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Based on staff interviews, tour and observation of the facility, review of pertinent hospital wide policies and procedures, and review of medical records, it was determined that the Governing Body failed to demonstrate that it is effective in carrying out the operation and management of the hospital. The facility did not provide the necessary oversight and leadership as evidenced by the lack of compliance with 42 CFR 482.12, Condition of Participation - Patient Rights.

Based on observation, staff interview, and review of facility documents, it was determined that the facility failed to ensure that Acute Dialysis Service is provided in a safe manner in accordance with service policies.

A. Based on staff interview, and review of facility documents, it was determined that facility policies and the requirements of AAMI RD52:2004, "Dialysate for Hemodialysis" are not followed for the independent testing of dialysate conductivity prior to patient treatment.

Findings include:

Reference # 1: AAMI RD52:2004 "Dialysate for Hemodialysis" document states in section 5.6, "Injuries related to improper dialysate are rare, but they can and do happen when all procedures are not followed. Frequently, when the error occurs, several patients have been exposed before the facility recognizes the mistake. For example, because one of the concentrates is quite acidic and the other is basic, connecting the wrong concentrates to the machine could result in dialysate that could harm the patient. Thus, it is necessary for the operator to follow the manufacturer's instructions regarding dialysate conductivity and to measure approximate pH [measurement of the degree of acidity or alkalinity of a substance] with an independent method before starting the treatment of the next patient."

Reference #2: FMS Clinical Services policy FMS-CS-IS-I 510-028A titled, "Checking Conductivity of the Final Dialysate" states, "Conductivity of the final dialysate shall be checked with an independent meter and compared to the reading on the dialysis machine before each treatment begins." Procedure section of this policy states, "Note: allowable ranges per dialysate bath in use should not vary more than +/- 0.3 from the expected dialysate bath range."

1. Dialysis staff, responsible for checking conductivity of dialysate before patient treatment was not able to state the allowable variation of the machine reading and meter reading of the dialysate, according to facility policy.

a. On 3-8-11, at 11:15am, Staff #10 was interviewed in the acute dialysis treatment room during patient treatment. When asked about the testing of dialysate for conductivity prior to patient treatment, Staff #10 responded that the conductivity of dialysate is measured using the Myron L meter and stated that the acceptable range of result is "13.5 to 14.5." When asked what the allowable variation of conductivity reading is from machine to meter, Staff #19 responded that he/she "usually goes with a range", but that the variation should not be more than "0.1." The policy does not specify a range of acceptable conductivity readings and states an acceptable variation of 0.3, not 0.1.

Reference #3: FMS Clinical Services policy FMS-CS-IS-I-510-026C titled Myron L (D-1) Conductivity Meter Calibration states in Meter Calibration section, "1. After verification has determined the meter needs calibration, remove bottom panel of meter and identify the Calibration Control so you can find it by touch while calibrating. 2. Test a sample of the 14.0 mmho Standard Solution (be careful not to splash solution inside the meter). Rationale: corrode internal fixtures. 3. Fill cell cup in Myron L Meter to just above the top electrode with standard solution. 4. Drop the plunger into the cell cup and lift it about half way out of the cell and drop it back 3 or 4 times. Rationale: Rinses cell of dried previously used solution. 5. Discard sample and repeat Steps 3 & 4. 6. Press the black button and observe pointer reading."

1. On 3-8-11, at 11:20am, Staff #10 was observed demonstrating the calibration of a Myron L (D-1) meter using a 14.0 mmho solution. Staff #10 filled and discarded the standard solution three times before pressing the black button to observe the reading; however, he/she did not use the plunger, mentioned in step 4 of the policy, during the meter calibration. This procedure is not in compliance with above reference.

2. Four Myron L (D-1) meters were observed stored in a plastic basin, haphazardly on top of each other, on the sink counter in the acute dialysis treatment area on 3-8-11. None of the four meters were stored with the bottom panel attached to the meters, mentioned in step 1 of the policy, in order to protect the Calibration Control from movement, which may put the meter out of calibration, and exposing the inside of the meter to splash, which may lead to corrosion, mentioned in step 2 of the policy. This is not in compliance with above reference.


B. Based on observation and review of facility documents, it was determined that staff failed to demonstrate the testing of chlorine and chloramines in water used to prepare dialysate, according to facility policy.

Findings include:

Reference #1: AAMI RD:52:2004/A3:2007 "Dialysate for hemodialysis: Amendment 3-Annex E: Special considerations for acute hemodialysis" states in section E.3.4, Carbon Adsorption media, "Testing to demonstrate that the level of chloramine or total chlorine is less than 0.1mg/L should be performed before each treatment using a sample obtained from a port located between the two beds or filters."

Reference #2: FMS Clinical Services policy FMS-CS-IS-I-510-046A titled, "Granular Activated Carbon Filter Monitoring" states in Frequency of Testing, "Total Chlorine testing from a sample valve located after the first carbon filter, or bank of carbon filters, will be performed as follows: Portable RO Systems: For Conventional Dialysis Treatments: Prior to the beginning of each treatment and approximately every two hours thereafter. Post Second Carbon Filter: If the total chlorine level exiting the first filter or first bank of filters is equal to, or exceeds 0.10 ppm, testing after the second filter or bank of filters will be performed as outlined in the Granular Activated Carbon Filter Breakthrough Action Plan-Portable Water Systems".

1. On 3-8-11, Staff #10 demonstrated the testing of total chlorine that he/she stated is conducted prior to patient treatment and every two hours. Staff #10 obtained the water sample from the port exiting the RO machine, which is post second carbon filter rather than from the port between the two carbon filters. This is not in compliance with above reference.


C. Based on observation, staff interview, and review of facility documents, it was determined that staff failed to properly maintain the Total Dissolved Solids (TDS) meter used to verify the performance of the Reverse Osmosis (R.O.) machine, according to manufacturer's Directions for Use (DFU).

Findings include:

Reference #1: AAMI RD:52:2004/A3:2007 "Dialysate for hemodialysis: Amendment 3-Annex E: Special considerations for acute hemodialysis" states in section E.3.6, Reverse Osmosis, "The user may define monitoring in terms of percent rejection and product water conductivity (RO). Compliance with both monitored parameters is required, since an increase in feed water contaminants may result in product water unsuitable for hemodialysis applications even though the percent rejection of the membrane modules remains high."

Reference #2: Myron L Company Three Range DS Meter Operating Instructions, provided by Staff #9 on 3-8-11, states, "Your model 532 three range DS Meter is a compact instrument which operates on the principle of electrical conductivity. It will quickly determine the conductivity or ppm/Total Dissolved Solids of almost any solution." The Operating Instructions state in the section titled, "To Recalibrate the Meter", "1. Remove the bottom cover using fingernails or a small screwdriver to loosen the front or rear edge. Identify the three Calibration Controls so you can find them by touch while calibrating. 2. Test another sample of the Standard Solution (be careful to not splash solution inside the meter)." In the section titled, "Water inside the meter", the Operating Instructions state, "Your Myron L meter is a rugged instrument and will withstand water exposure around its cell, meter movement, and switches. However, care should be taken to keep water from leaking in around the bottom cover. It is not sealed (to prevent condensation from forming)."

1. Four Myron L (TDS) meters were observed stored, haphazardly on top of each other, in a plastic basin on the sink counter in the acute dialysis treatment area on 3-8-11. None of the four meters were stored with the bottom panel attached to the meters, leaving the Calibration Controls exposed to movement, which may put the meter out of calibration, and to exposure to liquid contamination, which is cautioned against in Manufacturer's Operating Instructions.

2. On 3-8-11, at 11:00am, Staff #10 provided documentation in the daily log that he/she had verified the calibration of three of the four TDS meters before initiating patient treatment the morning of 3-8-11. (One meter was observed with a note that the meter was found to be broken.) Staff #10 stated that the meters' calibration is verified each morning and are used, without further verification of calibration, before each patient treatment throughout the day. On 3-8-11, at 11:05am, Staff #10 determined, during his/her demonstration of the calibration of the TDS meter, that two of the three TDS meters available for use were out of calibration. At 12:30pm, Staff #8 conducted a verification of the calibration of the three TDS meters available for use and found that all three meters were out of calibration and needed recalibration. The meters are not maintained to ensure that they are properly within calibration at the time of use.

Based on review of the facility's policies and procedures, staff interview, reviews of medical records, and other facility documents, it was determined that the facility failed to protect and promote the rights of each patient.

Findings include:

1. The facility failed to ensure that the confidentiality of patient records was maintained. (Cross refer Tag 0146)

2. The facility failed to ensure that the use of restraint was in accordance with appropriate restraint technique. (Cross refer Tag 0167)

3. The facility failed to ensure that the physician order for the use of physical restraint was not written on an as needed basis (PRN). (Cross refer to Tag 0169)

4. The facility failed to ensure that if restraint or seclusion are discontinued prior to the expiration of the original order, that a new order is obtained prior to the reinitiation of the use of restraint or seclusion. (Cross refer Tag 0171)

5. The facility failed to ensure that the condition of patients who were restrained was not monitored by a physician, other licensed independent practitioner or trained staff at an interval determined by hospital policy. (Cross refer Tag 0175)

6. The facility failed to notify CMS of the death of a patient who had been in restraints 13 hours earlier. (Cross refer Tag 214)

Based on a tour of six patient care units and interview with administrative staff it was determined that the hospital failed to ensure that the confidentiality of patient records was maintained on three of the six units.

Findings include:

1. On March 8, 2011 at 11:00am accompanied by Administrator #3, an index card with the name of Patient #32, his/her chief complaint and date of birth and an 'Abnormal EKG' strip with the name of Patient #33 were found in regular trash cans in the Nurses Station in the Emergency Department (ED).

2. On March 8, 2011 at 11:55am accompanied by Administrator #21, two EKG strips with the name of Patient #34 and a partially filled-out Restraint Flow Sheet containing the name and other personal information of Patient #3 were found at the Nurses Station in the Critical Care Unit.

3. On March 9, 2011 at approximately 11:15am, 4 pages of a schedule dated March 9, 2011 which contained the names and types of treatments scheduled for nineteen PT patients were found in a regular trash can in the Physical Therapy (PT) Department.

4. Administrator #1, at 12:15pm on March 8, 2011, stated that the documents containing patient information should be put in a bin for recycling.

Based on observation of one patient in physical restraints it was determined that the use of restraint was not in accordance with appropriate restraint technique.

Findings include:

1. A tour of the Critial Care Unit was conducted on the morning of March 8, 2011, accompanied by Administrator #21. During the tour Patient #3 was observed to be in bilateral soft wrist restraints. The restraint on the patient's right wrist was placed over an intravenous hub, pressing the hub into the patients wrist.

Based on a review of facility policy and procedure, review of the medical records of seven patients who were physically restrained, and interview with administrative staff it was determined that an order for the use of physical restraint was written on an as needed basis (PRN) in one of seven medical records.

Findings include:

Reference: The ' Documentation' section of facility policy and procedure titled ' Restraints - Acute Care ' indicated: " ....
PRN RESTRAINT ORDERS ARE NEVER TO BE WRITTEN OR ACCEPTED. "

1. Review of a PHYSICANS ORDER SHEET in the medical record of Patient #21 indicated the following telephone order dated 1/4/11 at 1700 (5:00pm): " X - wrist restraints as needed for pt (patient) safety. " There were no other orders for physical restraint dated 1/4/11 in the medical record.

2. On March 11, 2011 at 1:40 pm Administrator #1 stated that the PRN order should not have been ordered by the physician or accepted by the nurse.

Based on a review of a facility policy and procedure it was determined that if restraint or seclusion are discontinued prior to the expiration of the original order, that a new order needn't be obtained prior to the reinitiation of the use of restraint or seclusion.

Findings include:

Reference: The 'Guidelines for the Use and Maintenance of all Restraints' section of facility policy and procedure titled 'Restraints - Acute Care' indicated: ".....
5. Restraints may be terminated early in the time limit of the order. If the same behavior is evident more than 1 hour after the restraint was removed and if alternatives remain ineffective, a new restraint order must be obtained [sic]
....."

1. If a patient is released from restraints or seclusion due to cessation of the behavior/behaviors that necessitated the intervention, the restraint/seclusion may not be reinitiated without a new order. The facility may not allow reapplication of restraint or seclusion using the original order once the order has been discontinued. The only time a patient may be released and then returned to restraint/seclusion is during the performance of required nursing interventions such as toileting, range of motion, etc.

Based on a review of facility policy and procedure and interview with administrative staff it was determined that the condition of the patient who is restrained was not determined by hospital policy.

Findings include:

Reference #1: The PURPOSE section of facility policy and procedure titled 'Restraints - Acute Care' indicated: "Appropriate use of restraints.
There are two uses of restraints:
1. Medical/Surgical use: to prevent the patient from interfering with appropriate medical treatment by pulling/grabbing at tubes, related to confusion/disorientation, inability to remember instructions, grabs at tubes/drains, and/or likely to fall/climb OOB (out of bed).
2. Behavior Management - When the patient expresses severely aggressive behavior that poses an imminent danger to the patient or others. ....."

Reference 1a: The POLICY section of facility policy and procedure titled 'Restraints - Acute Care' indicated: 'Guidelines for the Use and Maintenance of all Restraints' indicated: ".....
7. Observation of the patient is required hourly for the medical-surgical patient. Observation should occur every 15 minutes for patients who are unstable, in locked or 4-point cloth restraints. If restraint and seclusion is [sic] used simultaneously, then the patient needs to be continually monitored face to face by an assigned staff member for safety and care needs.
....."

1. The above policy references did not indicate how the condition of the patient in restraint for behavior management would be determined. Reference 1a indicated that a 'medical -surgical patient' may be placed in seclusion. Seclusion is only to be used for the management of violent or self-destructive behavior. The policy did not indicate time frames for toileting , offering of food and fluids, release of restraints, monitoring of vital signs, ambulation (if feasible), etc. Additionally, the policy did not indicate when nursing staff would reassess the need for continued restraint use.

2. Interview with Administrator #1 on March 9, 2011 at 2:45pm indicated there were no facility policies regarding physical restraints other than the one referenced.

Based on a review of the medical record of one patient who died within 24 hours of having been physically restrained and interview with administrative staff it was determined that the facility failed to notify CMS of a death that occurred within 24 hours after the patient had been removed from restraint.

Findings include:

1. Review of a NURSING RESTRAINT FLOW SHEET dated 1/5/11 in the medical record of Patient #21 indicated that the patient was in bilateral soft wrist restraints until 12:00pm on 1/5/11. A PHYSICIANS ORDER SHEET in the same medical record indicated the entry, dated 1/6/11 at 1:05am: "Pt pronounced (dead) (at) 1:05am date 1-6-11." The patient had only been out of restraints for 13 hours and 5 minutes when he expired.

2. Interview with Administrator #1 at 1:20pm on March 10, 2011 indicated that there was no evidence available that the death of Patient #21 was reported to CMS as required.

Based on observation, it was determined that the facility failed to ensure that the patient was supervised according to the Monitoring Inpatients During Treatment policy.

Findings include:

Reference: The Monitoring Inpatients During Treatment policy stated, "Access--All patient connections are secure and visible AT ALL TIMES due to serious risk of exsanguinations that could go undetected if the access was covered."

1. On 3/8/11 in the presence of Staff #6, at approximately 2:00 PM Patient #18 was observed receiving hemodialysis treatment. The patient's hemodialysis access was not visible, as the patient was covered with a sheet from head to toe. Upon further review, Patient #18 had a groin access. The above policy was not followed.


B. Based on medical records reviewed for patients receiving hemodialysis treatment, it was determined that the facility failed to ensure that 2 of 3 patients were evaluated.

Findings include:

1. On 3/10/11 Medical Record #31 indicated on the hemodialysis flowsheet (no date documented) that Patient #31 underwent a dialysis treatment beginning at 11:35 AM. The blood pressure at that time was 166/81, at 12:03 PM was 189/86, at 12:30 PM was 196/82, at 12:35 PM was 200/77, at 12:30 PM was 182/84, and at 1:05 PM was 180/79. In the comment section it is documented "v/s (vital signs) stable." There was no evidence that the physician was notified of the increase of blood pressure.

2. On 3/9/11 at approximately 11:00 AM, Medical Record #16 contained documentation that on 3/8/11 at 8:11 AM the patient's blood pressure, taken in the left arm, was 84/64 while sitting. Antihypertensive AM medications were held according to physician orders. The patient's blood pressure was rechecked at 8:16 AM was 84/39 in the left arm in a supine position. The next blood pressure was taken at 9:40 AM and it was 86/64 (no arm mentioned) and at 11:00 AM it was 90/60 supine, 98/68 sitting and supine again 98/68 (no mention in which arm it was taken).

3. There was no evidence that the patient was closely monitored or if any actions were taken to ensure that the patient was safe or that the physician was notified.

Based on staff interview, document review, and review of Medical Record #2, it was determined that the facility failed to ensure pharmacy policy regarding food/drug interactions was implemented.

Findings include:

Reference: Facility policy, "FOOD DRUG INTERACTION POLICY" stipulates, "POLICY: Pharmacy, Nursing, and Food/Nutrition Services collaborate to identify potential Food/Drug interactions as an integral component of the patient's medical and nutritional care. ..."

1. Medical Record #2 evidenced conflicting data regarding Patient #2's food allergies, therefore, putting Patient #2 at risk for not receiving medical and nutritional care in accordance with the "FOOD DRUG INTERACTION POLICY."

a. The electronic Medical Record #2 showed no evidence that Patient #2 had a shellfish.

b. The paper copy of Medical Record #2 showed evidence that Patient #2 has a shellfish allergy.

c. During an interview on 3/8/11 at 1:40 PM and upon review of dietary records, Staff #4 stated that a shellfish allergy was not listed on the dietary records for Patient #2.

d. During an interview on 3/8/11 at 1:50 PM, Staff #13 confirmed that Patient #2 did have a shellfish allergy and that the electronic Medical Record #2 did not evidence that Patient #2 had a shellfish allergy. At this point, Staff #13 stated he/she needed to get the shellfish allergy into the electronic system quickly because Patient #2 was scheduled for an MRI and patients who have shellfish allergies should not get MRI intravenous contrast because the patient may have an allergic reaction.

A. Based on documentation provided for review and staff interview, it was determined that the facility failed to ensure that all prescribers' medication orders specify the order of drug administration when multiple orders for the same therapeutic class of drugs, with the same indications, are ordered for a patient. This deficient practice was identified in 2 of 4 patient's Post Anesthesia Care Unit (PACU) records (Patient #5, # 6).

Findings include:

1. On 3/9/11 at 12:00 PM, a review of Patient #5's PACU orders revealed that the physician ordered 2 different narcotic analgesics, Morphine and Fentanyl, for moderate pain without specifying which Schedule II narcotic should be administered first and which narcotic should be administered second. The PACU order sheet (form # PACU-0001-2) contained the following orders signed by the physician on 3/9/11 at 9:15 AM:
"5. Narcotics
Morphine 1 mg IV (1 milligram intra-venous) q 10 min (every 10 minutes) to a total maximum dose of 5 mg for moderate pain
Fentanyl 25 mcg (micrograms) IV q 10 min. to total maximum dose of 100 mcg for severe or moderate pain." The words "or moderate pain" were added to the pre-printed PACU order sheet by the physician.

a. The physician did not specify whether Morphine or Fentanyl should be administered 1st for moderate pain.

b. At 12:05 PM on 3/9/11, Staff #41 stated that he/she would administer Fentanyl first because "Fentanyl is stronger", however, this was not specified by the physician.

2. On 3/9/11 at 1:30 PM a review of Patient #6's PACU orders revealed that the physician ordered 3 different medications for nausea/vomiting without specifying which medication should be administered first, second, and/or third. The PACU Order sheet, (form # PACU-0001-2) contained the following orders, signed by the physician on 3/8/11 at 10:17 AM:
"7. Medicate for nausea/vomiting prn (as needed) with:
Reglan 10 mg IV x 1 (Reglan 10 milligrams intra-venous 1 time)
Zofran 4 mg IV x 1
other phenergan 25 mg IV q 1 min (every 1 minute) x 1 minute ..."

a. According to the "Surgical Profile" sheet, page 12, Zofran 4 mg IV was administered at 10:40 AM., Reglan 10 mg IV was administered at 11:40 AM, and Phenergan 25 mg IV was administered at 12:40 PM.

b. The "Surgical Profile" sheet, page 10, shows documentation that at 10:30 AM on 3/8/11, Patient #6 complained of nausea and was "medicated for nausea as ordered".
At 11:40 AM, it was documented that the patient "still complained nausea Dr. aware Reglan ordered and given", and at 12:40 PM, "pt (patient) still complained nausea Dr aware orders reced (received)."

c. There was no documentation in Medical Record #6 to specify that Zofran should be administered 1st, Reglan to be administered after Zofran, and that Phenergan should be administered after Zofran and Reglan.

d. Staff #2, on 3/8/11 at 2:00 PM, confirmed that there was no documentation in the medical record to show that additional physicians' orders for Reglan to be given after Zofran, and Phenergan to be given after Zofran and Reglan, were issued by the physicians, after the original orders for Zofran, Reglan, and Phenergan were signed and dated by the physician.

e. Staff #2 stated that the facility did not have a policy/procedure delineating the order of administration of anti-emetic medications.

B. Based on document review, it was determined that the facility failed to ensure that all medication orders specified the dose and frequency for administration of medication.

Findings include:

1. Medical Record #19 contained the following physician hemodialysis orders dated 1/25/11 at 11:00 and 1/27/11 at 10:45 respectively: "Miscellaneous/PRN (as needed) Orders--For BP (blood pressure) below: 90 give 100-500 mls (milliliters) NSS (Normal Saline Solution) IV (intravenous) PRN." The orders did not specify the amount and the frequency for administration of the saline.


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C. Based on document review, it was determined that the facility failed to ensure that medications were administered in accordance with physicians orders in 2 of 3 hemodialysis Medical Records reviewed (#19, #30).

Findings include:

1. On 3/10/11, Medical Record #30 contained a Physician Orders Hemodialysis Orders sheet dated 1/5/2011 at 1240 for "Heparin Doses & Flushes, Loading: 5000 units/ml (milliliter); and Miscellaneous/PRN, For BP below: 90 give 100mls 25% Albumin IV PRN."

a. The hemodialysis flowsheet dated 1/5/11 revealed that a loading dose of Heparin 5000 units/ml was not administered. The flowsheet in the section of Hemodialysis Orders also indicated that the "pt on heparin drip." The No Heparin box was checked, and the Sodium Chloride 0.9% flushes 50 ml every 30 minutes was also checked. There was no evidence that Sodium Chloride 50 ml was given every 30 minutes. There was no evidence that the physician was contacted for a clarification of orders.

b. The hemodialysis flowsheet indicated that the patient's blood pressure on 1/5/11 at 1800 was 69/47. There was no evidence that Albumin IV PRN was given at this time for low blood pressure, as ordered by the physician.

2. On 3/10/11 review of Medical Record #19 revealed the following:

a. The hemodialysis flowsheet dated 1/27/11 at 10:45 AM indicated that the dialyzer used during treatment was a F-160NR (non reuser). On 1/27/11 at 10:45 AM a physician telephone order for hemodialysis treatment lacked the type of dialyzer to be used during treatment. There was no evidence that the physician was contacted for a clarification of orders.

b. The Physician Orders Hemodialysis Orders sheet dated 1/24/11 at 14:00 indicated, "Weight removal this treatment (kg) [kilogram]: 3 Kg." The hemodialysis flowsheet indicated that the Target Fluid Removal was 2 kg., and the Net Fluid Removal was of 1.3 kg. There was no evidence as to why the ordered weight removal was not achieved.

Based on medical record review and staff interview, it was determined that the facility failed to ensure that for 2 of 4 Post Anesthesia Care Unit (PACU) patients (Patients #5 and #6) medications were administered by a nurse in accordance with the Nursing Practice Act.

Findings include:

REFERENCE: Nursing Practice Act, N.J.S.A. 45:11-23 et seq.

The New Jersey Board of Nursing Statutes 45:11-23 states "... Definitions ... The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician. ....."

1. On 3/9/11 at 12:00 PM, a review of Patient #5's PACU orders revealed that the physician ordered 2 different narcotic analgesics, Morphine and Fentanyl, for moderate pain without specifying which Schedule II narcotic should be administered first and which narcotic should be administered second. The PACU order sheet (form # PACU-0001-2) contained the following orders signed by the physician on 3/9/11 at 9:15 AM contained the following orders:
"5. Narcotics
Morphine 1 mg IV (1 milligram intra-venous) q 10 min (every 10 minutes) to a total maximum dose of 5 for moderate pain
Fentanyl 25 mcg (micrograms) IV q 10 min. to total maximum dose of 100 mcg for severe or moderate pain." The words "or moderate pain" were added to the pre-printed PACU order sheet by the physician.

a. The physician did not specify whether Morphine or Fentanyl should be administered first for moderate pain.

b. At 12:05 PM on 3/9/11, Staff #41 stated that he/she would administer Fentanyl first because "Fentanyl is stronger", however, this was not specified by the physician and there was no additional documentation in the patient's medical record that the nurse obtained clarification from the physician regarding the sequence of administration of Fentanyl and Morphine.

2. On 3/9/11 at 1:00 PM a review of Patient #6's PACU orders revealed that the physician ordered 3 different medications for nausea/vomiting without specifying which medication should be administered first, second, and/or third. The PACU Order sheet, (form # PACU-0001-2) contained the following orders, signed by the physician on 3/8/11 at 10:17 AM:
"7. Medicate for nausea/vomiting prn (as needed) with:
Reglan 10 mg IV x 1 (Reglan 10 milligrams intra-venous 1 time)
Zofran 4 mg IV x 1
other phenergan 25 mg IV q 1 min (every 1 minute) x 1 minute ..."

a. According to the "Surgical Profile" sheet, page 12, Zofran 4 mg IV was administered at 10:40 AM., Reglan 10 mg IV was administered at 11:40 AM, and Phenergan 25 mg IV was administered at 12:40PM.

b. The "Surgical Profile" sheet, page 10 shows documentation that at 10:30 AM on 3/8/11, Patient #6 complained of nausea and was "medicated for nausea as ordered". At 11:40 AM, the patient "still complained nausea Dr. aware Reglan ordered and given", and at 12:40 PM, "pt (patient) still complained nausea Dr aware orders reced (received).

c. There was no documentation in Medical Record #6 to specify that Zofran should be administered first, Reglan to be administered after Zofran, and that Phenergan should be administered after Zofran and Reglan.

d. Staff #2, on 3/8/11 at 2:00PM, confirmed that there was no documentation in the medical record to show that additional physicians' orders for Reglan to be given after Zofran, and Phenergan to be given after Zofran and Reglan were issued by the physicians, after the original orders for Zofran, Reglan, and Phenergan were signed and dated by the physician.

e. Staff #2 stated that the facility did not have a policy/procedure delineating the order of administration of anti-emetic medications.

3. According to the Nurse Practice Act, it it not considered to be within the scope of nursing practice for the nurse to determine which medication should be administered without specific orders from the prescriber.

Based on a review of the medical records of six patients it was determined that medical record entries were not complete, timed, and/or authenticated in three of six medical records.

Findings include:

1. Review of a PHYSICIANS ORDER SHEET in the medical record of Patient #21 indicated the order dated 1/5/10 at 1025 (10:25am): "Fleet enema daily prn (as needed)." The order did not include an indication for use of the enema.

2. Review of a 'Hospitalist General Admission Order Set' form (Page 1 of 5) in the medical record of Patient #21, indicated the preprinted order dated 1/3/11: "Ondansetron (ZOFRAN) 4MG ___; 8MG ___; route PO ___; IV ___ Q6hr prn." The dosage and the route of administration were checked-off by the physician, but the order did not include an indication for use of the medication.

3. Review of the 'Medications' section (Page 2 of 2) of a physician's orders sheet (Form # 10-10) in the medical record of Patient #21, indicated the following order dated 1/4/11 at 1700 (5:00pm): "Lorazepam (Ativan) 2mg IV (intravenously) Q3H (every three hours) PRN (as needed)." The physician did not add an indication for the use of the medication to the preprinted order.

4. Review of a 'Hospitalist General Admission Order Set' form (Page 1 of 5) in the medical record of Patient #22, indicated the preprinted order dated 2/4/11: "Ondansetron (ZOFRAN) 4MG ___; 8MG ___; route PO ___; IV ___ Q6hr prn." The dosage and the route of administration were checked-off by the physician, but the order did not include an indication for use of the medication. A set of eleven orders on a PHYSICIAN ORDERS: ADULT SEPSIS order sheet in the same medical record was dated by the physician, but not timed. A 'Severe Sepsis Screening' form in the medical record was filled-out and signed by the physician, but the form was neither dated nor timed.

5. Review of a AN IMPORTANT MESSAGE FROM MEDICARE ABOUT YOUR RIGHTS form dated 3/8/11 in the medical record of Patient #36 included the entry "Pt (Patient) is mentally unable to sign" on the 'Signature of Patient or Representative' line. The writer of the note on the signature line did not authenticate the entry.

Based on tours of the hospital, it was determined that the facility failed to ensure that all facilities, supplies, and equipment were maintained at an acceptable level of safety and quality.

Findings include:

1. A tour of the Emergency Department conducted with Administrator #3 on the morning of March 8, 2011 indicated the following:

a. Waiting Room:

i. Cobwebs were observed in the corners.

ii. Heavy dust was noted atop vending machines.

iii. The soda machine had a piece of melted chocolate on top of it.

b. Entrance from Waiting Room:

i. Heavy dust atop alarm system wall-mounted box was noted.

c. Nurses Station:

i. A drawer beneath the countertop contained an accumulation of dust, grit, and paper scraps.

ii. A Physician Cabinet under the countertop contained an open box of pretzels and a large container of peanuts. The cabinet contained a Gastrostomy Feeding Tube that expired on 3/31/10. A shelf in the cabinet had brown raised stains. The cabinet door was delaminated in two areas at the bottom and was held to the cabinet by one screw - the door was hanging. A drawer next to the cabinet with the broken door contained grit, pieces of food, paper scraps, etc.

iii. Heavy dust behind printers and computers on the desk was noted.

iv. Heavy dust atop a wall-mounted phone was noted.

v. The Policy and Procedure wall shelf had heavy dust on the shelves.

vi. The bottom drawer on an island counter didn't close properly. It stayed open about 1.5 inches.

d. Pediatrics Room:

i. Heavy dust atop the wall cabinet above the sink was noted.

e. Hallway:

i. Heavy dust atop a metal blanket warmer cabinet was noted
.
ii. A biohazard box, across from Bay 14, containing needles and other sharps, was found not to have a protective lid. The needles and sharps were clearly visible inside the box and could be reached with a hand.

f. Nourishment Room:

i. Cabinet doors under the sink had raised, red, tacky stains on top of them.

ii. A four-section plastic bin had a heavy accumulation of whitish crystals and crumbs at the bottom of each section.

iii. The freezer in the refrigerator was totally frosted over. The freezer door could not be opened.

iv. The refrigerator contained a cup of salad, a cup of yellow pudding, and a cup of brown pudding. None of the food items were dated.

g. Clean Utility Room:

ii. Clumps of dust were observed on the floor.

ii. A stainless steel pail on wheels in the corner had dried brownish, raised stains, grit, cellophane and other refuse inside of it.

h. Behavioral Health Hallway:

i. Recliners across from Bay 16 had heavy dust, pretzel pieces, dust, grit, a used transdermal nicotine patch, and other refuse beneath them.

i. Hallway across from Nurses Station:

i. Heavy dust was observed atop a wall mounted x-ray light.

ii. A handwashing sink was found to have a heavy accumulation of dried soap on the splash guard. The laminate was partially separated from the particle board.


2. A tour of the Critical Care Unit conducted with Administrator #1 on the morning of March 8, 2011 indicated the following:

a. Waiting Room:

i. Dust and a used drinking straw were observed beneath the television.

ii. A cabinet beneath the counter top next to the sink had three used paper towels in it.

iii. The chairs in the room had coins, paper scraps, dust, hair, grit, etc. between the seat cushions on the cloth-backed chairs.

b. Nurses Station:

i. A bottom drawer under the counter top was found to contain a spray bottle with a cloudy yellow liquid in it. The entry 'Air Fr L' was made in black marker on the bottle. It was not clear what the bottle contained.

ii. Drawers under a cabinet across from Bay CCU9 contained large amounts of whitish crystals and broken pretzel pieces inside of them.

c. Patient Nourishment Area:

i. The refrigerator thermometer read 28 degrees Fahrenheit.

ii. Behind and beneath the refrigerator were heavy clumps of dust, straw wrappers, butter wrapper papers, plastic caps, grit, raised brown stains, and other pieces of refuse.

d. Medication Room:

i. The Leather Restraint Cabinet contained a leather limb restraint which had a raised blood-like, raised stain on the interior and exterior of the restraint.

ii. Behind the medication refrigerator was found dust, patient identification stickers, vial caps, grit, used alcohol pads, dried out elastic band pieces, cellophane , paper scraps, etc.

iii. A wall cabinet above the Pyxis Machine contained a Temporary Pacing Electrode Catheter with an expiration date of 7/31/10 and one with an expiration date of 10/31/10.

e. Hallway:

i. A cabinet beneath the sink across from Bay CCU12 had a broken handle. The handle was hanging by one screw.


3. A tour of the Maternal Child Health Unit conducted with Administrator #11 on the afternoon of March 9, 2011 indicated the following:

a. Nursery:

i. 13 green cap Vacutainers with an expiration date of 2/28/11 and 1 purple cap Vacutainer with an expiration date of 9/31/09 were found with supplies available for use.

b. PACU:

i. 4 "Chlamydia Trachomatis and Neisseria Gonorrheae (CT/GC) Amplified DNA Assay Collection Kits for Male Urethral Specimens" with an expiration date of 10/31/10 were found in a cabinet next to the blanket warmer.

c. Housekeeping Closet:

i. A spray bottle containing a milky white liquid did not to have a label identifying the contents.

d. Pantry:

i. A cabinet above the microwave oven had dried stains, spilt coffee, and crystals on it.

ii. The refrigerator had a yellowish liquid spilt on the interior doors.


4. A tour of the Physical Therapy Unit conducted with Administrator #1 on the afternoon of March 9, 2011 indicated the following:

a. Main Room:

i. Dust was observed atop the resuscitator and the traction machine.

ii. A treatment table had a tear on the naugahyde on a corner of the table.

b. Therapist Charting Area:

i. A drawer contained food, "body butter", and crumbs atop a container of peanut butter.

ii. The wall shelves were very dusty.

c. Incontinence Room:

i. Raised black, tacky, stains were observed at the bottom of a metal cabinet. The bottom drawer had grit and stains in it.

ii. A pillow on the exam table had cracks throughout the cover. The synthetic filling fibers were visible and protruded through the cracks in the cover.

d. Whirlpool Room:

i. A storage cabinet (white plastic) had yellow, black, and brown stained shelves. Some of the stains were dried and separated from the shelves.

ii. The cabinet contained a spray can of Aerosol Stainless Steel Polish, a spray bottle of Invacare disinfectant, an opened gallon container of d-Foam, an open bottle of "Decadent Amber Luxurious Body Mist', and other chemicals on shelves containing sterile patient items such as gauze pads, sterile latex powdered surgical gloves, Filament Reinforced Skin Closures, Carragauze, Abdominal pads, etc. The bottom shelf contained an opened bottle of HB Quat (disinfectant) next to individually wrapped Sterile All Purpose Sponges which were spread out on the shelf out of the box.


5. A tour of the Little Egg Harbor satellite facility was conducted with Administrator #3 on the morning of March 10, 2011 indicated the following:

a. Radiology Room:

i. Cabinets above the sink and counter had an accumulation of dust.

ii. A wall with metal plates and cables had exposed gypsum.

iii. A cabinet beneath the sink had black and green stains in it.

iv. The waiting area had love seats with scrap papers, candy wrappers, grit, etc between the cushions.

b. Storage Room (Old Processor Room):

i. Two developer containers containing liquid were heavily soiled.

ii. The floor had a heavy accumulation of black, brown, and green stains; grit; dust; and other refuse. The floor drain was heavily occluded with black and green material.

iii. Film storage cabinets were heavily rusted at the bases.

c. Physical Therapy:

i. Film Storage Room had three boxes of film stored on the floor.

ii. A metal cabinet had a bent right front door with sharp metal exposed at the top.

d. Treatment Room:

i. Exam table had two cuts in the naugahyde, approximately 2 inches long each. The interior synthetic material was visible.

ii. Another table had an area of approximately 12 inches by 4 inches of burned naugahyde. The cloth beneath was exposed.

iii. Two drains on the floor had rubber flooring tiles around them which were raised. The tiles were uneven causing a fall danger. Other floor tiles in the room were not closely abutted.

iv. Two dead bugs were observed atop a ceiling light cover in the room.

Based on observation, staff interview, and review of facility documents, it was determined that the facility failed to ensure that Acute Dialysis Service Infection Control policies, based on CDC document, Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients" are implemented.

Findings include:

Reference #1: CDC document, Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients states, "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. Therefore, items taken to a patient's dialysis station, including those placed on top of dialysis machines, should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being returned to a common clean area or used for other patients."

Reference #2: FMS Clinical Services policy FMS-CS-IC-II-155-110A, titled Cleaning and Disinfection states, "Clean and disinfect all equipment that is to be removed from the patient treatment area."

1. On 3-8-11, at 12:55pm, Staff #10 was observed cleaning dialysis machine "Y" after patient treatment. Staff # 10 was observed removing the hemodialysis machine log binder that had been placed on the machine before it was cleaned. Staff # 10 did not clean the log binder before placing it on the overbed table in the treatment area. This practice is not in compliance with References #s 1 and 2 above.

2. On 3-8-11, at 1:00pm, Staff #10 was observed cleaning the dialysis machine "W" after patient treatment. Staff #10 was observed removing a cardboard box of gloves from the top of the "soiled" dialysis machine, and replaced the box of gloves on the top of the dialysis machine after it had been cleaned. The box of gloves was not cleaned when it was removed from the soiled machine and the cardboard box and exposed contents is not apparently cleanable between patient treatments. This practice is not in compliance with References #s 1 and 2 above.

Reference #3: CDC document titled, "Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients" states in Cleaning and Disinfection section, "After each patient treatment, clean environmental surfaces at the dialysis station, including the dialysis bed or chair, countertops, and external surfaces of the dialysis machine, including containers associated with the prime waste."

Reference #4: FMS Clinical Services policy FMS-CS-IC-II-155-110A, titled Cleaning and Disinfection states, "Clean dialysis station (chairs, bed, table, machine, I.V. pole, TV's, TV remote control, hand sanitizer dispenser and holder etc.) after each patient treatment and before the next patient with a 1:100 bleach solution."

1. On 3-8-11, at 12:55pm, Staff #10 was observed cleaning dialysis machine "Y" and surrounding treatment area after patient treatment. Staff #10 failed to clean the prime bucket located on the side of the dialysis machine. Upon interview, Staff #10 stated that the bucket was not cleaned because it was not used. Staff # 10 also failed to clean the overbed table next to dialysis machine "Y".

2. On 3-8-11, at 1:00pm, Staff #10 was observed cleaning the dialysis machine "W" after patient treatment. Staff #10 failed to clean the stethoscope that was left hanging on the pole on the dialysis machine.

3. The computer, keypad, and stand near the window treatment station were not cleaned after patient treatment, observed at 1:00pm. The computer table, the keypad, and the base were observed soiled with an accumulation of dirt and dust.

4. The above practices are not in compliance with References #s 3 and 4 above.

Reference #5: CDC document titled, "Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients" states, "Contact transmission can be prevented by hand hygiene (i.e. handwashing or use of a waterless hand rub), glove use, and disinfection of environmental surfaces. Of these, hand hygiene is the most important."

Reference #6: FMS Clinical Services policy FMS-CS-IC-II-155-090A titled Hand Hygiene lists several instances when hands "will be washed with antimicrobial soap and water", which includes, "entering and leaving the treatment area." It also lists when hands "will be decontaminated using alcohol based hand rub or by washing hands with antimicrobial soap and water", which includes, "before direct contact with patients, after removing gloves, after contact with equipment, computers, furniture or other items near the patient."

1. On 3-8-11, Staff #10 was observed at 12:10pm, taking the temperature of the patient in the window bed and touching the dialysis machine with gloved hands. Staff #10 removed the gloves but failed to wash his/her hands or to use hand rub before donning gloves, taking the temperature of the patient in the interior room and touching that patient's dialysis machine.

2. On 3-8-11, Staff #10 was observed leaving the dialysis treatment room to make copies of the patient's chart and to obtain measured medicine cups (for bleach solution preparation) from the medication cart on the outside patient unit. Staff #10 failed to wash his/her hands or to use hand rub before leaving the dialysis treatment room or upon returning to the dialysis treatment room.

A. Based on observation and staff interview on March 9, 2011 at 12:15 PM, it was determined that the facility failed to conform with The Association for the Advancement of Medical Instrumentation (AAMI) requirements, " Chemical Sterilization and High Level Disinfection in Health Care Facilities " ST 58; incorporated herein by reference.

Findings include:

Reference # 1: The Association for the Advancement of Medical Instrumentation (AAMI) requirement, section 6.5.6, Drying and inspection indicates, after devices are rinsed, they should be visually inspected for cleanliness and working condition and then dried in accordance with the device manufacturer's instructions, to remove residual fluids.

1. Olympus Cystoscopes and Ureteroscopes are not dried with alcohol and air after the rinse process as required by the scope manufacturer instructions.

2. Staff # 2 & #12 indicated that the scopes are not dried using alcohol and air.


Reference # 2: The Association for the Advancement of Medical Instrumentation (AAMI) requirements, " Chemical Sterilization and High Level Disinfection in Health Care Facilities " ST 58; section 7.3, Manufacturers' instructions for use indicate that Health care personnel should follow the device manufacturer's written instructions.

1. Cystoscopes and Ureteroscopes are processed using OPA high level disinfectant in a manual soak system. The Metricide OPA manufacturer instructions indicate that the solution must be maintained at a minimum temperature of 68 degrees Fahrenheit (F). There is no documentation provided to assure the manufacturer's minimum temperature requirement is achieved and maintained.

2. Staff #2 & #12 indicated that they were unaware of the manufacturer's instructions for this parameter.

Reference #3: AAMI Requirement 7.4.1 indicates the use of high level disinfectants in patient treatment rooms is not recommended.

1. Cystoscopes an Ureteroscopes are soaked in the OPA high level disinfectant and rinsed in Operating Room D, providing a possible source of cross contamination to the patient.


B. Based on observation and review of sterilization documentation on March 8, 2011 at 1:30 PM, it was determined that the facility failed to conform with The Association for the Advancement of Medical Instrumentation (AAMI) requirements, " Comprehensive guide to steam sterilization and sterility assurance in health care facilities " ST 79; incorporated herein by reference.

Findings include:

Reference #1: AAMI requirement 3.3.6.8, Hand washing facilities indicates, hand wash facilities should be conveniently located and designed, and should be located in or near all areas in which instruments and other devices are decontaminated and prepared for sterilization, as well as in all personnel support areas.

1. There is no hand wash sink provided in the decontamination area of the sterile processing department.

Reference #2: AAMI requirement 8.10.1, Handling and inspection indicate that supplies should be handled carefully. Care should be taken to avoid dragging, sliding, crushing, bending, compressing, or puncturing the packaging or otherwise compromising the sterility of the contents.

1. Approximately 10 peel pouches of graspers and needle holders were observed jammed into bins in the Central Supply Storeroom, which may compromise the integrity of the sterile items.

2. The peel packs containing Laryngeal Mask Airway (LMA) equipment are jammed into the Difficult Airway Cart, compromising the sterile integrity of the items. One LMA peel pack was found perforated.

3. The Blood Set equipment is jammed into the Invasive Cart, which may compromise the integrity of the sterile items.


Reference #3: AAMI requirement 10.3.2, Sterilizer records indicate, for each sterilization cycle, the following information should be recorded: specific contents of the load and specific description of the items to include quantity, department, sterilizer and cycle.

1. The autoclave records for the sterilizers between Operating Rooms A & D, and B & C were reviewed for the time period 12/27/10 to 1/2/11, and 1/3/11 to 1/9/11. Documentation was incomplete and did not correlate the surgical items processed with the sterilizer used, load number, and cycle parameters recorded on the digital tape documentation.


C. Based on observation on March 9, 2011 at 1 PM, it was determined that the facility failed to follow the CDC guideline for Disinfection and Sterilization in Healthcare Facilities, 2008.

Findings include:

Reference #1: CDC Guideline, Section 7, ii, High Level Disinfection of Endoscopes indicates, do not use the carrying case designed to transport clean and reprocessed endoscopes outside of the healthcare environment, to store an endoscope inside the healthcare environment.

1. Two adult bronchoscopes and one pediatric bronchoscope were observed to be stored in the scope suitcase, which does not allow the scope to hang freely to remove residual moisture and prevent possible bacterial growth.

2. One adult bronchoscope was observed in the suitcase with a note indicating the scope is damaged and in need of repair. The scope is stored on the difficult airway cart and is available for use.


D. Based on observation on March 9, 2011 at 11:15 AM, it was determined that the facility failed to maintain a safe and sanitary hospital environment.

Findings include:

1. The cabinets in Operating Room D, for storing linen and clean and sterile supplies, are soiled with dust.

2. In Operating Room D, the foot pedal assembly for the operating table is soiled with dust, hair, and a sticky yellow residue.

3. In Operating Room D, the bottom surfaces of equipment and tables are soiled and dusty.

4. The bottom interior cabinet of the Unicart in the scrub area between Operating Rooms A & D is soiled with dust and an iodine residue.

5. The interior of the cabinet in the sub sterile area between Operating Rooms A & D is soiled.

6. The bottom interior cabinet of the Red A Smart Storage Cart in the Orthopedic Storeroom is soiled with dust and dirt.

7. The environmental services cleaning cart was observed stored in the sterile corridor outside Operating Room C. The mop bucket contained water with disinfectant, which may provide a safety issue and potential source of contamination.

8. Staff # 20 stated that there is insufficient space available to store the two environmental service cleaning carts in the janitor's closet.


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9. On 3/8/11 on the Telemetry Unit, at approximately 11:30 AM, in the medication area, boxes were observed on the floor, preventing cleaning of the floor.

10. On 3/9/11 on the 4th floor, at approximately 11:00 AM, in the Nourishment Area, the perimeter of the floor had dirt build up and the lower cabinets had dirt particles.

11. On 3/10/11, at the Forked River Outpatient Physical Therapy Center, at approximately 9:30 AM, the following conditions were observed:

a. The electric-stim and ultrasound equipment had no bio-medical stickers indicating when the equipment was last tested/serviced.

b. The work out bikes had dusty residue.

c. The hydrocollators and the cold pack container had white residue on the outside surfices.

d. The washer and dryer area was dusty.

12. On 3/10/11, at the Forker River Outpatient Physical Therapy Center, at approximately 11:00 AM, the X-Ray Room had dirt, dust and cobweb along the floor perimeter and the floor in the Dark Room area had a dirt build up along the perimeter.

E. Based on document review and interview, it was determined that the facility failed to ensure that the following policies were followed.

Findings include:

Reference: The Tuberculosis (TB) Surveillance --Employee Population stated, "Procedure: 2. TB testing will be performed anually on all employees (with a negative history), as per New Jersey...Employees identified as working in high risk departments by the Infection Control Committee will be tested semi-annually. These areas include ED (emergency department), Clinic, Flexible Procedure Room and Respiratory."

1. On 3/10/11at approximately 12:00 noon, a roster of staff members who had received TB testing was reviewed. Employee health files were reviewed and revealed that Staff #45 a part-time employee working in the Emergency Department had the last documented negative PPD in May of 2007. Staff #42, #43, #44 off-site employees had the last documented negative PPD in March of 2006, April of 2007, and in October of 2007, respectively. This is not in accordance with the above reference.

2. The above was confirmed by Staff #30.

Reference #2: The Guidelines for Handwashing/Hand Hygiene stated, "A. Alcohol-Based handrub:...3. Alcohol Based Hanndrub is not effetive against lostridium difficile (Cdiff). If you are caring for a patient with a diagnosis of Cdiff, hands must be washed with soap, water and friction. B. (Routine) Handwashing Procedue/Technique ...6. Apply hospital-approved hand soap and throughly dstribute over hands and wrists. 7. Vigorously rub hands using good friction for 20 seconds covering all surfaces including wrists and under nails...."

1. On 3/9/10 at approximately 2:00 PM in the presence of Staff #28, it was observed that Staff #46 had completed care of a patient who was positive for Cdiff. Staff #46 washed his/her hands in the bathroom, however, hand washing occured only for approximately 10 seconds instead of at least 20 seconds, as required in the above reference.


F. Based on document review, observation and interview, it was determined that the facility failed to ensure that policies for controlling infections and communicable diseases were followed.

Findings include:

Reference #1: The Isolation of Patients with Resistant Organisms policy and procedure stated, " Procedure: F. Culture positive patients must remains on Contact Isolation ..... Patients with cultures positive for MRSA and/or VRE will remain on Contact Isolation Precautions throughout their hospitalization and on all future hospitalization. "

Reference #2: The Infection Control/Environmental Services policy and procedure stated, "1. Procedure: 2. Isolation Rooms ... Contact and C-Diff staff gown and put on gloves before entering ... "

1. On 3/8/11 at approximately 10:30 AM in the presence of Staff #13 and #6 a tour of the telemetry unit was done. During an interview of Patient #37 it was discovered that Patient #37 had a history of MRSA. There was no evidence of a Contact Sign posted outside of Patient #37's room.

2. On 3/8/11 at approximately 10:45 AM Staff #27 stated that only gloves would be necessary for patients on isolation during cleaning of the room.

3. On 3/8/11 interviews with Staff #13 and Staff #47 revealed that if the patient had a history of MRSA only gloves would be necessary when caring for that patient.

4. The above referenced policies were not followed.

Based on observation and staff interview on March 9, 2011 at 11:45 AM, it was determined that the cleaning procedure between surgical cases is not conducted appropriately. Staff # 19 did not adhere to the training protocols he/she was provided and trained for; specifically to the Operating room unit he/she was assigned.

Findings include:

Reference: The Environmental Sanitation--Surgical Setting policy stated, "Procedure: A. After each surgical procedure: ...5. Wipe off furniture and equipment with germicidal cleaner."

1. Staff #19 was observed cleaning Operating Room C following a patient procedure. Staff #19 used one cleaning cloth soaked in Sani-master 4 disinfectant to clean the OR procedure table, pillow, Mayo stands, wall mounted monitoring equipment, interior and exterior of the trash receptacles, mobile monitoring equipment, and the legs of equipment touching the floor with the same cloth. Staff #19 was then observed to use the same cloth again on the Operating Room procedure table providing a source of cross contamination.

2. Upon interview with the Environmental services director he/she indicated that this was not the policy and procedure in place for the cleaning of the Operating Rooms and associated areas.