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Based on observation and interview, the facility failed to allow patients' in the psychiatric unit personal privacy by posting their names (first and last) next to their assigned room number in a hallway that is accessible to the general public for 15 of 15 patients'. The census at the time of the survey was 126.
Findings included:
1. Observation of the Psychiatric Unit on 07/07/10 at 3:35 PM showed a locked door with a caller mechanism and a button for alerting the nursing staff permission to enter the unit. When the door buzzes, the locked door may be opened and all visitors are on the patient care unit. To the left of the nursing station was a white writing board with the first and last names of the patients' adjacent to their room numbers.
In an interview on 07/07/10 at 3:40 PM with Staff I, RN, Director of Critical Care and Staff J, RN Clinical Coordinator, it was verified that the general public was allowed on the psychiatric unit, "not in the patient rooms, but in the hallways and common areas".
In an interview on 07/08/10 at 2:04 PM with Staff Q, RN, Director of Psychiatric Services, the white boards were discussed, and the regulation explained and understood, that patients' have the right to personal privacy. This included limiting the release or disclosure of patient information when the general public is allowed on the unit. Patient information, such as the patient's presence in the facility, location in the hospital, and patient names and room numbers on white boards, must be restricted from the general public.
Observation of the Psychiatric Unit on 07/09/10 at 11:59 AM revealed the same white board in full view of the public revealing only the patients' first and last initials next to their assigned rooms.

Based on observation, interview, and record review, the facility failed to ensure a registered nurse properly supervised the nursing care for one patient (Patient #36) receiving renal dialysis (a procedure which removes toxins from the blood when patient kidneys are not able to function properly) during two separate dialysis treatments. Two patients were scheduled for dialysis on the initial day of the survey. The hospital census was 126.

Findings included:

1. Record review of Policy and Procedure #7-02-02, titled DaVita Inc Acute Services Teammate Accessibility, revision date 09/2009, showed patients are to be monitored visually and audibly at all times and are not to be left unattended.

Observation on 07/08/2010 at 9:40 AM, Staff T, Registered Nurse (RN) is observed in room 270 while Patient #36 continues to dialyze in room 271. There is no ability to observe Patient #36 from room 270.

Observation on 07/08/2010 at 9:55 AM showed Staff T stood in room 270 for 10 minutes while the surveyor looked at supplies. Patient #36 continued to dialyze in room 271 without observation.

During an interview on 07/08/2010 at 1:40 PM, Staff T stated Patient #36 became unstable and experienced a significant drop in blood pressure during dialysis. The patient's blood pressure "started at 111/40 and got as low as 60's/30's" (normal blood pressure is 90/60 to 130/80). Fresh Frozen Plazma (a form of blood transfusion which supplements red blood cells to increase blood pressure) was infused in the patient, but the patient was unable to recover his/her blood pressure and the dialysis was discontinued.

During an interview on 07/08/2010 at 2:10 PM, Staff T stated if an ICU patient is dialyzing, the nurse staffing ratio is one nurse per patient. If the patient is from a floor other than the ICU, or if the patient is an overflow patient in the ICU (patients placed in a specific unit based on limited inpatient bed availability, as opposed to specific needs), the nurse staffing ratio is one nurse per two patients'. Staff T stated when she has two patients' at the same time, she may leave one patient without direct observation for up to 30 minutes. Staff T also stated a patient who may become unstable (significant changes in heart rate or rhythm, blood pressure, or breathing status) requires one on one attention until they are stabilized. This also takes direct observation away from a second patient.

2. Observation on 07/09/2010 at 11:05 AM, showed Patient #36 receiving dialysis. The dialysis access site is covered with blankets and unable to be assessed.

During an interview on 07/09/2010 at 11:05 AM, Staff T stated the dialysis access site should be visible at all times, but Staff T covered the patient and access site with blankets because "the patient was cold".

Based on observation, interview, and record review, the facility failed to ensure outdated and/or expired supplies were removed from the inpatient dialysis (a procedure to remove toxins from the blood when patient kidneys are not working properly) area. This had the potential to affect all patients receiving inpatient dialysis. Two patients were scheduled to receive dialysis on the initial day of survey. The hospital census was 126.

Findings included:

Record review of Policy and Procedure #7-03-01, titled DaVita Inc. Infection Control in the Hospital Dialysis Setting, with a revision date 09/2009, showed expiration dates will be checked on all disposable supplies and will be disposed of and not used.

Record review of Policy and Procedure #7-03-07, titled DaVita Inc. Disposable Supplies, with a revision date 09/2009 showed expiration dates will be checked on all disposable supplies and will be disposed of and not used.

Observation on 07/08/2010 at 9:40 AM, showed the following expired items in the dialysis area:
-250 Medisystems Hemodialysis Fistula Needle sets (needles placed in patients arms for dialysis), size 17 gauge by one inch long, Lot #6920F2, expired 09/2009;
-250 Medisystems Hemodialysis Fistula Needle sets, size 17 gauge by one inch long, Lot #6Y07F4, expired 2009;
-two Deionized Water and Reagent grade Salts (solution used to calibrate dialysis machines), Batch #031990EB, expired 03/19/2010;
-one blue top blood collection tube (used for drawing blood), Lot #B010901 expired 01/2010;

Observation on 07/08/2010 at 9:55 AM, showed the following expired items in the dialysis area:
-two blood culture bottles (used when drawing blood to check for bacteria in the blood), Lot #9078166, expired 01/31/2010, and Lot #9078155, expired 01/31/2010;
-NIST Traceable Conductivity Standard Solution (used to calibrate dialysis machines), Batch #031990EB, expired 03/19/2010, but was also labeled with an open date of 05/17/2010.

During an interview on 07/08/2010 at 9:55 AM, Staff T stated NIST Traceable Conductivity Standard Solution expires 30 days after it has been opened. Staff T also verified the expiration dates of all outdated supplies found.

Based on observation, interview and record review the facility failed to ensure the staff followed their policy when staff did not cleanse their hands before and after patient contact and between glove changes when changing a wound dressing for 3 patients (#3, #38, and #39) of 3 patients observed. The facility also failed to ensure hemodialysis machines (equipment used to remove toxins from the blood when patient kidneys are not functioning correctly) were thoroughly disinfected between patients in the hemodialysis area and failed to enforce their contact isolation policy for one patient (#32) while receiving a dialysis treatment in order to prevent the spread of infectious disease. These findings have the potential to affect all patients receiving inpatient dialysis, as well as patients, staff and visitors, throughout the hospital. Two patients were scheduled to receive dialysis on the initial day of survey. The hospital census was 126.
Findings included:
1. Record review of the facility policy titled Hand Hygiene revised 3/10 revealed, in part, the following information:

Purpose: To establish good hand hygiene techniques.
Policy: Hand hygiene is practice according to the 5 moments of hand hygiene:
1. before touching a patient;
2. before clean/aseptic procedure;
3. after body fluid exposure risk;
4. after touching a patient;
5. after touching patient surroundings and in accordance to the Standard Precautions guidelines

-Observation on 7/8/10 at 9:30 AM revealed Staff C, Wound Care
Registered Nurse (RN), gloved and removed the dressing on Patient #3's right heel and cleansed the wound. Staff C removed the gloves and re-gloved, and placed a clean dressing on the right heel. No hand washing with soap and water or hand sanitizer was done between glove changes.

An interview on 7/8/10 at 9:35 AM, Staff C stated there was slight drainage from the wound and a dry Aquacel (a dressing which absorbs drainage) would be placed over the wound.

An interview on 7/8/10 at 9:40 AM, Staff A, Director of Surgical/Orthopedics, stated he/she observed Staff C had not cleansed his/her hands between glove changes.

-Observation on 7/9/10 at 10:46 AM, revealed Staff S, Physician, entered Room 1551 without washing hands with soap and water or hand sanitizer. Staff S donned gloves and examined the patient's mouth. He/she then removed the gloves and exited the room and reached back into the room and used hand sanitizer.

An interview on 7/9/10 at 10:48, Staff R, Administrative Director of Nursing Services, was asked if he/she observed the physician enter the room, don gloves, examine the patient's mouth, remove the gloves and exit the room and then reach back into the room to use foam sanitizer. Staff R stated he/she did not observe the physician but was watching the nurse.


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2. Record review of Policy and Procedure #7-03-01, titled DaVita Inc. Infection Control in the Hospital Dialysis Setting, with a revision date 09/2009, showed equipment will be thoroughly wiped down with an appropriate disinfectant after every treatment (Policy:2) and the dialysis delivery system will be disinfected prior to next use, in addition to normal daily disinfection practices (Hospital Dialysis Setting Hygiene:31).

Observation on 07/08/2010 at 1:40 PM, showed the dialysis machine in room 271 had significant dust on the screen. The top of the dialysis machine had several round residue rings which the surveyor was able to remove with gentle friction of his/her finger. Staff P, RN Manager of Telemetry, and Staff T witnessed this observation.

During an interview on 07/08/2010 at 1:40 PM, Staff T stated the machine had been cleaned and disinfected and was ready to use for the next patient. Staff T stated the dust is residue from the cleaning product used on the machine and the residue rings on the dialysis machine was from placing jugs of solutions on top of the machines.


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3. Review of the Policy and Procedure titled: Isolation Precautions initiated 03/96 and revised 04/02 and 05/09 states -in part:

Purpose: To give the patient with a communicable disease and/or infection maximum care with minimum danger to the patient's visitors, hospital personnel and other patients. Policy: 1. It is the role of the attending physician to initiate isolation precautions for the care of the patient with a communicable disease, in compliance with the hospital policy. In the event the physician does not order these precautions, or too little isolation is ordered, the Infection Control Chairman, physician member, Infection Control Practitioner or the Registered Nurse on the unit has the authority to institute any appropriate isolation procedures. The physician responsible of the patient will be notified.8. During an observation on 07/08/10 at 3:30 PM, while Patient #32 was receiving a dialysis treatment it was noted there was no sign posted to warrant the patient's condition of "contact isolation".

During an interview on 07/08/10 at 3:35 PM with Staff T, RN, Dialysis Nurse, stated that there is no need to post a sign because she is always sitting there watching the patient.

During an observation on 07/08/10 at 3:45 PM, Staff T, RN, Dialysis Nurse walked away from the door of the patient's room and with her back turned to the patient's door, proceeded to put on isolation garments in preparation to go back and enter patient's room. This observation revealed an opportunity for anyone to enter patient's room without notice of contact isolation requirements.

In an earlier interview on 07/08/10 at 2:00 PM, Staff T stated that she may not be in sight of a patient during dialysis treatment for up to 30 minutes while getting supplies or caring for another patient.

During an observation on 07/08/10 at 12:50 PM on the Orthopedic floor with Staff N, RN, the following dressing change events occurred:
? Nurse failed to perform hand hygiene upon entering Patient's (#38) room for a dressing change on a fresh right knee arthroplasty (total knee replacement);
? Nurse put on gloves;
? Nurse removed old dressing containing visible drainage;
? Nurse washed around dressing with washcloth;
? Nurse applied clean dressing - did not remove gloves or use hand hygiene;
? Nurse removed gloves and washed hands before leaving the Patient's room.

During an observation on 07/08/10 at 1:29 PM on the Orthopedic floor with Staff N, RN, and Staff I, RN, Director of Clinical Care, the following dressing change events occurred:
? Staff N, opened sterile bandage package and put on gloves;
? Staff N, removed old bandage with visible drainage;
? Staff N, washed around incision touching the incision at times;
? Staff N, did not remove gloves even though Staff I, put a clean pair of gloves on the patient's bed within reach;
? Staff N, applied antibiotic cream, and put on a clean bandage without removing gloves or washing hands.

During an interview on 07/08/10 at 1:43 PM, Staff I, RN, Director of Clinical Care, verified the observation and stated that he/she witnessed the same events.