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Based on observation, interview and record review, the governing body failed to:
1. Ensure that the hospital protected and promoted patient's rights at all times (Refer to A 115)
2. Monitor radiological services and follow recommended guidelines for the monitoring of radiation safety services/preventive maintenance of radiation emitting devices and following the physicist's recommendation for maintaining C-Arms (Refer to A 528).

3. Have oversight of the laboratory services and blood products transfusion services (Refer to A 576).

4. Ensure that the dietary services were met for each patient (See A618).

5. Provide a sanitary environment and have an active/effective infection control program (Refer to A 747).




The cumulative effects of these systemic problems resulted in the Hospital's failure to ensure the provision of quality health care in a safe and acceptable environment.

Based on observation, interview and record review the facility failed to:

1. Ensure patients were not receiving treatment without consent (Refer to A 131).

2. Ensure patients were assessed and their care plan met their needs (Refer to A 115).

3. Ensure patient's blood draw and blood transfusion were performed in a safe manner (Refer to A 747, A 749, A 576 and A 593).

4. Ensure patient with special needs was receiving appropriate care (Refer to A 115).

5. Ensure patient received care in a safe setting (Refer to A 115 adn A 144).


Findings

1a. During the initial tour of the facility's Emergency Department (ED) on 7/27/16 at 2:30 pm, Patient 22 was observed in the ED triage area getting blood drawn. During concurrent interview with the registered nurse (RN 1) she stated patients get triaged and blood drawn prior to seeing the ED's doctor.

A review of Patient 22's medical record indicated Patient 22 had not signed the consent for treatment.

1b. During an observation on 8/1/16 at 4:10 pm., in ED triage area, Patient 28 was observed getting her blood drawn while lying in a bed in Triage 1 area with a breathing treatment.

A review of Patient 28's medical record indicated the patient had not signed consent for treatment. When asked RN 1 stated Patient 28 was having difficulty breathing and needed immediate assistance.

2. During an observation in ED on 7/27/16 at 3:05 pm., Patient 27 was observed lying on her side and receiving an intravenous (IV) drip of Insulin. Patient 27 had a bed pan full of urine sitting on top of the trash can. When asked how she was feeling, Patient 27 cried and stated she was upset that medical doctor (MD 2) was trying to send her to another general acute care hospital (GACH 2). Patient 27 wanted to stay at current hospital (GACH 1).

A review of Patient 27's medical record indicated she was brought in by ambulance on 7/27/16 at 7:14 am. A review of her medical record indicated the patient had a blood sugar of 799 milligram per deciliter [(mg/dl) normal range from 70 to 100 fasting and less than 140 two hours after meal].

A review of MD 2's documentation indicated Patient 27 would pay the 20 percent (%) of the cost incurred if she refuses to transfer to GACH 2. MD 2 documented Patient 27 was refusing transfer to GACH 2. Same day, at 9:09 pm., Patient 27 was admitted to the inpatient ward of GACH 1. Patient 27 had nausea and vomiting. Also, as of 8/1/16 there was no assessment by social services.

3. During an observation Patient 26 on 7/27/16 at 10:30 am., the patient was observed sitting on her bed talking with a visitor. Concurrently, during an interview with her nurse and the charge nurse, they stated Patient 26 was receiving two units of packed red blood cells (PRBC). When asked for documentation of the assessment of her active bleeding there was no nursing notes. A review of Patient 26's medical record indicated the patient was admitted for bleeding from uterine fibroids. There was no documented evidence of past history or history of previous blood transfusions.

Concurrently, RN 3 was asked if there was a consult pending. RN 3 stated there was a consult for Gynecology. A review of the consult request in Patient 26's medical record indicated MD 10 documented he was refusing to see Patient 26 because the patient was refusing to have a hysterectomy (surgical removal of the uterus).

According to the Patient 26's medical record on 8/1/16 the patient received a total of six units PRBCS. There was no documentation that MD 10 explained to the patient treatment options or the risks involved with receiving six units of blood.

MD 10 documented he was recommending a hysterectomy to treat Patient 26's uterine fibroids. There was no documented evidence of Patient 26's past history of blood transfusion. During an interview on 8/1/16 at 12:45 pm., Patient 26 stated she had not been transfused previously.

4. During an observation on 7/28/16 at 4:10 pm., Patient 31 was observed sitting on her bed. During an interview with RN 4, at the same time as the observation on 7/28/16, at 4:10 pm, RN 4 was asked what Patient 31 was admitted for. RN 4 stated the patient had pneumonia. Upon further interview with RN 4, when asked if Patient 31 had any other conditions, she stated Patient 31 had seizures, cannot talk, cannot hear and cannot see. When asked how does Patient 31 communicate, RN 4 stated the patient does not communicate. When RN 4 was asked how the patient walked, RN 4 stated the patient did not walk and had contractures. Patient 31 was brought in from a group home. When asked if she had a communication board RN 4 stated "No."

A review of Patient 31's medical record indicated the patient was admitted on 7/28/16 and had been evaluated for a possible infection of the gastrostomy tube [(GT)- a tune surgically inserted directly into stomach for administration of nutrition and medication] and ventriculoperitoneal (VP) shunt (surgically placed device to drain excess cerebrospinal fluid in the brain).

5. According to the Patient 31's medical record a care plan included: adjustment of a call light and teaching on its use with verbalization of understanding; impaired mental status and physical mobility with a patient goal to maintain optimal function regardless of sensory deficits.

A review of Patient 31's consent indicated it was signed by the patient's care giver. There was no documented evidence the care giver had the right to sign consent on behave of the patient.

A policy and procedure for patients with special needs was requested but not provided.

A review of a policy and procedure dated 10/13 titled "Assessment and Reassessment" indicated all patients will have a timely assessment of pertinent medical and psychosocial variables and reassessment as a part of patient care."

The cumulative effects of these systemic problems resulted in the facility's inability to ensure that patieent's rights were being protected and promoted at all times.

Based on observation, record review and interview, the facility failed to obtain consent from patients for treatment, inform patients of their health status, and failed to ensure patients were involved in their care planning/treatment and failed to ensure that the patient's physician certified that he explained the procedure's risk and benefit to the patient and/or his or her representative for seven of 30 sampled patients (10, 11, 22, 26, 27, 28, 31).

Findings:

1. During the initial tour of the facility's Emergency Department (ED) on 7/27/16, at 2:30 pm., Patient 22 was observed in the ED triage area getting blood drawn. During an interview with the registered nurse (RN 1), stated patients get triaged and blood drawn prior to seeing the ED's doctor. A review of Patient 22's medical record indicated Patient 22 had not signed the consent for treatment.

2. During an observation on 8/1/16, at 4:10 pm, in the ED's triage area, Patient 28 was observed getting blood drawn in Triage 1 area and receiving a breathing treatment. A review of Patient 28's medical record indicated Patient 28 had not signed a consent for treatment. When asked, RN 1 indicated Patient 28 was having difficulty breathing and needed immediate assistance.

3. During an observation in the ED on 7/27/16 at 3:05 pm, Patient 27 was observed lying on her side. Patient 27 was observed receiving an intravenous drip of Insulin. Patient 27 had a bed pan full of urine sitting on top of the trash can. When asked how she was feeling, Patient 27 cried and stated she was upset that medical doctor (MD 2) was trying to send her to another general acute care hospital (GACH 2). Patient 27 wanted to stay at current hospital (GACH 1).

A review of Patient 27's medical record indicated she was brought in by ambulance on 7/27/16 at 7:14 am. A review of her medical record indicated the patient had a blood sugar of 799 milligram per deciliter [(mg/dl) normal range from 70 to 100 fasting and less than 140 two hours after meal].

A review of MD 2's documentation indicated Patient 27 would pay the 20 percent (%) of the cost incurred if she refuses to transfer to GACH 2. MD 2 documented Patient 27 was refusing transfer to GACH 2. Same day, at 9:09 pm., Patient 27 was admitted to the inpatient ward of GACH 1. Patient 27 had nausea and vomiting. .

4. On 7/27/16, at 10:30 am, Patient 26 was observed sitting on her bed talking with a visitor. Concurrently, during an interview with her nurse and the charge nurse, both indicated Patient 26 was receiving two units of packed red blood cells (PRBC). When asked for documentation of the assessment of Patient 26's active bleeding, there were no nursing notes. A review of Patient 26's medical record indicated the patient was admitted for bleeding from uterine fibroids. There was no documented evidence of past history or history of previous blood transfusions.

Concurrently, RN 3 was asked if there was a consult pending. RN 3 stated there was a consult for Gynecology. A review of the consult request in Patient 26's medical record indicated MD 10 documented he was refusing to see Patient 26 because the patient was refusing to have a hysterectomy (surgical removal of the uterus).

According to the Patient 26's medical record on 8/1/16 the patient received a total of six units PRBCS. There was no documented evidence of oversight or referral for evaluation of blood utilization. There was no documentation that MD 10 explained to the patient treatment options or the risks involved with receiving six units of blood.

MD 10 documented he was recommending a hysterectomy to treat Patient 26's uterine fibroids. There was no documented evidence of Patient 26's past history of blood transfusion. During an interview on 8/1/16 at 12:45 pm., Patient 26 stated she had not been transfused previously.

A review of the blood transfusion policy and procedure titled "Blood Utilization Standard for Adults" dated 3/26/15, indicated the facility's established standards for blood utilization and oversight. There was no documented evidence in Patient 26's medical record reflecting a blood utilization review and/or evaluation by a hematologist.

5. On 7/28/16 at 4:10 pm., Patient 31 was observed sitting on her bed. RN 4 was asked what Patient 31 was admitted for. RN 4 stated the patient had pneumonia. When asked RN 4 if Patient 31 had any other conditions she stated Patient 31 has seizures, cannot talk, cannot hear and cannot see. When asked how does Patient 31 communicate RN 4 stated the patient does not communicate. When RN 4 was asked how the patient walked, RN 4 stated the patient did not walk and had contractures. Patient 31 was brought in from a group home. When asked if she had a communication board RN 4 stated "No."

A review of Patient 31's medical record indicated the patient was admitted on 7/28/16 and had been evaluated for a possible infection of the gastrostomy tube [(GT)- a tune surgically inserted directly into stomach for administration of nutrition and medication] and ventriculoperitoneal (VP) shunt (surgically placed device to drain excess cerebrospinal fluid in the brain).

A review of Patient 31's consent indicated it was signed by the patient's care giver. There was no documented evidence the care giver had the right to sign consent on behalf of the patient.


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6. A review of the facesheet indicated Patient 10 was admitted to the facility on July 19, 2016, with diagnoses that included hypotension, near syncope and end stage renal disease.

A review of the Consent to Surgery/Special Procedures/Anesthesia (with Physician Certification) for Hemodialysis indicated a telephone consent was obtained from the patient's sister on 7/19/2016 at 8 p.m. The section for the Physician Certification indicated that the physician hereby certify that the procedure was discussed the procedure to the patient and/or patient representative was blank.


7. A review of the facesheet indicated Patient 11 was admitted to the facility on July 15, 2016, with diagnoses that included uremia, confusion and dislodged dialysis catheter.

A review of the Consent to Surgery/Special Procedures/Anesthesia (with Physician Certification) for Hemodialysis indicated a telephone consent was obtained from the patient's granddaughter on 7/15/2016, at 8 p.m. The section for the Physician Certification indicated that the physician hereby certify that the procedure was discussed the procedure to the patient and/or patient representative was blank.

Based on observation and interview, the facility failed to ensure the patients had the right to receive care in a safe setting.

Findings:

On July 27, 2016, at 2:15 p.m., during the tour of the ER with RN 5 the following was observed:

a. The phlebotomy tray placed on top of a bedside drawer which contained vacutainers with needles were left unattended which was accessible for unathorized access and had the potential for patient's safety.

b. Medications: Lorazepam 2mg/ml open and undated, 2 - 10 ml syringes of 0.9 % sodium chloride and 2 - IV access Catheter Kit left unattended and potential for unauthorized access.

c. The medication room in the ED 2 was left opened and potential for unauthorized access.

2. During the tour of the unit on 3-East on July 28, 2016, at 1:15 p.m., with RN 7, it was noted the call light system in the unit was visible however it was not audible.

During an interview with RN 7 at the time of observation, stated the call light should be audible and visible in order to attend to patients needs when the patient call for help to ensure patient safety.

Based on observation, interview, and record review, the facility failed to provide ongoing assessment and nursing care to meet the patients' needs.

Findings:

1 . A review of the clinical record indicated Patient 9 was admitted to the facility on July 23, 2016, with diagnosis of oral cancer.
During tour of the unit with RN 1 on July 27, 2016, at 10:30 a.m., Patient 9 was observed lying in a special bed (alternating pressure pad/mattress). On top of the bed were a disposable chux, a gray/blue drawsheet, fitted sheet and underneath the fitted sheet was a sheet that was folded twice.
Patient 9's record indicated on admission, July 23, 2016, Patient 9 had the following pressure ulcers:
1. A stage III on coccyx area 1 which measures 1.1 cm by 1.2 cm .
2. A stage II on coccyx area 2 which measures 1.5 cm by 4 cm.
3. A stage II on the right foot area 5 which measures 6 cm by 4 cm.
4. A stage II on the right foot area 6 which measures 2 cm by 1 cm.
5. An unstageable on the right toe area 10 with black and scabs.

A care plan was developed on July 23, 2016, addressing the actual impaired skin related to open wounds. The use of pressure reduction/relief device was not checked as one of the interventions to promote healing and prevent new sores from developing.

During an interview with Risk Manager on August 1, 2016, at 210 p.m., the facility did not have a policy regarding the number of linens to be use on a patient lying on air loss/alternating pressure mattress to get the most of the benefit for wound healing. Risk Manager presented information from a Manufacturer that showed to use a mattress cover, one low-friction glide sheet and one (1) microclimate body pad. There was no indication that extra two (2) linens underneath of the patient's buttocks could be used.
The facility policy, dated May 2014 and titled, "Standard Precaution" stipulated on a specialty bed "no more that two layers (anything folded is considered 2 layers) and no plastic. Manufacturer recommendation to use a flat sheet with a breathable underpad."
2. A review of the facesheet indicated Patient 10 was admitted to the facility on July 19, 2016, with diagnoses that included hypotension, near syncope and end stage renal disease.

On July 29, 2016, at 12:15 p.m., Patient 10 was observed receiving hemodialysis treatment via left lower arm AVF (anterio-venous fistula - abnormal connection between an artery and a vein). The patient was dialyzing on a 2 potassium (K) and 2.5 calcium (Ca) bath/dialysate. The dialyzer (artificial kidney) was F160 NR. The blood flow rate (BFR ) was 300 and DFR was 600. The patient was dialyzing in dedicated machine for patients on isolation (Hepatitis positive). However, the patient was sharing a room with another patient who is not Hepatitis B positive.

A review of the Dialysis Treatment Summary indicated the following:

a. On July 19, 2016, the documented hemodialysis order was duration of 3 hours, BFR of 300, DFR of 600, dialyzer type was F160 and bath of 2 K /2.5 Ca. The DFR from the start of treatment until termination was 500. There was no written documentation why the ordered DFR was not met. The documentation indicated at 2300, the patient's blood pressure (B/P) reading was 88/47 and was administered by the bolus normal saline. There was no indication as to how much normal saline was administered and for what reason it was administered.
The access site was assessed as WNL (within normal limit) and access flow was good.

b. On July 21, 2016, the documented hemodialysis order was duration of 3 hours, BFR of 300, DFR of 600, dialyzer type was F160 and bath of 3 K /2.5 Ca.

The documented BFR from 10:15 a.m. through 11:30 a.m. was between 200 to 250 and there was no documentation reason why the ordered BFR was not met.

The documented DFR from the start of hemodialysis treatment through termination was 700 and there was no documented reason why the ordered DFR was not met.

The B/P reading during hemodialysis treatment were as follows:
At 8:45 a.m., documented 94/46.
At 9 a.m., documented was 80/48 and noted "kept moving".
At 11 a.m., documented 90/44 and "goal down".
At 11:15 a.m., documented 84/48 and "goal down".
At 11:30 a.m., documented 91/47 and "treatment finished".

There was no written documentation to indicate the patient was assessed by the registered nurse when having hypotensive episode.

c. On July 27, 2016, the documented hemodialysis order was duration of 3 hours, BFR of 300, DFR of 600, dialyzer type was F160 and bath of 2 K /2.5 Ca.

The following documentation indicated:
At 3:46 p.m., the patient's B/P reading was 57/45 and was administered 300 cc of normal saline and patient symptomatic.
At 4:16 p.m., the B/P reading was 92/48 and patient in no distress.
At 4:31 p.m., the B/P reading was 88/48 and administered 100 cc of normal saline.
At 5 p.m., there was no documented B/P reading and was administered 100 cc of normal saline.
At 5:31 p.m., the B/P reading was 77/46 , patient in and out of sleep, elevated leg and administered 100 cc of normal saline.
At 5:46 p.m., the B/P reading was 87/47, patient not in distress and was administered 100 cc of normal saline .
At 6 :01 p.m., the B/P reading was 85/44 and administered 100 cc of normal saline.
There was no documentation if the normal saline administered was for blood pressure.

During an interview with RN 3 on August 1, 2016, at 12 noon, while reviewing medical record, RN 3 stated patient who is HBsAg positive must dialyze in the separate room to protect the susceptible patient. RN 3 added that access site AVF or AVG should be assessed for bruit and thrill.

3. A review of the facesheet indicated Patient 11 was admitted to the facility on July 19767, 2016, with diagnoses that included uremia, confusion and dislodged dialysis catheter.

A review of the Dialysis Treatment Summary indicated the following:

a. On July 27, 2016, the documented hemodialysis order was duration of 3 hours and 15 minutes, BFR of 300, DFR of 600, dialyzer type was F160 and bath of 3 K /2.5 Ca.
The BFR from the start of treatment until termination was between 160-200. There was no written documentation reason why the ordered BFR was not met.

b. On July 25, 2016, the documented pre and post hemodialysis treatment the patient was assessed as having moderate edema. However, there was no documentation the location and degree of edema present.

c. On July 23, 2016, the documented hemodialysis order was duration of 3 hours and 15 minutes, BFR of 300, DFR of 600, dialyzer type was F160 and bath of 3 K /2.5 Ca.

The BFR from initiation of hemodialysis treatment until termination of treatment was 350. There was no written documentation reason why the ordered BFR was not met.

The Pre and Post Treatment Assessment indicated under the GI (gastro-intestinal) system the patient's stomach is distended. There was no written documentation that the RN further assessed the patient's stomach being distended.

d. On July 21, 2016, the documentation indicated at 7:40 p.m., the B/P reading was 118/64 and flushed 100 ml of normal saline. At 8:40 p.m., the patient's B/P reading was 117/74 and was administered 150 ml of normal saline to flush the line. At 9:40 p.m., the B/P reading was 90/71 and flushed 50 ml of normal saline.

There was no written documentation of a physician order and/or indication why flushing of different amounts of normal saline was performed.

e. On July 17, 2016, at 7 a.m., the patient's B/P reading was 198/107 and noted line secured.
At 7:15 a.m., the patient's B/P reading was 187/104 and noted sleeping and arousable.
There was no written documentation the RN further assessed the patient during hypertensive episodes.

The Pre treatment weight of the patient was taken and read as 95. 3 lbs. The Post treatment weight of the patient was blank.

f. On July 15, 2016, the documentation indicated at 9 p.m., the B/P reading was 100/84 and was administered 300 cc of normal saline.
At 10 p.m., the B/P reading was 102/50 and was administered 300 cc of normal saline.

There was no written documentation to indicate why the patient was administered a total of 600 cc of normal saline.

During an interview with RN 3 while reviewing the patients clinical record she stated that when the ordered BFR/DFR was not met, the reason for not meeting should be documented and notify the physician and document. She also stated that hypertension (high blood pressure) is when the B/P reading was when systolic was >180 and/or diastolic was >100. The RN should assess the patient and informed the primary nurse so as to receive medication when necessary then document in the clinical record.

Review of the dialysis policies titled :
1. Dialysing Patients with Positive Hepatitis B Antigen (HBsAg+) indicated patients that are HBsAg positive must dialyze in the separate room.
2. Evaluation of AV Fistula and Graft indicated palpate the access for thrill (vibration caused by blood flow through the access and bruit (swishing sound created by high pressure flow of blood against the walls of the vessel) and document findings on treatment sheet.
3. Treatment of Hypotension During Renal Replacement Therapy indicated to administer a normal saline bolus of 100-200 ml of IV (intravenous) medications as directed by the credentialed physician. Recheck blood pressure. If B/P is still unresponsive, give additional saline up to 500 ml to IV medications as directed by the physician.
4. Evaluating the Patient Post Treatment in FMS Inpatient Services indicated weight the patient and compare pre treatment weight, document the results on the treatment record. The purpose is to evaluate if the patient obtained the calculated volume removal goal. Also report any abnormal findings to the Charge Nurse of the patient and attending credentialed physician.

Based on interviews and medical record reviews, the facility failed to ensure the licensed nursing staff followed the policy and procedure for a titration order (order for medications whereby the dose may be increased or decreased in response to patient condition, physiologic target, or therapeutic goal) of Propofol (a short-acting intravenous [IV] anesthetic agent also commonly used in intensive care setting for patients receiving mechanical ventilations) for one patient of 30 sampled patients (5).

Findings:

On 7/29/2016, at around 10 a.m., a review of Patient 5's medical record indicated the patient had a physician's order to start Propofol IV (intravenous) on 6/15/2016 at 10:44 a.m., and titrate every five minutes to a goal of RASS -2. (Richmond Agitation Sedation Scale, a method used to assess patients' level of sedation in the intensive care unit. A score of - 2 indicates light sedation). The order was discontinued on 6/17/2016 at 10:43 a.m.

On 7/29/2016 at 10:15 a.m., during an interview, the registered nurse (RN 1) stated each IV infusion rate change on a Propofol titration order should have a RASS assessment to support the adjustment.

On 7/29/2016 at 12 noon, a review of the printouts of Patient 5's nursing assessment flow sheet and the electronic medication administration record (eMAR) was conducted with RN 1 and the Director of Pharmacy (DOP). RN 1 and DOP confirmed the flow sheet indicated there were several missing RASS assessments for the documented Propofol rate adjustments; 21 out of 65 entries of the Propofol rate adjustments in the eMAR did not have supporting RASS assessments recorded in the flow sheet. A further review of those 65 Propofol rate entries indicated there were five increases in infusion rate when the RASS scores were at -4 (deep sedation).

On 7/29/2016 at 12:15 p.m., during a concurrent interview in the presence of RN 1 and DOP, the Director of Critical Care (DCC) confirmed the RASS scores of -4 were outside of the order parameter; the goal of Patient 5's Propofol order was to keep the patient at light sedation, not deep sedation. DCC also confirmed there was no documented clinical justification to support such rate increases when RASS was at -4. RN1 , DOP and DCC agreed there should be documentation that physician was notified and approved the rate increases outside of the parameters. Upon further review of the Patient 5's medical record, RN 1 confirmed there were no new orders for the Propofol rate increase and no evidence that the physician had been notified.

The facility's policy and procedure, titled "Medication Management: Titrated Medications", dated 4/2016, indicated "documentation of titration ... shall be included in eMAR ... noting the final dose, rate, time of change, parameters ... prior to and following each dosage adjustment ... Medications ordered for titration or weaning shall be administered according to Physician specified parameters ... Patient status shall be monitored according to the assessment parameters and endpoint targets ... "

Based on observation and interview, the facility failed to ensure medical records were protected from destruction.

This deficient practice had the potential for the medical records to be destroyed in the event there was a fire and the sprinkler system was activated.

Findings:

During a tour of the medical records department on August 1, 2016, at 8:13 a.m., the following was observed:
1. The room was sprinklered.
2. Medical records were stored in 8 open rolling shelves. There were medical records stored in a 3 shelf cart.

During an interview on August 1, 2016, at 8:15 a.m., the coding manager stated the records needed be scanned before they are sent to the facility's contracted storage company.

Based on observations and interviews, the facility failed to ensure staff completed and returned the medication lists (patient charge forms) accompanying two opened (used) intubation kits (tracheal intubation, the placement of a flexible tube into the trachea, or windpipe, to maintain an open airway), one opened emergency box for cardiovascular operating room (CVOR), and four opened crash carts code blue boxes.

Findings:

On 7/27/2016 at 10:30 a.m., during an inspection of the pharmacy with the director of pharmacy (DOP), there was an opened intubation kit on the counter next to the sink. There was a post-it note on top of the loosely placed lid which had first and last names written on it. Inside the kit, there was a blue paper, titled "intubation kit medication list". The medication list had an area indicated for a patient label, however, there was no patient label on the paper. The column titled "amount used" next to a list of medications was blank.

On 7/27/2016 at 10:40 a.m., during a concurrent interview, the DOP confirmed the medication list was incomplete and there was no indication when it was used, who opened the kit at which unit, and the amount of medications that had been used.

Further inspection of the pharmacy area revealed one more opened intubation kit without medication list, one opened CVOR box with medication list not completed, and five opened code blue boxes. One of five code blue boxes had no medication list in it; another one of five code blue box had a med list without patient name or where the box was from; the other three boxes contained med lists that were incomplete.

On 7/28/2016 at 11:15 a.m., during an interview, the Clinical Care Coordinator-Education indicated during a code (code blue, an emergency situation announced in the hospital in which a patient is in cardiopulmonary arrest), the charge nurse would be responsible to document the process and medication used. She agreed those medication lists returned with the opened code boxes should not be blank.

The facility policy and procedures on "Medication Management Emergency Medications", dated 6/2016, indicated: " ...If used, the intubation kit must be returned to the pharmacy for replacement with a patient label."

The facility policy and procedures on "Cardiopulmonary - Code Blue Response", dated 1/2016, indicated the Unit Charge Nurse and/or Nurse Manager would be responsible as a recorder

Based on observations, interviews and record review, the facility failed to ensure emergency drug boxes that had been used were returned to the pharmacy in a manner that would prevent unauthorized access during transport and the accountability sheet (medication list) completed with patient information, unit location, date and time of used, and amount of medication used.

Findings:

On 7/27/16 at 10:30 a.m., during an inspection of the pharmacy with the director of pharmacy (DOP), there was an opened intubation kit on the counter next to the sink. The lid for the kit was loose. There was a post-it note on top of the lid with first and last names written on it. Inside the kit, there was a blue " intubation kit medication list " that did not contain any patient information. The column titled " amount used " next to a list of medications was blank. Upon emptying the kit, the DOP pointed out there were three used medication vials that were not part of content approved for the kit. Among the medications that were listed, two appeared to be used.

On 7/27/2016 at 10:40 a.m., during a concurrent interview, the DOP confirmed the medication lists were incomplete and there was no indication when it was used, who opened the kit at which unit, and how much medication had been used. If the post-it note was lost, the pharmacy would not be able to bill the medication used and/or check for discrepancy.

Further inspection of the pharmacy area revealed the following: one more opened intubation kit without medication list; one opened CVOR box with medication list not completed; and five opened code blue boxes. One of five code blue boxes had no medication list in it; another one of five code blue box had a med list without patient information. All of the medication lists from these boxes did not indicate the amount of medications used. The DOP confirmed there was no tracking system to find out which unit these boxes were from. These boxes were brought to the pharmacy with opened and removable lids. The pharmacy would not be able to reconcile medications used if the medication list was lost or not included in the loosely covered boxes.

On 7/28/2016 at 11:15 a.m. during an interview, both RN2 and DOP acknowledged the potential for unauthorized access to these emergency boxes after used because these boxes would not be re-sealed after use and during transport back to the pharmacy.

The facility policy and procedures on "Medication Management Emergency Medications", dated 6/2016, did not address how to prevent unauthorized access after the emergency box has been opened and prior to reconciliation and refilling by the pharmacy department.

The facility policy and procedures on "Crash Cart Policy and Checklist", dated 6/2013, indicated the medication lists currently in use did not match the ones included in the policy and procedure.

Based on observation, interview and record review, the facility failed to:

1. Provide radiological services in a safe manner (Refer to A 553).

1. Follow physicist's guidelines for C-ARM readings (Refer to A 537).

2. Assure the Director of Radiology wore a badge/meter to monitor radiation exposure (Refer to A 538).

3. Provide radiological services in a safe manner (Refer to A 553).

The cumulative effect of these systemic failures resulted in the potential for the unsafe delivery of care from radiation emitting devices.

Based on record review and interview, the facility failed to ensure the director of radiology would wear a radiation exposure meter/badge, failed to monitor radiation emission weekly, failed to follow guidelines to maintain the radiation emission equipment within the baseline range set by the physicist and assure that the base line range for radiation emission was established after radiation emitting equipment repair, failed to monitor and follow directions when C-Arm 1 and C-Arm 2 were repaired and failed to provide a policy and procedure for radiology services and demonstrate oversight over the Radiological Services.

Finding:

During an interview with the Director of Radiology on 8/1/16, when asked who maintains/repairs the C-Arms ((a medical imaging device that is based on X-ray technology and can be used flexibly to reveal real-time imagery of a patient's internal structures. The name is derived from the C-shaped arm used to connect the X-ray source and X-ray detector to one another) , stated all repairs and maintenance of the radiation emitting equipment is done by the manufacturer. When asked if any of the three C-Arms had repairs in the last year, she stated C-Arm 1 had several repairs by the manufacturer including on 3/20/16 and 6/1/16, and C- Arm 2 had a repair on 6/7/16. When asked if the physicist evaluated the C-Arm 1 and 2 after each repair, she stated the physicist had not evaluated the C-Arms 1 and 2 after repairs.

A review of a facility's document titled GE Healthcare Service report, dated 3/20/16 and 6/1/16, indicated a corrective repair for C-Arm 1 and C-Arm 2 on 6/7/16. A review of the facility's document titled Weekly Fluoroscope Monitoring indicated a "Baseline values were the measurements taken at the time the yearly physicist's report is performed. New baseline values must be established if any repairs or maintenance were performed on this machine. If indicated kept or mA is outside of the above range, notify your Department Manager immediately. This machine CANNOT be used until repaired."

According to the GE Healthcare Service report dated 3/20/16 and 6/1/16, C-Arm 1 and C-Arm 2 were in continual use and there was no documentation for the service repair in the columns for documenting repairs. There was no documentation of the physicist establishing a new baseline for the kept range and the mA range after each repair as recommended.

A review of the documentation of the physicist's last visit report dated 8/4/15 for C-Arm 1 and C-Arm 2, indicated the physicist established radiation emission baseline for the radiation emitting equipment. There was no documentation of contacting the physicist or evaluation by the Governing Body, Medical Staff Committee or QAPI committee, or an assigned qualified radiology services supervisor.

The facility's policy and procedure for Radiation services upon request was not provided despite being requested on several occasions.

The facility failed to follow recommended guidelines for the safe use of radiation emitting equipment.

On 8/1/16 the director of radiation services was observed without wearing a meter/badge for radiation exposure. Concurrently, during an interview, the director of radiology stated she does not wear radiation exposure counter meter/badge.

Based on observation and record review, the facility failed to ensure that all employees who were working in the Radiology Department wore a radiation exposure meters/badges.

Finding:

On 8/1/16, from 9:30 am to 11:05 am., during an interview, the Director of Radiology department was asked who was reviewing employees' radiation exposure meters/badges for amount of radiation exposed, stated she was. Concurrently, the Director of Radiology department was observed not wearing the radiation exposure meter. The Director was asked why she was not wearing a radiation exposure meter, she stated she did not need to wear the meter/badge.

Based on interview and record review, the facility failed to maintain radiology meeting minutes/in-services and documentation of who was monitoring radiation emissions at the facility.

Finding:

During an interview conducted with the Director of Radiology on 8/1/16, the radiology meeting minutes were requested. The Director of Radiology stated there were no radiology meetings minutes or radiology in-services record. When asked who monitored the radiation emission at the facility, she stated the radiology technician was recording the radiation emission baselines once a week for the three radiation emitting equipment (C-Arm) in the facility. The weekly measurements were documented in a book titled "Weekly Fluoroscope Monitoring" for each of the three C-Arms. There was no documentation of which facility's employee or physician was in charge of monitoring the weekly radiation emission baseline readings recorded by the radiology technician weekly. When asked who oversees the radiation emissions, the Director of Radiology stated a contracted physicist reviews the radiation equipment and the weekly log once a year. She stated the Physicist last annual visit was on 8/4/15.

Based on observation, interview and record review the facility laboratory services failed to:

1. Draw Patient 20's and Patient 21's blood using an aseptic technique (Refer to A 576).

2. Notify 64 patients, who has received blood transfusions, about a blood donor tested positive or was exposed to conditions including but not limited to Hepatitis B and Hepatitis C (Refer to A 593).

Findings:

During an observation in the Emergency department on 7/27/16 at 2:45 pm., in the Triage 1 area, behind the registration desk and in plain view of the patients in the waiting room, laboratory technician (LT 1) was observed collecting blood from Patient 20. In Triage 2 area, LT 1 was observed collecting blood from Patient 21. During an observation of the phlebotomist cart, there were fifteen 22 gauge needles observed with the sterile lower sheath that punctures the tube blood is drawn into, was removed and exposed to room air. When LT 1 was asked why the needles had the lower cover sheath removed, he stated that he was busy in the emergency department (ED) and this practice allowed faster blood draw.

During an interview with the Laboratory Services Director on 7/26/16 at 4:30 pm, he stated removing the lower sheath of the needles was an acceptable practice and could be left removed overnight. He indicated the aseptic technique was still maintained although the sterile seal broken and the lower part of the needle exposed to the room air and other air contaminants.

The facility was not able to provide either a manufacturer or a facility's policy indicating this was an acceptable practice.

The cumulative effect of these systemic failures of failing to draw blood in a safe and sanitary manner and informing patients of quarantined/recalled blood resulted in the Laboratory Services Department inability to ensure the provision of quality health care in a safe environment.

Based on observation, interview and record review, the facility failed to provide proper notification and counseling to 64 patients who received blood transfusion that was later recalled or quarantined for potentially infectious blood. Also the facility failed to notify patients about blood donors later tested positive or was exposed to conditions including but not limited to Hepatitis B and C.

Finding:

During a tour of the laboratory on July 27, 2016, at 10:25 a.m., there was a room designated as "Blood Bank." There was a refrigeration unit for cross matched blood, a refrigerator for blood not cross matched and a cryo-fridge. There was no designated area for quarantined blood.

During another tour of the facility Blood Bank on 8/1/16 at 9:30 a.m., the Laboratory Services Supervisor (LSS) indicated the facility did not have a designated area to store quarantined blood. Also, LSS indicated the blood testing was completed by the blood collection company (Blood Bank 2) and sent to the facility. LSS further indicated quarantined blood would be placed in the drawer by the counter and returned to Blood Bank 2 via the daily courier from Blood Bank 2. When asked how patients were notified if Blood was recalled from Blood Bank 2 reported to the facility, LSS stated that there was blood used at the hospital that was positive for Hepatitis B or C, HIV, malaria and chemotherapy medication: Hepatitis C from nine donors; Viral Mononucleosis from one donor; Hepatitis B from four donors; Malaria from eight donors; Cruezfeld Jacob Disease from two donors; West Nile Virus from one donor; Medications including cancer medication from four donors.

The LSS stated MD 3 would review the information from the look back report and determine if the patients received blood transfusion would require physician's notification. When asked if the facility contacted the blood transfusion recipient directly, LSS stated "No."

A review of the look back Blood Bank units transfused at the facility dated from 2013 to 2016 indicated there were 64 notifications from the blood bank 2. A further review of these notifications indicated twenty nine (29) out of 64 were sent to the patients ' attending physicians. The facility's pathologist noted " No further work up " on 35 out of 64 notification letters. There was no documentation the facility made attempts to notify the patients.

A review of MD 3's notification indicated a waiting time up to four months prior to informing physicians of the testing results of recalled blood transfused to patients.

A review of the facility's policy and procedure dated 03/12 titled "Blood Bank, Look Back" indicated to immediately quarantine the blood product and to notify the attending physician. If the attending physician cannot be notified, it is the responsibility of the laboratory manager to notify the patient by certified mail at least three times over eight weeks period.

Based on observation, interview and document review, the hospital failed to ensure that dietary services met the needs of all patients. The census was 131. The hospital failed to:

1. Provide organized dietetic services as evidenced by findings of unsafe food handling practices and supervision of the dietary department (Cross Reference A619).
2. Ensure that dietary staff were competent in cooling and documenting a time and temperature safety food (formerly called potentially hazardous food), testing the chemical sanitizer, clean and sanitize food service equipment, properly storing and labeling refrigerated foods, serve correct portion sizes and prepare food according to the recipe. These deficient practices had the potential to affect all admitted patients, staff and visitors who eat in the cafeteria. The improper storage of refrigerated food, improper washing and sanitizing of food service equipment, improper testing of chemical sanitizer could result in growth of microorganisms that could cause food borne illness. The incorrect portion sizes and failure to follow recipes could result in inadequate calories and protein that may be necessary for weight maintenance and wound healing. (Cross Reference A622).
3. Ensure that individual patient nutritional needs were in accordance with recognized dietary practices. Patients who received the entrée, pot roast, received less calories and protein than was planned on the menu. The sodium content of two of the dishes was not in compliance with physician's orders. Portion sizes of the pot roast and chicken breast for patients on low fat or cardiac diets were less than what had been planned on the diets. (Cross Reference A629).
4. Ensure there was an effective system in the prevention of infections when it failed to maintain a sanitary environment for food storage, preparation and distribution. There were several deficient practices observed in the hospital's kitchen that could contribute to the growth of microorganisms capable of food borne illness due to improper storage of dry and refrigerated foods, improper washing and sanitizing of food service equipment, improper testing of chemical sanitizer, improper maintenance of dish washing equipment. The patient census was 131. (Cross refer A 622, A 749)
5. Ensure there was adequate water on hand to meet the need of its patients, staff and other persons who come to the hospital during an emergency. In addition, the detailed written plan did not match the food supplies on hand. (Cross Reference A703)
6. Develop a plan to ensure that the quality of its emergency drinking water was appropriate for its patients. This has the potential to affect 633 patients in a three to seven day period according to the hospital's written plan. (Cross Reference A722).
7. Ensure the maintenance of dietetic services equipment per manufacturers' guidance (Cross Reference A701).
The cumulative effect of these systemic problems resulted in the inability of the hospitals' food and nutrition services to direct and staff in such a manner to ensure that the nutritional needs of the patients were met in accordance with practitioners' orders and acceptable standards of practice.

Based on observation, review of facility documents and staff interviews, the hospital failed to provide organized dietetic services as evidenced by findings of unsafe food handling practices and supervision of the dietary department. These deficient practices had the potential to affect all patients, staff and visitors.

Findings:

Several deficient practices were identified during the survey from 07/27/16 through 08/01/16 in the areas of employee competence, food storage, meal production and distribution, equipment maintenance, dish washing, emergency supplies adequacy and preparation. (cross refer A622, A630, A703, A749, A722)

Review of the contracts revealed that the dietetic service was being provided by a food management company. The contract management company was responsible for the provision of the dietetic staff including the food service director, chef, registered dietitian and food service staff.

Based on observation, review of facility documents and staff interviews, the facility failed to ensure that dietary staff were competent in cooling and documenting a time and temperature safety food (formerly called potentially hazardous food), testing the chemical sanitizer, clean and sanitize food service equipment, properly storing and labeling refrigerated foods, serve correct portion sizes and prepare food according to the recipe. These deficient practices had the potential to affect all admitted patients, staff and visitors who eat in the cafeteria. The improper storage of refrigerated food, improper washing and sanitizing of food service equipment, improper testing of chemical sanitizer could result in growth of microorganisms that could cause food borne illness. The incorrect portion sizes and failure to follow recipes could result in inadequate calories and protein that may be necessary for weight maintenance and wound healing. The patient census was 131.

Findings:

Labeling
During a tour of the kitchen on July 27, 2016 at 10:19am, three bags containing chicken were observed in a container on the lower shelf in the refrigerator. Two of the bags were unopened and one was opened. One of the unopened bags was partially thawed and two other bags were completely thawed. None of these bags were labeled or dated to indicate when the bags were placed in the refrigerator for thawing.

A check of the temperature at 10:30 am on 7/27/16 showed one of the bags as 49.8 degrees Fahrenheit (F), while the second bag was 40.4 degrees F. These items were neither labeled nor dated with the use by date.

Two individually wrapped pieces of meat about 10 lbs. each, which was described as "turkey" was also observed in the same area as the chicken.

Other items in the refrigerator that were not labeled or dated included 3 rolls of pork approximately 10 lbs. each; four rolls of beef approximately 10 lbs. each, and three beef pot roasts. There was also salami with a use by or freeze by date of 4/17/16. This item had exceeded the manufacturer's recommendation by three months.

There was an opened bag of pepperoni with no label or date and another bag of pepperoni was labeled with a date of 7/14/16 - 7/17/16. This use by date had been exceeded by 10 days. A bag of capicolla*** was not labeled or dated. The manufacturer's label indicated it was packed 1/16.

On another shelf in the same refrigerator, three bags of a yellow colored liquid were observed in a container. These bags were not labeled or dated as to when it was to be used or discarded. The hospital chef (HC) stated it was liquid eggs

The chef stated that a dietary employee was responsible for assuring that items that had exceeded their use by date were discarded. The same employee was responsible FIFO (first in first out), the storeroom, refrigerator and freezer inventory maintenance.

At 10:40 am, on 07/27/16, a piece of white meat labeled "turkey" was observed in a stainless steel pan in the refrigerator. Dietary employee (DE 1) was observed removing the piece of turkey from the refrigerator and placing it on the counter to prepare. The turkey had a blue colored label with Mon (Monday) but with a date of "7/28/16 (Tuesday) and use by 7/29". In a concurrent interview, HC stated that the item was prepared two days earlier, on Monday, roasted for an entrée turkey tetrazzini, and a small portion put side (leftover) to be used for salads.

DE 1 was interviewed about the cooling of the piece of turkey since it was not consumed on Monday. He indicated he did not complete the cooling process because a different cook had prepared the item. A check of the facility cooling log indicated that the turkey was received by DE1 at 150 degrees F. There were no other temperatures documented other than a final temperature of 38 degrees F.
The proper method to cool****
Cleaning and Sanitizing
At 11: 49 am on 07/27/16, the ice machine stored in the kitchen was inspected. The lid was observed to have a build- up of light brown/dark brown substance. The filter had a build- up of light brown substance.
The Food Service Director indicated that the ice machine bin had recently been cleaned by dietary staff and the filter cleaned once a week.
At 12:05 pm, the ice machine interior was inspected. The interior piping that was covered with a black colored insulation material was covered with a fuzzy white and dark brown substance in covering internal components of the machine. The Maintenance supervisor (MS) stated that ice machine had been cleaned and sanitized the month before by one of the maintenance technician.
At 3:00 pm on 7/27/16, the container of the robot coupe which was dripping in water was stored away as clean was observed to have a both a green and white colored residue on the cover and blade. Dietary Staff 2 (DS2) according to HC had recently used the robot coupe. In an interview with DS2 at 3:05 pm, he indicated that he had attempted to use the robot coupe to puree chicken but found out it had broken. DS 2 indicated he had sent the robot coupe to the dish washer to be cleaned. The Director of Foodservice and HC who were present were not able to explain why the robot coupe that was washed had a white residue and green, possibly from a vegetable that was pureed before the chicken remained in the container after being cleaned twice.
On 7/29/16 at 4:48 pm, a plastic container of a food blender was stored away as clean in the kitchen. An inspection of the container showed a solidified build- up of greyish colored substance on the rubber gasket, rim of the container and base of the container. DS 3 who was present was interview on the cleaning procedure of the blender. He admitted not separating the base from the container prior to washing. This deficient practice could result in growth of microorganisms and cross contamination of the new product being prepared in the same container.

Sanitizer testing
DS 4 was asked to check the concentration of the chemical sanitizer in the sanitizing bucket. According to the manufacturer's instructions, the test strip needs to be immersed into the solution for 10 seconds and checked against the color chart. DS 4 tested the sanitizer three times and twice did not immerse the test strip as long as instructed by the manufacturer. DS 4 immersed it 6 seconds and 7 seconds the first and second times respectively.

Portion Size
During tray line observation on 07/27/16 at 12: 12 pm, DS 5 was observed dishing out the entrée, pot roast. According to the production sheet, patients were to be served 8 ounces of the entrée, DS 5 used a 6 ounce ladle instead.

Review of the training records indicated that all these dietary staff attended various training including Thawing of food and preventing cross-contamination.

Based on observation, review of clinical record and staff interviews, the hospital failed to ensure that individual patient nutritional needs were in accordance with recognized dietary practices. Patients who received the entrée, pot roast, received less calories and protein than was planned on the menu. The sodium content of two of the dishes was not in compliance with physician's orders. Portion sizes of the pot roast and chicken breast for patients on low fat or cardiac diets were less than what had been planned on the diets.

Findings:

During tray line observation on 07/27/16 at 12: 12 pm, DS 5 was observed dishing out the main entrée, pot roast, during the lunch meal. According to the production sheet, patients were to be served 8 ounces of the entrée, DS 5 used a 6 ounce ladle instead. Although, DS 5 used a 6 ounce ladle, the entrée was spilling over in the dish that the food was being served.

Interview with the Hospital Chef (HC) revealed the size of the bowl was only 6 ounces. It was unclear how many times the entrée had been served with patients receiving less calories and protein than was planned.

Visual assessment of the Herbed Baked chicken breast indicated the portion sizes to be less than the 3 ounces stated on the menu. Two random pieces weighed indicated each of the pieces to be 2-3/4 ounces. This was ¼ ounce less than what the patients should have received.

Observation during the same meal showed the same entrée served to all patients on regular and sodium restricted diets. The other variation of the entrée was the potato free pot roast for patients on renal diets. The alternate entrée was Baked Tilapia.

A taste test of the pot roast revealed a very salty dish. The pot roast for patients on the renal diet tasted more salty than the regular diet. A taste of the baked tilapia revealed a salt-free unflavorful entrée. The saltiness of the pot roast made it inappropriate for a low sodium diet. The lack of salt in the tilapia makes it too restrictive for patients on regular diet and therefore not in accordance with physician orders.

Review of the recipe for the pot roast and interviews with the foodservice director and HC on 07/27/16, at 12:30 pm, revealed that the pot roast should have been prepared using a low sodium base keeping it within the low sodium range. In an interview with DS 5 on 7/27/16, at 2:25 pm, she indicated that she had followed the recipe for pot roast but later acknowledged that there was no low sodium base in the kitchen so she substituted the low sodium base with regular base that was higher in sodium. Since the menu was not designed for the regular base, the result was a salty dish.

Consistency
Observation during tray line on 07/27/16 at 12:30 pm showed the pureed squash prepared for patients on pureed diet was watery. The registered dietitian who was present during the observation acknowledged the consistency of the pureed squash was thinner than it should have been. DS 5 stated in the concurrent interview, that she had prepared the squash. She had not added any additional water but she did not add the thickener to the vegetables either. She stated she did not want to add the thickener because it could become "like jelly".

Based on observation and staff interviews, the facility failed to maintain its food service equipment per manufacturers' guidance. The dish machine, freezer and reach in refrigerator were operational in a manner that had the potential to affect food quality and/or increase the potential of growth of microorganisms that could cause food borne illness. The facility also failed to maintain a clean, and sanitary environment.This deficient practice had the potential for cross contamination and spread of infection causing harm to the patients.

Findings:

1. During the tour of the kitchen on 07/27/16, starting at 10:29 am, the walk in freezer was observed to have a significant build-up of ice. The condenser, shelving and several boxes of food were completely covered in frost. The floor of the freezer had ice build-up in different areas about an inch thick. Other areas had frost.

The food service director (FSD), who was present during the observation, stated the door was broken and needed to be replaced.
At 3:29 pm, on 07/27/16, the dish machine was observed to be leaking water around the doors of the machine. A check of the water temperature showed a reading of 214 degrees Fahrenheit (F). The recommended water temperature for a high temperature dish machine is 180 degrees F at the manifold. The maximum water temperature recommended by the FDA for high temperature machines is 194 degrees F. Water temperature at above this temperature results in reduced sanitizing of the dish surface due to increased water evaporation.

A check of the actual temperature at dish level was 156 degrees F. The recommended temperature at dish surface is 160 degrees F. The hospital did not have in place a system to validate the accuracy of the temperature gauge or explanation as to the discrepancy between the high temperature reading and low dish surface temperatures.

The pressure gauge on the machine also read 58 psi. The manufacturers set pressure was 50 psi as demonstrated by the metal label attached to the machine.

The hospital was not aware that the machine may not have been adequately sanitizing the dishes prior to being tested by the surveyor. Food service staff were actively washing dishes prior to the check of the machine.

The FSD stated the dish machine was also being repaired with plans for major parts replacement, scheduled later that evening.
At 12:56 pm on 07/27/16, an inspection of the reach in refrigerator across from the tray line was done. The rubber gasket around the door was warped at the lower right hand corner thereby preventing a complete seal of the door. Milk which was stored in the refrigerator was 51 degrees F. The recommended temperature of refrigerated food is between 36 and 41 degrees F. Temperatures above this range could result in growth of microorganisms.



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2. During a tour of the facility on July 27, 2016 at 10:25 a.m., in the blood bank room of the laboratory, the faucet of the handwash sink had an accumulation of green and white deposits.

During a tour of the facility on July 27, 2016, at 10:50 a.m., in the loading dock the following was observed:
1. There were soiled towels on top of a yellow plastic bag inside a linen container from the contracted linen company.
2. There were three linen containers filled with empty carton boxes.
At the same time, during an interview, the director of facility services stated the linen containers were used to store the empty carton boxes.

At 10:55 a.m., in the radiology department, in one of the dressing rooms, there was an oxygen tank.
At the same time, during an interview, the clinical manager could not explain why the oxygen tank was stored in the dressing room.

A review of the facility's policy and procedure titled Medical Gas Cylinders with an effective date of 5/2016 stipulated a dry, well ventilated location is required for storing cylinders. Protect cylinders from rusting and corrosion. Walls of this room must have a fire resistance rating of one hour. Door must be the self-closing type, if not closed constantly.
At 11:02 a.m. , in the emergency department, the 4 shelf linen cart was not fully covered exposing the clean linens. The linen cart was located along the wall next to the restroom.

During a tour of the coronary care unit from 1:40 p.m.-2:14 p.m., the following was observed:
1. In the nurses' station, the trash was overflowing.
2. In the nurses' station, the handwash sink had a hot water temperature of 100 degrees Fahrenheit.
At the same time, during an interview, the director of facility services stated the hot water temperature should not be more than 110 degrees Fahrenheit.

A review of the facility's Water Temp at Location Max 120 F from January -July 2016, indicated readings were documented in the following areas: water tank, basement, surgery, 1st floor, ER, 2nd floor, CCU, 3rd floor, ICU, and Cath lab. There were no documented water temperature readings for July, 2016 in all the above mentioned areas.

3. In the central supply/linen room, the clean linen cart was not fully covered. The zipper on the sides was open.

4. In the restroom of room 8, the bedpan and measuring container were stored on the floor.
At the same time, during an interview, the charge nurse stated both items should be thrown away.

5. In the restroom of room 5, the bedpan was stored on the floor.

6. In room 5, the wall paper behind the hand wash sink was peeling off.

7. The ceiling vents in room 1,2,6,8,9 and 10 had an accumulation of dust.
During a tour of 2 South from 2:15 p.m.- 2:42 p.m., the following was observed:

8. In room 259, the soiled linen cart filled with soiled linen was partially open.

9. In the restroom of room 259, the call light string was approximately 3-4 inches long.

10. In the restroom of room 259, 2 bedpans and a measuring container were stored on the floor. The call light string was approximately 3-4 inches long. The ceiling vent had an accumulation of dust.

11. The soiled linen cart was 2/3 full. The bed was made. The ceiling vent above the bed had an accumulation of dust..
During an interview, at 2:32 p.m., the director of telemetry stated the patient in room 256 was discharged at 6 p.m. on 7/26/16. A review of the housekeeping log indicated room 256 was not included in the discharge room cleaning.

During an interview on July 27, 2016, at 4:25 p.m., the interim director of environmental services stated room 256 was not texted by the bed coordinator when the patient was discharged. The soiled linen attendant pulls the soiled linen in the cart. The beddings pulled by nursing staff and the environmental services staff makes the bed.

A review of the facility's Shine-Patient Room -Discharge Cleaning
Place the rolled bundle of linen into a soiled linen hamper.
High dust everything above shoulder level: ceiling, vents, lights, walls, blinds, television, and horizontal ledges.

12. In the restroom of room 254, the call light string was approximately 3-4 inches long.

13. In room 253, the soiled linen cart was full and did not close completely. The cart was partially open.

14. In room 253, the room temperature was 79 degrees Fahrenheit. The patient in bed B stated " It could be cooler. My head is warm. "

15. The temperature in room 252 was 89 degrees Fahrenheit. The room was occupied at the time of the observation.

At the same time, during an interview, the director of facility services stated there was no acceptable room temperature range. The temperature was adjusted based on patient's comfort level. Each room had a thermostat.

During an interview on July 27, 2016, at 3:05 p.m., the director of facility services stated for about two weeks they had a problem with the air handlers. A chiller was installed. However, it was not blowing enough air. causing the room temperature in the facility to be elevated.

During a tour of the physical therapy services department on July 27, 2016, at 2:50 p.m., the following was observed:

16. The vinyl linen cart cover was worn out and cracked. The clean linens were overstacked and sticking out from the shelves exposing the clean linens.

17. There were 3 recliners and two stacks of chairs stored along the wall in the treatment area.
At the same time, during an interview, the physical therapy staff II stated the recliners and chairs were stored in the treatment area but were not used by their department.
During a tour of the facility on 7/28/16, from 1 p.m. - 3:10 p.m., the following was observed:

18. At 1:55 p.m., in 2 NORTH, room 222, there were 3 gloves on the floor.
In 2 EAST (telemetry), the following was observed:

19. At 1:45 p.m., in the soiled linen room, two soiled linen carts were overflowing.

20. At 1:55 p.m., in the nurses' station, the trash receptacle was overflowing.

In 2 WEST, the following was observed:
21. At 2 p.m., in room 278-bed B , there was a box electric fan with a sticker dated 2/20/16.

22. At 2:05 p.m., the clean linen closet in the hallway had an accumulation of dust and debris on the floor under the cart.

23. At 2:10 p.m., inside the dirty utility/biohazard room, there was a soiled glove on the floor and the floor had dust and debris.

24. In the dirty utility room, the soiled linen cart was overflowing.

25. At 2:12 p.m., a certified nursing assistant was walking down the hallway with a bundle of rolled soiled linen.
At the same time, during an interview, the certified nursing assistant stated, he did not get a soiled linen cart.
The charge nurse stated the soiled linen was from room 239, where a patient was discharged ( approximately 25-30 feet from the soiled utility closet).

26. At 2:15 p.m., in room 235, there was a box electric fan with no sticker.
At the same time, during an interview, the director of facility services stated the engineering staff bringing the electric fan up to the patient room should put a sticker.

A review of the facility's policy and procedure titled Electrical Environmental Safety Test Ground Quality Check with an effective date of 2/11 stipulated to verify that there is a low resistance connection between the grounding blade of the plug and all readily accessible metal surfaces which could become accidentally " live " trough contact with an internal circuit if the device were dropped or otherwise damaged.

27. The water fountain in the hallway next to room 245 had low water pressure and there was an accumulation of green and white deposits around the opening dispensing the water.
A review of the facility's Cleaning Procedures Manual stipulated for water fountains, the inspection standards included the fountain is free from mineral deposits and the water fountain is clean and dried to a streak-free finish.
During a tour of 2 North on July 28, 2016, from 2:25 p.m.-2:40 p.m., the following was observed:

28. At 2:25 p.m., in room 227, the soiled linen cart was full. There was a box electric fan with no sticker.
At the same time, during an interview, the director of facility services stated the staff bringing the fan to the room should put a sticker.

29. In room 226, soiled linen was hanging on the sides of the soiled linen cart.

30. In room 226, there was a stand fan with a sticker dated 7/26/16.

31. In room 226, the room temperature was 61 degrees Fahrenheit.

32. At 2:32 p.m., in room 227, a chair was blocking the door.

33. At 2:33 p.m., in room 223, there was a box electric fan with no sticker.
During an interview on August 1, 2016, at 8:32 a.m., the infection control manager stated the two concerns with the big box electric fans were: cleaning and the spread of infection.

34. In room 222, the Foley catheter drainage bag was touching the floor. The drainage bag was hooked up to the portion of the bed that moved up and down when the bed height was adjusted. The nurse adjusted it to approximately 1 inch from the floor. Placing the Foley catheter drainage bag that close to the floor had the potential for housekeeping to hit it with a portion of the mop holder during mopping of the floor.

A review of the facility's policy and procedure titled Catheter Associated Urinary Tract Infection Prevention Bundle with an effective date of 5/2014 stipulated to keep the drainage bag off of the floor especially when the patient's bed is placed down due to fall risk.

35. At 2:38 p.m., in room 200, the soiled linen cart was full. There was a box electric fan in use by bed B. The temperature in the room was 74 degrees Fahrenheit.

36. In room 201, there was a box electric fan with no sticker.
During a tour of the intensive care unit on July 28, 2016, from 2:42 p.m.-3:10 p.m., the following was observed:

37. In room 1, the door was wide open and a trash receptacle was placed in front of the door.

38. In room 2, the door was wide open and a trash receptacle was blocking the door. when the trash receptacle was removed, the door started to close. The door did not close completely leaving a gap approximately 1/2 inch wide.

39. In room 4, the Foley catheter drainage bag was approximately 1 inch from the floor.

40. In room 6, a sequential machine wrapped in plastic was placed on top of the cover of a soiled linen cart.

41. In room 7, the soiled linen cart had no cover.

42. At 2:58 p.m., in the linen room, a 5 shelf linen storage cart was not covered.

43. In room 11, the cover of the soiled linen cart did not close completely. There was a gap measuring approximately 2 inches wide.

44. In room 12, the soiled linen cart cover was open (upright 90 degrees).
During a tour of 3 WEST on July 29, 2016, from 9:15 a.m.-9:50 a.m., the following was observed:

45. At 9:15 a.m., in the nurses' station, the handwash sink hot water temperature was 92 degrees Fahrenheit.

A review of the facility's policy and procedure titled Domestic Hot Water Temperature with an approval date of 6/28/2000 stipulated domestic hot water temperature will be taken monthly in various areas of the hospital. Temperatures shall be maintained between 105 and 120 degrees Fahrenheit in compliance with State of California Administrative Code Title 22, Section 70863.

46. At 9:20 a.m., in room 326, when the call light in the restroom was activated, the light above the door came on. There was no audible sound in the hallway.
At 9:30 a.m., at the nurses' station, the call light was audible.
During an interview on July 29, 2016, at 9:30 a.m., the charge nurse stated the volume could be adjusted. The charge nurse proceeded to adjust the volume and the call light was clearly audible throughout the unit.

47. In room 329, there was a closet approximately 5 ' 6 " high. On top of the closet there was a box electric fan and a sequential machine stored at the edge of the closet. Both items were not secured.

48. At 9:34 a.m., in room 329, there was dust and debris on the floor.

49. In room 337, there was a plastic basin stored on top of the hand wash sink.

50. At 9:42 a.m., in the clean linen closet, there was a clean gown on top of the step stool.

51. At 9:47 a.m., in room 335, there was dust and debris on the floor.

52. At 9:48 a.m., In room 334, there was dust and debris on the floor.

53. In room 334, parts of a yellow gown was hanging on the sides of the trash receptacle.

54. At 9:50 a.m., in room 332, there was dust and debris floor on the floor..
During an interview on July 29, 2016, at 9:20 a.m., the EVS staff assigned to the unit stated she worked from 6 a.m.-2:30 p.m. Her assignment included cleaning 18 rooms, mop the floor in the hallway, throw trash, clean the nurses' station, medication room and the waiting room.

During an interview on July 29, 2016, at 5 p.m., the EVS director stated the EVS staff should clean the rooms first. Approximately 15 minutes should be spent to clean each room.

A review of the facility's Cleaning Procedures Manual stipulated the inspection standard -floor is clean and free of dust, debris and spills.

The inspection standards for linen room -rooms are clean and free of dust and debris. Floors are dust -free and exhibit an acceptable shine. Linens are covered and protected from contamination. Underneath shelves are free of dust and other items.
During a tour of the emergency department on July 29, 2016, at 4:30 p.m., the following was observed:

55. In the registration area, the trash receptacle was overflowing.

56. In the nurses' station, the trash receptacle was overflowing.

57. At 4:45 p.m., the restroom was dirty.
During an interview on July 29, 2016, at 5 p.m., the environmental services director stated there was a total of 10 staff working from 6 a.m.-2:30 p.m. There was one staff for each patient care units and 1 staff assigned to the emergency department. There was a total of 7 staff working from 2:30 p.m.-11 p.m. Of the seven, one staff was assigned to radiology and emergency department.
During a tour of the linen storage room in the basement on August 1, 2016, at 8:20 a.m., the following was observed:

58. There was an EVS staff filling up a linen cart. She stated the floor in the linen storage room was cleaned daily.

59. There were clean linens stored on open shelves that were not in plastic.

60. The floor under the storage shelves was thick with dust.

61. There was a 3 shelf cart, in the middle shelf, there were 11 blue gowns that were exposed and not covered in plastic. in the bottom shelf, there were towels that were not stored in plastic.

62. At 8:32 a.m., in the hallway outside the linen room, there was a linen cart with linens with a delivery date of 7/29/2016. The plastic covering was torn open exposing the clean linens.
At the same time, the infection control manager stated the cart should be inside the linen storage room.

63. At 8:40 a.m., a staff from the contracted linen company brought a cart containing mop heads with the plastic cover torn exposing the clean mop heads. The cart was left in the hallway.

Based on observation, review of facility documents and staff interviews, the hospital failed to ensure there was adequate water on hand to meet the need of its patients, staff and other persons who come to the hospital during an emergency. In addition, the detailed written plan did not match the food supplies on hand.
Finding:
During the review of its emergency water supplies on 8/1/16, several containers had date of purchase that had exceeded one year. The document by the hospital showed that " long term storage of bottled water may result in ....off-odor or taste." There was no documented evidence the hospital had a plan in place to ensure the rotation of bottled water to ensure that the quality was maintained for use in an emergency
On 08/01/16 at 11:55 am, a tour of a space where emergency food and water was stored was conducted. There were 64 - 5 gallon bottles of water stored. According to the plan, the emergency water should be for 633 patients, staff and visitors for between 3 to 7 days. Based on the recommended calculation of 1 gallon of water per person per day, the hospital needed at a minimum 633 gallons of water on hand. It had 320 gallons.
The registered dietitian (RD) and hospital chief Operating Officer (COO), who was present during the observation, provided no explanation of why the plan and the products on hand did not match.
The area in which the food and water was stored was cluttered and unorganized. The walls were unfinished. There were overhead pipes in this area with no protection to prevent food such as cold cereal boxes from being damaged in the event of a leak.
Many of the cases of food were still in boxes wrapped in plastic on many wooden pallets with not special order or grouping to ensure easy access to food. In the event of an emergency, hospital staff would have a difficult time locating items in the room.
The RD indicated that in case of emergency, the canned items would be used in meal preparation. Further review of the plan showed the kitchen preparing food from scratch such as preparing beef stew, use of frozen green beans, frozen corn, etc. in recipes. The recipes did not provide guidance on the preparation of the canned goods the facility did have on hand.
During the review of its emergency water supplies on 8/1/16, several containers had date of purchase that had exceeded one year. The document by the hospital showed that " long term storage of bottled water may result in ....off-odor or taste." There was no documented evidence the hospital had a plan in place or a policy/procedure to ensure the rotation of bottled water to ensure that the quality was maintained for use in an emergency.

Based on observation, interview and record review, the facility failed to
1. Ensure action was taken when the temperature and humidity readings were not within the acceptable parameters in the operating rooms and cardiac cath lab.
2. Ensure temperature and humidity readings were done daily and documented in the intensive care unit and recovery room.

This deficient practice had the potential for bacterial growth and infection in the patient care areas when the readings were not within the acceptable parameters.

Findings:

1. During a tour of the intensive care unit on July 28, 2016, 2:42 p.m.-3:10 p.m., there was no temperature/humidity measuring device noted in the unit. The unit consisted of 16 beds.

During an interview on July 28, 2016, at 2:47 p.m., the charge nurse stated they did not keep a daily log of the temperature and humidity. They just called engineering whenever the unit temperature was high.

2. During a tour of the recovery room on August 1, 2016, at 8:45 a.m., there was no temperature/humidity measuring device in the unit.
At the same time, during an interview, the interim director of surgery stated she used a handheld device to check the temperature and humidity daily but did not keep a log.

At the time of the tour, there were two patients in the recovery room.

3. During a tour of the operating rooms on August 1, 2016, from 10:37 a.m. - 10:45 a.m., each operating room had a temperature/humidity measuring device.

A review of the facility's procedure suite temperature and humidity log from January 5, 2016 - August 1, 2016 indicated the following:
Cardiac Cath Lab 1
January 4,5,6,7,8,11,12,13,14,15, 17,18, 19,20, 21, 22, 26, 27, 28, 29 - the temperature readings were between 64-68 degrees Fahrenheit
January 5 - the humidity reading was 61-62%
February 1,2,3,4,5,6,8,9,10,11,12,15,16,17,18,19, 22,23,24,25,29 the temperature readings ranged from 64-68 degrees Fahrenheit
February 19,22 - the humidity readings were between 61-62%
March 1,2,3,4,7,8,9,10,1114,15,16,17,18,21,22,23,24,25,28,29,30,31- the temperature readings ranged from 64-68 degrees Fahrenheit
April 1,4,5,6,7,8,10,11,12,13,14,15,18,19,20,21,22,25,26,27,28,29 the temperature readings were between 64-68 degrees Fahrenheit
May 2,3,4,6,5, 9,10,11,12,13 16,17,18,19,2023,24,25,26,2728,31 the temperature readings were between 64-68 degrees Fahrenheit
June 1,2,3,6,7,8,10,13,14,15,16,17,18,20,21,22,23,24,27,28,29,30 the temperature readings were between 64-69 degrees Fahrenheit.
July 1,4,5,6,7,8,10,11,12,13,18,20,21,22,25 the temperature readings were between 65-69 degrees Fahrenheit , July 26 - 77 degrees Fahrenheit and July 29 - 76 degrees Fahrenheit.

Cardiac Cath Lab 2
January 1,2,3,4,6,7,8,9,11,12,131415,16,17,18,19,20,21,22,26,27,28,29,30 the temperature readings ranged from 64-68 degrees Fahrenheit
February 1,2,3,4,5,6,8,9,10,11,12,15,16,17,18,19,21,22,23,25,26,27,29 the temperature readings ranged from 64-68 degrees Fahrenheit.
March 1,2,3,4,56,7,,8,9,10,11,12,14,15,16,17,18,19,20,23,24,25,26,28,29,30,31 the temperature readings were between 64-68 degrees Fahrenheit.
April 1,4,5,6,7,8,10,11,12,14,15,16,18,19,20,21,22, 23,24,25,26,27 the temperature readings ranged from 64-68 degrees Fahrenheit
May 2,3,4,5,6,9,10,11,12,13,16,17,18,19,20,21,22,23,24,25,26,27,28,29,31 the temperature readings ranged from 64-69 degrees Fahrenheit
June 1,2,3,5,6,7,8,9,10,11,13,14,16,17,18, 20,21,22,23,24,27 the temperature ranged from 64-68 degrees Fahrenheit
June 28-the temperature reading was 77 degrees and the humidity was 65-66%. There was a notation "reported." There was no documentation of what action was taken by Engineering.
July 1,2,3,4,5,7,8,9,10,11,12,13,1618,19,20,25 the temperature readings ranged from 66-68
July 20 -79 degrees Fahrenheit
July 28 -79 degrees Fahrenheit Notify Engineering


At the bottom of the form there is a section comments/actions take for out of range readings and circle out of range date(s) reported to Engineering. There was no documentation noted.
Procedure suite temperature and humidity must be checked and logged every day. INITIAL in the appropriate degree/date box. Room temperature must fall between 68 degrees F and 75 degrees F. Room humidity must fall between 30% and 60 %. If the temperature or humidity falls out of range the following action must be taken and documented on the log: NOTIFY ENGINEERING.

During an interview on August 1, 2016, at 5:45 p.m., the cath lab manager could not explain why the acceptable range on the form was 68-73 and 68-72 degrees Fahrenheit.

A review of the facility's operating room temperature/humidity log from 2014-2016 indicated the facility's acceptable range for temperature was 68-73 from 2014-October 2015. From November 2015-July 2016, the facility's acceptable range for temperature was 68-72.
A review of the facility's Procedural/Sterile Storage Areas Daily Temperature & Humidity Log indicated the intensive care unit was not an area included in the daily monitoring of temperature and humidity.

A review of the facility's Procedure Suite Temperature and Humidity Log f0r 2015 and 2016 indicated the following:
October, 2015 -Cardiovascular Operating Room and OR 6 - the temperature readings ranged from 54-64 degrees Fahrenheit. There was documentation that Engineering was called on October 2, 2015 for the temperature of 57 degrees Fahrenheit in the cardiovascular operating room. There was no documentation of the action taken by engineering. There was no documentation engineering was called on the other days that the temperature was below 68 in the cardiovascular operating room. There was no documentation that engineering was called for operating room 6 temperature readings below 68 degrees Fahrenheit.
November, 2015 - In operating rooms 1,2,3,4,6 and cardiovascular operating room-the temperature ranged from 57-67 degrees Fahrenheit. There was no documentation engineering was called.
December, 2015- In operating rooms 1,2,3,4,6 and cardiovascular operating room the temperature readings ranged from 54-67 degrees Fahrenheit. There was no documentation engineering was called.
January, 2016- In operating rooms 1,2,3,4,6 and cardiovascular operating room the temperature readings ranged from 58-67 degrees Fahrenheit. There was no documentation that engineering was called.
February, 2016 -In operating rooms 1,2,3,4,6 and cardiovascular operating room the temperature readings ranged from 58-67. There was no documentation engineering was called.
February, 2016- On February 22, in operating room 1, the humidity reading was 62%. There was no documentation engineering was called.
March, 2016-In operating rooms 1,2,3,4,6 and cardiovascular operating room the temperature readings ranged from 57-67 degrees Fahrenheit. There was no documentation engineering was called.
March, 2016- In operating room 1, on March 6 the humidity reading was 62%. There was no documentation engineering was called.
In operating room 3, on March 6, the humidity reading was 62%. There was no documentation engineering was called.
In operating room 6, on March 28, the humidity reading was 66%. There was no documentation engineering was called.
April, 2016- In operating rooms 1,2,3,4,6 and cardiovascular operating room, the temperature readings ranged from 56-67. There was no documentation engineering was called.
On April 18, in operating room 6, the temperature was 90 degrees Fahrenheit. There was no documentation engineering was called.
May, 2016- In operating rooms 1,2,3,4,6 and cardiovascular operating room, the temperature readings ranged from 59-57 degrees Fahrenheit. There was no documentation engineering was called.
June, 2016- In operating rooms 1,2,3,4,6 and cardiovascular operating room, the temperature readings ranged from 54-67 degrees Fahrenheit. There was no documentation engineering was called.
In operating room 1, on June 18, humidity reading was 63%; on June 21, humidity reading was 65%; on June 22, humidity reading was 62%; and on June 23, humidity reading was 61%. There was no documentation engineering was called.
In operating room 2, on June 18, the humidity reading was 64%; on June 21, the humidity reading was 65%; on June 26, the humidity reading was 69%; on June 27, the humidity reading was 71%. There was no documentation engineering was called.
July, 2016-in operating rooms 1,2,3,4,6. and cardiovascular operating room, the temperature readings ranged from 56-67 degrees Fahrenheit. There was no documentation engineering was called.

Based on observation, interview, and record review, the facility failed to provide a sanitary environment, have active infection control program to prevent, control, and investigate infections and communicable diseases. The facility's infection control program failed to:

1. Ensure the needle was sealed not pre-inserted to a vacutainer hub (holder) prior to drawing the patient's blood (Refer to A749).

2. Ensure the peel packs that contained surgical instruments with hinged [clamps, nerve hooks, grasps, forceps, hemostats] are not in closed position, no colored tape on the handle, no presence of stains (rust), markings and multiple surgical instruments are not stacked on top of another instruments. The peel packs are not crumpled and with no stain marks (Refer to A749).

3. Ensure gel pads and operating table mattress not having stain, residual tapes, and tears when in use (Refer to A749).

4. Ensure the registered nurse change gloves after touching indwelling catheter tubing and draining bag prior to providing care to a patient (Refer to A749).

5. Ensure the soap dispenser in nursing station handwashing sink is filled with handwashing soap at all times (Refer to A749).

6. Ensure triage rooms have handwashing sink, soiled and clean blood pressure cuff were not mixed together and no intravenous (IV) solution bags in a plastic crate on the floor (Refer A749).

7. Ensure IV lines and tubing are labeled with date, time and person who hang it, opened betadine solution and sterile water containers with date, blood glucometer (machine to check blood sugar) storage away from a thrash bin (Refer to A 749).

The cumulative effects of these systemic problems resulted in the hospital's inability to provide an effective hospital wide infection control program and to provide patient care in a safe and effective manner.

Based on observation, interview, and record review, the facility failed to: (1) Ensure the needle was sealed not pre-inserted to a vacutainer hub (holder) prior to drawing the patient's blood.
(2) Ensure the peel packs that contained surgical instruments with hinged [clamps, nerve hooks, grasps, forceps, hemostats] are not in closed position, no colored tape on the handle, no presence of stains (rust), markings and multiple surgical instruments are not stacked on top of another instruments. The peel packs are not crumpled and with no stain marks.
(3) Ensure gel pads and operating table mattress not having stain, residual tapes, and tears when in use.
(4) Ensure the registered nurse change gloves after touching indwelling catheter tubing and draining bag prior to providing care to a patient.
(5) Ensure the soap dispenser in nursing station handwashing sink is filled with handwashing soap at all times.
(6) Ensure triage rooms have handwashing sink, soiled and clean blood pressure cuff were not mixed together and no intravenous (IV) solution bags in a plastic crate on the floor.
(7) Ensure IV lines and tubing are labeled with date, time and person who hang it, opened betadine solution and sterile water containers with date, blood glucometer storage away from a thrash bin.


Findings:


On July 27, 2016, at 2:15 p.m., during a tour of the emergency department (ED), a blood drawing station was observed located by the registration area. The blood drawing is within view of the patients/visitors in the waiting area.

The phlebotomy tray (a tray with equipment for blood collection) was observed on top of a bedside drawer which contained vacutainers (vacuum tubes) with different color of rubber stoppers, tapes, alcohol pads, torniquets, and ten (10) hubs with attached to needles, the small end of needles were without proctive plastic cap covers exposed to air, thus breaking the needle sterility.


Phlebotomist A prepared Patient 12 for blood drawing. [Phlebotomist A was wearing glove, gown and facial shield]. After Patient 12's arm was cleaned with antiseptic (alcohol wipe), the phlebotomist picked up the needle that was already attached to vacutainer hub and inserted the needle into Patient 2's vein and then inserted vacutainer tube via the large end of the hub, the small end of the needle penetrating the stopper to draw blood to a vacutainer tube.


During an interview with Phlebotomist A, on July 27, 2016, at 2:25 p.m., he stated he pre-inserted the blood collection needle to a hub (holder) in the laboratory because the ED is a busy area, and the blood draw would be done faster if the needle was pre-inserted to the vacutainer hub ahead of time.

A review of the facility policy titled, "Venipuncture" datedDecember 2014 listed the supplies and equipment needed and procedure to perform venipuncture. The policy did not explicitly indicate that the sealed needle can be broken and attached to the vacutainer hub ahead of time.

Review of the Manufacturer's handout indicated "Do not use needle if label has been torn before venipuncture". Also review of the phlebotomy guide.org indicated prior to entering the room all supplies should be gathered and organized. The supplies should be clean and still in packaging if applicable. It is necessary for the patient to observe the phlebotomist removing the needle from fresh packaging to ensure they are clean/sterile.

2. On July 27, 2016, at 10:30 a.m., during wound care observation for Patient 9, RN 1 and RN 2 were wearing gown, gloves, and mask while preparing Patient 9 for wound care. RN 1 touched the indwelling catheter tubing and urine draining bag, without removing the soiled gloves, RN 1 proceeded to turn Patient 9 onto his left side. Then RN 1 picked up the bilateral wrist restraints from the foot of the bed, rolled the wrist restraints, and placed them in the bedside drawer. RN 2 removed the soiled dressing on the coccyx (tail bone area) pressure ulcer and applied a new medi-honey dressing.


A review of Patient 2's physician order dated July 25, 2016, indicated to clean coccyx (tailbone area) pressure ulcer with normal saline/wound cleanser, apply medi-honey dressing, change every 5-7 days or p.r.n. (as needed) if soiled.


During an interview with RN 1 on July 27, 2016, at 10:30 a.m., she stated that she should have changed her gloves after touching the indwelling catheter tubing and urine collecting bag to prevent cross contamination. RN 2 stated he failed to cleanse Patient 2's pressure with normal saline as ordered by the physician.


The facility policy dated January 2014, titled, "Hand Hygiene" indications hand washing and hand antisepsis should be done before and after direct contact with patients, blood/body fluids or equipment and environmental items touched by patients.



3(a). On July 27, 2016, at 2 p.m., during the initial tour of the Emergency Department (ED 1) with RN 5, there were three (3) triage areas being utilized as triage rooms. Triage Rooms 1 and 3 did not have handwashing sink.


In Triage Room 1, there were four (4) used/soiled blood pressure (B/P) cuffs mixed with sealed B/P cuffs in the plastic bin. There was a plastic crate that contained eleven (11) intravenous solution bags of normal saline. This plastic crate was being used to keep the room door open.

During an interview with RN 4, on July 27, 2016, at 2 p.m., RN 4 stated Triage Room 1 was a charting area, now is being used as a triage room, the soiled B/P cuffs are single patient use and should be disposed after use to prevent cross contamination, and the room was hot and we used a plastic crate to keep the door open.

3(b). In the ED 1, the following was observed:
- IV tubing of 0.9 % Sodium Chloride connected to a patient was on the floor.
- Intravenous lines on patients no label as to the date and time it was hang and who hang it.

According to the facility policy dated November 2010, titled, " IV Therapy" indicated label dressing with date and time changed
and initial of person changing.

3(c). In the ED 2, the following was observed:
- Betadine Solution and Sterile Water opened and undated
- Blood glucometer was beside the waste material container on top of the pyxis machine
- In beds 2, 3 and 6, the mattress had holes, tears, stains, with residual tapes

4. During the tour of the unit 2 East (Telemetry) on July 29, 2016, at 8:50 a.m., the soap dispenser in the nursing station handwashing sink was empty. During an interview with RN 6, she stated the soap dispensed had been empty since 7:30 a.m., and the environmental services (EVS) was informed.


During an interview with Infection Control Officer on July 29, 2016, at 8:55 a.m., she stated every soap dispenser in the facility should be monitored by the EVS staff every shift, and soap dispenser should be filled with handwashing soap.


A review of the facility policy dated January 2014, titled, "Hand Hygiene" indicated hand hygiene product should be accessible at the point of patient care (when possible/feasible) and (at minimum) at entrance to patient's room, at bedside, or other convenient locations.


5. On August 1, 2016, at 10:45 a.m., during the tour of the operating room (OR) with the registered nurse (RN 8), the following was observed:

a. The peel packs that contained surgical instruments (clamps, nerve hooks, grasps, forceps, hemostats) with hinged are in closed position, colored tape on the handle, presence of stains (rust), markings and multiple surgical instruments stacked on top of other instruments. The peel packs were crumpled and with stain marks.

On August 1, 2016, at 11:20 a.m., RN 9 opened a sterilized major tray (use for major type of surgery) and found hinged surgical instrument were closed position. The surgical instrument were crowding and 18 forceps placed on top of the other surgical instruments.

During an interview with RN 9, she concurred that hinges should be in opened position, no overcrowding of instruments and no stains, markings. RN 9 also stated the peel packs should not be crumpled.


b. There was yellow stain on the center, edges and lower areas of the gel pad on top of the operating mattress. The operating mattress and arm rest had residual tapes and tears.

During an interview with RN 8 on August 1, 2016 at 11:25 a.m., RN 8 stated yellow stain was betadine stains.

Based on observation, interview and record review, the facility failed to ensure that emergency care was being properly provided by emergency room medical/nursing personnel so as to ensure the health and safety of patients.

Findings:

During the initial tour of the facility's Emergency Department (ED) on 7/27/16, Patient 23 was noticed in the hallway lying in bed. Concurrently, during an interview, the registered nurse (RN 2) stated Patient 23 "comes here often seeking drugs."

A review of Patient 23's medical record indicated the patient was admitted on 7/25/16 to the ED with a chief compliant of suicidal ideation and hearing voices. On 7/26/16 at 2:00 am., Patient 23 eloped.

On 7/26/16, Patient 23 was re-admitted for suicidal ideation and hearing voices. He was cleared and discharged to home on 7/28/16 at 09:08 am.

On 7/28/16, at 11:53 pm, Patient 23 registered at the ED with a chief complaint of suicidal ideation. At 12:43 am, he did not answer when called for triage.

According to the medical record Patient 23 had 16 visits admissions to ED from January 2016, to 7/27/16. There was no documented evidence the consultations with social services or attempts to arrange such a consultation for the patient was done.

On 7/28/16, at 4:45 pm, during an interview with RN 1, when asked how long triage takes after a patient registered, she stated about 10 to 15 minutes. When asked how long Patient 23, who expressed suicidal ideation should have waited before triage, she stated "as soon as possible". When asked why there was no documentation of Patient 23 being triaged in 10 to 15 minutes, there was no explanation.

A review of the ED log for 7/27/16, indicated there were 150 patients seen that day and the following occurred:

1. Four patients eloped.

2. Two patients were transferred to a general acute care hospital (GACH 4) and GACH 5.

3. Fourteen patients left without being seen or receiving treatment.

4. Two patients left Against Medical Advise (AMA).

5. One patient expired and was sent to the morgue.

A review of the facility's policy and procedure titled Suicide Assessment, dated 6/2/16, stipulated patients assessed to have suicidal ideation will be closely monitored, including one to one monitoring. According to the facility's Triage policy, patients are triaged "as soon as possible after arrival."

During an interview with RN 1 on 7/27/16, at 3:10 pm, she stated the patients presenting to the ED with "non urgent" medical complaints would be triaged, sent downstairs to a different floor by the elevator and would be treated in ED 2 by nurse practitioner (NP 1).

During a tour of ED 2, Patient 32 was waiting to be seen by NP 1 for fall and laceration repair.

A review of the facility's policy and procedure titled "surge plan" dated 5/25/16 indicated "patients requiring noncurrent care will be assessed, if there is unavailable bed in ED will be send to ED 2 (Fast Track).

The facility was not able to provide any documentation that ED 2 had been reviewed /approved by the Office of Statewide Health Planning and Development or the Department of Public Health prior to patients being seen in that area.