HospitalInspections.org

Based on document review and staff interview, the facility failed to submit a hospital budget plan to the state planning agency as required by the regulation. The facility identified 1 hospital budget plan prepared per fiscal year.

Failure to submit the hospital's capital budget to the state planning agency could potentially result in the hospital engaging in an expansion, or other major renovation to their facility, without the knowledge of the state planning agency.

Findings include:

1. Review of documentation revealed the facility lacked a policy/procedure that addressed the development and approval of the annual budget or the submission of the facility's budget plan to the State health planning agency.

Review of the Board of Director's Meeting Minutes, dated October 3, 2012, revealed the Board approved the facility's Fiscal Year 2013 Operating and Capital Budget. However, the document failed to show the facility submitted the 2013 Operating and Capital Budget to the State planning agency.

2. During an interview and review of the facility's budget plan on 1/30/13 at 9:40 AM, the Chief Financial Officer (CFO) acknowledged the facility failed to submit the Fiscal Year 2013 Operating and Capital Budget to the State health planning agency and had not done so for the past two years. The CFO further stated the facility failed to have a policy that addressed the facility's budget.

3. During an interview on 2/4/13 at 11:30 AM, the CFO provided documentation to show the facility sent the facility's Fiscal Year 2013 Operating and Capital Budget to the state health planning agency on 1/31/13 after the surveyor brought it to the facility's attention.

Based on review of policies, procedures, water culture, endotoxin (an endotoxin is a bacterial toxin produced within some bacteria that is released when the bacteria disintegrate potentially causing the hemodialysis patient to experience pyrogenic symptoms that could include fever, chills, and hypotension) documents, chlorine logs, AAMI (Association for the Advancement of Medical Instrumentation)Water Quality reports and staff interviews, the facility failed to ensure that CS A (Contracted Service A) implemented a system to ensure that all monthly water cultures, endotoxins, daily chlorine logs, and quarterly AAMI water quality reports from 1/1/2012 through 12/31/12 were signed and dated to indicate review by the CS A Medical Director and Inpatient Program Coordinator for acute inpatient hemodialysis. The facility provided approximately 143 dialysis treatments between 1/1/12 and 12/31/2012.

Failure to have a system in place that oversees and ensures that the water quality used for acute inpatient hemodialysis that includes, monthly water cultures, quarterly AAMI water quality reports and chlorine logs are reviewed could potentially allow for unsafe water to be used for the hemodialysis treatment and could potentially cause illness and/or death to the hemodialysis patient.

Findings include:

1. Review of the CS A inpatient services facility policy titled, "Microbiological Monitoring: Portable Water Purification Systems for Inpatient Services", Effective Date 29-FEB-2012, includes in part, "...To define the monitoring of microbiological contaminant level in treated water...applies to Portable water purification systems for inpatient services...Responsibility...[CS A] staff...Pre and post cleaning and disinfection microbiological samples will be collected at a minimum of monthly...Monthly trending of results shall be completed and presented at QAI meeting..Medical Directors must sign the monthly summary report of all microbiological sample results...

-Review of the CS A inpatient services facility policy titled, "Microbiological Monitoring: Dialysate for Inpatient Services, Effective Date 29-FEB-2012, includes in part, "...Defines the monitoring of the microbiological contaminant levels in final dialysate... applies to all hemodialysis machines...Manager...Ensure microbiological monitoring data is presented and reviewed at the monthly QAI (Quality Assessment and Performance Improvement) meetings...Routine sample...When to test...Minimum of monthly...Medical Directors must sign monthly summary report of all biological sample results..."

-Review of the CS A inpatient services facility policy titled, "Instructions for Completing the Inpatient Total Chlorine Log for Portable Water Systems, Form IP-PS-TCL-1," Effective Date 15-JUL-2009, includes in part, "...Purpose to provide instruction for the correct documentation of the Inpatient Portable System Total Chlorine Log...this document applies to all [CS A] Inpatient Services locations...Responsibility...Medical Director...Review and sign summary reports regarding the...log sheet at the Quality Assessment and Performance (QAI) meetings...Enter the date the Inpatient Program Coordinator...reviewed the document..."1. Indicate facility name...2 Indicate facility location number... 8. Signature of the Inpatient Program Coordinator...has reviewed the document...9. Enter the date the Inpatient Program Coordinator reviewed the document...10. Enter the ID number for the portable RO equipment..."

-Review of the document titled, "MEDICAL DIRECTOR AGREEMENT" included in part, "...This MEDICAL DIRECTOR AGREEMENT is made by and between ...[CS A] ...and Associates in Kidney Care...9. Oversee the safety and quality of the water used for patient treatments...The Medical Director shall...Ensure, as leader of the IA Committee, that water and dialysate monitoring is continuously reported to the AI Committee...Review and sign each month the following reports: AM water quality reports, chlorine and chloramines logs and endotoxin/colony count reports..."

2. Review of the documents titled "Portable RO 1 Outlet," (Portable RO - Portable Water Purification Systems) monthly water culture and endotoxin laboratory reports from 1/1/12 through 12/31/12, showed CS A Medical Director failed to initial 7 laboratory culture result documents indicating review of the culture results, dated 2/26/2012, 4/21/12, 4/22/12, 11/14/12, 11/17/12, 12/22/12, and 12/25/12.

-Review of the documents titled, "Portable RO 2 Outlet, monthly water culture and endotoxin laboratory reports from 1/1/12 through 12/31/12, showed CS A Medical Director failed to initial 11 laboratory microbiological culture and endotoxin result documents to indicate review of the culture and endotoxin results dated 2/26/12 11:45 AM and 3:30 PM, 4/21/12 11:30 AM and 3:00 PM, 6/23/12 10:00 AM and 2:30 PM, 7/14/12 9:00 AM and 1:00 PM, 11/17/12 10:00 AM and 2:00 PM, and 12/22/12.

-Review of the documents titled, "Distribution Loop 3, Return," monthly water culture and endotoxin reports from 1/1/2012 through 12/31/12, showed CS A Medical Director failed to initial 8 laboratory microbiological culture and endotoxin report to indicate review of the culture and endotoxin results occurred for 2/26/12 11:30 AM and 3:30 PM, 4/21/12, 4/22/12, 6/23/12 10:00 AM and 2:30 PM, and 7/14/12 9:00 and 1:00 PM.

3. Review of the documents titled, "Inpatient Portable RO Machine Total Chlorine Log," BW-1 (Better Water, a brand of RO). The log included an area at the bottom left for the Inpatient Nurse Manager to sign and date. The document included entries for chlorine checks completed by staff on 40 treatment days from 1/11/12-12/12/12. Further review of the chlorine log documents lacked documentation that the logs were reviewed, signed and/or dated by the CS A Inpatient Nurse Manager and/or the CS A Medical Director.

-Review of the documents titled, "Inpatient Portable RO Machine Total Chlorine Log", BW-2. The log included an area at the bottom left for the Inpatient Nurse Manager to sign and date. The document included entries for chlorine checks completed by staff on 35 treatment days from 5/14/12-12/6/12. Further review of the chlorine log documents lacked documentation that the logs were reviewed, signed, and/or dated by the CS A Inpatient Nurse Manager and/or the CS A Medical Director.

-Review of 4 documents titled, "Inpatient Portable RO Machine Total Chlorine Log" that included entries for chlorine checks completed by staff on 14 treatment days from 5/2/12 through 8/22/12 failed to identify which RO machine was used, and lacked documentation that the logs were reviewed and/or signed by the CS A Inpatient Nurse Manager and/or the CS A Medical Director.

4. Review of 3 documents titled, "Environment Test Report," that included the AAMI quarterly water analysis results for RO BW-1, RO BW-2, and city water dated 12/26/12 and 12/29/12 respectively, showed CS A Medical Director failed to initial the final water analysis reports indicating review of the AM water analysis reports.

5. During an interview on 1/30/13 at 9:20 AM, the Acute Dialysis Manager and the Inpatient Dialysis Coordinator acknowledged that the monthly culture, endotoxin, and chlorine logs failed to include the CS A Medical Director and Inpatient Clinic Manager's signature to indicate review of the documents. The Acute Dialysis Manager reported that it is the facilities policy that the CS A Medical Director initial the culture and endotoxin laboratory results and monthly chlorine logs to indicate review by the CS A Medical Director.

Based on document review, staff, and patient interviews, the facility failed to ensure patients (or support person where appropriate) were informed of their visitation rights, including the ability to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend for 11 of 11 patient records reviewed. (Patients # 1, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18) The facility had 1 Patient Rights and Responsibilities policy and 1 Visitors policy. The facility identified a current census of 51 in-patients at the time of the survey.

Failure to inform patients of their visitation rights could potentially result in the staff failing to extend visitation rights to all patient populations.

Findings include:

1. Review of "Patient's Bill of Rights" brochure, provided to the patient upon registration, failed to inform patients of their visitation rights, including the ability to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

-Review of "Patient Information and Visitors Guide" booklet, provided to the patient upon admission, failed to inform patients of their visitation rights, including the ability to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

-Review of policy/procedure titled, "Patient Rights and Responsibilities," dated 6/11, showed the facility had the correct language in the policy including the patient's right to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

-Review of policy/procedure titled, "Visitors Policy," dated 12/12, approved by the Board of Directors on 1/17/13, showed the facility had the correct language in the policy including the patient's right to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

Review of documentation in patient medical records revealed the following patients signed they received a copy of the Patient Bill of Rights:
- Patient # 1 - admitted 1/30/13
- Patient # 8 - admitted 1/28/13
- Patient # 9 - admitted 1/19/13
- Patient # 10 - admitted 1/28/13
- Patient # 11 - admitted 1/27/13
- Patient # 12 - admitted 1/28/13
- Patient # 13 - admitted 1/28/13
- Patient # 14 - admitted 1/26/13
- Patient # 15 - admitted 1/28/13
- Patient # 16 - admitted 1/28/13

2. During interviews on 1/28/13 at 11:50 AM, Patients # 17 and # 18 verified they were informed of their patient rights.

-During an interview on 2/4/13 at 3:55 PM, the Patient Relations Representative acknowledged the patients received the "Patient's Bill of Rights" brochure and the "Patient Information and Visitors Guide" booklet upon admission. The Patient Relations Representative further acknowledged the patient rights information provided did not include the patient's right to receive designated visitors including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

-During an interview on 2/5/13 at 7:50 AM, the Interim Chief Nursing Officer (CNO) verified the language in the "Patient's Bill of Rights" brochure and the "Patient Information and Visitors Guide" booklet had not been updated to include the requirements of the regulations: the right to receive visitors whom you designate, including, but not limited to a spouse, a domestic partner (including a same sex domestic partner), another family member or friend. The CNO further acknowledged the appropriate policies/procedures had been updated but the information provided to the patient to inform them of their rights related to patient visitation rights had not yet been updated.

Based on document review, observation, and staff interview, the facility failed to document manufacturer's recommended shortened expiration date on 2 of 2 vials of Anectine (Succinylcholine Chloride, a drug used during general anesthesia) in an anesthesia cart. The facility identified an average of 270 surgical procedures using general anesthesia performed at the facility per month.

Failure to document the manufacturer's recommended shortened expiration date on the Anectine could potentially result in the anesthesia providers using drugs with reduced potency on patients.

Findings include:

1. Review of the manufacturer's directions for Anectine (succinylcholine chloride), dated 4/11, revealed in part, "Store in refrigerator ... vials are stable for up to 14 days at room temperature without significant loss of potency."

2. Observations during a tour of the pre-surgical holding area on 1/29/13 at 7:30 AM revealed 2 anesthesia carts (a cart with several drawers that contain supplies and medications). Observations in 1 of the 2 anesthesia carts revealed 2 of 2 vials of Anectine stored at room temperature. Further observation of the Anectine revealed the pharmacy staff labeled the vials of Anectine with shortened expiration dates of 2/26/13 (28 days after date of observation) and 3/14/13 (44 days after the date of observation).

3. Interviews revealed:

- on 1/29/13 at the time of the observations, Anesthesiologist A (a physician with specialized training in the administration of medications to relieve pain during surgery), who was present during the observations, stated the pharmacy stocked both anesthesia carts with identical medications on a tray. The pharmacy staff removed the medication trays daily, and stored the medications in the pharmacy overnight. The pharmacy staff labeled the vials of Anectine with a shortened expiration date once they removed the Anectine from storage in the refrigerator.

- on 1/29/13 at 11:50 AM the Pharmacy Manager stated the pharmacy staff stocked the medication trays in the anesthesia carts, and stored the trays at room temperature in a secured location in the pharmacy overnight. When the anesthesiologists used a vial of Anectine, the pharmacy staff removed a vial of Anectine from the pharmacy's refrigerator. The pharmacy staff labeled the vial of Anectine with a shortened expiration date (a date prior to the manufacturer ' s printed expiration date, due to the drug loosing potency faster at room temperature) 3 months after the date they removed the vial from the refrigerator.

After reviewing the manufacturer's directions for Anectine, the Pharmacy Manager acknowledged the manufacturer required the pharmacy staff to document a shortened expiration date of 14 days, not 3 months, on the vials of Anectine. The Pharmacy Manager stated the pharmacy staff would remove all of the Anectine with a 3 month shortened expiration date from the anesthesia carts.

Based on observation, review of documents and staff interviews the facility failed to ensure expired supplements and puddings from the stock supplies were not available for patient use. The hospital identified a census of 51 patients.

Failure to remove all expired supplements and supplies from the stock supplies could potentially result in ingestion of harmful products.

Findings include:

1. Observation on 1/28/13 at 1:30 PM, with the Director of Nutritional Services, revealed 3 of 3 chocolate Glucerna 8-oz. ( a nutritional supplement) supplements expired on 1 Jan 13 in the dietary storeroom, ready for patient use.

-Observation on 1/28/13 at 3:30 PM, with the Director of Women and Family Care, revealed the unit had a census of 2 obstetric/gynecological patients. The following expired nutritional supplements were available for patient use in the labor and delivery diet kitchen:

3 of 5 Kozy Shack chocolate pudding expired on 1/24/13
1 of 6 Kozy Shack sugar free vanilla pudding expired on 1/12/13
7 of 7 Kozy Shack vanilla pudding expired on 1/25/13
3 of 6 Kozy Shack SmartGels Tropical expired 1/12/13
The puddings and SmartGels were in the refrigerator, ready for patient use.

2. Review of policy titled Dietary Food Safety-Dating, reviewed on 10/1/10 sated in part ...The purpose of this policy is to ensure the safety of all food items. Dietary Department Storage-Any expired items will be disposed of immediately. At the time of delivery any expired food items-nourishments inpatient refrigerators on the nursing units or food items that would expire within 24 hours will be disposed of by the dietary nourishments staff member immediately.

3. During an interview on 1/28/13 at 1:30 PM, the Director of Nutritional Services verified the expired supplements were available for patient use.

-During an interview on 1/28/13 at 3:30 PM, the Director of the Women and Family Unit verified the expired puddings and SmartGels were available for patient use.

I. Based on observation, review of documents and staff interviews, the facility staff failed to remove all food debris and other debris from the tray line drip tray conveyor belt, 2, 4-slice toasters, range hood, flat top griddle, and stainless steel shelving in the dietary department. The facility identified a census of 51 patients.

Failure to remove all food debris and other debris from the equipment in the dietary department could potentially result in contaminated food served to patients, staff and guests.

Findings include:

1. Observation on 1/28/13 at 1:30 PM, with the Director of Nutritional Services, revealed the following:

-The tray line drip tray conveyor belt contained a moderate to large amount of dried on food debris, lint, dust, and paper wraps from food condiments.

-2 of 2- 4-slice toasters with large accumulations of bread crumbs, and a black-brown dried on black debris

-1 of 1- range hood with large accumulation of lint and dust on the removable filters

1- of 1- flat top griddle with large accumulation of black-brown dried on debris on the back and sides

-Stainless steel shelving holding clean pots/pans with large amount of dust and lint build-up.

2. Review of facility policy titled Cleaning Schedules reviewed dated 9/09, stated in part. Schedules for cleaning are established for equipment and the general Food Service areas of the facility. Daily cleaning duties are assigned to each job duty. These duties are posted in a visible location within the department. These duties must be completed prior to clocking out at the end of the shift.

-Review of the invoice for the contract cleaning company dated 11/2/12 showed cleaning of 2 hoods.

-Review of cleaning schedules for January 2013 lacked documentation that showed staff cleaned the shelves holding the pots/pans, tray line drip tray conveyor belt, toasters, or flat top griddle.

3. During an interview on 1/28/13 at 1:30 PM, Director of Nutritional Services, verified the above findings during the initial tour of the dietary department.



27303


II. Based on document review, observation, and staff interview, the facility failed to ensure surgical services staff followed the manufacturer's directions for use of a disinfectant during 2 of 2 observations of the surgical services staff cleaning the operating room after a patient had surgery in the room. The facility identified an average of 270 surgical procedures performed at the facility per month.

Failure to follow the manufacturer's directions for the disinfectant could potentially result in the disinfectant failing to kill all bacteria on the surface, and the bacteria possibly spreading to a patient, causing an infection.

Findings include:

1. Review of the manufacturer's directions for "HB Quat Disinfectant Cleaner", copyright 2011, revealed in part, "Apply ... solution to ... surfaces thoroughly wetting surfaces with a ... sprayer.... Treated surfaces must remain wet for 10 minutes."

2. Observations of staff cleaning OR #4 on 1/29/13 at 8:50 AM revealed the following information.

- The OR Charge Nurse sprayed down the anesthesia machine with HB Quat Disinfectant. The disinfectant solution stayed wet for less than 1 minute before the solution dried.

- The OR Charge Nurse sprayed the black plastic cushions on the OR Patient Table with the HB Quat Disinfectant. The OR Charge Nurse wiped the solution across the surfaces of the cushions. The OR Charge Nurse lifted the cushions off of the table, wiped the underside of the cushion and the table with a rag saturated with HB Quat Disinfectant. The OR Charge Nurse waited about 20 seconds, and before the cushion and table had dried, placed the cushions back on the table.

- Registered Nurse (RN) E placed a sheet on the OR table when the table still had several areas where the HB Quat Disinfectant was still wet. RN E placed the sheet on the wet areas, which had not remained wet for the manufacturer's recommended 10 minutes.

- During the cleaning process, the OR staff failed to cleanse a curved steel rod holder for the sterile drapes. After the OR staff brought the next patient in the room, and Anesthesiologist B had started administering general anesthesia to the patient, Anesthesiologist B placed the steel rod holder under the patient's head, and secured the drapes to the holder.

3. Observations of staff cleaning OR #3 on 1/20/13 at 8:05 AM revealed the following information.

- The OR Charge Nurse sprayed the OR Patient Table with HB Quat Disinfectant. The spray failed to cover all the areas of the plastic cushions on the table. Before the cushions had dried, the OR Charge Nurse removed the wet middle cushion, and placed it on the wet foot cushion.

- The OR Charge Nurse sprayed the anesthesia machine with HB Quat Disinfectant, and allowed the liquid to remain wet for approximately 10 seconds, prior to wiping off the liquid with a rag.

- RN F went to place a sheet on the OR Patient Table 7 minutes after the OR Charge Nurse sprayed the HB Quat Disinfectant on the OR Patient Table. RN F noticed the HB Quat Disinfectant had not fully dried on the bed. RN F took the folded sheet, and fanned air over the table to dry the liquid. After the liquid dried, a few seconds later, RN F placed the sheet on the bed.

- During the cleaning process, the OR staff failed to cleanse a curved steel rod holder for the sterile drapes. After the OR staff brought the next patient in the room, and Certified Registered Nurse Anesthetist G (a nurse with advanced training in the administration of anesthesia) had started administering general anesthesia to the patient, CRNA G placed the steel rod holder under the patient's head, and secured the drapes to the holder.

4. During an interview on 2/5/13 at 11:00 AM, the OR Charge Nurse acknowledged the observations the OR staff had failed to wait 10 minutes for the HB Quat Disinfectant to dry. The Director of Surgical Services acknowledged the staff failed to follow the manufacturer ' s requirements directions for HB Quat Disinfectant, when the staff failed to wait 10 minutes for the HB Quat Disinfectant to dry.

5. During an interview on 2/4/13 at 2:46 PM, the Infection Preventionist stated the Infection Control Committee had approved the HB Quat Disinfectant for use in the hospital. She stated the manufacturer required staff to leave the solution wet for 10 minutes on the surface for it to kill the bacteria. When she heard what the surveyor had observed, she stated the OR staff should have allowed the disinfectant to remain wet for 10 minutes in order to kill all the bacteria on a surface.



29846


III. Based on CDC (Center for Disease Control) guidelines, MMRW (Morbidity and Mortality Weekly Report), review of facility and CS A (Contracted Services A) policies and procedures, documents, observations and staff interviews, the facility failed to ensure CS A acute dialysis staff performed hand hygiene prior to donning gloves, performed hand hygiene and donned gloves prior to touching the dialysis machine, remove contaminated gloves and perform hand hygiene prior to touching surfaces that may be touched by ungloved hands.

Failure to ensure all CS A acute dialysis staff performs hand hygiene and wear gloves in accordance with the hospital and Contracted Services A (CS A) policies and procedures could potentially result in the transmission of infectious agents to objects such as medical equipment, common supplies, environmental surfaces, patients, staff and/or visitors, potentially resulting in illness.

The facility reported a census of 2 inpatient hemodialysis patients at the time of the survey.

Findings for observations in the acute inpatient treatment area on 1/30/13 included:

1. Review of CDC MMRW Recommendations and Reports titled "Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients", dated April 27, 2001 included in part, " ... The hemodialysis machine and its components also can be vehicles for patient-to-patient transmission of bloodborne viruses and pathogenic bacteria. The external surfaces of the machine are the most likely sources for contamination. ... Contact transmission is the most important route by which pathogens are transmitted in health-care settings, including hemodialysis units. ... Contact transmission can be prevented by ... glove use ... In addition, nonsterile, disposable gloves provide a protective barrier for worker's hands, preventing them from becoming soiled or contaminated. ... Hands should always be washed after gloves are removed... If hands are not visibly soiled, use of a waterless antiseptic hand rub can be substituted for hand washing ..."

-Review of the hospital policy titled, "Hand Hygiene" Revision Date: 6/10, included in part, "...All health care workers are expected to use proper hand hygiene as indicated...d. Decontaminate hands before having direct contact with patients...G. Decontaminate hands after contact with a patient's intact skin...J. Decontaminate hands after contact with inanimate objects (including medical equipment)...K. Decontaminate hands after removing gloves..."

-Review of CS A Inpatient Services Policy titled, "Personal Protective Equipment, Document Number, FMS-CS-IC-155-080A, Effective Date, 04 -Jan-2012, stated in part, "...Disposable gloves must be used: When touching any part of the dialysis machine or equipment at the dialysis station...Change gloves and practice hand hygiene after each patient and/or station contact...Avoid touching surfaces with gloved hands that will be touched with ungloved hands (for ex. patient charts) ..."

2. Observation on 1/30/13 at 9:45 AM in the acute dialysis treatment area showed RN (Registered Nurse) DA setting up dialysis machine (a machine that that filters a patient's blood to remove excess water and waste products when the kidneys are damaged) #19. Without performing hand hygiene and/or donning gloves, RN DA touched the dialysis machine screen. RN DA left dialysis machine #19, walked to a closet where the portable RO (reverse osmosis) is stored performed hand hygiene and donned gloves. While in the closet RN DA calibrated of the Phoenix Meter (a hand-held device used to measure pH, conductivity, and temperature.). When Staff DA completed calibrating the meter, RN DA removed and discarded the gloves, and without performing hand hygiene left the closet, walked to a storage cupboard and obtained clean supplies that included a roll of tape and a bag of normal saline. RN DA carried the supplies to machine #19 and placed the supplies on the tray table. RN DA without performing hand hygiene and/or donning gloves picked up a container of chlorine residual test strips (determines the amount of chlorine in the dialysis water), removed a strip, disconnected a hose located on the right side of dialysis machine #18 and obtained a fluid sample and reconnected the hose to the dialysis machine. Continued observation showed RN DA without performing hand hygiene left machine #19, walked to a supply closet, obtained a dialyzer (the filter that cleans blood during the dialysis treatment), carried the dialyzer back to machine #19, and without performing hand hygiene donned gloves, opened the protective outer wrap of the liter of normal saline, placed the bag on the IV hook attached to the dialysis machine, opened, removed the blood lines and attached the bloodlines to the dialysis machine. Continued observation showed RN DA opened the bag of normal saline and inserted the bloodline tubing (blood flows from the body through the tubing and filter then back to the body) into the bag of normal saline and primed the bloodlines and dialysis machine. RN DA removed the gloves and performed hand hygiene.

Continued observation showed RN DA returned to the closet where the portable RO (Portable Water Purification System) was stored, without performing hand hygiene and/or donning gloves, gathered 2 wands (a device used for the delivery of dialysate) one for bicarbonate and one for acid. RN DA carried the wands to an area of the room opposite of the dialysis machines, removed papers from a file cabinet, and walked back to the dialysis machine and placed the wands into gallon containers containing bicarbonate and acid. Without performing hand hygiene and/or donning gloves RN DA touched the controls located on the screen of the dialysis machine at machine #19.

Continued observation at 10:20 AM showed RN DA at machine #19. RN DA without performing and hygiene and /or donning gloves touched the dialysis machine screen, picked up a permanent marker from the tray table at machine #19, carried the marker to the nurses desk and set the marker on the desk. And 10:28 AM RN DA returned to machine #19 and without performing hand hygiene and/or donning gloves touched the screen of the dialysis machine.

Continued observation at 10:50 AM showed RN DA assisting DP (Dialysis Patient) #1 into the dialysis chair. During this transfers the patient's phone, a book, and pencils fell to the floor. Wearing gloves RN DA picked up the patient's phone cover and without performing hand hygiene and/or donning clean gloves touched the screen of the dialysis machine.

-Observation at 11:08 AM showed RN DA, without performing hand hygiene, donned gloves and touched the screen of the dialysis machine at machine #19.

-Observation at 2:30 PM in the acute dialysis room showed RN DA with gloved hands, touched the red biohazard bag to secure it onto the metal bag holder. Without changing gloves and/or performing hand hygiene, RN DA picked up a bottle of Betadine (a topical antiseptic), poured Betadine onto 2 by 2 gauze pads and wrapped the gauze around the patient's CVC (Central Venous Catheter) limbs. RN DA removed the gloves and performed hand hygiene, walked to the closet where a locked box for medications is located, removed medications from the box, returned to machine #19. RN DA, without performing hand hygiene, donned clean gloves and touched the screen of the dialysis machine. RN DA removed the bag of normal saline hanging the IV hook located on the dialysis machine, rolled the bag of normal saline to expedite flushing the blood lines. Then, while wearing the same potentially contaminated gloves, clamped DP #1's bloodlines, and removed the Betadine gauze from DP #1's CVC limbs. Continued observation showed RN DA, without performing hand hygiene, donned gloves, attached syringes that contained normal saline to each of the ports located on the patient's CVC limbs, removed the syringes, then attached syringes that contained heparin into the CVC ports, instilled the heparin, removed the syringes and attached new caps to the CVC ports. RN DA then removed the dialyzer and bloodlines from the dialysis machine, placed both into a red biohazard bag and walked over to a bedside hospital table located between the two dialysis machine and, without removing gloves and/or performing hand hygiene, charted in DP #1's record. While wearing the same gloves, RN DA walked back to machine #19 touched the screen of the dialysis machine, removed a stethoscope hanging from the dialysis machine, carried the stethoscope out of the dialysis machine #19 area and across the room, approximately 10' and assessed the DP #1's lung sounds.

-Observation at 3:40 PM, in the acute dialysis treatment area, showed DP #10 at dialysis machine #18. During this observation RN DA, without performing hand hygiene, donned gloves and completed a Betadine scrub to the patient's vascular access site located on the patient's right arm and inserted two dialysis needles into the patient's fistula (surgically created communications between the native artery and vein in an extremity). RN DA removed her gloves and without performing hand hygiene donned clean gloves, flushed the bloodlines and attached the bloodlines to the Patient's vascular access.

3. During an interview on 1/30/13 at 12:00 PM with the Inpatient Dialysis Coordinator and CS A Inpatient Clinical Manager, the Inpatient Clinical Manager reported that the facility follows CDC guidelines. The Inpatient Clinical Manager also reported that the facility follows CS A Inpatient policies and procedures for acute hemodialysis treatments. Both the Inpatient Dialysis Coordinator and the Inpatient Clinical Manager acknowledged the findings and agreed that it is the policy to perform hand hygiene after removing potentially contaminated gloves and that PPE (Personal Protective Equipment) that includes gloves, are to be donned when touching the dialysis machine.

Based on document review and staff interview, the facility failed to ensure anesthesia providers (anesthesiologists and anesthetists) performed a post-anesthesia evaluation after the patient had recovered from anesthesia in 1 of 2 sampled open surgical records (Patient #1) and 6 of 6 closed surgical records (Patients #2, 3, 4, 5, 6, and 7). The facility identified an average of 270 surgical procedures per month using general anesthesia.

Failure to perform a post-anesthesia assessment after the patient had recovered from general anesthesia (when an anesthesia provider administers medication to render the patient unconscious during surgery) could potentially result in the anesthesia provider failing to detect complications from the medications they administered, and failing to provide appropriate treatment for the complications.

Findings include:

1. Review of the Medical Staff Rules and Regulations, approved and adopted 8/22/12, revealed in part, "The anesthetist or anesthesiologist shall maintain a complete anesthesia services record ... For each patient who receives general anesthesia ... this record shall include ... a postanesthesia [sic] evaluation." "The individual who administered the patient's anesthesia, or another individual credentialed and qualified to provide anesthesia ... must also perform a postanesthesia [sic] evaluation of the patient and document the results of the evaluation ..." The Medical Staff Rules and Regulations lacked a requirement for the anesthesia provider to examine the patient after the patient had fully recovered from anesthesia.

2. Review of the policy "Anesthesia Care and Documentation," reviewed 9/08, revealed in part, "The Anesthetist or Anesthesiologist shall maintain a complete record to include ... a post-anesthetic follow-up of the patient's condition." The policy lacked a requirement for the anesthesia provider to examine the patient after the patient had fully recovered from anesthesia.

3. Review of open surgical records on 2/4/13 at 4:00 PM revealed the following information.

- Patient #1 underwent a surgical procedure that required general anesthesia (medication to render the patient unconscious during surgery) on 1/30/13. The anesthesia ended at 12:08 PM, and the anesthesia provider (an anesthesiologist or Certified Registered Nurse Anesthetist, CRNA) immediately transported Patient #1 to the Post Anesthesia Care Unit (PACU), a specialized area to allow patients to receive close nursing monitoring after receiving anesthesia). The anesthesia provider evaluated Patient #1 immediately when they transferred care to the PACU nurses. They also evaluated Patient #1 at 12:15 PM (7 minutes after Patient #1 arrived at the PACU).

4. Review of closed surgical records on 2/5/13 at 4:15 PM revealed the following information.

- Patient #2 underwent a surgical procedure that required general anesthesia on 1/26/13. Anesthesiologist B transferred Patient #2 to the PACU at 3:15 PM. Anesthesiologist B evaluated Patient #2 when he transferred Patient #2 to the PACU and at 3:25 PM (10 minutes after Patient #2 arrived at the PACU). Patient #2 was discharged from the hospital on 1/27/13 at 10:45 AM. Patient #2's medical record lacked documentation Anesthesiologist B, or another anesthesia provider, examined Patient #2 after 1/26/13 at 3:25 PM for recovery from the anesthesia administered during the surgery.

- Patient #3 underwent a surgical procedure that required general anesthesia on 1/21/13. CRNA C (a nurse with advanced education in the administration of anesthesia) administered general anesthesia to Patient #3. CRNA C transferred Patient #3 to the PACU at 2:50 PM. CRNA C evaluated Patient #3 when she transferred Patient #3 to the PACU and at 3:00 PM, (10 minutes after Patient #3 arrived at the PACU). Patient #3 was discharged from the hospital on 1/21/13 at 5:40 PM. Patient #3's medical record lacked documentation CRNA C, or another anesthesia provider, examined Patient #3 after 1/21/13 at 3:00 PM for recovery from the anesthesia administered during the surgery.

- Patient #4 underwent a surgical procedure that required general anesthesia on 1/10/13. Anesthesiologist A administered general anesthesia to Patient #4. Anesthesiologist A transferred Patient #4 to the PACU at 5:00 PM. Anesthesiologist A evaluated Patient #4 when he transferred Patient #4 to the PACU. Patient #4 was discharged from the hospital on 1/11/13 at 10:45 AM. Patient #4's medical record lacked documentation Anesthesiologist A, or another anesthesia provider, examined Patient #4 after 1/10/13 at 5:00 PM for recovery from the anesthesia administered during the surgery.

- Patient #5 underwent a surgical procedure that required general anesthesia on 1/1/13. Anesthesiologist B administered general anesthesia to Patient #5. Anesthesiologist B transferred Patient #5 to the PACU at 6:25 AM. Anesthesiologist B evaluated Patient #5 at 6:37 AM (12 minutes after Patient #5 arrived at the PACU). Patient #5's medical record lacked documentation Anesthesiologist B, or another anesthesia provider, examined Patient #5 after 1/1/13 at 6:37 AM for recovery from the anesthesia administered during the surgery.

- Patient #6 underwent a surgical procedure that required general anesthesia on 12/6/12. Anesthesiologist B administered general anesthesia to Patient #6. Anesthesiologist B transferred Patient #6 to the PACU at 11:05 AM. Anesthesiologist B evaluated Patient #6 when he transferred Patient #6 to the PACU and at 11:08 AM, (3 minutes after Patient #6 arrived at the PACU). Patient #6 was discharged from the hospital at 12:05 PM. Patient #6's medical record lacked documentation Anesthesiologist B, or another anesthesia provider, examined Patient #6 after 11:08 AM for recovery from the anesthesia administered during the surgery.

- Patient #7 underwent a surgical procedure that required general anesthesia on 12/3/12. Anesthesiologist D administered general anesthesia to Patient #6. Anesthesiologist B administered general anesthesia to Patient #7. Anesthesiologist D transferred Patient #7 to the PACU at 1:45 PM. Anesthesiologist D evaluated Patient #7 when he transferred Patient #7 to the PACU. Patient #7 was discharged from the hospital on 12/3/12 at 4:20 PM. Patient #7's medical record lacked documentation Anesthesiologist D, or another anesthesia provider, examined Patient #7 after 1:45 PM for recovery from the anesthesia administered during the surgery.

5. During an interview on 2/5/13 at 11:00 AM, the Director of Surgical Services acknowledged the anesthesia providers failed to examine the selected patients for the patients' recovery from anesthesia. The Director of Surgical Services acknowledged the patients required more than 12 minutes to recover sufficiently from anesthesia to the point where an anesthesia provider could fully examine the patient for their recovery.