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Based on record reviews and document reviews, observations, interviews and review of the acceptable Plan of Correction submitted, it was determined the hospital failed to implement their corrective actions for the deficient practices cited during the 6/24/11 survey to achieve Condition Level Compliance. The hospital failed to ensure the governing body was responsible for the interventions outlined in their plan of correction as an institution as evidenced by continued deficient practices in the following regulatory areas:

482.12- The Governing Body failed to ensure the hospital achieved Condition Level Compliance by inconsistent implementation of corrective actions determined by the hospital to achieve and sustain compliance.

Areas of continued noncompliance identified included:

482.21- Quality Assessment Performance Improvement: The hospital failed to ensure that improvement activities such as medical errors and problem prone areas were set as a priority.

482.23- Nursing Service: The hospital failed to ensure that nursing services were organized to consistently provide supervision of the necessary care and services to meet the needs of each patient.

482.41- Physical Environment- The hospital failed to maintain an environment that ensures the safety of patients specifically with compliance of the Life Safety Code requirements.

482.42 -Infection Control: The hospital failed to ensure that the environment was sanitary to avoid sources and transmission of disease.

482.51- Surgical Services: The hospital failed to ensure that surgical services met professional standards of care related to continued operating room humidity ranges beyond acceptable standards, incomplete surgical records and provision of surgical post operative care.

The cumulative effect of this lack of oversight and systemic issues resulted in the Governing Body's ineffectiveness for the conduct of the hospital as an institution. This has the potential to affect the health, safety, and well-being of all the patients the hospital serves.


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Based on observation, interview and document review, the hospital failed to provide and maintain an environment that would promote patient safety and well being for individuals on the Psychiatric Unit.

The findings included:

On 9/19/11 at approximately 10:40 A.M., a tour was conducted on the Psychiatric Unit with SP #4 and SP #5. The following was observed:

Replacement locked entrance double doors were ordered on 7/18/11, but not delivered. Staff were observed to have difficulty unlocking the right side of the double door with their keys. Maintenance was called and replaced the locking mechanism while surveyors were on site.

Room 3009 had a nightlight with exposed edges from a clear insert covering.

Room 3011 had a hole in the wall with wires accessible.

The seclusion room had a gap in a section of baseboard adjacent to the door, and a hole in the wall with rough edges.

All patient rooms still had loopable door handles, as discussed with staff at the time of the full survey which concluded on 6/24/11. Replacement door handles had been ordered on 9/16/11, and are due to be shipped on 10/17/11, according to SP #4 and reviewed invoices.

Patient Rosters from 8/28/11 through 9/11/11 were reviewed with SP #6, on 9/20/11 at approximately 8:30 A.M. According to the rosters, Room 3009 was patient occupied on 13 days; census during that time ranged from 4 to 7 patients placing these patients potentially at risk due to the environmental hazards.

Based upon the Plan of Correction for this deficient practice, monthly environmental rounds were to be conducted on patient care units. Review of facility audits per the Plan of Correction on 9/19/11 at approximately 1:00 P.M. indicated no audits from the Psychiatric Unit were included. Interview with SP #6, Psychiatric Unit staff nurse, on 9/19/11 at approximately 11:00 A.M., revealed environmental rounds had not been conducted on a regular basis.





29568

Based on medical record review and staff interview, it was determined the hospital failed to implement the least restrictive interventions prior to the administration of a chemical restraint for 1 patient (Patient #4 ).
The findings included:

On 9/19/11 at 12:00 P.M. , a record review for Patient #4 and an interview with a Psychiatric Unit staff person #6 was conducted.

According to documentation in the electronic record, Patient #4 was admitted to the Psychiatric Unit after being brought to the Emergency Department (ED) by the police. A relative alleged the patient destroyed property, threatened a family member with a knife, and attempted to hit that person with a pipe. The ED Nurses Note at 17:20 indicated Haldol (tranquilizer) 5mg IM (intramuscularly) and Ativan (antianxiety) 2mg IM were administered to the patient. There was no documentation in the record to describe the behavior that warranted the use of these medications, or if any less restrictive interventions were used prior to the use of this chemical restraint.

On 9/11/11 at 0710, Nurses Notes identified the patient acted out; called staff names, went onto the patio and started to disrobe. The note further stated the patient was very intrusive and aggressive, and Security was called. Haldol 10mg and Ativan 2mg IM was administered at 0650. There was no documentation to describe what aggressive behavior was exhibited by the patient, if less restrictive or alternative methods were attempted prior to the administration of the chemical restraint, or what, if any, intervention was provided by Security.

Based upon record review, interview and observations, the hospital failed to ensure that restraints were used in accordance with physicians orders for Patient #11.

The findings included:

During observations on the medical unit on 9/22/11 at approximately 2:50 P.M., Patient #11 was observed seated in a geri chair with a tray locked in place. When approached, the patient was asked why the tray was in place and answered in nonsensical manner. When asked to release the tray, the patient was not able to follow commands or understand what to do. Review of the medical record in the presence of hospital staff, confirmed that the patient was not able to independently release the tray on command and therefore prohibited the free movement of the patient which constituted a restraint. Staff confirmed they had not considered the device a restraint and therefore had no order from the physician.

During the entrance conference, SP #4 was asked about restraint audits that were to be done according to the plan of correction with a completion date of 8/28/11. It was stated that no record audits were conducted because the facility had no patients in restraints.

Based on interview and record review, the hospital failed to ensure orders for the use of restraint must never be written as a standing order or on an as needed basis (PRN) for 2 of 2 applicable patients. Patient #4 and Patient #7.
The findings included:

1. On 9/19/11 at 12:00 P.M., a record review for Patient #4 and an interview with a Psychiatric Unit staff person #6 was conducted. Review of the physician orders indicated the following:

9/6/11, Haldol 10mg IM/po q (every) 6 h (hours) PRN Agitation; and on 9/8/11, Benadryl 50mg po/IM q 6 h PRN Agitation.
Review of the Medication Administration Record (MAR) indicated the following:

Haldol 10mg IM was administered on 9/7, 9/8, 9/9, 9/10, 9/11, and 9/12.
Ativan 2mg IM was administered on 9/6, 9/7, 9/8, 9/9, 9/10, 9/11, and 9/12.
Benadryl 50mg was administered on 9/8, 9/9, 9/10, 9/11, 9/12, 9/17, and 9/18.

2. Medical record review for Patient #12 was conducted on 9/22/11. On 8/15/11, at 0754 hours, an order was written for "soft restraints as necessary". Review of the documentation of the patient restraint/seclusion physician order sheet noted restraints were applied on 8/15/11 at 0804 A.M. and ended on 8/16/11 at 0804 A.M. Also noted on the form was the indication for use was "anticipation of patient needs". There was no clarification of what the actual patient need was nor was there any description on that patients response to the use of the device. In addition, the type of restraint was not specified to meet the patients' need other than "soft limb" without clarification of 1 point 2 point or 3 point soft limb restraint. Findings were discussed and confirmed with SP #1 on 9/22/11.

Based on interviews, observations, document review and review of the submitted and accepted Plan of Correction, it was determined the hospital continued to fail to meet the Condition of Participation of Quality Assessment Performance Improvement (QAPI) as evidenced by:

1. Failure to implement the Plan of Correction to achieve and sustain the reduction of medical errors. Please refer to A266.


2. Failure to conduct monthly QAPI meetings to ensure oversight, review, monitoring, implementation of corrective actions, and tracking of medical errors, and safety performance improvement activities as per the Plan of Correction. Please refer to A274.


3. Failure to incorporate collected patient care data to improve patient care as outlined in the Plan of Correction. Please refer to A274.


4. Failure to set priorities for its performance improvement activities that focus on high-risk, high volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, patient safety, and quality of care related to the physical environment and infection control. Please refer to A285.

Based on interview and document review, the hospital failed to ensure reduction of medical errors.

The findings included:

1. Record review for Patient #2 noted a physicians order dated 9/17/11 at 10:25, for Prozac 10 mg daily starting today. Review of the medication administration record found no evidence that the medication was administered as ordered for 9/17/11. Findings were confirmed with SP #1 on 9/19/11 at 11:30 A.M.

2. On 9/19/11 at 12:00 P.M., a record review was conducted for Patient #4. The Nurses Notes indicated on 9/8/11, PRN Haldol 10mg and Cogentin 2mg were given at 0945. No corresponding physician order was located for these medications.
An interview was then done with a SP #6, who verified no physician order could be found for these medications.

3. On 9/19/11, a medical record review for Patient #7 noted a physicians order for Ferrous Sulfate, 325 mg qd (every day) written on 9/9/11 at 9:45 A.M. Review of the medication administration record found no evidence that the medication was administered according to the physicians orders on 9/9/11 and 9/10/11. Interview with SP #1 at 12:30 P.M. 9/19/11 revealed if the medication has been given, the nurse should have placed their initials under the date on the medication administration record. If the medication had not been administered, a reason why the medication was not administered should also have been placed in the medical record.

4. Record review for Patient #12 on 9/22/11 noted a physicians order for Procrit, 20,000 units sc ( sub cutaneous) every week. When the medication administration record was reviewed there was no evidence that the medication had been given. On 8/20/11, a telephone order was received at 0755 hours again for Procrit, 20,000 units. This order was later discontinued. Interview with the SP #12 detailed that Procrit is not on the formulary of the hospital. It was stated the physician should have been notified and the order for another similar medication should have been ordered. Further review of the medical record failed to produce any evidence that the physician had been notified that Procrit was not available or that the medication had not been administered as ordered.
Interview with SP #1 confirmed the findings on 9/22/11 at 10:00 A.M.
Please refer to A395

Based on interview and document review, the hospital continued to fail to incorporate collected patient care data to improve patient care as outlined in their Plan of Correction.

The findings included:

1. Per the hospital Plan of Correction, humidity gauges were installed in all Operating Room Suites on 8/22/11. The humidity percentage was to be logged daily; rooms out of compliance were to be rechecked with a portable gauge; and maintenance was to be contacted to verify if gauges were working properly. If the suite was still out of compliance, that suite was to be closed until the situation was corrected.
Please refer to A701.


2. Chart audits were not performed bi-weekly, then monthly on the Psychiatric Unit: therefore Pharmacy could not perform oversight auditing as outlined in the Plan of Correction. Additionally, chart audits were not done bi-weekly for 3 months for all patients with restraint or seclusion orders, also outlined in the Plan of Correction.
Please refer to A164.

3. Environment of Care Rounds for the facility were to be instituted on 7/30/11, per the Plan of Correction. The hospital failed to provide evidence that rounds were conducted on all patient care areas.


An interview with representatives of the Quality Assurance and Performance Improvement Committee on 9/22/11 at approximately 3:10 P.M. revealed the audits for Environment of Care and medication errors on the Psychiatric Unit were not available for review.

It was also reported the Performance Improvement Management Council meeting on 9/6/11 did not include Nursing and Clinical QAPI Committees for the areas of: pain management; pressure ulcer; restraint/seclusion; plan of care; and nursing assessment and care documentation.

According to the Plan of Correction that was submitted and accepted, the results of these audits were to be reported to the QAPI (PIMC) each month.
Please refer to A701.

Based on interview and document review, the hospital continued to fail to set priorities for its performance improvement activities that focus on high-risk, high volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, patient safety, and quality of care related to the physical environment and infection control.

The findings included:

1. Per the hospital Plan of Correction, humidity gauges were installed in all Operating Room Suites on 8/22/11. The humidity percentage was to be logged daily; rooms out of compliance were to be rechecked with a portable gauge; and maintenance was to be contacted to verify if gauges were working properly. If the suite was still out of compliance, that suite was to be closed until the situation was corrected.

On 9/20/11 at 7:25 A.M. the surgical service department was toured in the presence of hospital staff noting the following observations.
The operating room #1 had a dehumidifier on with the humidity registering 70%.
In room #2, at 7:30 A.M. the humidity gauge read 72%. Observation and interview confirmed there was no dehumidifier in the room.
In room #4 at 7:40 A.M., a wall mounted humidifier was noted with the humidity gauge reading 72%.
In room #5 at 7:42 A.M. the humidity gauge read 72% without any dehumidifier noted in the room.
Operating room #6 was noted at 7:45 A.M. with a humidity reading of 72%
Operating room humidity control log was requested and received on 9/22/11. The range for the humidity is to be between 30-60% to be acceptable and maintenance is notified when the reading are beyond the parameters of 30-60%. There was no evidence that each time the gauges read beyond the 60%, maintenance had been notified.
Humidity tracking logs were reviewed for the month of June, July, August and September which noted the following humidity ranges for each room.
Room # 1 with a dehumidifier ranged from a high of 92% in June to a high of 87% in September
Room #2 without a humidifier ranged from a high of 90 % humidity in June to a high of 79% in September
Room #4 with a dehumidifier ranged from a high of 73% in June to a high of 78% in September
Room #5 without a dehumidifier ranged from a high of 88% in June to a high of 81% in September
Room #6 without a dehumidifier ranged from a high of 99% in June to a high of 82% in September
Interviews with MD #9 at 2:45 P.M. on 9/20/11 indicated the humidifiers are a temporary solution and that the ventilation system needs to be replaced in order to have the humidity under control in the operating suites. According to the Plan of Correction, the hospital was to monitor the effectiveness of the dehumidifiers and if effective, a dehumidifier would be installed in all operating "units" with a completion date of 7/29/11. Review of an invoice noted 4 additional dehumidifiers were ordered 8/25/11 and received on 9/22/11.
Please refer to A701.


2. Review of audits presented at the time of revisit to the hospital did not include any documentation related to the Psychiatric Unit Environment of Care Rounds.
Based upon the Plan of Correction for this defiencient practice, monthly environmental rounds were to be conducted on patient care units. Review of facility audits per the Plan of Correction on 9/19/11 at approximately 1:00 P.M. indicated no audits from the Psychiatric Unit were included. Interview with SP #6, Psychiatric Unit staff nurse, on 9/19/11 at approximately 11:00 A.M., revealed environmental rounds had not been conducted on a regular basis.
An interview with representatives of the Quality Assurance and Performance Improvement Committee on 9/22/11 at approximately 3:10 P.M. revealed there were no Environment of Care Rounds from the Psychiatric Unit.
Please refer to A144.

Based on observations, interviews and record reviews, it was determined the hospital failed to meet the Condition of Participation in Nursing Services as evidenced by:


1. Registered Nurses did not continuously assess patient care needs related to pressure ulcers, skin assessments, wound care dressings, proper positioning of patients, or compliance with physician orders. Please refer to A0395.

2. The hospital did not ensure that nursing staff developed and kept current nursing care plans. Please refer to A0396.

3. Nursing staff did not follow hospital policy regarding the proper method of disposal of a controlled drug in accordance with the Plan of Correction submitted and accepted. Please refer to A404.

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Based on observations, interviews and record reviews, it was determined registered nurses did not continuously assess patient care needs related to pressure ulcers, skin assessments, wound care dressings, proper positioning of patients, or compliance with physician orders for 10 of 18 sampled patients (# 2, 3, 4, 5, 6, 7, 11, 12, 15,and #16).

The findings included:

1. Record review for Patient #2 noted a physicians order dated 9/15/11 for vital signs to be done every shift. Review of the electronic medical record in the presence of hospital staff confirmed vital signs were not taken in accordance with the physicians order on 9/16; 9/17/9/18. In addition, on 9/17/11 at 10:25, an order was written by the physician for Prozac 10 mg daily starting today. Review of the medication administration record found no evidence that the medication was administered as ordered for 9/17/11. Findings were confirmed with SP #1 on 9/19/11 at 11:30 A.M.

2. Record review for Patient #3 noted a physician order for "strict I&O" (intake and output) on 9/11/11. Medical record showed missing entries on 9/13; 9/15; 9/16 and on 9/17. Interview with SP #1 and SP #4 on 9/19/11 at 4:30 P.M.confirmed the gaps in following the physicians order for strict I&O.

In addition, the medical record contained an order for Alleyn Ag to sacrum with a dressing change every 3 days written on 9/14/11. Further review failed to provide evidence that the wound treatment was done according to orders. Interview with SP#4 at 4:15 P.M. verified that the due date for the treatment was on a weekend when there was no wound care nurse on duty and there had been no coverage put into place to ensure that treatments were completed as ordered. According to the Plan of Correction, with a completion date of 6/24/11. the wound care team had been enhanced and coverage was increased from 5 days a week to 7 days/8 hours per day.

3. On 9/19/11 at 12:00 P.M., a record review was conducted for Patient #4. The Nurses Notes indicated on 9/8/11, PRN Haldol 10mg and Cogentin 2mg were given at 0945. No corresponding physician order was located for these medications. An interview was then done with a SP #6, who verified no physician order could be found for these medications.

4. A record review of Patient # 5 was conducted on 9/19/11 on 9/20/11 at approximately 8:30 A.M. with SP #1. The Skin Assessment Braden Scale on 9/17 at 0955 identified a score of 8 points and was recorded by SP # 8; on 9/17/11 at 2030 an entry was recorded by SP #9 that noted the Skin Assessment Braden Scale score was 13 points; and the entry on 9/18/11 at 1100 indicated a score of 11 points by SP #10.

The electronic record identifying wounds for this patient noted a medial sacrum wound on 9/3/11 at 1432; the same area was identified as a decub on 9/4/11 at 1414; and on 9/5/11 at 0410 and 9/9/11 at 1225, the same area was noted as a Diabetic Ulcer. The entries from 9/3/11 through 9/14/11 identified the medial sacral wound as a Stage III pressure ulcer once.
On 8/31/11 at 8:30 A.M., an entry was made on the physician order sheet for Left Ischia Allevyn adhesive; Sacrum Algesite adhesive change Q (every) 3 days. The order was noted by SP #11 at 11:07 A.M. There was no documentation in the record that identified an area located on the left Ischia which required treatment.
Treatment, including a dressing change, was ordered every 3 days. Review of the treatment record indicated a dressing change on 8/22/11. No treatment was noted on 8/25/11 or 8/28/11; a dressing change was initialed as done on 8/29/11, 7 days later; and there was no documentation for 9/1/11, or 9/4/11. A dressing change was noted 11 days later on 9/10/11 and 5 days later on 9/15/11. No further dressing changes were identified in the record as of 9/19/11.

5. On 9/22/11 at approximately 2:05 P.M. on the Surgical Unit, the following was observed:
Patient #6 did not have bilateral heels off loaded and the bilateral Sequential Compression Devices (SCD) were applied but not activated.
Patient #8 was seated in a chair with both uncovered feet resting on the lower metal bar of the over the bed table.
Patient #9 was lying in bed with the left foot against the footboard.
Patient #10 was lying in bed and bilateral heels were not off loaded.

A record review of Patient #6 was conducted on 9/22/11 at approximately 2:15 P.M. with SP # 7 on the Surgical Unit. SP #7 acknowledged there was a physician order for the SCD, and they should have been activated, orders for the patient ' s heels to be off loaded and bilateral heel protectors to be worn. The physician had ordered Allevyn dressing to bilateral heels with silvadene every 3 days change kling daily on 9/13. There was no notation that either had been done for 4 days from 9/13/11 to 9/17/11. Review of the record also indicated the sacral and buttock pressure ulcers were a stage II, however, no stage was assigned to the right and left heel blisters.

6. On 9/19/11, a medical record review for Patient #7 noted a physicians order for Ferrous Sulfate, 325 mg qd (every day) written on 9/9/11 at 9:45 A.M. Review of the medication administration record found no evidence that the medication was administered according to the physicians orders on 9/9/11 and 9/10/11. Interview with SP #1 at 12:30 P.M. 9/19/11 revealed if the medication has been given, the nurse should have placed their initials under the date of the medication administration record. If the medication had not been administered, a reason why the medication was not administered should have been placed in the medication administration as well.

7. On 9/22/11 at approximately 2:35 P.M., Patient observations were conducted on the Medical Unit with the Medical Unit Manager and the following was observed:
Patient #11 was not wearing bilateral Sequential Compression Devices (SCD) as ordered.
Patient #3 was lying in bed, both heels were not off loaded, and there was no date on the dressing.

8. Record review for Patient #12 on 9/22/11 noted a physicians order for Procrit, 20,000 units sc ( sub cutaneous) every week written on 8/10/11. When the medication administration record was reviewed there was no evidence that the medication had been given. On 8/20/11, a telephone order was received at 0755 hours again for Procrit, 20,000 units. This order was later discontinued on 8/20/11.

Interview with the SP #12 detailed that Procrit is not on the formulary of the hospital. It was stated the physician should have been notified and the order for another similar medication should have been ordered. Further review of the medical record failed to produce any evidence that the physician had been notified that Procrit was not available or that the medication had not been administered as ordered.
On 8/12/11 at 10:30 A.M. Patient #12 had a physicians order written for "urgent physical therapy consult to eval (evaluate) for back brace for thoracic compression fracture". Record review failed to provide any evidence that the consult was done as ordered. Interview with SP #1 confirmed the findings on 9/22/11 at 10:00 A.M.

The hospital did not ensure that dressing changes for ulcers are done as ordered by the physician. The hospital did not ensure that wounds were consistently assessed, monitored and documented correctly.

The Findings included:

Patient #16 has a pressure ulcer on the sacrum with an order for cskin prep wipes followed by Allevyn AG with the dressing to be changed every 3 days. The electronic medical record shows the dressing to have been changed. The wound assessment notes in the EMR indicate that the dressing was changed on 9/5 and then not again until 9/11. The patient went to the OR for an open reduction of a right hip intertrochanteric fracture on 9/8/2011. After surgery, the orders for the dressing change were not rewritten.

In an interview with the MD # 9 on 9/22/2011 at 3 P.M., he was asked if dressing changes should be done on the day of surgery if the surgery was unrelated to the ulcer. He indicated that the dressings should be changed on the day of surgery. In response to a question about the rewriting of orders after surgery, MD #9 responded that all orders are to be rewritten, that it is the responsibility of the surgeon to rewrite all orders including orders for the wound care team. Please refer to A0338.


Review of the EMRs for patients Patient # 16 and Patient #15 showed that the wound assessments were done erratically on various shifts with varying degrees of consistency and detail regarding the wounds. The status and progress of the wound care could not be meaningfully assessed due to inconsistency and differences of the assessments.

Patient #15 was admitted on 8/7/2011 with venous ulcers to the right foot, right leg and an ulcer on the sacrum. She has a history of poorly controlled diabetes, hypertension and venous ulcers. A wound assessment done on Aug. 7, 2011 at 1300 notes a right ankle decubitus, stage 3 and a left ankle decubitus, not staged, but noted to have yellow slough and black eschar, irrigated with saline and dressed with gauze pads. There is no documentation of the sacral ulcer.

The wound assessment page in the EMR on Aug. 8 at 0500 notes a right ankle diabetic ulcer with a dry and intact dressing, but drainage with a foul odor. A sacral pressure ulcer is noted to be a stage 2, pale pink with red granulation. No dressing noted.

A wound assessment page on Aug. 12 at 1830 notes a leg leg venous ulcer, the dressing change with drainage documented as " None " but drainage odor noted as " Mild Odor. " Appearance is that of a Dry Scab, 3 cms in length and 5.5 cm in width. A venous ulcer is noted on the right leg, dressing changed. Drainage amount is " Moderate. " Drainage description is " Serous. " With mild odor and black eschar. A further note indicates that it was impossible to measure the wound, but the leg circumference was 29 cm.

An assessment of the sacral ulcer on Aug. 15 at 1800 describes it as stage 2, 15 cm long by 15 cm wide. There is nothing to indicate if this is a change in size, as there was no measurement previously. The drainage is described a minimal and serous.

On Sept. 13 at 1751, the sacral ulcer is described as 1.5 cm long by 1.0 cm wide and stage 2.

On Sept. 18 at 1436, the wound assessment label is noted to be " Discontinued. "


For patient Patient #16, the wound assessment of Sept. 2, 2011 at 0800 notes a sacral pressure ulcer, stage 2 with gauge pad dressing open to air. On Sept. 2 at 1550, the wound assessment notes skin tear, stage 2, 3.8 cm long by 2.5 cm wide. dressed with Allevyn AG.

On Sept. 5 at 2011 at 1000, the wound assessment for the sacrum notes a dressing change for the ulcer with minimal drainage and no other description.

On Sept. 9 at 0900, the sacral ulcer is described as a diabetic ulcer, dressing dry and intact with no drainage and no odor.

On Sept. 11 at 1545, it is described as a pressure ulcer with moderate, serous drainage, stage 2, measuring 7.3 cm wide and 8.5 cm long. From Sept. 12 through Sept. 18, the dressing is described as dry and intact with no further description of the ulcer itself.

Based on observations, interviews and record reviews, it was determined the hospital did not ensure that nursing staff developed and kept current nursing care plans for 5 of 18 sampled patients (#2, 4, 5, 6, and #7 ).
The findings included:
1. Record review for Patient # 2 noted an admission date of 9/15/11. Review of the care plan found no evidence of an evaluation or discharge preparation. The findings were discussed and confirmed with SP #1 on 9/19/11 at 11:30 A.M.

2. On 9/19/11 at 12:00 P.M., a record review for Patient #4 and an interview with a Psychiatric Unit staff nurse SP #6 was conducted. According to documentation in the electronic record, Patient #4 was admitted to the Psychiatric Unit after being brought to the Emergency Department (ED) by the police. A relative alleged the patient destroyed property, threatened a family member with a knife, and attempted to hit that person with a pipe. The physician orders included the use of chemical restraints.
Review of the Care Plan did not identify specific behaviors, and least restrictive interventions or approaches to be attempted prior to the use of chemical restraints.

3. A record review of Patient #5 was conducted on 9/19/11 on 9/20/11 at approximately 8:30 A.M. with SP #1. The Care Plan did not identify specific or individual nursing interventions to address the needs of this patient related to the sacral pressure ulcer.

4. A record review of Patient #6 was conducted on 9/22/11 at approximately 2:15 P.M, with SP #7 on the Surgical Unit. SP #7 acknowledged there was a physician order for the Sequential Compression Devices (SCD), and they should have been activated. Additional orders for the patient's heels to be off loaded and bilateral heel protectors to be worn were also verified with the staff person. The Care Plan did not include any of these interventions specific to this patient.

5. During review of the medical record for Patient # 7 on 9/19/11, a review of the care found no evidence that interventions related to Hepatitis C, HIV or onset of episodes of pitting edema had been addressed. Additionally, on 9/9/11 and order was written for ensure (nutritional supplement) 240 cc q8 hours ( every eight hours) to be given due to the patient being underweight with severe temporal wasting . The ensure order was increased on 9/10/11 to 240 cc qid ( four times a day). There was no evidence that the care plan was revised to reflect the supplements needed to increase protein caloric intake. Findings were confirmed with SP #1 and SP #4 on 9/19/11 at 3:25 P.M.

15910

Based on observation and interview, the facility failed to assure disposal of unused controlled medications be witnessed by two nurses according to the hospital policy.

The findings included:
During a 9/22/11 medication pass observation on the psychiatric unit the following situation occurred. The unit nurse obtained a 1.0 mg tablet of lorazepam from the unit's Omnicell station to administer to a patient. the medication order for the patient was for a dose of 0.25mg of lorazepam. The nurse correctly split the tablet to obtain the correct dosage for the patient, resulting in an excess tablet fragment of 0.75mg. Hospital policy requires that the disposal of unused portions of controlled medications be witnessed by two nurses. The nurse explained that she understood the policy, however compliance was not always possible. Frequently the unit is staffed with only one nurse and other nurses are not available to come and witness drug disposal. In this instance the unit nurse asked SP #19, a nurse from the PI dept. who was accompanying the medication pass observation, to witness the disposal of the excess lorazepam. Staff Person #19 stated she was unable to witness the disposal because she did not have the proper authorization and proceeded to leave the area. The unit nurse proceeded with the disposal of the unused portion of the lorazepam unwitnessed by a second nurse. With only one nurse on the unit and other nursing staff unavailable to witness drug disposal it is impossible to have 2 nurses witness controlled drug disposal as the policy requires.
Proper disposal of unused controlled medications during medication administration was identified as a problem during the June 24, 2011 survey. The Plan of Correction resulting from that survey addressed this issue with a completion date of August 25, 2011. As September 23, 2011 this issues was unresolved. See tag 0491

Based upon record review and interview, the hospital failed to provide complete information related to services provided and care and treatment for 2 of 18 samled patients. Patient # 4 and #5.


The findings included:


1. Review of the physician orders for Patient # 4 and an interview with a Psychiatric Unit staff nurse SP #6 indicated the following:
Review of the electronic notes indicated the Medical Provider ' s entry on 9/8/11 at 1838 and 9/10/11 at 1751 identified Haldol 10mg IM and Ativan 2mg IM every 8 hours for agitation. No corresponding physician order was found that indicated these meds should have been given every 8 hours.

Review of the Nurses Notes indicated on 9/8/11, PRN Haldol 10mg and Cogentin 2mg were given at 0945. There was no corresponding physician order for this medication.
The electronic medication records indicated Depakene 500mg as discontinued. There was no physician order to verify this directive.

According to the Plan of Correction, record audits, monitoring data and inservices were to have been conducted with completion date of 8/25/11.

2. Record review for Patient #5 was conducted with SP #1 on 9/20/11 at approximately 8:30 A.M. On 8/24/11 at 1:00 P.M., an entry was made on the Physician Order Form for Wound Care to continue Algisite/Allevyn dressing until Biostep arrived, then stop Algisite/Allevyn and start Biostep. The order did not include location or frequency; furthermore, it was not noted by a nurse.

On 8/31/11 at 8:30 A.M, an entry was made on the Physician Order Form for Left Ischia Allyvyn adhesive; Sacrum Algesite adhesive change Q (every) 3 days. The order was noted by SP #11 at 11:07 A.M. There was no documentation in the record that identified an area located on the left Ischia which required treatment.
On 9/7/11 at 8:35 A.M., an entry was made on the Physician ' s Order Form to Start Biostep today to sacrum. Change every three days. The order was not noted by a nurse.

Based upon record review and interview, the hospital failed to ensure that medical record entries were legible for 2 of 18 sampled records. Patient #3 and #5.

The findings included:

1. Medical record review was conducted on 9/19/11 for Patient #3 which revealed an order that was not legible. On 9/16/11, several orders were written including orders for wound treatments. Interpretation of the wound treatment was asked of several nurses during the record review. Interviews with SP #1, and #4 at the time of review each read the entry differently. Several interpretations were provided- none with clarity.
2. Record review for Patient #5 was conducted with SP #1 on 9/20/11 at approximately 8:30 A.M. Review of the physician orders for 9/19/11 (time not clear) included an illegible entry. The order was noted by SP #13 on 9/19/11 at 10:40 A.M., and when asked to identify the entry, SP #13 could not do so. Four other staff nurses were asked to identify the entry, and were unable to read the entry.

Based upon record review and confirmed by interview, the hospital failed to ensure the all record entries were timed when signed by the clinician for 4 of 18 sampled records. Patient #1, 2, 3, and #7.

The findings include:


1. Record review for Patient #1 was reviewed on 9/19/11 and revealed the following medical entries were not dated.
Admitting physician's order for same day surgery dated 9/14/11 by MD #1.
Discharge Instruction Sheet dated 9/19/11 was not timed when signed by MD #1.
Medication Reconciliation Form was not timed when signed by MD #1.
Post operative anesthesia standing orders dated 9/19/11 were not signed when discharged from the Post Acute Care Unit (PACU).
These findings were confirmed with SP #3 during the morning of 9/19/11 at approximately 7:45 A.M.

2. Record review for Patient #2 revealed telephone orders were taken and transcribed on 9/15/11 at 0045. There was no evidence of the date nor the time that the physician signed the orders. On 9/16/11, an order to discontinue Ativan (anti-anxiety medication) 0.5 mg was written and signed but not timed by the physician. These findings were confirmed with SP # 1 on 9/19/11 at 11:30 A.M.

3. The medical record for Patient #3 was reviewed and noted the Medication Reconciliation Form dated 9/9/11 was not timed when signed by MD #2. During the review of the preoperative verification checklist, it was also noted that two nurses did not verify selected items in the verification list as required by policy. Additionally, a review of the Surgical Core Improvement Project dated 9/12/11 was also noted not to have been timed when signed by the two (2) physicians. These findings were confirmed with SP #1 & SP #4 during the record review.

4. Review of the medical record for Patient # 7 revealed the Medication Reconciliation Form without the date nor time that it was signed by the physician. This finding was confirmed with SP#1 at 12:30 P.M. on 9/19/11.






29568

15910

Based on observation and interview the facility failed to assure it ' s policy of witnessed drug disposal had been operationalized.

The findings included:

1. During an interview on 9/21/11 at 1:40 P.M., SP #12 stated the educational inservicing which included the procedures for witnessed disposal of unused controlled medications had only been completed by 68.1% of the nursing staff. This In-servicing was an element of the Plan of Correction from the June 24, 2011, which had a completion date of August 25, 2011.
2. During a medication pass observation on 9/22/11 on the psychiatric unit, the unit nurse obtained a 1.0mg tablet of lorazepam from the unit ' s Omnicell station to administer an ordered dose of 0.25mg lorazepam to a patient. The nurse correctly split the tablet to obtain the correct dosage for the patient, resulting in an excess tablet fragment of 0.75mg. The nurse stated that she had a dilemma in that policy and procedures required two nurses to witness the disposal of unused medication and that normally there was only one nurse on the unit. The nurse further stated that when this situation occurred, an attempt would be made to get another nurse to come to witness the disposal, however, frequently other nurses were unavailable for this task. The nurse proceeded to ask SP #19, a nurse from the PI dept. who was accompanying the medication pass observation, to witness the disposal of the excess lorazepam. Staff Person #19 stated she was unable to witness the disposal because she did not have the proper authorization and proceeded to leave the area. The unit nurse proceeded with the disposal of the unused portion of the lorazepam unwitnessed by a second nurse.

Based on interview the facility failed to assure medications utilized are subject to review and correlation with medication orders by a pharmacist and that medications orders get to the pharmacy and medications get back to the patient promptly.

The findings included:

1. During an interview on 9/20/11 at approximately 1:40 P.M. while answering questions on pharmacy systems and operations, SP #12 acknowledged that current pharmacy systems /procedures did not include a 100% reconciliation of all medications obtained by nursing from the Omnicell medication dispensing system with physician drug orders processed by pharmacy in the Meditec h system. Staff Person #12 further acknowledged that such a situation could result in medication use without pharmacy review.
The pharmacy uses the Meditech system for patient pharmacy information and medication management. And it is through the use of the Meditech that medication orders are linked with a patient and receive clinical screening and analysis through pharmacy review.
2. Record review for Patient #12 showed an order for Procrit 20,000 units sc (sub cutaneous) every week was written on 8/10/11. The Medication Administration Record (MAR) contained no evidence that Patient #12 had received this medication. During an interview on 9/23/11 at approximately 11:45 A.M. , SP #12 stated that Procrit is not a formulary item and the procedure for processing this order would be to communicate Procrits nonformulary status to the unit to have the physician rewrite the order for a therapeutically equivalent product on the formulary. SP#12 could produce no evidence that this order had been received or addressed by pharmacy. Please refer to A0395.

Based upon observation, interview and record review, the hospital failed to ensure that dietary staff were able to demonstrate a thorough understanding of their job responsibilities.


The findings included:


During a tour of the Dry Food Storage Area of the kitchen on 9/19 at 2 P.M., 2 large Rubbermaid bins, one containing white flour and one containing whole wheat flour, were observed not to be dated. SP #20, stated on interview that no flour should be added to the bins until the supplies contained within them were used. He stated, also, that they should have expiration dates, though the contents were used quickly.

A tour of the Dry Storage area on 9/22/ 11 showed that both bins were marked with expiration dates. SP #20 indicated that staff in the kitchen responsible for that area had been instructed to indicate on the bins the dates they were filled and the expiration dates. There were written instructions that no flour was to be added until the contents had been used up. The bins were then to be washed and new flour added with expiration dates.


Observations and tours of the kitchen area containing the three-compartment sink on 9/19, 9/20, 9/21 and 9/22 from 10 to 11 A.M. each day, revealed that 1 of 2 employees assigned to the area and responsible for ensuring the correct amount of sanitizer /disinfectant in the third compartment used for sanitizing hand-washed kitchen pots, pans and colanders could not correctly gauge the correct concentration needed using the test strips available for that sanitizer. This could result in improper sanitizing if too little was used to possible allergic reactions in patients/staff if too much was used and it transferred to the food.

The sanitizing agent used, Ecolab 22 Multi Quat Sanitizer, was dispensed into the sink with an automatic dispensing system set up by company according to the Director of the Dietary Service. The staff assigned was to use the test strips to determine if the concentration was correct.

The surveyor observed one employee, SP #21, on 9/19 at 10:30 A.M. along with SP #20 and SP #3, hold the test strip in the water longer than indicated by the instructions on the test strip package. The instructions indicated that the strip should be held in the water for 10 seconds and not moved around in the water. SP #21 held it in the water for 20 seconds and moved the strip around. The strip, therefore, showed a concentration of 400, rather the correct concentration of 200 parts. The sink was emptied and the process started again until the correct concentration was achieved. The surveyor observed in the presence of SP #20 and SP #3 that SP #21 could not perform the test correctly on 9/20 and 9/21.
On 9/22/11, the surveyor watched a second employee, SP #22, use the test strip correctly.

When interviewed on 9/22 at 11 A.M., SP #20 stated that SP #21 was instructed to get a supervisor to help him test the water until he could assume the task correctly. SP #20 stated that the log which listed the times on the log listing the concentration testing was changed from specific times to any time that the water was changed, making the log better reflective of the actual work in the kitchen.

15910

Based upon observations, staff interviews and review of hospital documents, it was determined that the Hospital failed to be constructed, arranged, and maintained to ensure the safety of patients.

Standard level deficiencies as well as Life Safety Code deficiencies not corrected from the June 2011 survey are noted for the Governor Juan Luis Hospital as of September 23, 2011. Because of the uncorrected Life Safety Code issues, the facility does not meet the NFPA Life Safety Code Standard; additionally other environmental standards are not met.
The cumulative effect of these deficiencies is that the Condition of Participation of Physical Environment is not met.
Please refer to Hospital Regulation Requirements and Life Safety Code K tag Statement of Deficiencies.

15910

Based on record review, interviews and observations it is determined that the hospital failed to ensure that the Life Safety from Fire requirements are met. The findings are limited to citations from the June 2011 surveys that have not been corrected. The findings included in the K Tags included in this report prove that the facility is not in compliance with the NFPA requirements as stipulated in CFR 482.41 (b). Standards: Life Safety from Fire

15910

Based on record review, interviews and observations it is determined that the hospital failed to ensure that the Life Safety from Fire requirements are met. The findings are limited to citations from the June 2011 surveys that have not been corrected. The findings included in the K Tags included in this report prove that the facility is not in compliance with the NFPA requirements as stipulated in CFR 482.41 (b). Standards: Life Safety from Fire

Based on observations and document review, the hospital failed to maintain the environment of the hospital and assure patient safety.
The findings include:
During the tour of the operating suite on 9/19/11 at 7:45 A.M. while accompanied by hospital staff, cracked floor tile was noted on operating room #2. Staff confirmed the observation and corrections were made later on 9/22/11.
In operating room #6 at 7:45 A.M., an electrosurgical piece of equipment was noted without an inspection sticker. Staff confirmed the finding and corrections were made onsite.

On 9/22/11 at approximately 10:00 A.M. on the Surgical Unit the following was observed:
The corner of wall near the Nurse ' s Station had no baseboard
Room 3091, the IV (intravenous) pole was pitted with rust
Room 3094, B bed, over bed table missing corner and over bed light had section that was separated, a container labeled Silvadene (antibiotic cream), and the right side rail had chipped paint.
Two holes in the wall between Room 3093 and 3095
Room 3095, bathroom wall behind commode had peeling plaster
Room 3093, closet door missing
Room 3097, bathroom shower floor had worn areas
Handrails on the right side of the hallway near Room 3097 had chipped paint

The Medical Unit was also observed and the following was identified:
Room 3135, Dispatch disposable bleach towels container on sink, bathroom plaster peeling behind commode
Room 3127, bathroom baseboard separated behind commode
Room 3125, Janitor closet open
Room 3124, bathroom plaster peeling behind commode and sink dripping
Room 3121, bathroom spray hose on floor; floor tiles missing behind commode
Room 3123, baseboard off

On 9/21/11 at approximately 11:45 .AM. the following was observed on the 3rd Floor:
Room 3104, the 3 handrails had no end cap, exposing metal edges
Room 3075, no end cap at either end
Outside of Nursery Entrance at double doors, 3 handrails with no end caps
Inside Nursery Entrance at double doors, exposed metal on handrail
Outside the Gastroenterology Suite, broken handrail and end cap
Review of the hospital's Plan of Correction identified monthly Environment of Care Rounds Program to patient care areas to continually assess the hospital physical environment and develop/implement strategies to manage the identified risks and continue on-going building maintenance program was to be completed on 7/30/11.

Based on observations, staff interviews, review of policies and procedures related to infection control , medical record reviews and document reviews conducted from 9/19/11 to 9/23/11, it was determined that the hospital failed to achieve compliance with the Condition of Participation for Infection Control as evidenced by:


1. The hospital failed to develop and implement control measures to isolate a patient with suspected tuberculosis. Please refer to A749.

2. The hospital failed to ensure that the infection control officer maintained an accurate and up to date infection control log. Please refer to a 750.

3. The hospital leadership failed to address the prior known infection control problems identified. Please refer to A756.

4. The hospital failed to sustain compliance with corrective measures taken after the 6/24/11 survey. Please refer to A749.

Based upon record review, interview and observation, the hospital failed to implement measures regarding the identifying, controlling preventing and investigating infections within the hospital.

The findings included:

1. On interview with the Infection Control Officer on 9/22/2011 at approximately 2:15 P.M. she stated that there were physicians in the hospital reluctant to place patients on isolation. In order to have patients who needed isolation properly placed, the hospital developed a Statement of Authority allowing nurses to place patients in isolation. This Statement of Authority was assigned and approved by MD #9 and SP #26 on 8/17/2011.

It reads: The Hospital Administrator and the Medical Staff approves the authority of the Infection Control Committee and the Infection Control Coordinator to institute any surveillance, prevention and control measures or studies when there is a reason to believe that any patient or personnel may be in danger. In the interest of early identification and the implementation of control measures, the registered nurse may institute cultures or transmission-based precautions or isolation measures as they become necessary. The attending physician will be notified as soon as possible of any such action. The need for such action will be documented in the patient ' s medical record.

When the Infection Control Coordinator was asked if this meant that a registered nurse could order cultures or laboratory tests to determine if isolation was warranted, she replied, " Yes. "

By authorizing registered nurses to order tests and isolation precautions, the hospital authorized nurses to perform outside of their delineated duties and authority of nursing practice acts. The hospital did not institute any training to permit nurses to practice in this manner to help ensure that the proper tests and isolation were ordered. As a result, orders for isolation were not found in the charts of at one patient whose isolation was ordered by a registered nurse. While ordered by registered nurses, there was no documentation in the chart of Patient #15, indicating the need for this isolation as indicated in the Statement.


2. The hospital failed to have procedures and policies in place to ensure that patients were properly placed on isolation including the correct type of isolation for the diagnoses with orders signed by physicians. The hospital did not have procedures in place to ensure that hospital personnel were trained and knowledgeable in the reason(s) for each patient ' s isolation and how to clean equipment when used for a patient in isolation which would then be used for other patients.

The room in which Patient #10 was located had a stop sign on the door indicating that the patient was on isolation on 9/21/2011 at approximately 10:30 A.M. The CNA (certified nurse aide) entering the room was unable to tell the surveyor why the patient was on isolation. The CNA asked SP # 24 the reason for the isolation. SP #24 indicated that the patient had had chicken pox, but that the isolation was d/d ' s on 9/14 and SP #24 removed the Stop/Isolation sign. Review of the medical record revealed that there was no order for the isolation, but that MD #10 an order to d/c (discontinue) it on 9/14. SP #7 also could not locate the original start order for the isolation.

Review of the medical record for Patient #17 on 9/22/2011 who was on isolation for MRSA of the abdomen according to SP #25, did not have a doctor ' s order for the isolation. On interview with SP #25 on 9/22/2011, she told the surveyor that the Infection Control Officer indicated on the electronic medical record if the patient had previously been diagnosed with MRSA or VRE. If they had been, the nurse contacted the physician, but the nurse placed the patient on isolation. The nurse decided what type of isolation depending on the diagnosis. SP #25 stated that physicians had to order the discontinuation of the isolation.



3. During the tour of the operating rooms on 9/19/11 at 7:45 A.M. operating room #4 and at 7:42 A.M. in operating room 5, sections of anesthesia tubings from the anesthesia equipment, were observed to have pulled together with adhesive tape. Above and below the existing adhesive tape, it was noted that the tubes had remnants of glue where prior tape had been placed and removed. The tubing was observed to dirty and not a smooth surface to facilitate cleaning. Staff interview confirmed the tape and that there was no way to effectively clean adhesive tape and the remaining glue was a breeding ground for potential bacteria compromising the surgical environment.


4. During medical record review for Patient # 3 on 9/19/11, pictures of pressure ulcers taken according to policy were requested. Interview with SP #4 and SP#1 confirmed at 4:15 P.M. that wounds are measured weekly and a photograph is taken and placed in the chart. A photograph was provided dated 9/14/11 of a wound located on the sacrum. The staff person hand in the photograph was noted to be without the benefit of gloves. SP #1 stated that staff should have worn gloves according to their policy and agreed with the breech in policy.



5. On 9/20/11 at approximately 8:15 A.M., an interview was conducted with SP # 14, SP # 15, SP #16, and SP #17. They were asked how they cleaned the multi-use glucometer units. One GN (Graduate Nurse) responded they have used bleach wipes, and the other three said they used alcohol wipes.

6. On 9/20/11 at approximately 9:20 A.M. on the Medical Unit, SP #16 was observed to enter the room of a patient on precautions for MRSA (Methicillin-resistant Staphylococcus aureus) and remove a disposable gown. SP #16 then proceeded to unwrap the gown and stepped into another patient isolation room across the hall before being questioned by the surveyor.
A few minutes later, a housekeeping staff came to the Medical Unit wearing disposable gloves and pushing a large grey receptacle. The receptacle had a pile of disposable gloves on top. The staff person opened the door to the soiled utility wearing the gloves, and exited the room carrying a plastic bag, which he placed into the receptacle. The housekeeping staff person went through the double doors to the Surgical Unit without changing gloves. The same housekeeping staff person returned to the Medical Unit a few moments later, and exited through the double doors leading to the hallway and elevators. The staff person was seen by the elevator wearing disposable gloves, pushed the elevator button and entered the elevator.

7. On 9/20/11 at 9:40 A.M. on the Medical Unit, SP #18 was observed in a room of a patient identified with MRSA (Methicillin-resistant Staphylococcus aureus), performing a dressing change. S/he was wearing a disposable head covering and gown. S/he exited the room and went to the supply cart in the hallway outside the precaution room without removing the gown or head covering, and obtained supplies from the bottom drawer of the cart. S/he returned to the precaution room where s/he put on 2 pair of disposable gloves. When asked why s/he was double gloving, s/he said the gloves were porous, and tore easily. SP #1 asked if SP #18 had reported this to anyone, and s/he replied s/he had not.

8. On 9/21/11 at 10:40 A.M. . a tour was conducted on the Medical Unit with a Clinical Coordinator, SP #4, and a Manager. During the tour, it was observed Patient # 13 had a sign posted outside the patient room which directed all persons to see the nurse before entering the room. This patient was on precautions, personal protective equipment (PPE) was necessary before entering the room. One of the staff present on tour spoke with a visitor, and the visitor proceeded to enter the patient ' s room without checking with the nurse. None of the staff present stopped the visitor from entering, or attempted to signal to the visitor they should check with the nurse before going into the room.

9. On 9/22/11 at approximately 2:00 P.M., two staff persons were observed to enter the elevator on the first floor as they transported a patient in a hospital bed. Both staff persons were wearing disposable gloves.

10. On 9/22/11 at approximately 2:10 P.M. on the Medical Unit, a staff person who identified themselves as a staff person from the Hemodialysis Unit, was observed wearing disposable gloves. When asked, the staff person said they had just transported a patient to the Medical Unit from Hemodialysis. Shortly after, two staff were observed to move an empty bed into a patient room on the Medical Unit; one staff wore disposable gloves.

11. Based on observation and interview, 1 of 2 CNAs performing blood glucose tests on patients in isolation were unable to state the reason the patient was on isolation. On 9/21/ 2011 at 10 A.M., the surveyor observed a CNA approach the room of Patient # 10 which had a Stop/Isolation sign on the door. When asked why the patient was on isolation, the CNA replied she did not know. She approached SP #24, who indicated that the isolation had been d/c ' d as of 9/14 and the sign should have been removed. The surveyor watched SP #27 measure the blood glucose of Patient # 23. She then, also, cleaned the glucometer with an alcohol swab, though she did clean it thoroughly. When asked how she cleaned glucometers after testing patients on isolation, she replied that she always cleaned the glucometers with a alcohol swab which is what she had been trained to do.

12. On 9/22 at approximately 11 A.M. the surveyor observed SP #28, CNA perform a blood glucose test on a patient in Room 3121. She was able to identify the source of the isolation as an MRSA in an abdominal wound. After performing the test, she went to the door of the room and passed the glucometer to another CNA, SP #29, who quickly wiped the glucometer with an alcohol swab , but did not wipe all areas of the instrument. When asked how she cleaned the glucometer after testing patients in isolation, she stated that they used alcohol swabs. She stated that was how she cleaned the instruments regardless of the type of isolation.

When interviewed on 9/22/2011 at approximately 2:30 P.M., the infection control officer produced the page in the Infection Control Procedure Manual providing instructions on how to clean the glucometer between patients. The manual states, " After each use in the absence of body fluid contamination, the user will wipe the exterior surfaces of the glucometer with alcohol pads. If Body fluids are on the glucometer after use, the user will first clean the contamination using the alcohol wipes then wipe the exterior of the equipment again with a new set of alcohol wipes to disinfect. " When asked if staff were trained in how to clean the glucometer after being in isolation rooms with infections not destroyed by alcohol, she stated that the company someone from the company had told them to use alcohol pads for everything.

The glucometer used is the Precisio Xceed Pro Blood Glucose Monitor with Precision PCx plus Test Strips. It is manufactured by Abbott Laboratories. A call to Abbott Laboratories and a discussion with a technical support person conversant with this instrument on 9/21/2011 at P.M. on 9/21/2011, stated that there were various cleansing agents available for this machine manufactured by different companies including those for bacteria and viruses. The technical support person stated that where there was not one available for a specific contaminant, isolation bags were available for the instrument. The glucometer is placed in the isolation bag which is then disposed in the hazardous waste receptacle when the staff member is existing the isolation room. This information was conveyed to the Infection Control Officer who indicated that the hospital would change their policy to ensure proper cleaning of the glucometers and proper training of staff as part of their infection control procedures.

13. Patient #18 had a history of anemia, poor appetite, high fever, dizziness and cough X2 weeks who was referred by her PMD to the hospital on 5/4/11 for evaluation and subsequent admission. During the course of her stay in the hospital her fever and chills remained persistent.

Physician notes dated 5/24/11 at 9:30 states: ... Anticipate discharge and to begin therapy with the HIV clinic within 24 hours; ...s history (newly diagnosed HIV, persistent high fever, chills, cough, and malaise) classically suggests a strong suspicion of TB infection in which the hospital ' s next course of action would be in ruling out of said TB infection. Patient allowed to ambulate hallways and cafeteria and was discharged on 5/27/11. During this time, the hospital failed to develop or implement existing guidelines for the management of suspected tuberculosis. On 6/6/11 Patient #18 returned to the hospital. ED triage assessment dated 6/6/11 at 15:44 states:

Complaining of vomiting and diarrhea x 3 days. Complaints intermittent fever for 5 weeks. Complaints of abdomen pain since 6/3/11 with weakness...On 6/7/11, patient was transferred from the ED to PCU (progressive care unit). .. notes dated 6/7/11 at 08:10 states...Patient presently in PCU labored breathing during PM, this AM patient restless and anxious. Metabolic/Respiratory acidosis, R/O Sepsis.

A review of the lab report findings include a sputum AFB cultures and stain obtained from Patient # 18 on 6/8/11 at 00:01 and was received by the lab on 6/9/11 at 13:51.

There was no evidence in the medical record that the airborne precautions had been taken by the hospital infection control surveillance team despite the fact she was being ruled out for Pulmonary TB.

Medical provider notes dated 6/11/11 at 14:14 states:
AFB in sputum report from lab...Pulmonary TB, Immune deficiency syndrome.

A review of the reference lab reports revealed that AFB was isolated in the sputum collected both on 6/8/11 and 6/13/11.

There was no evidence that airborne precautions had been taken by hospital infection control surveillance team. The hospital failed to develop and implement guidelines for the appropriate management of suspected and diagnosed patients with tuberculosis in order to reduce the risk of exposure to other patients, staff and persons visiting the hospital.


A review of the Governor Juan Luis Hospital procedure manual titled - Exposure to Tuberculosis: Effective as of November 2006 states:

Policy: To ensure that staff, patients and visitors who have been exposed to tuberculosis (TB) are screened appropriately and in a timely fashion.

Procedure: Attending physician or nurse will notify infection control of suspected tuberculosis infected patient. Patient will be placed on airborne precautions until diagnosis of TB is ruled out.

Once the patient is confirmed with active TB. Infection Control will notify the physician, Department of Health and the Employee Nurse. Areas of the Hospital in which the patient has spent significant time prior to verification of active disease status will be notified by phone immediately and written notification will be completed within 48 hours of confirmation.

After investigation of contacts, Infection Control along with the Department of Health will notify patients and visitors who may have come in contact with the patient with confirmed diagnosis of TB.

The Hospital failed to implement any of its own policy:

Based on observation, staff interview and record review conducted from 9/19/11 through 9/23/ 11, it was determined that facility failed to maintain a log of incidents related to infectious and communicable diseases.

The findings included:

During an interview with SP # 23 conducted on 9/21/11, it was revealed that the facility failed to maintain a log of incidents appropriately documenting infectious and communicable diseases. SP #23 was asked to produce a list of patients with corresponding room numbers as well as the isolation procedure used and the infectious pathogen of concern on a daily basis for surveillance purposes. The response was the hospital did not have that information.

On 9/21/11 during a tour of the hospital and record review, it was noted that following patients were placed on isolation by the nursing staff:
Room 2321 -Non sampled Patient #19 - MRSA of the surgical wound.
Room 2327 - Non sampled Patient # 24, - MRSA of the blood.
Room 3119 - Patient # 13 - MRSA of the blood .
Room 3129 Patient # 15 - VRE.
Room 3121 - Patient # 17, - MRSA of the wound.
Room 3096A - Non sampled Patient #20 - MRSA of the wound.
Room 3096B- Non sampled Patient #21 - MRSA of the wound.
Room 3090- Non sampled Patient #22 - Chicken-Pox.
None of the above listed patients and their corresponding infectious disease process were included in the infection control log.

Based upon observations, interviews and record reviews, the hospital failed to ensure that leadership implemented corrective interventions to achieve compliance with prior infection control problems identified. Additionally, the Plan of Correction was not implemented to sustain compliance.

The findings included:

1. On 9/20/11 at approximately 8:15 A.M., an interview was conducted with SP #14, SP #15, SP #16 , and SP #17. They were asked how they cleaned the multi-use glucometer units. One GN (Graduate Nurse) responded they have used bleach wipes, and the other three said they use alcohol wipes.
2. On 9/20/11 at approximately 9:20 A.M. on the Medical Unit, SP #16 was observed to enter the room of a patient on precautions for MRSA (Methicillin-resistant Staphylococcus aureus) and remove a disposable gown. SP #16 then proceeded to unwrap the gown and stepped into another patient isolation room across the hall before being questioned by the surveyor.
A few minutes later, a housekeeping staff came to the Medical Unit wearing disposable gloves and pushing a large grey receptacle. The receptacle had a pile of disposable gloves on top. The staff person opened the door to the soiled utility wearing the gloves, and exited the room carrying a plastic bag, which he placed into the receptacle. The housekeeping staff person went through the double doors to the Surgical Unit without changing gloves. The same housekeeping staff person returned to the Medical Unit a few moments later, and exited through the double doors leading to the hallway and elevators. The staff person was seen by the elevator wearing disposable gloves, pushed the elevator button and entered the elevator.
3. On 9/20/11 at 9:40 A.M. on the Medical Unit, SP # 18 was observed in a room of a patient identified with MRSA (Methicillin-resistant Staphylococcus aureus), performing a dressing change. (S/he) was wearing a disposable head covering and gown. (S/he) exited the room and went to the supply cart in the hallway outside the precaution room without removing the gown or head covering, and obtained supplies from the bottom drawer of the cart. (S/he) returned to the precaution room where s/he put on 2 pair of disposable gloves. When asked why s/he was double gloving, s/he said the gloves were porous, and tore easily. SP #1 asked if s/he had reported this to anyone, and s/he replied s/he had not.
4. 9/21/11 at 10:40 A.M. a tour was conducted on the Medical Unit with a Clinical Coordinator, SP #4 , and a Manager. During the tour, it was observed Patient #13 had a sign posted outside the patient room which directed all persons to see the nurse before entering the room. This patient was on precautions, personal protective equipment (PPE) was necessary before entering the room. One of the staff present on tour spoke with a visitor, and the visitor proceeded to enter the patient ' s room without checking with the nurse. None of the staff present stopped the visitor from entering, or attempted to signal to the visitor they should check with the nurse before going into the room.
5. On 9/22/11 at approximately 2:00 P.M., two staff persons were observed to enter the elevator on the first floor as they transported a patient in a hospital bed. Both staff persons were wearing disposable gloves.
6. On 9/22/11 at approximately 2:10 P.M. on the Medical Unit, a staff person who identified themselves as a staff person from the Hemodialysis Unit, was observed wearing disposable gloves. When asked, the staff person said they had just transported a patient to the Medical Unit from Hemodialysis. Shortly after, two staff were observed to move an empty bed into a patient room on the Medical Unit; one staff wore disposable gloves.
Review of the hospital Plan of Correction indicated ongoing observation of hemodialysis staff infection control practices, with results submitted to the QAPI team. It also identified a specific policy on the cleaning of the glucometer completed and approved by 7/21/11. Education on the policy began on 8/8/11 and continue with new staff.

Based upon observation, document review and interview, it was determined that the hospital failed to meet the Condition of Participation for Surgical Services by failing to provide surgical services in accordance with acceptable standards of practice as evidenced by:

1. Failing to address a long standing known issue of excessive humidity in the operating rooms producing significant amounts of condensation on walls, floors and equipment. Please refer to A0940. This failure impacts on potential for bacterial growth and the potential for compromising the integrity of hospital equipment.
2. Failing to have a surgical roster that was accurate and current. Please refer to A0945.
3. Failing to ensure that high standards of surgical care were maintained. Please refer to A0940.
On 9/20/11 at 7:25 A.M. the surgical service department was toured in the presence of hospital staff noting the following observations.
The operating room #1 had a dehumidifier on with the humidity registering 70%.
In room #2, at 7:30 A.M. the humidity gauge read 72%. Observation and interview confirmed there was no dehumidifier in the room.
In room #4 at 7:40 A.M., a wall mounted humidifier was noted with the humidity gauge reading 72%.
In room #5 at 7:42 A.M. the humidity gauge read 72% without any dehumidifier noted in the room.
Operating room #6 was noted at 7:45 A.M. with a humidity reading of 72%
Operating room humidity control log was requested and received on 9/22/11. The range for the humidity is to be between 30-60% to be acceptable and maintenance is notified when the reading are beyond the parameters of 30-60%.
Humidity tracking logs were reviewed for the month of June, July, August and September which noted the following humidity ranges for each room.
Room # 1 with a dehumidifier ranged from a high of 92% in June to a high of 87% in September
Room #2 without a humidifier ranged from a high of 90 % humidity in June to a high of 79% in September
Room #4 with a dehumidifier ranged from a high of 73% in June to a high of 78% in September
Room #5 without a dehumidifier ranged from a high of 88% in June to a high of 81% in September
Room #6 without a dehumidifier ranged from a high of 99% in June to a high of 82% in September
Interviews with MD #9 at 2:45 P.M. on 9/20/11 indicated the humidifiers are a temporary solution and that the ventilation system needs to be replaced in order to have the humidity under control in the operating suites. According to the Plan of Correction, monitoring of the dehumidifiers for their effectiveness and would be installed in all operating "units" and was to be done with a completion date of 7/29/11. Review of an invoice noted 4 additional dehumidifiers were ordered 8/25/11 and received on 9/22/11.
According to American Institute of Architects, humidity ranges of 30% to 60% is desirable and the hospital policy indicates their range is also 30% to 60%.
The hospital failed to maintain acceptable standards of practice as it relates to operating room humidity.
Cross refer to A0724
Based upon record review and interview, the facility failed to provide necessary surgical care ensure high standards of surgical care for Patient #1 Evidence includes the following:
Review of the surgical record for Patient #1 noted that the anesthesiologist, MD #10, failed to verify and mark the surgical site as required by facility policy. The surgical procedure included laterality on the right ring finger as noted in the surgeons verification dated 9/19/11. In the section for the verification by the anesthesiologist, the area noted as "marking of the surgical site" was checked off as "N/A". Interview with SP #2 confirmed the surgical record should have been noted for site verification by the anesthesiologist. Further review of the surgical record noted on the post anesthesia record a medical entry of "unable to obtain peeds (pediatric) patient in reference to the blood pressure. Interview with the nurse of record for the patient in the morning of 9/19/11 revealed the surgical arena did not have a blood pressure cuff small enough for the patient. The nurse presented a small adult cuff s/he tried to use on the patient and indicated it was too big and there were no pediatric cuffs available. In the presence of SP #4, it was stated that the pediatric cuff that had been used in the past were not operational and there were none available.

Based upon observation, review of hospital documents and interview with staff, it was determined the the surgical services failed to achieve compliance with the OR (operating room) physician privileges roster. The corrective actions as indicated in the Plan of Correction had not been sustained as evidenced by the roster was not complete nor current for 2 of 6 applicable practioners. (MD #3 and MD #4) Based upon the Plan of Correction, the completion date for corrective actions was 6/24/11.

The findings included:

A review of the binder used as the OR physician privileges roster was reviewed on 9/20/11 in the presence of facility staff. The binder contained copies of individual clinical privileges for reappointment/initial appointment.

The privileges requested by MD #3 and MD #4 were noted without being signed or dated by the department chair as being reviewed and recommended for privileges as requested.

Interview with MD #9 at 8:45 A.M. confirmed the document had not been signed accordingly.