HospitalInspections.org

Based on review of medical records (MR), policies and procedures, facility tour observations, review of the unit Environmental Safety Check Logs, facility complaint log, facility complaint investigation and interviews with staff, it was determined the facility failed to:

1. Ensure patients were cared for in a safe environment.

2. Follow facility policy and procedure for restraints.

Findings include:

Please refer to tag A-0144, A-0159, A-0168 and A-0178 for findings.

Based on facility tour observations, review of the unit Environmental Safety Check Logs, and staff interviews, it was determined the facility failed to ensure patients were cared for in a safe environment.

These deficient practices had the potential to negatively affect all patients admitted to the Special Services Unit (psychiatric unit).

Findings include:

1. During a tour of the Special Services Unit on 1/28/2020 at 11:00 AM the following ligature risks were identified:

a. 10 out of 10 patient room entry door hinges were not rounded or piano hinge style and could be used to support a rope or other ligature for hanging or strangulation.

b. 10 out of 10 patient room bathroom door hinges were not rounded or piano hinge style and could be used to support a rope or other ligature for hanging or strangulation.

c. 10 out of 10 patient rooms contained an automatic wall mounted paper towel dispenser with a flat top panel able to support weight and could be used to support a rope or other ligature for hanging or strangulation.

d. 7 out of 10 patient rooms contained an automatic wall mounted soap dispenser with a flat top panel able to support weight and could be used to support a rope or other ligature for hanging or strangulation.

e. The patient sitting area contained a wall mounted television with a 16-18 inch looped cable that hung below the television and could be used as a ligature for hanging or strangulation.

A review of the Environmental Safety Rounds for the months of October 2019 through January 2020 revealed no identified environmental safety concerns.

An interview was conducted on 1/28/2020 at 12:00 PM with Employee Identifier (EI) # 14, Special Services Unit Director, who confirmed the ligature risk findings.

2. An interview was conducted with EI # 15, Plant Operations Manager, and EI # 14 on 1/29/2020 at 8:10 AM. During the interview the surveyor asked EI # 15 if the drop in ceilings tiles in 10 out of 10 Special Services Unit patient rooms were clipped down and unable to be lifted by a patient. EI # 15 verbalized none of the tiles in the patient's rooms of the Special Services Unit were clipped down.

EI # 15 then obtained a ladder and a second tour was conducted with EI # 15 and EI #14 on 1/29/2020 at 8:20 AM to 9:00 AM. During the second tour EI # 15 was able to lift the ceiling tiles from the position easily in patient rooms 164 and 170. Once the tile was displaced from the drop in section a series of long horizontal circular and short circular plumbing pipes were exposed along with the light fixture in the patient rooms that could be used:

a. To support a rope or other ligature for hanging or strangulation with the horizontal plumbing pipes.

b. Broken off and used for self-harm or harm to others with the short plumbing pipes.

c. Removal of the light fixture for electrocution, self-harm or harm to others with the light fixture.

EI # 15 verbalized the pipes were throughout the ceiling in all of the Special Services Unit and were abandoned pipes no longer used by the hospital.

There was no documentation of an patient risk assessment strategy for the Special Services Unit.

EI # 15 and EI # 14 confirmed the above findings prior to the end of the second tour on 1/29/2020.

Based on review of the facility complaint log, facility complaint investigation, medical records (MR), facility policy and procedure, and staff interview(s) it was determined the patient(s) was placed in a manual hold for administration of psychotropic medications. The facility failed to recognize the use of a manual hold as a restraint.

This did affect Patient Identifier (PI) # 24, 1 of 1 reviewed complaint(s) involving a restraint and had the potential to negatively affect all patients served by the facility Special Services Unit.

Findings include:

Policy: Restraints and Seclusion
Policy Number: AHW.400.0052
Review Date: 2/29/2016

Policy and Procedure:
A. Definitions
...6. Restraints: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely...

...C. Ordering...
...3. In non-emergent situations, a LIP (Licensed Independent Practitioner) must provide an order for restraints prior to initiation.

4. In emergency application situations, a RN (Registered Nurse) may initiate application... An order is still required and must be obtained immediately; not exceed 1 hour from initiation.

...8. The following guidelines regarding ordering and evaluation are specific to Violent/Self destructive Restraints: When a restraint or seclusion is used for the management of violent and/or self-destructive behavior that jeopardizes safety, the RN immediately notifies the LIP to obtain an order.

D. Patient Monitoring and Assessments: ...Ongoing assessment and monitoring will be concluded by a trained staff member... Documentation of Restraints/Seclusions will be performed by the assigned staff...and scanned into the patient's MR.

F. Documentation Requirement
The following documentation shall be included in the MR:
The patient's condition or symptom(s) that justify the use (of a) restraint.
Any alternatives and/or strategies attempted
Type of restraint used
The patient's response to the intervention(s) used...
Individual patient assessments...
Related patient/family education
Related patient/family notification (as warranted)
Revisions to the Plan of Care
Orders for the use of (a) restraint by an authorized LIP
Notification of the use of restraint to the attending LIP (as required)
...Face to face evaluations...

1. Review of the facility complaint log revealed a complaint dated 9/10/19 was received from an unsampled patient on the Special Services Unit which involved PI # 24.

PI # 24 was admitted to the Special Serviced Unit on 9/9/19 with a diagnosis of Psychosis unspecified.

Review of the Nursing Notes dated 9/9/19 at 21:25 revealed documentation of "patient agitation noted with patient exposing his private area (genitals) in lobby area. Patient redirected with physician notified with orders received for Geodon 20 milligrams (mg) IM (intramuscular)..."

Review of the Medication Administration report dated 9/9/19 at 9:30 PM for PI # 24 revealed Geodon 20 mg was administered IM.

Review of a facility complaint investigation written by Employee Identifier (EI) # 19, Mental Health Technician (MHT) for the Special Services Unit, dated 9/19/19 revealed the following documentation related to PI # 24, "we were about to give him/her a shot. He/She said he/she wasn't going to take one and that he/she was going to fight me...He/She then pushed me in my chest and I took him/her down on the bed and the nurse gave him/her a shot..."

Further review of the complaint investigation revealed EI # 10, Director of Nursing, had reviewed video surveillance of the incident.

An interview was conducted on 1/29/2020 at 11:46 AM with EI # 10 and EI # 14, Special Services Unit Director. During the interview EI # 14 stated PI # 24 was placed in a hold over the bed with one person on each side for the Geodon to be administered. EI # 14 then demonstrated the hold used by the Special Services Unit, with the help of another staff member by a holding the staff members arm down (which EI # 14 verbalized would occur on each side of the patient) and the employee's leg over the patient's leg (which EI # 14 verbalized would also occur on each side of the patient) to prevent movement of the arms and legs.

The surveyor asked if the patient hold used on PI # 24 would allow him/her to freely move his/her extremities. EI # 14 replied "no."

The surveyor asked EI # 10 if the hold described by EI # 14 was the hold used on PI # 24 for the administration of the Geodon in the video surveillance on 9/919. EI # 10 stated "yes."

The surveyor then requested documentation of an physician order for the manual hold (restraint) and any restraint documentation. EI # 14 replied the facility was not aware that a manual hold was a restraint and there was no documentation of a physician order for the manual hold or any restraint documentation for PI # 24.

Based on review of the facility complaint log, facility complaint investigation, medical records (MR), facility policy and procedure, and staff interview(s) it was determined the patient(s) was placed in a manual hold for administration of psychotropic medications. The facility failed to have a documented physician's order for a restraint.

This did affect PI # 24, 1 of 1 reviewed complaint(s) involving a restraint and had the potential to negatively affect all patients served by the facility Special Services Unit.

Findings include:

Policy: Restraints and Seclusion
Policy Number: AHW.400.0052
Review Date: 2/29/2016

Policy and Procedure:
A. Definitions
...6. Restraints: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely...

...C. Ordering...
...3. In non-emergent situations, a LIP (Licensed Independent Practitioner) must provide an order for restraints prior to initiation.

4. In emergency application situations, a RN (Registered Nurse) may initiate application... An order is still required and must be obtained immediately; not exceed 1 hour from initiation.

...8. The following guidelines regarding ordering and evaluation are specific to Violent/Self destructive Restraints: When a restraint or seclusion is used for the management of violent and/or self-destructive behavior that jeopardizes safety, the RN immediately notifies the LIP to obtain an order.

...F. Documentation Requirement
The following documentation shall be included in the MR:
...Orders for the use of (a) restraint by an authorized LIP
Notification of the use of restraint to the attending LIP (as required)...

1. Review of the facility complaint log revealed a complaint dated 9/10/19 was received from an unsampled patient on the Special Services Unit which involved PI # 24.

PI # 24 was admitted to the Special Serviced Unit on 9/9/19 with a diagnosis of Psychosis unspecified.

Review of the Nursing Notes dated 9/9/19 at 21:25 revealed documentation of "patient agitation noted with patient exposing his private area (genitals) in lobby area. Patient redirected with physician notified with orders received for Geodon 20 milligrams (mg) IM (intramuscular)..."

Review of the Medication Administration report dated 9/9/19 at 9:30 PM for PI # 24 revealed Geodon 20 mg was administered IM.

Review of a facility complaint investigation written by Employee Identifier (EI) # 19, Mental Health Technician (MHT) for the Special Services Unit, dated 9/19/19 revealed the following documentation related to PI # 24, "we were about to give him/her a shot. He/She said he/she wasn't going to take one and that he/she was going to fight me...He/She then pushed me in my chest and I took him/her down on the bed and the nurse gave him/her a shot..."

Further review of the complaint investigation revealed EI # 10, Director of Nursing, had reviewed video surveillance of the incident.

An interview was conducted on 1/29/2020 at 11:46 AM with EI # 10 and EI # 14, Special Services Unit Director. During the interview EI # 14 stated PI # 24 was placed in a hold over the bed with one person on each side for the Geodon to be administered. EI # 14 then demonstrated the hold used by the Special Services Unit, with the help of another staff member by a holding the staff members arm down (which EI # 14 verbalized would occur on each side of the patient) and the employee's leg over the patient's leg (which EI # 14 verbalized would also occur on each side of the patient) to prevent movement of the arms and legs.

The surveyor asked if the patient hold used on PI # 24 would allow him/her to freely move his/her extremities. EI # 14 replied "no."

The surveyor asked EI # 10 if the hold described by EI # 14 was the hold used on PI # 24 for the administration of the Geodon in the video surveillance on 9/919. EI # 10 stated "yes."

The surveyor then requested documentation of an physician order for the manual hold (restraint). EI # 14 replied was no documentation of a physician order for the manual hold.

Based on review of the facility complaint log, facility complaint investigation, medical records (MR), facility policy and procedure, and staff interview(s) it was determined the patient(s) was placed in a manual hold for administration of psychotropic medications. The facility failed to document a patient face-to-face assessment.

This did affect PI # 24, 1 of 1 reviewed complaint(s) involving a restraint and had the potential to negatively affect all patients served by the facility Special Services Unit.

Findings include:

Policy: Restraints and Seclusion
Policy Number: AHW.400.0052
Review Date: 2/29/2016

Policy and Procedure:
A. Definitions
...6. Restraints: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely...

...C. Ordering and Face to Face Evaluation

...8. The following guidelines regarding ordering and evaluation are specific to Violent/Self destructive Restraints: When a restraint or seclusion is used for the management of violent and/or self-destructive behavior that jeopardizes safety, the RN immediately notifies the LIP to obtain an order. The LIP performs a face to face evaluation within 1 hour of initiation of (the) restraint or seclusion and authenticates the verbal order, including date and time of the authentication...

...F. Documentation Requirement
The following documentation shall be included in the MR:
...Face to face evaluations...

1. Review of the facility complaint log revealed a complaint dated 9/10/19 was received from an unsampled patient on the Special Services Unit which involved PI # 24.

PI # 24 was admitted to the Special Serviced Unit on 9/9/19 with a diagnosis of Psychosis unspecified.

Review of the Nursing Notes dated 9/9/19 at 21:25 revealed documentation of "patient agitation noted with patient exposing his private area (genitals) in lobby area. Patient redirected with physician notified with orders received for Geodon 20 milligrams (mg) IM (intramuscular)..."

Review of the Medication Administration report dated 9/9/19 at 9:30 PM for PI # 24 revealed Geodon 20 mg was administered IM.

Review of a facility complaint investigation written by Employee Identifier (EI) # 19, Mental Health Technician (MHT) for the Special Services Unit, dated 9/19/19 revealed the following documentation related to PI # 24, "we were about to give him/her a shot. He/She said he/she wasn't going to take one and that he/she was going to fight me...He/She then pushed me in my chest and I took him/her down on the bed and the nurse gave him/her a shot..."

Further review of the complaint investigation revealed EI # 10, Director of Nursing, had reviewed video surveillance of the incident.

An interview was conducted on 1/29/2020 at 11:46 AM with EI # 10 and EI # 14, Special Services Unit Director. During the interview EI # 14 stated PI # 24 was placed in a hold over the bed with one person on each side for the Geodon to be administered. EI # 14 then demonstrated the hold used by the Special Services Unit, with the help of another staff member by a holding the staff members arm down (which EI # 14 verbalized would occur on each side of the patient) and the employee's leg over the patient's leg (which EI # 14 verbalized would also occur on each side of the patient) to prevent movement of the arms and legs.

The surveyor asked if the patient hold used on PI # 24 would allow him/her to freely move his/her extremities. EI # 14 replied "no."

The surveyor asked EI # 10 if the hold described by EI # 14 was the hold used on PI # 24 for the administration of the Geodon in the video surveillance on 9/919. EI # 10 stated "yes."

The surveyor then requested documentation of a face to face evaluation for the manual hold (restraint). EI # 14 replied there was no documentation of a face to face evaluation for PI # 24.

Based on review of the Facility PI (Performance Improvement) documentation, facility policy and interviews, it was determined:

1. The facility failed to implement a hospital wide PI program that measured, analyzed, and tracked quality indicators.

2. The facility used the data collected to monitor the effectiveness and safety of services and quality of care

3. The facility failed to initiate Performance Improvement Projects.

4. The facility failed to identify areas for improvement and high-risk, high-volume or problem-prone areas.

5. The facility failed to show measurable improvement in indicators for which there is evidence that it will improve health outcomes

6. The facility failed to measure, analyze, and track adverse patient events and medical errors.

7. The facility failed to incorporate hospital wide Performance Improvement Projects (PIP).

8. The facility governing body failed to specify the frequency and detail of data collection.


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

Findings include:

Refer to A 273, A 283, A 286, A 297 and A 309 for findings.

Based on review of the Facility PI (Performance Improvement) documentation, facility policy and interviews, it was determined the facility failed to implement a PI program to include:

1. An ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes

2. Program to measure, analyze, and track quality indicators and other aspects of performance that assess processes of care, hospital service and operations.

3. Incorporation of quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions.

4. The hospital use of the data collected to monitor the effectiveness and safety of services and quality of care

5. The frequency and detail of data collection was specified by the hospital's governing body.

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

Findings include:

Policy: Hospital-Wide PI Plan
Date Reviewed: 1/14/2020

I. Introduction

A. Preface: Crenshaw Community Hospital continue to build and further refine a program of PI that will continuously monitor, analyze, and improve performance of clinical and other processes to improve patient outcomes. Organized continuous quality improvement requires input from objective performance data, customer feedback and the strategic plan...

...G. Goals and Objectives: The goals and objectives of the PI program are to ensure that the organization designs processes well, and systematically monitors, analyzes, and improves it's performance to improve the quality of patient outcomes...

...II. Planning

...2. Medical Staff: The Medical staff is accountable for the overall quality of medical care rendered to the patients in the hospital by assuring that appropriate ongoing and systematic objective indications of patient care and/or PI activities are in place...

3. Quality Assurance/Quality Improvement Committee (QA/QI)
...The QA/QI Committee is responsible for:

...Review of data collected for important aspects of care, reaching conclusions, and making recommendations, and initiating action plans to correct...
Communicates findings, conclusions, recommendations, and actions to the Medical Staff, Department Heads, and Other Staff.
Determine aspects of care, processes, or problems to be assigned to a PI Team...

III. PI Plan - Program Structure

...Overall PI initiatives are:
...Manage data to obtain necessary information to achieve goals
Integrate proven performance initiatives into processes throughout the organization as appropriate.

IV. PI Process

A. Approach: The approach to performance will be facilitated with the use of the PDCA process.

1. Plan the improvement project - identify the process to be improved
2. Do data collection - collect and organize data
3. Check the effectiveness of the action - document the results from the actions
4. Act to improve the action, hold the gains, and continue the process...

B. Monitoring Performance Through Data Collection

...The data will be organized so that situations in which an evaluation of the quality or appropriateness of care as indicated, are easily identified...

C. Analysis: Data is aggregated and analyzed on an ongoing basis using appropriate statistical techniques to analyze and display data. The hospital compares it's performance over time with other sources of information...These comparisons are used to look for excessive variability or opportunities for improvement. The hospital will intensively analyze undesirable patterns or trends in performance and sentinel events...

...E. Role in Risk Management: ...As part of measurement and assessment activities...occurrence screening criteria will be utilized to identify adverse patient occurrences. Results will be tabulated and trended...

1. On 1/30/2020 Employee Identifier (EI) # 17, Quality Assurance Coordinator and Risk Manager, provided to the surveyor the facility PI Program.

Review of the facility PI Program revealed separate data forms for the first, second, and third quarters of 2019 where each facility department reported data to be entered into the hospital wide PI program and the quarterly PI meetings for 2019.

Further review of the facility PI Program revealed no documentation the data collected from the facility departments had been organized into a hospital wide program to measure, analyze and track quality indicators, the facility had tracked medical errors with data demonstrating improvement in patient care, safety, and reduction of medication errors, had a performance improvement project(s), and the facility incorporated quality indicator data submitted to or received from medicare quality reporting and quality performance programs.

An interview was conducted on 1/30/2020 at 7:56 AM with EI # 17, who verbalized there was no documentation of the above findings for the facility and there was no documentation the governing body determined the distinct improvement projects to be conducted by the facility.

Based on review of the Facility PI (Performance Improvement) documentation, facility policy and interviews, it was determined the facility failed to implement a PI program to include:

1. Areas for improvement were identified.

2. High-risk, high-volume or problem-prone areas were identified.

3. Actions were taken for improvement, those actions were measured and tracked to determine if improvements were achieved.

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

Findings include:

Policy: Hospital-Wide PI Plan
Date Reviewed: 1/14/2020

I. Introduction

A. Preface: Crenshaw Community Hospital continue to build and further refine a program of PI that will continuously monitor, analyze, and improve performance of clinical and other processes to improve patient outcomes. Organized continuous quality improvement requires input from objective performance data, customer feedback and the strategic plan...

...G. Goals and Objectives: The goals and objectives of the PI program are to ensure that the organization designs processes well, and systematically monitors, analyzes, and improves it's performance to improve the quality of patient outcomes...

...II. Planning

3. Quality Assurance/Quality Improvement Committee (QA/QI)
...The QA/QI Committee is responsible for:

...Review of data collected for important aspects of care, reaching conclusions, and making recommendations, and initiating action plans to correct...
Communicates findings, conclusions, recommendations, and actions to the Medical Staff, Department Heads, and Other Staff.
Determine aspects of care, processes, or problems to be assigned to a PI Team...

III. PI Plan - Program Structure

...Overall PI initiatives are:
...Manage data to obtain necessary information to achieve goals
Integrate proven performance initiatives into processes throughout the organization as appropriate.

IV. PI Process

A. Approach: The approach to performance will be facilitated with the use of the PDCA process.

1. Plan the improvement project - identify the process to be improved
2. Do data collection - collect and organize data
3. Check the effectiveness of the action - document the results from the actions
4. Act to improve the action, hold the gains, and continue the process...

...C. Analysis: Data is aggregated and analyzed on an ongoing basis using appropriate statistical techniques to analyze and display data. The hospital compares it's performance over time with other sources of information...These comparisons are used to look for excessive variability or opportunities for improvement. The hospital will intensively analyze undesirable patterns or trends in performance and sentinel events...

1. On 1/30/2020 Employee Identifier (EI) # 17, Quality Assurance Coordinator and Risk Manager, provided to the surveyor the facility PI Program.

Review of the facility PI Program revealed separate data forms for the first, second, and third quarters of 2019 where each facility department reported data to be entered into the hospital wide PI program and the quarterly PI meetings for 2019.

Further review of the facility PI Program revealed no documentation areas for hospital wide improvement were identified, High-risk, high-volume or problem-prone areas were identified, actions were taken for improvement and those actions were measured and tracked to determine if improvements were achieved.

An interview was conducted on 1/30/2020 at 7:56 AM with EI # 17, who verbalized there was no documentation of the above findings for the facility.

Based on review of the Facility PI (Performance Improvement) documentation, facility policy and interviews, it was determined the facility failed to ensure the PI program measured, analyzed, and tracked adverse patient events and medical errors.

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

Findings include:

Policy: Hospital-Wide PI Plan
Date Reviewed: 1/14/2020

...IV. PI Process

...E. Role in Risk Management: ...As part of measurement and assessment activities...occurrence screening criteria will be utilized to identify adverse patient occurrences. Results will be tabulated and trended...

1. On 1/30/2020 Employee Identifier (EI) # 17, Quality Assurance Coordinator and Risk Manager, provided to the surveyor the facility PI Program.

Review of the facility PI Program for 2019 revealed no documentation of adverse patient events and medical errors were measured, analyzed, and tracked.

An interview was conducted on 1/30/2020 at 7:56 AM with EI # 17, who confirmed the above findings.

Based on review of the Facility PI (Performance Improvement) documentation, facility policy and interviews, the facility failed to ensure Performance Improvement Projects (PIP) were developed, measurable progress was achieved and incorporated into the hospital-wide QAPI program.

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

Findings include:

Policy: Hospital-Wide PI Plan
Date Reviewed: 1/14/2020

I. Introduction

A. Preface: Crenshaw Community Hospital continue to build and further refine a program of PI that will continuously monitor, analyze, and improve performance of clinical and other processes to improve patient outcomes. Organized continuous quality improvement requires input from objective performance data, customer feedback and the strategic plan...

...G. Goals and Objectives: The goals and objectives of the PI program are to ensure that the organization designs processes well, and systematically monitors, analyzes, and improves it's performance to improve the quality of patient outcomes...

...II. Planning

3. Quality Assurance/Quality Improvement Committee (QA/QI)
...The QA/QI Committee is responsible for:

...Review of data collected for important aspects of care, reaching conclusions, and making recommendations, and initiating action plans to correct...

III. PI Plan - Program Structure

...Overall PI initiatives are:
...Integrate proven performance initiatives into processes throughout the organization as appropriate.

IV. PI Process

A. Approach: The approach to performance will be facilitated with the use of the PDCA process.

1. Plan the improvement project - identify the process to be improved
2. Do data collection - collect and organize data
3. Check the effectiveness of the action - document the results from the actions
4. Act to improve the action, hold the gains, and continue the process...


1. On 1/30/2020 Employee Identifier (EI) # 17, Quality Assurance Coordinator and Risk Manager, provided to the surveyor the facility PI Program.

Review of the facility PI Program revealed no documentation of a PIP.

An interview was conducted on 1/30/2020 at 7:56 AM with EI # 17, who confirmed the above findings.

Based on review of hospital policy, facility PI (Performance Improvement) program and staff interviews it was determined the governing body failed to ensure:

1. The facility PI included indicators to identify and reduce medical errors.

2. The number of distinct improvement projects to be conducted annually was determined.

3. Approve the improvement projects to include in the PI program.

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

Findings include:

Policy: Hospital-Wide PI Plan
Date Reviewed: 1/14/2020

I. Introduction

A. Preface: Crenshaw Community Hospital continue to build and further refine a program of PI that will continuously monitor, analyze, and improve performance of clinical and other processes to improve patient outcomes. Organized continuous quality improvement requires input from objective performance data, customer feedback and the strategic plan...

...G. Goals and Objectives: The goals and objectives of the PI program are to ensure that the organization designs processes well, and systematically monitors, analyzes, and improves it's performance to improve the quality of patient outcomes...

...II. Planning

...2. Medical Staff: The Medical staff is accountable for the overall quality of medical care rendered to the patients in the hospital by assuring that appropriate ongoing and systematic objective indications of patient care and/or PI activities are in place...


1. On 1/30/2020 Employee Identifier (EI) # 17, Quality Assurance Coordinator and Risk Manager, provided to the surveyor the facility PI Program.

Review of the facility PI program revealed no documentation of hospital wide indicators to identify and reduce medical errors and an improvement project.

An interview was conducted on 1/30/2020 at 7:56 AM with Employee Identifier (EI) # 17, Quality Assurance Coordinator and Risk Manager, who verbalized there was no documentation the governing body determined the number of distinct improvement projects to be conducted annually, included indicators to identify and reduce medical errors, and approved the improvement projects to included in the facility PI program.

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

a. Staff followed the facility policy for vital signs, all distal pulse checks and observe for signs of necrosis after infiltration while administering a Levophed drip on the Medical/Surgical unit.

b. Staff clarified and documented specific orders for wound care.

c. Staff documented the specific wound care provided.

This had the potential to negatively affect all patients served by the facility. This affect Patient Identifier (PI) # 8, 1 of 1 patients on a Levophed drip and 2 of 2 current inpatient MR's reviewed with wounds, including PI # 2 and PI # 1.

Findings include:

Policy: Critical Care Use of Norepinephrine (Levophed) Drip
Policy Number: PHARM-47.08
Review Date: 12/30/2018

Policy:

To administer a Norepinephrine (Levophed) critical care drip safely and appropriately to reverse hypotension in cardiogenic, septic, or neurogenic shock patients that remain unresponsive to fluid replacement.

Procedure:
Administration of Norepinephrine:

Adult Infusion:

Maintain two large-bore IV (intravenous) lines (only in two large veins such as the AC(anticubital)) at all times during critical care drips.

Monitoring

Hypertension:

Norepinephrine is a potent vasoconstrictor and may cause hypertension.

Monitor rate of flow

Check BP (blood pressure) every 2 to 3 minutes...

Extravasations:

Extravasation of Levophed into tissue may cause tissue necrosis

Use of large vein is always preferred to decrease risk of extravasation (preferably the anticubical (AC) vein.)

IV should be checked prior to administration for patency, and monitored frequently during administration (check IV site at least hourly)

Peripheral Blood Flow:

Evaluate for paresthesia and coldness of extremities, because the peripheral blood flow may decrease due to vasoconstrictive properties of Norepinephrine.

Check all distal pulses.

Policy: Administration of Critical Care Drips
Policy Number: PHARM-47.01
Review Date: 12/30/2018

Policy:

To have guidelines for each critical drip used in this facility for staff to use when administering critical medications.

Procedure:

Each critical care drip administered at Crenshaw Community Hospital, will have easy to find and easy to follow guidelines in order to safely administer these medications.

A notebook containing all policies and procedures on these drips will be located in both the Med/Surg (Medical Surgical) and ER (Emergency Room) for easy reference.

All policies will include...monitoring...

Before administering a critical care drip, the nurse must find and read the policy...

Policy

Manual: Administrative House Wide
Title: Wound Care and Documentation
Policy Number: AHW.700.0010
Revision Date: 5/21/2019
Review Date: 5/21/2019

Purpose: Is to establish guidelines for the care of a patient's wound and ensure that appropriate and concise wound care and measurements performed and documented.

Procedure:
...3. If a wound is observed, it will be documented and measured immediately as a baseline and at least every shift thereafter and as needed.

4. All wounds will be documented within the patient's medical record using the Wound Care Flowchart within the EHR (Electronic Health Record) at least every shift as needed.

5. All wound care will be ordered by the physician.

Wound Care and Guidelines and Measurements

Procedure:
1. All wounds will be assessed and measured upon admission and as per MD's orders.
...8. Document measurements on Wound Care Documentation Flow Sheet.

9. Documentation must also include location of a wound and date measurement was taken.

10. Wounds must also be documented within the patient's medical record using the Wound Care Flow Sheet Form ...

Dressing Changes and Assessment

1. During dressing changes, the RN (Registered Nurse)/LPN (Licensed Practical Nurse) shall assess and document on the wound assessment flow sheet:

a. Location of the pressure ulcer(s)
b. Size (measurement as per policy)
c. Color, temperature, edema, color, moisture, and appearance around ulcer
d. Stage of the Wound ...
e. Exudate and Drainage ...

Manual: Nursing
Title: Standards of Patient Care Practice
Policy Number: MS.300.0380
Revision Date: 5/9/2019
Review Date: 5/9/2019

Achievement of Patient Care Goals

Standard IX: The medical record will reflect documentation of the care provided for the patient.

1. Vital signs will be documented in the medical record as indicated by physician order and/or nursing policy.

2. Records will reflect all treatments performed and the patient's response to those treatments.

1. PI # 8 was admitted to the facility on 10/16/2019 with admitting diagnoses of Urosepsis, Renal Failure and possible Sepsis.

Review of the documentation from the Emergency Room (ER) on 10/16/2019 at 4:26 PM revealed no documentation of the size of IV site # 1 located at the right wrist .

Further review of the ER documentation revealed the patient left the ER on 10/16/2019 at 5:27 PM and transferred to the Medical/Surgical area.

Review of the Med/Surg nursing assessment dated 10/16/2019 at 7:00 PM revealed the patient arrived to the floor with a Levophed drip infusing to the right AC (anticubical) and was an 18 gauge needle with no signs and symptoms of infiltration. Further review revealed the patient had a # 22 gauge needle IV to the right forearm with 1/2 normal saline (NS) infusing at 125 ml (milliters) an hr (hour) and the patient's blood pressure on arrival was 88/61.

Further review of the Med/Surg nursing assessment dated 10/16/2019 at 7:00 PM revealed the pulses were checked and were within normal limits. Further review revealed no documentation as to which pulses were checked.

Review of the nursing assessment dated 10/16/2019 at 8:18 PM revealed the nurse documented the IV sites were now in the right wrist and the right AC. Further review revealed no documentation of an infiltration of the 22 gauge to the right forearm nor a new IV restarted to the right wrist. The nurse failed to document the fluids infusing at each site.

Review of the nursing assessment dated 10/18/2019 at 11:50 PM revealed the IV to the right wrist was infiltrated and restarted to left forearm using a # 20 Jelco.

Review of the nursing assessment dated 10/19/2019 at 8:00 PM revealed a # 18 gauge to the right AC and infusing D5W (Dextrose 5% in Water) with 1 amp (ampule) Bicarb per liter at 100 ml/hr and # 20 gauge to left wrist infusing the Levophed drip at 18.8 ml/hr. The nurse failed to ensure the Levophed was infusing to the large bore IV site per hospital policy.

Review of the nursing assessment dated 10/20/2019 at 8:05 AM the nurse documented under IV - Venous Access peripheral line # 20 gauge and # 22 gauge. IV Site - right antecubital and left wrist.

Review of the nursing assessment dated 10/20/2019 at 8:00 PM revealed the IVF (intravenous fluids) were infusing to the right AC and the Levophed drip was infusing to the left wrist which is a # 22 gauge IV site.

Review of the nursing documentation dated 10/20/2019 at 10:15 PM the IV site to the left wrist infusing the Levophed had infiltrated and was restarted to left upper chest area with an #18 gauge and the Levophed was restarted. Further review revealed no documentation of observations to be conducted to monitor for signs and symptoms of necrosis of the tissue due to the infiltration of the Levophed drip.

Review of all the nursing documentation within the MR from 10/16/2019 to 10/21/2019 at 6:14 AM when the Levophed drip was discontinued revealed the patient's pulses were assessed once a shift and no documentation as to what was assessed or which pulses were assessed each time, the patient had only one large bore ( 18 gage) IV line while on the Levophed drip, the IV site was not assessed each hour per the facility policy.

Review of all the vital sign (VS) documentation within the MR revealed the computerized VS were documented every 1 to 3 hours and the hand written VS sheet for the Levophed drip,the VS were documented every 10 minutes. The staff failed to follow the facility policy and proper review of the policy prior to monitoring of the Levophed drip to ensure VS to be taken every 2 to 3 minutes.

An interview was conducted on 1/30/2020 at 10:40 AM with Employee Identifier (EI) # 10, Director of Nursing, who confirmed the staff did not follow hospital policy for the Levophed drip, and confirmed the above mentioned findings.



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2. PI # 2 was admitted to the hospital on 1/25/2020 with diagnosis of Hypercalcemia.

Review of the MR revealed Physician Orders dated 1/25/2020 at 0800 (8:00 AM) for wound care orders of "Clean wound with NS (Normal Saline), apply xeroform, with 4 x (by) 4's, ABD (Abdominal Pad) and secure with paper tape." The Physician's Order failed to assess PI # 2's wound care by not specifying the wound site or frequency of wound care in the wound treatment order. The SN (Skilled Nurse) failed to clarify with the physician the wound site and frequency of how often the wound care was to be provided.

Review of the admission Nursing Shift Assessment at time of admission dated 1/25/2020 at 11:23 AM revealed documentation of "pt (patient) admitted to room via stretcher wound to chest wall noted wound to coccyx ..." Review of the Wound Location body audit sheet revealed PI # 2 had wounds to the right chest wall and the coccyx. There was no further documentation of the wound to the coccyx until time of discharge planning on 1/28/2020 at 4:20 AM where the SN documented the coccyx wound as a Stage 2 Pressure Ulcer.

Review of the MR revealed no documentation of wound measurements to the coccyx, physician wound care orders for the wound to the coccyx, wound protocol was initiated by the nurse or that wound care was provided throughout hospital stay until time of discharge.

During an interview on 1/30/2020 at 11:43 AM with EI # 10, Director of Nursing, the surveyor asked "Did this patient have a wound to the coccyx throughout his/her hospital stay that required ongoing treatment?" and EI # 10 replied, "Yes, he/she should have been getting a dressing to it (the coccyx wound) and it should have been documented that it was measured on admission." EI # 10 confirmed staff did not follow facility policy for wound care.


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3. PI # 1 was admitted to the facility on 1/24/2020 with diagnoses including Cellulitis Right (Rt) Calf and Infected Hematoma.

Review of the MR revealed a physician's order dated 1/25/2020 at 2:10 PM as follows: "Dress wound to RLE (Right Lower Extremity). Cover with ABD pad and wrap loosely with kling". The physician's order failed to specify the frequency of wound care and the type of solution to be used to cleanse the wound in the treatment care order.

Review of the 1/25/2020 Patient Progress Notes revealed the following:

...3:57 AM Nursing Shift Assessment: ..."wound cleaned and new dressing applied". There was no documentation of the specific wound care provided.

...8:00 AM Nursing Shift Assessment: ..."wound cleaned. ABD applied with ABD pad placed underneath for bloody drainage... Wound Flow Chart: Wound cleaned with wound cleanser then NS". There were no physician orders for the wound cleanser and NS.

...8:40 PM Wound Flow Chart: ..."Dressing changed". There was no documentation of the specific wound care provided.

Review of the 1/26/2020 Patient Progress Notes revealed the following:

...1:40 AM Nursing Shift Assessment: ..."Wound cleansed and redressed". There was no documentation of the specific wound care provided.

...8:00 AM Wound Interventions: "Simple dressing change". There was no documentation of the specific wound care provided.

Review of the 1/27/2020 Patient Progress Notes revealed the following:

... 8:00 AM Wound Interventions: "Simple dressing change". There was no documentation of the specific wound care provided.

...2:00 PM Wound Flow Chart: ... Dressing: "Dressing removed was saturated with blood. Placed telfa, abd, and gauze cling (kling)". There was no physician's order for the telfa provided.

2:04 PM Nursing Shift Assessment Amended 3:21 PM: "Changed right leg dressing - cleansed with cleansing solution, applied telfa, abd pads and cling (kling). The SN failed to specify what type of cleansing solution was used to cleanse the wound. There were no physician orders for the cleansing solution and the telfa used to provide wound care.

An interview was conducted on 1/28/2020 at 11:15 AM with EI # 7, Registered Nurse, who verified the SN failed to verify and obtain specific orders for wound care and the frequency of wound care to be provided. EI # 7 also verified the SN failed to document the wound care provided and follow the physician's orders.

An interview was conducted on 1/30/2020 at 11:10 AM with EI # 10, who stated, "the physician did give a verbal order for the cleansing solution and frequency of how often wound care was to be provided, but the nurse failed to document it". EI # 10 then submitted a late entry physician's order dated 1/29/2020 for clarification to order written 1/25/2020 for the cleansing solution and the frequency of the wound care to be provided.

Based on facility policy and procedure and staff interview it was determined the facility failed to ensure an area for the quarantine of blood products was in place to take appropriate action when notified that blood or blood components it received are at increased risk of transmitting Human Immunodeficiency virus (HIV) or Hepatitis C Virus (HCV).

This had the potential to negatively affect all patients receiving blood or blood products.

Policy: Quarantine and Disposition of Blood Products
Policy Number: LAB-06-028a
Reviewed: 1/14/2020

Summary and Explanation: The screening of donated blood and the quarantine of blood and blood components represent critical processes that should be followed to ensure that blood units are safe...Until blood products are fully evaluated and found to be acceptable for release to a transfusing facility or patient, they must be kept separate from other products that have already been through the testing process and made available. Quarantine refers to that separation...

Procedure: When notification is received from a blood product provider regarding a product lookback, current inventory is checked first... If the particular unit is found in the current inventory, it is placed immediately in the quarantine area located in the blood bank refrigerator...

1. A tour of the facility laboratory was conducted on 1/28/2020 at 9:33 AM with Employee Identifier (EI) # 16, Laboratory Director.

During the tour the blood bank refrigerator was observed and found to not have an area for the quarantine of blood products.

EI # 16 confirmed the facility laboratory, including the blood bank refrigerator, did not have an area for the quarantine of blood products prior to the end of the tour.

Based on review of The Georgia Diet Manual, observation and interview, it was determined the facility failed to ensure the dietary manual was reviewed by the medical staff and Registered Dietician.

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

Findings include:

During a tour of the Dietary Department on 1/28/2020 at 11:23 AM, the surveyor requested the therapeutic diet manual. Employee Identifier (EI) # 9, Dietary Manager, provided the surveyor The Georgia Diet Manual with copyright date of 2015 on 1/29/2020 at 7:47 AM. EI # 9 confirmed that the Diet Manual has been used for "a few years now". Review of the Dietary Manual revealed documentation of a letter stating the manual was reviewed and approved on the Registered Dietician's last visit to the facility on January 3, 2020. The letter was signed and dated by the Registered Dietician on 1/28/2020. The surveyor observed EI # 9 place the sheet in the manual just prior to EI # 9 providing the diet manual to the surveyor.

The surveyor requested documentation from EI # 9 of the services the Registered Dietician provided on January 3, 2020. Review of the documentation revealed the dietary manual was not reviewed on January 3, 2020. EI # 9 confirmed that the dietary manual had not been reviewed by the Registered Dietician. Review of the Dietary Manual revealed no documentation of the dietician's and medical staff approval for use.

An interview was conducted on 1/29/2020 at 10:01 AM with EI # 9, who confirmed the dietary manual had not been approved by the medical staff and the registered dietician.

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

Findings include:

Refer to Life Safety Code violations

Based on observations and interviews it was determined the facility failed to provide the patients with a method of alerting staff of needs while being treated in the Special Services Unit.

This had the potential to affect all patients served by the facilities Special Services Unit.

Findings include:

1. A tour of the Special Services Unit was conducted on 1/28/2020 at 11:00 AM with Employee Identifier (EI) # 14, Special Services Unit Director, during the tour the surveyor observed 10 semi- private patient rooms within the Special Services Unit with a door to each room which could be closed for privacy. The patients' beds were not visible from the nurses' station.

The 10 semi- private patient rooms contained no operational call light and/or method of alerting staff of a patient need at the bedside.

EI # 14 confirmed the above findings prior to the end of the tour.

Based on observations, review of facility policies and procedures, Potter and Perry Fundamentals of Nursing, Centers for Disease Control and Prevention (CDC) Frequently Asked Questions (FAQ's) regarding Safe Practices For Medical Injection, CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities (2008), Autoclave 3M Attest Load list and Documentation Log, Register of Operations, Maintenance Ice Machine Log, and interviews with the staff, it was determined the facility failed to ensure the staff:

a) Followed the facility policy and procedure for proper hand hygiene and gloving.

b) Staff monitored the effectiveness of the steam sterilizer (autoclave) at least weekly per CDC guidelines.

c) Provided a clean environment for medications prior to administration.

d) Staff cleaned the rubber diaphragm of the medication vial prior to drawing up Intravenous (IV) medications as recommended per CDC and facility policy.

e) Disposed of contaminated syringes immediately after use as directed per the facility policy.

f) Ensure the ice machine in the dietary department was cleaned on a monthly basis per facility policy.

This did affect PI # 23, 1 of 1 patients observed for Outpatient Surgery, 1 of 3 medication pass observations, and the dietary department

This had the potential to negatively affect all patients in this facility.

Findings include:

Potter and Perry Fundamentals of Nursing
6th edition
Chapter 34: Medication Administration page 847

Correct Administration ...For safe administration, the nurse uses aseptic technique and proper procedures when handling and giving medications.

CDC: Frequently Asked Questions (FAQs) regarding Safe Practices for Medical Injection

"Medication Preparation Questions

1. How should I draw up medications?

Parenteral medications should be accessed in an aseptic manner (free from contamination caused by harmful bacteria, viruses, or other microorganisms). This includes using a new sterile syringe and sterile needle to draw up medications while preventing contact between the injection materials and the non-sterile environment. Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it."

Facility Policy: Sterilization Quality Control
Manual: Surgery
Policy Number: 94
Revision Date: 9/15

2. The autoclave is cleaned weekly ...

3. Biological Indicators are run after cleaning... Log books and record keeping are maintained by Central Sterile staff.

CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities (2008)
Recommendations for Disinfection and Sterilization in Healthcare Facilities

C. Recommendations

16. Monitoring of Sterilizers

d. Use biologic indicators to monitor the effectiveness of sterilizers at least weekly with an FDA-cleared commercial preparation of spores (e.g., Geobacillus stearothermophilus for steam) intended specifically for the type and cycle parameters of the sterilizer.

Facility Policy: Universal/Standard Precautions
Manual: Infection Control
Policy Number: IC: 1100.0050
Review Date: 05/2016

Policy:

Universal/Standard Precautions are designed to reduce the risk of transmission from both recognized and unrecognized sources of infection in hospitals...

Procedure:

1. Gloves:

b. ...Wearing gloves does not replace the need for handwashing because of the following:

i. Gloves may have small non-apparent defects or be torn during procedure.

ii. Hands can become contaminated during removal of gloves.

4. ... Hands must also be washed immediately after removing gloves.

5. All employees must take precautions to prevent injuries ...

d. After use, disposable syringes ... must be places in puncture resistant containers for disposal.

Facility Policy: Universal Precautions
Manual: Surgery
Policy Number: 36
Review Date: 9/13

Universal Precautions OR (Operating Room)

Protection with the Appropriate Barriers
1. Hands and other contaminated skin surfaces must be washed immediately and thoroughly when contaminated with blood and body fluids:

a. before and after all patient contact

b. after removal of gloves.

Facility Policy: Handwashing
Manual: Infection Control
Policy Number: IC: 1100.0060
Revision Date: 05/27/2016

Policy:

... Hands are to be washed in the following instances:

5. After removing gloves.

Facility Policy: Syringe and Needle Disposal
Policy Number: IC: 300.0300
Review Date: 12/2/2019

Procedure:

2. Immediately after use ... Syringes and needles are placed into a puncture resistant, one-way container specifically designed for that purpose.

Policy
Title: Maintenance and Cleaning of Dietary Ice Machines

Policy Number: D.T.E 102.0040

Effective Date: 8/1/18

Policy: The dietary department is responsible for the monthly cleaning of the ice machine. Documentation will be kept in the dietary department. The maintenance is responsible for cleaning the filters of the ice machine. They are responsible for accurate documentation of cleaning being performed.

Purpose: Cleaning of the ice machine is done to assure ice is kept clean and sanitized.

Procedure:

...4. Cleaning should be scheduled and performed once a month.

5. The maintenance department will clean the motor parts and external parts on a monthly basis and document.

1. A review of the cleaning and disinfection process of surgical instruments in the facility steam sterilizer (autoclave) was conducted on 1/29/2020 at 9:15 AM with Employee Identifier (EI) # 6, OR Technician and EI # 2, Surgery Manager/Assistant Director of Nursing (ADON). The surveyor asked EI # 6 when a biological indicator was performed in the steam sterilizer (autoclave). EI # 6, stated, "I do one with each load".

Review of the Autoclave 3M Load list and Documentation Log on 1/29/2020 at 9:30 AM for BI (Biological Indicator) revealed results documented begining the week of January 9, 2020. The survey requested the BI documentation logs for the month of November, December 2019 and the first (1st) week of January 2020. EI # 6 stated, "I just started these in January 9, 2020". There were no BI documentation logs provided to the surveyor for November, December 2019 and the 1st week of January 2020.

Review of the Register of Operations on 1/29/2020 at 9:45 AM revealed the facility performed surgeries requiring steam sterilization (autoclave) in November and December 2019.

The facility failed to monitor and document the effectiveness of the steam sterilizer (autoclave) at least weekly as directed per the facility policy and per CDC guidelines.

An interview was conducted on 1/29/2020 at 9:50 AM with EI # 2, at 9:50 AM who verified the facility performed surgeries requiring steam sterilization in November and December 2019. EI # 2 stated, "The BI should have been performed at least weekly and the results should have been documented".

2. An observation was conducted in the Outpatient Surgery Department by the surveyor on 1/30/2020 from 7:30 AM to 7:50 AM to observe Employee Identifier (EI) # 3, Registered Nurse (RN)/Infection Control Nurse, prepare PI # 23 for a Colonoscopy.

EI # 3 started PI # 23's IV, removed his/her gloves, obtained new gloves and cleaned and disinfected the bedside table without performing hand hygiene between glove changes.

EI # 3 then applied new gloves and performed a finger stick blood glucose on PI # 3. EI # 3 removed his/her gloves obtained new gloves and cleaned and disinfected the glucometer without performing hand hygiene between glove changes.

An interview was conducted on 1/30/2020 at 7:50 AM with EI # 3 who verified he/she should have performed hand hygiene between glove changes.

3. An observation was conducted by the surveyor on 1/30/2020 at 7:59 AM in Endoscopy Room on PI # 23 for a Colonoscopy.

At 8:01 AM EI # 3 applied gloves, secured PI # 23 on the bed, removed his/her gloves and left the Endoscopy Room without performing hand hygiene.

At 8:05 AM EI # 4, Certified Registered Nurse Anesthetist (CRNA), applied gloves and flushed PI # 23's IV line. EI # 4 then removed his/her without performing hand hygiene. EI # 4 proceeded to apply clean gloves and retrieved an alcohol prep pad and a bath cloth on the floor. EI # 4 disposed of the dirty supplies and removed his/her gloves without performing hand hygiene.

At 8:30 AM EI # 4 retrieved 3 labeled syringes from the anesthesia lock box (2 syringes of Propofol and 1 syringe of Lidocaine) and placed the syringes in his/her shirt pocket. EI # 4 failed to maintain the Propofol and Lidocaine syringes in an aseptic manner as directed per CDC guidelines.

At 8:32 AM EI # 4 retrieved 1 syringe of Lidocaine and 1 syringe of Propofol from his/her shirt pocket and administered the medications IV to PI # 23. EI # 4 then placed the contaminated syringes into his/her shirt pocket with the remaining 1 syringe of Propofol. EI # 4 failed to maintain the 1 remaining syringe of Propofol in an aseptic manner as directed per CDC guidelines. EI # 4 failed to dispose of the used syringes in a puncture resistant container as directed per the facility policy.

At 8:45 AM EI # 4, removed gloves, applied clean gloves, and obtained 1 vial of Propofol from the anesthesia lock box without performing hand hygiene. EI # 4 then withdrew the IV medication into a syringe without cleaning the vial top with alcohol as recommended per CDC. EI # 4 proceeded to place the prepared syringe of Propofol in his/her front shirt pocket. EI # 4 failed to maintain the Propofol syringe in an aseptic manner as directed per CDC guidelines.

At 8:55 AM EI # 4 obtained a vial of Ondansetron and withdrew the IV medication into a syringe without cleaning the vial top with alcohol as recommended per CDC.

At 9:02 AM EI # 5, Surgeon, completed the procedure, removed his/her gown and gloves, retrieved PI # 23's medical record and left the Endoscopy Room without performing hand hygiene.

An interview was conducted on 1/30/2020 at 10:05 AM with EI # 4 and EI # 2. EI # 4 verified that he/she failed to follow the CDC guidelines for preparation of IV medications and facility policy for hand hygiene and disposal of syringes. EI # 2 verified the staff failed to follow the facility policy for hand hygiene.


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4. An observation was conducted on 1/28/2020 at 10:43 AM to observe EI # 7, Registered Nurse, perform a medication pass on the Medical Surgical Unit.

During the observation, EI # 7 went to an area at the nurse's station designated as the "kitchen" to perform hand hygiene. EI # 7 had two medications, Xopenex Nebulizer Solution 0.63MG (milligram) vial and Cardizem 5 mg/ml (milliliter) vial in his/her hands prior to performing hand hygiene. As EI # 7 prepared to wash his/her hands, he/she placed both medications on the countertop adjacent to the sink. EI # 7 did not sanitize the area prior to placing the medications on the countertop.

After EI # 7 performed hand hygiene, he/she then proceeded to the "medication room" to prepare the medications. Prior to preparing the medications, EI # 7 placed both medications on the countertop which was visibly unclean with a dried brown substance. The surveyor asked EI # 7 was the countertop already cleaned prior to his/her preparing the medications. EI # 7 responded that "It should already be clean". EI # 7 did not sanitize the surface area prior to placing the medications on the countertop.

An interview was conducted on 1/28/2020 at 11:15 AM with EI # 8, Medical Surgical Manager, who confirmed EI #7 should not have placed the medications on both surfaces prior to ensuring both surfaces were sanitized and cleaned properly.

5. A tour of the Dietary Department was conducted on 1/28/2020 at 1:36 PM. Review of the Maintenance Ice Machine Cleaning Log revealed the last time the ice machine was "cleaned and descalled" was 9/3/19.

During an interview conducted on 1/28/2020 at 2:07 PM with EI # 9, who was also present at the time of the tour, confirmed the ice machine had not been cleaned since September of 2019 and should be cleaned on a monthly basis.