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Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by the registered nurse failing to document notification of the physician for an elevated blood pressure for 3 (#9, #18, #30) of 3 patients reviewed for elevated blood pressures out of a total sample of 30. Findings:

Patient #9
Patient #9 was admitted to the hospital on 1/10/17 for pneumonia. Review of her vital sign graphic sheet revealed a blood pressure of 176/98 on 1/10/17 at 8:10 p.m. Further review of Patient #9's assessment form for 1/10/17 and her rounding form for 1/10/17 revealed no documentation the patient's elevated blood pressure was reported to her physician.

An interview was conducted with S2DON on 1/11/17 at 11:15 a.m. She confirmed the nurse should have reported the patient's elevated blood pressure to the patient's physician. With S2DON's review of the patient's medical record, she confirmed there was no documentation the patient's physician was notified.

Patient #18
Patient #18 was admitted to the hospital on 12/05/16 with diagnoses of Atrial Fibrillation, Diabetes, Congestive Heart Failure, and Chronic Obstructive Pulmonary Disease. Review of her vital sign graphic sheet revealed a blood pressure taken on 12/05/16 of 97/50 at 11:51 a.m., then a blood pressure of 172/82 at 1:54 p.m. Further review of patient #18 assessment form for 12/05/16 and her rounding sheet dated 12/05/16 revealed no documentation the patient's elevated blood pressure was reported to her physician.
In an interview with S2DON on 01/11/17 at 2:50 p.m. she confirmed that there was no documentation the patient's physician was notified of the elevated blood pressure.
Patient #30
Patient #30 was admitted to the hospital on 10/19/16 with diagnoses of Heart Failure, Coronary Artery Disease, Diabetes, Chronic Renal Failure, and Super Ventricular Tachycardia. Review of her vital sign graphic sheet revealed a blood pressure taken on 10/21/16 of 198/95 at 5:48 a.m. Further review of patient #30 assessment form for 10/21/16 and her rounding sheet dated 10/21/16 revealed no documentation the patient's elevated blood pressure was reported to her physician.
In an interview with S2DON on 01/12/17 at 9:50 a.m. she confirmed that there was no documentation the patient's physician was notified of the elevated blood pressure.





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Based on record review and interview, the hospital failed to ensure nursing care was provided by qualified nursing personnel as evidenced by failing to evaluate the competencies of 3 out of 3 (S2DON, S5LPN, and S6RN) nursing personnel records reviewed for competencies. Findings:

Review of the personnel records for S2DON, S5LPN and S6RN revealed no evidence of documented nursing skill competencies.

An interview was conducted with S2DON on 1/12/17 at 11:00 a.m. She reported she was new to her Director of Nurses position, but as far as she was aware the only form of nursing skill competencies on the nurses and herself was the self-evaluation form of their skills (all dated 07/30/14) in their personnel files.

Based on observation and interview the hospital failed to ensure patients' medical records were stored where they were protected from water damage. This was as evidenced by folders of medical records stored on rolling open metal shelving in a room that had active sprinklers. Findings:

Observation on 01/11/17 at 10:20 a.m. of the medical record room revealed 9 rolling metal shelving units on tracks containing 24 shelves on each side. The cabinets contained paper records dating from present to 2006. Further observation revealed the room had active sprinklers.
In an interview on 01/11/17 at 10:20 a.m. with S7MR (Medical Records Director) it was confirmed the paper medical records on the open metal shelves in the cabinets were not protected if the sprinklers were activated or if there was a water leak from the ceiling.

Based on observation, record review and interview, the facility failed to ensure that periodic inspections of equipment were made. This was evidenced by the failure to have inspections performed on a portable x-ray unit every 6 months as recommended by the manufacturer.
Findings:

On 01/11/17 at 1:00 p.m., during the tour of the radiology department, a portable x-ray unit was observed in the hallway outside the department. There was no indication of a current inspection noted on the equipment.

Review of the manufacturer's recommendations for maintenance and service of the portable x-ray unit provided by S9Director of the Radiology Department revealed the required maintenance checks should be conducted every 6 months.

On 01/11/17 at 3:15 p.m., an interview with S9Director of the Radiology Department confirmed that maintenance checks on the portable x-ray unit had not been conducted every 6 months as recommended by the manufacturer.

Based on observation and interview, the facility failed to maintain the physical plant and environment to ensure the safety and well-being of patients by failing to maintain the functional status of the bathrooms in the examination rooms of the radiology department. Findings:

On 01/11/17 at 1:30 p.m., during the tour of the radiology department, observation revealed a closed door in x-ray room #2 with a sign denoting that it was out of order. An interview with S9Director of the Radiology Unit at this time confirmed that there were plumbing issues which rendered the bathroom nonfunctional. He stated the bathroom had been out of order for over one year.

Further observation of the radiology department revealed a closed door in x-ray room #1 with a sign indicating it was not available for use. Observation and interview at this time with S9Director of the Radiology Unit confirmed that the toilet seat was broken off the toilet and was leaning against the wall. S9Director of the Radiology Unit stated that the ventilation fan also was not functional.

Based on record review and interview, the hospital failed to ensure the infection control officer was qualified based on education, training, or certification as evidenced by appointing an infection control officer with lack of evidence of education, training or a certification in infection control. Findings:

Review of S2DON personnel file revealed she was the current Director of Nurses and Infection Control Officer. With further review of her personnel record revealed she had no former experience as an Infection Control Officer and no certification as having been trained as an Infection Control Officer.

An interview was conducted with S2DON on 1/12/17 at 9:30 a.m. She reported a few months ago she was appointed the Director of Nurses and the Infection Control Officer. She further reported her only infection control experience was she had collected data for the previous infection control officer and had taken a few brief continuing education computer classes on topics related to infection control.

Based on observation, record review and interview, the hospital failed to ensure the infection control officer developed a system for controlling infections and communicable disease of patients and personnel. This deficient practice is evidenced by:
1. Failing to ensure acceptable standards of practice for infection control were followed with disinfecting a glucometer after obtaining a capillary blood glucose reading;
2. Failing to ensure hospital furnishings were maintained to ensure all surfaces could be adequately cleaned; and
3. Failing to disinfect potentially infectious surfaces based on manufacturer directions for use of those products.
Findings:

1. Failing to ensure acceptable standards of practice for infection control were followed with disinfecting a glucometer after obtaining a capillary blood glucose reading.

Review of the hospital policy for Glucometers revealed in part, Glucometers should be decontaminated daily and any time contamination with blood or body fluids occurs or is suspected. The manufacturer states that general cleaning should be done with the following:
Super Sani-Cloth.

An interview was conducted with S5LPN on 1/11/17 at 11:40 a.m. When questioned on what she cleaned the glucometer with after performing a capillary blood glucose, she reported either a sani-wipe or an alcohol wipe.

An interview was conducted with S2DON on 1/11/17 at 3:00 p.m. She reported the nurses are suppose to clean the glucometer after each use with a sani-wipe. When questioned if the hospital's glucometer policy was correct, she verified it was not correct. The glucometer should be cleaned after each patient use.

2. Failing to ensure hospital furnishing were maintained to ensure all surfaces could be adequately cleaned.

An observation was conducted on 1/10/17 at 1:30 p.m. of two (2) tall gray chairs with vinyl cushions in the seat of the chairs. The chairs were located in front and to the side of the nursing station and were positioned in front of a nursing computer. Both chairs had cracked vinyl seats and were unable to be cleaned adequately.

An interview was conducted with S2DON on 1/10/17 at 1:30 p.m. S2DON verified the chairs could not be adequately cleaned due to the cracks in the vinyl seats.

On 01/11/17 at 1:10 p.m., observation of patient room a revealed a chair available for use that had tears in the arm covering, exposing the porous foam underneath the covering.

An interview with S11Housekeeping Supervisor on 01/11/17 at 1:10 p.m. confirmed the chair arm could not be adequately cleaned and disinfected due to the tears in the vinyl, exposing the foam underneath.

3. Failing to disinfect potentially infectious surfaces based on manufacturer directions for use of those products.

On 01/11/17 at 1:00 p.m., during a tour of the radiology unit, an interview was conducted with S10Radiology Technician concerning disinfection procedures of potentially infectious surfaces. She stated she uses the disinfectant Lemon Quat - she sprays the surface, allows it sit one to two minutes, and wipes it off with a dry cloth.

On 01/11/17 at 1:05 p.m., an interview with S12Laundry Staff revealed she also uses Lemon Quat disinfectant, spraying it on surfaces and allowing it to sit for about two to three minutes before wiping off with a dry cloth.

On 01/11/17 at 1:10 p.m., an interview with S11Housekeeping Supervisor revealed she uses Lemon Quat disinfectant for routine and deep cleaning of patient rooms - she sprays the disinfectant directly on the surface and allows it to air dry. For deep cleaning, she saturates a cloth with the disinfectant and wipes down all surfaces.

Observation of the manufacturer label Directions for Use on the bottle of Lemon Quat revealed: For disinfection of hard, non-porous surfaces the solution should be applied with a brush, cloth, mop, sponge, auto scrubber, mechanical spray device, hand pump, coarse pump or trigger spray device or by immersion so as to thoroughly wet surfaces, and that treated surfaces must remain wet for 10 minutes and allowed to air dry.

On 01/11/17 at 1:15 p.m., further interview with S11Housekeeping Supervisor confirmed that it was not a sufficient procedure to allow the disinfectant to sit for less than 10 minutes and wipe off with a dry cloth.







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