HospitalInspections.org

Based on observation, interview, and policy review, the provider failed to ensure:
*Emergency equipment (endotracheal tube for maintaining an airway) was functional in two of two crash carts located in patient care areas (emergency room [ER] and patient care unit).
*Supplies were not outdated in one of one operating room (OR).
*Intravenous fluids in the ER and the medication room were not outdated.
Findings include:

1. Observation on 6/13/16 at 1:50 p.m. of the OR revealed outdated supplies and medications:
*A suture extractor with an outdate of May 2016.
*Three surgical mesh sheets (to support organs or tissues) with a May 2016 expiration.
*One bottle of packing strip (to pack wounds) with a May 2016 expiration.

2. Observation on 6/13/16 at 4:15 p.m. of the medication room located behind the nurses' station revealed multiple bags of outdated intravenous (IV) (to have been injected into a vein) fluid solutions, including:
*Two one-thousand milliliter (ml) bags of lactated ringers with expiration dates of August 2015 and March 2016.
*One-thousand ml bags of 5 percent (%) dextrose and 0.9% sodium chloride:-One bag had expired December 2015.
-Four bags had expired April 2016.
*One one-thousand ml bag of 5% dextrose and 0.45% sodium chloride had expired February 2016.
*Two one-thousand ml bag of 0.45% sodium chloride had expired in January 2016.
*One two-hundred fifty ml bag of 0.9% sodium chloride had expired April 2016.
*One one-hundred ml bag of 5% dextrose had expired May 2016.

Interview at that time with the director of nursing (DON)services revealed:
*She would have expected the nursing department to monitor those IV fluids for expiration dates as one of their scheduled duties.
*There was a weekly sign-off list for all nursing duties at the nurses station.
*The list had not included monitoring the IV fluids for expiration dates.



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3. Observation on 6/13/16 at 4:25 p.m. in the ER revealed the following supplies had expired:
*One 0.9 % normal saline 50 ml IV bag expired March 2016.
*One intubation stylet expired May 2016.
*One endotracheal tube expired May 2016.
*Two IV bags of 5% Dextrose and 0.45% normal saline expired 6/1/2016.

4. Observation and testing of endotracheal blade functioning revealed:
*On 6/13/16 at 4:25 p.m. in the ER testing one of several endotracheal blades (ET) revealed it did not fit any of the handles located in the ER crash cart.
*On 6/14/16 at 8:33 a.m. on the patient care unit testing of one of several ET blades revealed the light was not functioning.

Interview and testing of the ET blade at the time of the above observation with registered nurse (RN) C revealed she:
*Connected the ET blade to a handle and the bulb on the blade did not work.
*Replaced the batteries in the handle, reconnected the blade, and the bulb did not work.
*Attempted to replace the bulb with a spare bulb, and it was not the correct size.
*Removed the blade from the crash cart.
*Stated the crash carts were opened monthly to check for outdates, and the ET blades should have been checked at that time for proper functioning.

5. Interview on 6/15/16 at 9:40 a.m. with the DON revealed crash carts were checked every shift and opened once a month to check for outdates. At that time the ET blades should have been checked for proper function. There was not a policy for checking emergency supplies on the crash carts. Staff should have been checking monthly for outdates in the ER.

Based on observation, interview, and policy review, the provider failed to ensure:
*Medications were not available for unauthorized access in three of three medication storage areas (operating room [OR], emergency room [ER], and patient care unit).
*Nursing staff maintained accountability for controlled medications located on one of three crash carts (patient care unit).
*Nursing staff maintained an accurate account of controlled medications for one of one observed patient (22) who used home medications.
Findings include:

1. Observation on 6/13/16 at 1:50 p.m. of the OR revealed an unsecured anesthesia cart contained two bottles of Suprane outdated February 2016 and April 2016.

Observation of the OR on 6/15/16 at 10:00 a.m. with RNs B and C revealed:
*The anesthesia cart remained unsecured.
*The medication cart was secured and contained another bottle of Suprane expired April 2016.

Interview at that time with RNs B and C revealed:*They agreed the above medications had been outdated.
*The medication cart in the OR had not been routinely stocked with medications, so they had not monitored the cart for outdated medications.
*The anesthesia medications were supplied and monitored by the pharmacist or the anesthetist.
*They had not known the anesthesia medications had been unsecured in the anesthesia cart.
*The nursing staff were responsible for monitoring for outdated supplies monthly, but it had not been done.

Interview on 6/15/16 at 11:45 a.m. with the DON regarding the above outdated supplies and medications, and the unsecured medications revealed:*She agreed the above medications had been outdated.
*The nursing staff never touched the anesthesia cart.
*She was not aware the anesthesia medication was to have been secured.



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2. Observation on 6/13/16 at 4:12 p.m. in the ER revealed:
*The padlock to the medication refrigerator was lying on top of the refrigerator.
*Inside the medication refrigerator was:
-Two vials of Rocuronium.
-Ten vials of Diltiazem.
-One vial of Lorazepam.
*The red break away tab on the crash cart immediately fell to the floor when a drawer was gently pulled. Once opened multiple medications were accessible to unauthorized individuals.

Interview on 6/13/16 at 4:42 p.m. with the DON revealed:
*The medication refrigerator should have been locked. The staff might have opened the refrigerator preparing for an incoming ER patient and had forgotten to relock it.
*A new red break-away tab should have been replaced after caring for the previous ER patient.
*The ER doors had punch key locks, but the unlocked medication refrigerator and unlocked crash cart allowed medication access by unauthorized staff.
*The ER was accessible by laboratory staff, aides, and housekeeping staff via the punch key locks.

Review of the provider's Schedule III Controlled Substance Security policy dated October 2014 revealed Schedule II and III drugs would have been stocked on nursing units either in automated dispensing cabinets or in a locked cabinet.

3. Observation on 6/14/16 at 8:10 a.m. of the medication cart of patient 22's medication blister pack revealed:
*The blister pack was for clonazepam 0.5 milligrams.
*There were nineteen and one-half pills remaining in the blister pack.
*The back of the bubble containing the half pill had been resecured with tape.

Review of the provider's controlled medication count sheet revealed the nurses that morning (6/14/16) had documented twenty pills remained in the blister pack.

Interview and review on 6/14/16 at 8:10 a.m. with RN C regarding patient 22's controlled medication count sheet confirmed:
*The count sheet was incorrect. The nurse(s) had documented there were twenty clonazepam pills remaining in the blister pack.
*One bubble on the blister pack had been opened, retaped, and a half pill was in that space.
*There were nineteen and one-half pills in the blister pack not twenty as documented on the count sheet.
*The patient was on clonazepam 0.25 milligrams, the nurse had split the pill in half, and retaped the other half back into the blister pack.
*Per hospital policy the nurse should have wasted the half of pill not administered and not retaped it back into the blister pack.

4. Observation on 6/14/16 at 8:33 a.m. of the bottom drawer of the patient care unit crash cart revealed:
* A clear plastic container with the below listed medications:
-Three vials of Midazolam.
-Three vials of Fentanyl.
-One vial of Ketamine.
-One vial of Flumazenil.
*There was no record with the medications for accountability.

Interview and observation at the above time of the medications with RN C revealed:
*She was not able to locate a count sheet for the above medications.
*The medications were not counted monthly when the crash cart was opened.
*She was not sure how accountability of the medications was maintained.

Interview on 6/14/16 at 9:53 a.m. with pharmacist (H) revealed there should have been a controlled medication sign-out sheet with the above listed crash cart medication for accountability.

Review of the provider's Schedule III Controlled Substance Security policy revealed "Record keeping, accountability will be maintained either by:
-Automated dispensing cabinet removal process (bio ID, password)
-Proof of use sheets issued with each drug.
--Change of shift counts are required
--Proof of use sheets must be accounted for via a tracking process."

Based on observation, interview, document review, and policy review, the provider failed to:
*Follow-up in a timely manner with infection control (IC) concerns identified through Glow Germ audits.
*Ensure one of one sampled patient (9) had been placed on isolation precautions for clostridium difficile (C-diff).
*Ensure cross-contamination had not occurred to a wound and environmental surfaces during observation and photographing of one of one wound.
*Ensure medication set-up was performed on a clean surface by registered nurse (RN) J for one of one observed patient's (10) medication pass.
Findings include:

1. Interview on 6/13/16 at 1:00 p.m. during the entrance meeting with the director of nursing (DON) revealed the infection control coordinator (ICC) role was shared by herself and RN B.

Interview on 6/14/16 at 10:00 a.m. with RN B to discuss the IC program revealed:
*She was responsible for performing audits to monitor for trends in IC practices.
*She was responsible for gathering all infection information for tracking and trending.
*She placed all monthly IC information into the computer marked Infection Control Meeting.
She did not have IC meetings with departmental staff.
*The DON took that information to the monthly medical executive committee (MEC) meeting and reviewed any concerns.
*Performance improvement (PI) audits had included a new program called Glow Germ. The nurse would leave an invisible mark on a surface and return later with an black light to check if staff had effectively disinfected the surface.
*The program began in July 2015, but the provider had multiple housekeeping staffing changes, so the Glow Germ PI had been held until the staff were oriented into their roles.
*RN B stated the results of those Glow Germ audits had been poor, but the housekeeping staff had received further instruction to improve the results.

Review of the January 2016 through May 2016 monthly IC meeting minutes and MEC meeting minutes regarding the Glow Germ PI results revealed:
*January 2016:
-IC minutes had no mention of the December results.
-MEC minutes had no mention of the results.
*February 2016:-IC minutes had included the January 2016 results indicating only one of fifteen areas had been cleaned.
-The ICC had discussed the results with the director of housekeeping, and she would discuss it with her staff.
-MEC minutes indicated the Glow Germ audits were reviewed. Discussion was held, and "close follow-up" would pursue with the departments.
*March 2016:
- IC minutes had no mention of the February Glow Germ results.
-MEC minutes indicated the audit was reviewed, discussion was held and the results improved greatly with education that was provided. They would continue to monitor.
*April 2016:
-IC minutes had no mention of the March results.
-MEC minutes had no mention of the results.
*May 2016:-IC minutes had no mention of the April results.
-MEC minutes had no mention of the results.

Interview on 6/15/16 at 8:20 a.m. with RN B regarding identifying, reporting, and follow-up on Glow Germ results to the MEC/infection control committee revealed:*She had not known the results of the Glow Germ PI had not been reported.
*The computer program for the IC meeting had regenerated the information from month-to-month, but somehow the Glow Germ PI had not regenerated, so she was not prompted to report the information.
*The Glow Germ PI audits should have been added to the IC meetings.
*The housekeeping staff had been re-educated regarding poor results again on 5/26/16, but the ICC did not have a chance to review the most current PI results.
*Other than the initial education no further follow-up had been done.

Interview on 6/15/16 at 11:45 a.m. with the DON regarding follow-up of Glow Germ PI results revealed:
*Her expectation of the IC program was RN B would perform the audits and gather IC information.
*The DON would take that information to the MEC and present it.
*The DON would also email the current IC material to the nursing staff and to other department heads if it applied to them.
*RN B did not attend MEC meetings.

Interview on 6/15/16 at 2:45 p.m. with the DON revealed:
*Follow-up of the weekly Glow Germ PI audits from July 2015 through May 2016 indicated percentage of appropriately disinfected areas:
-July 2015: 33.3%-100%.
-August 2015: 83%-100%.
-September 2015: No audits.
-October 2015: 23.5%.
-November 2015: No audits.
-December 2015: No audits.
-January 2016: 7.1%.
-February 2016: 76.9%.
-March 2016: 31.8-40%,
-April 2016: No audits.
-May 2016: 50%.
*She had not been told about the Glow Germ findings.
*RN B was conducting the PI audits, and the DON did not participate in the Glow Germ program.
*She was not aware the Glow Germ audits had not been presented to the MEC.
*She was not able to locate a policy for following up on identified concerns.

Review of the provider's February 2015 Establishing Infection Prevention and Control Policy revealed:*The purpose was to protect the patient, employee, and visitor by establishing infection control prevention and control policies.
*Administrative standard of Operating Procedures would have been developed by infection prevention and control for practices, procedures and illness of significant risk for transmission of disease or illness.
*Reference used for the policy was APIC (Association for Professionals in Infection Prevention and Control and Epidemiology, Inc.) APIC Text of Infection Prevention and Control and Epidemiology, 2005 edition.



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2. Observation 6/14/16 at 7:15 a.m. of the white board in the medication room used to document information about the patients and their status revealed patient 9 had C-diff written as part of his patient information.

Interview on 6/14/16 at 7:25 a.m. with RN I and the ICC revealed:
*The patient had been on isolation for C-diff, they had not been able to obtain a stool specimen, and he was removed from isolation because he had formed stools.
*He reported on 6/12/16 he was having loose stools again but had not been placed on isolation.
*They were not sure if the loose stools were from the laxative or the antibiotics the patient was receiving.
*The patient should have been placed on contact precautions on 6/12/16 after reporting to the nursing staff he was having loose stools.
*Contact isolation precautions were initiated by nursing staff on the morning of 6/14/16.
*The patient did not have an infectious disease and was scheduled for discharge on 6/14/16.

3. Observation and interview on 6/14/16 at 8:53 a.m. of patient 10's medication administration pass revealed RN J:
*Conducted the medication pass on the countertop and handwashing sink in the patient's room.
*Removed the medications from the medication drawer in the patient's room and used the countertop and handwashing sink as her base in the patient's room. There was very little counter space for RN J to work on without incorporating the sink.
*RN J did not disinfect the counter space prior to or after her medication pass.
*RN J was asked by the surveyor if the area used for the medication pass was a clean area, and she stated "yes."

4. Observation on 6/14/16 at 9:00 a.m. of RN I taking photographs of patient 7's surgical wounds revealed she:
*Entered the room and laid her supplies on the countertop adjacent to the handwashing sink.
*Put on a pair of clean gloves, adjusted the patient chair to a reclining position, and pulled the back of the chair away from the wall.
*Determined it would be best if the patient stood up for the procedure, assisted another nurse to place a gait belt around the patient's waist, raised the reclining chair to a sitting position, and assisted the patient to stand.
*Retrieved the measuring tape and camera from the countertop adjacent to the handwashing sink.
*Adjusted the patient's clothing for access to the surgical wound and pulled back the dressing on that wound.
*Used the contaminated paper measuring tape, placed it next to the surgical wound touching the inside of the wound dressing, briefly touched the inside of the dressing with her contaminated gloves, and took a picture of the wound.
*Pulled the dressing back up over the surgical wound and did not remove her contaminated gloves.
*Pulled the dressing down on the second surgical wound, took a picture, and pulled the dressing back up over the wound.
*Did not remove her contaminated gloves, and she:
-Assisted the patient to sit back down into the recliner, removed the gait belt, and readjusted the patient's clothing.
-Retrieved a medication bin offered through the door by the pharmacist and placed it in the patient's medication drawer.
-Placed the camera on the counter next to the handwashing sink.
-Put a blanket over the patient, handled the patient's water container, moved the overbed table next to the patient's chair, opened the privacy curtain, and removed her contaminated gloves.
-Used hand sanitizer, picked up the camera, and exited the room.

Interview with RN I immediately after the above procedure revealed:
*To prevent cross-contamination of the patient wound and environmental room surfaces she should have removed her contaminated gloves after handling the patient's dressing and completed hand hygiene.
*The camera was contaminated and required disinfection.

Review of the provider's 4/29/16 Hand Hygiene policy dated revealed hand hygiene should have been performed:
*"After contact with a patient's intact skin, body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled.
*Moving from contaminated body site to clean body site during patient care.
*After contact with contaminated surfaces and/or objects/medical equipment in the immediate vicinity of the patient."

Based on record review and interview, the provider failed to ensure corrective action plans were completed for five of five (infection control, laboratory, radiology, surgery, and Hospital Engagement Network) reviewed quality indicators not meeting the provider's target goal. Findings include:

1. Interview and review on 6/15/16 at 12:10 p.m. with the quality coordinator regarding the Performance Improvement Scorecards 2015 and 2016 revealed:
a. The Glow Germ marking would have been removed by housekeeping practices upon recheck starting in July 2015.
*The indicator was on a quarterly monitoring schedule with a 100 percent (%) target goal.
*Review of the Performance Improvement Scorecard 2015 revealed:
-Quarter July through September the target goal of 100% had not been met for July (41%) and in August (92%), and no score for September.
-Quarter October through December the target goal of 100% had not been met for October (24%).
*Review of the Performance Improvement Scorecard 2016 revealed:
-Quarter January through March the target goal of 100% had not been met. Results testing documented indicated January (7.1%), February (76.9%), and March (35.4%).
*There was no documented plan of action documented for the identified below target results in 2015 or 2016.

b. The Performance Scorecard 2016 revealed:
*Laboratory indicator number one was the explanations given by staff would meet or exceed the mean score of 95%. The results documented indicated:
-January through March quarter results did not meet the target goal, January (88%) and March (93%).
-April through May quarter results did not meet the target goal, April (87%) and May (92%).
*Laboratory indicator number three was "Review of negative quick step tests to culture results would be 100%. The results documented indicated:
-January (91.7%) and February (88%).
*There was no documented corrective action plan for indicator one results below goal in January and February; and the action plan documented for indicator three was continue to monitor.

c. The Performance Scorecard 2016 revealed:
*January through March quarter the repeat analysis program would be greater than or equal to 95%, and the result documented was 91.4%.
*The action plan indicated "seeking information." There was no explanation who should be providing additional information or a target date to receive the information.

d. The Performance Scorecard 2016 revealed:
*"Temperatures and humidity in the operating room will be within ACORN recommended ranges of temperature 68 to 73 degrees F and humidity 20 to 60%." The target goal was 100% and monitored monthly.
*January through March quarter revealed January (16%), February (86%) and March (88%).
*April monitoring was documented at 87%.
*There was no corrective action plan documented.

e. The Performance Scorecard 2016 revealed:
*Readmissions within thirty days of discharge should have been less than or equal to 7%.
*The indicator was on a monthly monitoring schedule.
*In March the result was 9%; there was no corrective action plan documented. The quality coordinator stated there was a small number of discharges that month.

f. Interview on 6/15/16 at 12:10 p.m. with the quality coordinator regarding the Performance Improvement Scorecards 2015 and 2016 revealed:
*Corrective action plans were not completed or were incomplete for the above indicators.
*It was difficult at times to get monitoring results from the responsible individuals.
*She did not routinely follow-up on results that had not met target goals.

Review of the provider's Quality Assessment and Performance Improvement Plan (APIC) dated March 2016 revealed:
*The APIC chairperson was responsible for collecting, and organizing data, and quality reports from each department and service.
*"The APIC applied to all departments, services, practitioners, and staff involved in the delivery of care."
*Each department and service would report to the APIC committee according to their assigned schedule.
*When appropriate action should have been taken for indicators to maintain a level that met or exceeded the targeted goal, assigned a more stringent threshold, or removed from monitoring.
*Compliance with the APIC plan should have been monitored and reported to administration. Any noncompliance should have been addressed by administration as appropriate.

Based on interview, policy review, and activity consultation report review, the provider failed to ensure a planned program of activities for all Swing Bed patients. Findings include:

1. Interview on 6/13/16 at 4:30 p.m. with the chief nursing officer/activity designee revealed:
*She was the activity designee.
*She completed all the activity assessments.
*They had an activity consultant who consulted quarterly but was also their social work consultant.
*They did not have an activity calendar with scheduled activities.
*The nursing staff offered them informal activities at different times of the day if the patient wanted to do an activity.
*There were activity supplies in the patient lounge area.

Review of the activity consultant quarterly consultation reports revealed:
*She had provided consultation during the past year on 7/22/15, 10/29/15, and 4/19/16.
*During the 4/19/16 consultation she reviewed the activities that had been documented in swing bed patients medical records as patients had participated in them. They included:
-Phone.
-Fix hair.
-Visits.
-TV.
-Reading.
-Puzzles.
-Crafts and games.
-Music.
-Word find.
-Watching church (on TV).
*Other consultation reports had not addressed specific activity participation.
*There was no evidence of discussion of planned activity programming with patients.
*There was no evidence she had met with any patients to assess their satisfaction with activities.
*The reports did not demonstrate if her review was an electronic medical record review, or if she was present in the facility.

Review of the provider's April 1985 Activities Program policy revealed:
*"The Activities program is to assist in meeting the mental, social, spiritual, cultural, creative and recreational needs of the patient.
*The activity program should be part of the total care plan, which helps maintain and expand the patient's level of functioning. Each activity program is based on the patient's interests and needs. The program needs to maintain the patient's dignity, independence and contributes to the therapeutic environment in the swing bed care facility.
*The Occupational Therapist (OT) will review and cosign all activities for swing bed patients."

Interview on 6/15/16 at 11:20 a.m. with registered nurse C revealed the OT did not have any oversight of the activity program.