HospitalInspections.org

Based on findings from observation, interview and document review, the following lapses in acceptable infection control practices were identified at the hospital's inpatient and outpatient settings: (1) 3 of 3 staff did not perform hand hygiene, (2) 1 of 1 staff did not clean nondisposable patient equipment after use, (3) disinfecting wipes for cleaning equipment were not available, (4) lack of a policy and procedure (P&P) for cleaning and disinfecting patient care equipment and (5) hydrocollator cleaning inadequately documented. Additionally, (6) the hospital has not conducted an infection control risk assessment, (7) the Infection Control Program has not been reviewed/revised since 2013, and (8) the Infection Preventionist lacked training in infection control. These findings could lead to the spread of infection.

Findings regarding (1) above include:

--Per observation on 6/14/16 at 12:00 pm, Staff A did not perform hand hygiene before donning gloves to perform a glucose fingerstick. Staff A removed the gloves after completion of the fingerstick and did not perform hand hygiene. He/she acknowledged this finding at the time of observation.
-- Per observation on 6/15/16 at 12:10 pm, Staff B did not perform hand hygiene before donning gloves to perform a glucose fingerstick. He/she acknowledged this finding at the time of observation.

-- Per observation on 6/15/16 at 4:40 pm, Staff C did not perform hand hygiene after removing gloves. He/she acknowledged this finding at the time of observation.

Findings regarding (2) above include:

-- Per observation on 6/14/16 at 1:40 pm, Staff D auscultated a patient's lungs after a respiratory treatment with a stethoscope and did not clean the stethoscope after use. He/she
revealed he/she does not routinely clean a stethoscope between patients and acknowledged this finding at the time of observation.

Findings regarding (3) above include:

-- Per interview of Staff E on 6/15/16 at 11:00 am, he/she revealed patient equipment in the outpatient Behavioral Health clinic is cleaned and disinfected with Purell hand sanitizer applied to a paper towel, disinfecting wipes are not available

Findings regarding (4) above include:
-- Per interview of Staff F on 6/15/16 at 2:00 pm, he/she revealed there was no P&P for cleaning and disinfecting patient care equipment in the hospital or outpatient clinic.

Findings regarding (5) above include:

-- Per review of the hospital's P&P titled, "Hot Pack Protocol," last revised 4/2016,it indicated that physical therapy (PT) staff should thoroughly clean the hydrocollator one time every week.

-- Per review of the hospital's hydrocollator cleaning log (dated 1/1/16 - 6/14/16), the hydrocollator was cleaned monthly on 1/13/16, 2/18/16, 3/3/16, 4/21/16 and 5/11/16, not weekly.

-- During interview of Staff G on 6/15/16 at 11:30 am, the above finding was acknowledged.

Findings regarding (6) above include:

-- Per interview of Staff F on 6/15/16 at 12:00 pm, he/she indicated the hospital has not conducted an infection control risk assessment to prioritize the selection of quality indicators for infection preventing and control.

Findings regarding (7) above include:

-- Per interview of Staff F on 6/15/16 at 12:00 pm, he/she indicated the hospital's Infection Control P&P was last reviewed 12/2013.

Findings regarding (8) above include:

--Per review of the hospital's Infection Preventionist's personnel file, it lacked evidence of infection control training. During interview of Staff F on 6/16/16 at 11:00 am, he/she confirmed the lack of infection control training.

Based on findings from document review and interview, the hospital lacked written policies and procedures (P&P) for the collection, preservation, transportation, receipt and reporting of specimen handling.

Findings include:

-- Per review of the Laboratory P&P manual on 6/15/16 at 12:15 pm, it lacked evidence that that the hospital had established P&P's for the collection, preservation. transportation, receipt, and reporting of specimen results.

--During interview of Staff H on 6/15/16 at 12:15 pm, he/she acknowledged the above findings.

Based on findings from document review, medical records (MR) review and interview, 6 of 6 MRs reveiw of patients at risk for pressure ulcer development (Patients #1, #2, #3, #4, #5 and #6, lacked nursing documentation regarding turning and poositioning, skin breakdown preventative measures, skin assessments and wound assessments. Also, nursing staff lacked training in skin care (e.g., skin assessment, pressure ulcer staging and documentation). Additionally, the facility does not track and trend pressure ulcer data in its quality assessment performance improvement (QAPI) program. These lapses could increase patients' risk for skin breakdown.

Findings include:

-- Per review of the hospital's policy and procedure (P&P) titled "Clinical Nursing Skills," dated 12/2015, it instructed staff to inspect the patient's skin at least once a shift and document the assessment. It also instructed staff to use the Braden scale to determine skin breakdown risk assessment and document the findings. (The Braden Scale For Pressure Sore Risk (Braden scale) requires scoring of patient risk factors.)

Additionally, it indicated any pressure ulcer should have an assessment documented. For patients at risk for pressure ulcer development (i.e., Braden score < 19) nursing staff should implement turning and positioning every 2 hours if bedridden and hourly if chairfast. Also, nursing staff should place patients at risk on a pressure reducing mattress and/or chair cusion.

-- Per review of Patient #1's MR, nursing documented a Braden Scale score of 15 (at risk) with an activity subscore of 2 (chairfast). The MR lacked nursing documentat ion of consistent skin assessment every shift and description of Patient #1's pressure ulcer on her coccyx (i.e. type, location, stage, size, pain) Additionally, the MR lacked documentation from 3/10/16 - 6/15/16 that Patient #1 was turned and positioned every 2 hours and/or placed on a pressure reducing mattress and/or chair cushion.

--Per review of Patient #2s MR on 5/7/16 nursing documneted a Braden sacore of 14 (moderate risk) with an activity sub score of 1 (bed rest). The MR lacked nursing documentation regarding turning and positioning of Patient #2 from 5/7/16 - 5/11/16. The patient was not placed on a pressure reducing mattress.

-- Per review of Patient #3's MR, on 5/13/16 nursing documented a Braden score of 13 (moderate risk) with an activity subscore of 2 (chairfast). The MR lacked nursing documentation regarding turning and positioning of Patient #3 from 5/13/16 - 5/17/16. The patient was not placed on a pressure reducing mattress and/or chair cushion. Documentation of Patient #3's pressure ulcer on coccyx lacked complete description (i.e., type, location, stage, size, pain).

The same lack of nursing documentation regarding skin assessment every shift, turning and positioning, implementation of preventative measures and pressure ulcer description was found in Patients #4, #5 and #6 MRs.

--During interview of Staff I on 6/14/16 at 12:20 pm, the above findings were acknowledged.

--During interview of Staff J on 6/16/16 at 9:30 am, he/she revealed nursing staff have not had training regarding skin assessment and pressure ulcer staging. A newly formed skin care team is in the process of being developed. He/she acknowledged the above findings.

--During interview of Staff F on 6/16/16 at 11:00 am, the hospital's QAPI program does not track and trend pressures ulcers.

This STANDARD is not met as evidenced by: Based on findings from medical record (MR) review and interview, in 4 of 7 surgical patients (Patients #7, #8, #9 and #10) MRs reviewed, provider entries lacked times and/or dates.

Findings include:

The following MR entries lacked times and/or dates:

- Patient #7 (date of surgery 6/9/16) - Anesthesia record lacked time of physician signature.

- Patient #8 (date of surgery 6/9/16) - Anesthesia record lacked time of physician signature.

-- Patient #9 (date of surgery 6/14/16) - Anesthesia record lacked date and time of physician signature and Anesthesia discharge order lacked time.

-- Patient #10 (date of surgery 6/14/16) - Physician orders lacked date and time of physician signature.

--During interview of Staff K on 6/14/16 at 4:00 pm, he/she acknowledged the above findings.

Based on findings from medical record (MR) review, document review and interview, the hospital did not ensure that patient events (i.e., patient falls) were fully investigated and analyzed to prevent recurrence.

Findings include:

-- Per MR review, Patient #11 was admitted to the hospital on 12/24/15. He was identified as a high risk to fall. Interventions to prevent falls included e.g., non-skid foot wear, call bell within reach, walker, clutter free environment.

-- Per review of the form titled "Accident/lncident Report," dated 1/10/16, Patient #11 was found on the floor in his bathroom. The investigation indicated Patient #11 was non compliant with use of his call bell. Staff documented reinforcement with the patient regarding the use of his call bell and the need to use it for his safety.

-- Per MR review, on 1/15/16,Patient #11 remained a high risk to fall. Interventions to prevent falls included e.g., non-skid foot wear, call bell within reach, walker, clutter free environment.

-- Per review of the form titled "Acciden/lncident Report," dated 1/20/16, Patient #11was found on the floor in his room. The investigation indicated he got up from his bed without using his walker, tripped and fell. He was educated to his use walker at all times.

-- Per MR review, on 1/21/16, Patient #11 remained a high risk to fall. Interventions to prevent falls included e.g., non-skid foot wear, call bell within reach, walker, clutter free environment.

-- Per review of the form titled "Acciden/lncident Report," dated 1/22/16, Patient #11 was found on the floor in his room. The investigation indicated he did not use his walker and the patient was counseled about this.

The facility's investigations did not indicate additional interventions to be put into place to prevent falls.

-- During interview of Staff F on 6/16/16 at 1:30 pm, the above findings were acknowledged.

Based on findings from document review and interview, the facilty's infection control program was incomplete. Specifically, surveillance information was collected and recorded but not analyzed.This prevents trends from being
recognized and strategies for improvement from being developed.

Findings include:
-- Per review of the hospital's Infection Control log, dated 1/2016 - 5/2016, occurrences of infection were documented i.e., the type of infection, culture results and the antibiotic administered. However, analysis of potential causative factors for the infections described was not documented. Additionally, there was no indication that baseline thresholds were established and trending analysis was done.

-- During interview with Staff F on 6/16/16 at 11:00 am, he/she acknowledged the above findings.