HospitalInspections.org

Based on observation, policy review, document review, and staff interview the facility failed to ensure they provided care for patients in a safe setting.

Findings were:

During a tour of the second floor of the hospital on the surgical/ortho unit it was observed that medication carts were sitting in the medication room. These carts are taken into patient rooms for medication pass and then returned to the main medication room. A rolling blood pressure machine was observed being taken from room to room and used on patients.

Interview with staff #7 and #8 revealed the carts are taken into each patient room and are never wiped down between patients and rooms. Both also confirmed the blood pressure machine is taken into patient rooms and never wiped down between patients.

Facility policy titled "Infection Control Plan" states, in part "Wash hands or use an alcohol based waterless hand cleaner: Before and after invasive procedures; Between patients; Before donning and after removing gloves."

Document titled "Hand Hygiene and Glove Use Monitoring Worksheet for Data Collection" provides the following information for Ortho second floor:
* 6/23/14 data collection: Hand Hygiene 50% compliance; Glove Use 60% compliance;
* 7/11/14 data collection: Hand Hygiene 20% compliance; Glove Use 60% compliance;
* second page of worksheet has area for Conclusions and Corrective Actions Taken; these areas are blank with no documentation of actions taken to address deficiencies found on the audits.

In an interview with the Infection Control Coordinator and the Director of Risk Management both stated the deficiencies noted on the data collection forms should be addressed and there was no documentation to determine actions taken in response to the deficiencies observed.

Failure of glove use, hand washing, and cleaning of equipment used on patients and in patient rooms has the potential to lead to cross contamination of patients and infections and provides patients with an unsafe treatment environment.

Based on review of meeting minutes, secret shopper data collection, and staff interview the facility did not identify opportunities for improvement and changes that would lead to performance improvement.

Findings were:

Review of meeting minutes dated 2/19/14 for Infection Control Committee states under 2014 Plan:
* Increase Hand Hygiene Compliance rate by 10% from 67%. Benchmark was at 73%. Monthly surveillence will be done instead of quarterly. Feedback will be provided to the departments.

Review of meeting minutes for Performance Improvement Committee states the following:
* Observed Hand Hygiene complies with guidelines. Goal >/= 90%. Documented values are 98.3-100%. Goal met. Continue to track and trend.

Document titled "Hand Hygiene and Glove Use Monitoring Worksheet for Data Collection" provides the following information for Ortho second floor:
* 6/23/14 data collection: Hand Hygiene 50% compliance; Glove Use 60% compliance;
* 7/11/14 data collection: Hand Hygiene 20% compliance; Glove Use 60% compliance;
* second page of worksheet has area for Conclusions and Corrective Actions Taken; these areas are blank with no documentation of actions taken to address deficiencies found on the audits.

In an interview with the Infection Control Coordinator and the Director of Risk Management both stated the deficiencies noted on the data collection forms should be addressed and there was no documentation to determine actions taken in response to the deficiencies observed. Both stated the numbers provided in the Performance Improvement Committee meeting came from directors of the units observations and the Hand Hygiene and Glove Use Worksheet that came from secret shoppers observations were not reported at the Performance Improvement meetings. Both confirmed the data from each group does not match.

Based on policy review, document review, and staff interview the facility failed to ensure their licensed personnel followed hospital policy in regard to administering intravenous (IV) push medication.

Findings were:

Facility policy titled "Drug Distribution" states, in part "A Licensed Vocational Nurse (LVN) may not administer medications by IV push or IV bolus into existing IV lines or heparin locks."

Medication administration records for patient #1 reveals staff #9, an LVN administered IV push Benadryl to the patient twice on 7/15/14.

In an interview with the pharmacy interim director and the director of nurses in the conference room on 8/12/14 both acknowledged the policy presented was the current policy for use and it indeed stated that LVNs could not give IV push medications to patients.