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Based on interview and record review facility Metabolic Support Service staff, who conduct patient nutrition assessments, failed to meet current Missouri state licensure requirements as directed by the Dietitian Practice Act. The facility census was 365 patients.

Findings included:

1. Record review of the Missouri Revised Statutes, Chapter 324 Occupations and Professional General Provisions, Section 324.200 dated 08/28/09 directed, in part, the following:
-Paragraph 1 Commission on Accreditation for Dietetics Education (CADE), is the American Dietetic Association's accrediting agency for education programs preparing students for professions as registered dietitians.
-Paragraph 3 Dietetics practice was defined as the application of principles derived from integrating knowledge of food, nutrition, biochemistry, physiology, management, and behavioral and social science to achieve and maintain the health of people by providing nutrition assessment and nutrition care services.
-The primary function of dietary practice is the provision of nutrition care services that shall include, but not limited to: assessing nutrition care needs; establishing priorities, goals and objectives; providing nutrition education counseling; developing, implementing and managing nutrition care systems; engage in medical nutritional therapy as defined under the definition of dietetics practice.
-Paragraph 4 Dietitian is defined as one engaged in dietetic practice as defined.
-Paragraph 7 Licensed dietitian is a person licensed pursuant to the provisions of this section 324.200 through 324.225 to engage in the practice of dietetics or medical nutrition therapy.
-Paragraph 8 Medical Nutrition therapy, nutritional diagnostic, therapy, and counseling services which are furnished by a registered dietitian.
-Paragraph 9 Registered dietitian is a person who has completed a baccalaureate degree granted by an accredited college or university; completed academic requirements of a didactic program in dietetics approved by the CADE; successfully completed the registration examination for dietitians and accrued seventy-five hours of approved continuing professional units every five years; as determined by the committee on dietetic registration.

2. Record review of the facility policy titled, Metabolic Support Responsibility, #25-01, dated 01/09 in part, directed the following:
-Identification and treatment of critically malnourished or at nutritional risk {patients} are a high priority.
-Refers the reader to the facility standard of care {Nutrition Care Plan} #TX.14.
-Members of the Metabolic Support Services (MSS) were Registered Dietitians, Registered Pharmacists and Registered Nurses.
-The responsibility of the MSS included assisting the primary physician to identify and treat patients at nutritional risk.

Record review of the facility policy titled, Parenteral and Enteral Consults and Dosing Service, #25-02, dated 03/09, in part, directed the following:
-The policy provided procedures related to MSS management of parenteral and enteral therapy including assessment, initiation, monitoring and discontinuation.
-Upon initiation of the MSS, either the MSS dietitian, the MSS Nurse or the MSS pharmacist will screen the patient's chart and complete an assessment; calculate calorie, protein and fluid requirements based on patient height, weight and weight history; assess the patient's nutritional status including adequacy of current intake and develop a plan of care.

Record review of the facility policy titled, Nutritional Assessment and Decision Making, #25-06, dated 03/09 in part, directed the following:
-The policy was the Metabolic Support {Service} will utilize a systematic process of obtaining, verifying, and interpreting data to make decisions about the nature and cause of nutrition-related problems.
-All patients on parenteral nutrition and enteral nutrition will have chart documentation according to the Nutrition Care Plan (Standard TX.14).
-Documentation included summary of subjective and objective assessment of the patient's current nutrition status and nutritional requirements.
-Patient nutritional requirements shall be summarized based on the nutrition assessment and should include protein, calorie, fluid, electrolyte and micronutrient requirements.
-Nutrition assessment shall include an assessment and documentation of factors relevant to route of specialized nutrition support administration. Relevant factors may include the following; ability to eat, presence of gag reflex, functional status of the gastrointestinal tract, mental status, enteral and vascular access, and schedule of tests and invasive procedures.

3. Record review of the facility policy titled Nutrition Care Plan, #TX.14, revised 02/10 in part, directed the following:
-The purpose of the policy was timely identification of inpatients who were at nutritional risk.
-Directed staff to provide nutrition assessment to those found to be at risk.
-Directed staff to develop a nutrition therapy plan of care and an ongoing plan for monitoring nutritional status.
-All patients screened and found to be at nutritional risk will have a comprehensive nutrition assessment completed by a dietitian or a member of the Metabolic Support Service (MSS) with in twenty four hours of referral.
-Referenced the facility standard of care.
-Stated the Standard of Care: An interdisciplinary committee collaborates to standardize nutrition care practices throughout the organization; including development of metabolic/nutrition care protocols, facilitation of staff education and approval of the Nutrition Care Manual.

4. During an interview on 06/07/10 at 1:55 p.m., the Assistant Director, Food and Nutrition Department stated the following:
-The facility had dietitians who worked under his/her direction in the Food and Nutrition Department.
-The facility also had dietitians who worked in the outpatient Oncology (cancer) department, the outpatient clinics, the diabetes center and two dietitians who worked in the Pharmacy on the MSS who were not under his/her direction.
-All dietitians used the same nutrition assessment policy and procedure (called TX.14) facility wide and independent of the department they were assigned.

5. During an interview on 06/11/10 at 9:35 a.m. the Metabolic Support Service (MSS) team coordinator, Staff NNNN and the MSS Dietitian, Staff LLL stated the following:
-There were currently six members of the MSS team.
-There were two Registered, licensed dietitians (RD, LD) plus two Registered Nurses (RN) and two Registered Pharmacists (RPh) on the MSS team.
-All six team members were cross trained and provided the same nutrition assessment care to any patient assigned.
-Not all team members prepared medications.
-Not all team members administered medications.
-Three of the team members were permitted to place feeding tubes into patients.
-The three who placed feeding tubes were the two RNs and one RPh.
-All members of the MSS, when assigned to a patient, independently performed assessment of height, weight, and body mass index, assessed access to feeding (enteral or intravenous), lab values, and allergies.
-All members of the MSS, when assigned to a patient, independently assessed estimated nutritional needs by calculating patient caloric requirement, protein requirement, and fluid intake goals.
-All members of the MSS, when assigned to a patient, independently wrote nutrition assessment notes in the patient medical record with reasons for selection of enteral (tube feeding) or parenteral nutrition (intravenous nutrition).
-The MSS Dietitian, Staff LLL stated the MSS team members followed the facility policy titled Nutrition Care Plan #TX.14.
-The MSS Coordinator, Staff NNNN contradicted the MSS Dietitian, Staff LLL and stated the MSS team members only partially followed the facility policy titled Nutrition Care Plan #TX.14.

Based on observation the facility failed to ensure the personal privacy of 18 patients by displaying their name on a dry-erase board where they were visible to the public passing by. And, Observation, interview, and record review the facility failed to provide personal privacy for all patient's in hyperbaric unit, and 500 East Unit.

The facility census was 365.

Findings Included:

1. Observation on 06/09/10 at approximately 3:00 p.m., on the Cardiac Care Unit (CCU), revealed two dry-erase boards on the unit. Staff hung these boards on the wall, in two hallways/corridors, visually accessible to the public walking by. The boards contained the last names of 18 patients, their physician, and their assigned nurse.


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2. Observation of the hyperbaric (treatment with 100 percent oxygen) unit on 06/09/10 at 2:30 p. m. showed a large erasure board, approximately five feet long by 4 feet wide with all patient full first names on the board and the time of their appointment for hyperbaric treatment.
3. Interview with Staff WW, RN (registered nurse) Program Director Nurse Manager of the Hyperbaric Unit stated, "Family of patient's only come into the hyperbaric unit if the patient is anxious and requests family member to stay, which is rare."
4. Observation of 500 East Inpatient Unit on 06/11/10 at 9:15 a. m. showed an erasure board, two feet wide and three feet long, with the patient's first initial of first name, and first three initial's of last name in the corridor where the public walks into the unit.
5. Interview with Staff HHHH, RN (registered nurse) Quality Nurse for Cardiovascular Services showed confirmation that this is the patient's and their room number.


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6. Observation on 06/10/10 at 3:37 p.m. in the step down unit on 5th floor showed a white dry erase board with patent's full last names.
7. During an interview on 06/10/10 at 3:37 p.m. Staff MM, Performance Improvement Facilitator said that visitors come in from the outside into this unit.

Based on observation, interview and record review the facility failed to develop a care plan addressing the use of restraints for two of two patients reviewed with restraints (Patients #7 and #8). The facility identified seven total patients with restraints. The facility census was 365.
Findings Included:
1. Review of a facility policy entitled, "Interdisciplinary Patient Plan of Care," revised 07/08, revealed the plan of care is to be reviewed and updated each shift on a continual basis as needed by the Registered Nurse (RN). If additional problems are identified by nursing, an order for the appropriate plan of care will be placed by the care provider identifying the problem.
Review of Patient #8 ' s History and Physical (H & P) dated 06/03/10 revealed the Review of the patient ' s Physician ' s orders revealed orders for wrist restraints on 06/06-07/10.
Review of the patient ' s care plan revealed staff failed to initiate and develop a care plan for the restraints, to include a goal and interventions.
During an interview and observation on 06/07/10 at 2:55 p.m. the patient had bilateral wrist restraints on. RN Staff member Q said the nurse caring for the patient when the restraint orders were received should have initiated the restraint care plan. RN Staff member Q confirmed there was no restraint care plan as of this date and time.
2. Review of Patient #7 ' s Emergency Department record revealed the patient was admitted on 06/05/10 with a diagnosis of a gunshot wound.
Review of the patient ' s Physician ' s orders revealed orders for wrist restraints on 06/06-07/10.
Review of the patient ' s care plan revealed staff failed to initiate and develop a care plan for the restraints, to include a goal and interventions.
During an interview on 06/07/10 at 3:15, RN Staff member P confirmed there was no restraint care plan as of this date and time.

Based on policy reviews, record reviews, observations and interviews the facility failed to:
- prevent the development of a pressure sore;
- consistently and/or accurately document assessment, measurement, stage, and further describe pressure sores;
- follow physician's orders;
- develop a system which would identify pressure sores, their stage, location, and if they were facility acquired;
- utilize their nutritional support staff for evaluation of increased protein needs, vitamins, etc. when a patient had pressure sores.

The hospital census was 365.

The severity and cumulative effect of these systemic practices resulted in the facility being out of compliance with 42 CFR (Code of Federal Regulations) 482.23 Condition of Participation: Nursing Services.

Based on observation, interview and record review the facility failed to prevent the development of a Stage II (partial thickness skin loss-usually presenting as an abrasion, blister, or shallow crater) pressure sore, failed to consistently and/or accurately document assessment, measurement, stage, and further describe pressure sores for two of eight patients with pressure sores (Patients #42, and #59).

The facility also failed to follow physician's orders to elevate Patient #59's heels, failing to reduce the pressure to an existing pressure sore.

The facility also failed to develop a system which would allow them to identify pressure sores, their stage, location, and if they were facility acquired. Facility staff could not prepare a list of patients with pressure sores when requested. The facility's quality improvement data regarding pressure sores only included review of documentation of turns for high risk patients, and documentation of a thorough assessment, such as, was the assessment completed.

The facility also failed to utilize their nutritional support staff for evaulation of increased protein needs, vitamins, etc. when a patient has pressure sores. The facility census was 365.

Findings Included:

1. Review of Patient #42 ' s History and Physical (H & P) dated 05/21/10 revealed the patient was admitted on that date with diagnoses of coronary artery disease, diabetes, and hypertension.
Review of the patient ' s nursing admission assessment, dated 05/21/10 and timed at 9:04 a.m., revealed the patient ' s skin was intact on that date.
During an interview and observation on 06/09/10 at 8:40 a.m., Registered Nurse (RN) Staff member GGGG said staff identified a Stage I (persistent redness) pressure sore on the patient ' s coccyx (tailbone) when the patient was transferred from the step-down unit to the Cardiac Care Unit (CCU) on 05/29/10. This Stage I pressure sore was not measured or described in the assessment documentation. Observation revealed a Stage II (partial thickness skin loss-presenting as a shallow crater) elongated pressure sore measuring approximately 2.0 centimeters (cm) by 0.2 cm on the coccyx.
Review of the Registered Dietitian ' s (RD) evaluation dated 05/28/10 revealed no evidence the patient had been assessed for nutritional needs related to the pressure sore.
Review of the patient ' s laboratory results revealed an Albumin level (a protein in the blood which can be somewhat indicative of healing ability) was low at 2.5 on 05/28/10 and 3.3 on 06/07/10.
During an interview on 06/10/10 at 9:24 a.m. the RD, Staff member LLL, said the RD ' s don ' t formally document regarding wounds when doing an assessment. The RD ' s have been using a new computer tool and it could be made to be more specific to pressure sores.
Review of Skin assessment documentation from 05/29-06/10/10 revealed the following:
a) Staff failed to measure the coccyx pressure sore until 06/02/10. It measured 0.5 inches (normal standard is to measure using centimeters, and measure length by width by depth, if any).
b) The pressure sore remained a Stage I on 06/03/10 even though serosanguinous (bloody) drainage was documented (a pressure sore can ' t drain unless open which makes it a Stage II or greater).
c)The second measurement, dated 06/04/10, was 2.5 cm by 1.0 cm, but the pressure sore was still a Stage I.
d)On 06/06/10, the pressure sore was documented as a Stage II, measuring the same as above.
2. Review of Patient #59 ' s H & P dated 06/09/10 revealed the patient was admitted on that date with diagnoses of peripheral vascular disease (poor circulation in the lower extremities-creates a high risk for development of pressure sores), and a right-sided below the knee amputation. The patient was thin, cachectic, not eating or drinking and had low albumin and pre-albumin levels (both used to assess nutritional/protein levels).
Review of a nursing skin assessment dated 06/09/10, timed 11:20 p.m., revealed the patient had an ulceration on the left ankle. Staff failed to measure, stage or describe this pressure sore.
Review of a Physician ' s Progress Note dated 06/10/10 revealed the patient had a Stage II pressure sore over the boney prominence of the left ankle. The patient suffered from malnutrition.
Review of the nursing admission assessment regarding the skin revealed staff failed to complete the skin temperature, turgor (hydration), and description portions of the assessment.
Review of nursing skin assessments dated 06/10/10, timed 7:50 p.m., revealed the pressure sore measured 1 cm, had scant drainage, and was a Stage II on the outer ankle. On 06/11/10 at 8:14 a.m., the pressure sore was red and yellow.
Review of the wound care nurse ' s assessment dated 06/10/10 revealed the pressure sore had swollen; slightly pink tissue surrounding the wound bed to 1.5 cm.
Review of wound care orders dated 06/10/10 revealed an order to elevate the left leg on a pillow (keeping the heel off of the bed-reducing pressure)
Review of a nursing skin assessment dated 06/10/10, timed 7:50 p.m., revealed the skin portion of the assessment was blank.
Observation on 06/11/10 at 9:50 a.m. revealed staff failed to elevate the patient ' s heels/leg off of the bed with a pillow as ordered. The patient had a Stage II pressure sore on the inner, not outer left ankle. The pressure sore measured approximately 1 cm by 1 cm, circular in appearance, with reddened tissue that surrounded it to about 2 cm by 2 cm.
During an interview on 06/11/10 at 10:12 a.m., Registered Nurse Staff members FFFF and EEEE said nurses don ' t measure or stage pressure sores, they wait for the wound nurse to do that. So, once a measurement is obtained it stays in the computer until it is changed-indicating a daily measurement that may not be accurate.
3. During an interview on 06/11/10 at 11:40 a.m. , RN Staff member AAAAA said a report including stage, site, and facility-acquired pressure sores cannot be generated. At any given time the units are not aware of who has pressure sores, where they are, or how many may be facility-acquired. Trends regarding this data is not considered. Quality data is based on a random monthly audit (review of patients on one day of month). This surveyor requested a list of patients in-house with pressure sores, their stage, site and whether facility-acquired or not, on entrance on 06/07/10 at 1:00 p.m. As of exit at 12:00 p.m. on 06/11/10, this list had not, and could not be provided.


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4. Record review of the facility policy titled Nutrition Care Plan, #TX.14, revised 02/10 directed in part, the following:
-The purpose of the policy was to provide appropriate nutrition care in a timely, effective, efficient manner utilizing a standardized interdisciplinary process.
-All inpatients were screened within twenty four hours of admission.
-Nutrition screening questions included a question regarding the presence of decubitus ulcers or non-healing wound.

During an interview on 06/11/10 at 9:35 a.m. the Metabolic Support Service (MSS) team coordinator, Staff NNNN and the MSS Dietitian, Staff LLL stated the following:
-There were six members of the MSS.
-The MSS consisted of dietitians, registered nurses and registered pharmacists.
-The team members worked interchangeably and monitored patients assigned to the MSS.
-When assigned, the team member calculated protein, calorie and fluid requirement for patients.
-The team members did not assess skin integrity.
-If a patient had a pressure ulcer or an open wound, the team member may electively write in a free text section of the nutrition assessment that the patient had a pressure ulcer or an open would.
-The MSS Dietitian, Staff LLL stated he/she knew that patients with pressure ulcers or open wounds required more protein, calories and fluid to aide in healing.
-No members of the MSS team made bedside rounds with the Wound Care nurses.
-There was no formalized communication between the MSS and the Wound Care nurses.

Based on interview and record review facility staff failed to ensure therapeutic diets were written and prescribed only by the practitioner (physician or licensed independent practitioner) responsible for the patients care. The facility census was 365 patients.

Findings included:

1. Record review of the facility policy titled, Diet Orders, revised 11/08 in part, directed the facility physicians {practitioners} write the diet order or confirm a verbal diet order on the physician's order sheets and further directed those orders were transmitted from the nursing units, via computer to Food and Nutrition department.

Record review of the facility policy titled, Nutrition Care Plan, #TX.14, revised 02/10 in part, directed the dietitian's ordering privileges included modifications of diet restrictions, including but not limited to mineral {such as sodium, calcium, potassium} modifications; down grade diet consistency (mechanical to puree); or changes in calorie and protein levels; addition or deletion of high protein/high calorie snacks /supplements/fortified foods.

2. During an interview on 06/07/10 at 1:55 p.m. the Assistant Director of Food and Nutrition Services stated all facility dietitians, including dietitians in the outpatient cancer center, the outpatient services, the diabetes center and the Metabolic Support Services, should be following the policy titled Nutrition Care Plan, #TX.14.

During an interview on 06/11/10 at 9:35 a.m. the Metabolic Support Service (MSS) dietitian, Staff LLL stated the following:
-He/she wrote patient diet orders.
-He/she felt it was permissible for a dietitian to independently change (regress) a patient's diet (if a patient's physician ordered a regular diet, he/she felt it was permissible to independently change the physician's order to a mechanical soft diet).
-During his/her years of professional practice, he/she had independently written diet orders in the facility.

Based on observation, interview and record review facility staff failed to ensure the facility diet manual was accessible and readily available to all medical and nursing staff.
The facility census was 365 patients.

Findings included:

1. Record review of the facility Food and Nutrition Services policy titled Diet Manual Approval, last revised 03/10 directed the American Dietetic Association {ADA}Manual of Nutrition Care was the approved diet manual for use in prescribing modified diets for patients. The policy further directed the ADA Manual of Nutrition Care was accessible through the facility intraweb home page under manuals.

2. During an interview on 06/07/10 at 1:55 p.m. the Assistant Director of Food and Nutrition Services stated the approved facility diet manual was the American Dietetic Association (ADA) Nutrition Care Manual that was available to facility staff through the hospital intranet (computer) system.

3. During an interview on 06/08/10 at 1:00 p.m. Assistant Nurse Manager, Staff AAAA and Registered Nurse, Staff BBBB stated the following:
-The facility did not have a diet manual.
-If they had a question about a diet they would call the Dietary department.
-They would call the Dietary department for reference material.
-Felt there may be information on the facility intra-web (computer).

Observation on 06/08/10 at 1:00 p.m. revealed Assistant Nurse Manager, Staff AAAA opened the facility intra-web computer program and found the ADA Nutrition Care Manual however did not open the computer option because he/she felt it contained information regarding diabetes from the American Diabetes Association (also ADA).

4. During an interview on 06/11/10 at 11:09 a.m. Registered Nurse (RN), Staff JJJJ stated he/she had been employed with the facility for two years and would use a computer reference called Micro-medex to look up any diet reference material or he/she would call the diet office.

5. During an interview on 06/11/10 at 11:12 a.m. RN, Staff CC stated the following:
-He/she had been employed with the facility for eleven years.
-Staff used diet sheets for diet information.
-Diet reference material could be found on a computer program called Micro-medex.
-Micro-medex was the main source of information.

6. During an interview on 06/11/10 at 11:15 a.m. Unit Secretary, Staff LLLL stated the following:
-He/she had no knowledge of a facility diet manual.
-The unit did not have a hard copy of a diet manual.
-He/she would call the Dietary department for information on any diet.
-Or he/she may call the Registered Dietitian (RD) for diet information.
-He/she may try to use the Micro-medex computer program for diet reference material.

7. During an interview on 06/11/10 at 11:18 a.m. Unit Secretary, Staff MMMM stated the following:
-He/she had been employed with the facility since 12/09.
-Would look on the facility intranet computer system for a diet manual.

Observation on 06/11/10 at 11:18 A.M. revealed Unit Secretary, Staff MMMM found the Food and Nutrition Department's intra-web page then with verbal prompting from the Unit Manager was able to find the ADA Nutrition Care Manual.

Based on observation and interview the facility failed to insure all patient use equipment received periodic preventive maintenance inspections. This deficient practice affects all patients in the facility. The facility census was 365.

Findings include:

1. Observation at 2:36 P.M. on 06/08/10, during a tour of the facility attached Urgent Care Center, revealed a vital sign monitor, located in the triage area of the unit, with a preventive maintenance sticker attached indicating the monitor was due for preventive maintenance service on 03/20/10.

2. Observation at 9:21 A.M. on 06/09/10, during a tour of the south campus building, revealed a micro gas monitor, located in the Pediatric Unit on the 7th floor, with a preventive maintenance sticker attached indicating the monitor was due for preventive maintenance service on 08/2009.

3. Staff BB Emergency Management Officer confirmed both monitors were overdue for preventive maintenance servicing at that time.


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4. Review of Utilities Management/Preventative Maintenance effective date 12/2008 states "The Department of BioMedical Equipment Services will check all operating room equipment prior to initial use and routinely in accordance with the BioMedical Preventative Maintenance Schedule."
5. Observation on 06/08/10 at 1:45 P.M. in the Meyers Center operating room number 5 an ATS 3,000 tourniquet (a device that acts as an automatic tourniquet) number 14 had a biomedical sticker with last date checked 9/09 and date due: 5/10. An interview immediately following this observation with Staff JJ, Director of Meyer Orthopedic and Staff MM, Performance Improvement facilitator they both verified that the biomedical check was past due.
6. Observation on 06/08/10 at 2:00 P.M. in the Meyers Center in storage alcove A an ATS 3,000 tourniquet number 15 had a biomedical sticker with last date checked 9/09 and date due: 5/10. An interview immediately following this observation with Staff JJ, Director of Meyer Orthopedic and Staff MM, Performance Improvement facilitator they both verified that the biomedical check was past due.
7. Observation on 06/08/10 at 2:15 P.M. in the Meyers Center in operating room number 6 an ATS 3,000 tourniquet number 4 had a biomedical sticker with last date checked 9/09 and date due: 5/10. An interview immediately following this observation with Staff JJ, Director of Meyer Orthopedic and Staff MM, Performance Improvement facilitator they both verified that the biomedical check was past due.
8. During an interview on 06/08/10 at 2:20 P.M. Staff JJ, Director of Meyer Orthopedic, stated that the ATS 3000 tourniquet number 12 in operating room 2 had a due date of 5/10.

Based on observation and record review the facility failed to follow infection control policies while caring for one of one patient observed with an intravenous (IV) line (Patient #14). The facility census was 365.

Findings Included:

1. Review of a facility policy entitled, "Intravenous Needle, Peripheral Insertion, Maintenance and Discontinuing," revised 05/08 revealed the following when discontinuing an IV line:

a) Remove dressing
b) Put gloves on
c) Apply alcohol sponge over cathlon insertion site, quickly pull back on cathlon (plastic sheath left in the vein when the needle is removed-when inserting an IV) and remove
d) Apply firm pressure with sponge over the site to prevent hematoma
e) Apply Band-Aid over site

Observation on 06/08/10 at 9:48 a.m. revealed the following:

a) Registered Nurse (RN) ZZZZ put gloves on, removed the old dressing, put his/her gloved finger over the cathlon insertion site, pulled the cathlon out and kept pressure on the site with the contaminated gloved finger. Staff member ZZZZ failed to use the alcohol sponge initially to clean and apply pressure to the site.

Based on observation and interview, the facility failed to provide an environment designed to avoid the transmission and prevent the spread of infectious disease. The facility failed to ensure that staff followed accepted isolation precautions for three of three patients in the Dialysis Unit. The facility failed to follow their infection control policy in six patients (Patient 28, 31, 55, 61, 24, and 45) and provide clean operating table pads in four out of seven operating rooms observed. And, based on observation, interview, and record review the facility failed to follow standards of practice for infection prevention for four patients, Patient 28, Patient 31, Patient 55, and Patient 61.

The census at the time of the survey was 365.

1. Observation of the dialysis unit on 06/09/10 at 10:30 AM revealed a locked unit with a large room and three patient beds. The nurses ' station sits directly in front of the beds with full view of the patients ' . The clean storage room is to the right and is separated by a door. The nursing staff break room is to the left. The three beds currently have patients in them receiving dialysis treatments. The curtains are open and pulled back. There is a sign at the foot of bed #1 reading Contact Isolation.

2. Observation on 06/09/10 at 11:03 AM Staff JJJ, RN and Staff KKK, PCA (Patient Care Assistant) put on gowns, gloves, and mask to care for Patient in bed #1. Staff JJJ, RN cares for the patient access cite while Staff KKK, PCA, takes care of the dialysis machine. As soon as the RN was finished discontinuing the Patients tubes from the dialysis machine, the PCA proceeds to remove all of the tubing from the dialysis machine to the disposal area - across the room - still wearing her gown, gloves, and mask and passing beds 2 and 3 with patients still in them. The PCA returned to bed #1 and began cleaning the dialysis machine without protective garments in preparation for the next dialysis Patient. This observation was also observed by Staff HHH, RN and Staff A, RN. When Staff HHH, RN spoke to the PCA about her protective garments, the PCA then put them back on. When the PCA finished cleaning the dialysis machine, The PCA began removing her mask, gown, and gloves as he/she walked past beds #2 and #3 only completing the task when he/she arrived at the disposal area. The PCA then went into the clean storage area and returned to bed #1 with tubing and items for the next patient. The PCA placed the items on top of the dialysis machine.

3. In an interview with Staff A, RN, and Staff HHH, RN, at the time of observation it was stated that the PCA is walking back and forth through the bed #1 (contaminated) area possibly because there is no delineating marks as to when you are in the bed #1 space or when you are out of the bed #1 space. When the Patient was hooked to the dialysis machine the PCA wore protective coverings but when the Patient is no longer hooked to the dialysis machine he/she removed the protective garments, cleaned the dialysis machine - which is still dirty because the Patient is still in the bed and he/she is prematurely preparing for the next dialysis Patient.

4. The observation immediately following shows Staff HHH, RN, speaking to the PCA about this observation. The PCA then picked up all of the items on top of the dialysis machine and went back into the clean storage with them. Now the clean storage is contaminated.

5. In an interview with Staff JJJ, RN, and Staff A, RN, immediately following these observations, agreed that the Staff KKK, PCA, needed further education on infection control and isolation precautions and that the isolated Patients may be better cared for in a different location on the unit with delineating features.



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6. Observation on 06/09/10 at 9:30 a. m. showed Staff VV, RN (registered nurse), OCN (oncology certified nurse) washed hands in sink and then turned the faucet off with his/her clean hands, then dried his/her hands with paper towels. He/She then went to perform a treatment on Patient 28, and then went directly to Patient 28 chart to document without removing his/her gloves.
7.. Interview of Staff VV, RN (registered nurse) OCN (Oncology Certified Nurse) at 10:45 a. m. showed that Outpatient Oncology Department uses the same infection control policy as the hospital for hand hygiene.
8. During an observation on 06/10/10 at 8:42 A.M. Staff RN MMM Left Patient 44's room after passing medication and failed to wash hands or use disinfectant hand sanitizer
9. During an observation on 06/10/10 at 9:10 A.M. Staff RN, AAAAA entered Patient 45's room to give medication and failed to wash hands or use disinfectant hand sanitizer.
10. During an observation on 06/10/10 at 9:10 A.M. Staff RN, AAAAA left Patent 45's room and failed to wash hands or use hand sanitizer.
11. During an observation on 06/10/10 at 9:10 AM Staff RN, AAAAA entered Patent 45's room to complete medication pass and failed to wash hands or use disinfectant hand sanitizer.
12. During an interview on 06/10/10 at 12:00 P.M. with Staff NNN, Nurse Manager said her expectation was for staff to wash hands or use disinfectant hand sanitizer before entering a patients room and after leaving a patients room. Observation on 06/10/10 at 4:05 p. m. showed Staff YYY, PCA (patient care assistant) went to document on the electronic chart without removing his/her gloves after completing treatment on Patient 55.
13. Observation on 06/11/10 at 9:45 a. m. showed Staff GGGG, RN (registered nurse) did not remove gloves before reaching for clean linen for Patient 61.
14. Further observation of Staff GGGG, RN (registered nurse) did not wash hands, or use hand sanitizer after removing his/her gloves.
15. Observation on 06/16/10 at 2:00 p. m. showed Staff ZZ, RN (registered nurse) did not remove his/her gloves to document in the electronic chart after performing treatment on Patient 31.
16. Further observation on 06/16/10 at approximately 2:10 p. m. showed Staff ZZ, RN (registered nurse) continued to use his/her dirty gloves to get liquid soap out of clean supply area, and getting medical supplies out of clean storage area
17. Record review of Procedure 7.02: Discharge Room Cleaning Procedure does not specifically identify the area where the computer keyboard, mouse, and touch screen computer screen be cleansed between patients.
18. Record review of Hand Hygiene Policy clearly states "Healthcare personnel are to clean their hands: before and after wearing gloves."


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19.During an observation on 06/09/10 at 9:17 AM in operating room number 10 the operating room table pad showed areas of adhesive. An interview immediately following this observation with Staff LL, Clinical Coordinator of surgical services, Staff II, Administrative Director of Surgical Services, and Staff MM, Performance Improvement Facilitator they verified that there was adhesive on the pad.
20. During an observation on 06/09/10 at 9:25 AM in operating room number 11 the operating room table pad showed areas of adhesive. An interview immediately following this observation with Staff LL, Clinical Coordinator of surgical services, Staff II, Administrative Director of Surgical Services, and Staff MM, Performance Improvement Facilitator they verified that there was adhesive on the pad.
21. During an observation on 06/09/10 at 9:37 A.M. in operating room number 2 the operating room table pad showed areas of adhesive. An interview immediately following this observation with Staff LL, Clinical Coordinator of surgical services, Staff II, Administrative Director of Surgical Services, and Staff MM, Performance Improvement Facilitator they verified that there was adhesive on the pad.
22. During an observation on 06/09/10 at 10:04 AM in operating room number 16 the operating room table pad showed areas of adhesive. An interview immediately following this observation with Staff LL, Clinical Coordinator of surgical services, Staff II, Administrative Director of Surgical Services, and Staff MM, Performance Improvement Facilitator they verified that there was adhesive on the pad.

Ensure that the hospital works cooperatively with the designated, OPO, tissue bank and eye bank in educating staff on ... reviewing death records to improve identification of potential donors.

This STANDARD is not met as evidenced by: Based on interview and policy reviews the facility failed to have a policy in place for the reviewing of death records. The facility census was 365.

Findings Include:

1. During an interview on 06/08/10 at 10:00 A,M, with Staff N, Vice President Organizational Development, Administrator he/she said that a policy for reviews of death records was not available at this time, but he/she would check on it.
2. Review of the policy Organ and Tissue Donation effective date of 06/09/10 showed an added Organ and Tissue Donation Process and the Post-Donation Process both set up with small short sentences in colored boxes. The boxes connected to show each step to be taken. The last two boxes of the Post Donation Process showed "After action review within 72 hours of donation and information summary for O &T committee." This gave a time as to when the reviews should take place.
3. During an Interview on 06/09/10 at 11:00 A.M. Staff L, Accreditation Program, Manager; Quality Resources Department said that the Organ and Tissue Donation Process and the Post-Donation Process were added to the policy after the survey process was started.