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Based on observation and interview the facility failed to supervise ancillary personnel inserting IVs (intravenous) for 1 (P#3) of 4 (P#1, 3, 5 and 6) patients observed. This deficient practice has the potential to result in personnel continuing to attempt procedures such as IV insertion, after multiple unsuccessful attempts, and can result in damage to patient's veins, (fluid infuses into the tissues surrounding the venipuncture site) and make it more difficult to get venous access (start an IV) in the future. The findings are:

A. On 08/05/19 at 1:00 pm during observation, P#3 was observed with multiple areas on her arms that were covered with gauze and tape. In addition P#3 had a small heat pad with coban (compression dressing) wrapped around the arm on the left anticubital (elbow pit) area where an infiltration was observed.

B. On 08/05/19 at 1:05 pm during interview, both S (Staff) #'s 26 (Radiology Tech) and 6 (RN Registered Nurse) confirmed P#1 had multiple attempts made to start an IV. S#6 confirmed P#3 had 11 unsuccessful attempts made by various facility staff.

C. On 08/06/19 at 3:30 pm during interview, S#24 Director of Nursing (DON) confirmed that there was no policy which stated the number of attempts which can be made to start an IV, but a policy needs to be developed. In addition, DON confirmed staff should have consulted the provider to ask if testing, which did not involve IV administration of contrast dye (substances injected to enhance parts of the body during radiologic procedures), would have been appropriate.

D. Record Review of "The Infusion Nurses Society (INS) An Infusion Nurses Society White Paper" undated, defines infiltration as, "the inadvertent administration of fluid into the surrounding tissue instead of into the intended vascular pathway." Application of compresses (absorb the excess fluid, calm the pain and reduce the inflammation) and cold compress is recommended for a recent infiltration. In addition, the Paper states, "Peripheral catheter insertion requires skills derived from experience to minimize patient discomfort and complications, decrease risk of needle stick injury and blood exposure, and enhance patient satisfaction."

Based on record review and interview the facility failed to provide services in accordance with appropriate written policies for 2 P#s (P#s 1 and 2) of 10 patient records reviewed. The deficient practice has the potential to result in patients returning to the facility multiple times due to discharge planning that does not reflect the patient's unique circumstances. The findings are:

A. Record review of agency "Discharge Planning" policy dated 07/2009 revealed, [name of facility] will ensure every patient admitted to Acute or Swing Bed status will receive adequate discharge planning in cooperation with the Multi-Disciplinary Team (MDT), which reflects the patient's unique circumstances and respects his/her rights of choice and self-determination. Relevant information gathered in the assessment process will be relayed to other MDT members to facilitate coordination of discharge plans."

B. Record review of P#1's medical record revealed P#1 had been a patient in the ED (Emergency Department) 3 times and been admitted to the hospital 3 times (144 hr.) since 06/02/19.

C. Record review of P#1's "Discharge Summary" dated 07/13/19 revealed P#1 was discharged to "home or self care with a history of recurrent falls and severe recurrent symptomatic anemia (low red blood cell count) required multiple transfusions (blood) and his wife is not able to help him up and he has called EMS (ambulance) for help to get up off the floor."

D. On 08/05/19 at 11:00 during interview, Director Case Management (DCM) and Chief Nursing Officer (CNO) confirmed P#1''s recent admission 08/01/19 due to life threatening anemia, indicated a need for a case management conference which should include a multidisciplinary team composed of a social worker, patient's primary physician, hematologist (physician specializing in blood disorders) and the family. CNO and DCM confirmed no care conference had been scheduled in the past, but the number of recent admissions, the critical condition of the patient and the inability of the patient and wife to provide self care indicated a need for significant intervention.

E. Record review of P#2's medical record revealed 7 visits to the facility ED and 1 hospital admission (24 hr.) since 06/18/19.

F. On 08/05/19 at 11:15 during interview, DCM confirmed P#2 had not been referred to home health and her frequent visits to the ED for low blood pressure and medication management indicated a need for a referral.

Based on record review, interviews and observations, the facility failed to have a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel which includes ongoing training for PPE (Personal Protective Equipment) and infection control practices in the kitchen. This failed practice places patients and personnel at risk for acquiring communicable diseases. The findings are:

A. On 08/05/19 at 1:30 pm during interview, the Environmental Services Supervisor Staff #1 (S#1) confirmed that she did not provide ongoing training to personnel regarding the use of PPE (Personal Protective Equipment).

B. On 08.05.19 at 2:10 pm during interview, S#5 stated that she uses gloves when cleaning hospital rooms. S#5 was not aware of what PPE was to be used for various chemicals used for cleaning.

C. Record review of the Safety Data Sheet (SDS) for the chemical that was used to clean hospital rooms reveals the requirement for PPE; Gloves and Eye Protection. The SDS further reveals that the chemical was a skin irritant.

D. On 08.05.19 at 2:10 pm, during interview Staff #24 (Chief Nursing Officer) confirmed that due to the cleaning chemical used, long sleeves should be used by staff to prevent adverse reactions or skin irritation.

E. On 08.06.19, observation of the kitchen / dietary area, various items were found to be undated and unsealed. This included bread, tortillas, and other food products. The dry storage area contained various dead insects throughout the floor and stove hoods that were stored in the room.

F. On 08.06.19, at 9:30 am during interview, S#28 (Dietary Director) stated the kitchen had been closed for about a month due to the hood needing replacement. S#28 confirmed that various items were not labeled / sealed and disposed of the items as they were identified.

G. On 08.06.19 at 2:00 pm, during interview, S#27 (Infection Control Nurse) stated he had not reviewed the kitchen due to it not being fully functional.

Based on record review and interview, the medical records were not complete and/or accurately documented for 2 (P#'s 2 and 8) of 10 records reviewed. The deficient practice has the potential to result in record keeping that could 1) indicate the care was not done, 2) contain gaps indicating poor or inadequate clinical care and 3) result in poor patient care by other healthcare team members. The findings are:

A. Record review of P#2's medical record "Urine Dipstick" and "UA Microscopic" dated 07/26/19 revealed 4 plus bacteria, 3 plus blood and 2 plus protein, values designated as "abnormal" and indicating a need for additional testing. No results of additional testing were included in P#2's electronic record.

B. Record review of Mayo Clinic "Patient Care and Health Information" website undated revealed, "A urinalysis is a test of your urine. A urinalysis is used to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease and diabetes. A urinalysis involves checking the appearance, concentration and content of urine. Abnormal urinalysis results may point to a disease or illness. For example, a urinary tract infection can make urine look cloudy instead of clear. Increased levels of protein in urine can be a sign of kidney disease. Unusual urinalysis results often require more testing to uncover the source of the problem."

C. On 08/06/19 at 3:00 pm during interview, Infection Control Manager (ICM) confirmed the results of additional testing were not included in the medical record (culture and sensitivity -C&S testing was done) and have to be scanned and uploaded after the results are faxed from an outside laboratory to the facility. ICM also confirmed the medical record department (responsible for uploading the results) had not uploaded the C&S results for P#2.

D. Record review of P#8's "Prescription" dated 07/16/19 revealed an order for an IV (intravenous) antibiotic to be administered every 12 hours (P#8 was going to the hospital every 12 hr. to receive IV antibiotics).

E. On 08/06/19 at 2:45 pm during interview, Director of Case Management (DCM) confirmed the documentation in the hospital record indicated a hospital visit for antibiotic therapy was performed on 07/24/19 for P#8, but was recorded on the 08/01/19 visit. DCM confirmed the unit clerk failed to register P#8 for each of the required visits for antibiotic therapy. DCM confirmed training was required to ensure the unit clerk was aware of the need to put documentation of each visit to the hospital under the correct date in the electronic record.

Based on record review and interview, the facility failed to maintain a record that includes documentation of pertinent information necessary to monitor the patient's progress such as medication changes and physician notification of laboratory results for 1 (P#5) of 10 records reviewed. The deficient practice has the potential to delay care which could result in sepsis (infection) and life-threatening complications. The findings are:

A. Record review of P#5's "Urine Culture" results dated 08/02/19 and resulted 08/03/19 at 1:05 am (Saturday morning) revealed a positive urine culture (>100,000 Enterococcus bacteria) present in the urine.

B. On 08/06/19 at 1:50 pm during interview ICM (Infection Control Manager) confirmed contact with the physician for P#5 was not initiated until 08/06/19 even though the results were faxed to the hospital on 08/03/19. ICM confirmed the method of tracking infections and informing physicians of results on weekends (Friday beginning at 4:00 pm until Monday at 7:00 am) was not working. ICM confirmed the present process could pose problems for patients when results of positive laboratory testing, indicating infection is received on the weekend. Results are not reviewed until ICM returns on Monday at 7:00 am. In addition, ICM confirmed documenting physician contact and medication changes on a copy of the laboratory result which is not uploaded into the medical record, but maintained on a spread sheet.

C. On 08/06/19 at 1:55 pm during interview, Director of Case Management (DCM) confirmed the process should be reviewed to ensure patient safety and prompt reporting of laboratory results to physicians. DCM confirmed there is no current policy outlining what the process should include (timely reporting and review of laboratory results) and how to update physician contact in the current electronic record.