HospitalInspections.org

Based on interview, record review, and policy review, the provider failed to ensure the corrective action plan developed in response to one of one sampled patient (10) that was improperly restrained by one of one staff member (Q) was fully implemented for completion. Findings include:

1. Review of the South Dakota Department of Health Licensure and Certification (SD DOH L&C) Healthcare Online Self-Reporting Form submitted on 1/3/23 regarding the application of a restraint on patient 10 revealed on 1/1/23 at 5:03 p.m.:
*Patient 10 had returned to his room after altercations with his peers during gym.
*He began to hit and kick things in his room.
*Staff member Q without the directive of the nurse or other staff members to assist ran down the hall and entered the patient's room.
*Staff member Q walked the patient out of the room with his hands pulled behind his back.
-He was behind the patient with his arms intertwined with the patient's, nearly pinning the patient's elbows together.
*The patient got one arm free, staff member R attempted to assist by initiating a team control hold and was unsuccessful.
-Staff member R had not called out "team" to alert staff member Q know she was attempting to initiate a team control hold.
*Staff member Q and the patient ended up sitting on the floor with the staff member behind the patient.
*Staff member R went to unlock the seclusion room and upon her return the patient was face down in a headlock position.
*"The patient stopped fighting and began coughing/choking" and staff member Q "removed his arm from around the patient's neck."
*Staff member R "instructed them that we needed to turn the patient over because he can't be on his stomach during a hold."
-At that time staff member Q and two code responders began to discuss how best to safely reposition the patient.

Review of the provider's corrective action plan on the SD DOH L&C Healthcare On-line Reporting form accepted by the SD DOH on 1/13/23 revealed eight corrective action interventions that should have been implemented. The following three corrective action plans had not been completed and/or implemented:
*"The Security Supervisor and Deputy Administrator will review of the security officer's training program and expectations."
-The corrective intervention should have been completed by January 31, 2023.
*The "Director of Quality and Compliance will review the camera footage of 10 percent of high-risk events for 6 months and report out to quality counsel monthly.
-"Action: Started effective January 3rd and will run until July 3rd 2023."
*"All staff will be educated on the dangers of positional asphyxiation, unapproved HSC physical control holds and the process of reporting abuse and neglect.
-Action: Required reading will be sent to all staff and completed by February 13, 2023."

Interview and review with director of compliance and quality B on 2/28/23 at 12:40 p.m. of the camera footage for the 1/1/23 restraint applied by staff member Q on patient 10 confirmed at:
*5:00 p.m. the resident entered his room. Staff member Q was behind the nurse area talking with another staff member.
*5:01 p.m. staff member Q walked down the hallway and entered the patient's room.
-Staff member S walked down the hall and entered the room.
-Both staff members exited the room and began walking up the hallway, they stopped and looked back, then continued to walk up the hallway towards the nurse's station.
*5:02 p.m. staff member Q was at the nurse's station watching the camera monitor, then takes off and runs down hallway towards the patient room and enters.
*5:03 p.m. staff member Q exits the room with the patient's arms pinned behind him and walks up the hallway.
*5:04 p.m. As they struggle in the hold both end up in a sitting position on the floor.
-Staff member Q was seated behind the patient in a hold with his arm up around the patient's neck.
-Another staff member attempts to assist during the struggle and the patient flips onto his stomach with staff member Q on top.
*5:05 p.m. patient 10 remains prone and no longer struggling.
*5:06 p.m. patient was not moving and another staff member instructed that they needed to move him into the safety chair.
-The patient began to struggle when staff were attempting to put him in the safety chair.
-5:08 p.m. patient was in the safety chair and taken to a quite area.
*At no time during the above incident described was there an approved restraint hold applied by staff member Q.

Interview on 3/1/22 at 10:22 a.m. with director of compliance and quality B confirmed:
*She was not aware the above listed corrective action interventions had a completion date.
*The corrective action plan had not been fully implemented.
*There was no tracking to ensure the corrective action plan had been implemented.
*The deputy administrator had met but did not move forward on that corrective intervention.
*The action items listed above had not been added to the quality counsel agenda.

Interview on 3/1/22 at 10:38 a.m. with director of nursing C confirmed:
*He was a member of the committee that had developed the corrective action plan.
*He was aware of the completion dates outlined on the corrective action plan.
*The corrective action plan had not been monitored "close enough" to ensure completion.

Interview on 3/1/23 at 11:09 a.m. with administrator A confirmed:
*Staff member Q was a member of the unit security team.
*Unit security had been instructed they were not to be the main provider of restraints during a code.
*Unit security were to have taken directives for action from the nurses.
*The unit security checklist (orientation) had been reviewed but they wanted to build up that program with more substantial content.
-The security supervisor and deputy administrator had barely started on upgrading that program.

Review of the provider's undated Nonviolent Crisis Intervention policy revealed the use of physical control techniques not expressly sanctioned by SDHSC [South Dakota Human Service Center] may be cause for disciplinary action.

Based on interview, record review, and policy review, the provider failed to ensure one of six sampled patient's care plans (18) included interventions and goals for inappropriate sexual behaviors towards other patients.
Findings include:

1. Review of patient 18's medical record revealed:
*She was admitted on 2/3/23 with a diagnosis of schizophrenia.
*An inpatient progress behavior note and an independent progress note both dated 2/24/23 documented the following:
-She had been observed in the day hall holding onto another patient's hand.
-Staff had called her name several times, she had not responded, and continued to stroke patient 31's hand.
-She then began to pull at his shirt sleeve as if attempting to take it off.
-When staff approached both patients she was "staring off as in a trance."
-She was not wearing her brief or pants; her pants were on a chair in a row behind them.
-Patient 31 was sitting in his chair and staring ahead at the television.
-She was walked back to her room and her pants were put back on.
-A minute later she returned to the day hall, staff asked her if she was okay and she responded with something incoherent.
-She went to the bathroom a couple minutes later, came out with a small towel, was asked if she needed the laundry room opened, and appeared to be herself after that.

Review of the provider's Detailed Incident Report dated 2/24/23 revealed:
*The same information that was stated above.
*When patient 31 had been questioned "about the incident [no date or time documented] he stated he didn't know what was going on and "I don't know she was naked."

Review of a physician progress note dated 2/27/23 for patient 18 revealed:
*She had an incident over the weekend where she "exhibited some inappropriate behavior."
*Staff were able to intervene and "took care of the problem."
*"Otherwise, the patient was doing better."

Interview and review on 3/2/23 at 12:00 p.m. of patient 18's medical record with adult acute nurse manager F confirmed:
*Staff had not initiated a nursing short-term care plan for inappropriate behavior.
*Nursing short-term care plans were initiated to address patient problems that were not permanent.
*The treatment plan dated 2/23/23 had not been updated to reflect inappropriate behavior towards another patient.
*Patient rounds were officially conducted by the treatment team weekly on Mondays and Thursdays. At that time short-term care plan problems could have been transferred over to the patient's treatment plan.

Review of the provider's undated Nursing Short-term Care Plan policy revealed:
*A nursing plan of care for patients with acute, short term problems should have been completed.
*The short-term care plan addressed acute problems, identified specific, and immediate interventions for direct care staff to utilized when specific problems occurred.
*Short-term care plans were initiated by the registered nurses/licensed practical nurses or the direct care staff.

Based on observation, interview, document review, job description review, and policy review, the provider failed to ensure pharmacy services provided oversight and monitoring for the security and accountability of the following:
*Medications used for emergency situations stored in two of two observed code carts (wing Aspen 2 and ECT room).
*Medications used for anesthesia in one of one electroconvulsive therapy (ECT) procedure room.
*A controlled substance (medication that has a high potential for drug diversion) that was placed unsecured on one of two nurse's stations in the ECT procedure room by one of one registered nurse (RN) K.
Findings include:

1. Observation on 2/28/23 at 11:25 a.m. with RNs M and D with the code cart located on Aspen 2 revealed:
*It had several drawers that contained multiple life-saving equipment, a defibrillator, and emergency medications.
*The drawers were secured shut with two red pull away Ziploc tags.
-Those Ziploc tags had no numbers, letters, or markings on them for staff to check and identify when the last time the cart had been accessed for security purposes.
*There was a Lifepak 30e defibrillator and code cart checklist form on a clipboard on top of the cart.
-The night shift was responsible for checking the cart daily during their shift.
-On the form there was a spot for the staff to check to ensure the plastic locks were in place.
-There had been check marks in those daily check spots.
*There was no area on the form to document:
-When the last time the code cart had been accessed by the staff.
-By whom the code cart had been accessed and why.
-After the code cart was accessed, if the medication (med) trays were secured shut and what the numbers were on the Ziploc tags.
*RN M pulled the red tabs and opened the second drawer of the code cart.
*Inside of that drawer were two trays with a clear cover over them for viewing of the contents.
*There was a photocopy of the meds inside of the trays placed on top of them.
*The covers were secured shut with blue Ziploc tags.
-Those Ziploc tags had numbers on them.
*Inside of the trays were multiple meds used for lifesaving events such as:
-Atropine injectables (nervous system blocker).
-Epinephrine injectables (used to treat several allergic reactions).
-An Epi-pen.
-Ativan injectables (anti-anxiety med).
-Morphine Sulfate vial (pain reliever).
-Naloxone injectables (commonly used to treat a drug overdose).
*Located in one of the drawers were several of the blank red Ziploc tags for the staff to replace the broken ones with.

Interview on 2/28/23 at the same time at the above observation with RNs M and D regarding the code cart revealed:
*They:
-Confirmed the cart was used for patients during a critical and lifesaving events.
-Were aware of the meds located inside of the cart.
-Agreed the meds had the potential for harm should they have been accessed used inappropriately.
-Agreed some of those meds were frequently diverted (stolen) for improper use.
-Were unsure what happened with the tray of meds after the cart was opened and if any meds were used.
*They stated:
-"We have house supervisors that works 24/7 and they typically take it."
-"Where it goes after that, not sure."
-"The pharmacy puts the blue tags on the med trays, we don't do that."
-"Not sure how they check on this."
-"No, the pharmacy is not open 24/7 and no one can get in there that we know of when it's closed."
-"Maybe the house supervisors but none of us can."
-"We get our red tags from central supply [CS]. They keep the extra tags down there."
*The CS department had access to the code carts and they would have checked the cart for outdated supplies and restocked them.
*They confirmed:
-The CS department had access to the code carts, the contents inside of it, and the blank red Ziploc tags.
-It would have been easy to open the cart and take any of the contents, that included the meds, and without anyone's knowledge.
*After the code cart was opened, it would have been secured shut with two red blank Ziploc tags.
*To their knowledge, there was no tracking system in place to ensure the security of the meds in the code carts.
*RN M stated:
-"With these red tags, the cart could sit for days before anyone would open it."
-"Meds could be gone for days before anyone would know."
-"There's no way to track the opening and closing of this cart and by who."

2. Observation on 3/1/23 at 7:55 a.m. in the ECT procedure room revealed there was a code cart located by one of the nurse's stations in the area. It was secured shut with two blank and red colored Ziploc tags. The process and form for checking the security and contents in the cart had been the same as the findings observed above.

Interview on 3/1/23 at 8:20 a.m. with RNs K and L regarding the observations of the code cart located in the ECT procedure room revealed:
*The process for checking the carts security and readiness for a critical event had been the same as the one located on Aspen 2.
*They agreed there was no tracking process in place to support:
-When the cart was opened and by whom.
-Why the cart and its contents had to have been accessed.
*They stated:
-"The house supervisors take care of the med trays after the carts opened and if any meds are used."
-"That's when pharmacy is not here to take care of them."
-"The trays are taken to the house supervisor's office until pharmacy is open and they can come get it."
-"We put the red tags on it then. Those other tags are pharmacies."
*There were several departments that had access to the house supervisor's office:
-Security.
-Marking.
-Mail lady.
-Maintenance.

Interview on 3/1/23 at 10:08 a.m. with RN L regarding the code carts revealed:
*She was one of six nursing house supervisors.
*She confirmed the house supervisors were responsible for the med trays in all the code carts after they had been opened and accessed for an emergency situation.
*She stated:
-"After a code we take the trays and either store them in our office until pharmacy is open or just take them back there if they are open."
-"They can sit in our office for hours or days before pharmacy is available to take care of them."
-"There are six house supervisors, we work 12 hour shifts, so there could be several of us in our office between the time we put an opened med tray in there to when it gets to pharmacy."
-"No, they are not locked up in our office. Any house supervisor can take a med if they wanted to."-"That includes those other departments that can get into our office when we are not there."
-"This is not good, but they told me we couldn't store them in the Omnicell because they are dirty."
-"There's a med tray in the Omnicell that we replace the opened ones with."
-"The red tags are stored in central supply. They restock the carts. They need the red tags to put on the carts after they are done restocking them."
*She agreed:
-Unauthorized staff had the capability to access the meds in those trays when it was restocked or stored in the house supervisor's office.
-The process for ensuring the storage of those meds were not secure and left them vulnerable for diversion.

3. Observation and interview on 3/2/23 at 8:15 a.m. with RN E and x-ray technician P in the central supply area revealed:
*In the office area there was a large plastic caddy with several drawers.
*Inside of the top drawer was multiple red Ziploc tags that were blank and looked exactly like the ones on the code carts.
*They confirmed the red Ziploc tags were used to put on the code carts after they had been checked for expired items or restocking after a critical event.
*A nurse would have brought the code cart down after an event to help them restock it.
-The med trays were no longer in the cart at that time.
*There was always a nurse to help with the restocking of the code carts.

Interview on 3/1/23 at 2:05 p.m. with pharmacists H and I regarding the stocking process for the code carts revealed they:
*Had no knowledge of:
-What the process was with the red Ziploc tags on the code carts and the security process for them.
-What staff had access to the code carts and the med trays in them.
*Had been responsible for restocking the med trays in the carts.
*Confirmed:
-After a critical even the house supervisor would have brought the med trays to pharmacy for checking and restocking.
-No one had access to the pharmacy department after hours of operation.
-The pharmacy department was responsible for the Ziploc tags placed on the med trays and would replace them with new ones after they had been accessed.
-The pharmacy had documentation of what number of tray and the numbered Ziploc tags that were on each of the med trays and their location.
-There was no tracking process in place once the Ziploc tags had been removed from the med trays.
-The house supervisors were responsible for the med trays until pharmacy was available to restock them.
*Were not sure, but thought the med trays had been stored in the house supervisor's office when they were not available.
*Relied on verbal communication from the house supervisor on what meds were removed from the trays and from what unit.
*Would not have known who the patient was that required the use of those meds.
*Stated: "Sometimes we know the unit because they announce it."
*Were unaware unauthorized staff had access to the house supervisor's office and that those meds were available for possible diversional activity.
*Would have checked the med trays for the following:
-When outdated meds had been replaced.
-Quarterly to ensure the numbers still matched what they had documented on their forms.
*Agreed:
-The process for tracking the security of the code carts created the potential for diversion of the meds inside those carts.
-The above processes had not ensured those drugs had been stored in a secured manner.
-The pharmacy department was responsible for the management and security of all medications within the hospital.

4. Observation and interview on 3/1/23 at 6:35 a.m. with certified nurse anesthetist (CRNA) J regarding the anesthesia med cart revealed:
*He had just drawn-up the necessary sedating meds for the three patients who were scheduled for an ECT procedure.
*The prepared meds had been placed on top of the anesthesia med cart.
*The med cart had several drawers and contained meds and supplies they might need during the procedure.
*In the top drawer there was a divided tray that contained sedating, paralytic, and heart rate stabilization meds. Some of those meds included:
-Propofol (sedative).
-Succinylcholine (paralytic).
-Atropine (helps increase a low pulse).
*The anesthesia cart required the use of a key to lock and unlock it.
-The key was stored in a magnetic key box attached to the side of the CRNA's anesthesia machine.
*The magnetic key box was easily removed from the machine and the lid slid open and shut without difficulty.
*There was no documentation found to support what meds were in the cart and the accounting of those meds.
*Each patient had their own ECT treatment form that the CRNA, nurse, and physician would document:
-What meds and the dosage the patient used.
-Intravenous location and the type of fluids administered.
-Treatment parameters, vitals, and length of seizure activity.
-Medical progress notes by the physician.
*There was no other document used to support:
-What meds were in the med tray.
-The amount of each med that was in the med tray.
-When they were accessed and by whom.
-When they were secured after being accessed and by whom.
-When expired meds were replaced and by whom.

Observation on 3/1/23 at 8:15 a.m. of the anesthesia med cart in the ECT room revealed:
*CRNA J was nowhere to be found in the ECT procedure area.
*The key for the cart was still located in the key slot and in the unlocked position.
*The cart was unlocked, and the meds were not secured from access by all staff.

Interview on 3/1/23 at the same time as the above observation of the anesthesia med cart with RN K revealed:
*She confirmed the cart was unlocked and the meds inside of it could have been easily accessed.
*She stated:
-"The key is kept in this black magnetic box attached to the anesthesia machine."
-"These meds don't have to be accounted for or locked up."
-"There are no controlled meds in this cart."
*She agreed the meds were used for anesthesia and some of them for sedation.
*She could not see the concern with the meds:
-Not being secured and easily accessed by any staff.
-Being unsecured while the CRNA was not in the area.
*She stated:
-"This has never been a concern before, so why now."
-"These are replaced as needed."

Interview on 3/1/23 at 10:20 a.m. with RN L regarding the anesthesia med cart revealed she:
*Was aware:
-That a key was used to lock and unlock the cart.
-There were meds in the cart that had been used for sedating and paralytic purposes.
*Was not aware:
-The key was stored in an unsecured area and accessible to unauthorized staff.
-There was not accounting process for those meds in the cart.
*Stated:
-"No one should have access to that key and those meds."
-"It needs to be locked up and secured when the CRNA is not by it."
-"Ultimately they [CRNAs] are responsible for that cart and those meds."
-"I thought they had to get the key out of the Omnicell like we do in other areas."
*Agreed:
-All meds were required to have been stored and secured in a manner to prevent unauthorized access.
-There should have been a monitoring process in place to ensure the security of those meds.

Interview on 3/1/23 at 2:45 p.m. with pharmacists H and I regarding the anesthesia med cart revealed:
*They were not involved with the security and monitoring of the meds located in the anesthesia med cart.
*They were not aware of:
-What meds were used by the anesthesia department.
-How the meds the CRNAs used were kept secured and replaced after use.
-How those meds were used by the CRNAs.
*Pharmacist J stated:
-"We were told years ago not to mess with the anesthesia department and their meds."
-"It has been on our radar but never discussed."
*They agreed those meds should have been monitored and secured like all the other meds in the hospital from unauthorized access and possible diversional activity.

Observation on 3/1/23 at 3:10 p.m. of the ECT procedure area and the anesthesia med cart with pharmacists H and I revealed:
*No one was in the area and the nurse's office was open.
-Her office had two doors that allowed for access from the patient waiting area and the procedure room.
*Both nurse's office doors had been opened and we were able to walk into the procedure room without difficulty.
*The anesthesia med cart was locked and the key to unlock it was stored in the black magnetic box attached to the side of the anesthesia machine.
*The cart was able to have been opened with that key and that would have allowed access to those meds by both pharmacists and the surveyor.
*No one else was in the area to ensure the security of those meds.
*They agreed:
-There would not have been a way to audit or track a med from that tray if it had been diverted.
-All meds in the hospital should have been accounted for with limited access to them.

5. Observation on 3/1/23 at 7:26 a.m. to 7:34 a.m. of RN K with patient 1 revealed:
*The patient had tolerated her ECT procedure and the staff were waiting for her to arouse.
*That was the patient's first ECT procedure and it had been difficult for her to agree to the ECT procedure.
*The staff were concerned how her behavior might have been upon awakening from the procedure.
*There had been discussion of giving her Ativan (antianxiety med) intravenously (IV).
*RN K retrieved a 2 milligram (mg) vial of Ativan from the Omnicell (automated med dispensing machine).
-She placed the vial of Ativan on top of the anesthesia med cart.
*At 7:34 a.m. the patient was moved to the recovery area.
*The physician had decided not to order any Ativan for the patient and the vial was never opened.

Continued observation from 7:35 a.m. through 8:15 a.m. of RN K in the ECT procedure and recovery area revealed:
*She had moved the Ativan vial from the anesthesia cart to the nurse's station by the recovery area.
*She left the area and then returned to the procedure area to assist with another patient.
*In the recovery area there had been two mental health associates (MHA).
-They had been waiting for patient 1 to take her back up to the acute care area.
-One MHA was sitting at the nurse's station where the vial of Ativan was located and the other MHA was standing approximately three feet away from it.
*The vial of Ativan remained at the nurse's station and unsecured from access by unauthorized staff through the entire observation period.

Interview on 3/1/23 at 8:20 a.m. with RN K regarding the unsecured vial of Ativan revealed she:
*Had thought the vial of Ativan was still located on top of the anesthesia cart where she had originally placed it.
*Was not concerned that it was left unsecured and left for access and possible diversion from other unauthorized staff members.
*Stated:
-"It's checked out to me in the Omnicell and I plan on returning it when I get a chance."
-"We can do that, return a med."
*Was not aware that two unlicensed and unauthorized staff had access to that vial of Ativan.
*Agreed:
-The vial of Ativan was left unsecured and created the potential for possible diversion of that med.
-The vial of Ativan should have been returned to the Omnicell when it was determined the patient had not required the use of the med.

Interview on 3/2/23 at 8:50 a.m. with administrator A, director of compliance B, and director of nursing C regarding the above observations and interviews revealed they:
*Had not been aware of the concerns for med security, accountability, and monitoring identified through the above observations and interviews.
*Confirmed the vial of Ativan should not have been taken out of the Omnicell until it was ordered by the physician or it should have been returned immediately.
*Agreed:
-The pharmacy department was responsible for the accountability and security of all meds entering and leaving the facility.
-Some of the anesthesia and code meds were considered high-risk for drug diversion and should have been secured with a monitoring and accountability process in place for those meds.
-All meds should have been accounted for with limited access to unauthorized individuals.

Review of the provider's 2016 Pharmacy director's job description revealed:
*Purpose: "Directs the activities of a facility or institution pharmacy unit by dispensing medications, ........... and/or planning and organizing the hospital pharmacy according to hospital policies."
*Functions: "Maintains drug inventory by determining the stock needed, receiving the order, completing inventory cards, and restocking the shelves to ensure the inventory is well-stocked and orderly."
*Knowledge:
-"The regulatory and enforcement procedures in drug areas."
-"State and federal laws and hospital regulations regarding regulation of pharmacy practices."

Review of the provider's undated Code Blue Box policy revealed no documentation to support a process to ensure the meds in those carts had a process in place for the staff to follow to ensure the accountability and security of those meds.

The provider did not have a policy in place to monitor the meds that were used by the anesthesia department to ensure that the potential for drug diversion of those meds had not occurred.

Review of the provider's undated Drug Diversion Prevention policy revealed:
*"It shall be the policy of the SDHSC Pharmacy to institute practices that will prevent and deter drug diversion within the hospital."
*Procedure:
-"It shall be the responsibility of the Director of Pharmacy to institute measures that will deter and prevent and or detect any drug diversion that may occur in this institution."

A. Based on observation, interview, and review of facility's policies and procedures the provider failed to ensure hand hygiene and glove use had been used while performing the following:
*Blood sugar testing for two of two sampled patients (4 and 32) by one of one registered nurse (RN) N.
*Assisting patients during mealtime by one mental health associate (MHA) O. Findings include:

1. Observation on 2/28/23 at 11:30 a.m. with RN N performing blood sugar testing on patients revealed:
*RN N :
-Cleansed patient 4's finger with an alcohol prep pad.
-Had used a lancet to pierce the patient's skin on their finger.
-Obtained a drop of blood for the testing.
*RN N repeated the same process for the blood sugar testing for patient 32.

Interview with RN N following the observations above revealed:
*That was her usual practice to check patient's blood sugars.
*She would usually have used hand sanitizer before and after performing blood sugar testing.
*She agreed that she did not properly sanitizer hands during the above observed procedure.

2. Observation on 2/28/23 at 12:30 p.m. with MHA O assisting patients at mealtime revealed she:
*Had applied a pair of gloves without performing hand hygiene and opened a salsa packet for a patient.
*Removed dirty plates from the dining table and then assisted another patient with those same gloves.
*Removed her gloves and without performing hand hygiene applied a new pair of gloves and then started to remove more dirty dishes.
*Prepared a cup of hot tea for another patient with those same gloves.

Interview with MHA O following the above observation revealed:
*She agreed that she had not performed hand hygiene before and after her glove usage.
*She had received training on hand hygiene with glove usage.

Interview on 3/1/23 at 10:00 a.m. with adult acute nurse manager F regarding the above observations revealed:
*Staff should have been following the policy and procedure for obtaining patient blood sugar tests.
*RN N should have performed hand hygiene before and after glove use when obtaining patient's blood sugars.
*MHA O should have performed hand hygiene before and after glove use.

Interview on 3/2/23 at 9:30 a.m. with administrator A, director of nursing C, and director of compliance and quality B regarding the above observations with RN N and MHA O revealed:
*They all agreed that staff should have been following the facility's policy and procedure for patient blood sugar testing, hand hygiene, and glove use.
*DON C re-enforced that staff had received yearly training on hand hygiene.

Review of provider's undated policy for Blood Sugar Testing revealed:
*"Testing Patients:"
-Gather all equipment.
-Explain the procedure to the patient.
-Perform hand hygiene.
-Put on gloves.
-Insert the test strip into the meter.
-Identify puncture site on finger which should be free from lesion, callouses and edema.
-Clean the patient's finger with a alcohol prep pad and then wipe with a cotton ball or let air dry.
-Prepare lancet device.
-Puncture the site with the lancet.
-Touch the blood drop to the edge of the test strip.
-Apply pressure to puncture site with a cotton ball or dry gauze.
-After blood sugar result has been obtained dispose of the lancet in a sharps container, remove gloves and perform hand hygiene.

Review of provider's undated Handwashing Technique and use of Hand Sanitizers revealed:
*Clean hand before:
-Preparing food, water, or medication.
-Eating.
-Caring for a patient.
-Donning gloves.
*Clean hands after:
-Using the toilet or assisting a patient in using the toilet.
-Handling body secretions.
-Eating and feeding patients.
*Following glove removal.
*Following exposure to any blood or other potentially infectious material even if gloves had been worn.




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B. Based on observation, interview, and record review, the provider failed to ensure hinged surgical instruments were sterilized in the open position. The hinged surgical instruments such as scissors and forceps were sterilized in the closed and locked position not allowing for the steam to have contact with every surface. Findings include:

1. Observation and interview on 3/7/23 at 11:30 a.m. with X-ray technician P revealed:
*All observed hinged surgical instruments had been sterilized in the closed position. Scissors were closed. Forceps were closed and locked.
*She was an X-ray tech. She had no formal training in sterile processing. Her training had come from hands on training with an employee who no longer was employed by the provider.
*She had been trained by the previous employee to close the hinged instruments.
*She had been "filling in" doing the sterile processing for about eight months.
*She had been trained by the previous employee to close the hinged instruments.

2. Record review and interview, on 3/7/23 at 12:15 p.m. with the director of infection control G, clinical support nurse manager E, and X-ray technician P revealed:
*They all agreed the hinged instruments should have been in the open position for sterilizing.
*Director of infection control G had conducted a "Instrument Cleaning, Wrapping/Packaging, and Sterilization COMPETENCY" with x ray technician P on 2/10/23.
-X-ray technician P had passed the competency.
-The "Peel Pack/Pouch" section, item 2. stated "all instruments must be in the open position or disassembled to their smallest parts" was marked as passed.
*Director of infection control G and clinic support nurse supervisor E had not observed the sterile processing for quality control.
-The only time sterilization was observed was during the competency.
*Director of infection control G had completed occasional checks on the instruments in the clinic, but there was no documentation to verify that had been done.

3. Review of the policies provided in regard to cleaning and sterilizing surgical instruments: At the time of the survey there was no policy identified that addressed sterilizing hinged instruments in the open position.