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Based on observation, interview, and record review, the facility failed to use two patient identifiers when obtaining a blood specimen for a blood glucose on a patient. This deficient practice had the potential to affect all patients whom received care on the ICU. Findings include:

During an observation and interview on 6/26/18 at 2:00 p.m., staff member A removed the unit-based glucometer and lifted a sheet of purple paper attached to a clip board. The purple paper was covering another sheet of paper, which had several patient identifier stickers. The staff member stated she had not put the resident's sticker on the sheet yet, because he was a new admit, but planned to put his sticker on the sheet so she could scan the sticker when she needed to get a blood glucose on the patient. She stated she would go ahead and scan his wrist band since there was not yet a sticker on the sheet for the patient.

During an interview on 6/26/18 at 2:10 p.m., staff member A stated it was her process to scan the patient identifier sticker on the clip board when doing the patient's glucose. She stated she thought it was acceptable because the purple sheet was covering the patient names. The staff member was not able to explain the risk for missed patient identifiers while using the current method.

During an interview on 6/26/18 at 2:12 p.m., staff member B stated it was the expectation, and a topic of continued education with staff, to obtain at least two patient identifiers when administering care, and using equipment used to obtain blood samples. She stated it was not an acceptable technique to use a sheet of paper with several patients' identifying stickers, instead of scanning the patient's wrist band, to confirm a patient's identity.

During an interview on 6/28/18 at 8:30 a.m., staff member C stated it was the expectation for staff to use the barcode identification for confirmation of patient identifier. She stated it was the expectation to use the patient's wrist band and another form of identification before collecting a specimen. She stated it was not acceptable for staff to use a patient identifier which was not on the patient. The staff member stated the barcode identifiers for patient identification was a quality improvement project for all nursing staff. She stated the PI project was assessed to be 98% effective for using the barcode scanning for patient identification. She stated the process will be re-adjusted to account for any "work-around" by staff, and the QA will continue to educate staff and work on improving patient outcomes.

A review of the facility's policy and procedure titled, Identification of Patients, showed, "To ensure that all patients are properly identified prior to any care, treatment or services provided...1. Identifiers: a. Staff will use at least two patient identifiers (neither to be the patient's room number) taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures. b. Whenever administering medications or blood products, the patient's armband will be scanned... 2. Principles of Identification: a. A system for positive identification of all hospital inpatients fulfills four (4) basic functions: i. Provides positive identification of patients from the time of admittance or acceptance for treatment. ii. Provides a positive method of linking patients to their medical records and treatment. iii. Minimizes the possibility that identifying data can be lost or transferred from one patient to another...."

Based on record review and interview, the facility failed to ensure a Plan of Care was dated as effective for 1 (#16) of 37 sampled patients. Findings include:

Review of patient #16's Plan of Care, with a start of care dated 6/14/18, showed it did not have dates of when the physical therapist and the nurse practitioner had signed off the Plan of Care for patient #16.

During an interview on 6/26/18 at 9:17 a.m., staff member M stated there were no dates when the nurse practitioner and the physical therapist had signed off on patient #16's Plan of Care, dated 6/14/18. The staff member stated all plans of care should be signed and dated as soon as the facility signed off on the care plan.

Based on record review and interview, a discharge summary was not completed for 1 (#13) of 37 sampled patients. Findings include:

Review of patient #13's medical chart showed the patient was discharged on 5/22/18. No discharge summary was found.

During an interview on 6/26/18 at 3:00 p.m., staff member L stated the patient did not have a discharge summary in his medical chart for his discharge on 5/22/18.

Based on observation, interview, and record review, the facility failed to ensure the mitigation of the risk for device associated infection by failing to disinfect a unit-based glucometer after use for 1 (#37) of 37 sampled patients. The facility failed to ensure staff practiced measures to mitigate healthcare-associated infection risk by not wearing protective clothing over scrubs during the gathering process of surgical instruments in the OR suite that were transported to the sterilization department; and failed to clean the baffles in the hood vents, the fan guards in the walk in refrigerator, the soup ladles were left uncovered, an ice scoop was not properly stored when not in use, and cooked chicken fillets were left open to the air in the walk in cooler. Findings include:

1. During an observation on 6/26/18 at 2:00 p.m., staff member A brought one of the two unit-designated glucometers into patient #37's room. The staff member placed the glucometer on top of the patient's bed spread. The staff member used the glucometer to collect the blood sample from the patient, then placed the glucometer back on the bed. Staff member A picked up the glucometer, left the patient's room and re-docked the meter on its docking station. Staff member A walked away and failed to disinfect the glucometer after use.

During an interview on 6/26/18 at 2:10 p.m., staff member A stated she did not clean the glucometer after every use. She stated she was not aware it was necessary, and thought the device only needed to be cleaned once a shift.

During an interview on 6/26/18 at 2:12 p.m., staff member B stated it was the expectation of staff to disinfect the unit dose devices, such as the glucometers, after each patient use. She stated it was important to disinfect the glucometer after each use, even though they may not appear visibly soiled, there was still a potential to spread microorganisms.

A review of the facility's policy and procedure titled, Cleaning of Unit-Based Medical Equipment, showed, "To reduce the risk of transmission of microorganisms from patient care to the patient. Patient care equipment must be cleaned/disinfected between patients. 1. All unit-based medical equipment must be cleaned promptly after each patient use according to manufacturers' recommendations/specifications using PDI Sani-Cloth or A 456 Disinfectant Cleaner, both approved disinfectant/germicidal cleaners. 3. All non-disposable personal care equipment will be cleaned and returned to the designated clean areas in each department."


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2. During observations on 6/25/18 at 9:08 a.m. the following items were noted in the kitchen and/or the cafeteria:

- An ice scoop was sitting on top of the ice in the cafeteria ice cooler.

- The hood vent baffles, in the cafeteria and the main kitchen, were covered with a brownish grease, containing a gritty appearing dust.

- The vent grills, above the dishwasher, were covered with a black, greasy layer of dust. One of the vents was above the clean dish area.

- Multiple sized soup ladles were located in the main kitchen, on the pots and pan rack, above a preparation table. There was no covering for the soup ladles, which protected the ladles from being contaminated from flying insects or dust particles.

During an interview on 6/25/18 at 10:50 a.m., staff members H and I stated they had not thought about the ladles needing to be shielded from contaminants, while hanging on the overhead rack.

- The plastic fan guards, in the walk-in cooler, had accumulated greasy gray dust within the squares of the guard. Fresh vegetables, in boxes, and a bag with green leaves hanging out, was observed under the fans. Two small plates, with three chicken fillets, were observed with plastic wrap partially covering the meat. The chicken had a date of 6/25/18. The wrap did not completely cover the chicken fillets on either plate.

During an interview on 6/25/18 at 9:08 a.m., staff member J stated he walked through the cafeteria, reviewing what needed to be cleaned regarding the hood vent baffles, with the evening janitor.

During an interview, on 6/25/18 at 10:54 a.m., staff members H and I stated janitorial services, for the facility, cleaned the baffles. The staff members were not sure how often the baffles were cleaned.

During an interview on 6/27/18 at 3:05 p.m., staff member K stated he cleaned the hood screen baffles in the cafeteria and the main kitchen, weekly. The staff member stated he had been gone for the past three weeks and someone else had covered for him.

Review of the cleaning schedules for the night time janitorial staff, with dates from 5/28/18 through 6/25/18, did not show that the night janitor was cleaning the hood vent baffles in the main kitchen or the cafeteria.

Review of the Master Cleaning Schedule, for the kitchen staff, dated 4/1/18 through 6/24/18, did not show that the kitchen staff had cleaned the hood vent baffles in the main kitchen or the cafeteria.

During an interview on 6/27/18 at 2:33 p.m., staff members H and I stated the vents above the dishwasher had not been on any cleaning list, and had been added to the cleaning list. Staff member H stated the hood vent baffles would now be cleaned once a week by the night crew. The staff member stated she was aware the hood vents had been missed a couple of times, as a new person had been doing the night cleaning in the kitchen and cafeteria. Staff member H stated a holder for the ice scoop had been placed on the side of the cafeteria ice cooler.


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3. During an observation on 6/26/18 at 1:20 p.m., staff member F entered OR suite #2, sanitized her hands and applied gloves. Staff member F was wearing a scrub top and bottoms, a head covering and shoe covers. The surgical case in OR suite #2 was done and surgical instruments along with blood saturated gauze pads were on the instrument table that had been used during the case. Staff member F did not have a gown or apron on that covered her scrub top or bottoms. Staff member F stood in front of the instrument table and gathered the used surgical instruments and placed them in sterilization trays. Staff member F leaned forward several times over the instrument table to reach the used surgical instruments. There was no barrier or protective clothing present between staff member F's scrub attire and the used bloody gauze pads, surgical instruments, and the surgical table. After staff member F had gathered the surgical instruments and placed them in the sterilization trays, staff member F placed the trays in a cart to be transported to the Sterilization Department.

During an interview on 6/26/18 at 1:20 p.m., staff member F stated the only other place she went in the hospital with the same scrub attire on after she delivered the used surgical instruments was the cafeteria to get lunch. Staff member F stated if she soiled her scrubs she would change them prior to leaving the OR department.

During an interview on 6/27/18 at 7:55 a.m., staff member G stated the facility followed AORN standards. Staff member G stated the facility did not have a policy and procedure to address attire used during the process of gathering used surgical instruments after a surgical case to be transported to the Sterilization Department.

Based on interview and record review, the facility failed to include an assessment in the discharge evaluation of the patient's capacity for self-care, or to be cared for by others, in the environment from which the patient was admitted for 2 (#s 8 and 9) of 37 patients. Findings include:

1. Review of patient #8's EHR, showed the patient was admitted to the facility on 6/20/18. A discharge evaluation was started for the patient on 6/22/18. Review of the Care Management Evaluation, dated 6/22/18, failed to include an assessment which established the patient's capacity for self-care in the environment from which she was living prior to being admitted into the facility.

2. Review of patient #9's EHR showed the patient was admitted to the facility on 5/3/18. A discharge evaluation was started for the patient on 5/4/18. Review of the Care Management Evaluation, dated 5/4/18, failed to include an assessment which established the patient's capacity for self-care in the environment from which she was previously living prior to her admit.

During an interview on 6/25/18 at 3:36 p.m., staff member E stated not every patient was evaluated for ADL's or capacity for self-care from their previous living situation. She stated the ADL's were often evaluated either by the nurse or the PT/OT. She stated the patient's capacity for self-care needs may not always be identified on the discharge evaluation.

During an interview on 6/26/18 at 1:36 p.m., staff member D stated she would assess limited ADL's and inquire if the patients had help at home. She stated she did not always include the patient's capacity for self-care on every discharge evaluation because it was usually completed by the nurse or PT/OT.

Review of the facility's policy titled, Discharge Planning-SJB, showed, "To provide discharge planning focused on meeting patient's healthcare needs after discharge. 1. Discharge planning identifies patient's initial and continuing physical, emotional, symptom management, housekeeping, transportation, social and other needs, and arranges for services to meet them."

Based on interview and record review, the facility failed to complete a timely reassessment of a patient's discharge plan after an order was placed to update the patient's discharge needs for 1 (#18) of 37 sampled patients. Findings include:

Review of patient #18's discharge plan, showed the patient was admitted to the facility on 6/17/18. A discharge evaluation was started on 6/19/18 for the patient. An order was received by the Care Managers on 6/21/18 which showed, "patient does not want to go back to [facility]." A review of patient #18's EHR on 6/26/18, showed the facility had not completed a timely reassessment to the patient's discharge evaluation.

During an interview on 6/25/18 at 3:36 p.m., staff member E stated it was the expectation of the case management team to generate a discharge evaluation as soon as possible, without causing the patient delay in their discharge. She stated it was expected for staff to reassess the evaluation with any new changes which occurred during a patient's stay at the hospital within 24-48 hours of receiving an order.

During an interview on 6/26/18 at 9:53 a.m., patient #18 stated she had not heard from case management on her discharge changes. She stated she did not wish to go back to [facility], and hoped there was another facility nearby she could go to for rehabilitation. The patient stated she was uncertain what her plan for discharge was at that time.

During an interview on 6/26/18 at 1:36 p.m., staff member D stated she had received the order for patient #18 to reassess her discharge plans. She stated she had not completed the order to re-evaluate the patient because she was currently in the ICU and was expected to discharge to the medical floor before being discharged. She stated she would usually wait to start or make changes to the discharge plan until the patient discharged from the ICU. She stated it was important not to delay the discharge of the patient from the facility, and to ensure a well-established discharge plan to reduce the occurrence of readmission for patients.

Review of the facility's policy and procedure titled, Discharge Planning-SJB, showed, "To provide discharge planning focused on meeting patient's healthcare needs after discharge... 4. As the patient's condition changes, the plan will be evaluated and revised. a. The patient and family will continue to be included and informed in all aspects of the discharge planning. 5. Care Management will coordinate the necessary community referrals/transfers as ordered by the physician."