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Based on observation, interview, and policy review it was determined the facility failed to ensure a Registered Nurse (RN) supervised nursing staff to ensure staff provided care in accordance with the facility's policies and procedures for two (2) of thirty (30) sampled patients (Patients #10 and #11). Observations and interviews revealed nursing staff failed to change tubing on intravenous (IV) fluids in accordance with facility policy.

The findings include:

Review of facility policy titled "IV Therapy-Peripheral Site Access and Management" dated July 2012 revealed Registered Nurses were to initiate and monitor IV therapy and add medications to IV solution according to the physician's order. Further review of the policy revealed IV tubing, including add-on devices, would be replaced every 96 hours unless otherwise clinically indicated.

1. Review of the medical record revealed the facility admitted Patient #10 on 11/12/13 with diagnoses that included Pneumonia. Review of physician's orders revealed staff was to administer Zithromax (antibiotic) intravenously for five days to Patient #10. A review of the Medication Administration Record (MAR) revealed the Zithromax was listed on the MAR for Patient #10 and staff was to document the administration of the medication on the MAR.

Observation during a tour of the medical surgical floor on 11/12/13 at 1:00 PM revealed a solution of Normal Saline on an IV pole beside Patient #10's bed that staff had utilized to flush the patient's IV line after the administration of the Zithromax. However, continued observations revealed the IV tubing connected to the Normal Saline solution had been labeled with the date and time, 11/06/13 at 11:30 PM, and had not been replaced as of 11/12/13 at 1:00 PM, a timeframe of approximately six days.

An interview was conducted on 11/12/13 at 1:10 PM with RN #1 revealed she had provided nursing care to patient #10. RN #1 stated she was aware of the facility's protocol to replace IV tubing every 96 hours; however, RN #1 offered no explanation as to why the IV tubing had not been replaced, and stated Nursing must have "just overlooked" changing the IV tubing. RN #1 stated she had also overlooked the need to change the IV tubing.

Interview with the Infection Control Nurse on 11/12/13 at 1:45 PM revealed the IV tubing dated 11/06/13 that was observed on 11/12/13 to be connected to the solution of Normal Saline administered to Patient #10 should have been changed on 11/10/13. The Infection Control Nurse stated it was facility policy for nursing staff to change the IV tubing in an effort to prevent infections.

2. Medical record review revealed the facility admitted Patient #11 on 11/11/13 at 7:00 PM after being assessed by the Emergency Room physician. Patient #11's diagnosis included Pneumonia, Urinary Tract Infection, Altered Mental Status, and Anemia. Continued review of the medical record revealed Patient #11's physician had prescribed Zithromax to be administered intravenously to Patient #11 on a daily basis.

During a tour of the medical floor on 11/12/13 at 3:15 PM, a solution of IV medication was observed that, based on documentation on the medication, was to be hung on 11/12/13 at 1:00 PM. Continued observation of the medication revealed the IV tubing used to administer the medication had been labeled and initialed by Registered Nurse (RN) #5 as being hung on 11/11/13 at 9:00 PM. Documentation on the tubing also revealed the tubing was to be discarded on 11/11/13 at 9:00 PM. However, on the day of the observation, 11/12/13 at 3:15 PM, the tubing continued to be utilized to administer the patient's medication.

Interview with the Medical Surgical Supervisor on 11/12/13 at 3:20 PM revealed the nurse (RN#5) had failed to properly document the IV medication administration on 11/11/13 at 9:00 PM. RN #5 was not at the facility on the day of the observation and was unavailable for interview.

Based on observation, staff interview, and policy review, it was determined the Infection Control Nurse failed to ensure staff implemented policies developed for the prevention of infections when equipment, including the Computers on Wheels, was used at the bedside for one (1) of three (3) patients that were on infection control precautions and/or had compromised immunity (Patient #9). Facility staff was observed to take a soiled/stained Computer on Wheels into the room of Patient #9 who was on infection control precautions. Staff also left the patient's room with the same Computer on Wheels without cleansing the Computer on Wheels and returned the equipment to the nurses' station.

The findings include:

Review of the facility's policy titled "Electronic Device Disinfection," dated 06/01/07, revealed disinfection of computers, keyboards, and all electronic devices would prevent the transmission of microorganisms from the device's surface to the patient or employee and lessen the opportunity for contamination of the immediate environment. Further review of the policy revealed when Computers on Wheels were taken into isolation rooms, they would be protected from direct contamination and must be disinfected immediately upon leaving the isolation room.

Review of Patient #9's medical record revealed the facility admitted the seven-month old infant on 11/08/13 with a diagnosis that included pneumonia. Patient #9 was admitted to the Progressive Care Unit (PCU) accompanied by both parents. Patient #9 received Intravenous (IV) antibiotics (Rocephin) 50 milliliters (ml) daily.

Observation of the medication pass conducted on 11/12/13 at 11:50 AM during a tour of the PCU revealed Registered Nurse (RN) #1 administered liquid Motrin 80 milligrams (mg) by mouth through a syringe to Patient #9 due to an elevated temperature. Further observation revealed signage was posted on the door to Patient #9's room that indicated the patient was on Neutropenic Precautions (precautions for infants with low Neutrophil Blood Count). According to the precautions, staff and visitors were required to dress in a hospital gown, gloves, and mask before entering the patient's room. Staff applied the appropriate protective equipment (gowns/gloves/masks) before they entered the patient's room and pushed the Computer on Wheels to the patient's bedside to administer medications. However, observation revealed the Computer on Wheels taken to the patient's bedside at the time of the medication administration during the observation was unclean and had a buildup of dirt on the top and sides of the computer and a buildup of lint and hair on the wheels of the computer. In addition, liquid stains were on and around the keyboard; a sticky substance was on the base of the computer above the wheels; and a sticky substance was noted on the support drawer beneath the keyboard.

An interview was conducted on 11/12/13 at 12:10 PM which revealed the Computers on Wheels were hard to keep clean due to the wheels constantly picking up hair/dirt from the floors. RN #1 stated each Computer on Wheels was required to have a protective cover over the keyboard and offered no explanation why the Computer on Wheels she had taken into Patient #9's room did not have the protective cover. In addition, RN #1 failed to clean the Computer on Wheels upon leaving Patient #9's room and stated she/he did not know when the computer was cleaned last.

The Medical Surgical Supervisor stated in interview on 11/12/13 at 1 2:15 PM that nurses were to clean the Computers on Wheels after leaving a room where isolation precautions were implemented. The Medical Surgical Supervisor stated it was difficult to keep the Computers on Wheels clean because the wheels picked up dirt/hair from hallways. The Medical Surgical Supervisor confirmed the Computer on Wheels taken into Patient #9's room was soiled and should have been cleaned before and after entering the patient's room where the need for infectious precautions had been identified.

The Infection Control Nurse stated in interview on 11/13/13 at 9:00 AM that it was facility policy to clean the Computers on Wheels after leaving the rooms with infection control precautions. The Infection Control Nurse stated keyboard covers had been ordered for the Computers on Wheels but had not been received. The Infection Control Nurse stated the facility had a system in place for monitoring the cleanliness of charts, counters, floors, and nursing stations; however, the Computer on Wheels had not been included in the monitoring.