 10 was asked about the medication in which EI # 10 stated the medication was too much to discard (10 milliliters- ml) and it would be used on the next patient.

An interview conducted 8/19/15 at 9:45 with EI # 15, Operating Room Manager, verified the policy for single and multi dose vials were not followed and the medication should have been labeled.

5. An observation conducted on 8/20/15 at 9:10 AM with EI # 14, Anesthesiologist, performing an Epidural Catheter placement in Labor and Delivery. The observation revealed during the procedure a vial of medication was opened from which EI # 14 withdrew medication using a needle and syringe. There was no cleaning of the septum with an alcohol prep before the needle was inserted into the septum per facility policy.

An interview conducted 8/20/15 at 9:45 with EI # 9, Nurse Manager, verified the policy for single and multi dose vials were not followed.





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6. An observation was conducted on 8/19/15 at 10:45 AM with EI # 7, Respiratory Therapist (RT) in the ICU to observe care. Upon entering the room, EI # 7 introduced self and explained reason for being in the room. EI # 7 then removed stethoscope from around his/her neck and completed an assessment of the patient's lungs. EI # 7 then placed stethoscope back around his/her neck. EI # 7 removed a small pulse oximeter (pulse ox) from his/her pocket and placed on the patient's finger. Once completed, EI # 7 placed the pulse ox back into his/her pocket. EI # 16, Respiratory Manager, removed a pair of gloves from the box on the wall and placed the gloves on EI # 7 computer to don. EI # 7 did not don gloves at any time during the observation. Once the patient respiratory treatment was complete, EI # 7 completed a post assessment using a stethoscope that was removed from around his/her neck. The patient was assessed and EI # 7 placed the stethoscope back around his/her neck. EI # 7 then removed the pulse ox from his/her pocket placed on the patient's finger. When the procedure was complete, EI # 7 replaced the pulse ox to his/her pocket.

During the observation EI # 7 failed to sanitize hands before and after contact with the patient, EI # 7 failed to clean the stethoscope and pulse oximeter prior to placing back in pocket or around neck. EI # 7 also failed to clean the stethoscope and the pulse oximeter prior to using on the patient.

An interview was conducted on 8/19/15 at 12:00 with EI # 16 who confirmed the above mentioned findings.

7. An observation was conducted on 8/19/15 at 11:00 AM on the Medical Surgical area with EI # 17, Respiratory Therapist, to observe care.

During the observation EI #17 introduced self and reason he/she was there. EI # 17 removed the stethoscope from around his/her neck and completed a pre assessment of the patient's lungs. When complete, EI # 17 placed the stethoscope back around his/her neck, then removed the pulse ox from his/her pocket and placed on the patient's finger. Once complete, EI # 17 placed the pulse ox back into his/her pocket. The nebulizer treatment was administered to the patient. Once complete, EI # 17 completed a post assessment using the stethoscope and the pulse ox which was not cleaned prior to use or after use either time. The stethoscope was placed around his/her neck and the pulse ox was placed back in his/her pocket, thus contaminating the inner pocket of the uniform.

An interview conducted on 8/19/15 at 12:00 PM with EI # 16 confirmed the above mentioned findings.