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Based on observation, document review and interview, the facility failed to ensure that the confidentiality of patient records requirements was met when Patient 4's Medication Administration Record (MAR) was left open in plain sight on the medication cart in the main hallway. This lack of confidentiality could have resulted in a breach of Patient 4's medical information and potential emotional trauma to the patient.

Findings:

During a medication pass observation on 10/21/15 at 7:30 AM, RN Staff 1 was observed preparing a medication for Patient 4. The nurse was in the main hallway, outside of Patient 4's room and she left the locked medication cart in the hallway with the MAR open to Patient 4's medication record. The MAR contains the patient's name, medical record number, names of medications and indications for those medications, including diagnoses. RN staff went into Patient 4's room, apparently administered the prepared medication, returned to the medication cart and charted that she had administered the medication.

A review of form DSP 304 E/S (Rev. 3/97), Rights of Individuals With Developmental Disabilities, indicated that people with developmental disabilities have "A right to dignity, privacy and humane care." A review of Facility Bulletin No. 63, Release of Information, dated February, 2014, indicated that "All PDC [Porterville Developmental Center] staff will comply with confidentiality and Health Information Portability and Accountability Act (HIPAA) requirements." The policy continues "The basic guideline is that all information and records obtained in the course of providing services to an client is confidential..."

In an interview with RN Staff 2 on 10/21/15 at 10:50 AM, she acknowledged that leaving the open MAR in plain sight in the hallway was not acceptable and did not protect Patient 4's confidentiality of her medical record.

Based on observation, document review and interview, the facility failed to safeguard Patient 4's medical record in a confidential manner when RN Staff 1 left Patient 4's Medication Administration Record (MAR) on the medication cart in the hall. The MAR was open to Patient 4's medication sheets, in plain view of anyone in the hall. This had the potential of breaching Patient 4's confidentiality regarding her medical record and diagnoses, if anyone had seen the exposed medication records.

Findings:

During a medication pass observation on 10/21/15 at 7:30 AM, RN Staff 1 was observed preparing a medication for Patient 4. The nurse was in the main hallway, outside of Patient 4's room and she left the locked medication cart in the hallway with the MAR open to Patient 4's medication record. The MAR contains the patient's name, medical record number, names of medications and indications for those medications, including diagnoses. RN staff went into Patient 4's room, apparently administered the prepared medication, returned to the medication cart and charted that she had administered the medication.

A review of form DSP 304 E/S (Rev. 3/97), Rights of Individuals With Developmental Disabilities, indicated that people with developmental disabilities have "A right to dignity, privacy and humane care." A review of Facility Bulletin No. 63, Release of Information, dated February, 2014, indicated that "All PDC [Porterville Developmental Center] staff will comply with confidentiality and Health Information Portability and Accountability Act (HIPAA) requirements." The policy continues "The basic guideline is that all information and records obtained in the course of providing services to an client is confidential..."

In an interview with RN Staff 2 on 10/21/15 at 10:50 AM, she acknowledged that leaving the open MAR in plain sight in the hallway was not acceptable and did not protect the confidentiality of Patient 4's medical record.

Based on observation, document review and interview, the facility failed to ensure that staff followed accepted standards of practice when RN Staff 1 did not wash her hands between patients during medication administration. This had the potential of spreading germs from one patient to another or to staff and for the potential increase of resistant bacteria.

Findings:

During a medication pass observation on 10/21/15 at 7:30 AM, RN Staff 1 did not wash her hands after suctioning the tracheostomy of Patient 2. RN Staff 1 simply changed gloves and checked the formula residual of the patient' s stomach, then proceeded to administer Patient 2 ' s medications via his gastrostomy tube (a tube used to deliver liquid nourishment or medications directly into the patient''s stomach, when said patient cannot eat or drink anything because of the increased risk of choking and inhaling food or liquids into his lungs). RN Staff 1 was then observed to not wash her hands after administering medications to Patient 2 and moving on to administer medications to Patient 3.

A review of the CDC Morbidity and Mortality Weekly Report, October 25, 2002/Vol.51/ No. RR-16, Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002; 51 (No. RR-16): Page 24; page 27; page 32, indicated that " Hand hygiene is required regardless of whether gloves are used or changed. Failure to remove gloves after patient contact or between ' dirty ' and ' clean ' body-site care on the same patient must be regarded as nonadherence to hand-hygiene recommendations." The report goes on to say that " Failure to perform appropriate hand hygiene is considered the leading cause of health-care-associated infections and spread of multiresistant organisms and has been recognized as a substantial contributor to outbreaks." The CDC recommends that indications for handwashing and hand antisepsis are " When hands are visibly dirty or contaminated with proteinaceous material ...wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water."

In a review of facility Nursing Procedure No. 7.5, Medication via Nasogastric, Gastrostomy and Jejunostomy Tube, dated 2/25/15, indicated that staff are to " Wash your hands and change gloves before and between each client/patient. " A review of Nursing Procedure No. 53, Handwashing/Hand Hygiene, dated 10/27/14 indicated under Special Considerations, A. "Handwashing with soap or antimicrobial soap and water as follows: When hands are visibly dirty or contaminated with blood or other body fluids."

In an interview on 10/21/15 at 10:20 AM with RN Staff 2, she acknowledged that suctioning a patient' s tracheostomy would soil staff 's hands and that staff should wash their hands after such a procedure. She also acknowledged that staff should wash their hands between patients.

Based on interview and record review, the facility failed to perform an annual evaluation for one of 12 personnel files reviewed (Pharmacy Technician 1). This failure had the potential for lack of oversight and pharmacy staff not to be meeting facility standards.

Findings:

A review of staff member personnel files was conducted on 10/22/2015. In reviewing the annual review for Pharmacy Technician 1, it was noted that the last performance review was completed 3/20/2014.

In a concurrent interview with the Human Resources Director, she stated she would need to check the current filing to see if there was a more current evaluation for Pharmacy Technician 1.

An interview with the Standards Compliance Coordinator (SCC) was conducted on 10/23/2015 at 11:15 AM. The SCC was asked what the facility policy was in regards to performance evaluations. The SCC stated the performance evaluations are to be performed annually.

A review of the Facility Bulletin Number 158 indicates that all employees are required to receive a performance evaluation once during a 12 month period which is to be included in the employee's personnel file.

In reviewing Pharmacy Technician 1's personnel file, the annual performance evaluation had not been done for 18 months, which is out of compliance with the facility's policy.

Based on observation and interview the facility failed to ensure that equipment is stored in a manner to ensure an acceptable level of safety and quality in the clean/dirty supply room.

Findings:

During the initial tour of the facility on 10/19/2015 at 3:30 pm, observations in the clean/dirty supply room noted that the dirty side of the room was on the left when entering through the door. The clean side of the room was on the right hand side and the sides were delineated by red tape on the floor. There was an approximate four foot section between the two lines. During concurrent interview with the Supervising RN (SRN), she stated that the section in the middle was a neutral zone, where nothing was to be stored.

During observation of the neutral zone it was noted that a rolling stand for medical monitoring equipment was stored in the zone. Interview with the SRN revealed that the stand should not have been stored there. Observation further revealed that it was not apparent whether the stand was clean or dirty.

Based on observation, document review and interview, the facility failed to ensure that the system for controlling infections and communicable diseases of staff and patients was implemented when a staff member did not wash her hands between patients or after suctioning a patient's tracheostomy and then administering medications to that same patient, via the gastrostomy tube. This had the potential of spreading germs from the patient's respiratory tract to staff or to the patient's other open skin areas, namely, the gastrointestinal tract.

Findings:


During a medication pass observation on 10/21/15 at 7:30 AM, RN Staff 1 did not wash her hands after suctioning the tracheostomy of Patient 2. RN Staff 1 simply changed gloves and checked the formula residual of the patient 's stomach, then proceeded to administer Patient 2 's medications via his gastrostomy tube (a tube used to deliver liquid nourishment or medications directly into the patient 's stomach, when said patient cannot eat or drink anything because of the increased risk of choking and inhaling food or liquids into his lungs). RN Staff 1 was then observed to not wash her hands after administering medications to Patient 2 and moving on to administer medications to Patient 3.

A review of the CDC Morbidity and Mortality Weekly Report, October 25, 2002/Vol.51/ No. RR-16, Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002; 51 (No. RR-16): Page 24; page 27; page 32, indicated that " Hand hygiene is required regardless of whether gloves are used or changed. Failure to remove gloves after patient contact or between ' dirty ' and ' clean ' body-site care on the same patient must be regarded as nonadherence to hand-hygiene recommendations." The report goes on to say that " Failure to perform appropriate hand hygiene is considered the leading cause of health-care-associated infections and spread of multiresistant organisms and has been recognized as a substantial contributor to outbreaks." The CDC recommends that indications for handwashing and hand antisepsis are "When hands are visibly dirty or contaminated with proteinaceous material ...wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water."

In a review of facility Nursing Procedure No. 7.5, Medication via Nasogastric, Gastrostomy and Jejunostomy Tube, dated 2/25/15, indicated that staff are to "Wash your hands and change gloves before and between each client/patient." A review of Nursing Procedure No. 53, Handwashing/Hand Hygiene, dated 10/27/14 indicated under Special Considerations A. "Handwashing with soap or antimicrobial soap and water as follows: When hands are visibly dirty or contaminated with blood or other body fluids." A review of Infection Control Guideline 2.8, Hand Washing/ Hand Hygiene, dated June, 2008, indicated that staff are to wash hands "Before and after wearing gloves." The guideline also indicated that "Hand washing with soap is indicated: a)Before and after direct client contact. [and] b) After contact with a source of microorganisms (body fluids and substances, mucous membrane, non-intact skin, inanimate objects) that are likely to be contaminated."

In an interview on 10/21/15 at 10:20 AM with RN Staff 2, she acknowledged that suctioning a patient''s tracheostomy would soil staff 's hands and that staff should wash their hands after such a procedure. She also acknowledged that staff should wash their hands between patients.