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The Condition of Participation for Quality Assurance and Performance Improvement (QAPI) is not met based on the facility not having an effective quality program to develop, implement and maintain an ongoing, hospital-wide, data-driven quality assessment and performance improvement program related to nursing care of patients in the facility.

These failures present a substantial probability to adversely affect all patients' physical health and well-being.

The findings include:

The facility's Nursing Services Program (Refer to Condition for Coverage A0385, and Standards A0392, A0396, A0398, and A0405).

The Condition of Participation for Nursing Services is not met based on the facility's failure to: 1) Maintain complete and accurate documentation of telemetry monitoring, interventions, and patient responses in the medical record; 2) Identify patients using 2 patient identifiers during medication administration; 3) Administer medication via a Gastrectomy Tube per facility protocol and Standards of Practice; 4) Sanitize the hub of a medication vial prior to drawing up medication for administration; 5) Provide and respond to the care needs of patients related to the prevention and potential spread of infections; 6) Provide adequate supervision and evaluation of the clinical activities of non-employee personnel.

These failures present a substantial probability to adversely affect all patients' physical health and well-being.

The findings include:

1) The facility's Nursing Services Program (Refer to Condition for Coverage A0263, and Standards A0392, A0396, A0398, and A0405).

Based on observations, interviews, and record reviews, the facility failed to provide and respond to the care needs of 5 (Patients #2, #7, #12, #13, and #14) of 15 sampled patients related to the prevention and potential spread of infections.

The findings include:

1). An observation of Employee L on 10/14/14 at 7:43 am revealed she was in Room #133 (a contact isolation room) wearing the appropriate Personal Protective Equipment (PPE). Employee L was completing vital signs (vitals) and an Accu-Check on Patient #7. After completing her tasks, Employee L removed the PPE, sanitized her hands and wheeled the vital signs machine and Accu-Check machine in to the next room.

A medical record review reveals that Patient #7 is on contact isolation for diagnoses to include Candida Parapsilosis and Tropicalis, Staphylococcus Aureus, Methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas Aeruginosa.

At 7:52 am, Employee L entered Room #134 (a contact isolation room), donned the appropriate PPE and began vital signs on Patient #2. After completing the tasks, Employee L removed the PPE, sanitized her hands, and wheeled both the vital signs machine and Accu-Check monitor to Room #135 (a contact isolation room).

A medical record review revealed that Patient #2 is on contact isolation for diagnoses to include Staphylococcus Aureus.

At 8:04 am Employee L entered Room #135, donned the appropriate PPE, and completed both vital signs and an Accu-Check (blood glucose monitoring) on Patient #12. After completing the tasks, Employee L removed the PPE, sanitized her hands, and wheeled both the vital signs machine and Accu-Check to Room #137 (a contact isolation room).

A medical record review revealed that Patient #12 is on contact isolation for diagnoses to include Staphylococcus Aureus, Enterococcus Faecalis, MRSA, Proteus Mirabilis, and Pseudomonas Aeruginosa.

Employee L donned new PPE and entered Room #137 (a contact isolation room) at 8:09 am. After completing her tasks for Patient #13, Employee L removed the PPE, sanitized her hands, and wheeled both the vitals machine and Accu-Check to Room #139 (a non-contact isolation room).

A medical record review for Patient #13 revealed he is on contact isolation for diagnoses to include Pseudomonas Aeruginosa, Corynebacterium, MRSA, and Staphylococcus Aureus.

A medical record review for Patient #14 revealed he was admitted into the facility for a Post-Operative Polymicrobial Intra-Abdominal abscess status post-incision and drainage with the placement of a jejunostomy tube. Patient #14 has no diagnosed infections requiring contact isolation.

At 8:20 am, Employee L donned gloves and entered the room. After completing her tasks, Employee L removed her gloves, sanitized her hands, and wheeled both the vitals machine and Accu-Check to the hallway. The Accu-Check machine was removed from the rolling cart and placed on the base. The vital signs machine was plugged into the hallway socket. Each patient was observed with their own individual blood pressure cuff, but Employee L was not observed disinfecting the vital signs machine, wires, or Accu-Check machine prior to use on the next patient and storage.

2). During an observation of the East Hall on 10/13/2014 at 5:49 am, Employee K was observed exiting Room #135 (a contact isolation room) using a wheeled lab cart with labs supplies to include tourniquets, blood lab tops (multi-colored), alcohol preps, specimen bags, etc.

An interview with Employee K on 10/13/14 at 5:50 am revealed she is allowed to take multi-patient use items into and out of patient rooms when she is drawing blood and completing labs. Employee K stated that she was unaware of why Patient #12 in Room #135 was on contact isolation; she just draws the blood.

A medical record review for Patient #12 revealed he is on contact isolation for diagnoses to include Staphylococcus Aureus, Enterococcus Faecalis, MRSA, Proteus Mirabilis, and Pseudomonas Aeruginosa.

At 5:53 am, an observation of Employee K revealed they were wheeling the same lab cart with supplies into Room #137, another contact isolation room, after donning both a gown and gloves. Employee K pushed the cart of supplies next to the Patient #13's bedside, collected the needed blood specimens and with gloved hands, placed the specimens on top of the clean supplies on the cart, wheeled the cart near the door, removed her gown and gloves. Employee K then picked up the tubes of blood with ungloved hands, labelled and bagged the blood specimens. She exited the room, sanitized her hands, and wiped the cart's handles with "Super Sani-Cloth" (purple top).

A medical record review revealed that Patient #13 is on contact isolation for diagnoses to include Pseudomonas Aeruginosa, Corynebacterium, MRSA, and Staphylococcus Aureus.

At 6:05 am, Employee K entered Room #139, a non-contact isolation room, with the same cart of supplies and proceeded to complete Patient #14's blood specimens.

A medical record review for Patient #14 revealed he was admitted into the facility for a Post-Operative Polymicrobial Intra-Abdominal abscess status post-incision and drainage with the placement of a jejunostomy tube. Patient #14 has no diagnosed infections requiring contact isolation.

An interview with the Chief Nursing Officer on 10/13/14 at 2:22 pm revealed the facility uses phlebotomy staff from Memorial Hospital under an agreement. The CNO stated that if there is a problem that is identified, the facility would call the Laboratory Director at Memorial Hospital directly and address any issues.

An interview with Employee N on 10/14/14 at 11:22 am revealed the facility uses their staff to monitor the Memorial Hospital Contract/Ancillary staff, and will call or email her directly when issues are observed. She stated for example, last year the night shift reported a Lab Tech to her for not using Personal Protective Equipment (PPE) in a contact isolation room.

A review of the Standards & Transmission Based Isolation Precautions Policy with a last review dated of 12/4/2014, revealed the policy applies to all Specialty Hospital employees, contract staff, medical staff volunteers, and students providing direct care to a patient or indirect care by being present in a patient's room. When possible, use single, patient-use or disposable items. Patient care equipment must be disinfected with the hospital approved disinfectant before use on another patient just prior to leaving an isolation room.

Based on observations, interviews, and record reviews, the facility failed to provide adequate monitoring for 1 of 1 Phlebotomist observed providing laboratory services.

The findings include:

During an observation of the East Hall on 10/13/2014 at 5:49 am, Employee K was observed exiting Room #135 (a contact isolation room) using a wheeled lab cart with labs supplies to include tourniquets, blood lab tops (multi-colored), alcohol preps, specimen bags, etc.

An interview with Employee K on 10/13/14 at 5:50 am revealed she is allowed to take multi-patient use items into and out of patient rooms when she is drawing blood and completing labs. Employee K stated that she was unaware of why Patient #12, in Room #135, was on contact isolation; she just draws the blood.

A medical record review for Patient #12 revealed he is on contact isolation for diagnoses to include Staphylococcus Aureus, Enterococcus Faecalis, Methicillin-resistant Staphylococcus aureus (MRSA), Proteus Mirabilis, and Pseudomonas Aeruginosa.

At 5:53 am, an observation of Employee K revealed they were wheeling the same lab cart with supplies into Room #137, another contact isolation room, after donning both a gown and gloves. Employee K pushed the cart of supplies next to Patient #13's bedside, collected the needed blood specimens and with gloved hands, placed the specimens on top of the clean supplies on the cart; wheeled the cart near the door, and removed her gloves and gown. Employee K then picked up the tubes of blood with ungloved hands, and labeled and bagged the blood specimens. She exited the room, sanitized her hands, and wiped the cart's handles with "Super Sani-Cloth" (purple top).

A medical record review revealed that Patient #13 is on contact isolation for diagnoses to include Pseudomonas Aeruginosa, Corynebacterium, MRSA, and Staphylococcus Aureus.

At 6:05 am, Employee K entered Room #139, a non-contact isolation room, with the same cart of supplies and proceeded to complete Patient #14's blood specimens.

A medical record review for Patient #14 revealed he was admitted into the facility for a Post-Operative Polymicrobial Intra-Abdominal abscess status post-incision and drainage with the placement of a jejunostomy tube.

An interview with the Chief Nursing Officer on 10/13/14 at 2:22 pm revealed the facility uses ancillary staff from Memorial Hospital for laboratory services under an agreement. If there is a problem that is identified, the facility calls the Laboratory Director at Memorial Hospital directly and addresses any issues.

An interview with Employee N on 10/14/14 at 11:22 am revealed the facility uses their staff to monitor the Memorial Hospital Contract/Ancillary staff and will call or email her directly when issues are observed. She stated for example, last year the night shift reported a Lab Technician to her for not using Personal Protective Equipment (PPE) in a contact isolation room.

A review of the Standards & Transmission Based Isolation Precautions Policy with a last review date of 12/4/2014, revealed the policy applies to all Specialty Hospital employees, contract staff, medical staff volunteers, and students providing direct care to a patient or indirect care by being present in a patient's room. When possible, use single patient-use or disposable items. Patient care equipment must be disinfected with the hospital approved disinfectant before use on another patient, just prior to leaving an isolation room.

Based on observations, staff interviews and record reviews, the facility: (1) failed to identify 2 (Patients #4 and #5) of 6 patients by using 2 patient identifiers during medication pass; (2) failed to administer medications through a Gastrostomy Tube for 1 (Patient #15) of 6 medication observations, using acceptable Standards of Practice; and (3) failed to sanitize the hub of a medication vial during medication pass for 1 (Patient #15) of 6 medication observations.

The findings include:

1). Patient #15 is ventilator-dependent and has multiple medical problems. During observation of medication pass for Patient #15 on 10/14/14 at 6:13 am, Employee P removed Hydralazine 10 mg 1 tablet, and 1 pack of Psyllium from the medication cabinet in the patient's room to administer to the patient. Employee P crushed the Hydralazine 10 mg and placed it in a plastic medication cup. Approximately 30 cc's of water was added to the cup to dilute the medication. The medication was drawn up in a piston syringe and pushed through the gastrostomy tube after the nurse checked for placement. One pack of Psyllium/Metamucil was diluted in approximately 8 oz. of water and pushed through the tube. Approximately 40 cc's of water was added to the tube to clear the tube. Employee E did not allow the medications to flow by gravity through the Gastrostomy Tube.

An interview with Employee P on 10/14/14 at 7:30 am revealed that you can place the medication into the syringe and let it flow by gravity; that it is the best method, and she knows it is the best method. Employee P stated that you have to do medication pass and you have to get all of your medications out. Employee P stated that it takes an awful long time; that "sometimes you are waiting in between each medication and you have to flush each medication and it does not work out for us."

Review of the Policy and Procedures revised on 5/6/14 for Medication Administration via G-Tube, revealed in Step 10, the following: "Using a 30-60 syringe for administration or funnel, pour at least 15 ml. of water into the syringe or funnel before medication administration. Tilt the tube to allow air to escape, as the fluid flows downward. Then administer each medication individually diluted with at least 15 ml. of room temperature tap water slowly and steadily, flushing with tap water between each medication. After giving the medication, pour at least 15 ml. of water into syringe or funnel to irrigate the tube. If patient is fluid-restricted, may flush with 10 ml. of tap water and mix each medication with 10 ml. of tap water."

2). During medication pass for Patient #15 on 10/14/14 at 6:13 am, Employee P removed Heparin Sodium 5000 units SQ and Reglan 10 mg IV, from the patient's cabinet in her room to administer. Employee P flipped the outer cap from the single Heparin vial and then inserted the needle into the vial to remove the medication without sanitizing the rubber stopper. Employee P left the empty vial on the counter. The medication was administered to the patient subcutaneously in the left lateral thigh. The needle was discarded. Employee P returned to the medication cabinet area in the room to prepare the next injection for Patient #15. Employee P took the syringe, picked up the empty Heparin vial, and inserted the needle in it to withdraw medication. She then picked up the Reglan 10 mg IV vial and inserted her needle to withdraw the medication. Employee P was told to stop, that she could not give that medication to Patient #15. The Director of Nurses, who was in the room observing the medication pass, obtained additional saline supplies for the nurse to continue with medication pass.

An interview with Employee P on 10/14/14 at 7:41 am revealed that when you are taking the caps off of single vials, you are fine; you do not have to wipe the stopper. Employee P stated that she will wipe the stopper of a multi-dose vial; that she was more concerned with the opened multi-dose vials sitting up on the cabinet.

Review of Lippincott Manual online revealed that for single-dose or multi-dose vials, the rubber stopper is cleaned with an antiseptic pad.

3). A medical record review revealed Patient #4 was admitted into the facility for multiple left lower leg wounds, osteomyelitis and gangrene of the foot, status post- amputation. During a medication administration observation for Patient #4 on 10/13/2014 at 7:30 am, Employee A, after donning appropriate Personal Protective Equipment (PPE), entered the room, greeted Patient #4, and stated she was there to give him his morning insulin. Patient #4 nodded. Employee A told Patient #4 that his blood sugar level for the morning was 162. Employee A scanned Patient #4's armband, scanned the Lispro insulin and proceeded to prepare to administer the medication, after administering Lispro 2 units subcutaneously. Employee A stated that she would be back after breakfast to administer the morning medications. Employee A completed her documentation, removed her PPE, sanitized her hands, and left the room.

An interview with Employee A on 10/13/2014 at 7:40 am revealed that she does not have any other medications to give at this time. She stated that she would be starting her morning medication pass later. Employee A was asked by this surveyor to let her know when she began passing her morning medications, because another observation was required.

4). A medical record review for Patient #11 revealed he was admitted into the facility for a left-sided gluteal ulcer. A medication administration observation for Patient #11 on 10/13/2014 at 9:08 am revealed, after entering the room, Employee A informed Patient #11 that she was there to give him his morning medications. Patient #11 responded by saying 'OK'. Employee A went over to the computer and verified all the medications against the Medication Administration Record. She then went to the bedside, poured water in a cup for Patient #11, and named the medications to be administered as she placed them in the medication cup. Patient #11 nodded and said, 'OK' during the interaction. Patient #11 took his medications as requested by Employee A. Employee A then administered Heparin (to the abdomen) and Detemir Insulin (to the right arm). Employee A completed her documentation, removed her PPE, sanitized her hands, and left the room.

An interview with Employee A on 10/13/14 at 9:34 am revealed patients who are alert and oriented can give verbal verification by stating their name. She stated, "While I am scanning, I check the armband. I also look at the Medical Record Number (MRN) as a second identifier. I asked Patients #3 and #11 their names during my initial assessment, earlier in the shift." She stated that the surveyor was not there to witness that part of the verification process.

An interview with the Chief Nursing Officer on 10/13/14 at 2:25 pm revealed nurses are required to verify 2 identifiers when administering medications. However, some of the patients are here so long that the staff gets familiar with the patients and become comfortable with them. This is an opportunity for education to reinforce the importance of the verification process.

5). A review of the Patient Identification/Two Identifiers Policy with a last review date of 5/28/2014, revealed staff should confirm the correct patient prior to all treatments or medications using two patient identifiers. This should be accomplished in the following descending order:
a. Ask the patient to state his/her name and date of birth, if medically able, and compare with the medical record.
b. Ask family member to verify the patient's full name, date of birth, and compare with medical record.