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4. For Patient #22, there was no consent for photography of the patient's pressure ulcer or for treatment, in the patient's medical record, as required.

Patient #22 was admitted to the Hospital in 9/2015 with Congestive Heart Failure (CHF) and pressure ulcers.

Review of the clinical record indicated there was no consent for care and treatment when the patient was admitted 9/29/15.

Further review, indicated Patient #22 was evaluated in the Hospital's Emergency Department (ED), and found to have pressure ulcers on the bilateral buttocks. The pressure ulcers were then photographed on 9/29/15, and the photographs were filed in the clinical record.

During interview on 10/7/15 at 10:00 A.M., Nurse #4 said that it was the facility's policy to obtain photographs of pressure ulcers when identified, and a referral is made to the Wound Ostomy Continence Nurse (WOCN) for follow-up care and treatment. Nurse #4 said that another photograph would be obtained prior to the patient's being discharged.

Record review identified there was no consent signed by the patient/health care representative to obtain photographs of the patient's buttocks.

During interview on 10/8/15 at 12:50 P.M., Medical Records Personnel #1 said that there was no consent to photograph in the clinical record for Patient #22, and there should have been.

Please refer to A0396.








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Based on observations, record reviews and interviews, the Hospital failed to consistently follow its' policy for consent to photograph, for four applicable patients (#2, #3, #21 and #22), in a total sample of 32. Findings include:



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1. For Patient #21, the Hospital failed to obtain a signed consent to photograph pressure ulcers (bed sores) on the patient's body.

Review of the Hospital's Policy, dated issued 6/24/05, Privacy: Photography-Videotaping and Other Imaging of Patients, indicated the following;

a. Specific consent shall be obtained prior to photographing the patient from the parent(s) or legal guardian for all purposes except abuse, neglect or in emergencies.
b. Completed consent form will be retained in the medical record.

Patient #21 was admitted to the hospital in 9/2015 with abdominal pain, nausea and sepsis requiring surgical intervention.

Review of the medical record indicated a Pressure Ulcer Evaluation Form was initiated on 9/16/15, and noted a left buttock pressure ulcer was present on admission. A photo was obtained and placed on the Pressure Ulcer Evaluation Photo Sheet.

Review of the medical record indicated that additional pictures were obtained of the patient's buttock (right and left side) on 9/191/5, 9/21/15, 9/22/15 and 9/24/15.

Review of the medical record indicated there were no signed consents for photographs.

During an interview on 10/7/15 at 9:20 A.M., Nurse #3 said she was not aware of any required photography consents. The Wound Nurse said there was not a formal consent used when pictures were taken of wounds, but consent was implied when the general consent for treatment was signed.

Review of the document titled, "General Consent for Treatment," indicated there were no references to photography and the consent only indicated financial responsibility for medical bills.

2. For Patient #5, there was no consent in the medical record for photography of the patient's body. Record review indicated the presence of a photograph of a pressure ulcer on Patient #5's buttocks.

The Wound Nurse was interviewed at 8:00 A.M. on 10/6/15 and indicated that she thought no specific consent form was needed to take the picture as it was implied in the general consent form.

3. For Patient #2, there was no consent for photography of the patient's body. Record review indicated there were two photographs of a pressure ulcers on the patient's buttocks in the wound care notes. Review of the record indicated there was no consent for photography of the patient as per the hospital policy.

Based on observations, record reviews and interviews, the Hospital failed to consistently follow its' policy for activating the Health Care Proxy for two patients (#4 and #19), in a total sample of 32. Findings include:

According to the Hospital policy, titled Advanced Directive Health Care Proxy, the Attending Physician must document in the medical record the determination that the patient lacks the capacity to make health care decisions and must notify the patient's Health Care Proxy of the decision.

1. For Patient #4 entered the Hospital unable to provide informed consent for a surgical procedure. Record review indicated there were seven informed procedural consents to include: arterial line (a-line) insertion, cardioversion, IVC filter, Transesophageal echocardiogram (TEE), tracheostomy and second a-line, signed by a family member.

The Physician failed to provide a written determination that Patient #4 was no longer able to make informed medical decisions and that the Health Care Proxy was invoked as described in the policy.


2. For Patient #19, who underwent a urological procedure, the informed procedural consent indicated Patient #19 was unable to sign because of confusion. The Physician failed to follow hospital policy by not providing a written determination in the clinical record that Patient #19 was no longer able to make informed medical decisions and that the Health Care Proxy was invoked.

Based on observation and interview, the Hospital failed to consistently provide confidentiality for patient information for 6 nonsampled patients. Findings Include:



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1. During tour of the Hospital's nourishment kitchens, on 10/6/15 at 1:00 P.M., the following were observed;
a. in the 36 North unit refrigerator there was a bowl of fruit with a patient's medical record label on it;
b. in the 22 South unit freezer there was a cooler bag with a patient's medical record label on it.

The refrigerators are accessible to the public in that other patients, families and visitors may access the contents of these refrigerators without supervision.

The labels on the food items included patient name, medical record number, attending physician, date of birth, patient care unit and health care insurer, all which is private and protected information and not for public view.

The Director of Food Service said the dietary staff does not use the labels from the patient's medical record to identify a food item for a patient.




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2. The Surveyor observed on the Maternity unit, at 10:00 A.M. on 10/5/15 and Patient Care Unit #24N, on at 10:30 A.M., on 10/6/15, in patient refrigerators, labels that included patient name, medical record number, attending physician, date of birth, patient care unit and health care insurer, on food items of 3 nonsampled patients.

3. On 10/7/15, at 2:10 P.M., the Surveyor observed a vase of flowers displayed on the counter at the Nurses Station on Unit 22. The vase had a patient sticker on it in plain view of visitors that included the patient name, medical record number, attending physician, date of birth, patient care unit and health care insurer.

Based on , observation and interview, document, record and policy review the hospital failed to ensure the care plan/orders for the care and management of pressure ulcers were implemented, for 1 sampled patient (#22) out of 32 sampled patients. The wounds declined. Findings include:

For Patient #22, the Hospital failed to ensure the policy, and care plan had been followed relative to pressure ulcers.

Review of the Hospital's policy entitled: "Wound Care Procedure" issued 6/2012, indicated the following:

- Purpose was to fundamentalize procedures and techniques for wound cleansing, dressing application and securement.
- Normal Saline for wound cleansing.
- Apply selected dressing.

Patient #22 was admitted to the Hospital in 9/2015 with Congestive Heart Failure (CHF), atrial fibrillation (A-Fib), and Diabetes Mellitus.

According to the clinical record, Patient #22 was admitted to the Hospital with pressure ulcers on bilateral buttocks, and on the same day (9/29/15), a referral was generated to the Wound Ostomy Continence Nurse (WOCN) Consultant for treatment,options and recommendations.

Review of the photographs and evaluation of the pressure ulcers, dated 9/30/15, indicated the following:

- Right buttock ulcer measured 1.3 centimeters (cm) x 0.6 cm and was identified as a Stage II ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound base.

- Left buttock ulcers (two present): one measured 0.7 cm x 0.4 cm, and the second ulcer measured 0.6 cm x 0.3 cm. The evaluation forms were signed by the Physician.

Review of the 9/2015 WOCN "Consultant's Note" indicated the presence of bilateral buttock pressure ulcers and identified "See Care Plan/pressure ulcer orders."

Review of the care plan (dated 9/29/15) for the pressure ulcers indicated to cleanse the ulcers with Normal Saline, pat dry, then apply an Exuderm (an opaque, non-breathable dressing which adheres to skin, so no separate taping is needed), change the dressing every three days and as needed. (There was no physician's order for this treatment). In addition, Z-Guard protective cream (cream used to protect minor skin irritation associated with diaper rash) would be applied to the groins/buttocks, after each incontinent episode.

Review of a nursing note, dated 9/30/15, indicated that Patient #22's family member did not want the facility to utilize Exuderm. There was no explanation as to why, nor any indication as to a potential allergy.

Further review of the record indicated that the patient was alert, oriented and could make his/her own decisions. There was no invoked health care proxy.

Review of the nursing notes (dated 9/30 - 10/6/15) documented that Z-Guard had been applied to the pressure ulcers, but not the Exuderm. Licensed nurses documented sporadically that the appearance of the pressure ulcers was clean and red.

Review of the 11:00 P.M. to 7:00 A.M., nursing note, dated 10/7/15, indicated that Z-Guard was applied to the pressure ulcers on the buttocks.

During interview on 10/7/15 at 9:50 A.M., Nurse #4 said that she was a Wound Nurse who worked with the WOCN, to ensure prescribed treatments were provided to pressure ulcers, and was about to complete the treatment for Patient #22.

During a treatment observation on 10/7/15 at 10:15 A.M., Nurse #4 said that Exuderm was the prescribed treatment for the pressure ulcers on the patient's buttocks. At this time, Nurse #29 entered the patient's room, and told Nurse #4 that the patient's family member said not to use the Exuderm. Nurse #4 said that Patient #22 was alert and oriented, and then asked Patient #22 about using the Exuderm dressing. Patient #22 looked at the Exuderm, and said that it was okay to use on the ulcers, and that he/she did not have an allergy to this, only to "paper tape."

Patient #22 was in the bathroom, and stood. Nurse #4 then provided peri-care using an incontinence foam cleanser. The surveyor observed that Patient #22 did not have Exuderm to either of the pressure ulcers. The right buttock had a shallow, cratered, red, raw, open ulcer, and was approximately 2 cm x 1.5 cm. with macerated wound edges. The left buttock ulcer was an irregularly shaped, shallow crater with fragments of macerated tissue in the wound bed. Ninety percent of the wound bed was red and raw. The entirety of the wound edges were macerated. The ulcer was approximately 3.5 cm x 2.5 cm. (appeared as though three ulcers had communicated and migrated together into one larger ulcer. The record previously identified the patient had two areas on the left buttock). The periphery to both ulcers was inflamed, with peeling, white tissue.

Nurse #4 used the same incontinence foam cleanser (not Normal Saline as the care plan indicated), and wiped across the right then left ulcers. She applied one Exuderm to the right ulcer, but the edges did not adhere. She then applied Exuderm to the left ulcer, and again the dressing did not adhere (incontinence foam contains emollients to protect skin from rashes) and fell loosely around the edges. Nurse #4 then assisted Patient #22 to sit on a support surface on the bedside chair.

During interview, directly after what had been observed, Nurse #4 said that she does not use Normal Saline, and prefers to use foam (did not indicate on spray can that this was a wound cleanser product).

Review of Nurse #4's note, dated 10/7/15, indicated that the patient continues with 3 open areas to left and right buttocks. Area cleansed and Exuderm applied per patient request (no description as to the appearance, maceration of wound edges, communication/migration of ulcers into one larger one on the left buttock, or inflamed periphery with white, peeling tissue).

During interview and record review on 10/8/15 at 8:30 A.M., the WOCN said that she had been a consultant WOCN for 24 years, and was familiar with Patient #22. She said that she recommended Exuderm to treat the patient's pressure ulcers, and described both ulcers as being Stage II. The WOCN said that she was never told the patient's family member did not want the Exuderm used. In addition, she said that the Z-Guard should not have been used in place of the Exuderm for the patient's pressure ulcers. The WOCN said that she cannot prescribe, but recommends treatments based on her experience and credentials as a certified wound ostomy continence nurse. The WOCN said that although an order for the Exuderm had not been written, it had been discussed and agreed to by the patient's physician. The WOCN said that it is the expectation for each nurse to provide the treatment, as planned, and to fully describe and assess the appearance and nature of the pressure ulcer in the clinical record.

The WOCN further said that she leads a team, who meets every month to review patient's wounds and treatment modalities, and had just met yesterday (10/7/15). The WOCN said that Nurse #4 was present, and did not mention Patient #22's wound condition, or the fact that the treatment prescribed had not been provided until yesterday. The WOCN said that there was no documented evaluation assessment of Patient #22's pressure ulcers, or the fact that the ulcers had worsened. The WOCN said that Nurse #4 should have used Normal Saline to cleanse the ulcers, as recommended. The WOCN said that appropriate care, treatment and documentation of the pressure ulcers had not been provided.

Based on observation and interview, the Hospital failed to consistently follow its' policy and procedure related to medication labeling. Findings include:

On 10/7/15, at 10:55 A.M., the Surveyor observed, in the Cardiac Catheterization Lab, two medication filled syringes at the recording nurse's computer station. The medication filled syringes, one labeled Fentanyl ( anorcotic pain reliever) and one labeled Versed ( a sedative/anxiolytic). The labels did not include the dosages of the medications in the syringes.

RN #2, who was sitting at the recording station in the cardiac cath lab, was asked about labeling of two medication syringes. RN #2 said the medication dosage should be included on the medication label, as per medication labeling policy.

Based on observation, record review (Patient #31) and Hospital policy titled Physician's Orders, the Hospital failed to ensure RN #15 received and documented a telephone order according to Hospital policy.

The Hospital policy titled Physician's Orders, dated August 2012, indicated that all telephone orders should be "read back" to the person that gave the order and then documented by the nurse.

The Surveyor observed on the Pediatric Unit, at 8:00 A.M. on 10/6/15, RN #15, discuss on a telephone, changing Patient #31 plans for intravenous (IV) fluids, and end the telephone call. The Surveyor observed RN #15 then answered the Pediatric Door Bell to enter Hospital personnel and then wrote the change of IV fluids in Patient #31 ' s medical record.

The Surveyor did not observe RN #15 write the telephone order in Patient #31's Medical Record according to Hospital policy and then read-back the telephone order to the provider, for correct information confirmation. The Surveyor observed RN #15 document the change of IV fluids in Patient #1's medical record as a Telephone Order Read Back (TORB).

Review of Patient #31's Medical Record, Doctor's Orders, dated 10/6/15 at 8:00 A.M., indicated RN #15 documented a Doctor's Order to decrease intravenous fluids to ½ ounce per hour as a TORB.

Based on observation, record review and interview, the Hospital failed to ensure that x-ray equipment was in in safe operating condition by having physics surveys. calibrations and preventative maintenance (PM) done annually for three x-ray rooms inspected. (rooms #3, #11 and #12). Findings include:

On 10/5/15 observation of x-ray Room #3 indicated there had not been any PM on the x-ray equipment since 2013. Observation of the x-ray machines in Rooms 11 and 12 indicated there had never been any PM performed on the x-ray equipment.

During an interview on 10/5/15, the Director of Radiology said the x-ray equipment in Room 11 and 12 had not had preventative maintenance annually as required and the equipment in Room three was 2 years overdue for PM.

Based on interview and maintenance record review, the Hospital failed to ensure an acceptable level of safety and quality relative to the dishwasher's operations and failed to monitor refrigerators in patients' room to ensure safe function for maintaining food quality. Findings include:

1. During an initial tour of the dietary department on 10/5/15 at 10:20 A.M., the Surveyor and the Director of Food Service (DFS) observed the operation of the dishwasher. The following were observed;
a. At 10:40 A.M., the wash temperature was 150 degrees Fahrenheit (F) and the rinse temperature was 180 degrees F.
b. At 10:48 A.M., the wash temperature was 151 degrees F and the rinse temperature was 182 degrees F.

Observation of the machine's temperature gauge dials indicated the required wash temperature was 160 degrees F and the required rinse temperature was 180 degrees F.

Review of the dishwasher's manufacturer instructional guide indicated the minimal temperature for wash was 150 degrees F and 180 degrees F for final rinse.

During an interview on 10/6/15 at 9:45 A.M., the DFS said the dietary staff use a temperature test strip (T-Stick Temperature Sensors) one to two times a week in the dishwasher. The strip would indicate if the internal water temperature is 160 degrees F when it was run through a wash cycle. She said this ensures the machine is maintaining the correct wash temperature.

Review of the Dishwashing Temperature Logs from 7/30/15 through 10/5/15 indicated that the wash temperature was below 150 degrees, as required by the manufacturer, on 37 of 55 days, ranging from 112 to 149 degrees.

During an interview on 10/6/15 at 10:55 A.M., the DFS said there was no evidence that the temperature test strips were done during the time frame of 7/30/15 through 10/5/15, but should have been because several wash temperatures were below the required 150 degrees F.



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2. The Surveyor observed on the Post-Partum Unit, on 10/5/15 at 1:45 P.M., a refrigerator in a patient care room. There were no temperature logs on or around the refrigerator.

During an interview on 10/5/15 at 1:45 P.M., the Post-Partum Nurse Manager (RN #10) said that all Post-Partum patient care rooms contained refrigerators and the Hospital did not monitor these refrigerator temperatures.

Food temperature affects the safety of food. Foods that require refrigeration and that are held at temperature above 45 degrees Fahrenheit over time, can become breeding grounds for bacteria, molds and other disease causing organisms. Improper refrigeration of food items over time can lead to food borne illnesses and even death.

Based on observations, records reviewed and interviews, the Hospital failed to consistently follow infection control standards and Hospital policy related to hand hygiene, medication handling, transport of soiled equipment, use of personal protective equipment and sharps safety; for 11 different staff observed (Physicians #1, #2 #6, #7 and #8; Registered Nurses (RN) #2, #6 and #30; Certified Registered Nurse Anesthetist (CRNA) #2, and Ultrasound Technician (US Tech) #1); Patient Care Technician (PCA) #1; ; one sampled patient (#23) in a total sample of 32 patients, two of three non-sampled patients (NS #1 and NS #3), two outpatients (OP #9 and #10) in a total sample 10). Findings include:

1. Review of the Hospital policy for use of droplet precautions indicated that droplet precautions are used for infections such as seasonal flu, pertussis, respiratory infection with Methicillin Resistant Staphylococcus Aureus (MRSA), in addition to contact precautions. Masks must be worn for droplet precautions and a gown and gloves for contact precautions.

On 10/6/15 at 11:15 A.M., the surveyor observed two staff in Room 12, an emergency room (ER) bay, that was designated by signage on the door as the patient (Nonsampled (NS) #3) requiring droplet precautions. Physician #6 and Registered Nurse (RN) #30 were observed in the room, examining the patient, with the room door open. RN #30 and Physician #6 were observed to be wearing only masks as their personal protective equipment (PPE). The Patient was observed to have a tracheostomy (hole in the neck that opens into the trachea and allows the patient to breath).

During an interview on 10/6/15 at 11:25 A.M., the ER resource nurse said the patient had a MRSA infection in his/her sputum and was coughing productively which is why the patient was put on droplet precautions. The surveyor inquired if contact precautions were also required and the resource nurse said yes. The surveyor pointed out that the two staff in the room were not wearing gowns or gloves which allowed their personal clothes and hands to be potentially cross contaminated with MRSA and spread it to other patients and surfaces within the ER.

2. Staff failed to follow aseptic techniques when preparing intravenous medications for injection per Centers for Disease Control (CDC) Standards which state that the access diaphragm (rubber stopper in the top of the medication bottle that staff puts the needle through) of vials should be cleansed using friction and a sterile 70% isopropyl alcohol,ethyl alcohol, iodophor, or other approved antiseptic swab. Allow the diaphragm to dry before inserting any device into the vial.

According to the Hospital Procedure for Intravenous (IV) Medication Administration, issued 6/2014, injection ports/caps of IV lines and IV bags were to be swabbed with alcohol before injection of IV medications.

a. On 10/7/15 at 9:40 a.m., surgical outpatient (OP) #10, was observed during induction of anesthesia. Physician #5, an anesthesiologist, gave the anesthetizing medications followed by Certified Registered Nurse Anesthetist (CRNA) #2, inserting an endotracheal tube without problems. During positioning and surgical scrub of the patient, the patient's blood pressure and heart rate decreased to 58/41 and 53. The CRNA withdrew 10 cubic centimeters (cc's) from a 100 milliliter(ml), bag of D5W labeled as containing Phenylephedrine 80 micrograms per milliliter(ml), which is used to raise blood pressure. The CRNA did not clean off the IV bag injection port with alcohol as required before withdrawing the medication and injecting it into the patient's IV.

b. On 10/8/15 at 11:40 A.M., the Surveyor observed Physician #1, in the Ambulatory Surgical Care (ASC) holding room, preparing a retrobulbar block for Outpatient #9, who was having a cataract removed. Physician #1 requested a vial of Lidocaine 1% and Wydase (potentiates the action of Lidocaine) from the nurse. Without cleansing the vial access diaphragms, Physician #1 drew up both Lidocaine and the Wydase into one syringe and then injected the medication into the patients upper eye and lower eye around the globe.

8. Physician #1 failed to perform a retrobulbar block using PPE (gloves) to protect himself and the patient from cross contamination and potential infection.

According to the Hospital Standard Precautions/ Body Substance Precautions Policy, issued 3/14/14, gloves are to be used when direct contact with blood or body fluids is anticipated. Injecting into the eye socket has high potential for blood exposure.

On 10/7/15, at 11:40 A.M., the surveyor observed Physician #1 perform a retrobulbar block of the left eye of OP#9 in the Ambulatory Surgical Care holding room. While awaiting Physician #1 arrival from the operating room (OR) where he was finishing another cataract (eye) surgery, the Surveyor spoke with OP #9 and the nurse in the holding room. The nurse stated she provided vital sign assessment and oxygen to the patient who was comfortable. Physician #1 arrived and was observed to perform hand hygiene with the alcohol based product by the door and entered the holding room. Physician #1 examined the patient's left eye, touched the bedrails which had been touched by the surveyor, the nurse and two of the escorts with the surveyor. The Surveyor then observed Physician #1 to come over to the prep cart in the room and withdraw supplies. Physician #1 and the nurse both touched the same drawers in the prep cart. Physician #1 then drew up, into the same syringe, two medications, without cleansing the vial access diaphragms. Physician #1, without donning gloves, injected OP #9's upper left eye and then with the same syringe, injected below the left eye. Physician #1 then accompanied the patient to the OR without washing his hands.

During an interview on 10/7/15 at 2:45 P.M., Physician #1 said that he doesn't wear gloves because he can feel the eye globe better and that this is his practice. He said he did perform hand hygiene before entering the patient's room before he did the block. When asked if this accepted practice under hospital infection control policies and surgical standards Physician #1 reiterated it was his practice only.

During an interview on 10/8/15 at 8:30 A.M., the Chief of Surgery said this practice was not acceptable in surgical care and would be addressed.


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9. The Hospital failed to ensure that infection control practices had been observed when a multidose vial of Lidocaine (injectable medication used for local anesthetic) had been opened, used and stored for future use, without being dated (considered expired).

During observation of the ICU Medication Room on 10/5/15 at 10:00 A.M., the surveyor observed a treatment cart, stored in the Medication Room. The top drawer had an opened 30 milliliter multidose vial of Lidocaine. The ICU Director was present, and said even though the Lidocaine was a multidose vial, that it was the facility's policy to discard the vial, despite what contents remain, after first use, and not to store unused contents. The Director discarded the vial immediately.

10. The Hospital failed to ensure Patient Care Technician (PCA) #1 performed appropriate infection control practices relative to hand hygiene, failed to wear gloves when she had potential exposure to blood and/or body fluid, and failed to disinfect a glucometer between patients in the ICU.

During an observation in the ICU on 10/5/15 at 11:20 A.M., the surveyor observed PCA #1 obtain a glucometer from a docking station that was stored on the Nursing Desk counter, and enter NS #1's room. PCA #1 did not perform hand hygiene. She did not wear gloves, as she pricked the patient's finger, and obtained a blood sample. PCA #1 placed the glucometer on the counter in the patient's room, then touched and depressed the keyboard to the electronic medical record inside the patient's room. PCA #1 picked up the glucometer, and placed the contaminated device back into the docking station at the nursing counter, without disinfecting it.

This left the next patient who has a blood glucometer check potentially exposed to blood borne infections.

During interview with Nurse #1 (identified as the Manager for the ICU), she said that re-education would be provided immediately for PCA #1 relative to disinfection of equipment, hand hygiene and wearing gloves.

11. The Hospital failed to ensure Nurse #6 performed proper infection control practices relative to aseptic technique for medication preparation and proper hand hygiene for NS #1.

a. During an observation in the ICU, as part of the medication pass on 10/5/15 at 11:38 A.M., the Surveyor observed Nurse #6 remove the cap from a vial of Lasix (medication used to treat edema), and a vial of Dilaudid (medication used for pain management). Nurse #6 did not wipe the rubber septum on either vial, before inserting a needle to withdraw the Intravenous medications she administered via the patient's central lines.

b. The surveyor then observed as Nurse #6 appropriately prepared Heparin (blood thinning medication) for a subcutaneous (sc) injection. Nurse #6 donned gloves, walked to the patient's bedside, lifted the nightdress off the patient's abdomen, then wiped the abdomen with alcohol and prepared to inject the medication, when she identified that the needle was bent in half. Nurse #6 discarded the medication into the sink, then discarded the syringe, removed her gloves, and exited the room, without performing hand hygiene after touching the patient. Nurse #6 walked to the Medication Room, obtained another vial of Heparin, returned back to the room, and prepared another dose of the Heparin with contaminated hands. Nurse #6 administered the Heparin sc into the patient's abdomen, without performing hand hygiene.

During interview with Nurse #6, directly after what had been observed, Nurse #6 said that she thought she performed hand hygiene, as it is the facility's policy to "foam in and foam out" (hand sanitizing foam mounted on the wall, outside of the room), and perhaps forgot. Nurse #6 also said that she thought she wiped off the rubber stopper to each medication, after the cap had been snapped off, but could not be sure, but would be more careful in the future.




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12) The Surveyor observed the Cardiac Catheterization Lab at 10:55 A.M. on 10/7/15. RN #2 was asked about labeling of two medication syringes. RN #2 picked up the medication filled syringes, one labeled Fentanyl and one labeled Versed, to show the Surveyor how these syringes were labeled and dropped one of the syringes on to the floor. RN #2 picked up the syringe from the floor and placed it back at the RN recorder's station. This medication was subsequently administered intravenously to Patient # 23, eventhough it was contaminated from falling on to the floor and should have been discarded.

13) The Surveyor observed the Endoscopy Suite at 1:00 P.M. on 10/6/15. RN #7 said that sometimes the endoscopic procedures were performed at the bedside or in the Imaging Department. RN #7 said a travel cart was used when a procedure was done outside of the Endoscopy Suite. RN #7 showed the Surveyor a green cinch sack that was used to transport the soiled endoscopes back to the department to be reprocessed. RN #7 said the drawstrings of the cinch sack were pulled tight to designate the equipment was soiled. According to the Hazard Communication section of the Exposure Control Plan, a Biohazard symbol or the use of a red bag is required for contaminated equipment to warn employees of a potential biohazard.

14) The Surveyor observed the Sterile Processing Department (SPD) at 10:00 A.M. on 10/6/15. Eight conventional (nonsafety) needles were observed in various sizes (30g x 0.5 in, 25g x 1.5 in, 26g x 1.5 in, 20g x 1.5 in, 27g x 1.25 in, 25g x 5/8 in, 19g x 1.5 in). The SPD Supervisor said these needles were added to the operating room case carts as needed. The SPD Supervisor said the Occupational Health Department maintained waivers for these conventional needles to enable them to be used instead of needles with safety devices.

According to the Exposure Control Plan, annual documentation of commercially available safer medical devices designed to eliminate or minimize occupational exposure ( needlestick injuries) was to be completed. The Surveyor reviewed the sharps waiver exemption forms which included only two of the seven conventional needles, sizes 30g x 0.5 in and 25g x 1.5 in.

15) On 10/6/15 at 2:30 P.M., the surveyor observed the reprocessing room of the ultrasound Department and interviewed Ultrasound Technician #1. During the interview, Ultrasound Technician #1 said the Hospital used OPA (ortho-Phthalaldehyde) to high level disinfect (the use of a chemical procedure that eliminates virtually all recognized pathogenic microorganisms) instruments between patients. Ultrasound Technician #1 reviewed the steps to achieve high disinfection. Ultrasound Technician #1 said after the correct amount of soaking time, the instrument was removed and placed under running water to remove the chemical. According to the manufacturer's directions for use, three separate immersion rinses are required to avoid serious side effects from chemical residue, such as tissue burns to patients or allergic reactions.



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16. During an initial our of the Dietary Department on 10/5/15 at 10:20 A.M., the following sanitation concerns were observed in food preparation and holding areas;

a. Four warming ovens were dirty inside and outside with food spillage and food particles.
b. A bag of sugar stored above the bakery preparation area was open to the air.
c. The large blast chiller was dirty inside with food spillage.

During a second tour of the Dietary Department on 10/6/15 at 9:45 A.M., the Surveyor observed the following sanitation concerns:

a. The four warming ovens remained dirty inside and outside with food spillage and food particles.
b. Two bags of sugar and a box of raisins, stored above the bakery preparation area, were open to the air.
c. The large blast chiller remained dirty inside with food spillage.

During an interview on 10/6/15 at 10:55 A.M., the Director of Food Service said the areas of concern would be cleaned. She said the equipment should not have been left dirty. She said the food items should not have been left open to the air. She said supervisors are doing daily sanitation rounds and should have noted these concern.



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17. On 10/6/15, at 9:00 A.M. on Patient Care Unit #22S, the Surveyor observed Physician #7 and Physician #8 in a patient room without Personal Protective Equipment (PPE, i.e., gowns, gloves, face shields). The Surveyor observed a Contact Precaution sign and precaution cart containing PPE outside the patient room. According to the Contact Precautions sign, all staff entering the room was to put on a gown and gloves when entering the room.

18. On 10/6/15, at 12:45 P.M., the Surveyor observed in the 2 Operating Rooms (OR) in Labor and Delivery, each OR contained a wooden cart on which rested an Electronic Fetal Monitor. Wooden carts were not able to be disinfected as blood and other potentially infectious material cannot be thoroughly removed from grooves and notches in the grain of the wood.