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Based on the extent of observations related to breaches in infection control practices it was determined the Infection Control Condition of Participation was not in compliance; as evidenced by the facility's staff's failure to ensure:

A. Proper hand hygiene was followed during 8 of 10 observations;

B. The performance of safe injection practices during 1 of 2 observations;

C. Utilization of appropriate personal protective equipment in 4 of 4 observations;

D. Appropriate cleaning of the environment and equipment for 2 of 2 observations; the cleaning of vents and provision of proper ventilation in high level disinfection area for 1 of 1 area, and the appropriate storage and transportation of linens in 2 of 2 observations;

E. Appropriate performance of indwelling catheter care for 1 of 2 observations;

F. Appropriate attire was worn and changed in surgical and clean areas to prevent cross contamination and the spread of infectious agents in 3 of 4 observations;

G. Appropriate infection control practices were followed during ventilator care;

H. Point of care devices were properly disinfected between patients in 2 of 2 observations;

I. Appropriate precautions were followed when caring for a patient on isolation in 1 of 2 observations;

J. Infection control practices were followed in surgical and clean areas;

K. Food and drinks were stored or ingested in appropriate areas in 4 of 5 observations; and

L. Facility equipment was maintained to prevent the spread of infection between patients in 3 of 3 observations.

See Citation A-0749 for further details.

Based on observations, interviews and documents reviews, it was determined the facility staff failed to ensure they followed their infection control plan by identifying, reporting, investigating and controlling potential areas and behaviors that could potentially result in an infection by:

A. Ensuring proper hand hygiene was followed during 8 of 10 observations;

B. Safe injection practices were followed during 1 of 2 observations;

C. Staff used personal protective equipment and used it appropriately 4 of 4 observations;

D. Staff appropriately cleaned the environment and equipment for 2 of 2 observations; Staff in areas where high level disinfection occurred had clean and appropriately ventilation for 1 of 1 area, and linen was appropriately stored and transported in 2 of 2 observations;

E. Appropriately perform care for indwelling catheters for 1 of 2 observations;

F. Appropriate attire was worn and changed in surgical and clean areas in 3 of 4 observations;

G. Staff followed infection control procedures during ventilator care;

H. Following established care and cleaning of point of care devices in 2 of 2 observations;

I. Appropriate precautions were followed when caring for a patient on isolation in 1 of 2 observations;

J. Staff followed infection control practices in surgical and clean areas

K. Food and drinks were stored or ingested in appropriate areas in 4 of 5 observations; and

L. Facility equipment was maintained to prevent the spread of infection between patients in 3 of 3 observations.

The findings include:

1. A. On 6/15/2015 and 06/16/2015 on CICU (cardiac intensive care unit), Patient rooms on PSU, GYN OR (gynecology operating room) and in L&D (labor and delivery) the following observations were made:

CICU on 6/15/15 at approximately 2:45 P.M. a central line was observed being placed; following the placement Staff #19 removed gloves, exited the room and went to nurses' station and began entering information on the computer without performing hand hygiene.

PSU on 6/15/15 at approximately 1 P.M. Staff #17 was observed caring for a patient on contact isolation. Staff #17 applied an ointment to the lower to mid thigh and sides of the knee and upper shin and calf area of Patient #3. Patient #3 had an abraised area on the knee where a scab was forming. Staff #17 applied the ointment, removed the glove of the right hand reached under the PPE (personal protective equipment (gown)) and pulled out the ID (identification badge), scanned the badge and returned it to under the PPE. Staff #17 never performed hand hygiene during this process.

GYN OR on 6/16/15 at approximately 11:25 A.M. while observing a surgical procedure Staff #53 removed bloody sponges from the waste receptacle for count, removed his/her gloves and picked up note paper and began documenting without performing hand hygiene. The same Staff member was observed holding a specimen collection container and collecting the specimen with no gloves on.

L&D on 6/16/15 at approximately 12:25 P.M. A Staff was observed removing bloody sponges to ensure count was correct. Gloves were removed and the Staff began to document without performing hand hygiene. Staff #29 acknowledged this was observed. Staff #2 was present during all the observations and acknowledged the observance of the same.

B. On 6/15/15 at approximately 3:40 P.M. Staff #21 was observed instilling a medication into an INT (intermittent needle therapy). Staff #21 did not clean the port site prior to instilling the medication.

C. PSU on 6/15/15 at approximately 1 P.M. Staff #17 was observed caring for a patient on contact isolation. Staff #17 applied an ointment to the lower to mid thigh and sides of the knee and upper shin and calf area of Patient #3. Patient #3 had an abraised area on the knee where a scab was forming. Staff #17 applied the ointment, removed the glove of the right hand reached under the PPE (personal protective equipment (gown)) and pulled out the ID (identification badge), scanned the badge and returned it to under the PPE. Staff #17 did not perform hand hygiene during this process.

An observation conducted on CICU on 6/15/15 at approximately 2:35 P.M. revealed Staff #19 and 20 walking down the hallway pushing a cart. Staff #19 and 20 were both wearing head coverings. Staff #19 had on a paper head covering and Staff #20 had on a cloth head cover. Staff #19 and 20 entered room #8 of CICU to perform a central line placement procedure. Staff #19 and 20 did not change their head covering or place a clean head covering over them prior to the initiation of the procedure.

On 6/16/15 between 9:15 and 10:50 A.M. in the GYN OR area 3 staff members were observed in room #3 wearing cloth head coverings with no disposable head covers over the cloth head covers. Also during this time observations were made in the Central Sterile area. On the clean side of Central Sterile 2 staff members were observed in cloth head covers with no disposable head covers over the cloth and one Staff in a floral scrub jacket that Staff #2 confirmed was not a part of the scrubs furnished by the facility.

In the L&D area where an observed C-Section was observed on 6/16/15 Staff #31 was observed making adjustment to the lights over the surgical table with bare hands after the light handle covers had been put in place. Staff #31 was also observed grabbing the sides of the light with bare hands at the same time.

D. CICU on 6/15/15 at approximately 2:45 P.M. a central line was observed being placed; following the placement Staff #20 was observed cleaning the handle used to move the portable ultra sound and the cable with the probe but did not clean the rest of the machine that was either touching or less than 4 inches from the patient's bedside. The instructions on the product used to clean the machine directed the user to keep the equipment wet for 4 minutes. The parts of the portable ultra sound that were cleaned was wet for approximately 1 minute.

On 6/15/15 at approximately 2:30 P.M. in SICU (surgical intensive care) Patient #4 was receiving plasmapheresis dialysis. The dialysis machine had tape residue and paint was chipped.

On 6/16/15 between 9:15 and 10:54 A.M. the Central Sterile area was observed. This area is where dirty surgical instruments are cleaned, processed and sterilized. In this area the eye wash sink had debris in the sink and the eye wash ports were uncovered. Under the eye wash station laying on the floor were folded towels and blanket that had dried water rings on them. The air vents and grills were visibly dusty. There were 3 Steris Washers 2 of which had a black and or brown substance flashing around the washers on one or both sides.

The area of Central Sterile was warmer than the corridors. In this area a concentrate enzymatic presoak and cleaner was used on surgical instruments. The label on the cleaner documents "Use adequate ventilation to maintain levels below established exposure limits." Staff #25 wore a standard paper mask and face shield.

The clean linen storage are was observed on 6/17/15 at approximately 10:30 A.M. The clean linen storage contained approximately 20 linen bins and storage shelving units total. Approximately 7 of the bins were not covered and contained clean linen. Staff #33 stated, "I am embarrassed for you to see this. I expected this to be near perfect."

F. CICU on 6/15/15 at approximately 2:35 P.M. Staff #19 and 20 were observed walking down the hallway pushing a cart. Staff #19 and 20 were both wearing head coverings. Staff #19 had on a paper head covering and Staff #20 had on a cloth head cover. Staff #19 and 20 entered room #8 of CICU to perform a central line placement procedure. Staff #19 and 20 did not change their head covering or place a clean head covering over them prior to the initiation of the procedure.

At approximately 2:45 P.M. the central line was observed being placed; following the placement Staff #19 removed gloves, exited the room and went to nurses' station and began entering information on the computer without performing hand hygiene.

I. PSU on 6/15/15 at approximately 1 P.M. Staff #17 was observed caring for a patient on contact isolation. Staff #17 applied an ointment to the lower to mid thigh and sides of the knee and upper shin and calf area of Patient #3. Patient #3 had an abraised area on the knee where a scab was forming. Staff #17 applied the ointment, removed the glove of the right hand reached under the PPE (personal protective equipment (gown)) and pulled out the ID (identification badge), scanned the badge and returned it to under the PPE. Staff #17 did not perform hand hygiene during this process.

J. On 6/16/15 between 9:15 and 10:50 A.M. in the GYN OR area 3 staff members were observed in room #3 wearing cloth head coverings with no disposable head covers over the cloth head covers. Also during this time observations were made in the Central Sterile area. On the clean side of Central Sterile 2 staff members were observed in cloth head covers with no disposable head covers over the cloth and one Staff in a floral scrub jacket that Staff #2 confirmed was not a part of the scrubs furnished by the facility. By not changing attire the facility staff increased the risk of introducing infectious agents and cross contamination in the surgical and clean areas.

K. On 6/16/15 between 9:15 and 10:50 A.M. in the GYN OR area 2 Staff were observed walking down the hallways of the surgical area. One of these Staff Members was carrying an open drink and drinking it. The other Staff was carrying what appeared to be a sliced bagel. This Staff was eating on half of the bagel. Staff #24 attempted to redirect this Staff who was eating to the lounge. This Staff initially ignored the redirection.

L. Other observations made during the days of the survey were: Opened and accessed sterile equipment placed back in the anesthesia cart of GYN OR #2; tears in the surgical table; soiled wheel casters stored on top of clean/sterile paper wrapped surgical items; tears or chips in the floor of the OR; chips in numerous doors through out the GYN OR and chipped paint in the over head light in GYN OR #2.

On 6/16/15 at approximately 12:03 P.M. the area of Surgical L&D was observed. The area contained paper towels stacked causing remaining paper towels to be wetted. While Patient #8 was observed undergoing a C-Section there were 3 infant warmers in the room. One was to be used during the birth of Patient #8's baby. The remaining 2 infant warmers were uncovered and exposed. One infant warmer had a notebook open and laid across the bed of the warmer. Staff #29 stated, "We have the additional warmers set up in case of an emergency." Also the floor of this room had cracks in the floor.

The floor of the GYN OR in the surgical corridor area had cracks or separations in the flooring where soil and or water had appeared to collect in areas.

The facility policy #890756 documents under Methods of Implementation and Control All employees will utilize standard precautions. Under sub-section Engineering Controls and Work Practices; In work areas where there is a reasonable likelihood of exposure to blood or other potentially infectious material, employees are not to eat, drink, apply cosmetics of handle contact lenses. Employee food and beverages are not to be kept in refrigerators or on counters where blood or other potentially infectious material is present. Under sub-section Personal Protective Equipment; All employees using PPE must observe the following precautions: Perform hand hygiene immediately or as soon as possible after removal of gloves or other PPE.

The facility also provided policy "#741309 Surgical Attire." Under the section titled "Procedure:
Sub-section A: #5 documents All surgical attire to include pant suits, hair coverings and cover jacket are to be laundered daily in an (Name of facility Company) accredited laundry.
B: #2 documents Disposable head coverings will be discarded after use. #3 documents Daily laundered fabric head covering may be worn with a disposable bouffant hair cover.
Sub-section H documents Protective barriers will be provided for all personnel #2 Gloves are changed and hand hygiene performed after each use and discarded in approved receptacles.
Sub section I documents Identification badges will be visible at eye level and be secure and clean. The use of lanyards is not recommended."
CDC's Healthcare-associated Infections - Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care Adhere to Standard Precautions
"Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered. These practices are designed to both protect HCP and prevent HCP from spreading infections among patients. Standard Precautions include: 1) hand hygiene, 2) use of personal protective equipment (e.g., gloves, gowns, masks), 3) safe injection practices, 4) safe handling of potentially contaminated equipment or surfaces in the patient environment, and 5) respiratory hygiene/cough etiquette. Each of these elements of Standard Precautions are described in the sections that follow.
Education and training on the principles and rationale for recommended practices are critical elements of Standard Precautions because they facilitate appropriate decision-making and promote adherence. Further, at the facility level, an understanding of the specific procedures performed and typical patient interactions, as described above in Administrative Measures as part of policy and procedure development, will assure that necessary equipment is available."


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2. A. During an observation of a central venous catheter dressing change conducted on 06/15/2015 and 06/17/2015, staff failed to perform hand hygiene between glove changes while performing patient care related to 2. C. and 2. F.

Ventilatory/Respiratory therapy care was observed on 06/17/2015, staff failed to perform hand hygiene between glove changes while performing patient care related to 2. C. and 2.G.

An interview was conducted 3:56 p.m. on 06/15/2015 during the end of the day meeting. The facility staff were informed of the findings and a policy/procedure was requested.

2. C. During an observation of a central venous catheter dressing change conducted on 06/15/2015 and 06/17/2015, staff failed to change gloves and perform hand hygiene before moving from a contaminated body site to a clean body site while performing patient care related to 2 F.

Ventilatory/Respiratory therapy care was observed on 06/17/2015, staff failed to change gloves and perform hand hygiene before moving from a contaminated body site to a clean body site while performing patient care related to 2. G.

An interview was conducted 3:56 p.m. on 06/15/2015 during the end of the day meeting. The facility staff were informed of the findings and a policy/procedure was requested.

2. F. An observation of a central venous catheter dressing change was conducted on 06/15/2015 at approximately 2:50 p.m. with Staff #36. Staff #36 performed hand hygiene, donned gloves and removed Patient #15's saturated right internal jugular (IJ) vein catheter dressing. Staff #36 failed to perform hand hygiene prior to donning sterile gloves to apply a new dressing.

An observation of a central venous catheter dressing change was conducted on 06/17/2015 at approximately 10:15 a.m. with Staff #46. Staff #46 performed hand hygiene, donned gloves and removed Patient #17's left Quinton catheter dressing. Staff #46 performed hand hygiene, donned sterile gloves, accessed port and cleaned, applied biopatch, removed gloves, failed to perform hand hygiene prior to donning gloves to apply a new dressing and write the date, time and initial of staff member applying the new dressing.

Review of the facility's policy titled "Hand Hygiene", which read in part "Policy: Hand hygiene is generally considered the most important single practice for preventing Healthcare- Associated Infections. The purpose of hand hygiene for routine patient care is to remove microbial contamination acquired by recent contact with infected or colonized patients or environmental sources. RESPONSIBLE PERSONS: A. All staff, volunteers, physicians, and contract employees. 3. Decontaminate hands a. Before having direct contact with patients. b. Before donning sterile gloves when inserting a central intravascular catheter. c. Before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical scrub. d. After contact with patient's intact skin .... e. After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled. f. If moving from a contaminated-body site to a clean-body site during patient care. g. After contact with inanimate objects .... h. After removing gloves."

An interview was conducted on 06/17/2015 at approximately 11:30 a.m., with Staff #2 and Staff #4. The surveyor informed Staff #2 and Staff #4 regarding the findings during observations. Staff #4 reported it is the facility's policy to do hand hygiene between all glove changes and this is what is expected of all staff.

2. G. An observation of ventilator/respiratory therapy care was conducted on 06/17/2015 at approximately 9:45 a.m. with Staff #49 Staff #49 performed hand hygiene, donned gloves and performed ventilator and respiratory care for Patient #15. Staff #49 removed gloves, did not perform hand hygiene, donned new gloves and logged into the computer to verify Patient #15's ventilator settings and proceeded to complete Patient #15's respiratory treatment. Staff failed to perform ventilator care/treatment in a manner to prevent the introduction of infectious agents and cross contaminants.

An interview was conducted on 06/17/2015 at approximately 11:30 a.m., with Staff #2 and Staff #4. The surveyor informed Staff #2 and Staff #4 regarding the findings during observations. Staff #4 reported it is the facility's policy to do hand hygiene between all glove changes and this is what is expected of all staff.

2. H. An observation was conducted on 06/17/2015 at approximately 10:45 a.m., during a blood glucose check on Patient #18. Staff #48 performed the glucose testing for Patient #18 wearing gloves and after completion of the testing, removed the strip with the blood sample from the glucometer with his/her gloved hands. Staff #48 then put on gloves to clean the glucometer with PDI Sani wipes. The surveyor informed Staff #48 regarding the findings during the observation and inquired if the glucometer was cleaned and disinfected according to manufacturer's instructions. Staff #48 stated, "This is what I was taught."

The survey team held a discussion of the observations and concerns on 06/17/2015 at 11:50 a.m. with Staff #1, Staff #2, Staff #4, Staff #5 and Staff #7.


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3 A. An observation on June 16, 2015 at 10:30 a.m., with Staff #12 revealed he/she failed to change gloves and perform hand hygiene between procedures for Patient #1. During the observation Staff #12 removed his/her gloves twice and failed to perform hand hygiene after glove removal. For further details see 3 E.

3 E. The following was observed during Foley catheter care on June 16, 2015 at 10:30 a.m.: Staff #12 performed hand hygiene and donned gloves to perform Foley catheter care on Patient #1. During Foley catheter care Patient #1 asked Staff #12 if he/she would "clean [his/her] belly". Staff #12 cleaned Patient #1's abdomen and applied Nystatin powder without changing gloves and performing hand hygiene. Staff #12 opened and closed the Nystatin powder with a dirty gloved hand. Staff #12 placed the Nystatin powder into a plastic bag on top of a cart in the room and then opened a drawer with the same dirty gloved hand and placed Nystatin in the drawer. Staff #12 then opened another draw to get a linen bag for the dirty linen with the same dirty gloved hand. Staff #12 then removed dirty gloves and donned a second pair of gloves without performing hand hygiene. Staff #12 continued with Foley catheter care then removed gloves and donned a third pair of gloves without performing hand hygiene. After the procedures were complete Staff #12 removed gloves and performed hand hygiene before leaving the room. Staff #12 failed to follow proper hand hygiene during the Foley catheter care potentially placing the patient at higher risk for urinary tract infection.

3 H. The following was observed during use of a point of care devices on June 16, 2015 at 11:30 a.m.: Staff #13 performed hand hygiene and donned gloves to perform a blood glucose check on Patient #2. Staff #13 placed all supplies including alcohol pad, gauze pads, finger stick device, glucometer strips container and glucometer in the bed with Patient #2. Staff #13 cleaned the site with alcohol prior to perform the finger stick for the blood sample. The first drop of blood was wiped away with gauze pad and the second drop was placed on the strip in the glucometer. The glucometer was then placed on the counter of the sink where there was a roll of toilet paper and a urinal containing urine. Staff #13 wiped the glucometer once with a "super sani-cloth" then removed gloves and performed hand hygiene. The container of glucometer strips was not cleaned. Staff #13 failed to clean the glucometer according to the facility policy and procedure and manufacture's guidelines.

An interview with Staff #4 revealed that the glucometers are used on multiple patients and the hospital policy for cleaning glucometers is directly from the manufactures guidelines.

Hospital policy titled "Whole Blood Glucose by NOVA STATstrip" states "The meter's external surface should be cleaned and disinfected with a fresh bleach wipe from the EPA-approved list D. 1. remove a fresh wipe from the canister and thoroughly wipe the surface of the meter (top, bottom, left, right sides) a minimum of 3 times horizontally and 3 times vertically avoiding there meter's bar code scanner and electrical connector."

The following ingredients are contained in the "super sani-wipes" according to Material Safety Data Sheet (MSDS): Isopropanol, benzyl-C 12-18 alkyldimethyl am ammonium chlorides, Quaternary ammonium compounds, C 12-18 alkyl (ethylphenyl, methyl, dimethyl, chlorides). The contact time listed is 2 minutes.

3. K. The following was observed during an interview on June 16, 2015:
On Unit 3 North there was a clear cup with an initial on the cup, containing a dark liquid observed on top of the counter at the nursing station and a clear cup with a logo containing a clear liquid on the desk beside the computers. Staff #16 was observed picking up the clear cup with the initial and drinking from it while standing at the nurses station.

On Unit 2 South Staff #15 was observed walking down the hall with a cup in hand. Staff #15 stopped at the nurses station and set the cup on the counter while talking with other staff members. Staff #15 picked up the cup and drank from it while continuing to walk down the hall.


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4 D. An observation was conducted on June 16, 2015 from approximately 1:15 p.m. to 1:22 p.m., with Staff #3 and Staff #9. The observation was made while waiting to interview a patient as part of the discharge planning review. Staff #54 exited Room 221 carrying linens, observable bedspread and sheets, rolled together under his/her arms and against his/her uniform. Staff #9 asked Staff #54 to place the linens in a blue bag for transport. Staff #54 reported the linens were extras in [name of patient]'s room and there were no blue bags in the patient's room. Staff #54 continued to carry the contaminated linens across the nurses' station and down the hall to the soiled utility room. The surveyor questioned if the linens had been transported appropriately, Staff #9 stated, "[He/she] should have transported the linens in a blue bag." Staff #9 reported the expectation would have been to leave the linens in the room and obtain a blue bag for transporting the linens.

An interview was conducted on June 17, 2015 at 9:37 a.m. with Staff #9. Staff #9 verified the observation conducted on June 16, 2015 of Staff #54 improperly transporting the soiled linens. The surveyor requested a copy of the facility's policy for linen transport. Staff #9 reported that Staff #54 had not handled the linen per the facility's policy.

Review of the facility's policy titled "Exposure Control Plan (ECP) for Bloodborne Pathogens" revised "11/2014" read in part: " Laundry: In accordance with Standard Precautions, all linens/laundry is considered contaminated. Contaminated linen should be handled as little as possible and with minimal agitation. Linen shall be bagged at the site of generation into plastic bags and closed to prevent leakage ..."


4 K. An observation was conducted on June 16, 2015 from approximately 11:25 a.m. to 11:35 a.m., with Staff #3. The observation revealed a variety of staff drinks in at least eight locations within the nurses' station. The surveyor asked Staff #9 if staff could have opened cups with liquids or any drinks in the nurses' station. Staff #9 stated, "Staff are not allowed to have opened drinks at their work station." Staff #9 collected the cups without lids and directed other nursing staff to remove the drinks from the area. One of three nurses commented "I thought we could have drinks if the top was closed." Before the drinks could be collected, a drinking cup with a partially closed lid was knocked over by one of two staff charting. A request was made for the facility's policy.

Review of the facility's policy titled "Exposure Control Plan (ECP) for Bloodborne Pathogens" revised "11/2014" read in part:"Engineering Controls and Work Practices: Engineering and work practice controls will be used to prevent or minimize exposure to bloodborne pathogens ... In work areas where there is a reasonable likelihood of exposure to blood or other potentially infectious material, employees are not to eat, drink ... Employee food and beverages are not to be kept in refrigerators or on counters where blood or other potentially infectious material is present ..."

An interview was conducted on June 17, 2015 at 9:30 a.m., with Staff #4. The surveyor clarified with Staff #4 that there was no other policy for food and drink in the nursing stations. Staff #4 reported the "Exposure Control Plan (ECP) for Bloodborne Pathogens" revised "11/2014" was the policy in place. The surveyor reviewed the policy with Staff #4 related to the indication that no food and drink should be in the nurses' station. Staff #4 stated, "Potentially infectious specimens are brought into the nurses' stations, like urine cultures and other specimens. The nurses' station is an area where there is a potential for exposures to infectious materials." The surveyor shared the observation findings with Staff #4. Staff #4 reported there should be no beverages in the nurses' station whether opened or closed per policy.

Based on staff interview and document review, it was determined the facility staff failed to ensure the discharge needs initial assessment/evaluation was performed for three of the five patients reviewed for discharge planning. (Patients #9, #11, and #12)

The findings included:

An interview and review of the facility's policy titled "Discharge of Patients" was conducted on June 15, 2015 at approximately 1:15 p.m., with Staff #3 and Staff #9. Staff #3 reported the facility had two pathways related to discharge planning. Staff #3 reported that case management might not be consulted for "non-complicated" patients that were generally independent. Staff #3 reported the discharge planning for "non-complicated" patients was handled by nursing staff. Staff #9 reported nursing and case management utilized the same policy related to discharge. The policy titled "Discharge of Patients" read in part: "B. Discharge planning should begin at the time of admission and is an ongoing process of determining patient/family needs to provide continuity of care."

1. Patient #9 was admitted on May 13, 2015 and discharged from the facility on May 16, 2015. His/her discharge plans included sternal wound care provided by a home health agency. Patient #9 was readmitted to the facility on June 9, 2015 for surgical exploration and debridement of his/her sternal wound. Review of the June 9, 2015 initial assessment by the Registered Nurse (RN) related to post discharge needs revealed the section had not been completed and was blank. [Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue.]

An interview was conducted on June 16, 2015 at 9:08 a.m., with Staff #3 and Staff #9. Staff #9 verified Patient #9's initial assessment for post discharge needs had not been completed. Staff #3 reported the questions in the post discharge needs section of the initial nursing assessment can trigger the need to involve case management and other therapies.

2. Patient #11 was admitted to the facility for shortness of breath (SOB) on April 1, 2015 and discharged to a skilled nursing facility on April 3, 2015. Patient #11's initial assessment for "Functional Screening" by the RN indicated the patient had mobility deficits, but failed to indicate the area of deficit. Patient #11 was readmitted to the facility for shortness of breath on April 25, 2015 and discharged on April 27, 2015.

An interview was conducted on June 16, 2015 at approximately 9:30 a.m., with Staff #3. Staff #3 acknowledged the above findings. Staff #3 reported the "Functional Screening" relates to treatment needs and post discharge needs.

3. Patient #12 was admitted on April 27, 2015 for cellulitis involving his/her right foot and discharged from the facility on May 11, 2015. Review of the April 27, 2015 initial assessment by the RN related to post discharge needs had been left blank. Patient #12 was readmitted to the facility on May 27, 2015 for the surgical removal of gangrenous toes on his/her right foot. The readmission initial assessment dated May 27, 2015, indicated Patient #12 did not have deficits in mobility. Although the RN documented in other areas of the readmission initial assessment that Patient #12 had decreased muscle coordination, a right foot wound, and "unsteady gait." [Cellulitis is a skin infection that happens when bacteria spreads through the skin to deeper tissues.]
An interview was conducted on June 16, 2015 at approximately 11:00 a.m., with Staff #3 and Staff #9. Staff #9 verified the findings. Staff #9 reported if nursing staff documented on the fall assessment that the patient had deficits; those deficits should have been noted on the "Functional Screening" for treatment and discharge needs. Staff #3 and Staff #9 verified facility staff had failed to gather needed information on the initial discharge needs assessments for Patients #9, #11, and #12.

Based on staff interview and document review, it was determined the facility staff failed to ensure recommendations from treatment staff were addressed and implemented as part of the discharge plan for one (1) of five (5) patients reviewed for discharge planning. (Patients #11).

The findings included:

A review of Patient #11's electronic medical record (EMR) was conducted on June 16, 2015, with Staff #3 and Staff #9. The EMR revealed Patient #11 was admitted to the facility for shortness of breath (SOB) on April 1, 2015 and discharged to a skilled nursing facility on April 3, 2015. Patient #11's EMR documented the patient was readmitted to the facility for shortness of breath on April 25, 2015 and discharged on April 27, 2015.

Physical therapy documentation indicated Patient #11 should continue physical therapy after discharge from the facility and use a roller walker for ambulation. Review of the April 27, 2015 discharge plan and instructions did not include information related to continued physical therapy and the use of a roller walker. Staff #3 reviewed the physician's orders for discharge and reported the patient was returning to a skilled nursing facility. Staff #3 reported the discharge instructions reflect the physician's discharge orders. Staff #3 reported the physician had not written an order for continued physical therapy or for the roller walker. Staff #3 and the surveyor reviewed Patient #11's EMR for documentation related to the reason the physical therapy discharge recommendations were not implemented as part of the discharge plan. Staff #3 stated, "There's no evidence the patient refused or that staff followed up with getting the PT (Physical therapy) and walker ordered for after discharge." Staff #3 reported the facility was not able to provide evidence Patient #11's discharge planning had been implemented.