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Based on interview, record review and policy review the facility failed to follow their policy to initiate and document contact within one day of receiving a complaint for three patients (#32, #33, and #34) of six records reviewed. The facility census was 33.

Finding included:

1. Review of the facility policy titled "Resolving Patient Complaints/Grievances (Core)" effective date 05/1/2011, showed the following:
-upon receipt of the complaint/grievance, the assigned manager must respond to complainant, acknowledging occurrence and follow-up. The initial response acknowledging receipt of the complaint/grievance shall occur within one working day. Communication can be via telephone or visit, and must be documented in the Complaint Management Database (CMD).

2. Review of the Safety Event System (SES) showed Patient #32 called the facility with a complaint on 03/07/2011 at 3:40 PM.

Review of the SES showed a letter to the mother was dated 03/21/11, (14 days latter).

3. Review of the SES showed Patient #33's mother contacted the facility with a complaint on 02/07/11 at 2:44 PM.

Review of the SES showed an email from staff stating a call had been made to the mother on 02/11 /11, (4 days later).

4. Review of the SES showed the facility received a complaint letter on 07/25/11 from Patient #34's mother.

Review of the SES showed the staff had called the complainant on 07/27/11, (2 days later)

During an interview on 08/12/11 at 11:00 AM Staff RR, Risk Management Consultant, stated that there was no documentation on the SES to show that these complainants were contacted within one day of receiving their complaint.

Based on observation, interview, and review of State Statutes, the facility failed to post or display signs to inform the public of the usage of Physician Assistants in the emergency department. This had the potential to affect all patients accessing emergency care at the facility. The facility census was 33.

Findings included:

1. Record review of Missouri Revised Statutes, Chapter 334 section 334.748 enacted in 1989, showed the following direction: No physician assistant shall be used in any office of a physician or in a clinic or hospital unless a notice stating that a physician assistant is utilized is posted in a prominent place in such office, clinic or hospital.

2. Observation on 08/08/11 of the Emergency Department (ED) patient care area and waiting area at 2:15 PM showed no signage informing patients or visitors that physician assistants were utilized.

3. During an interview on 08/08/11 at 3:50 PM, Staff N, ED Nurse Manager, stated the ED utilized the services of physician assistants, and confirmed that there were no signs in the ED informing patients that physician assistants were utilized.

During an interview on 08/08/11 at 3:10 PM, Staff O, ED Medical Director, confirmed that physician assistants assisted with triage and treatment of patients.

Based on observation and interview, the facility failed to ensure that protected health information (PHI) of patients discharged from care was maintained in a manner to protect against unauthorized access. The facility census was 33.

Findings included:

1. Observation on 08/09/11 at 10:40 AM on the Obstetrics Unit showed four large binders stored in the Lactation Consultation Room, which contained approximately 650 birth certificates from 02/20/07 through 07/31/08. The room had no locking mechanism, and was at the end of a hallway out of view from the nursing station.

2. During an interview on 08/09/11 at 10:45 AM, Staff P, Obstetrics Nurse Manager, stated the room was designed for use by a Lactation (breast feeding) Consultant, but was rarely used now because lactation consultations were done in patient rooms. Facility staff who were new mothers were allowed to use the room for breast pumping, and the room could potentially be used by a visitor if the need arose. Staff P stated storage of hard copy birth certificates was discontinued in 2008 when the facility began storing documents electronically, but final disposition of the accumulated birth certificates had not yet been determined.

Based on interview and record review, the facility failed to ensure medical record entries were timed in three (Patient #10, #11, #13) of six current patient medical records and one (Patient #3) of three discharged patient medical records; and failed to ensure medical entries were legible for two (Patients #5 and #36) of 15 records reviewed. The facility census was 33.

Findings included:

1. Review of the Rules and Regulations of the Medical Staff of the facility, approved 10/19/10, Article II Medical Records, 2.1 Contents of Medical Records, C. Manner of Entries; All clinical entries in the patient's medical record, including, but not limited to, history and physicals, procedure notes, progress notes and orders, shall be legible, accurately dated, timed and authenticated, either in writing or electronic form, by the person making such entry.

2. Record review of current Patient #10's physician progress notes showed the physician signed a note dated 08/09/11 but failed to time the note.

During an interview on 08/11/11 at 9:24 AM Staff U, Director of Risk Management reviewed the patient's physician's progress note dated 08/09/11 and confirmed the progress note was not timed.


3. Record review of current Patient #11's multipage signed admission history and physical showed page two was not timed or dated and page three was not timed.

During an interview on 08/11/11 at 9:40 AM Staff U reviewed the document and stated page two was not timed or dated and page three was not timed.

4. Record review of current Patient #13's physician's progress notes dated 08/10/11 showed the note was not timed.

During an interview on 08/11/11 at 9:55 AM, Staff U reviewed the progress note and confirmed the note was not timed.

5. Record review of discharged Patient #3's physician's progress notes showed an untimed death note.

During an interview on 08/10/11 at 9:30 AM Staff U reviewed the progress note and confirmed the death note was not timed.


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6. Record review of current Patient #5's medical record on 08/09/11 showed a form titled Anesthesia Record. The procedure listed was illegible, as was the diagnosis. The narrative section contained five documented entries that were illegible. There were three notations regarding medications that had been given, and all were illegible. The back of the form had a place for the Anesthesiologist to sign and print his/her name under two separate sections. The printed name and the signature were illegible in both sections.

7. Record review of Patient #36's medical record on 08/09/11 showed a form titled Anesthesia Record. The procedure listed was L&D (Labor and Delivery). The narrative section contained illegible documentation. There were three notations regarding medications that had been given, and all were illegible. The back of the form had a place for the Anesthesiologist to sign and print his/her name under two separate sections. The printed name and the signature were illegible in both sections.

8. During an interview on 08/09/11 at 9:40 AM, Staff P, Obstetric Nurse Manager, reviewed the procedure notes for Patients # 5 and #36, and agreed that the documentation was illegible. Staff P was unable to interpret the signature of the physician(s).

During an interview on 08/09/11 at 9:45 AM, Staff M, Vice President of Patient Care Services, reviewed the procedure notes for Patients # 5 and #36, and agreed that the documentation was illegible. Staff M was also unable to interpret the signature of the physician(s).

Based on interview and record review facility staff failed to ensure physician's orders were dated, timed and signed in four (Patients #6, #7, #12 and #13 ) of 14 current patients and one (Patient #2) of three discharged patients records reviewed for dated, timed and signed orders. The facility census was 33.

Findings included:

1. Review of the Rules and Regulations of the Medical Staff of the facility, approved 10/19/10, Article II Medical Records, 2.4 Physician Orders showed the following direction; all orders shall be in writing, dated, time-stamped and signed by the responsible Physician.

2. Record review of current Patient #12's physician's orders dated 08/12/11 showed an untimed, signed order to discontinue infusion of intravenous solution sodium chloride.

During an interview on 08/11/11 at 9:45 AM, Staff U reviewed the order and confirmed the order was not timed as required.

3. Record review of current Patient #13's physician's orders showed the following:
-An order for Zofran (anti-nausea medication) was signed, but not dated or timed.
-An order for Colace (stool softener) was signed, but not dated or timed.

During an interview on 08/11/11 at 9:55 AM Staff U reviewed the patient's physician's orders and confirmed the orders were not timed or dated.

4. Record review of discharged Patient #2's physician's orders dated 06/12/11 showed an untimed order to change Dilaudid (narcotic pain medication).

During an interview on 08/10/11 at 9:05 AM Staff J, Director of Health Information Management (HIM) reviewed the physician's order and confirmed the order was not signed or timed.



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5. Record review of current Patient #6's medical record on 08/11/11 showed a pre-printed order form dated 08/01/11 authorizing Enoxaparin (anticoagulant) to prevent blood clots. The order was signed and dated by the physician, but was not timed.

During an interview on 08/11/11 at 9:20 AM, Staff Q, Nurse Manager, reviewed the order and agreed the order was not timed.

6. Record review of current Patient #7's medical record on 08/09/11 showed a pre-printed Nursery Admission Orders form dated 08/09/11 authorizing Hepatitis B Vaccine, if approved by the patient's parent. The order was signed and dated by the physician, but was not timed.

During an interview on 08/09/11 at 9:35 AM, Staff P, Obstetric Nurse Manager, reviewed the order and agreed the order was not timed.


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Based on interview and record review the facility failed to ensure physician's verbal and telephone orders in five (Patient #10, #13, #24, #26, #29) of six current and in one (Patient #4) of three discharged patients medical records were authenticated (signed, dated and timed) by the physician within forty eight hours. The facility census was 33.

Findings included:

1. Review of the Rules and Regulations of the Medical Staff of the facility, approved 10/19/10, Article II Medical Records, 2.4 Physician Orders showed the following direction; all orders shall be in writing, dated, time-stamped and signed by the responsible Physician; provided that for verbal orders such orders shall be signed no later than 48 hours after issued by the responsible Physician.

2. Record review of current Patient #10's physician's orders showed the following:
-A verbal order for vancomycin (antibiotic) with an untimed, undated signature.
-A telephone/verbal order to hold blood culture (tests) until tomorrow morning with an untimed, undated signature.

During an interview on 08/11/11 at 9:34 AM Staff U, Director of Risk Management reviewed the patient's verbal/telephone orders and confirmed the orders were not timed or dated.

3. Record review of current Patient #13's physician's orders to continue Morphine were not signed, dated or timed.

During an interview on 08/11/11 at 9:55 AM Staff U, Director of Risk Management reviewed the patient's physician's orders and confirmed the order was not signed, timed or dated.

4. Record review of discharged Patient #4's physician's orders dated 07/04/11 showed a verbal order for supplemental dietary beverage electronically authenticated by the physician on 07/13/11.

During an interview on 08/10/11 at 9:44 AM Staff J, Director of Health Information Management (HIM) reviewed the physician's orders and confirmed the verbal order was not authenticated within forty eight hours as required.

5. Record review of current Patient #24's physician's orders showed the following
-A telephone order dated 08/03/11 at 6:15 PM for 16 units insulin (a medication used to treat diabetes) (Novolog) and switch patient to high dose insulin regimen with no signature, date or time.

6. Record review of current Patient #26's physician's orders showed the following:
-A telephone order dated 08/05/11 at 4:00 PM for Nitropatch (a medication used to treat chest pain) 0.2 milligrams (mg) on during day off at night with no signature, date or time.
-A telephone order dated 08/03/11 at 9:25 PM for Benadryl (allergy medication) 25 mg PO (by mouth) x 1 tonight with no signature, date or time.
-A verbal order for mechanical soft solids, thin liquids signed with no date.
-A telephone order dated 08/0411 at 1:15 PM for Apple Enlive (nutritional supplement) TID (three times a day) signed with no date or time.
-A telephone order written on 08/02/11 at 10:10 PM to remove nitro patch, ok to give rhythmo (a medication which treats rapid heartbeats) Benadryl 25 mg PO x 1 signed with no time.
-A telephone order written on 08/02/11 at 2:00 PM to please change Intravenous (IV) Valium order to as needed (PRN) not scheduled signed no time.
-A telephone order written on 08/02/11 at 3:00 PM to decrease IV fluids to 75 milliliters/hour, give 20 mg Lasix (diuretic) IV push x 1 now, 2 D Echo (heart test) in am, consult Dr. Schwarze signed with no time.
-A telephone order written 08/01/11 at 5:45 PM for Clondine (blood pressure medication) 0.2 mg PO every 3 hrs PRN for systolic blood pressure >160, physical therapy and occupational therapy evaluation and treat, magnesium and sedimentation rate (lab test) in AM signed with no time.

7. Record review of current Patient #29's physician's orders showed the following:
-A telephone order written on 08/05/11 (no time) to draw PT/INR & PTT (a test which measures how long it take the blood to clot) now STAT (immediately) signed with no date.
-A telephone order written on 08/05/11 at 9:00 AM to discontinue (D/C) Zocor (a medication to treat high cholesterol), D/C Coreg (heart medication), D/C Isosorbide Dinitrate (a medication to treat heart failure), hold Coumadin (a blood thinner) 0.25 mg Risperdal (an antipsychotic) PO every 8 hours PRN for agitation signed with no time.

During an interview on 08/10/11 at 10:00 AM Staff Q, Nurse Manager, stated after reviewing the orders they were not complete.

Based on interview and record review the facility failed to ensure patients had a history and physical completed within twenty four hours of admission in two (Patient #10, #13) of six current and in two (Patient #3, #4) of three discharged patient's medical records reviewed for completed history and physicals. The facility census was 33.

Findings included;

1. Review of the Rules and Regulations of the Medical Staff of the facility, approved 10/19/10, Article II Medical Records, 2.2 History and Physical Requirements, directed the following; A Physician or Dental member of the Medical Staff or a member of the Allied Health Professional Staff (in accordance with State law) will complete an admission history and physical examination provided such Dental members and Allied Health members are appropriately privileged and authorized to perform such examinations, and signed prior to surgery or within 24 hours after admission or registration, whichever comes first for all patients, including obstetrical patients.

2. Record review of current Patient #10's admission history and physical on 08/11/11 at 9:10 AM showed staff admitted the patient on 08/08/11 and showed the physician failed to authenticate the document.

During an interview on 08/11/11 at 9:20 AM Staff U, Director of Risk Management reviewed the patient's history and physical and confirmed the physician failed to authenticate and complete the document.

3. Record review of current Patient #13's medical record on 08/11/11 at 9:45 AM showed staff admitted the patient on 08/10/11 at 7:13 AM.

Review of the paper documents and the computer entries of the patient's medical record showed the physician failed to provide an admission history and physical for the admission within twenty four hours as required.

During an interview on 08/11/11 at 9:52 AM Staff U reviewed the paper documents and the computer entries for the patient and confirmed the patient did not have and admission history and physical provided within twenty four hours.

4. Record review of discharged Patient #3's admission history and physical showed staff admitted the patient on 06/02/11 and the physician electronically authenticated the document on 06/06/11.

During an interview on 08/10/11 at 9:20 AM Staff U reviewed the patient's admission history and physical and confirmed the documentation was not completed within twenty four hours of admission as required.

5. Record review of discharged Patient #4's admission history and physical showed staff admitted the patient on 07/04/11 and the physician authenticated the document on 07/13/11.

During an interview on 08/10/11 at 9:44 AM Staff U reviewed the patient's admission history and physical and confirmed the documentation was not completed within twenty four hours of admission as required.

Based on observation, interview, and policy review, the facility failed to ensure a safe medication storage environment by performing daily temperature checks for medication freezers in the Pharmacy and on the Obstetrics Unit; and failed to adjust the freezer temperature dial when temperatures were outside the acceptable limits on 32 of 189 dates reviewed. This had the potential to affect all patients received obstetrical services at the facility. The facility census was 33.

Findings included:

1. Review of the facility's policy titled, "Refrigerator and Freezer Temperatures," last reviewed 04/01/2010 showed the following direction:
- Drug storage areas (refrigerators and freezers) will be inspected daily by the Pharmacist. A record log of temperature readings is maintained on the outside of the refrigerator.
- If temperature varies outside the normal range the Pharmacist will attempt an adjustment of the temperature dial and re-evaluate in two (2) hours.
- If unsuccessful the Pharmacist will notify the Engineering Department to fix the refrigerator.
- In such a case, all drugs will be removed and stored elsewhere until repairs are completed.
- In the event of a variance from normal temperature range, the Pharmacist will be consulted immediately to determine the disposition of drugs.

2. Review of the Pharmacy Freezer Temperature Logs on 08/11/11 from February through July, 2011 showed the following:
- February, 2011
- Two dates were blank, indicating a temperature was not recorded.
- The freezer temperature exceeded the acceptable temperature range of -10° Fahrenheit (F.) to -20° F. on eight dates recorded. Only one of the dates showed evidence that the thermostat was adjusted, as specified by policy.
- March, 2011
- Four dates were blank, indicating a temperature was not recorded.
- The freezer temperature exceeded the acceptable temperature range of -10° F. to -20° F. on eight dates recorded. Only two of the dates showed evidence that the thermostat was adjusted, as specified by policy.
- April, 2011
- Two dates were blank, indicating a temperature was not recorded.
- The freezer temperature exceeded the acceptable temperature range of -10° F. to -20° F. for six dates recorded. Only one of the dates showed evidence that the thermostat was adjusted, as specified by policy.
- May, 2011
- Two dates were blank, indicating a temperature was not recorded.
- The freezer temperature exceeded the acceptable temperature range of -10° F. to -20° F. for nine dates recorded. None of the dates showed evidence that the thermostat was adjusted, as specified by policy.
- June, 2011
- Three dates were blank, indicating a temperature was not recorded.
- July, 2011
- Four dates were blank, indicating a temperature was not recorded.
- The freezer temperature exceeded the acceptable temperature range of -10° F. to -20° F. for three dates recorded. Only one of the dates showed evidence that the thermostat was adjusted, as specified by policy.

3. Review of the Freezer Temperature Log for medication storage on the Obstetrics Unit on 08/09/11 showed that eight temperatures had been recorded to date for the month of August, 2011. Of the eight temperatures recorded, five had exceeded the acceptable temperature range of -4° F. to 14° F. None of the dates showed evidence that the thermostat was adjusted, as specified by policy.

4. During an interview on 08/09/11 at 9:50 AM, Staff P, Obstetrics Nurse Manager, stated the freezer in the Obstetrics unit contained Cervidil, a medication used to induce labor. Staff P stated nursing staff were responsible for recording the temperatures daily, and if the temperature was out of range, they were to request adjustment of the thermostat.

5. During an interview on 08/09/11 at 1:35 PM, Staff S, Pharmacist, stated the Pharmacy did not receive a call from the Obstetrics Unit to adjust the thermostat during the month of August, 2011. Staff S stated the temperature range was listed incorrectly on the form used by the Obstetrics Unit, and stated the appropriate range of temperatures was -4° F. to -14° F. (-10° F. to -20° F.) Staff S confirmed that the freezer in Pharmacy also contained Cervidil, and stated that he/she would contact the manufacturer of Cervidil to determine whether the medication was acceptable for use.

Based on interview, the facility failed to ensure that a single pharmacist was responsible for the overall administration of the hospital wide pharmacy service. The facility census was 33.

Findings included:

1. Record review of the facility's organizational chart showed the position of Pharmacy Director was vacant.

2. During an interview on 08/09/11 at 1:30 PM, Staff S, Pharmacist, stated the Pharmacy Director position had been vacant since April, 2010. An Interim Director had been appointed for an unknown period of time, but that person vacated the position in April, 2011 and the Chief Nursing Executive had been appointed as the Interim Director. On 08/08/11, the Vice President of Patient Care Services was appointed as Interim Director. Staff S stated that the Pharmacy Director duties had been split among pharmacist staff since April, 2010.

Based on observation, interview and record review the facility
-Dietary department staff failed to clean and maintain kitchen equipment and storage containers used in preparation of patient meal service.
-Failed to document daily assessments for two crash carts (rolling cart with a set of trays/drawers/shelves with emergency medication/equipment which is used to potentially save someone's life).
-Failed to document the correct lock number for one crash cart of three crash carts observed. These had the potential to affect all patients needing emergency medication/equipment. The facility census was 33.

Findings included:

1. Record review of the U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code showed direction for facility dietary staff including Chapter 3-305.11 Food Storage food shall be protected from contamination by storing the food in a clean, dry location; where it is not exposed to splash, dust, or other contamination.

2. Observation on 08/08/11 at 1:20 PM through 1:50 PM in the facility dietary department showed the following:
-A brown food debris spattered scoop stored in the bulk sugar bin.
-A bulk food container covered with food spills around the rim and cover of the container.
-Two bulk food containers (one with bread crumbs and one with cornmeal) with lids spattered with dried foods on the lids and rims of the lids.

3. Observation on 08/08/11 at 1:47 PM in the facility dietary department showed staff failed to clean and maintain a table mounted can opener covered with brown, sticky food spatters on the blade, holster and area around the base of the mounting plate.

During an interview on 08/08/11 at 1:47 PM Staff E, Cook examined the can opener and stated the can opener needed cleaning and the can opener was cleaned once a day but used all throughout the day.


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4. Record review of the facility policy titled "NUR-PC-Crash Cart Check List and Exchange revision date 12/07/10 stated that daily crash cart and defibrillator checks will be performed by a designated person when the department was open and providing patient care. The checks would include charging the defibrillator while unplugged from a power source and discharging it at the designated level of joules (in accordance with the manufacture), assessing the integrity of the lock, and reviewing the noted expiration dates. This would be documented on the Crash cart/defibrillator check list.

5. Observation on 08/09/11 at 10:15 AM on 3 North showed a crash cart integrity lock with the number 6806024 but the number recorded on the Code Cart Checklist had been recorded from 08/06/11 through 08/09/11 as 6806027.

6. Observation on 08/09/11 at 1:00 PM on 3 East showed an Adult Code Cart Checklist with no documentation in the spaces of 08/02/11, 08/07/11 and 08/08/11.

7. Observation on 08/09/11 at 1:15 PM on 3 East showed a Pediatric Code Cart Checklist with no documentation in the spaces of 08/07/11 and 08/08/11.

During an interview on 08/09/11 at 1:30 PM with Staff LL, Registered Nurse (RN) stated that all crash carts were to be checked daily and documented on the Code Cart Checklist. Staff LL confirmed the facility and unit was open on these days. Staff LL stated that a new lock had been placed on the cart and it was obvious the staff had transferred the number from the orange pharmacy tag (which was to indicate when a particular drug was to expire) and it still had the old integrity seal number on it.

Based on observation, interview and record review facility failed to ensure:
-Dietary staff washed hands when required, wore effective hair restraints, and store foods used in patient meal service in a safe manner to protect against cross contamination;
-Staff performed hand hygiene when entering or exiting patient rooms, after touching contaminated objects, and before applying or changing gloves per the facility's policy for four (#6, #23, #24, and #28) of five patients observed during nursing procedures;
-Staff followed the facility standard of practice for isolation precautions for one patient (#6) of one patient observed on isolation precautions. The facility census was 33.

Findings included:

1. Record review of the U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code showed the following direction for facility dietary staff:
-Chapter 2-301.14 When to Wash; After touching bare human body parts other than clean hands and clean, exposed portions of arms; After handling soiled equipment or utensils; During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; Before donning gloves for working with food; and After engaging in other activities that contaminate the hands.
-Chapter 2-402.11 Hair Restraints Effectiveness; Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment.
-Chapter 3-304.15 Gloves, Use Limitation-If used, single use gloves shall be used for only one task, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.
-Chapter 3-305.11 Food Storage food shall be protected from contamination by storing the food in a clean, dry location; where it is not exposed to splash, dust, or other contamination.

2. Observation on 08/08/11 at 1:20 PM through 1:50 PM in the facility dietary department showed the following:
-Multiple opened partial bags and boxes of foods including wild rice, vegetarian refried beans, great northern beans, dried onions, gluten free pasta stored on shelving in the dry food storeroom.
-An uncovered steam table pan of raw broccoli and cauliflower on a cart in the walk-in refrigerator.
-An opened, case of cheese burritos with the plastic liner opened to air stored on a shelf in the walk-in freezer.
-Staff stored an opened thirty-two ounce container of lemon juice, with manufacturer's label directing "refrigerate after opening" out on a counter unrefrigerated.

During an interview on 08/08/11 at 1:20 PM Staff D, Manager of Food and Nutrition stated the following:
-The pan of broccoli and cauliflower and the frozen cheese burritos should be covered.
-The dried foods in the store room should be labeled with the date when opened.

During an interview on 08/08/11 at 1:50 PM Staff E, Cook stated the container of lemon juice was opened on 08/04/11 and had been stored out on the counter, unrefrigerated since that time.

3. Record review of the facility policy titled, "Hand washing (HACCP{hazard analysis critical control point, a system used in food service to identify possible food contamination areas})", policy #F007, date revised 12/10 showed direction for dietary staff to wash hands before putting on gloves and after removing gloves.

Record review of the facility policy titled, "Disposable Glove Use", policy #F021, date revised 03/11 showed the following direction for dietary staff:
-Wash hands before putting on disposable gloves.
-Disposable gloves must be changed when dirty or ripped and when moving from one task to another.
-Hands must be washed or hand sanitizer used after removing disposable gloves.

4. Observation on 08/10/11 at 10:21 AM through 10:52 AM showed the following:
-Staff I, Food service worker applied disposable gloves without hand washing.
-Staff I, with gloved hands, removed a telephone head set from his/her head, handed it to Staff D, Manager of Food and Nutrition who placed it on his/her own head (touching hair and hairnet).
-Staff E, Cook rubbed gloved hands on his/her apron then,continued to prepare foods for patient meal service.
-Staff G, Cook with gloved hands, touched his/her glasses then, without removing soiled gloves and hand washing continued to prepare foods for patient meal service.
-Staff I with gloved hands, discarded trash then, without removing soiled gloves and hand washing returned to patient meal tray assembly tasks.
-Staff D touched his/her head to adjust the telephone head set and failed to wash hands before touching equipment and surfaces in the tray assembly area.
-Staff G gloved without hand washing and prepared foods for patient meal service.

5. Record review of the facility policy titled, "Uniform Dress Code (HACCP)" policy #E004, date revised 12/10 showed direction for dietary staff to wear the approved hair restraint when on duty.

6. Observation on 08/10/11 at 10:35 AM showed Staff G wore ineffective hair restraint with strands of hair exposed from underneath the edges of the hair restraint and onto his/her shoulder. Further observation showed Staff G threw a kitchen towel over his/her shoulder in direct contact with the exposed hair.

7. Observation on 08/10/11 at 10:46 AM on patient unit 4N showed Staff H delivered patient meal trays on a tray cart with an unzipped plastic covering (could be zipped to protect the trays from cross contamination such as coughs, sneezes, dust, sprays during transport in elevators and hallways).

During an interview on 08/10/11 at 10:46 AM Staff H stated he/she knew the plastic covering should be zipped however he/she never zipped it.

8. Observation on 08/10/11 at 10:47 AM on patient unit 4N showed Staff H opened the plastic covering of the tray cart, (fully exposing the remaining trays on the cart,) delivered a tray to a patient, failed to replace the covering while he/she was in the patient's room.

During an interview on 08/10/11 at 10:47 AM Staff D stated the plastic covering over the tray cart should have been pulled down and closed over the remaining trays on the cart.


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9. Record review of the facility's policy titled, "Standard Precautions," last revised January, 2001, showed the following direction:
- The following elements must be observed by all health care workers (HCW) regardless of the patient's diagnosis.
- Perform hand hygiene before and after patient contact and after taking off gloves.
- Change gloves: Before moving from dirty to clean tasks on the same patient.
- Remove gloves and perform hand hygiene before leaving room.
- Contact Precautions: Hands must be washed with soap and water or use alcohol-based product immediately before leaving the room.

10. Observation on 08/08/11 at 3:00 PM showed Staff NN, Registered Nurse (RN) removed a transparent dressing which was covering an intravenous (IV) lock (a vein access) from Patient #23's left hand. Staff NN applied pressure at the insertion site with folded gauze without wearing gloves. He/she then removed the cardiac telemetry (the adhesive pads used to attach the heart monitor). Staff NN did not wash his/her hands or use alcohol-based product between the tasks.

11. Observation on 08/09/11 at 11:00 AM showed Staff KK, RN, provided Foley catheter (a flexible tube that is passed through the urethra and into the bladder to drain urine) care to Patient #24. Staff KK placed the wash cloths which he/she had used to clean the perineum (the area between the anus and the vagina) on a clean dry towel which she placed on the floor. With the dirty gloves he/she picked up several items in a stack of clean linen which was on the table top and removed some linen for the patient. He/she then removed the dirty gloves and put on clean gloves without washing his/her hands. He/she then wiped down the bedside table top with disinfectant wipes, picked up the towel with wet washcloths from the floor and placed them in the dirty linen. He/she picked up the Foley catheter tubing and examined it. Staff KK removed the dirty gloves and without washing his/her hands, repositioned the patient; moved the bedside table beside the patient; picked up the water container and offered the patient a drink and then pushed the privacy curtain aside. No hand washing was observed between any of these tasks.

12. Observation on 08/09/11 at 2:10 PM showed Staff SS, RN, provided Foley care to Patient #28. Staff SS wore gloves to cleanse Patient #28's perineum. Staff SS removed the dirty gloves and without washing or using alcohol-based product on his/her hands. Staff SS replaced the wedge between the patient's legs and reprogrammed the alarming pump.

During an interview on 08/11/11 at 1:30 PM Staff FF, Infection Prevention, stated that the expectation would be for hands to be cleansed between glove changes when doing Foley catheter care; staff should cleanse hands before entering a patient's room and when leaving a patient's room; staff should wear gloves when removing an IV lock or with any procedure where there might be exposure to blood or bodily fluids.


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13. Observation on 08/10/11 at 8:40 AM showed Staff K, RN, and Staff T, RN, preparing to enter the room of Patient #6, who was on contact isolation precautions. Neither nurse performed hand hygiene before applying isolation gown and non-sterile gloves. Staff K removed the transparent PICC (Peripherally Inserted Central Catheter - a tube inserted through a vein that is used to deliver intravenous fluids and medications) dressing which was soiled with dried blood, then removed non-sterile gloves and applied sterile gloves. Staff T did not perform hand hygiene before application of the sterile gloves. Staff T then removed a blood-soiled piece of surgical tape that had been used to stabilize the PICC. Without changing gloves, Staff T proceeded to cleanse the insertion point and the skin around it. Staff K removed his/her mask, gown and gloves and left the room briefly to obtain a different type of dressing. When he/she returned to the room, Staff K failed to tie the waistband of the (new) isolation gown before handing the retrieved item to Staff T. Without changing gloves or performing hand hygiene, Staff T then applied the clean dressing to the PICC insertion site. Without changing gloves or performing hand hygiene, Staff T used his/her soiled, gloved hand to reach beneath his/her isolation gown and retrieve an ink pen from a uniform pocket, then dated and timed the dressing he/she had just applied. Without decontaminating the pen, Staff T returned the ink pen to his/her pocket. Without removing the contaminated gloves, Staff T went to the computerized work station and began making entries into the patient's electronic medical record.

14. Observation on 08/11/11 showed Staff II, Nephrologist (a physician specializing in kidney disorders), exited Patient #6's room, who was on contact isolation precautions. Staff II removed his/her isolation gown and non-sterile gloves, and left the patient's room without performing hand hygiene.

15. During an interview on 08/11/11 at 1:30 PM, Staff FF, Infection Control Nurse, made the following statements:
- During orientation, employees are taught to perform hand hygiene before applying gloves and between glove changes.
- Employees should wear gloves to remove an IV lock due to the possibility of contact with blood.
- Employees should tie isolation gowns at the waist to ensure adequate protection of clothing and to keep the gown from dragging through sources of contamination.
- Gloves should be removed, and hand hygiene should be performed, when changing from a "dirty" (potentially contaminated with body fluids or other contagions) process to a "clean" process.

Based on record review and interview, the facility failed to ensure that Registered Nurse (RN) staff within the Emergency Department (ED) obtained and/or kept current the certifications required for their positions. The facility census was 33.

Findings included:

1. Review of the Emergency Department (ED) staff certification database on 08/10/11 showed the following:
- Five of 31 RNs did not have proof of current certification in Advanced Cardiac Life Support (ACLS):
- Staff UU, Registered Nurse (RN), was hired 01/19/04, and assumed his/her current position in the ED on 05/10/10. Staff UU had never obtained ACLS certification.
- Staff VV, RN, was hired 01/14/10, and assumed his/her current position in the ED on 12/20/10. There was no evidence of ACLS certification being obtained.
- Staff YY, RN, was hired 05/27/08, and did not change positions since his/her hire date. ACLS certification expired 11/30/10.
- Staff WW, RN, was hired 10/29/91, and assumed his/her current position in the ED on 04/14/08. ACLS certification expired 03/31/11.
- Staff XX, RN, was hired 2/18/08, and did not change positions since his/her date of hire. ACLS certification expired 03/31/11.

- One of 31 RNs did not have proof of current certification in Basic Life Support (BLS):
- Staff TT, RN, was hired 07/24/89, and assumed his/her current position in the ED on 01/02/07. BLS certification expired 02/28/11.

- Six of 31 RNs did not have proof of current certification in Pediatric Advanced Life Support (PALS):
- Staff ZZ, RN, was hired 10/27/06, and did not change his/her position in the ED since date of hire. There was no evidence that Staff ZZ obtained PALS certification.
- Staff TT, RN, was hired 07/24/89, and assumed his/her current position in the ED on 10/02/07. PALS certification expired 02/28/11.
- Staff AAA, RN, was hired 05/26/09, and did not change his/her position since date of hire. There was no evidence of PALS certification.
- Staff YY, RN, was hired 05/27/08, and did not change his/her current position in the ED since date of hire. PALS certification expired 12/31/10.
- Staff CCC, RN, was hired 06/04/07, and did not change his/her position since date of hire. There was no evidence of PALS certification.
- Staff DDD, RN, was hired 04/17/07, and assumed his/her current position in the ED on 06/06/10. PALS certification expired 2/28/11.

2. During an interview on 08/08/11 at 2:00 PM, Staff N, ED Nurse Manager, stated ED nurses were required to obtain (and maintain) certification in BLS, ACLS, and PALS within six months of being hired. Staff N stated the Human Resource department kept track of certification status and sent notifications when re-certifications were due.

3. During an interview on 08/10/11 at 1:15 PM., Staff M, Vice President of Patient Care Services, stated ACLS, BLS, and PALS certification was not current for the individuals referenced above, and staff with lapsed certifications would be removed from the staffing plan as appropriate until certification was obtained/updated. Staff M stated that Staff CCC was hired in 2007, before PALS certification requirement added and was added to the list of those employees who would receive training.