HospitalInspections.org

Based on observation on one (1) of four (4) inpatient units toured and staff interview, it was determined that the facility failed to ensure each patient's right to privacy.

Findings include:

1. During a tour of "5 Stainton" Medical/Surgical floor on 1/28/20 at 1:30 PM, patient charts were visible at the nurse's station. The outside cover of the charts were labeled with each patient's name. The names could be easily read from the walkway in front of the nurse's station that is accessible to patients and visitors.

2. The above finding was confirmed by Staff #19 and Staff #93 on 1/28/20 at 1:33 PM.

Based on review of one (1) out of two (2) medical records of patients who were physically restrained (#27), staff interview and review of facility documents, it was determined that the facility failed to ensure that the patient's care plan is modified in accordance with policy and procedure.

Findings include:

Reference: Facility policy titled, "Restraint Use" states, "... Plan Of Care: The restrained patient's electronic plan of care shall be modified to address appropriate goals and objectives related to restraint use and interventions implemented to assure the patient's safety and encourage the prompt discontinuation of restraint."

1. On 1/29/20 at 12:15 PM, a review of Medical Record #27 for restraint use, indicated that the patient was admitted on 1/27/20 for alcohol withdrawal and seizures.

a. On 1/29/20, nursing documentation indicated that the patient kept "wandering" requiring redirection and eventually a lap belt was placed.

(i) At 2:51 AM, nursing documentation indicated that the patient was placed on non-violent restraints for reason: "interfering with medical care," patient pulled IV (intravenous) access. A 1:1 (one-to-one) observer was placed.

c. At 3:39 AM, the patient was placed on violent leather restraints on all four (4) extremities due to "behavior dangerous to patient/others." The patient continued to be on 1:1 observation with security staff present, and was moved to the Intensive Care Unit (ICU) for closer observation.

(i) Review of the patient's Care Plan, revealed that the plan of care was not modified to address the use of restraints.

2. The above findings were confirmed by Staff #92.

Based on two (2) of two (2) staff interviews (Staff #67 and Staff #68) and a review of facility policy, it was determined that the facility failed to ensure that all patients are continuously monitored by staff during hemodialysis treatments on the inpatient Dialysis Unit.

Findings include:

Reference #1: Contractual agreement titled, "IN-HOSPITAL DIALYSIS SERVICES AGREEMENT," effective August 22, 2019, states, "... 1.04 PROVIDER and HOSPITAL may jointly and mutually develop a written protocol governing specific responsibilities and procedures to be used by Provider Staff in rendering Services to Patients. PROVIDER shall provide policies, procedures, and techniques pertaining to the methods by which the Services are rendered at HOSPITAL [sic] pursuant to this Agreement. ..."

Reference #2: Contracted Dialysis Provider policy titled, "Monitoring Inpatients During Treatment" states, "... Supervision [bullet] All patients must be under continual visual observation by (dialysis provider) Service Staff. ... [bullet] The (dialysis provider) Inpatient Service staff is not to leave the patient unattended during the treatment. ..."

1. During a tour of the inpatient hemodialysis unit, the following was revealed:

a. On 1/28/20 at 1:15 PM, during interview, Staff #68 stated that only one (1) RN is required on the unit for three (3) patients and that no additional staff members are required to be present on the hemodialysis unit. Staff #68 stated that many times he/she is the only staff member in the unit and no other staff members are present.

(i) This surveyor questioned Staff #68 how he/she would get supplies if patients were dialyzing and he/she was the only staff member on the unit. Staff #68 stated that he/she would leave the unit to go to the supply room located across the hall. Staff #68 stated that he/she would leave the patient who was receiving dialysis alone on the dialysis unit while he/she would get the supplies, thus, leaving the dialysis unit without a registered nurse.

b. On 1/29/20 at 11:20 AM, during an interview, Staff #67 stated that there are times when he/she is the only staff member on the unit with patients. Staff #67 stated that if he/she needed any supplies that were not available on the unit, he/she would leave the patient who was dialyzing to get the supplies from the supply room across the hall. Staff #67 stated that the patients would be left alone on the dialysis unit while he/she would get the supplies, thus, leaving the dialysis unit without a registered nurse.

A. Based on staff interview and review of one (1) out of two (2) medical records of patients receiving in-patient hemodialysis (#23), it was determined that the facility failed to ensure a comprehensive hemodialysis plan of care developed by the registered nurse for a patient receiving in-patient hemodialiysis.

Findings include:

1. On 1/28/20, a review of Medical Record #23 revealed the following:

a. Patient #23 was admitted to the hospital on 1/20/20 with a diagnosis of Cellulitis of the left foot and a history of end stage renal disease. There was evidence that Patient #23 was receiving in-patient hemodialysis.

b. As of 1/28/20, the medical record lacked evidence that a hemodialysis plan of care was initiated by the Registered Nurse.

2. On 1/28/20, Staff #25 confirmed the above finding.


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B. Based on medical record review, review of facility policy, and staff interview, it was determined that the facility failed to ensure that each patient receives a nursing care plan that is consistent with his/her medical needs for one (1) out of one (1) chart reviewed for wound care (Patient #33).

Findings include:

Reference: Facility policy titled, "Interdisciplinary Plan of Care" states, "... 5. Upon admission to the hospital, the RN will initiate the IPOC [Interdisciplinary Plan of Care] based on the assessed problems/needs gathered from the admission assessment - noting at least two problems/needs with time frame for meeting specific goals for the care of the patient/family set in the plan."

1. On 1/29/20, a review of Medical Record #33, in the presence of Staff #25, revealed the following:

a. A History and Physical (H&P) dated 1/22/20, stated, "...Assessment/Plan ... 65-year-old gentleman presented with worsening pain and drainage of his forearm surgical wound site. ... There is a high suspicion of necrotizing fasciitis. ..."

b. The patient had a surgical procedure to address the wound on 1/23/20 and again on 1/24/20. A wound vac was placed on 1/24/20.

c. A wound care nurse began following the patient on 1/27/20.

d. A review of the Interdisciplinary Plan of Care lacked evidence of a nursing plan of care to address Patient #33's skin integrity.

2. The above findings were confirmed by Staff #25 on 1/29/20 at 2:08 PM.

Based on observation, staff interview, and document review conducted on 1/27/20 and 1/28/20, it was determined that the facility failed to ensure that the Food Services Director adequately managed the daily operations of the dietary services in accordance with his/her job description and the New Jersey State Sanitary Code, Sanitation in Retail Food Establishments and Food and Beverage Vending Machines (N.J.A.C. 8:24).

Findings include:

Reference #1: Facility document titled, "Dining Services Director/General Manager Expectations" states, "... 8. Managers round in their departments 2 times per day with a purpose: ... c. Communicate with the employees to determine if they are compliant with polices. d. Walk the department to ensure that polices are being met, seek to find things that you can make positive comments or corrective actions. ..."

Reference #2: Facility policy titled, "Department Safety and Sanitation" states, "... B. Manual Pot Washing 1. Manual washing of pots is completed in a three compartment sink: wash sink, soak sink, and sanitizing sink. 2. Approved sanitizing agent is used in the sanitizing sink. To ensure appropriate concentration of sanitizing agent, designated test strips are used to measure concentration. 3. Water in sinks is changed on a regular basis. 4. After pots and dishes are washed, they are air dried before being put away in designated area. Floor Maintenance: 4. Any defects in flooring are reported to Plant operations for timely repair to ensure safety and sanitation.

Reference #3: Facility policy titled, "Department Safety and Sanitation" states, "...Preventative Safety and Maintenance... 2. preventative maintenance is performed by Plant Operations on a scheduled basis. ..."

Reference #4: Facility policy titled, "Infection Control Guidelines for Nutritional Services" states, "... 4. Storage of Food... a. Food is stored in designated areas in clean wrappers or containers with covers and properly marked and dated. ..."

Reference #5: N.J.A.C. 8:24-4.11(2) states, "Clean equipment and utensils shall be stored: (i) In a self-draining position that allows air drying; and (ii) Covered or inverted."

Reference #6: N.J.A.C. 8:24-4.8(k) states, "A test kit or other device that accurately the concentration in mg/L [milligram/Liter] of sanitizing solutions shall be provided. 8:24-4.8(i) states, "Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device."

Reference #7: N.J.A.C. 8:24-6.5(b) states, "The physical facilities shall be cleaned as often as necessary to keep them clean."

1. On 1/27/20, during a tour of the Main Kitchen in the presence of Staff #7, Staff #8 and Staff #11, the following observations were made:

a. At 11:30 AM, during a tour of the pot washing area, Staff #13 was observed washing pots and pans.

(i) Staff #13 was using -40 Hydrion sanitation solution testing strips, which had expired on 3/15/16 (Refer to Reference #2).

(ii) Pots and pans (approximately 50) were stacked on top of each other without allowing them to air-dry (Refer to Reference #5).

b. The floors around the cook's area in the main kitchen were cracked in multiple areas (Refer to Reference #3).

(i) During interview, Staff #7 stated that he/she was aware of multiple areas in the kitchen with cracked and eroded floors needing repair.

c. On 1/27/20 at 12:30 PM, during a tour of the Telemetry Unit with Staff #12, the following was observed:

(i) The microwave was visibly dirty with brown debris on the roof and door (Refer to Reference #1 and Reference #7).

(ii) The refrigerator in the pantry area had visibly torn and peeling door gaskets (Refer to Reference #1 and Reference #3).

(iii) The pantry door laminate was peeling off from corners and door handles (Refer to Reference #1 and Reference #3).

(iv) Patient food stored in two (2) plastic bags in the patient refrigerator was not labeled (Refer to Reference #4).

2. The above findings were confirmed by Staff #6 and Staff #7.

Based on observation, staff interviews, and document review conducted on 1/28/20 and 1/29/20, it was determined that the facility failed to ensure that it was constructed, arranged, and maintained to ensure the safety of the patients, visitors, and staff.

Findings include:

1. The facility failed to ensure compliance with the 2012 edition of the National Fire Protection Association's Life Safety Code (Refer to Tag A0710).

Based on observation, document review, and staff interview, it was determined that the facility failed to ensure compliance with the National Fire Prevention Association's (NFPA) Life Safety Code (101), 2012 edition.

Findings include:

Reference #1: NFPA 101:19.2.2.1 "Components of the means of egress shall be limited to the types described in 19.2.2.2 through 19.2.2.10."

1. On 1/29/20 at 11:30 AM, in the presence of Staff #33, a revolving door with two (2) solid wedge sections located on opposite sides of the revolving door were identified as an exit door by an illuminated EXIT sign in the Emergency Department (ED) Waiting Room. This revolving door was the main exit from the waiting room and lead directly to the outside (Refer to Reference #1).

a. These solid wedges block 100 percent of the exit opening when the door stops rotating.

(i) During an interview on 1/29/20 at 11:35 AM, Staff #33 stated, "if the revolving door stopped in a position that placed the solid wedge sections across the exit opening, a person would be required to manually rotate the revolving door to the opening to exit."

(ii) During a review of the hospital Construction Plans Page A0-1.2, dated 6/11/10, the revolving door was identified as a means of egress.

b. Revolving doors is not listed in the code as permitted means of egress. It is omitted, therefore it is not permitted.

c. Staff #33 confirmed these findings.

This finding resulted in an Immediate Jeopardy (IJ). The Administrator was informed of the IJ and was provided with the IJ Template on 1/29/20 at 4:05 PM.

On 1/30/20, the facility submitted an acceptable Removal Plan for the Immediate Jeopardy findings.

On 2/5/20, an on-site revisit was conducted. It was determined that the facility had disabled the revolving door in the Waiting Area, and installed a temporary door equipped with panic hardware for immediate egress. In addition, the facility had posted Security Officers in the ED Waiting Area 24 hours a day, 7 days a week. As a result of this revisit the Immediate Jeopardy for K211 was removed as of 2/5/20.

Reference #2: NFPA 101:9.7.2.1 "Where supervised automatic sprinkler systems are required by another section of this code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility."

1. On 1/29/20 at 11:45 AM, in the presence of Staff #33, the water supply for the required automatic sprinkler system was lacking supervisory signaling devices which would alert staff if the water supply was shut off.

a. During an interview on 1/29/20 at 2:30 PM, Staff #33 confirmed that the valves controlling the water supply for the sprinkler system were not electronically supervised to automatically transmit an audible and visual signal to a constantly attended location or remote receiving location.

This finding resulted in an Immediate Jeopardy (IJ). The Administrator was informed of the IJ and was provided with the IJ Template on 1/29/20 at 4:05 PM.

On 1/30/20, the facility submitted an acceptable Removal Plan for the Immediate Jeopardy findings.

On 2/5/20, an on-site revisit survey was conducted. It was determined that the facility had conducted hourly fire watch in the Pump Room. The hourly fire watch will be conducted until a permanent electronic monitoring system is in place. As a result of this revisit survey, the IJ for Tag K352 was removed.

Based on observation, staff interviews, review of facility documents, and nationally recognized infection prevention and control guidelines, it was determined that the facility failed to ensure an adequate infection control program that seeks to minimize infections and communicable diseases is maintained.

Findings include:

1. The facility failed to ensure it provides a safe and sanitary environment for the provision of hemodialysis treatments that adheres to facility's policies and nationally-recognized Infection Control guidelines (Refer to Tag A0749, A - E).

2. The facility failed to ensure that appropriate Personal Protective Equipment (PPE) is provided for staff (Refer to Tag A0749, I).

3. The facility failed to ensure a safe and sanitary environment for the provision of surgical services and Labor/Delivery, Recovery, and Postpartum (LDRP) services (Refer to Tag A0749, J, M and N).

4. The facility failed to ensure that its Isolation and Standard Precautions, Hand Hygiene policy is implemented and adhered to by all personnel (Refer to Tag A0749, L).

A. Based on observation, staff interview, and facility document review, it was determined that the facility failed to ensure that two (2) out of two (2) opaque containers are labeled in accordance with facility policy.

Findings include:

Reference #1: Contractual agreement titled, "IN-HOSPITAL DIALYSIS SERVICES AGREEMENT" effective August 22, 2019, states, "... 1.04 PROVIDER and HOSPITAL may jointly and mutually develop a written protocol governing specific responsibilities and procedures to be used by Provider Staff in rendering Services to Patients. PROVIDER shall provide policies, procedures, and techniques pertaining to the methods by which the Services are rendered at HOSPITAL [sic] pursuant to this Agreement. ..."

Reference #2: Contracted Dialysis Provider Policy titled, "Mixing Bleach" states, "... 4. Label opaque container with "Bleach Solution", strength of solution, date and time prepared and your initials. ..."

1. On 1/27/20 at 11:00 AM, in the In-patient Dialysis Unit, there was an opaque container with clear liquid inside, located on a shelf in the patient bathroom. Staff #67 stated that the patient bathroom is not for patient use and is considered a dirty room. Staff #67 stated that the container was a bleach solution used to clean equipment after dialysis.

a. The container was not labeled as "Bleach Solution" and lacked the strength of the solution, date and time prepared, and the initials of the staff member who prepared it.

2. On 1/28/20 at 1:05 PM, in the In-patient Dialysis Unit, there was an opaque container with clear liquid inside, located on a shelf in the patient bathroom. Staff #67 stated that the container was a bleach solution used to clean equipment after dialysis.

a. The container was not labeled as "Bleach Solution" and lacked the strength of the solution, date and time prepared, and the initials of the staff member who prepared it.

b. On 1/28/20 at 1:10 PM, Staff #66 confirmed the above finding and stated that the bleach solution should be mixed and labeled everyday.

This finding resulted in an Immediate Jeopardy (IJ). The Administrator was informed of the IJ and was provided with the IJ Template on 5/5/20 at 10:07 AM.

On 5/6/20, the facility submitted an acceptable Removal Plan for the Immediate Jeopardy findings.

On 5/8/20, an on-site revisit was conducted. During the revisit, a tour of the In-patient Dialysis unit was performed which revealed no current patients receiving hemodialysis treatments. In addition, there were no contracted hemodialysis staff on site. During a tour of the In-patient Dialysis unit there were no unlabeled opaque containers observed. Review of the staff education documentation on the labeling of hemodialysis solutions was conducted. It was determined that the components of the removal plan were implemented. As a result of this revisit the Immediate Jeopardy for Tag A0749 was removed as of 5/8/20.

B. Based on one (1) out of two (2) observations of staff performing cleaning and disinfection (Staff #67), staff interview, and facility document review, it was determined that the facility failed to ensure that staff clean and disinfect equipment after completion of the hemodialysis treatment.

Findings include:

Reference #1: Contractual agreement titled, "IN-HOSPITAL DIALYSIS SERVICES AGREEMENT" effective August 22, 2019, states,
"... 1.04 PROVIDER and HOSPITAL may jointly and mutually develop a written protocol governing specific responsibilities and procedures to be used by Provider Staff in rendering Services to Patients. PROVIDER shall provide policies, procedures, and techniques pertaining to the methods by which the Services are rendered at HOSPITAL [sic] pursuant to this Agreement. ..."

Reference #2: Contracted Hemodialysis Provider policy titled, "Cleaning and Disinfection of the Dialysis Station" states, "... Dialysis Station Area including the dialysis machine, chair/bed and other reusable equipment utilized during dialysis [sic] treatment ... All work surfaces shall be cleaned and disinfected with 1:100 bleach solution after completion of procedures. ..."

1. On 1/27/20 at 12:42 PM, after the completion of a patient's hemodialysis treatment in Station #A, this surveyor observed a bright red substance smeared on the outer lower rail of the patient's bed. The transport staff arrived and Staff #67 informed them the patient could go back to his/her room.

a. At 12:50 PM, prior to the patient leaving the station, Staff #67 stated that the patient's bed, that is used during hemodialysis, does not need to be cleaned prior to the patient being transported back to his/her room. This surveyor informed Staff #67 of the bright red substance on the bed rail. Staff #67 confirmed that there was a bright red substance on the bed rail and that it could be blood. Staff #67 removed the bright red substance from the bed rail with a bleach cloth.

2. On 1/27/20 at 1:15 PM, during the cleaning and disinfection of the hemodialysis machine in Station #A, after a patient completed hemodialysis. The following was observed:

a. Staff #67 did not clean and disinfect the inside of the crit line clamp that was used during the treatment.

b. Staff #67 lifted a jug of 3 K [potassium] 2.5 Ca [calcium] acid solution from the base of the hemodialysis machine, cleaned and disinfected the base of the machine then placed the acid jug back onto the machine. Staff #67 did not clean and disinfect the acid jug prior to returning it to the base of the hemodialysis machine.

c. Staff #67 did not clean the base of the patient's bedside table.

d. Staff #67 confirmed that the hemodialysis machine and station was clean and available for use on the next patient. Staff #67 confirmed the above findings.

This finding resulted in an Immediate Jeopardy (IJ). The Administrator was informed of the IJ and was provided with the IJ Template on 5/5/20 at 10:07 AM.

On 5/6/20, the facility submitted an acceptable Removal Plan for the Immediate Jeopardy findings.

On 5/8/20, an on-site revisit was conducted. During the revisit, a tour of the In-patient Dialysis unit was performed which revealed no current patients receiving hemodialysis treatments. In addition, there were no contracted hemodialysis staff on site. Documentation of staff education on the cleaning and disinfection of the patient's bed prior to leaving the In-patient Dialysis unit, and the cleaning and disinfection of the hemodialysis machine after each use was reviewed. The contracted hemodialysis staff education was completed as of 1/31/20. It was determined that the components of the removal plan were implemented. As a result of this revisit the Immediate Jeopardy for Tag A0749 was removed as of 5/8/20.

C. Based on observation, staff interview, and review of facility documents, it was determined that the facility failed to ensure the separation of clean and dirty areas to prevent cross-contamination on the In-patient Dialysis Unit.

Findings include:

Reference #1: Contractual agreement titled, "IN-HOSPITAL DIALYSIS SERVICES AGREEMENT" effective August 22, 2019, states, "... 1.04 PROVIDER and HOSPITAL may jointly and mutually develop a written protocol governing specific responsibilities and procedures to be used by Provider Staff in rendering Services to Patients. PROVIDER shall provide policies, procedures, and techniques pertaining to the methods by which the Services are rendered at HOSPITAL [sic] pursuant to this Agreement. ..."

Reference #2: Contracted Hemodialysis Provider policy titled, "Dialysis Precautions" states, "... Clean area: An area designated for clean and unused equipment, supplies and medications. Dirty area: An area where this [sic] is a potential for contamination with blood or body fluids and areas where contaminated or used supplies, equipment, blood supplies or biohazard containers are stored or handled. Clean areas should be clearly designated for the preparation and handling of medications and unused supplies and equipment. Clean areas should be clearly separated from dirty areas ..."

1. During a tour of the In-patient Dialysis Unit on 1/27/20 at 11:00 AM, Staff #68 stated that the patient bathroom was being used as a dirty room. The following was revealed:

a. There was a package of clean pads sitting inside two (2) plastic basins. Staff #68 confirmed that these supplies were clean and available for use on patients.

b. There were two (2) acid jug wands and multiple empty clear containers being stored on a pad on top of a table. The table was approximately one (1) and a half (1/2) feet from a toilet.

(i) Staff #68 stated that the wands were clean and were drying on top of the pad on the table. Staff #68 stated that the clear containers are used during the cleaning and disinfection of the hemodialysis machines.

2. On 1/28/20 at 1:05 PM, in the Dialysis Unit's bathroom/dirty room, there were two (2) containers of Sani cloths, two (2) acid wands, an opened box of gloves, a jug of vinegar, two (2) blood pressure cuffs, and four (4) empty clear containers on top of a table located approximately one (1) and a half (1/2) feet from a toilet.

a. Staff #68 stated that the items on top of the table were clean supplies. Staff #68 stated that the toilet is only used to empty patient bedpans. Staff #68 stated that the table that contained clean supplies is present when the toilet is flushed. Thus, there is a potential for contamination of the clean supplies.

b. This finding was confirmed by Staff #24 and Staff #25.

This finding resulted in an Immediate Jeopardy (IJ). The Administrator was informed of the IJ and was provided with the IJ Template on 5/5/20 at 10:07 AM.

On 5/6/20, the facility submitted an acceptable Removal Plan for the Immediate Jeopardy findings.

On 5/8/20, an on-site revisit was conducted. During the revisit, a tour of the In-patient Dialysis unit was performed which revealed no current patients receiving hemodialysis treatments. During a tour of the Dialysis unit's patient bathroom/dirty room, there were no clean supplies observed in the area. In addition, there were no contracted hemodialysis staff on site. Documentation of staff education on cleaning and disinfection practices ensuring separation of clean and soiled supplies was reviewed. The contracted hemodialysis staff education was completed as of 1/31/20. It was determined that the components of the removal plan were implemented. As a result of this revisit the Immediate Jeopardy for Tag A0749 was removed as of 5/8/20.

D. Based on observation, staff interview, and facility policy review, it was determined that the facility failed to ensure that medications are stored in a clean area on the In-patient Dialysis Unit.

Findings include:

Reference: The Centers for Disease Control and Prevention's (CDC) publication, "Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients, MMWR, Vol. 50, No. RR-5, April 27, 2001" states, "... Infection Control Precautions for All Patients ... Any item taken to a patient's dialysis station could become contaminated with blood and other body fluids and serve as a vehicle of transmission to other patients either directly or by contamination of the hands of personnel. ... additional measures to prevent contamination of clean or sterile items include a) preparing medications in a room or area separated from the patient treatment area and designated only for medications; ... Do not handle and store medications or clean supplies in the same or an adjacent area to where used equipment ... are handled."

1. During a tour of the Dialysis Unit on 1/27/20 at 11:00 AM, the medication refrigerator and medication dispenser were located in Station #C, where a patient was dialyzing in a bed. There was a portable reverse osmosis machine, a hemodialysis machine with a blood filled extracorporeal circuit, and a patient's bed in the Station. The patient's bed was approximately three (3) feet from the medication counter, refrigerator, and dispenser. There was a portable cardiac monitor, that was connected to the patient, on the medication counter.

b. Staff #67 confirmed that the medication storage area was in the patient's station.

2. On 1/27/20 at 12:00 PM, while a patient was dialyzing in Station #C, Staff #68 removed a single dose vial of Epogen from the medication refrigerator that was located inside of Station #C. Staff #68 prepared a syringe of Epogen at the medication preparation counter located inside Station #C then administered the Epogen to the patient who was dialyzing in Station #C.

a. During interview, Staff #68 stated that if a patient in Station #A or Station #B needs to receive a medication, the staff will remove the medication from the medication refrigerator or medication dispenser, located in Station #C, and take the vial to the station where it is needed. Staff #68 stated that if a patient in Station #A needs a medication during dialysis, the medication would be prepared on the patient's bedside table in Station #A. Staff #68 stated that the same procedure would be used for a patient in Station #B.

3. On 1/27/20 at 12:25 PM, while a patient was dialyzing in Station #C, Staff #67 was observed removing two (2) single dose vials of Heparin from the automated medication dispenser located inside Station #C. Staff #67 exited Station #C with the vials of Heparin and placed them on the bedside table in Station #A.

a. At 12:33 PM, Staff #67 was observed preparing two syringes using the single dose vials of Heparin at the bedside table in Station #A. Staff #67 attached a syringe to the blue port on the Central Venous Catheter (CVC) and administered the Heparin. Staff #67 then attached a syringe to the red port on the CVC and administered the Heparin.

b. The above findings were confirmed by Staff #25 and Staff #67.

This finding resulted in an Immediate Jeopardy (IJ). The Administrator was informed of the IJ and was provided with the IJ Template on 5/5/20 at 10:07 AM.

On 5/6/20, the facility submitted an acceptable Removal Plan for the Immediate Jeopardy findings.

On 5/8/20, an on-site revisit was conducted. During the revisit, a tour of the In-patient Dialysis unit was performed which revealed no current patients receiving hemodialysis treatments. In addition, there were no contracted hemodialysis staff on site. During the tour it was also revealed that Station #C/Zone C was made a designated medication preparation area and clean utility area, for storage of clean supplies with lockable rolling cabinets. The area was not set up to provide hemodialysis treatment. Documentation of staff education regarding safe medication practices and separation of clean versus soiled supplies were reviewed. The contracted hemodialysis staff education was completed as of 1/31/20. It was determined that the components of the removal plan were implemented. As a result of this revisit the Immediate Jeopardy for Tag A0749 was removed as of 5/8/20.

E. Based on three (3) out of four (4) observations of staff on the In-patient Dialysis Unit (Staff #67, #68, and #69), staff interview, and review of facility documents, it was determined that the facility failed to ensure that glove changes and hand hygiene are performed by staff after touching used equipment, prior to touching equipment in another station, or retrieving clean supplies, while patients are dialyzing.

Findings include:

Reference #1: Contractual agreement titled, "IN-HOSPITAL DIALYSIS SERVICES AGREEMENT" effective August 22, 2019, states, "... 1.04 PROVIDER and HOSPITAL may jointly and mutually develop a written protocol governing specific responsibilities and procedures to be used by Provider Staff in rendering Services to Patients. PROVIDER shall provide policies, procedures, and techniques pertaining to the methods by which the Services are rendered at HOSPITAL [sic] pursuant to this Agreement. ..."

Reference #2: Contracted Hemodialysis provider policy titled, "Personal Protective Equipment" states, "... Change gloves and practice hand hygiene between each patient and/or station to prevent cross contamination. ... Avoid touching surfaces with gloved hands that will be touched with ungloved hands ...."

1. During observation on 1/27/20 at 12:00 PM, while wearing gloves, Staff #68 used the computer in Station #B, where a patient was dialyzing. Staff #68 exited Station #B, wearing the same gloves and opened the clean supply cabinet. Staff #68 did not remove his/her gloves and perform hand hygiene after exiting Station #B and prior to opening the clean supply cabinet.

2. On 1/27/20 at 1:00 PM, two (2) transport staff members were observed moving patients out of the In-patient Dialysis Unit. While wearing gloves, Transport Staff #69 touched the patient's bed in Station #C then touched the bedside table in Station #B where a patient was dialyzing with the same gloves. While still wearing the same gloves, Staff #69 touched the opened clean supply cabinet then moved the patient's bed in Station #B to make room for Patient #23's bed to be removed from Station #C.

a. At 1:35 PM, Staff #25 confirmed the above findings and stated that he/she saw that the transport staff had to move and touch items in Station B and the clean supply cabinet in order to remove the patient from Station #C.

3. On 1/27/20 at 1:20 PM, while wearing gloves, Staff #67 cleaned and disinfected the hemodialysis machine in Station #C. Staff #67 removed his/her gloves and without performing hand hygiene entered the clean supply cabinet to remove a roll of tape.

a. This finding was confirmed by Staff #24, Staff #25, and Staff #66.


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F. Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that endoscope reprocessing occurs in accordance with acceptable facility standards of practice.

Findings include:

Reference: Facility document titled, "Lippincott Procedures - Endoscope reprocessing, automated reprocessor" states, "1. [Name of facility] will reprocess endoscopes before use if the endoscope has not been used for more than 7 days... Performing high-level disinfection... Label the endoscope with the date and time of reprocessing... ."

1. On 1/29/20, seven (7) endoscopes were observed hanging in the Endoscopes Storage Cabinet located in the Endoscopy Suite.

a. One (1) endoscope was labeled with a date of "1/21", one (1) endoscope was labeled with a date of "1/22", and one (1) endoscope was labeled with a date of "1/27." The remaining four (4) endoscopes were not dated.

b. Upon interview, Staff #18 and Staff #84 stated that all endoscopes stored in the endoscope storage cabinet should have a label that includes the date that they were reprocessed. Staff #18 and Staff #84 confirmed that four (4) endoscopes in the endoscope storage cabinet were not labeled with their date of reprocessing.

c. Upon interview, Staff #84 confirmed that the endoscopes dated "1/21" and "1/22" were past their seven (7) day reprocessing time. He/she stated that both endoscopes should have been removed from the endoscopes storage cabinet and reprocessed.

2. Staff #1 and Staff #18 confirmed the above findings.

This finding resulted in an Immediate Jeopardy (IJ). The Administrator was informed of the IJ and was provided with the IJ Template on 5/5/20 at 10:07 AM.

On 5/6/20, the facility submitted an acceptable Removal Plan for the Immediate Jeopardy findings.

On 5/8/20, an on-site revisit was conducted. During the revisit, the endoscope storage was visualized. All observed scopes were tagged with the day the scopes were cleaned and another tag was placed to indicate expiration date for each scope. Documentation of staff education on tagging and reprocessing of scopes was reviewed. Staff interview revealed understanding of facility policy on endoscope tagging and reprocessing procedure. Endoscopy staff education was completed by 1/31/20. It was determined that the components of the removal plan were implemented. As a result of this revisit the Immediate Jeopardy for Tag A0749 was removed as of 5/8/20.

G. Based on observation and staff interviews, it was determined that the facility failed to ensure that clean and dirty items are kept separate.

Findings include:

1. During a tour of the MRI (Magnetic Resonance Imaging) suite on 1/29/20 at 10:50 AM, the following was observed:

a. An IV (intravenous) pole covered with a plastic bag was observed in the Soiled Holding Room. Upon interview, Staff #80 stated that the plastic bag indicated that the IV pole was clean and ready for patient use.

b. Upon interview, Staff #64 confirmed that clean equipment should not be stored in the Soiled Holding Room.

2. Staff #1, Staff #19, and Staff #64 confirmed the above findings.

H. Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that appropriate PPE (Personal Protective Equipment) is provided for staff.

Findings include:

Reference: Facility policy titled, "Diagnostic Imaging Infection Control" states, "... 7. PPE must be worn whenever there is a risk of being splashed with any fluids... ."

1. On 1/29/20 at 10:58 AM, during a tour of the Soiled Utility Room in the CT (Computed Tomography) area, a flushable utility sink was observed. There were no gloves or face shields available for use in the Soiled Utility Room.

2. On 1/29/20 at 11:15 AM, during a tour of the Soiled Utility Room in the Catheterization Lab, a flushable utility sink was observed. There were no gloves or face shields available for use in the Soiled Utility room.

3. Staff #1 and Staff #64 confirmed the above findings.


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I. Based on one (1) of one (1) observation of patient's on the Pediatric Unit, staff interview, and review of facility documents, it was determined that the facility failed to ensure that procedures for contact precautions are implemented by all staff.

Findings include:

Reference: Facility policy titled, "Isolation and Standard Precautions, Hand Hygiene, Respiratory Hygiene, Management of Multi-drug Resistant Organisms, and MRSA screening" states, "... 2. Personal Protective Equipment (PPE) ... REMOVING PPE - except for respirator, remove PPE at doorway before leaving patient room in the order listed below. ... A. Contact Precautions ... a. A minimum of a gown and gloves will be used for all staff, and Physicians/Practitioners entering patient's room regardless of room situation. ..."

1. During a tour of the Pediatric Unit on 1/28/20 at 10:34 AM, a dietary staff member exited Room #105 and entered the hallway outside the room while wearing a PPE gown and mask. The staff member did not remove and dispose of his/her PPE in the doorway prior to exiting the patient room.

a. Upon interview, Staff #44 stated that the patient in Room #105 (Patient #19) was on Contact Precautions for an abscess infected with Staphylococcus aureus.

2. The above was confirmed by Staff #19 and Staff #43 at the time of the observation.

J. Based on observation and staff interview, it was determined that the facility failed to ensure that environmental surfaces could be cleaned to prevent the transmission of infection.

Findings include:

1. During a tour of the Labor/Delivery, Recovery, and Postpartum (LDRP) units on 1/27/20, the following was observed:

a. Exposed wood was visible along the counter tops in the "Trans Nursery" and in the Medication Room.

b. The laminate was separating along the counter adjacent to the sink in the "Trans Nursery."

c. Uncleanable wall surface damage was visible in the Medication Room and the Operating Room (OR) recovery suite.

2. During an interview on 1/27/20 at 12:02 PM, Staff #19 and Staff #20 confirmed that the wood was exposed on countertops throughout the LDRP unit. The above findings were confirmed by Staff #19 and Staff #20 throughout the tour of the unit.


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K. Based on observation, staff interview, review of facility policies and procedures, and review of Manufacturer's Instructions For Use (IFU), it was determined that the facility failed to ensure implementation of its "Cleaning and Disinfection of Equipment" policy by adhering to manufacturer's IFU's for cleaning and disinfecting products.

Findings include:

Reference #1: Facility policy titled, "Cleaning and Disinfection of Equipment" states, "...Procedure: ...General...Non-critical items will be cleaned and disinfected according to manufacturer's recommendations with hospital approved agents used according to manufacturer's instructions. ..."

Reference #2: PDI Super Sani-Cloth manufacturer Instructions For Use (IFU) states, "...To Dispense Wipes: ...When not in use keep center cap of lid closed to prevent moisture loss."

1. On 1/27/20 at 11:25 AM, during a tour of the Intensive Care Unit (ICU), in the presence of Staff #12, Staff #32, and Staff #92, there were two (2) Super Sani-Cloth wipe containers with the center cap of the lid open and not being used, in the following areas:

a. In Room #262, a room with a patient on contact precautions

b. In Room #267, a room with a ventilated patient

2. When the Sani-Cloth containers lid remains open when not in use, the wipes can become dry, rendering them ineffective.

3. Staff #32 indicated that the lids should be closed and that he/she reminds the staff to close the lid, so the wipes don't dry out.


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L. Based on observation, staff interview, review of facility policies and procedures, and nationally recognized guidelines, it was determined that the facility failed to implement its infection control policies and procedures for hand hygiene practices.

Findings include:

Reference: Facility policy titled, "Isolation and Standard Precautions, Hand Hygiene, Respiratory Hygiene, Management of Multi-drug Resistant Organisms, and MRSA screening" states, " ... Procedure: 1. Hand Hygiene ... D. ... after touching blood/body fluids, secretions, excretions, contaminated items, immediately after removing gloves ... L. Decontaminate or wash hands after removing gloves. ... Hand hygiene technique... wet hands first with water... and rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers."

1. On 1/27/20 at 11:48 AM, observation of cleaning and disinfecting of Operating Room (OR) #8 was conducted and revealed the following:

a. At 11:50 AM, Staff #16 and Staff #42 doffed (removed) their gloves in the hallway, failed to perform hand hygiene, walked into OR #8 and donned (put on) new gloves and began cleaning the OR.

b. At 11:54 AM, Staff #16 doffed his/her gloves, opened a cabinet, donned new gloves and failed to perform hand hygiene.

c. At 12:04 PM, Staff #14 doffed his/her gloves, donned new gloves and failed to perform hand hygiene.

d. At 12:07 PM, Staff #14 doffed his/her gloves, donned new gloves and failed to perform hand hygiene.

e. The above findings were confirmed by Staff #17 at time of discovery.

2. On 1/28/20, during a tour of the ICU (Intensive Care Unit), the following was observed:

a. At 1:20 PM, Staff #63 performed hand hygiene and donned gloves in preparation for patient care. He/she then entered the patient's room and went to the bedside computer to enter information. Staff #63 then went to the patient's bedside and auscultated his/her lungs.

(i) Staff #63 did not change his/her gloves or perform hand hygiene after leaving the computer and prior to performing patient care.

b. At 1:26 PM, Staff #63 washed his/her hands for five (5) seconds, not 20 seconds as required by policy.

3. Staff #1 and Staff #19 confirmed the above findings.

M. Based on observation, staff interview and review of facility documents, it was determined that the facility failed to ensure implementation of their policy and procedure addressing reestablishing a clean environment in the Operating Room (OR) in between cases.

Findings include:

Reference: Facility document titled, "Cleaning the OR" states, " ... OR cleaning between cases ... Clinical alert: Ensure that cleaning begins to reestablish a clean environment after patient transfer from the area to decrease the risk of cross-contamination and infection transmission. ... "

1. On 1/27/20 at 11:51 AM, Staff #15 began cleaning the anesthesia equipment while the patient was still in the OR and was being transferred from the OR bed to the stretcher.

2. The above finding was confirmed by Staff #17 at time of discovery.

N. Based on observation, staff interview, review of manufacturer's instructions for use, and review of nationally recognized standards, it was determined that the facility failed to ensure that written manufacturers' instructions for use for all surgical instruments are followed.

Findings include:

Reference #1: ANSI (American National Standards Institute)/AAMI (Association for the Advancement of Medical Instrumentation) ST79:2017, written in "Foreword" states, "To facilitate user access to all AAMI consensus recommendations for steam sterilization in health care facilities, the first edition of ANSI/AAMI ST79, published in 2006, consolidated into one comprehensive guide the following AAMI recommended practices: ...ST46, ...ST42, ...ST37, ...ST35 and ...ST33..."

Reference #2: AAMI (Association for the Advancement of Medical Instrumentation) Comprehensive guide to steam sterilization and sterility assurance in health care facilities, 2017 edition, ST 79 section 7.3 states, " Manufacturers' written IFU [Instructions for Use]: The device manufacturer's current written IFU should be accessible, reviewed, and followed."

Reference #3: Pilling Instructions for Use and Reprocessing states, " ... Cleaning/Sterilization ... Cleaning: Automatic - All instruments must be cleaned in the completely open and disassembled (i.e. taken apart) configuration."

1. On 1/27/20 at 11:15 AM, Staff #32 confirmed that the facility's Infection Control program is based on Association for the Advancement of Medical Instrumentation (AAMI).

2. On 1/27/20 at 1:35 PM, a tray audit was conducted of a Cataract Tray ready for sterilization, in the Sterile Processing Department (SPD) and the following was revealed:

a. A Pilling Beaver Knife Handle was observed inside the tray fully assembled. Staff #39 confirmed the instrument should have been disassembled prior to cleaning (Refer to Reference #3).

3. The above findings were confirmed by Staff #17, Staff #18 and Staff #39.