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Based on observation and interview the facility failed to ensure outdated and unmarked medications and/or supplies were available for patient care. This had the potential to affect any patient in the facility. The facility census was six.

Findings included:

1. Observation on 08/27/13 at 9:00 AM on the West Nursing station showed one partially empty bottle of Hydrogen Peroxide (a clear liquid which is often used as a cleansing agent) in an unlocked cabinet. Nystatin (an antifungal medication) was found in an unlocked cabinet and behind another locked cabinet was an unopened prescription for Pramipexole (a drug which is used to treat Parkinson's) which had been sent to the facility by an outside pharmacy for a patient, now discharged. The facility had not given the medication to the patient.

2. During an interview on 08/27/13 at 9:19 AM, Staff B, Licensed Practical Nurse (LPN) stated that she did not know who had taken the Hydrogen Peroxide out of the Omnicell (an automated medication administration machine) but it should not be in the unlocked cabinet and should have a date on it when it was opened. She stated that the Nystatin and Pramipexole should have been sent back to the pharmacy or wasted since both patients had been discharged.

3. During an observation on 08/27/13 at 9:00 AM, in the Outpatient Clinic, intravenous (IV, within the vein), supplies showed the following outdates:
-Three extension sets (tubing that extends the length of the IV line) with expiration dates of 01/02.
-One Central Line (a line inserted into a large vein usually in the neck or near the heart to administer medicine or fluids) change kit with an expiration date of 09/10.
-10 filter spike kits (a spike shaped connector with a filter used to puncture the end of an IV solution bag) with expiration dates of 03/11.
-One Butterfly start kit (small vein infusion sets with flexible wings to hold the needle in position) with an expiration date of 04/08.

4. During an interview on 08/27/13 at 9:15 AM, Staff G, Registered Nurse (RN), Manager of Outpatient Clinics, stated that there was currently no quality assurance done on outdated supplies. She stated "we just all check when we think of it". She stated that there needs to be a system for checking these so that expired supplies don't get used by mistake.

5. During an interview on 08/28/13 at 3:15 PM Staff U, Chief Nursing Officer, stated that there was no policy related to checking outdated and/or expired supplies.





32280

Based on observation, interview and record review, facility Dietary and Housekeeping staff failed to ensure a sanitary environment, with easily cleanable floor surfaces in the facility kitchen's food storage pantry in accordance with 19 CSR 20-1.010, Sanitation of Food Service Establishments. The facility census six.

Findings included:

1. Record review of the United States Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code, Chapter 6-101.11 Surface Characteristics showed direction for the facility to ensure materials for indoor floors shall be smooth, durable and easily cleanable.

2. Record review of an undated facility environmental services (housekeeping) policy titled, "Night Shift Routine/ Duties" showed direction for staff to "sweep floor and wet mop floor making sure you reach under all equipment."

The procedure did not specify guidance for cleaning the food storage pantry, and no portion of the general housekeeping procedure directed staff to report to housekeeping or maintenance if floor surfaces are non-cleanable due to damaged, unsuitable (marred) surfaces or loose tiles.

3. Observation on 08/27/13 at 3:15 PM in the facility kitchen showed black adhesive residue smeared around the edges of eight vinyl floor tiles located under a food storage shelf in the kitchen's food pantry. The smeared adhesive provided a potential reservoir for collecting dust, crumbs, insects and bits of paper from food product wrappers.

4. During an interview at the same date and time, Staff Q, Director of Food Services, stated that even though kitchen personnel clean as they go and following each meal, housekeeping also comes in on a regular basis to provide deep cleaning in difficult areas. She stated that a work order had not been submitted for cleaning the tiles.

Based on observation, interview, record review and policy review the facility failed to ensure:
-Outdated and/or expired medications were not available for patient use for two of two medications.
-A method of monitoring the Crash Cart after it had been opened and a new red plastic security seal had been placed.
-Nursing overrides in the Omnicell (an automated medication dispenser which can only be accessed by an authorized staff member with a personal code which tracks the use) were used only in an emergency situation and
-A pharmacist was available to review all medications before being given to patients. This would place all patients in the facility at risk. The facility census was six.

Findings included:
1. Record review of the facility policy titled, "Pharmacy Operations", revised 05/04/10, showed:
- Responsibilities of authorized pharmacy personnel shall cause action for appropriate control.
- To maintain limited access for the direct purpose of proper security and inventory control.
-Pharmacist shall insure the proper dispensing, safekeeping and integrity of drugs located within facility.
2. Observation on 08/27/13 at 9:30 AM showed a locked drawer in the nursing station which contained multi dose inhalation medication (hand held devices which deliver medication to the lungs). One inhaler had no date as to when it had been first used and one inhaler had a date opened on 06/19/13 which was expired.
3. During an interview on 08/28/13 at 10:00 AM, Staff CC, Pharmacist, stated that the pharmacy should have been checking the drawer for outdates and expirations. He stated that they were aware that Respiratory Therapy removed the inhalers from the Omnicell and kept them in a drawer but [Pharmacy] did not include the drawer in their monthly check.
4. Record review of the facility policy titled, "Crash Cart Checks" revised 03/11, showed the following direction:
-The Crash Cart Quality Control Record will be completed. The following areas listed on the form will be examined.
-Lock Intact: nursing will mark "yes" or "no". if the seal is broken for any reason, the inventory should be checked, and restocked if necessary, before adding a replacement numbered seal.
-Lock Number: the red plastic seal number will be documented here.
-The Crash Cart will be secured with a plastic numbered seal to ensure complete and appropriate stock of medications and supplies. The new replacement seal number will then be documented in the comment section of the Crash Cart Quality Control Record.
5. Observation on 08/26/13 at 3:00 PM showed a Crash Cart on the West nursing floor which had three red plastic seals numbered 1281407, 1281408 and 1281409 in the third drawer.
6. During an interview on 08/26/13 at 3:00 PM Staff Y, Registered Nurse (RN) stated that these seals were intended for use if the Crash Cart was opened. She stated that the nurse would place the seal on the cart to secure it until the pharmacy could replace the medication which had been used. She stated this was also done on evenings and weekends after pharmacy was no longer in the building.
The facility policy shows the inventory should be checked, and restocked if necessary before adding a replacement numbered seal.

7. During an interview on 08/26/13 at 2:50 PM Staff FF, Pharmacy Tech, stated that she did the monthly checks of medications on the nursing floors and she did not track the red plastic seals that were kept in the Crash Carts and would not know if a seal was missing.
8. Observation on 08/27/13 at 08:45 AM showed seven red plastic seals in the Crash Cart of the ED. The tags were sequentially numbered from 1281452 to 1281458.
9. Record review of the facility policy titled, "Omnicell Override" effective 08/2012, showed:
-To define the use of the override function in the Omnicell systems and identify the best practices associated with its use.
-To develop a system by which nurses may obtain medications for new orders, missing doses and wasted doses, in emergency situations, prior to a pharmacist review.
-The override function allows for quick administration of medications in emergency and STAT situations when a delay in time to allow for the pharmacist order entry review/verification would cause patient harm or unnecessary pain/discomfort.

10. Record review of the Department of Pharmacy report titled, "Quality Report" dated 10/12, showed the overrides were 12.7% of all medications removed from West Omnicell for the period 07/12 - 09/12. Discussion: Override percentage increase since 07/12 is likely and primarily due to reduced frequency of pharmacist remote order entry review after-hours.
The same report dated 01/13 showed Omnicell Overrides were 15.25% of all medication removed from nursing station West for the period 10/01/12 - 12/31/12. Of the approximate 8,000 plus medications removed from this Omnicell; over 1,000 were overrides. [This means the pharmacist did not review these medication orders before the medications were administered to the patient].
Record review of the Department of Pharmaceutical Services Quality report dated 12/13 showed some of the overrides were Aspirin, Potassium tablets and Docusate Sodium (stool softener.)
Administration of these medications was not deemed emergencies and did not fit the criteria for the override of the Omnicell and therefore were unnecessary.
11. During an interview on 08/28/13 at 10:00 AM, Staff CC, Pharmacist, stated that if he were absent for an extended period of time, the facility would contract with an outside pharmacist to review physicians orders for the facility. He stated that during the evening and weekends the staff would use the override on the Omnicell to withdraw medications. He stated that most of the medications were unnecessarily overridden by nurses and nursing needed education as to the appropriate use of the overrides. He stated that he would not expect to be called on the weekend to review medications before they were given to the patient. The pharmacist stated that he remotely reviewed medication orders in the evening and once in the morning and once in the evening on the weekend but not at the same time every day.

Based on observation, interview, record review and policy review the facility failed to ensure hand hygiene related to glove use was used when they provided care to four (#1, #4, #5 and #6) of six in-patients and two ( #7 and #8) of two wound care patients observed. The facility also failed to ensure staff used appropriate hand hygiene when handling blood filled vials and patient equipment for two of two observations. These failed practices increased the risk of spreading infections and cross contamination and placed all patients and personnel at risk for hospital acquired infections (HAI) and contracting communicable diseases. The in-patient facility census was six.
Findings included:

1. Record review of the facility policy titled, "Infection Prevention Policy", reviewed 12/01/10, subject Engineering and Work Practice Controls and Personal Protective Equipment showed the following:
-Purpose: To minimize or eliminate risk of occupational exposure to bloodborne pathogens (pathogenic microorganisms that are present in the human blood that can cause disease or infection).
-Engineering and work practice controls shall be used to eliminate or minimize occupational exposure (exposure during performance of job duties that may place a worker at risk for infection). Where occupational exposure remains after institution of these controls, personal protective equipment shall also be used.
-Frequent, thorough hand hygiene is a fundamental component of infection prevention.
-Hand hygiene should be performed before and after patient contact, and before and after gloving.
-Gloves shall be changed and hand hygiene completed after contact with each patient.
-Gloves shall be replaced as soon as practical when contaminated or if torn, punctured, or their ability to function as a barrier is compromised.
-Non-sterile gloves shall be worn when: handling blood or other potentially infectious materials.

Record review of the facility policy titled, "Infection Prevention Policy" reviewed 10/01/10, subject Hand Hygiene showed the following direction:
-Purpose: To provide guidelines for effective hand hygiene in order to prevent the transmission of healthcare acquired pathogens and decrease the incidence of healthcare acquired infections.
- According to the Center for Disease Control (CDC) "Hand antisepsis (cleaning the hands with a alcohol-based formula when hands are not visibly soiled) reduces the incidence of health-care-associated infections". Alcohol-based hand rubs are the preferred means for routine hand hygiene. Facility personnel will use hand hygiene (hand washing and/or hand antisepsis) in the following:
-When hands are visibly dirty or contaminated with proteinaceous (relating to or of the nature of protein) material or are visibly soiled with blood or other body fluids, or exposure to potential spore-forming organisms is suspected or proven, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap (any cleaning product to which active antibacterial ingredients have been added to kill bacteria) and water.
-If hands are not visibly soiled, use an alcohol-based hand rub for routine decontamination of hands in all other clinical situations.
-Decontamination of hands if moving from a contaminated-body site to a clean-body site during patient care.
-Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.
-Decontaminate hands after removing gloves.

2. Observation on 08/27/13 at 8:30 AM of Patient #6 showed:
-Staff H, Registered Nurse (RN) put on clean gloves and removed opsite (a clear, see through dressing) from Patient #6's central line (a line that is inserted into a large vein typically in the neck or near the heart to administer medicines or fluids) site.
-Staff H removed the gloves and put on sterile gloves, without performing hand hygiene.
-She placed new dressing over the central line site.
-She then removed the sterile gloves and put on clean gloves, without performing hand hygiene.
-Staff H opened the door and assisted the patient out of the recliner chair and out into the hallway.
-She reentered the room with disinfectant wipes and proceeded to clean the recliner chair.
-She removed medical equipment including a blood pressure cuff and a metal pole on wheels used to hang IV bags for medication/solution administration before she removed her gloves.

During an interview on 08/27/13 at 8:45 AM, Staff H, RN stated that the facility policy on hand hygiene was to wash hands in between glove changes. She stated "Oh, I didn't and I usually don't".

3. Observation on 08/27/13 at 8:45 AM showed Staff B, Licensed Practical Nurse (LPN), entered Patient #5's room to discontinue an IV (within a vein) line. Staff B put on gloves and removed a roll of adhesive tape from a drawer outside of the patient's room. She entered the room with the same gloves on and tore the tape into pieces and attached them to the patient's bed rail. (Adhesive tape leaves residue on the bed rail when removed and can harbor bacteria.) Staff B removed the patient's IV line and held the visibly bloody line in her left hand, raised the lid of a sharps container (a container that is filled with used medical needles and other sharp medical instruments,such as an IV catheter) with her right hand, and placed the tubing inside. Wearing the same gloves she returned to the patient and held a clean cotton ball on the IV site. The nurse removed the pieces of tape from the bed rail and secured the cotton ball on the patient's arm. Wearing the same gloves she picked up the roll of tape and placed it on the sink where she removed her gloves and washed her hands. She picked up the roll of tape (which is now contaminated) and placed it back in the drawer outside of the patient's room.
4. Observation on 08/27/13 at 9:05 AM showed Staff B, LPN entered Patient #1's room to administer medications. Staff B put on gloves and scanned the patients identifying bracelet, then went to the computer and typed on the computer. Wearing the same gloves Staff B exited and reentered the room with a blood pressure cuff and took the patient's blood pressure and placed the pulse oximeter (a device which measures the amount of oxygen in the blood) on the patient's finger. She exited the room wearing the same gloves and pushed the mobile computer into the hall.
During an interview on 08/27/13 at 9:35 AM, Staff B, stated that she wasn't aware that she needed to change gloves and perform hand hygiene between touching inanimate objects (such as the computer or blood pressure cuff) and then the patient.
5. Observation on 08/27/13 at 9:00 AM showed Staff F, RN, entered Patient #4's room to administer medications. She put on gloves and typed on the computer, she touched her mouth and forehead with her gloved hands, touched the entry door and bathroom door knobs, opened the patient's dresser drawer and side table drawer, touched the patient, typed on the computer, left the room with her same gloved hands and removed alcohol wipes from a drawer outside the room. Staff F returned to the patient and administered oral medications, ear drops and an injection without changing gloves or performing hand hygiene.

6. Observation on 08/27/13 at 9:55 AM showed Staff F entered Patient #5's room to administer medications. She put on gloves without performing hand hygiene. She went outside the room and opened a drawer to get medication cups without changing her gloves and reentered the room. She opened the medications and put them in the cup, pushed buttons on the IV machine and then gave the patient her oral medications. She typed on the computer before removing her gloves.

During an interview on 08/27/13 at 3:19 PM, Staff F stated, "Yeah, I know, I thought about that [changing gloves and performing hand hygiene between direct patient contact and inanimate objects] when I was typing on the keyboard, I should have changed my gloves and washed my hands".

7. Observation on 08/27/13 at 9:50 AM showed Staff I, RN, and Staff J, Patient Care Tech (PCT), in the Wound Care Clinic with Patient #7 in a treatment room. Staff J put on clean gloves and removed a dressing from the lower left leg while Staff I, RN, was asking the patient questions. Staff J measured the wound and took a picture with a non-disposable camera. He then removed the blood pressure cuff and camera from the room and placed them on the nursing station counter top (the items remained on the counter for approximately 10 minutes) then removed his gloves.

During an interview on 08/27/13 at 10:03 AM, Staff I, RN, stated that he would use the blood pressure cuff and camera on another patient if needed and stated "when it is on the counter, it is clean".

During an interview on 08/27/13 at 10:04 AM, Staff J, PCT stated that if equipment was on the counter "it is dirty, we all know that". He stated that it [equipment] is clean when on the tables (located in front of the nursing station counter).

During an interview on 08/27/13 at 10:15 AM, Staff G, RN, Manager Outpatient Clinics, stated that the Wound Care Clinic nurses come from another facility but were expected to follow this facilities policies and procedures regarding infection control.

8. Observation on 08/27/13 at 10:40 AM, in the Wound Care Clinic, showed Staff L, Medical Doctor (MD), prepare to remove a skin lesion on the left upper arm of Patient #8 in treatment room two. Staff L positioned the patient's arm and chair and prepared the sterile field. After removal of the lesion and suturing (the process of joining two surfaces or edges together along a line by or as if by sewing) were completed Staff L's gloves were visibly soiled with blood. He removed his soiled sterile gloves and put on clean gloves without performing hand hygiene and began to examine the top of the patient's head for treatment of another skin lesion. Staff L burned off this lesion and a lesion on the patient's ear. After both of these areas were burned off Staff L removed his gloves and left the room.

During an interview on 08/27/13 at 11:05 AM, Staff L, MD, stated that he did hand hygiene at the end after he left the room. When asked if he should have used hand hygiene in between gloves changes he stated "never do, don't need to".

9. Observation on 08/27/13 at 10:46 AM, showed Staff GG, Phlebotomist, entered Emergency Room (ED) #3 and drew blood from a patient. She removed her gloves and carried the blood filled vials to the ED nursing desk where she applied labels.
During an interview on 08/27/13 at 10:49 AM Staff GG stated that she was not aware of the policy related to handling the tubes without gloves but this was her practice.
During an interview on 08/27/13 at 10:50 AM Staff C, Nursing Services Director, stated that she would leave her gloves on until the specimen was put in a plastic bag.
During an interview on 08/28/13 at 8:50 AM, Staff N, LPN, Education and Infection Control, stated that the expectation was that staff use hand hygiene in between glove changes and or if gloves were visibly soiled. She stated that staff have been trained on this and were expected to follow policy and procedure.

During an interview on 08/28/13 at 11:15 AM, Staff N, stated that her expectations for infection control is that hand hygiene should be performed between glove changes and between animate and inanimate objects.




27029




27727

Based on interview, policy review and record review the facility failed to ensure they included in their approved policies and procedures a written statement that specified the scope and complexity of radiological services offered. This had the potential to affect the safety of staff and the care and safety of all patients seeking radiological care from the facility. The facility census was six.

Findings included:

1, Record review of the facility's policy titled, "Radiology Policy and Procedures" dated 02/2013, showed it did not contain an approved written statement that specified the scope and complexity of services offered.

2. During an interview on 08/27/13 at 1:00 PM, Staff S, Director of Radiology, stated that it was the policy of the facility that all policies and procedures for Radiology were reviewed annually and approved by the Board of Directors, Medical Staff and Medical Director of Radiology. Staff S reviewed the manual and stated that neither Radiology nor Nuclear Medicine had a written statement that showed the scope and complexity of radiological services offered.

Based on interview and record review, the facility failed to ensure that contracted services for Nuclear Medicine had current written statements that specified the scope and complexity of nuclear medical services offered. This had the potential to affect the safety of staff and the care and safety of all patients who seek nuclear medical services at the facility. The facility census was six.

Findings included:

1. Record review of the Contracted Services listing for Nuclear Medical Services showed the department's policy and procedures, approved 02/13, followed nationally accepted standards of practice. Record review also showed that Nuclear Medical Services met quarterly to discuss safety and performance standards. No documentation was found to show that the facility had a current written statement that specified the scope and complexity of services offered by the hospital.

2. During an interview on 08/27/13 at 2:00 PM, Staff T, Director of Nuclear Medical Services stated that she did not have a written and approved statement showing the scope and complexity of Nuclear Medical services offered by the hospital.

Based on Observation, interview and policy review the facility failed to ensure protection of three of three boxes of medical records, stored in a basement storage room, from potential water damage. The facility census was six.

Findings included:

1. Review of the facility undated document titled, "Medical Staff Rules and Regulations", Medical Record/Documentation Standards showed that the patient's medical record will be maintained to safeguard against loss, defacement, and tampering and to prevent damage from fire and water.

2. Observation on 08/28/13 at 10:20 AM, of the medical record storage room, showed three cardboard boxes, which contained patient medical records, sitting on the floor. The boxes were approximately three feet inside the doorway of the room. Directly across the hallway from this room was a bathroom. There was approximately 15 feet between the bathroom door and the medical record storage room door. If the bathroom were to flood, there could be water damage to the medical records contained in the boxes on the floor.

3. During an interview on 08/28/13 at 10:25 AM, Staff R, Director of Medical Records, stated that another shelf is needed in order to get the boxes off of the floor to prevent water damage.

Based on interview, record review and policy review, the facility failed to incorporate Nuclear Medicine into their facility-wide Quality Assurance Performance Improvement (QAPI) Program. This had the potential to affect all patients receiving Nuclear Medicine services in the facility. The facility census was six.

Findings included:

1. Record review of the facility's policy titled, "Quality Improvement Plan: Hospital Wide" dated 08/22/12, showed the following: There is a planned, systematic, and ongoing process for monitoring, evaluating and improving the quality and appropriateness of patient care and organization wide activities. Ancillary Services - [Nuclear Medicine was not identified in the facility-wide list of departments].

2. During an interview on 08/27/13 at 2:00 PM, Staff T, Director of Nuclear Medicine, stated that she participated in quarterly meetings with the hospital's Radiation Safety Officer and the Director of Radiology. During the meetings they discussed different quality assurance issues and information sharing on common subject matter such as current safety issues or concerns and dosage shortages, all documented in minutes taken for each meeting. She stated that as a contracted service provider, she had not been assigned any specific performance improvement projects to report on, and neither she nor her employer had been tasked to generate or report specified data to the hospital that could be used as markers to improve patient services.

3. During an interview on 08/28/13 at 9:10 AM, Staff E, Licensed Practical Nurse (LPN), QAPI Coordinator, and Staff U, Chief Nursing Officer, confirmed that Nuclear Medicine was not in the Annual QAPI Plan and the department did not have a QAPI project, collect data, monitor patient services or participate in the facility-wide QAPI Program.






04467

Based on interviews, record reviews and policy reviews, the facility failed to ensure that the activity program for Swing Bed patients was directed by a qualified therapeutic recreation specialist or activities professional. This had the potential to affect all Swing Bed patients in the facility. The facility had one Swing Bed patient at the time of survey. The facility census was six.

Findings included:

1. Record review of the facility's policy titled, "Activities" dated 06/12, showed that the Chief Nursing Officer will appoint the Activity coordinator to develop, coordinate, conduct and evaluate a patient specific plan of care on all swing bed patients.

The facility policy did not state the necessary qualifications for the appointed Activity Coordinator.

2. During an interview on 08/20/13 at 10:15 AM, Staff D, Registered Nurse (RN), Charge Nurse, stated that Staff V, Licensed Practical Nurse (LPN), was the Activities Coordinator for Swing Bed Patients in the facility.

3. Record review of the personnel record for Staff V showed that she was an LPN with no other certifications or specialized training as an activity professional.

Record review of Staff V's job description showed her position as Case Manager with the following requirements: Licensed to practice as a Registered Nurse in the state in which the associate will be practicing and a graduate of an accredited school of nursing, BSN (Bachelor of Science in Nursing) or Bachelor's in health related field or equivalent work experience.
The job description showed no job title, responsibilities or qualifications to act as an Activity Coordinator.

4. Record review of the medical record for Swing Bed Patient #4 showed that the patient had been admitted on 08/12/13 for rehabilitation. The patient's medical record contained one activity note dated 08/14/13 documented by Staff V. The activity note showed that Patient #4's activity interests were magazines, newspapers and crossword books.

5. During an interview on 08/27/13 at 3:45 PM, Patient #4 stated that she didn't remember any activity person coming by to see her. She stated that she was a musician, played piano and sang, and had taught music for several years. She stated that she was active in her church and played cards with friends.

6. During an interview on 08/28/13 at 1:05 PM, Staff V stated that her job title was Case Manager, Social Services Designee, Activities Coordinator, Discharge Planner and Utilization Review Coordinator. She stated that she did have an activities calendar and supplied Swing Bed Patients with books, magazines and newspapers and had designated hair and nail days. She stated that she didn't visit Patient #4 every day because the patient was always so busy with rehabilitation activities. Staff V stated her supervisor was Staff DD, MSW (Master's in Social Work), Director of Social Services.