HospitalInspections.org

Based on observation, facility policy and procedure and staff interview(s) it was determined the facility failed to ensure expired and beyond use date medications and supplies were not available for patient use.

This had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy Number: MED - 5
Subject: Multi-dose Vials
Department: Nursing
Revised Date: 5/17

Policy: A multi-dose vial is a vial of liquid medication intended for parenteral administration (injection or infusion) that contains more than one dose of medication...

Procedure:

...If a multi-dose (vial) has been opened or accessed...the vial should be dated at time of opening or accessed and discarded within 28-days...

...The manufacturer's expiration date refers to the date after which an unopened multi-dose vial should not be used. The beyond-use-date refers to the date after which an opened multi-dose vial should not be used...

1. An observation of the Medical/Surgical nursing unit was conducted on 12/14/21 at 9:40 AM. During the observation, Atropine Sulfate 0.1 mg/ml (milligram/milliter) injection was found in the crash cart with an expiration date of 11/21.

An interview was conducted with Employee Identifier (EI) # 11, Registered Nurse (RN), on 12/14/21 at 9:49 AM who verified the Atropine Sulfate was expired and in the crash cart available for patient use.

2. A second observation of the Medical/Surgical nursing unit was conducted on 12/14/21 at 11:14 AM. During the observation, the following two opened multi-use vials were found in the medication refrigerator and available for patient use:

Novolog insulin with the opened date of 7/19/21, which was 148 days after the multi-dose vial was opened.

Lantus insulin with the opened date of 8/4/21, which was 132 days after the multi-dose vial was opened.

An interview was conducted with EI # 11 on 12/14/21 at 11:14 AM, who verified the Novolog and Lantus multi-dose vials were beyond the use date per the facility policy and available for patient use.



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3. A tour was conducted in the Emergency Department (ED) on 12/14/21 at 9:45 AM.

In ER (Emergency Room) # 1 exam room the crash cart was checked and the following supplies were found to be expired:

1- 18 gage needle expired 10/13/20
1- BD (blood) vacutainer expired 11/30/21

In exam room # 2 the following medications were found:

In the chest pain box was a tube of NTG (Nitroglycerine) paste 30 gms (grams) which was open and no open date was on the tube.

In exam room # 3 in the cupboard was a 500 ml bottle of Normal Saline (NS) which was open and no open date on the bottle.
Sitting on the counter in exam room # 3 was a sterile urine cup with the seal broken and available for patient use.

In the supply cart in the nurses office in ED the following supplies were found to be expired:

9 - BD (blood) vacutainer's expired 11/30/21.

An interview was conducted on 12/14/21 at 11:30 AM with EI # 9, Emergency Department Director, who confirmed the supplies were expired and disposed of the above mentioned supplies.

Based on policy review and staff interview it was determined the facility failed to ensure a system was in place for the patient notification of the administration of potentially Human Immunodeficiency virus (HIV) or Hepatitis C Virus (HCV) infectious blood or blood components if the facility was notified that blood or blood components it received are at increased risk of transmitting HIV or HCV and ensure an area for the quarantine of blood products was in place.

This had the potential to negatively affect all patients receiving blood or blood products at this facility.

Facility Policy: Look Back Protocol
Revised: 5/30/17

Principle: If any blood supplier notifies Washington County Hospital that a blood product used at this facility was collected from a donor later found to have an infectious disease that may have been transmitted by transfusion therapy, a look-back procedure is performed by blood bank personnel...

Procedure:

After receipt of written notification from the blood supplier that the donor upon subsequent donation is positive for transfusion related disease, blood bank personnel will determine the disposition of the product, quarantine and return to the blood supplier any potentially contaminated blood products...

1. A tour of the facility laboratory was conducted on 12/14/21 at 1:27 PM, during the tour the blood bank refrigerator was observed and found to not have a designated area for the quarantine of blood products.

Review of the facility Look Back Protocol Policy revealed no documentation of a system in place for patient notification of the administration of potentially HIV or HCV infectious blood or blood components.

An interview was conducted on 12/14/21 at 3:00 PM with Employee Identifier (EI) # 12, Laboratory Director, who confirmed the facility blood bank did not have an area designated for the quarantine of blood products and the facility Look Back Protocol Policy did not have a system in place for patient notification of the administration of potentially HIV or HCV infectious blood or blood components.

Based on observations, policy and standards and interviews with the staff it was determined the facility failed to have documentation preventive maintenance (PM) was completed for all essential mechanical, electrical, and patient-care equipment to ensure the equipment is maintained in safe operating condition in the therapy department and the emergency department.

This had the potential to negatively affect all patient served by these facility departments.

Findings include:

Facility Policy: Preventative Maintenance
Date Revised: 5/18/2009

Purpose:

To ensure that all-patient care equipment is electrically safe and functions according to manufacture's specifications.

Policy:

Patient care equipment will receive electrical safety and preventive maintenance inspections on an as needed basis. The frequency of inspections will depend on requirements set forth by JCAHO (Joint Commission Accreditation Health Organization...) by the manufacturer, frequency of failure and user errors.

Standards:

1. Each piece of equipment shall be tested according to the PM and safety schedule...

9. PM's shall be performed according the the PM procedures assigned to that equipment.

10. All results will be entered into the excel spreadsheet for that facility.

11. A highly visible label will be attached to the equipment tested, showing date inspected, next test date, technician's initials and service performed.

1. A tour of the inpatient therapy department was conducted on 12/15/21 at 8:47 AM and the outpatient therapy department on 12/15/21 at 9:35 AM with Employee Identifier (EI) # 14, Rehabilitation Director.

The tour of the inpatient therapy department revealed the following:

An Oxygen Concentrator, property identification (ID) number of 1185, with the last date of PM inspection documented as 10/19 and the next inspection due documented as 12 months.

A CAN DO Upper/Lower Body Exerciser with no documentation of a PM inspection date. There was no documentation of a property ID number.

A Nustep T 5 machine with no documentation of a PM inspection date. There was no documentation of a property ID number.

The tour of the outpatient therapy department revealed a Schwinn Stationary Bicycle with no documentation of a PM inspection date. There was no documentation of a property ID number.

An interview was conducted on 12/16/21 at 2:15 PM with EI # 14 who confirmed there was no documentation a PM inspection completed on the above equipment and no documentation of a PM inspection of the Oxygen Concentrator since 10/19.



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2. A tour was conducted on 12/14/21 at 9:45 AM of the Emergency Department (ED) with EI # 9, Emergency Department Director.

The tour of the ED revealed the following:

In exam room # 1 the Oxygen Saturation monitor revealed no documentation of a PM sticker.

Exam room # 2 revealed the Ottoscope had no documentation of a PM sticker and the
LJV (Ventilator) machine revealed no documentation of a PM sticker.

An interview was conducted on 12/14/21 at 12:15 PM with EI # 1, Director of Nursing, who confirmed all equipment should have PM stickers.

Based on United States Health Public Food Code 2017 regulations, Oasis 146 Multi-Quat (Quaternary) Sanitizer and Hydrion (QT-10) Quat Dispenser 0-400 PPM (parts per million) directions for use, observations, dietary logs and interviews, it was determined the hospital failed to ensure:

1. Food was stored in a safe and sanitary manner and labeled.

2. Sanitation procedures were performed according to manufacturer's recommendations and results were documented and included the 3 compartment sink and sanitation buckets.

3. The dishwasher temperature reached the minimum wash and rinse temperature prior to beginning lunch dish washing.

This had the potential to negatively affect all patients served by the facility.

Findings include:

United States Health Public Food Code 2017

3-302.12 Food Storage Containers, Identified with
Common Name of Food.
Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD...

3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.
...commercially processed food open and hold cold
(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in
(A) of this section and: Pf (Priority Foundation [Item]) (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date based on FOOD safety. Pf (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest- prepared or first prepared ingredient.
(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include:...
(2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (A) of this section;
(3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (B) of this section...

Product Specification Document Oasis 146 Multi-Quat Sanitizer

CLASSIFICATION:
Quat sanitizer
SCOPE:

Disinfectant - Cleaner - Sanitizer - Deodorizer with Organic Soil Tolerance for Hospitals, Institutional and Industrial Use Institutions - Hospitals - Nursing Homes - Health Care Facilities - Schools - Restaurants -

Food Services
DIRECTIONS FOR USE:
Oasis 146 Multi-Quat Sanitizer can be used to sanitize hard, non-porous food contact surfaces such as tables, counters, and food processing equipment.

...Sanitizing Eating and Drinking utensils
2. Wash with...compatible cleaner...
3. Rinse with potable water.
4. Sanitize in a solution...of .(200-400 ppm [parts per million]...Immerse all utensils for at least 1 minute. Use 2 minutes exposure time if required by the governing sanitary code...

Hydrion (QT-10) Quat Dispenser 0-400 PPM (parts per million)

Hydrion QT-10 Quaternary Test Paper provides a simple, reliable, and economical means to measure the concentration of Quaternary Sanitizers, including n-alkyldimethylbenzyl and/or n-alkyl dimethyl ethyl benzyl ammonium chloride, and Rocall II. With color matches at 0-100-200-300-400ppm (parts per million), the test paper measures concentrations between 0-400 ppm, detecting exhaustion of solutions that should be replaced as well as helping to avoid using excessive amounts of sanitizing agents.

Federal, State and Local health regulations require users of Quaternary Ammonium Sanitizer Solutions to have appropriate test kits available to verify the strength of sanitizer solutions. Sanitizer solutions are essential in the food service industry to ensure that sanitizers are at the proper concentration specified by the individual manufacturer.
...Dip the strip into the sanitizing solution for 10 seconds, then instantly compare the resulting color with the enclosed color chart which matches concentrations of 0-100-200-300-400 ppm. Test solution should be between 65 and 75 degrees Fahrenheit.

1. A tour of the Dietary Department was conducted on 12/14/21 at 11:10 AM.

Found in the pantry/dry storage were three (3) 8 ounce containers of Quaker Quick 5 Minute Grits, received in date(s) were 11/2/2020 with "best before 7/4/21". The surveyor asked EI # 3 Dietary Manager, if the grits should be served to patients. EI # 3 removed the grits from the shelves.

Found in the walk-in cooler was a plastic baggy with 4 pieces of dark color baked goods in muffin tins (appeared to be wheat muffins) not labeled with the common food name. There was a tray of golden color liquids in small cups and 2 cups of white liquid (possibly milk). The surveyor asked what the liquids were? EI # 3 reported they were juices from this morning's breakfast and milk. The surveyor asked if the milk was whole milk, 1% (percent), 2% or buttermilk? EI # 3 did not respond to the question.

Also, found in the walk in cooler was a large stainless bin of what appeared to be crumbled cornbread with no label and no date(s). There was 1 package of opened shredded cheese, the "in date" documented was 10/11/21. The surveyor asked how long shredded cheese was good once opened? EI # 3 reported the cheese was good for 2 weeks.

Found in the Truelle Refrigerator was one bin of dark thick liquid (possibly gravy), dated 12/12/21 to 12/14/21. There was no common food name label.

EI # 3 removed the above mentioned foods from the refrigerator.

An interview was conducted on 12/16/21 at 11:30 AM with EI # 3 Dietary Manager, who stated the products should been labeled, removed if expired and labeled to identify each product.

2. During the dietary department tour on 12/14/21 at 11:35 AM the surveyor observed December 2021 dietary temperature and chemical sanitation logs posted along the walls/doors of the department and the logs were missing documentation. The surveyor requested dietary logs from July 2021 to November.

Review of the 3-compartment Pot and Pan Sink Chemical Log revealed the month/year and "No less than 200 PPM" was included on the document header. There were blanks for entry of date (s), test time, initials of the person who performed the test, the water temperature, and PPM (strength of the sanitizer) for testing 3 times a day to correspond with the 3 daily meals.

Further review of the 3 compartment pot/pan sink chemical logs revealed no documentation for the following dates/times:

No July temperature and sanitizer strength log documentation for the 3 compartment pot/pan sink.
On 8/31/21, no temp (temperature) and no sanitizer strength for the noon meal.
On 9/5/21 no sanitizer strength for the breakfast meal.
On 11/5/21 no temp and no sanitizer strength for the evening meal.
On 12/1/21 no temp and no sanitizer strength for the breakfast meal.
On 12/3/21 no temp and no sanitizer strength for the evening meal.
On 12/12/21 no temp and no sanitizer strength for the evening meal.

Review of a document titled "Dietary Temperature Record" revealed 2 headings for Sanitation Buckets. Below Sanitation Buckets, were blanks for test (PPM of chemical strength), test time and initials of the person who performed the chemical strength test.

Review of the Dietary Temperature Record logs revealed the Sanitation Buckets strength of chemical sanitizer used during kitchen cleaning pre and post meal kitchen cleaning were not documented to include the sanitizer strength, time, and initials of the person who completed the testing for the following date/times:

No July 2021 sanitation bucket log documentation was provided.
On 8/6/21 no sanitizer test result was documented for breakfast preparation.
On 8/22/21 no sanitation test time, and no initials of the person who tested the sanitizer strength were documented.
On 9/5/21 no sanitizer test results were documented for lunch preparation.
On 9/19/21 no sanitizer test time and no initials of the person who tested were documented.
On 9/21/21 no sanitizer test results were documented for lunch preparation.
On 9/26/21 no sanitizer test results were documented for lunch preparation.
On 9/28/21 no sanitizer test results were documented for lunch preparation.
On 9/30/21 no sanitizer test results were documented for lunch preparation.
On 11/1/21 no sanitizer test results/time were documented for breakfast and lunch preparation.
On 11/12/21 no sanitizer test results/time were documented for lunch preparation.
On 12/4/21 no sanitizer test results/time were documented for breakfast preparation.
On 12/8/21 no sanitizer test results/time were documented for breakfast preparation.

3. At 12:18 PM on 12/14/21, the surveyor observed staff wash pots and pans in the 3 compartment sink. EI # 4, Cook removed a piece of QT 40 Hydrion strip from the strip container/color chart, immersed the strip in the water in the 3rd compartment then removed the strip from the sink.

There was no clock with a second hand to evaluate the strips immersion time used and no way to determine if the immersion time was at least 10 seconds. In addition, EI # 4 failed to compare the strip's color to the color chart on the Hydrion package.

The surveyor observed EI # 5, Assistant Cook dip (rinse) the pots/pans/utensils and bins in water in the sink compartment number 2. Then EI # 5 dipped pots/pans/utensils and bins in the 3rd compartment which contained the chemical sanitizer, Oasis 146 Multi-Quat Sanitizer, but not for more than 10 seconds for each pot/pan/utensil/ or bin.

The surveyor observed posted above the 3 compartment sink were manufacturer's instructions for use for the Oasis 146 Multi-Quat Sanitizer which revealed instructions to immerse all utensils for a period of not less than 1 minute.

During the procedure, EI # 3 Dietary Manager observed the 2 employees wash, rinse, sanitize procedure using the Oasis 146 Multi-Quat Sanitizer. EI # 3 confirmed staff failed to follow the manufactures DFU (Directions for use) in an interview during the observation.

4. On 12/14/21 at 12:40 PM, EI # 6 Dietary Aide was observed in the dishwashing room using the Ecolab Energy Star ES 2000 dish machine.

During machine preparation and run/rinse/dry of the first 2 dish loads the wash and rinse temperature high readings on the thermometer gauge on the ES 2000 was 100 degrees Fahrenheit.

Review of the hospital December 2021 Dish Machine Temperature Log revealed correct temperatures are wash 120 degrees and rinse 130-140 degrees. Notify the supervisor/supervisor personnel of any temperature noncompliance.

During the observations of lunch meal dish machine usage on 12/14/21 a 12:50 PM, the surveyor asked EI # 6 if the wash and rinse temperatures were within an acceptable range and EI # 6 reported it should be 120 degrees.

In an interview on 12/16/21 at 10:55 AM, EI # 3 Dietary Manager, confirmed the initial wash/rinse temperatures were not in an acceptable range. EI # 3 reported a problem with the temperature gauge was identified on 12/14/21 during the lunch meal dishwashing during the surveyor observations. EI # 3 reported the dish machine temperatures were currently being monitored manually with a temperature gauge.

Based on review of hospital policies and procedures, MR (medical records), observation and staff interview, it was determined the nursing staff failed to follow hospital policy and procedure and physician orders, perform and document:

1. Patient monitoring during blood transfusions per policy and procedure

2. Neuro (neurological) checks every (q) 4 hrs. (hours) as ordered.

3. Application and use of TED (thrombo-embolic deterrent) hose as ordered.

4. Bedside glucose monitoring and insulin administration per orders.

5. Foley catheter care per policy and procedure.

6. Wound assessment per policy and procedure.

7. Wound care orders were specific to the wound.

8. Wound assessment was consistent.

9. Diabetic Supplements were provided as ordered.

10. Critical Laboratory (lab) values were reported to the physician.

This affected 8 of 17 inpatient/observation record reviews and included MR # 10, MR # 6, MR # 15, MR # 12, MR # 1, MR # 14, MR # 11 and MR # 4 and had the potential to negatively affect all patients admitted to the hospital.

Findings include:

Facility Policy and Procedure: Blood Bank-Transfusion
Revised: 1/16/2015
Effective

To Administer Transfusion

1. Policy...
2. Important Points:

E. Observe the patient for the first fifteen minutes and frequently thereafter...
4. Procedure:
E. Just prior to the transfusion check the patient's temperature, blood pressure (BP) pulse, respiration, and record on Blood Transfusion Record...
J. Vital signs (VS-temperature/BP, pulse, respiration) are checked in 5 minutes and 20 minutes from beginning of transfusion and again when blood is discontinued...

Facility Policy and Procedure Title: Catheter Care
General Nursing
Effective Date: 01/2011

Policy

Catheter care will be provided bid (twice daily)...

Procedure

...19. document catheter care in the electronic health record...

Facility Nursing Policy and Procedure
Subject: Pressure Ulcer Prevention and Wound Care
Date Revised: 06/2017

Policy

...Dressing Changes and Assessment

a. Dressing changes will be performed as ordered by physician.

b. Dressing change information will be documented with each dressing change to include but not limited to...wound appearance (color temperature, edema, odor, moisture, and appearance of skin around the ulcer), drainage, and exudate...

c. Size (length, width, and depth) shall be documented at least weekly on surgical wounds, pressure ulcers, and stasis ulcers...

1. MR # 10 was admitted to the facility on 9/1/21 with diagnoses including Low Iron-Anemia.

Review of the Physician Entered Orders revealed on 9/1/21 at 1:19 PM, a blood bank (BB) order, PRBC (packed red blood cells), transfuse very slowly when available.

Review of the BB Record of Patient's Response documentation revealed unit 1 PRBC pre transfusion VS were documented on 9/1/21 at 4:00 PM and the 5 minute check (VS) at 4:05 PM. There were no 20 minute check (VS) documented and no transfusion completion date/time documented.

Review of the BB Record of Patient's Response documentation revealed unit 2's PRBC 20 minute VS check was completed at 9:10 PM and no tranfusion completion date/time was documented.

Review of the BB Record of Patient's Response documentation revealed no date unit 3 of the PRBC's was released by laboratory to nurse services. The pre transfusion VS was documented at 11:20 PM (no date) and the 5 minute check (VS) was at 11:18 PM which was 2 minutes prior to the pre transfusion VS. The 20 minute check/VS was documented at 12:08 AM which was 60 minutes after the 5 minute check. There was no documentation the date and time the transfusion was completed, and the post transfusion VS had no time documented.

In an interview on 12/16/21 at 12:01 PM, EI (Employee Identifier) # 1, Director of Nurses confirmed staff failed to follow the hospital policy and procedure for patient VS checks and documentation during blood transfusions.

2. MR # 6 was admitted to the facility Detoxification (detox) Unit on 2/5/21 at 11:06 PM with a diagnosis, Medical Detoxification.

Review of Nursing Orders (signed by the physician) revealed on 2/5/21 at 11: 11 PM an order for neuro checks q 4 hrs. x (for) 24 hrs., then q 6 hrs. x 48 hrs. In addition, there was a nursing order dated 2/5/21 at 11:45 PM for TED hose.

Review of the Nurse Initial Interview dated 2/6/21 at 1:00 AM revealed a medical history of seizures and the Nursing Progress Notes revealed the last q 4 hr. neuro check was documented on 2/6/21 at 7:30 AM. There was no documentation neuro checks were performed on 2/6/21 at 11:30 AM, and at 3:30 PM before the patient left the unit against medical advice at 5:00 PM.

In addition, there was no MR documentation TED hose were refused by MR # 6 and no documentation staff applied the TED hose as ordered.

In an interview on 12/16/21 at 9:40 AM, EI # 1, confirmed there was no documentation staff followed orders for q 4 hr. neuro checks and TED hose.

3. MR # 15 was admitted to the facility on 10/1/21 at 9:55 AM for a 23 hour observation with a diagnosis of Near Syncopal Episode.

Review of Nursing Orders (signed by the physician) revealed on 10/1/21 at 1:43 PM an order for neuro checks q 4 hrs. There were nursing orders dated 10/1/21 at 1:43 PM for bedside glucose QID (4 times daily) at 7 AM, 11 AM 4 PM and 9 PM.

MR review revealed neuro checks were documented on 10/1/2021 at 6:40 PM and not again for greater than 11 hours until 10/2/21 at 7:25 AM. The next neuro check was documented prior to discharge on 10/2/21 at 2:55 PM. The staff failed to perform and document neuro checks q 4 hr. as ordered.

Record review revealed a chemistry laboratory report dated 10/2/21, collected at 6:10 AM and reported at 7:29 AM, for a glucose result of 274.

Further record review included a diabetic flowsheet documentation dated 10/2/21 at 8:43 AM which revealed "blood glucose omitted, Tresiba FlexTouch insulin Pen, drug not here". There was no documentation treatment the 7:00 AM bedside glucose was obtained and no documentation the blood glucose 274 was addressed.

Review of the Medication Administration documentation for 10/2/21 confirmed Tresiba Flex pen 8 units subcutaneous daily was ordered at 10/1/21 at 1:07 PM and omitted 10/2/21 at 8:43 AM, reason documented was drug not here. There was no documentation the physician was notified, and an alternate treatment ordered.

In an interview on 12/16/21 at 10:22 AM, EI # 1, confirmed the staff failed to follow orders for q 4 hr. neuro checks and QID bedside glucose monitoring.

4. MR # 12 was admitted to the facility swing bed unit on 12/1/21 at 1:24 PM with diagnoses including Sepsis and Urinary Tract Infection.

Record review revealed physician orders dated 12/1/21 at 1:48 PM for a Foley catheter.

Review of the Nursing Patient Progress Notes dated 12/1/21 to 12/14/21 failed to reveal documentation Foley catheter care was performed.

In an interview on 12/16/21 at 3:00 PM EI # 1 confirmed staff failed to follow the hospital policy, perform and document Foley catheter care twice daily.

5. MR # 1 was admitted to facility on 12/10/21 with diagnoses including Posterior Cervical Laminectomy with Fusion.

An observation of care was completed 12/14/21 at 10:00 AM for surgical site incision care with EI # 11, Registered Nurse. The surveyor observed the surgical island dressing had a moderate to large amount of serosanguineous (ss)drainage with no detectable odor.

MR review revealed no documentation on 12/10/21 staff completed an assessment of the surgical incision.

Record review revealed a physician/s verbal phone order dated 12/11/21 at 3:30 AM to clean surgical incision with wound cleanser, pat dry and cover with island dressing every other day and prn (as needed).

Further review revealed on 12/11/21 at 7:50 PM the dressing was changed with moderate drainage noted. There was no exudate assessment for the presence/absence of odor.

Record review revealed surgical incision documentation dated 12/12/21 at 2:45 AM that the dressing was changed due to a large amount of ss drainage. There was no exudate assessment for the presence/absence of odor.

In an interview on 12/15/21 at 2:00 PM EI # 2, Swing Bed Manager, Hospital Case Manager confirmed the staff failed to follow the hospital policy for surgical incision assessment/documentation.




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6. MR # 14 was admitted to the facility swing bed unit on 11/10/21 with diagnoses including Right Leg Pain from Metastatic Prostate Cancer and Muscle Weakness (generalized).

Review of the Physician Orders dated 11/11/21 at 1:24 AM, revealed a verbal order for "Change dressing every 3 days and prn (as needed)...Cleanse with wd (wound) cleanser, pat dry, apply mepilex..." There was no documentation of where the wound was on the body and the wound type.

Review of the Wound Eval (Evaluation) and Assessment and nursing progress notes dated 11/11/21 to 12/3/21 revealed the following:

On 11/11/21 at 12:30 AM, a stage 2 "ulcer" was documented to the sacrum with measurements of 2.5 cm (centimeters) in length and 2.5 cm in width and a wound care dressing change was documented. There was no documentation of the depth of the ulcer. There was no documentation the wound was measured from 11/12/21 through the discharge date of 12/3/21.

On 11/12/21 at 7:30 PM, a "DTI (deep tissue injury)" was documented to the sacrum, which was inconsisent with the would type documented on 11/11/21.

On 11/15/21 at 12:00 PM, a "surgical incision" was documented to the sacrum, which was inconsisent with the wound type documented on 11/11/21 to 11/14/21.

On 11/20/21 at 11:43 AM, a "ulcer" was documented to the sacrum and a wound care dressing change was documented.

On 11/26/21 at 1:00 PM, a "ulcer" was documented to the sacrum and wound care dressing change, which was 6 days after the last wound care dressing change on 11/20/21.

An interview was conducted on 12/16/21 at 9:11 AM with EI # 1, who confirmed the facility work week was Sunday through Saturday, there was no documentation of wound measurements from 11/12/21 through 12/3/21, the verbal order for wound care did not contain the type or location of the wound, wound care was not provided as ordered on 11/23/21 and wound assessments were not completed per facility policy.

7. MR # 11 was admitted to the facility swing bed unit on 6/15/21 at 1:24 PM with diagnoses including Generalized Weakness and UTI (Urinary Tract Infection) with Hematuria and Retention.

Review of the Physician Orders dated 6/15/21 at 7:23 PM, revealed a verbal order to apply mepilex to sacrum every 3 days and prn for protection.

Review of the Nursing Progress Notes dated 6/15/21 - 7/27/21 revealed mepilex was applied to the sacrum:

On 6/16/21 with the next change documented on 6/21/21, which was 5 days.

On 6/24/21 with the next change documented on 7/4/21, which was 10 days.

On 7/4/21 with the next change documented on 7/8/21, which was 4 days.

On 7/8/21 with the next change documented on 7/13/21, which was 5 days.

On 7/13/21 with the next change documented on 7/21/21, which was 8 days.

There was no documentation the mepilex was changed from 7/21/21 through the discharge date of 7/27/21.

Review of the Physician Orders dated 6/18/21 at 7:30 AM, revealed a verbal order for a Diabetic Supplement three times a day.

Review of the MR revealed no documentation a Diabetic Supplement was provided to the patient three times a day as ordered.

An interview was conducted on 12/16/21 at 12:00 PM with EI # 1, who confirmed there was no documentation mepliex was applied to the sacrum every 3 days as ordered and a Diabetic Supplement was provided three times a day as ordered on the above dates.

8. MR # 4 was admitted to the facility medical/surgical unit on 7/27/21 with diagnosis of Pneumonia.

Review of the lab report dated 7/28/21 revealed a White Blood Cell (WBC) high critical result of 16.6 (normal 4.8 - 8.1) was reported to a Registered Nurse (RN) on the nursing floor. There was no documentation the RN reported the high critical result to the physician.

Review of the lab report dated 7/29/21 revealed a WBC high critical result of 17.3 was reported to a RN on the nursing floor. There was no documentation the RN reported the high critical result to the physician.

Review of the lab report dated 7/31/21 revealed a WBC high critical result of 19.7 was reported to a nurse on the nursing floor. There was no documentation the nurse reported the high critical result to the physician.

An interview was conducted on 12/16/21 at 10:05 AM with EI # 1, who confirmed there was no documentation the critical lab values were reported to the physician. EI # 1 was asked for a facility policy for reporting critical lab values and reported the facility did not have a policy for reporting critical lab values.

Based on medical record (MR) review and staff interview, it was determined staff failed to follow the rehabilitation treatment plan of physical therapy visits for swing bed services. This affected MR # 12, MR # 14 , 2 of 3 swing bed record reviews and had the potential to negatively affect all patients admitted to swing bed services.

Findings include:

1. MR # 12 was admitted to the facility swing bed unit on 12/1/21 at 1:24 PM with diagnoses including Sepsis and Urinary Tract Infection.

Record review revealed a PT (physical therapy) Evaluation and Plan of Treatment (POT) completed on 12/2/21 and the PT treatment frequency was 5 times a week for 4 weeks.

MR review revealed 4 PT treatments were provided from 12/6/21-12/12/21 on 12/6/21, 12/7/21, 12/8/21, and 12/9/21. There was no documentation of attempted/refused PT treatments and no reason 5 PT treatments were not provided as ordered.

In an interview on 12/16/21 at 11:45 AM EI (Employee Identifier) # 2, Swing Bed Manager, Hospital Case Manager confirmed staff failed to provide PT treatments per the POT.



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2. MR # 14 was admitted to the facility swing bed unit on 11/10/21 with diagnoses including Right Leg Pain from Metastatic Prostate Cancer and Muscle Weakness (generalized).

Review of the PT Evaluation and POT completed 11/11/21 revealed a PT treatment frequency of 5 times a week for 4 weeks.

Review of the PT Encounter Notes for the week of 11/21/21 to 11/27/21 revealed documentation of 4 PT treatments dated 11/26/21, 11/24/21, 11/23/21, and 11/22/21. There was no documentation of attempted/refused PT treatments and no reason 5 PT treatments were not provided as ordered.

An interview was conducted on 12/16/21 at 9:11 AM with EI # 1, Director of Nursing, who confirmed the hospital work week was from Sunday to Saturday and the staff failed to provide PT treatments per the POT for the above weeks.

Based on review of medical records (MR), facility policies and procedures and interviews with the staff it was determined the facility failed to ensure all physicians signed and dated all History and Physicals (H&P) per the facility policy. This affected 2 of 17 MR's reviewed and did affect MR # 7 and MR # 9, and had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy: Incomplete Medical Records
Revised Date: 07/2009
Reference Number # 6103

Facility Policy:

The Health Information Management Department shall house all discharged patient records, complete and incomplete.

Washington County Hospital and Nursing Home strives to have all medical records completed within 14 days of the patient's discharge.

Medical records shall be completed promptly and authenticated or signed by a physician, nurse or other responsible party within two (2) weeks following a patient's discharge.

The records of discharged patients should be completed within a period of time that in no event exceeds 30 days following discharge...

1. MR # 7 was admitted to the hospital on 1/23/21 and discharged on 1/26/21 with an admitting diagnosis of Detoxification Alcohol and Drugs.

Review of the closed record revealed the H&P was not signed by the physician until 5/4/21 which was 99 days after the patient was discharged.

An interview was conducted on 12/16/21 at 10:45 AM with Employee Identifier (EI) # 1, Director of Nursing, who verified the physician did not sign the H&P within the time frame per the facility policy which is 30 days after discharge.

2. MR # 9 was admitted to the hospital on 6/2/21 and discharged on 6/2/21 with an admitting diagnosis of Symptomatic Anemia with Shortness of Breath, Schizophrenia, Hypertension and Diabetes Type II.

Review of the closed record revealed the H&P was dictated and not signed by the physician until 7/15/21 which was 43 days after discharge.

An interview was conducted on 12/16/21 at 10:45 AM with EI # 1 who verified the physician did not sign the H&P within the time frame per the facility policy which is 30 days after discharge.

Based on observations, review of facility policies and procedures, Centers for Disease Control and Prevention (CDC) Frequently Asked Questions (FAQ's) regarding Safe Practices For Medical Injection and interviews with the staff it was determined the facility failed to ensure:

1. Employees washed or sanitized hands per facility policy and procedure

2. The staff cleaned the rubber septum of the medication vial prior to piercing it as recommended per CDC.

3. The staff cleaned the Intravenous (IV) port(s) prior to administration of IV medications.

4. The staff did not palpate IV site after cleansed with antiseptic when starting an peripheral IV site.

5. The Computer on Wheels (COW) was cleaned per facility policy and procedure.

This did affect 4 of 4 observations conducted at the facility and included MR (medical record) # 1 and had the potential to affect all patients served by the facility.

Findings include:

CDC: Frequently Asked Questions (FAQs) regarding Safe Practices for Medical Injection
Reviewed Date: 6/20/19

"Medication Preparation Questions

1. How should I draw up medications?

Parenteral medications should be accessed in an aseptic manner (free from contamination caused by harmful bacteria, viruses, or other microorganisms). This includes using a new sterile syringe and sterile needle to draw up medications while preventing contact between the injection materials and the non-sterile environment. Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it."

Facility Policy Number: INF-2
Subject: Hand Hygiene
Department: Infection Control
Reviewed/Revision Date: 5/17

Purpose: The facility promotes hand hygiene as an essential element in safe patient care. Hand hygiene is the single most effective action in the prevention of transmission of an infection...

Procedure:

...3. Careful hand hygiene must be performed:

Wash with Soap and Water:

...Before entering or leaving isolation rooms
Before and after gloves are used

Use of Alcohol Based Hand Sanitizer:

For everything else

Facility Policy Number: IVT - 2
Subject: Peripheral IV Lines
Department: Nursing
Reviewed/Revision Date: 3/12

...Procedure:

...5. Select and prepare site, the insertion site should not be palpated after the skin has been cleansed with the antiseptic...

Facility Policy Number: Not documented
Subject: Cleaning COW
Department: Risk Management
Reviewed/Revision Date: 3/12

Policy: The COW cart is to be disinfected before and after each patient use with an approved disinfectant agent.

Procedure:

1. Perform hand hygiene and apply gloves.

2. Disinfect the COW using the Super Sani-Cloth Germicidal Wipe. Wipe thoroughly over the entire machine. Allow it to dry for 2 minutes to ensure that it is properly disinfected prior to using on another patient.

1. An observation was conducted on 12/14/21 at 10:14 AM with Employee Identifier (EI) # 9, Emergency Department (ED) Director, to observe the administration of REGEN-COV (monoclonal antibodies Casirivimab and Imdevimab).

EI # 9 removed the REGEN-COV medication from the medication cart and obtained a 100 ml (milliter) IV infusion bag of Normal Saline (NS), removed the plastic top of the medication vial, and punctured the rubber septum of the vial without cleaning the rubber septum of the medication vial prior to piercing it as recommended per CDC.

EI # 9 withdrew 600 mg (milligrams) of the REGEN-COV medication, hung the NS 100 ml bag on a door hanger, then punctured the IV port of the NS bag and injected the REGEN-COV medication into the NS bag without cleaning the port of the NS bag prior to injecting the medication.

After performing hand hygiene and donning PPE (Personal Protective Equipment), EI # 9 entered ED room # 4 and prepared to start a Peripheral IV site. EI # 9 cleaned the Peripheral IV site with antiseptic then used glove hand to palpate the IV site after cleaning the site.

An interview was conducted on 12/16/21 at 2:48 PM with EI # 13, Chief Executive Officer, who was notified of the above findings and verified staff failed to follow Infection Control practices.

2. An observation was conducted on 12/14/21 at 11:10 AM with EI # 11, Registered Nurse (RN), to observe administration of subcutaneous (SQ) injections.

During the observation, EI # 11 entered the room with a COW and preceded to scan the patient's armband and administration of the SQ injections into the COW. EI # 11 failed to disinfect the COW before or after patient use as per the facility policy.

An interview was conducted on 12/16/21 at 2:48 PM with EI # 13, who was notified of the above findings and verified staff failed to follow Infection Control practices.

3. An observation was conducted on 12/15/21 at 9:50 AM with EI # 10, Licensed Physical Therapy Assistant, to observe an outpatient Physical Therapy session.

During the observation, EI # 10 failed to perform hand hygiene prior to patient contact twice, prior to donning glove to the right hand once and after removing gloves once.

An interview was conducted on 12/16/21 at 2:48 PM with EI # 13, who was notified of the above findings and verified staff failed to follow Infection Control practices.



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4. An observation of care was conducted on 12/14/21 at 3:40 PM in which EI # 7, Certified Nurse Assistant, performed glucose testing for MR # 1. EI # 7 was sitting in the nurse station working at the computer, got up and retrieved the glucometer, lancet, gauze and alcohol pad from the supply cabinet in the nurse station.

EI # 7 exited the nurse station and entered the patient room. EI # 7 obtained gloves from the clean glove supply box without first performing hand hygiene. EI # 7 donned gloves then performed glucose monitoring.

EI # 7 failed to perform hand hygiene before donning gloves and patient contact.

In an interview on 12/16/21 at 3:00 PM, EI # 1, Director of Nursing confirmed staff failed to follow facility policy and perform hand hygiene before donning gloves and before patient contact.

Based on observations of care, review of the hospital's Infection Control (IC) plan policies, and the facility hand hygiene compliance observation data it was determined the hospital failed to ensure the results of each observation for hand hygiene and the surveillance of antibiotics were incorporated into the IC program for proper tracking, trending, evaluation and if needed development of an action plan.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

Facility Policy: The Infection Control Program
Effective Date: 07/2002
Policy Number: 1-A-01

Facility Policy:

Washington County Hospital has an active hospital-wide Infection Control Program. The Program is to establish guidelines for prevention and spread of contagious, Infectious, or communicable able diseases...

The Infection Control Department is delegated the responsibility of:

1. Collection, collation and analytic review of Infection Control data presented to the Infection
Control Committee, with follow-up corrective action.

2. To initiate culture and sensitivity testing and to institute appropriate isolation procedures with the sanction of the Infection Control committee...

Facility Policy: The Duties and Responsibilities of Infection Control Director
Effective Date: 07/2002
Policy Number: 1-B-01

Facility Policy:

The Infection Control Director is responsible for:

...Developing and maintaining a system for identifying, investigation, reporting and preventing the spread of infections and communicable diseases among patients.

Maintain a log of all incidents related to infections and communicable diseases. (This log is not limited to Nosocomial and Healthcare-Acquired Infections.) The log documents infections (Health-Acquired and Community-Acquired) and communicable diseases of patients...

Carry out special projects or activities as directed by the Infection Control Committee or Administration. These activities may include investigation of outbreaks...

Facility Policy: Infection Control Performance Improvement Plan
Effective Date: 07/2002
Policy Number: 1-C-01

Purpose:

To maintain an effective hospital wide Infection Control Program for the preventions, identification, and control of Nosocomial and Healthcare-Acquired Infections by providing ongoing surveillance, interventions, evaluations and education...

Major Aspects of Care:

The following is a list of major aspects of care to be monitored by the Infection Control Department through direct observation and medical record abstraction:

2. Community-Acquired Pneumonia
a. Timeliness of antibiotic administration and
b. Blood cultures drawn before antibiotic administration started.

3. Improving Infection Control Compliance:
a. hand washing and
b. isolation procedures.

4. Nosocomial and Health-Acquired infections...

1. An interview was conducted on 12/16/21 at 1:00 PM with Employee Identifier (EI) # 1, Director of Nursing, to review the Infection Control Program (ICP) . During the interview with EI # 1, results of hand washing observations were reviewed. EI # 1 stated " the results are not in the Infection Control Program itself but in another program. The surveyor reviewed the results of the hand washing observations and then asked to see the tracking and trending results. EI # 1 stated there was no tracking or trending completed. EI # 1 was then asked to see the results of the handwashing observations in the ICP with the tracking and trending documentation, any improvements being documented, and any action plans taken. EI # 1 revealed there was no documentation in the ICP.

Review of the ICP revealed no documentation of tracking. trending, surveillance, or action plans for Covid 19 patients who have been admitted to the hospital or seen in the Emergency Department.

An interview was conducted on 12/16/21 at 2:30 PM with EI # 1 who confirmed the results of all the observations for handwashing and Covid 19 results were not carried over to the ICP.

Based on review of the facility Infection Control Program (ICP), facility policy and staff interviews it was determined the facility failed to demonstrate coordination among all components of the hospital responsible for antibiotic use and resistance including the facility IC Program.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

Facility Policy: Antibiotic Stewardship Program
Effective Date: May 6, 2019

Facility Policy:

The Washington County Hospital (WCH) promotes appropriate use of antibiotics while optimizing the treatment of patients and reducing possible adverse events associated with antibiotic use. WCH will have the required elements in the Program- Leadership, Accountability, Drug Expertise, Action, Tracking, Reporting and Education based upon Centers fro Disease Control and Prevention (CDC) Antibiotic Resistance Solutions Initiative.

Procedure:

1. Leadership

a. Accountability documents
b. Infection Prevention Plans
c. Performance Improvement Plans
d. Strategic Plans
e. Use of Electronic Health Record (EHR) to collect antimicrobial stewardship data.

4. Antimicrobial Stewardship Multidisciplinary Team

The team will collect, analyze and report data on its antimicrobial stewardship program on a Quarterly basis to the Infection Control Committee. The hospital will take any action needed on improvement opportunities identified in the quarterly meetings. This team is made up of the following members:

Pharmacy- Drug Expertise
Infection Preventionist - monitoring and education of the antimicrobial stewardship program.
Laboratory - Monitoring lab results
Director of Nursing (DON) Monitoring
Chief Operation Officer (COO) Leadership
Chief Executive Officer (CEO) Leadership; and
Physician - Responsible for program outcomes.

5. The Infection Preventionist will do the following:

1. Utilize the CDC Guidelines for Infection Criteria
2. Review patient records for infections and antibiotic usage patterns on a regular basis
3. Obtain and review monthly antibiogram for institutional trend
4. Monitor antibiotic resistance patterns...and Clostridium Defficile infections.

1. An interview was conducted on 12/16/21 at 1:00 PM with Employee Identifier (EI) # 1, Director of Nursing, to review the Facility Wide Antibiotic Stewardship Program.

Review of the documentation for the for the Facility Wide Antibiotic Stewardship revealed no tracking, trending, evaluation of use of antibiotics and no any action plans were documented.

EI # 1 was asked who was over the Facility Wide Antibiotic Stewardship and EI # 1 replied he/she was over the program. EI # 1 was then asked how or if the Pharmacy or Pharmacist was involved in the program and EI # 1 replied "no."

Review of the Employee Roster for the facility revealed there was not an employee with the title of Infection Preventionist who is to monitor the Antibiotic Stewardship per facility policy.

Further review of the information for the Antibiotic Stewardship revealed no documentation of review of infections and antibiotic usage patterns nor was there documentation of patient record reviews for infections and antibiotic usage patterns.

An interview was conducted on 12/16/21 at 2:30 PM with EI # 1 who confirmed the results of all the Antibiotic Stewardship results were not carried over to the ICP.

Based on review of hospital discharge planning process and staff interview, it was determined the hospital staff failed to assess its discharge planning process and review a sample of discharge plans. This had the potential to negatively affect all hospital inpatient admissions.

Findings include:

In an interview on 11/17/21 at 11:40 AM with Employee Identifier (EI) # 2, Swing Bed Manager, and hospital Case Manager, the surveyor asked EI # 2 how the hospital discharge planning process was reviewed, and where/how this is documented? EI # 2 response was "it is reviewed during the policy and procedure review annually."

The surveyor asked EI # 2 if the hospital tracks' patients that have been re-admitted to the hospital within 30 days and if a review of the patient's discharge plan was conducted? EI # 2 reported patients re-admitted to swing bed services within 30 days were tracked, but not the inpatient re-admits.

In an interview on 11/17/21 at 2:40 PM, EI # 1, Director of Nursing, confirmed there was no documentation hospital staff assessed the effectiveness of its hospital discharge planning process for acute inpatients admits. There was no documentation a review of inpatients re-admitted within 30 days was performed.