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Based on observation, interview and record review, the facility's registered nursing staff failed to supervise the care of patients assigned, in that patients were not provided with care and services prescribed by the physicians in 7 of 44 Patients. #s 15, 22, 34, 37, 38, 39 and 44
Findings :
Patient #15
On 01/15/2014 at 8:27 a.m. patient (# 15) was observed receiving hemodialysis treatment at a blood flow rate of 200 ml/minute and dialysate flow rate of 500 mls/ minute. The patient was utilizing Dialyzer Xenium 170 for her hemodialysis treatment.

Review of the patient's clinical record revealed a physician's order dated 01/14/14 for Dialyzer Xenium 150.
The Surveyor immediately notified the Charge Nurse and the Quality Director who was present that the patient was not utilizing the Dialyzer Xenium prescribed by the physician.
The Charge nurse stated that the patient should be on Xenium 150 and so she will call the physician and notify him that the patient was not on the prescribed dialyzer and secure an order to continue using Dialyzer Xenium 170.


Patient #22
Review on 01/16/2014 of patient ( #22) clinical record revealed a physician's order dated 01/14/2014 for " Social worker evaluation for home situation . Lives alone. PRN live in care taker stealing from her. Discharge plan "
Interview on 01/16/2014 at 10:15 a.m. with the patient on the dialysis unit, revealed she lives alone, there a male associate who helps her with her two dogs. She said the gentleman had stolen money from her.
The patient said she was not seen by the social worker or the discharge planner.

Interview on 01/16/2014 10:50 a.m. with the Social Work Director, she stated " I was not aware of the consultation, it is not a unit I typically check. It is an overflow unit. Whenever social work staff is available they cover that unit."

Patient # #38
Patient #38 was observed on 01/17/2014 at 10:10 a.m. in her room on 4 South. The patient was alert with periods of confusion.
Review of the patient's clinical record ( history and physical dated 01/13/2014 ) revealed the patient was admitted to the facility with history of nausea, vomiting and diarrhea.
Review on 01/17/2014 of the patient's clinical record revealed a physician's order dated 01/13/2014 for " stools for C Dif. "
Review of the patient's clinical record ( nurses' notes located in the computer) revealed documentation which indicated that the patient had a bowel movement on 01/14/14 and 01/17/14.
There was no documentation that why the patient's stool sample was not collected for C Dif.

Interview on 01/17/2014 at 10:14 a.m. with the RN# 108 who was assigned to the patient revealed there was no documentation why the stool specimen was not collected.

Patient #34
Patient # 34 was observed in her room on 01/16/2014 at 11:58 a.m.. The patient complained of pain in her buttocks and right foot. The patient's right foot was not elevated. Observation of the patient's right foot and ankle revealed it was swollen with some deformity.
Interview on 01/16/2014 at 11:58 a.m. with the patient revealed the doctor had ordered a special boot for her right foot but she did not have it.

Review on 01/16/2014 of patient # 34's clinical record, revealed a physician's order dated 01/13/2014 for " Pneumatic walker/ Cam boots. " Physician ' s order dated 01/14/2014. " Elevate right foot "

Review of a podiatrist documentation dated 01/14/2014 revealed the following entry in the patient's clinical record. " R durral foot to ankle pain, contusion. Cam boot awaiting "
Podiatrist progress notes dated 01/16/2014 at 9:20 a.m. documented : " Still no boots. (+ pain ) (R) foot. Multiple right foot fracture. Still trying to get cam walker boot. "

Review of the report of a CT of the patient's right foot without contrast revealed the following entry: " Small non displaced cortical fractures are identified involving the proximal and distal dorsal cortex of the medial cuneiform -and at least the plantar aspect of the navicular bone at the first cuneonavicular joint. In addition a nondisplaced hairline fracture is identified trans versing the body of the lateral cuneiform bone. "

Interview on 01/16/2014 at 12:00 p.m. with the Registered Nurse ( #109) assigned to the patient revealed she had requested the boot for the patient the day before but it had not arrived on the unit. She said she did not know why the boots were not provided for the patient since it was ordered by the physician on 01/13/2014.
During the conversation with the registered nurse assigned to the patient , the boot arrived on the unit and was applied to the patient ' s right foot by the registered nurse assigned to the patient and the Administrative staff accompanying the surveyor.



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Patient # 39

Review of medical record revealed Patient # 39 was admitted to the facility on 10/13/2013 and was discharged on 10/21/2013 to a Nursing Home where she was a resident.

Review of history and physical revealed the 76 year old patient was seen in the Emergency Room on 10/13/2013 for abdominal pain. CT of abdomen and pelvis showed gallstones with mildly distended gallbladder. Ultrasound of abdomen showed findings suggestive of acute calculus cholecystitis and umbilical hernia.

Physician examination revealed Patient # 39 had erythematous rash suggestive of candida infection under both breasts, edema of lower extremities and patchy erythemia.She was alert and oriented x 3 with no focal deficit.

Review of wound images dated10/14/2013 showed multiple rashes on buttocks, legs and under her breasts. There was an order to consult wound care nurse dated 10/14/2013. The patient had a laparoscopic cholecystectomy and an open ventral hernia repair done 10/15/2013.

Wound consult was done on 10/15/2013 with documentation the patient had yeast rash to breast and abdominal fold being treated with nyastatin powder. Recommend xenaderm daily to bilateral lower extremities.

There was no documentation that xenaderm cream was ever used.


Review of wound care documentation revealed documentation dated 10/15/2013, that 4 lap sites on abdomen covered with Dermabond(dressing) and 4 x 4 gauze was clean dry and intact with small amount of drainage.
Documentation on 10/15/2013, 10/18/2013 and 10/19/2013 noted small amount of drainage from JP drain site.

On 10/21/2013 at 00:38 notes documented JP drain site with mild drainage, patient refused dressing change. No documented follow up or teaching re-importance of changing soiled dressing. There was documentation that there was no dressing changes done.
There was no orders for dressing change and no documentation the nursing staff requested an order although there were documentation that there was drainage on the dressing.

Review of physician orders and nurses notes revealed Patient # 39 had a Foley catheter inserted on 10/13/2013 in the emergency room . The patient There was no documentation that an evaluation for continued use of the Foley catheter was done. The catheter was removed on discharge 10/21/2013 seven (7) days after it was initiated.
Review of bath record for Patient # 39 revealed one (1) documented entry that a bath was given on 10/21/2013 date of discharge.

Patient # 44

Review of admission assessment documentation revealed Patient #44 was admitted to the Unit on 12/21/2013 with history of nausea vomiting and generalized tremor for several days. On admission there was documentation the patient was lethargic, not eating, she had stage two pressure ulcers on right and left buttocks. There was no documentation the patient ' s physician was informed until 1/12/2014 when a wound consult was ordered. The physician made orders for wound care on 1/13/2014 to turn patient every 2 hours, Xenaderm and foam to sacrum daily, and heel protectors to both heels. There was no documentation of nursing intervention for the pressure ulcers prior to 1/13/2014.

Patient # 37
Patient # 37 was admitted to the Unit on 1/10/2014 with history of diabetes, psoriasis,dementia and decreased range of motion.
Infectious disease physician examination notes dated 1/13/2014 documented the patient had 2+ pedal edema bilaterally, with blisters on the right lower extremity. He had Gangrene of the left great toe and also ischemic ulcers on the other small toes and onchomycosis and discoloration indicative of ischemia of his toes.

Review of nurses notes dated 1/10/2014-1/17/2014 revealed documentation the patient had ulcers on first left toe, first right toe, and fourth left toe. There was no documentation the physician was informed per facility's protocol. There was no documentation nurses obtained an order for wound management and there was no documented nursing intervention.

During an interview on 1/16/2014 at 10:15 am with Staff # 103 RN Manager of the Unit , baths are offered daily and as needed. Patients are bathed on the morning or evening shift. Linen change is done at bath time and as needed. The Manager stated staff is expected to document baths however it has been a challenge to get staff to do so.
According to Staff # 103 when a patient is admitted with pressure ulcer or when one is identified staff is to inform the physician and document on the patient ' s clinical record.
She stated all Foley catheters require a medical indication for use and an evaluation of the indication for continued use. This must be documented on the patient ' s clinical record.

Review of Policy/Procedure dated 5/2012 gave the following information:
"Because the majority of nosocomial urinary tract infections are associated with the use of an indwelling urinary catheter, careful evaluation of the initial indication for catheterization and the need for continued catheterization is necessary. Indwelling urinary catheters are inserted only when medically indicated and left in place only for as long as clinically needed due to the potential for complications. Urinary catheters are not used solely for the convenience of patient care personnel.

Indication for use documented as:
Peri-operative and or Diagnostic procedure
Urine output monitoring in critically ill patients
Management of acute urinary retention and obstruction
To assist in pressure ulcer healing for incontinent patients
Gross hematuria/irrigation."

Review of Policy/procedure dated 2/2013 for wound and skin assessment documentation revealed the following information:
"A Complete skin assessment and Braden scale risk assessment will be conducted on each patient at admission and every shift. This assessment is to be documented in Meditech. In addition, any wounds found are to be classified staged, measured, and documented. Upon wound discovery notify physician to obtain "Routine Wound Management'' orders which are located in e-demand or obtain other treatment options. Interventions should also be included as well as patient response to interventions. Plan of care should also be updated regularly to reflect changes.
All pressure ulcers present on admission should be reported to the physician upon discovery and documented in the admission assessment. Obtain orders for " Routine Wound Management Ordrers " or other treatment options as specified by the physician".

Based on observation, record review and interview, the facility failed to ensure dietary services were organized in regards to environmental sanitation for 2 of 2 kitchens.

Findings include:

Clear Lake Regional Medical Center (CLRMC)
Kitchen

Observations on 1/14/14 at 9:35 a.m. with the Dietary Director, #81, the Chef #82, and the Dietary Manager #83 revealed the following:
-the floor in cooler #1 was dirty with trash and grime
-in the dry pantry area the floors under the wire racks were dirty with trash, dirt and grime. Several plastic sheaths on the bottom shelves of the wire racks were dirty with grime to touch. There was a brownish dried liquid area under a corner shelf. Chef #82 said it may be prune juice that had spilled and dried.
Further interview with Chef #82, he said up until 3 to 4 weeks ago, they had a porter that cleaned the dry storage area, but he had to be moved to the dish area and other responsibilities.
Further observations of the kitchen at this time revealed the following:
-four convection ovens had a hard, thick build-up of baked on black/brown grease and grime inside and on the doors
-hot boxes with a build up of hard, brown grime, grease and dirt on the sides and hinges
-the grill had a thick build up of hard, black baked on grease and grime.
-floor under the fryer had a thick accumulation of grease and the back splash had a hard, thick accumulation of black baked on grease
-the catch pan under the stove had a one inch thick accumulation of food particles, grease and grime
Interview at this time with Chef #82, he said they were working short staffed. He said the bottom two ovens had been cleaned two weeks ago and the top two should have been done next, but he had to use the staff to help prepare meals. He said an outside company came in twice a week to clean the cooking oil and the fryer. He said the catch pans should be cleaned weekly.

Mainland Medical Center (MMC)
Kitchen
Observation 1/15/14 at 8:35 a.m. of the kitchen revealed the following:
-the fryer had two compartments with a thick build up of black baked on grime/grease in the seams. Two lids for the fryer sections had a thick accumulation of brown baked on grime/grease on the underside of the lids. The fryer had a two-door cabinet underneath. Inside were two foil containers full of grease and a thick build up of grease and grime on the bottom shelf under the containers and on the floor underneath the fryer unit.
Interview at this time with Dietary Director #84, she said the census had been high and they had been a little short of help.
-the tilt skillet had a thick accumulation of grease, grime, and dirt on the support structures, the control dials and on the floor.
-the oven had a thick accumulation of hard, black baked on grease/grime inside the oven, on the door and the back splash.
-the bottom shelf under the convection oven had an accumulation of grease and grime
-four prep tables placed touching in a square had an accumulation of grease and grime on the bottom shelves. The floor under the prep tables had an accumulation of grease, grime and trash.
-the stand up oven had a hard, thick accumulation of black/brown baked on grease and grime inside and outside the unit
-two standing production racks in the cooler had an accumulation of grime on the rims that supported trays.
-the production box had a thick accumulation of food and grime in the edges of the floor by the door. There was an accumulation of dirt and grime on the floor under the shelving.
-the thaw box had a thick build up of food and grime in the edges of the floor by the door.
-in the dry storage area there was an accumulation of grime and trash under two wire racks along one wall.
Interview on 1/15/14 at 1:45 p.m. with Dietary Director #84, she said she used to have a person who worked from 3:30 p.m. to 12 a.m. who just did the heavy cleaning. She said the position had been vacant since some time in November 2013. She said she had been trying to get the position filled. She said the cleaning was done by each person responsible for their area of the kitchen. She said they were down four staff: 1 cook, 1 heavy cleaning person, 1 part-time dietitian and 1 tech.
Observation on 1/15/14 at 1:55 p.m. revealed a two compartment plastic bucket on a lower shelf in the kitchen. Interview at this time with Lead Cook #94, she said she filled the bucket with water on one side and sanitizing solution (quaternary ammonium) from the 3 compartment sink on the other side about one hour ago. A check of the concentration of sanitizing solution in the bucket at this time revealed it was at 100 ppm (parts per million). Dietary Director #84 was present at this time and said the solution should be between 200 and 300 ppm. A check of the sanitation solution from the 3 compartment sink revealed it was between 200 and 300 ppm.
Record review of the Galveston County Health District Inspection Report for Food Sanitation for Mainland Medical Center dated 12/16/13 at 2:10 p.m. revealed compliance was "out" for "Food contact surfaces of equipment and utensils not clean/not sanitized/not in good repair."
2.6 If the sanitizing water is not within the acceptable limits the FSW reports the problem to a supervisor immediately and does not use the dish machine until the problem has been resolved...."

CLRMC
Kitchen
Observation at 1/16/14 at 8:10 a.m. with Assistant Administrator #106 revealed a catch pan under the burners of the stove in the steam table section that had an inch of dried, burned food particles, grease and grime.
Interview on 1/17/14 at 9:43 a.m. with Dietary Director #81 for CLRMC he said he had 23 years experience in food service. He said he was in the middle of getting certified as a Dietary Manager. He said he worked for a food company and contracted as the interim Dietary Director in September 2013 for CLRMC. He said he rounded weekly on Tuesdays with Infection Control Nurse #65. He said they looked at dates, labels, and dish washer temperatures. He said they looked at general cleanliness, cooler and freezer temperatures, warmers, food temperatures, ceiling tiles, holes, handwashing, and condition of products.
Interview on 1/17/14 at 9:30 a.m. with Chief Operation Officer (COO) #107 and Assistant Administrator #106, they were informed of the sanitation issues found in the CLRMC kitchen. COO #107 said the facility had an outside company that did the heavy cleaning twice a week. He said they would look at adding another day.
Record review of the Job Description for the Dietary Director reviewed on 8/06 revealed the following:
"E1. Responsible for overall management of the FANS (Food and Nutrition Services) Department...
E5. Monitors and evaluates staff, including direct supervision and inspection of employee activities.

Record review of the facilities' Policy and Procedure for Cleaning/Sanitation of food contact Surfaces dated 4/1/11 revealed the following:
"5.0 PROCEDURE
Food contact Surfaces
-Countertops and work areas are to be cleaned and sanitized after each meal, as well as throughout the preparation times....
-To sanitize effectively, follow all directions carefully....Use test tapes provided to determine if sanitizing solution is adequate....
5.2 Walk-in Refrigerators, Freezers and Air Curtains
5.2.1 All walk-ins will be maintained for sanitation and safety according to established guidelines.
5.2.2 Walk-in refrigeration units will be cleaned thoroughly weekly. Any visible soil or spills will be cleaned up as they occur....
5.3 Dry Storage...
5.3.1 Inventory Clerk is responsible for ensuring that all racks, floors and items stored are organized and free of dust or debris.
5.3.2 All FANS [Food and Nutrition Service] employees are responsible for ensuring that all storage areas are organized and cleaned daily.
5.3.3 Dry Storage:
5.3.3.1 Storage areas are to be cleaned one section at a time.
5.3.3.2 ....(shelves are to be cleaned monthly or as soon as spills/drips occur)...."
5.2.28 Proper cleaning procedures for floors/walls/shelves to be maintained daily and as scheduled."

Based on observation, interview and record review, the facility failed to implement its policy and procedure when discontinuing patient's central venous catheter during hemodialysis treatment; failed to wash/clean hands after direct contact with patients and contaminated equipment, failed to administer antibiotic medication at scheduled times for patient with infection, failed to maintain environmental sanitation in the emergency room and rehabilitation unit, failed to implement its policy and procedure to label a peripheral intravenous line with date and time; failed to apply mask to a patient during insertion of Peripherally Inserted Central Catheter (PICC) and failed to change gloves and wash hands during wound care in 10 of 44 sampled patients . Patient #s 11, 12, 13, 14 , 15, 16, 17, 19, 22, 23)

Findings:

Central Venous Catheter Care
Patient #22
On 01/14/2014 at 10:15 a.m. patient (#22) was observed in the hemodialysis unit of the facility receiving hemodialysis. The patient had a central venous catheter to the jugular region. On 01/14/2014 at 10:20 a.m. Registered Nurse (#80) was observed discontinuing the external blood line from the patient's central venous catheter. During discontinuation of the central venous catheter, the registered nurse applied a plastic apron, donned a pair of gloves, and applied a mask to her face. The nurse used the gloves she had used to mask her face to access the patient's central venous catheter. During application of the mask to her face the gloves became contaminated from direct contact to the nurse's ears and hair
The registered nurse disconnected the patient's external blood line from the hubs of the patient's central venous catheter. Registered Nurse ( # 80) did not clean/ disinfect the hub of the catheter prior to discontinuing it from the external blood lines.

During an interview on 01/14/2014 at 11:05 a.m. with Registered Nurse (# 80) the Surveyor notified her that she did not clean the hub of the central venous catheter before accessing it and that she had used the gloves she had used to apply her mask to her face. Registered Nurse #(80) stated " I am sorry. "

Patient #15
On 01/15/2014 at 9:15 a.m. Registered Nurse (#72 ) was observed discontinuing patient # (#15's ) external blood line from her central venous catheter, post hemodialysis treatment.
During discontinuation of the catheter the registered nurse was observed wearing a plastic apron which protected the front of her clothing. She was not wearing a gown with sleeves.
During discontinuation of the patient's hemodialysis treatment , the contaminated, bloody blood lines were observed in contact with her arms which were not covered.
During discontinuation of the patient's central venous catheter, the registered nurse did not create a clean field to store the syringe with normal saline and Heparin used to pack the catheter post hemodialysis treatment. Registered nurse ( #72 ) removed the Normal Saline syringes from their wrappers and placed them on the blanket of the patient. She then flushed and packed the patient ' s central venous catheter utilizing the syringes stored on the patient ' s bed. The patient is transferred to the unit in her bed with the blanket which is potentially contaminated.

Review on 01/14/2014 of the facility's current policy and procedure on Discontinuation of Dialysis via Hemodialysis Catheter , # 749- 017 directed facility ' s staff as follows: " Wash hands, Place barrier under catheter Y, Rub hub with Chlorascrub swab for 10 to 20 seconds. "
Policy # 749- 023 Infection Control - Standards in Dialysis Unit and Cleaning of Equipment directed staff as follows " A Septic technique will be used during initiation and discontinuation of dialysis procedure"

HAND WASHING
Patient #15
On 01/15/2014 at 9:08 a.m. Registered Nurse ( #72) was observed at the bedside of the patient #15 ( hemodialysis unit) who was receiving hemodialysis treatment. Observation revealed registered nurse (#72 ) donned a pair of gloves and reset the alarms of the patient ' s hemodialysis machine. While resetting the alarms the telephone on the wall rang. She then used her disengaged hand to retrieve the telephone on the wall and spoke to the party on the end of the telephone.
She then removed her contaminated gloves and proceeded to write orders on the patient's clinical record located at the bedside of the patient. The registered nurse used her contaminated hands to touch and handle the hard copy of the patient's clinical record located on the overbed table at the patient's bedside. She did not wash/ clean her contaminated hands after removing the contaminated gloves used to touch and reset the alarms on the patient ' s hemodialysis machine.
Subsequent observation at 9:15 a.m. revealed Registered nurse ( # 72) reset the patient's hemodialysis and handled the patient's blood line. She then removed one hand of her contaminated glove, held it in her left hand while using her right hand to chart on the patient's treatment sheet located on the bedside table. The treatment sheet is filed into the patient's chart post hemodialysis treatment of the patient.

Patient #16
On 01/15/2014 at 9:45 a.m. Patient # ( 16) was observed in the facility's intensive care unit. The patient was receiving hemodialysis treatment via a triple lumen catheter, had a Foley catheter in place to bedside drain .
Interview on 01/15/2014 at 9:45 a.m. with the registered nurse assigned to the patient revealed she was admitted to the facility with a diagnosis of sepsis, urinary tract infection , currently on contact isolation for Clostridium Defficile . The nurse said the patient was on antibiotic therapy of Flagyl and Zosyn.
Subsequent observation on 01/15/2014 at 9:46 a.m. revealed the patient's attending infectious disease physician ( #73) , donned a gown and pair of gloves and entered the patient's room. The physician utilized his personal stethoscope to examine the patient's breath sounds. He then returned the contaminated stethoscope to his laboratory coat which he wore under the gown.
He touched the patient's Foley bag, then removed his contaminated gloves and exited the patient's room.
The infectious disease physician exited the patient's cubicle and entered the nurses' station. He did not wash/ clean his contaminated hands. On entering the nurses' station a nurse offered the physician an alcohol swab to clean his stethoscope. The physician cleaned the stethoscope with the alcohol pad and returned it to his contaminated laboratory coat pocket.

During an interview on 01/15/2014 at 9:50 a.m. with the infection control physician (#73) , the Surveyor notified him that she the Surveyor observed that he had examined the patient and did not wash his hands. He stated " You are absolutely right you caught me. "
Review of the patient's clinical record ( Physician's progress notes) revealed an entry which as follows : 1/14/14 " C diff associated with colitis "

Review of the Center for Disease Control article Rationale for Hand Hygiene Recommendations after Caring for a Patient with Clostridium difficile Infection Fall 2011 update documented : " alcohol does not kill C difficile spores. In addition several studies have found that handwashing with soup and water or with antimicrobial soap and water, to be more effective at removing Cdificile spores than alcohol based hand hygiene products from the hands of volunteers inoculated with known number of C difficile spores."

Patient #19
On 01/15/2014 at 10:26 a.m. patient # (19 ) was observed in the coronary care unit of the facility. The patient had an endotracheal tube to ventilator and a Foley catheter to bedside drain.
Observation on 01/15/2014 at 10:26 a.m. revealed registered nurse ( #75) was observed providing direct care to the patient and handling the patient's tracheostomy tubes. After completing the care the nurse removed her contaminated gloves and then proceeded to the computer and entered information in the computer. The registered nurse did not clean/ wash her contaminated hands.
Interview on 01/15/2014 at 10:28 a.m. with registered nurse (#75 ) revealed the patient has a diagnosis of sepsis and was receiving antibiotic of Vancomycin.
During an interview on 01/15/2014 at 10;28 a.m. with Registered Nurse (#75 ), the surveyor informed the nurse that she the Surveyor had observed that she did not wash/ clean her hands after removing her contaminated gloves. The registered nurse said she washed her hands before entering the patient's room.
Review of the patient's clinical record revealed a diagnosis of cellutitis of the leg with physician ' s order for Vancomycin 1 gm, every 12 hours and Meropenem I gm every 8 hours.(Meropenem is an ultra-broad-spectrum injectable antibiotic used to treat a wide variety of infections. )

Patient #17
On 01/15/2014 at 11:10 a.m. patient # (17 ) was observed in room 341. The patient had returned from the operating room. Observation at that time revealed Registered Nurse ( #74) was observed handing over the patient's care to the nurse on the unit.
Registered Nurse (#74 ) donned a pair of gloves and retrieved a marker from her pocket. She then used the marker to circle the dressing on the patient's right leg, left leg and sacral area. The wound dressings were saturated with drainage from the post operative sites.

The registered Nurse notified the accepting nurse that the patient had incision and drainage of boils on her right leg, left leg and buttocks and that patient's wounds dressings were saturated. She then outlined the periphery of the drainage on the dressings using her marker. She then returned the contaminated marker to her pocket, removed her contaminated gloves and retrieved the patient's chart with her contaminated hands. Registered Nurse (#74 ) did not clean / disinfect her contaminated hands.
On 01/15/2014 at 11:15 a.m., the Surveyor notified Registered Nurse (#74 ) that she did not clean/ wash her contaminated hands and clean her marker. She stated "I can clean it now."

Review of the facility's current policy and procedure on Infection Prevention and Control, # 946-06-001 directed staff as follows: " Clean hands are the single most important factor in preventing the spread of pathogens and antibiotics resistance in healthcare settings. Hand hygiene reduces the incidence of healthcare associated infections. "
" Hand Hygiene is indicated :" Before and after touching a patient, Before Clean/Aseptic procedures. After contact with body fluids or excretions, mucous membranes, non intact skin and wound dressings, Before moving from a contaminated - body site to a clean- body site during patient care, After contact with inanimate objects ( including medical equipment) in the immediate vicinity of the patient, After removing gloves, Before meals or eating snacks After personal use of toilet."

MEDICATION ADMINISTRATION
Patient #23
On 01/14/2014 during tour of the facility's CV intermediate Care unit ( Patient # 23) was observed in his room. An isolation cart was stationed outside the patient's room.
Interview on 01/14/20 01/ at 11:45 a.m. with the registered nurse( # 78) assigned to the patient revealed, the patient was admitted to the facility with diagnosis of Sepsis of a wound, but she did not know where the wound was located on the patient. She said the patient was receiving intravenous antibiotic for Vancomycin Resistant Enterococci. She said the patient was on isolation precaution for Vancomycin Resistant Enterococci .

Observation on 01/14/2014 at 11:50 a.m. of the patient revealed he had a left subclavian intravenous line in place. The patient was receiving Flagyl 500 mg intravenous. Hanging on the pole was Maxipen 1 gm in normal saline. The Maxipen was not been infused.

Interview on 01/14/2014 at 11: 52 a.m. with the Registered Nurse ( #78) assigned to the patient revealed the patient should have received Flagyl at 7:30 a.m. and the Maxipen should have been administered at 9:00 a.m. She said the patient was on isolation precaution for Vancomycin Resistant Enterococci.

Review on 01/16/2015 of the patient's clinical record revealed a physician's order dated 01/12/2013 for Flagyl 500 mg in 100 mls Normal Saline . The medication was scheduled to be administered at 7:30 a.m. and infused over one hour.
Review of the Medication Administration Record located in the computer revealed documentation that the medication was started at 10:41 a.m., i.e. three hours and 11 minutes past scheduled medication administration time.

Review of the Medication Administration Record revealed documentation which indicated that the medication, Maxipen was administered at 10:44 a.m. on 01/14/2014. Observation on 01/14/2014 at 11:50 a.m. revealed the medication had not started.

During an interview on 01/14/2014 at 11:52 a.m. with registered nurse ( #78) who was assigned to the patient, the Surveyor told the nurse that she had observed that the patient's antibiotic were not been administered at the scheduled time. Registered Nurse ( # 78 ) said she was "Swamped) and running behind because she had five patients and normally she is assigned 4 patients.



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Emergency Room
Observation 1/14/14 at 9:50 a.m. in the emergency department revealed the following:
-In the triage area there was a metal mayo stand with a dried blood stain the size of a penny.
-In the fast-track holding area dust / lint was noted on top of the cardiac monitors in room # ' s 1, 2, 3 and 4.
-At the nursing station three fabric chairs were noted to be heavily stained on the back portion. The arms of the chairs were also heavily stained.
-Treatment room # 18 had an overhead light used for suturing and the top surface was covered with a dust and lint.
-A vinyl chair was observed outside room #4 in the hallway. The vinyl in the seat of the chair had a 3 inch tear in the vinyl.

Rehabilitation Unit
Observation on 1/14/2014 at 10:50 am on 5 East Rehabilitation Unit at the facility revealed there was eight (8) semi private rooms and 16 patients. The unit was at capacity at the time of observation.
Further observation at that time revealed patient rooms were cluttered with various types of dusty exercise equipment.
The floor of patient rooms, hallways and the exercise gym had a dull discolored appearance with black streaks through the tiles possibly from a buildup of wax and dirt. There was a buildup of dust grains in the corners of the floors.
Doors to patient rooms had large chips and there were cracks in wall sidings in the hallway.

Observation revealed hand sanitizer dispensers mounted on walls inside and outside patient rooms had heavy build up of dust grains and dust webs at the base and on the tops.
Exercise equipment in the gym such as the light weight thread mil, parallel bar, standing frame and large exercise balls had heavy buildup of dust grains, dust webs and grease. Computer cart was also greasy and had a buildup of dust.

During an interview on 1/14/2014 at 11:15 am Staff #104 Unit Manager he stated the floor need stripping but the unit was constantly at capacity and it was difficult to get the cleaners in. The manager acknowledged the Unit needed cleaning and stated staff would get on it right away.

During an interview on 1/14/2014 at 1:35 pm with Staff # 68 RN Director who was touring with the Surveyor at the time of the observation, she stated a meeting was convened with housekeeping supervisor and staff on the Rehabilitation Unit and staff were assigned to immediately clean the unit. She stated a plan for continued cleaning and monitoring would be implemented.





33438

Failed to implement its policy and procedure to label a Peripheral Intravenous line with date and time; failed to apply mask to a patient during insertion of Peripherally Inserted Central Catheter (PICC), failed to change gloves and wash hands during wound care.

Findings:

Registered Nurse #(68)
On 01/15/2014 at 10:00a.m. Surveyor was in the Medical Surgical 5th floor unit for tour. During an observation and interview in Room 560, patient (11) stated "I am ready to go home today." Noted a Peripheral Intravenous line (IV) on Left upper arm without date and time of insertion. The Surveyor asked the patient when was it inserted, she said "This IV line was started on January 12 when I was at the Emergency Center in Pearland then I was admitted here, and they are using the same IV line". Surveyor called one of the hospital's Medical Surgical Directors (#68) seen the patient's IV that had no date and time of insertion.
During observation on 01/15/2014 at 10:35 a.m. the Surveyor went to Room 561 and interview patient (12), noted a Peripheral Intravenous line (IV) on Left lower arm without date and time of insertion. The Surveyor asked the patient when was it inserted, she said "It was placed yesterday". Surveyor called one of the hospital's Medical Surgical Directors (#68) seen the patient's IV that had no date and time of insertion.
During record review on 1/15/2014 at 10:45 a.m. the Surveyor requested patient (#11) chart, admitted on 1/12/2014 due to flank pain, no assessment note about Peripheral IV. Record review on 1/15/2014 at 10:55 a.m. the Surveyor requested patient (#12) chart, it showed the patient admitted on 1/9/2014 due to small bowel obstruction, no assessment note about Peripheral IV. The Surveyor asked for a policy about IV Therapy, the hospital's Medical Surgical Director (#68) provided a copy of policy title : "IV Therapy" in section 5.3 Procedure 5.3.21 stated "Label dressing with date, time, and size of needle".

Registered Nurse # (70)
On 01/15/2014 at 01:10 p.m. Surveyor was in the Radiology room to watch the PICC line procedure. Registered Nurse (#70) was observed preparing patient (#13) for PICC line insertion in Radiology room, drape was applied on the patient's body but no mask. PICC line insertion began by Registered Nurse (#70) at 01:15 p.m and ended at 01:35 p.m the patient did not wear a mask.
During an interview conducted on 1/15/2014 at 1:40 p.m with Registered Nurse#70, the Surveyor verified if the patient needs to wear mask during PICC line insertion, she said "It is not in included in our PICC line insertion policy."
During record review on 1/16/2014 at 08:30 a.m. Surveyor requested hospital's policies and procedures related to PICC line insertion, at 08:50 a.m. from one of the hospital's Cardio Vascular Directors (#66) provided Policy Title: 600-133 PICC-Insertion ,Maintenance, and Removal for Adult patients (MAINLAND CAMPUS ONLY) Section 4.2 bullet #8 says "The patient's face should be draped and/or patient should wear mask".
On 1/17/2014 at 11:30 a.m. The Surveyor received another hospital's policies and procedures related to PICC line insertion, from one of the hospital's Critical Care Service Line Director (#54) provided Policy Title: 600-133 PICC-Insertion ,Maintenance, and Removal for Adult patients Section 8.0 under 8.2. "PICC/Midline to be inserted using maximum barrier precautions". Surveyor verified with the hospital's Critical Care Service Line Director (#54) about the meaning of maximum barrier precautions, and she replied "The PICC team uses Lippincott procedure for PICC line insertion", the hospital's Critical Care Service Line Director (#54) provided the copy of the Lippincott procedure handed to Surveyor page 5 bullet # 21 says "Place a full body drape over the patient from head to toe. Cover everything except the insertion site to comply with maximal barrier precautions and, therefore, reduce the risk of central line related blood stream infection." Surveyor asked if which among these two policies is used by the hospital she replied "This one that I gave you because the other one is for Mainland Campus only".

Registered Nurse #(96)
On 01/16/2014 at 09:35 a.m. The Surveyor was in the Medical Surgical 5th floor unit to watch wound care procedure. Registered Nurse (#96) was observed removing old wound dressing in patient (14) then picked up a clean soaked gauze with Dakin Solution using the same gloves, she removed the contaminated gloves then took another pair of clean gloves without hand hygiene in between.
During an interview on 01/16/2014 at 09:43 a.m with Registered Nurse (#96) , the Surveyor told her that hand hygiene was missed in between of performing wound care she stated "I washed my hands prior to starting this entire procedure", the Surveyor verified procedure about wound care that is followed in the hospital and she answered "I follow whatever the doctor's order in the chart." Surveyor clarified to Registered Nurse JW that hand hygiene must be performed in changing gloves she replied "Yes you are right".
During record review on 1/16/2014 at 10:00 a.m. The Surveyor requested hospital's policies and procedures related to wound care, at 10:05 a.m. from one of the hospital's Medical Surgical Directors (#68) she said "We follow Lippincott Procedure about wound care", she provided a copy of a Lippincott procedure titled "Moist Saline Gauze Dressing Application" pages 3 to 4 bullets #2 and 3 say "put on gloves and other personal protective equipment, Discard the soiled dressing, inspect the wound, remove and discard your soiled gloves, perform hand hygiene and put a new pair of sterile or clean gloves, as indicated."