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Based on observation, interview, and record review, the provider failed to ensure one of one sampled critical care unit (CCU) patient (26) had appropriate physician's orders for the use and care of an oral gastric tube. Findings include:

1. Observation on 7/24/12 at 3:30 p.m. of patient 26 in his CCU room revealed:
*He had an oral gastric tube placed next to his endotracheal tube. That oral gastric tube was connected to wall suction.
*The suction level for that oral gastric tube was set at the high level.
*The suction control was set on the continuous mode.
*The canister of the suction unit was partially full of a green substance.

Interview and record review on 7/24/12 at 4:05 p.m. with registered nurses A and B regarding patient 26 revealed:
*The oral gastric tube had been placed by a physician at the time the patient was intubated on 7/23/12.
*The patient's record contained no orders for the use or care of the oral gastric tube.
*They agreed physician's orders should have been present for the oral gastric tube use and care.
*They agreed nursing staff should have noticed and sought physician's orders for the oral gastric tube.
*They confirmed oral gastric tubes connected to suction would normally have been connected to low intermittent suction not the high continuous suction. Neither nurse had been able to explain why the oral gastric tube was connected to high continuous suction.

Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed., St. Louis, MO., 2005, p. 419, revealed if appropriate physician's orders are not present for the care of a patient, nursing staff are obligated to seek those orders.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled critical care unit (CCU) patient (26) had a care plan that had been developed and revised to reflect the patient's current care needs. Findings include:

1. Observation on 7/24/12 at 3:30 p.m. and on 7/25/12 at 8:00 a.m. of patient 26 in his CCU room revealed he:
*Was intubated and on the ventilator.
*Had a Foley urinary catheter.
*Had intravenous fluids running.
*Was sedated with a continuous intravenous drip of Diprivan.
*Was in bilateral soft wrist restraints.
*Had an oral gastric tube.

Interview, record review, and care plan review on 7/25/12 at 8:00 a.m. with registered nurse (RN) B regarding patient 26 revealed:
*His current care plan only addressed his respiratory status and skin integrity.
*He had been receiving Fentanyl for pain relief for the prior two days.
*The registered dietitian had seen him on 7/24/12 during the evening and had recommended tube feeding.
*No care planning had occurred for the following areas:
-Restraints.
-Pain.
-Sedation.
-Fluid volume.
-Nutrition/oral gastric tube care and use.
*RN B agreed the patient's care plan was incomplete and had not been properly developed and revised to reflect the patient's current care needs.

Review of the provider's 6/1/12 documentation system policy revealed:
*Care plans were to have been initiated and updated throughout the stay as needed.
*The care plan should have reflected the individual care needs of the patient.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled pediatric same day surgery patient (9) received a medication according to accepted medication administration standards of practice. Findings include:

1. Review of patient 9's 7/24/12 medication administration record revealed she was to receive a one time albuterol nebulizer treatment prior to surgery.

Observation on 7/24/12 at 9:00 a.m. of respiratory therapist (RT) C who prepared and administered the above medication to patient 9 revealed:
*RT C acquired the albuterol solution from the automated medication dispensing system in the pre-operative area.
*RT C proceeded to the patient's room where he prepared the nebulizer with the albuterol. He then administered the albuterol to the patient. At no time did RT C ask for the patient's name or check the patient's identification bracelet.
*At the conclusion of the medication delivery RT C completed no documentation in the medication administration record or patient notes to indicate he had completed the medication delivery.

Interview and record review on 7/24/12 at 9:17 a.m. with RT C revealed he confirmed:
*He had not followed accepted medication administration standards of practice or the provider's policy for proper medication administration.
*It was imperative for patient safety to properly identify the patient, verify the physician's order at the patient's bedside, and document the administration of the medication after the administration had been completed.

Review of the provider's 3/20/12 medication, prescribing, and administration policy revealed:
*The standard five rules for safe medication administration correct patient, correct medication, correct time, correct dose, and correct route should have been followed at all times.
*"The medication administration record, respiratory care flow sheet, IV flowsheet, home/current medication reconciliation navigator and/or progress notes will be used to document medications."

Based on observation, interview, and policy review, the provider failed to ensure:
*Appropriate hand hygiene was completed in the pre-operative, intra-operative, and post-operative areas of the facility.
*One of one pediatric same day surgical patient's (9) intravenous catheter (IV) was inserted in a hygienic manner.
*One of one observed surgical room was properly disinfected between surgical cases.
Findings include:

1. Observations on 7/24/12 from 8:15 a.m. through 9:20 a.m. of patient 9's care in the pre-operative area revealed:
*Physician D entered the patient's room and performed a pre-anesthesia physical examination without performing hand hygiene. Physician D then left the patient's room without performing hand hygiene and proceeded on to see other patients in the pre-operative area.
*Child life specialist E entered the patient's room without performing hand hygiene. She then exited the room without performing hand hygiene after having direct contact with the patient.
*Respiratory therapist C never performed hand hygiene prior to preparing or administering a nebulizer treatment to the patient.

2. Observations on 7/24/12 from 10:30 a.m. through 11:15 a.m. of patient 9's care in the intra-operative and post-operative areas revealed:
*Physician D had not performed hand hygiene prior to or after the insertion of the patient's IV.
*Physician D inserted the IV needle into the patient's right hand and was unable to ascertain access to the patient's vein. He then proceeded to withdraw the IV needle and reused it again in the same hand to gain IV access.
*Physician F entered the operating room, handled multiple pieces of equipment, and repositioned the patient and operating table. Physician F then proceeded to walk over to the operating table where he gloved and gowned without performing any form of hand hygiene.
*After surgery physician F removed his contaminated gown and gloves and proceeded to handle equipment including the computers used by all of the operating room staff.
*After leaving the operating room physician F was noted going to the post-operative area where he was observed handling equipment and paperwork.

3. Observations and product label review on 7/24/12 from 11:10 a.m. through 11:30 a.m. of patient 9's operating room cleaning after surgery revealed:
*Staff were using a quaternary product to clean the operating room table and other surfaces.
*Staff applied the quaternary product to surfaces via a squirt bottle. They then wiped those surfaces with a cloth towel. The observed surfaces stayed wet with the quaternary solution for less then one minute after staff wiped them down.
*The manufacturer's recommendations for the quaternary product called for a wet contact/dwell time of ten minutes to ensure proper disinfection.

4. Interview on 7/24/12 at 2:30 p.m. with the director of cardiovascular services and the director of surgery confirmed:
*Appropriate hand hygiene had not occurred in the pre-, intra-, and post-operative areas as noted in findings 1 and 2.
*The quaternary product used in the disinfection process of the operating room was not used as directed by the manufacturer.

Interview on 7/25/12 at 9:30 a.m. with the chief nursing officer confirmed:
*The use of the same IV needle twice was not acceptable practice and was a breach of the provider's infection control practices.
*She agreed with the statements in the above interview.

Review of the provider's March 2012 policies on hand hygiene, cleaning of the operating room, gowning and gloving of the surgical team, and patient with peripheral intravenous therapy revealed:
*Hand hygiene should have been conducted prior to and after each procedure or patient contact.
*Disinfectant manufacturer's labels should have been followed to ensure proper disinfection.
*IV catheters were a single use item.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled pediatric same day surgery patient (9) received a medication according to accepted medication administration standards of practice. Findings include:

1. Review of patient 9's 7/24/12 medication administration record revealed she was to receive a one time albuterol nebulizer treatment prior to surgery.

Observation on 7/24/12 at 9:00 a.m. of respiratory therapist (RT) C who prepared and administered the above medication to patient 9 revealed:
*RT C acquired the albuterol solution from the automated medication dispensing system in the pre-operative area.
*RT C proceeded to the patient's room where he prepared the nebulizer with the albuterol. He then administered the albuterol to the patient. At no time did RT C ask for the patient's name or check the patient's identification bracelet.
*At the conclusion of the medication delivery RT C completed no documentation in the medication administration record or patient notes to indicate he had completed the medication delivery.

Interview and record review on 7/24/12 at 9:17 a.m. with RT C revealed he confirmed:
*He had not followed accepted medication administration standards of practice or the provider's policy for proper medication administration.
*It was imperative for patient safety to properly identify the patient, verify the physician's order at the patient's bedside, and document the administration of the medication after the administration had been completed.

Review of the provider's 3/20/12 medication, prescribing, and administration policy revealed:
*The standard five rules for safe medication administration correct patient, correct medication, correct time, correct dose, and correct route should have been followed at all times.
*"The medication administration record, respiratory care flow sheet, IV flowsheet, home/current medication reconciliation navigator and/or progress notes will be used to document medications."