HospitalInspections.org

Based on observation, interview, and record review, the hospital failed to obtain adequate informed consents for three of 31 sampled patients (28, 44 and 45). This has the potential for the patients or the patients' responsible parties to be unaware of potential risks versus benefits of a proposed treatment prior to consent to the treatment.

Findings:

1. During an interview and review of the clinical record of Patient 28 on 2/17/16, at 9:30 AM, the admission record documented she was re-admitted to the sub acute care unit on 1/27/16. It was noted she signed her hemodialysis (a treatment in which a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this adequately) consent on 1/27/16. It was illegible, but the nurse who witnessed it (Registered Nurse [RN] 7) stated she had obtained Patient 28's signature indicating informed consent. There was another consent for Prozac (antidepressant medication), dated 1/27/16. The signature for the antidepressant consent was different from the markings on the hemodialysis consent. RN 7 stated, "The physician signed that one."

During an observation and interview on 2/17/16, at 10 AM, Patient 28 was lying in bed, breathing with a ventilator (breathing machine) connected to a tracheotomy (a surgically created hole through the front of a person's neck to the windpipe [trachea] which provides an air passage to help a person breathe and is often needed with long term ventilator use) and formula connected to Patient 28's feeding tube (a tube that is placed either through the nose and passed through the windpipe down to the stomach or directly to the stomach to provide liquid nutrition). Patient 28 did not wake up when spoken to. During another observation of Patient 28 with RN 7 and Licensed Vocational Nurse (LVN) 1 at 11:15 AM, RN 7 physically touched the patient and encouraged her to answer questions. Patient 28's speech was difficult to understand and what could be understood did not seem to make a sentence. RN 7 was unable to identify what Patient 28 said with the approximately 6-8 words spoken.

During a review of the clinical record of Patient 28, a son was listed by name and a telephone number documented. The Minimum Data Set (MDS, an assessment tool) identified Patient 28's cognitive (ability to think, remember, and understand the environment) status on 9/3/15, as "Severely impaired--never/rarely made decisions." The MDS assessment dated 12/4/15, identified her cognitive status as severely impaired. RN 7 was asked if there was a re-assessment upon admission on 1/27/16. RN 7 stated, "No. Because she hadn't changed." RN 7 was asked if Patient 28's son could give consent. She replied, "The son doesn't return phone calls. Sometimes he's in jail. That's why he doesn't give his consent." RN 7 was asked how she could assess this patient in regards to obtaining an informed consent. RN 7 stated, "I talk to her and she seems to understand. Sometimes we can read her lips."

The hospital policy and procedure titled "Consent/Informed Consent" dated 1/2014, indicated: "...Policy:..1. Capacity to Consent. A person may give a valid consent only if he or she has 'capacity' which means he or she is able to understand the nature and consequence of a decision and to make and communicate the decision... If an adult lacks the capacity to make medical decisions, a surrogate decision-maker must be identified... iv. The hospital will establish a multi-disciplinary committee as a subcommittee of the Ethics Committee and delegate to it responsibility for acting as a surrogate decision-maker for patients who have no surrogate decision-maker... 4. 'Informed Consent' is required for those procedures which are complex or involve material risks that are not commonly understood. The patient's physician is responsible for providing the information the patient needs in order to make an informed decision and for obtaining the patient's informed consent or refusal for the recommended procedure. The hospital's role in the informed consent process is to verify that the physician obtained the patient's informed consent before the physician is permitted to perform the procedure..."



21905

2. During a review of the clinical record for Patient 44 and interview with LVN 3, on 2/17/16, at 9:04 AM, the clinical record indicated the patient was admitted on 2/15/16, with an abscess to the left lower extremity. The History and Physical dated 2/15/16, indicated the patient arrived to the Emergency Room (ER) with severe pain and redness to the posterior thigh. The "Assessment and Plan" section indicated the patient had an abscess of the left posterior thigh and a status post incision and drainage (I & D is a minor surgical procedure using a sharp instrument to release the pus and pressure built up under the skin caused by an abscess) was performed to the site. The nursing note dated 2/17/16, at 9:29 AM, read, "Received pt (Patient 44)...Admitting Dx (Diagnosis): cellulitis & abscess on left upper leg...ER nurse stated that pt had I & D at ER..." There was no informed consent noted in the clinical record indicating the physician had described the potential risks and benefits of the treatment prior to performing the I & D to the patient's abscess site. LVN 3 confirmed there was no informed consent obtained prior to the procedure, although there should have been one obtained.

3. During an observation on 2/17/16, at 9:44 AM, in the Intensive Care Unit, Patient 45 was observed with a tracheostomy attached to a ventilator.

During a review of the clinical record and interview with LVN 3, on 2/17/16, at 10 AM, an informed consent document was noted for the tracheostomy placement signed on 2/11/16. The document was incomplete which was confirmed by LVN 3. No additional information was provided.

The hospital policy and procedure titled "Consent/Informed Consent" dated 1/2014, indicated under the POLICY subheading, "...4. Informed Consent is required for those procedures which are complex or involve material risks that are not commonly understood. The patient's physician is responsible for providing the information the patient needs in order to make an informed decision and for obtaining the patient's informed consent or refusal for the recommended procedure. The hospital's role in the informed consent process is to verify that the physician obtained the patient's informed consent before the physician is permitted to perform the procedure..." Also under the subheading titled, Documenting Informed Consent it reads in part, "The doctor will complete the information in the Consent...form or provide the information... The patient's physician must document in the patient record that he or she has conveyed the information required for an informed decision..."



27137

Based on observation, interview and record review, the hospital failed to ensure:

1. One sampled patient who was waiting in the hallway on an ambulance gurney for a bed in the Urgent Care for 4 hours to receive a nursing re-evaluation or check during his wait. (Refer to A 395, item 1)

2. Five call lights were observed not functioning (Room 111C, 111D, 111F, 111G, 105A) as intended and three call lights were not accessible for the patients to use in Room 111B, 110B, and 110C. (Refer to A 395, item 2)

3. The physician's orders were followed for two sampled patients. (Refer to A 395, item 3)

4. Nursing was aware of the hospital's policy for the crash cart and ensure one crash cart contained all the contents listed. (Refer to A 395, item 4)

5. Pertinent, individualized nursing care plans were developed for 12 sampled patients. (Refer to A 396)

6. One registered nurse was oriented to the emergency department (ED) when she was transferred there from another department. (Refer to A 397)

7. Adequate supervision was provided to one contracted nursing personnel. (Refer to A 398)

The cumulative effects of these systemic failures resulted in the hospital's inability to ensure adequate nursing care to meet the needs of the patients.



27137

Based on observation, interview, and record review, the registered nurses failed to ensure there was adequate supervision when:

1. One of 31 sampled patients (27) was waiting in the hallway on an ambulance gurney for a bed in the Urgent Care for 4 hours with no nursing re-evaluation or check during his wait. This had the potential to result in medical conditions to go untreated.

2. Five call lights were observed not functioning (Room 111C, 111D, 111F, 111G, 105A) as intended and three call lights were not accessible for the patients to use in Room 111B, 110B, and 110C. This had the potential for the patients to be unable to call for required assistance.

3. The physician's orders were not followed for two of 31 sampled patients (38 and 45). This had the potential to result in untreated medical conditions which could result in an overall decline in the patients.

4. Nursing was unaware of the hospital's policy for the crash cart and one crash cart did not contain all the contents listed. This had the potential to result in the emergency personnel to be unaware of the contents and to ensure the crash cart contained all the emergency contents.

Findings:

1. During an observation and interview on 2/16/16, at 9 AM, Patient 27 was noted to be lying on an EMT (emergency medical technician) gurney in the hallway directly outside Urgent Care. An ambulance attendant (EMT 1) was sitting next to him. EMT 1 stated he brought Patient 27 to the hospital about 5 AM. and they have been waiting for a bed in the Urgent Care. EMT 1 stated no nurse has re-evaluated Patient 27 or taken the vital signs (blood pressure, pulse, temperature) since their arrival.

During an observation and record review on 2/16/2016, at 9:40 AM, the Chief Nursing Officer (CNO) assisted EMT 1 to bring Patient 27 into the Urgent Care. Patient 27's medical record was reviewed and it documented that vital signs had been taken at 5:45 AM and not repeated until 9:30 AM. The registered nurse in charge of the Urgent Care (RN 6) stated patients who were waiting for a bed in the Urgent Care should have their vital signs taken every two hours.

The hospital policy and procedure titled "Triage Treatment Protocols and Admission in the Emergency Department", dated 3/2014, indicated: "....2.12 It is the responsibility of the RN to continually reassess the status of those patients who are awaiting disposition to the treatment area ...."



21905

2a. During an observation and interview with the RN 25 (the charge nurse for the medical surgical unit) and the Certified Nursing Assistant (CNA) 1 on 2/16/16, at 11:46 AM, Room 111 was noted with eight patients. Patient 39 (Room 111) was observed lying in bed G with CNA 1 next to his bed. The patient appeared confused and the call light button was not observed within reach of Patient 39. CNA 1 indicated she removed the call light from the patient because "he is always on it" but he did have it earlier. CNA 1 and RN 25 proceeded to search for the call light. When the call light button was found, the cord was cut at the level of the wall; therefore, could not be accessible for Patient 39 to use. Patient 39 was approximately 2 feet from the call light. RN 25 stated CNA 1 is the assigned staff to care for Patient 39. She was asked how the nurse call system works. She stated the nurse call system includes a button at the wall with a cord that has the call light attached to it. The cord with the call light attached is what is provided to the patient. When the patient presses the red call light, it should be audible and visible above the patient room door and at the nurse's station.

During a review of the clinical record for Patient 39 and interview with RN 22, on 2/16/16, at 2 PM, the admitting diagnoses included: Altered Mental Status (AMS), Hypertension (high blood pressure), Diabetes Mellitus (a disease which results in the body's inability to produce enough insulin which results in elevated sugar levels), Abnormal Gait, Dementia and Convulsions. The care plan problem list included a care plan for patient's risk for harming himself, a care plan for pain and a care plan of fall. The fall care plan included an intervention which indicated, "...call bell within reach..."

2b. During an observation of Room 111 Bed B with RN 25, on 2/16/16, at 11:50 AM, the call light was not noted accessible to Patient 42 who was lying in bed. RN 25 proceeded to search for the call light, which was found on the floor.

During a review of the clinical record for Patient 42 with RN 22 and the Assistant Chief Nursing Officer (ACNO), on 2/16/16, at 2:50 PM, the patient was admitted on 2/11/16 with admitting diagnoses of Gastrointestinal (relating to the stomach or intestines) Bleed, Gastric Cancer and Anemia (a condition where you do not have enough healthy red blood cells to carry adequate oxygen to the body's tissue which can can cause weakness, fatigue and dizziness). Additional diagnoses included Failure to Thrive (FTT used to define faultering weight to indicate insufficient weight gain), nausea and vomiting, Schizophrenia (mental disorder), Diabetes, Gastritis (inflammation of the lining of the stomach), and Gastroesophageal Reflux Disease (a chronic digestive disorder which results in the stomach acid to flow back up through the food pipe [esophagus]). The care plan list was reviewed and there was a care plan which addressed his fall risk with an intervention to assist the patient from falling included "...call bell within reach..." A care plan was also developed due to the patient being harmful to himself due to the patient being impulsive and wandering tendencies and an intervention to assist the patient from harming himself is to "ensure safe environment".

2c. During an observation of Room 111 Bed C with RN 25, on 2/16/16, at 11:50 AM, Patient 43 was observed lying in bed. The call light was non functioning with no audible sound above the room door or at the nurse's station.

During a review of the clinical record for Patient 43 with RN 22 and the ACNO, on 2/16/16, at 3:20 PM, the patient was admitted on 2/14/16 with diagnoses of Mysitis (inflammation and degeneration of the muscle tissue), difficulty walking, and diabetes. A care plan problem was noted for fall risk with an intervention which included "call bell within reach".

2d. During an observation of Room 105 Bed A with RN 25, on 2/16/16, at 12 PM, Patient 41 was observed sitting at the edge of the bed with a lunch tray on the bedside table. When the call light was pressed to determine if it was functioning as intended, the call light was not audible or visible above the room door or at the nurse's station. Patient 41 stated, she thought the call light was broken when she called last night and no one came.

During an interview with Patient 41, on 2/16/16, at 1:38 PM, she stated she used the call light last night to get assistance to the bathroom. Patient 41 was asked how long she waited, but she was unsure. When no one came to her room, she walked to the door to ask for assistance. She said she used the call light again today to ask for a brief, but RN 22 entered the room as she was using her call light.

During a review of the clinical record for Patient 41 with RN 22 and the ACNO, on 2/16/16, at 2:40 PM, the patient was admitted on 2/14/16 for complaints of abdominal pain. The care plan problem list was reviewed and it included a fall care plan. The interventions included "...call bell within reach..."

2e. During an observation of Patient 40 with RN 25, on 2/16/16, at 11:55 AM, in Room 110 Bed C, the patient was observed lying in bed. A call light to contact the nurse was not noted within reach of the patient. The patient was asked if she had a call light that could be used to call the nurse. As she felt around her bed, she was unable to locate a call light. She stated she was unable to see due to being "Legally Blind and (having) Macular Degeneration (an eye disease that progressively causes severe vision loss)". RN 25 proceeded to feel around the bed for the call light, which was then given to the patient. After being given the call light, Patient 40 proceeded to demonstrate she could use the call light.

During a review of the clinical record of Patient 40 and interview with RN 25, on 2/16/16, at 2:15 PM, Patient 40 was admitted on 2/15/16. The care plan list was reviewed. A care plan was developed for the patient's fall risk due to her age, and unfamiliar environment. An intervention for the fall risk care plan included "call bell within reach..."

2f. During an observation of the Medical Surgical unit with RN 25, on 2/16/16, at 11:46 AM to 11:55 AM, in addition to the above call light issues, the following was noted:

Room 111 Bed F, the call light cord which extended to the patient, had no button at the end of the call light cord to use; therefore, the call light could not be used as intended.

Room 111 Bed D, the call light was non functioning with no audible sound above the room door or at the nurse's station.

Room 110 Bed B, the call light was on the bedside table and not accessible to the patient.

During an interview with RN 25, on 2/16/16, at 11:50 AM, she was asked how long have the call lights not been functioning as intended. She stated, they have not been working "on and off" but did not indicate a specific time frame. She was asked the process when repair of equipment, such as the call lights, is required. She stated, a "work order is generated" which goes directly to the maintenance/engineering department. She was not certain whether a work order request was generated and sent to the maintenance/engineering department for the nonfunctioning call lights.

During an interview with Engineer Staff 1, on 2/16/16, at 11:52 AM, he stated the maintenance department was aware of the nonfunctioning call lights in Room 111, but the call lights have been on back order for approximately six days. He stated they have no extra call lights available for patient use.

During an interview with the ACNO, on 2/16/16, at 1:33 PM, she stated, "I didn't know (referring to being aware the call lights have not been working)." She indicated the problem should have been brought to her attention and was not. She was asked to provide the policy and procedure for the nurse call system and the nurses' responsibility. During a subsequent interview with the ACNO, on 2/16/16, at 3:26 PM, after reviewing the hospital's policies and procedures, she stated they had no policy and procedure for the nurse call system/call light system and the nurses' responsibility.

During an interview with Director of Plant Operations, on 2/16/16, at 1:40 PM, he stated ES 1 informed him of the nonfunctioning call lights. He was informed the call lights have not been functioning for 1 to 1 1/2 weeks. Because he did not know the type of call lights to order from the vendor, no call light replacements had been ordered. He acknowledged there was no work order request for the nonfunctioning call lights for Room 111 or 105.

The hospital policy and procedure titled, "Reporting malfunction" effective date 6/15/09, indicated in part, "Equipment Malfunctions - Patient Care Equipment...When a malfunction is evident, the following steps should be taken...Double check procedure techniques to ascertain whether there is a true malfunction... If the malfunction continues to occur, call the Engineering department and inform them of the problem..."

3a. During a review of the clinical record for Patient 38, with RN 25, on 2/16/16, at 10:36 AM, the patient was admitted with diagnoses of cellulitis to the left foot and right big toe wound. In addition he was diagnosed with Diabetes with a physician's order to monitor blood sugars AC&HS (before each meal and at hour of sleep) and administer insulin as needed depending on the blood sugar results. A review of the blood sugar results in the clinical record showed the blood sugars were not monitored as ordered. RN 25 confirmed the blood sugars were not monitored as ordered. No further information was provided.

3b. During a review of the clinical record for Patient 45 and interview with Licensed Vocational Nurse (LVN) 3, on 2/17/16, at 9:30 AM, the physician's orders were noted. A physician's order dated 2/1/16, for nasogastric tube (NGT) feeding (a flexible tube that is passed through the nose to the stomach to provide nutrition for patients who are unable to take sufficient nutrition orally) at 45 cc/hr (cubic centimeters per hour) was noted. In addition to the order for the liquid nutrition to be taken via the NGT, there was an order for 200 cc's of water every six hours for a total of 800 cc's/24 hr of water daily. From 2/10/16 to 2/16/16, there was insufficient documented evidence the additional 800 cc's of water were provided as ordered. LVN 3 validated the findings.

3c. During a review of the clinical record for Patient 45 and interview with LVN 3, on 2/17/16, at 9:30 AM, the physician's orders were noted. A physician's order was noted to notify the physician if the blood sugar result was less than 60 milligrams per deciliter (mg/dl). On 2/15/16, at 6 PM, the blood sugar was 58 and there was no documented evidence the physician was notified. No further evidence was provided.

4a. During an observation in the emergency room, on 2/16/16, at 9 AM, with RN 26 (Nursing Supervisor), ACNO, and RN 16, the adult crash cart was noted with a red lock on it. A list of the contents was requested. RN 16 and RN 26 stated there is no list of contents, each drawer has a sticker with the list of contents on the sticker. The font size of the content sticker was difficult to read. On the top of the crash cart a sticker read "top of cart to side" included the ambu-bag. After searching for the ambu bag it was noted on another crash cart. The third drawer's sticker was partially torn off making it difficult to determine the exact contents of the third drawer. At 9:12 AM, the pediatric cart was observed. The pediatric crash cart had nine drawers with each drawer secured with blue plastic lock. It also had each drawer with a sticker indicating the contents inside the drawer. The bottom drawer of the cart indicated there was a "Medication Tray" and 2 IV (intravenous) start kits, 2 - extension sets, 2 - tuberculin syringes, 2 - 5 cc syringes, IV catheters including 2 - 24 gauge (g), 2 - 20 g, 2 - 22 g, 2 - 18 gauge. There were no IV start kits, no extension sets, no tuberculin syringes, no 5 cc syringes, no IV catheters of any size. This was validated by RN 26 and the ACNO. RN 26 stated, maybe it was mislabeled. When RN 26, was asked what happens to ensure the contents of the crash carts gets restocked and what happens to secure the contents of the crash carts until they are restocked. She stated the adult crash cart is secured after the central supply staff restocks it. The central supply staff places a green plastic lock which notifies staff it is ready for pharmacy to secure it and is ready and is fully stocked. She was unable to indicate what happens to the pediatric crash cart when the cart is opened to ensure it is secured until the contents are restocked. RN 26 stated, "once opened no way to secure..."

4b. During an observation and interview with ACNO and RN 28 (Charge Nurse to the Intensive Care Unit [ICU] and the telemetry unit), on 2/16/16, at 9:54 AM, an adult crash cart was noted in the telemetry hallway. The crash cart also had a sticker on each drawer identifying the content of each drawer. RN 28 was asked the process when the items in the crash cart are used. RN 28 stated, if the crash cart is opened there is no means to secure the contents including the emergency medications inside it. RN 28 stated, she would call the pharmacy to refill it. The policy and procedure for the crash cart was requested from ACNO.

The hospital policy and procedure titled, "CRASH CART", undated, indicated, "To ensure the availability of appropriate medications and supplies to effectively resuscitate a cardiac or respiratory arrest patient. Each crash cart shall contain a standardized binder, which includes a crash cart content list... A process shall be employed that ensures drug security, control and the availability of drugs identified by the Medical Staff for emergency use... To ensure that crash carts are standardized throughout the department and the facility... All crash carts shall be sealed with a tamper resistant red breakaway lock and assigned a log number... Crash carts will be open in a Code blue situation... Any time that a crash cart is opened, it will be replaced with a fully stocked cart by central supply staff/ designees, and will be Locked by Pharmacy staff after medication tray is added. Then the cart will be returned to the unit... Immediately after the code, The Nursing Supervisor shall notify Central Supply and a fully restock replacement crash cart will be delivered to the patient care area..."

Based on observation, interview and record review, the hospital failed to have pertinent, individualized nursing care plans for 12 of 31 sampled patients (29, 30, 38, 40, 42, 45, 47, 48, 49, 51, 52, 55). This had the potential that patients would not receive necessary care or have unmet care needs.

Findings:

1. During an interview and review of the clinical record for Patient 29 on 2/17/16, at 8:45 AM, the consents and admission paperwork were in Spanish. The charge nurse, Registered Nurse (RN) 8, stated he only spoke Spanish. Several care plans (anxiety, safety, hemodialysis) care plans were reviewed. There was no notation that Patient 29 only spoke Spanish on any care plan. RN 8 and Licensed Vocational Nurse (LVN) 1 confirmed this.

2. During an interview and review of the clinical record for Patient 30 on 2/17/16, at 10 AM, he was admitted on 2/12/16. One of his diagnoses was influenza and isolation was ordered on 2/13/16. Patient 30's care plans were reviewed (safety, respiratory, anxiety). None of his care plans addressed Patient 30 was on isolation.

The hospital policy and procedure titled "Care Plan, Patient Interdisciplinary Plan of Care", dated 11/2012, indicated: "Policy Purpose To provide each patient with an individual interdisciplinary plan of care that is collaborative and goal directed... A care plan outlines the care to be provided to an individual/family patient. It is a set of actions the care provider will implement to resolve/support nursing diagnoses identified by nursing assessment...that will include patient's admitting problems....needs, or other condition..."



21905

3. During a review of the clinical record for Patient 38, with RN 25, on 2/16/16, at 10:36 AM, the patient was admitted with diagnoses of cellulitis (bacterial skin infection) to the left foot and right big toe wound. There was no individualized care plan for the treatment to the left foot or an individualized care plan for the treatment of the right big toe.

During an observation of Patient 38 and interview with RN 26 (the treatment nurse), on 2/16/16, at 11:30 AM, Patient 38's right and left foot wounds were noted. The left fourth toe was uncovered and blackened. The inner portion of the right big toe was reddened. A review of the care plans was conducted and there was one care plan problem that was not specific to either the left foot or right foot. RN 26 stated, there should be two care plans to outline the care of each of the identified areas since they require different treatment interventions. No additional information was provided.

4. During an observation of Patient 40 with RN 25, on 2/16/16, at 11:55 AM, in Room 110 Bed C, the patient was observed lying in bed. A call light to contact the nurse was not noted within reach of the patient. The patient was asked if she had a call light that could be used to call the nurse. As she felt around her bed, she was unable to locate a call light. She stated she was unable to see due to being "Legally Blind and (having) Macular Degeneration (an eye disease that progressively causes severe vision loss)". RN 25 proceeded to feel around the bed for the call light, which was then given to the patient. After being given the call light, Patient 40 proceeded to demonstrate she could use the call light.

During a review of the clinical record of Patient 40 and interview with RN 25, on 2/16/16, at 2:15 PM, Patient 40 was admitted on 2/15/16. The care plans were reviewed, and there was no care plan to ensure staff were aware of the patient's vision impairment and to ensure staff would implement the care needs of the patient with vision impairment. RN 22 verified the findings.

5. During a review of the clinical record for Patient 42 and interview with RN 22, on 2/16/16, at 2:50 PM, the admitting diagnosis included diabetes mellitus. The physician's orders indicated he was being treated with regular insulin based on the results of the routine fingersticks. The care plans were reviewed and there was no care plan for the diabetes mellitus to ensure staff were aware of appropriate interventions to treat the problem.

6. During a review of the clinical record for Patient 45 and interview with Licensed Vocational Nurse (LVN) 3, on 2/17/16, at 9:30 AM, the physician's orders were noted. A physician's order dated 2/1/16, for nasogastric tube (NGT) feeding (a flexible tube that is passed through the nose to the stomach to provide nutrition for patients who are unable to take sufficient nutrition orally) at 45 cc/hr (cubic centimeters per hour) was noted. The care plan problems for the patient were reviewed. The nutrition care plan included interventions for a patient who was receiving a diet orally and not a diet provided via a nasogastric tube. Documented interventions after the NGT was placed for nutrition included: "demonstrates appropriate selection of meals...eating in response to internal cues other than hunger...encourage water intake..." LVN 3 acknowledged these were not appropriate interventions for a patient receiving NGT feeding. No additional information was provided.

The hospital policy and procedure titled, "CARE PLAN, PATIENT INTERDISCIPLINARY PLAN OF CARE POLICY AND PROCEDURE" effective date 12/2015, indicated the purpose of the care plan is "To establish guidelines for the initiation of Interdisciplinary plan of care for each patient admission...A care plan outlines the care to be provided to an individual/family/patient. It is a set of actions the care provider will implement to resolve/support nursing diagnoses...The plan of care will be based on the assessed needs of the patient and will include goals, problems/needs, proposed intervention(s), expected outcomes..."



27137



30719



32233

7. During an observation with RN 22, on 2/16/16, at 9:32 AM, in the patient's room, Patients 47 and Patient 48 were in bed with the head of the bed elevated at 45 degree angle. Patient 47 had a GT (Gastrostomy tube- a tube that has been surgically inserted in the stomach for the introduction of nutrient solution) formula of Fibersource HN (a nutritionally complete tube feeding formula with fiber) at 50 ml/hr (milliliter per hour). Patient 48 had a GT formula of Pulmocare (a therapeutic nutrition for people with COPD [chronic obstructive pulmonary disease], cystic fibrosis or respiratory failure patient) at 50 ml/hr. Patient 47 and Patient 48's GT tubing were not labeled and dated.

During an interview with RN 22, on 2/16/16, at 9:35 AM, she stated Patients 47 and 48 were unable to communicate because of their medical condition. RN 22 also stated she was unable to determine Patient 47 and 48's tubing for the formula were new or old.

During a review of the clinical record for Patient 47, the Physician's Order dated 1/1/16, indicated Patient 47 to receive a Fibersource HN at 50 ml/hr by Gastrostomy tube. During further review of the clinical record, the nutrition care plan did not indicate Patient 47 was receiving formula through GT.

During a review of the clinical record for Patient 48, the Physician's Order dated 2/1/16, indicated Patient 48 to receive Pulmocare at 50 ml/hr for 20 hours through GT. During further review of the clinical record, the nutrition care plan did not indicate Patient 48 was receiving formula through GT.

During an interview with RN 22, on 2/16/16, at 10:05 AM, she reviewed the clinical record for Patients 47 and 48 and verified there was no care plan found for the use of GT formula feeding for both patients.

8. During an observation with RN 22, on 2/16/16, at 9:40 AM, in the patients room, Patient 49 was in bed with the head part slightly elevated at 30 degree angle. He has an oxygen inhalation via nasal cannula. Patient 49 waved his hand when he was asked how he was doing.

During an interview with RN 22, on 2/16/16, at 9:42 AM, she stated Patient 49 was on Hemodialysis (a procedure in which impurities or wastes are removed from the blood) three times a week. RN 22 also stated Patient 49 was alert and oriented and he was able to make his needs known.

During a review of the clinical record for Patient 49, the Physician's Order dated 2/16/16, indicated Patient 49 to receive "Hemodialysis STAT ONCE [immediately one time] for 2 hours dry - DX [diagnosis]: Hypoxia [inadequate oxygen tension at the cellular level]." During further review of the clinical record for Patient 49, there was no documentation a care plan for Hemodialysis related to hypoxia was initiated.

During an interview with LVN 3, on 2/16/16, at 10:07 AM, she reviewed the clinical record for Patient 49 and verified there was no care plan found for a Hemodialysis order on 2/16/16 due to patient's hypoxia.

9. During a review of the clinical record for Patient 51, the Physician's Order/Blood Product dated 2/10/16, indicated Patient 51 to receive PRBC (packed red blood cells- red blood cells separated from liquid plasma) 2 units. During further review of the clinical record, there was no documentation a care plan for blood transfusion (BT- the administration of whole blood or a component, such as packed red cells, to replace blood lost) of PRBC was developed.

During an interview with LVN 3, on 2/16/16, at 10:15 AM, she reviewed the clinical record for Patient 51 and verified there was no care plan found for blood transfusion.

10. During a review of the clinical record for Patient 52, the Physician's Order dated 2/5/16, indicated Patient 52 to receive Lasix (medication to treat Pulmonary edema, edema with CHF, hepatic disease, nephrotic syndrome, ascites, hypertension) 40 mg IV [intra-venous] daily. During further review of the clinical record, there was no documentation a care plan for the use of IV Lasix was initiated.

During an interview with LVN 3, on 2/16/16, at 10:25 AM, she reviewed the clinical record for Patient 52 and she was unable to find a care plan for the IV Lasix.

11. During a review of the clinical record for Patient 55, the Physician's Order dated 2/14/16, indicated Patient 55 to receive an oxygen therapy of "Albuterol-ipatropium [a bronchodilator-anticholinergic medication to treat asthma, brochospasm, bronchitis and other reversible airway obstructions] inhalation 2.5 mg-0.5 mg - give 3 milliliters (ml) nebulizer [a method of administering a drug by producing a fine spray into the respiratory passages of the patient] every 6 hrs PRN [as necessary]." During further review of the clinical record, there was no documentation a care plan for the use of an oxygen therapy was initiated.

During an interview with LVN 3, on 2/16/16, at 2:45 PM, she reviewed the clinical record for Patient 55 and verified there was no care plan found for the oxygen therapy.

Based on interview and record review, the hospital failed to provide documented evidence one Registered Nurse (RN 16) was oriented to the emergency department (ED) when she was transferred there from another department. This had the potential to result in RN 16 being unprepared to perform her duties in the ED effectively affecting patient care.

Findings:

During an interview with RN 16, on 2/16/16, at 8:53 AM, she stated she has been an RN at the hospital for approximately two years.

During a review of RN 16's personnel file and interview with Human Resource Coordinator, on 2/17/16, at 11:12 AM, it was noted RN 16 transferred to the ED on 11/1/15. There was no documentation RN 16 was oriented to the ED. No further evidence was provided.

29618



32233

Based on observation, interview, and record review, the hospital failed to ensure adequate supervision was provided to one contracted nursing personnel (Registered Nurse [RN] 23). This had the potential to result in lack of quality of care provided to patients.

Findings:

During an observation on 2/16/16, at 2 PM, in Patient 49's room, RN 23 was seated on a chair wearing a PPE (Personal Protective Equipment). The yellow gown was worn mid way exposing her chest and back showing her [nurse] uniform. She was also observed wearing a mask but it was underneath her chin. Patient 49 was in bed with the head part slightly elevated at 30 degree angle. Patient 49 was connected to a Dialysis machine. On top of the Dialysis machine was a binder, a tablet computer and a box of blue colored gloves.

During further observation on 2/16/16, at 3:50 PM, in Patient 49's room, RN 23 had disconnected the tubing from Patient 49. She was still wearing the yellow gown mid way exposing her chest and back. She was also wearing gloves and a mask. After she had disconnected the tubing from Patient 49, at 3:55 PM, she took a bottle of distilled white vinegar and placed an amount halfway in the canister. She returned the canister back to the machine. She was observed going across the hallway to get some wipes from the purple top container (germicidal ultra bleach wipes) wearing the same gloves. After placing the wipes on top of the Hemodialysis machine, she removed her gloves and disposed of them and proceeded to the station without washing her hands. RN 23 was observed working for two hours but there was no evidence the hospital employees had told her to wear the PPE appropriately.

During an interview with RN 23, on 2/16/16, at 4 PM, she stated it was her first time to do a Hemodialysis treatment in the hospital. She stated she was using the dialysis binder to check for the parameters and the tablet computer was used for her to check the orders. She also stated she placed the box of gloves on top of the Hemodialysis machine as it was more convenient for her.

During a review of the clinical record for Patient 49, the Physician's Order dated 2/16/16, indicated Patient 49 to receive "Hemodialysis STAT ONCE [immediately one time] for 2 hours dry - DX [diagnosis]: Hypoxia [inadequate oxygen tension at the cellular level]." The Physician's Order dated 2/12/16, indicated Patient 49 to receive Hemodialysis treatment every Monday, Wednesday and Friday (current Hemodialysis order).

During an interview with the Vice President- Hospital Operations(VP) 2 and RN 24, on 2/17/16, at 9:50 AM, they were made aware of RN 23's care during a Hemodialysis treatment. VP 2 and RN 24 both stated RN 23 had violated the infection control practices.

Based on interview and record review, the hospital failed to follow its policy and procedure of having telephone or verbal orders signed by the physician within 48 hours, for four of 31 sampled patients (28, 31, 32, 52). This has the potential that medical records are not maintained within current clinical record standards.

Findings:

1. During a review of the clinical record and interview with Licensed Vocational Nurse (LVN) 1 on 2/17/16, at 9:20 AM, Patient 28 was admitted 1/27/16. Four telephone orders from 1/27/16 had not been signed as of 2/17/16, three weeks. This was verified by LVN 1.

2. During a review of the clinical record and interview with LVN 1 on 2/17/15, at 9:30 AM, Patient 31 was admitted 2/9/16 with the diagnosis of "Diabetic Foot Ulcer". Patient 31's physician's medication orders were reviewed: 1. Eight verbal/telephone orders from 2/9/16 had not been signed by the ordering physician (six days date). 2. One verbal/telephone order from 2/10/16 had not been signed (five days late). 3. Three verbal/telephone orders from 2/13/16 had not been signed (two days late). LVN 1 verified the information.

3. During a review of the clinical record and interview with LVN 1 on 2/17/16, at 9:30 AM, Patient 32 was admitted 12/3/15, with a diagnosis of "leukocytosis" (high white count, usually indicated infection). Robitussin DM (cough suppressant) was ordered verbally or by telephone on 1/8/16. It was not signed by the physician until 1/28/16, three weeks later. Pancrelipase (medication to help the body digest food) was ordered 1/21/16, either verbally or by telephone. As of 2/17/16, it had not been signed. Insulin was ordered 1/21/16 either verbally or by telephone. It was signed by the physician on 1/28/16, five days late.

The hospital policy and procedure titled "Telephone, Verbal and written order for Medication", dated 2/20/15, indicated: "....The prescribing practitioner must sign the written record of the verbal/telephone medication order within 48 hours of giving order."



27137



32233

4. During a review of the clinical record for Patient 52, the Physician's Order dated 2/5/16, indicated Patient 52 to receive Lasix 40 mg IV daily. During further review of the clinical record, there was no documented evidence the verbal order for Patient 52 was authenticated by the physician since the date it was ordered.

During an interview with LVN 3, on 2/16/16, at 10:25 AM, she reviewed the clinical record for Patient 52 and she verified the verbal order was not authenticated since it was ordered on 2/5/16.

Based on observation, interview, and record review, the hospital failed to ensure the licensed nurses documentation contained information necessary to monitor one of 31 sampled patient's condition (49) receiving a Hemodialysis (a procedure in which impurities or wastes are removed from the blood) treatment. This failure had the potential to result in unmet care needs.

Findings:

During an observation with Registered Nurse (RN) 22, on 2/16/16, at 9:40 AM, in the patient's room, Patient 49 was in bed with the head part slightly elevated at 30 degree angle. He had an oxygen inhalation via nasal cannula. Patient 49 waved his hand when he was asked how he was doing.

During an interview with RN 22, on 2/16/16, at 9:42 AM, she stated Patient 49 was on Hemodialysis three times a week. RN 22 also stated Patient 49 was alert and oriented and he was able to make his needs known.

During a review of the clinical record for Patient 49, the Physician's Order dated 2/16/16, indicated Patient 49 to receive "Hemodialysis STAT ONCE [immediately one time] for 2 hours dry - DX [diagnosis]: Hypoxia [inadequate oxygen tension at the cellular level]." During further review of the clinical record for Patient 49, there was no documentation by the licensed nursing staff for the Hemodialysis treatment ordered on 2/16/16. The Hemodialysis treatment was an additional order by the physician from Patient 49's current order of three times a week (Monday-Wednesday-Friday). It was ordered due to Patient 49's hypoxia.

During an interview with RN 24, on 2/17/16, at 9:15 AM, RN 24 reviewed the licensed nurses documentation and verified there was no information found for the Hemodialysis STAT order. He also stated the licensed staff did not document the reason for the order and Patient 49's response to the treatment.

During an interview with Vice President- Hospital Operations (VP) 2 and RN 24, on 2/17/16, at 9:50 AM, they were made aware of the lack of documentation by the licensed nursing staff for the one time STAT order of Patient 49's Hemodialysis treatment. VP 2 and RN 24 both gave no further information.

The hospital policy and procedure titled "Assessment/Reassessment of Patient" dated 4/16/15, read in part, "...A-3. The goal of the assessment/reassessment process is to provide the patient the best care and treatment possible... 7. All reported changes in patient condition will be documented, as well as the patient response in the medical record..."

Based on observation and interview, the hospital failed to maintain a safe environment in the Urgent Care area when one oxygen tank was unsecured. This had the potential for the area to be unsafe for patients, visitors and staff.

Findings:

During an initial observation in the Urgent Care on 2/16/16, at 8:45 AM, a portable oxygen tank was noted to be unsecured, leaning against a wall. The Chief Nursing Officer (CNO) agreed it was an unsafe situation and requested staff call Respiratory Care stat to secure the tank. At 9 AM, the CNO put the oxygen tank into a holder under an Urgent Care gurney.



32946

2. During an observation of the Medical Surgical (MS) unit with Registered Nurse (RN) 25, on 2/16/16, at 11:46 AM to 11:55 AM, the following was noted:

Room 111 Bed C, the call light was nonfunctioning with no audible sound above the room door or at the nurse's station.

Room 111 Bed F, the call light cord which extended to the patient, had no button at the end of the call light cord to use; therefore, the call light could not be used as intended.

Room 11 Bed G, the call light was found with the cord cut at the level of the wall.

Room 111 Bed D, the call light was non functioning with no audible sound above the room door or at the nurse's station.

Room 105 Bed A, the call light was non functioning and was not audible or visible above the room door or at the nurse's station.

During an interview with RN 25, on 2/16/16, at 11:50 AM, she was asked how long have the call lights not been functioning as intended? She stated, they have not been working "on and off" but did not indicate a specific time frame. She was asked the process when repair of equipment, such as the call lights, is required. She stated, a "work order is generated" which goes directly to the maintenance department. She was not certain whether a work order request was generated and sent to the maintenance department for the nonfunctioning call lights.

During an interview with Engineer Staff (ES) 1, on 2/16/16, at 11:52 AM, he stated the maintenance department was aware of the nonfunctioning call lights in Room 111 but the call lights have been on back order for approximately six days. He indicated he was the staff who cut the the cord to 111 Bed G otherwise it would keep signaling. He stated they have no extra call lights available for patient use.

During an interview with Director of Plant Operations (DPO), on 2/16/16, at 1:40 PM, he stated ES 1 informed him of the nonfunctioning call lights. He was informed by ES 1 the call lights have not been functioning for 1 to 1 1/2 weeks. Because he did not know the type of call lights to order from the vendor, no call light replacements had been ordered. He was asked if the maintenance department has a system to monitor the patients' call lights routinely to ensure they are in working order. He acknowledged the maintenance department does not check the call lights to ensure they are in working order. He acknowledged there was no work order request for the nonfunctioning call lights for Room 111 or 105.

The hospital policy and procedure titled, "Reporting malfunction" effective date 6/15/09, indicated in part, "Equipment Malfunctions - Patient Care Equipment...When a malfunction is evident, the following steps should be taken...Double check procedure techniques to ascertain whether there is a true malfunction... If the malfunction continues to occur, call the Engineering department and inform them of the problem..."



32233

Based on observation, interview, and record review, the hospital failed to ensure a safe environment when:

1. Hazardous chemicals were not stored according to policy and procedures. This had the potential to result in staff lacking awareness for safety.

2. Several call lights were not functioning as intended. This had the potential for patients to be unable to call for assistance which impacts the patient's safety.

Findings:

1. During an observation with Lead Engineer (LE) 2, on 2/16/16, at 8:35 AM, at the back of the hospital's driveway, a Water Supply Room (Locked area) had 264 gallon bottles of drinking water. There was a total of 1370 gallons of water inside the supply room. Besides the gallons of water, there were six containers (5 gallons each) of Enerex Chemical (a chemical compound used for treating steam boiler water in food and industrial plants) close to the door. One Enerex Chemical container was open and without a cover. The containers were marked as "Corrosive (is one that will destroy and damage other substances with which it comes into contact: it causes chemical burns on contact)."

During an interview with LE 2, on 2/16/16, at 8:37 AM, he stated the chemicals were used for the boiler. He also stated the containers should have not been inside the water supply room or close to the water bottles. He was aware the chemicals were marked as corrosive.

The hospital policy and procedure titled "Management of Hazardous Chemicals" dated 1/2015, read in part, "...7.5.5 Materials which are toxic as stored or which can decompose into toxic components from contact with heat, moisture, acids, or acid fumes should be stored in a cool, well ventilated place out of the direct rays of the sun...7.5.6 Corrosive materials are stored in a cool, well-ventilated area (i.e., above their freeze point) and in containers that will contain spills or leaks. NOTE: The containers are inspected at regular intervals to ensure they are labeled and kept closed. 7.5.7 Corrosives are isolated from other materials..."



32946

33399

Based on observations, interviews, and record review, the hospital failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases and conduct an active program for the prevention, control and investigation of infections and communicable diseases. These failures place the patient population, visitors and staff at risk for hospital acquired infections when:

1. Terminal cleaning (thorough cleaning done at the end of the work day to eliminate as many disease causing bacteria or viruses) was not performed daily in the areas connected to the operating rooms. The endoscopy processing room (specialized room used to clean medical equipment used for procedures) had no door to prevent the spreading of pathogens (disease causing bacteria or virus) into the restricted area of the operating room. (Refer to A 749, item 1)

2. Clean and sterile supplies were stored in the decontamination room. (Refer to A 749, item 2)

3. Operating room number two (one of two) did not meet state environmental standards. (Refer to A 749, item 3)

4. Surgical instruments were not properly sterilized. (Refer to A 749, item 4)

5. Glucometers (small, portable, hand held instrument that measure blood glucose immediately) were not disinfected between patient use. (Refer to A 749, item 5)

6. Healthcare workers did not have adequate vaccination screening. (Refer to A 749, item 6)

7. Within the Urgent Care, employees' personal belongings were placed in clean areas. One employee was observed eating in the nursing station. (Refer to A 749, item 7)

8. On Unit III, family and staff were not following appropriate isolation measures. (Refer to A 749, item 8)

9. Improperly handled soiled linen. (Refer to A 749, item 9)

10. Improperly stored medical waste. (Refer to A 749, item 10)

11. New Gastrostomy (GT, a tube inserted directly into the stomach to provide nutrition) tubing was not labeled with time, date and initials of person hanging the feeding. (Refer to A 749, item 11)

12. In the telemetry unit, Personal Protective Equipment (PPE) was not utilized appropriately by staff. (Refer to A 749, item 12)

The cumulative effects of these systemic failures resulted in the hospital's inability to ensure a sanitary environment environment placing all patients, staff and visitors at risk of being exposed to infections and communicable diseases.

30719



29618



32946



18790

7. During a concurrent observation and interview with the Chief Nursing Officer (CNO) and the Quality Analyst in the Urgent Care Center on 2/16/16, at 3:10 PM, in the Clean/Dirty utility room, two staff's personal back packs and one jacket are on the counter next to the sink, in the clean area. Binders, Christmas decorations, personal containers are stacked up within approximately 4" of the ceiling. The CNO verified "The top of the stack of boxes, etc, are too close to the ceiling. This room is really like a supply room rather than a Utility Room."

During an observation in the Urgent Care Center on 2/17/16, at 8:25 AM with IC 2 and Licensed Vocational Nurse (LVN) 1, LVN 2 was noted to be eating within the nurse' station area. The smell of her food permeated the area. One patient was in the treatment area and the pediatrics' door was shut. IC 2 stated, "She's not supposed to be eating there."

8. During an observation on Unit III on 2/16/16, at 9:30 AM with IC 2 and LVN 1, Patient 30 was in isolation with a diagnosis of influenza. A family member put on the Personal Protection Equipment (PPE) which included a gown, mask and gloves before entering the room. This family member then placed her purse strap over her shoulder and entered Patient 30's room with the purse fully exposed. IC 2 asked the charge nurse (RN 10) who had instructed this family member how to protect herself using PPE. RN 10 then put on a gown, mask and gloves and entered Patient 30's room. RN 10 did not tie the isolation gown in the back and the front neckline of the gown dropped down to her right elbow, exposing the top of her uniform, while she spoke to Patient 30 and his family member.



21905

During a review of RN 16's personnel file with Human Resource Coordinator, on 2/17/16, at 11:15 AM, the Hepatitis B vaccine acceptance/refusal form dated 12/9/13, was noted. On the form, RN 16 documented that she would accept the Hepatitis B vaccine. There was no documented evidence the Hepatitis B vaccine was offered and/or given to RN 16. No further evidence was provided.



32233

9. During an observation with Lead Engineer (LE) 2, on 2/16/16, at 8:50 AM, at the back of the hospital's driveway, a soiled linen cart full of soiled linens (enclosed in plastic bags) was found unsecured close to the main oxygen supply tank storage area. The linen cart was unattended.

During an interview with LE 2, on 2/16/16, at 8:52 AM, he stated the housekeeping staff forgot to store the cart inside the dirty linen locked storage room. He also stated the housekeeping staff collects the carts from the hospital and they would push them inside the dirty linen storage room.

10. During an observation with LE 2 and RN 22, on 2/16/16, at 9:10 AM, at the back patio, the "Biohazardous and Medical Wastes" locked storage area contained nine medical wastes containers. It was observed eight of the nine containers were not properly sealed and without the secured tape on both sides. The containers were also found to have several used intravenous medication tubing sticking out of the containers.

During an interview with RN 22, on 2/16/16, at 9:12 AM, she stated the staff should have placed the secured tape label on both sides and before the housekeeping staff would bring them to the storage area.

The hospital policy and procedure titled "MEDICAL WASTE MANAGEMENT PLAN CHECKLIST" dated 8/2007, read in part, "...Indicate in the medical waste management plan that the accumulation area utilized by the facility to store containers of medical waste for accumulation must be secured so as to prevent or deny access by unauthorized persons and posted with warning signs, on or adjacent to, the exterior of the entry doors, on entry doors, gates, or lids..."

11. During a concurrent observation and interview with RN 22, on 2/16/16, at 9:32 AM, in the patients' room, Patients 47 and Patient 48 were in bed with the head part elevated at 45 degree angle. Patient 47 had a GT formula of Fibersource HN at 50 ml/hr (milliliter per hour). Patient 48 had a GT formula of Pulmocare at 50 ml/hr. Patient 47 and 48's GT tubing were not labeled and dated.

During an interview with RN 22, on 2/16/16, at 9:35 AM, she stated Patients 47 and Patient 48 were unable to communicate because of their medical condition. RN 22 also stated she was unable to determine Patient 47 and Patient 48's tubing for the formula were new or old.

The hospital policy and procedure titled "IV/Enteral Tubing Change" undated, read in part, "...Tubing Changes: Enteral/Tube Feeding - every 24 hours...DOCUMENTATION: 1. All IV (Intravenous)/Enteral tubing changes are to be documented on the nursing flowsheet. 2. New tubing should be labeled with date, time and initials of person doing the tubing change..."

12. During an observation on 2/16/16, at 2 PM, in Patient 49's room, RN 23 was seated on a chair wearing a PPE. The yellow gown was worn mid way exposing her chest and back showing her nurse uniform. She was also observed wearing a mask but it was underneath her chin. Patient 49 was in bed with the head part slightly elevated at 30 degree angle. Patient 49 was connected to a dialysis machine. On top of the dialysis machine was a binder, a tablet computer and a box of blue colored gloves.

During further observation on 2/16/16, at 3:50 PM, in Patient 49's room, RN 23 had disconnected the tubing from Patient 49. She was still wearing the yellow gown mid way exposing her chest and back. She was also wearing gloves and a mask. After she had disconnected the tubing from Patient 49, at 3:55 PM, she took a bottle of distilled white vinegar and placed an amount halfway in the canister. She returned the canister back to the machine. She was observed going across the hallway to get some wipes from the purple top container (germicidal ultra bleach wipes) wearing the same gloves. After placing the wipes on top of the Hemodialysis machine, she removed her gloves and disposed of them and proceeded to the station without washing her hands. RN 23 was observed working for two hours but there was no evidence the hospital employees had told her to wear the PPE appropriately.

During an interview with RN 23, on 2/16/16, at 4 PM, she stated it was her first time to do a Hemodialysis (process involving a large portable machine that is attached to a patient so that their blood toxins and other fluids can be removed when the patient's kidneys no longer do it) treatment in the hospital. She stated she was using the dialysis binder to check for the parameters and the tablet computer was used for her to check the orders. She also stated she placed the box of gloves on top of the Hemodialysis machine as it was more convenient for her.

During an interview with the Vice President- Hospital Operations(VP) 2 and RN 24, on 2/17/16, at 9:50 AM, they were made aware of RN 23's care during a Hemodialysis treatment. VP 2 and RN 24 both stated RN 23 had violated the infection control practices.



33399

Based on observation, interview, and document review, the hospital failed to maintain a clean hospital with cleaning procedures maintained to minimize and treat infections or communicability of diseases when:

1. Terminal cleaning (thorough cleaning done at the end of the work day to eliminate as many disease causing bacteria or viruses) was not performed daily in the areas connected to the operating rooms. The endoscopy processing room (where examination equipment is cleaned) had no door to prevent the contamination of pathogens (disease causing bacteria or virus) into the restricted area of the operating room.

2. Clean and sterile supplies were stored in the decontamination room.

3. Operating room number two (one of two) did not meet state environmental standards.

4. Surgical instruments were not properly sterilized.

5. Glucometers (small, portable, hand held instrument that measure blood glucose immediately) were not disinfected between patient use.

6. Healthcare workers did not have adequate vaccination screening.

7. Within the Urgent Care, employees' personal belongings were placed in clean areas. One employee was observed eating in the nursing station.

8. On Unit III, family and staff were not following appropriate isolation measures.

9. Improperly handled soiled linen.

10. Improperly stored medical waste.

11. New Gastrostomy (GT a tube inserted directly into the stomach to provide nutrition) tubing was not labeled with time, date and initials of staff who hung the feeding.

12. In the telemetry unit, Personal Protective Equipment (PPE) was not utilized appropriately by staff.

These failures have the potential to transmit infections to patients, staff and visitors.

Findings:

1. On 2/16/16 at 8:40 AM in the surgical department of the hospital with Operating Room Technician (ORT) 1, Registered Nurse (RN) 29 (charge nurse) and RN 30 (circulating nurse), it was observed that the specialized room used to clean medical equipment used for procedures was adjacent to Operating Room (OR) 2, separated by a door, but open to the sterile part of the OR. During closer inspection, it was noted that the floor of the cleaning room was sticky to the foot and visibly soiled. RN 29 provided a check list for the terminal cleaning of the department, which is completed by environmental services at the end of each day. The last noted signature was dated 1/23/16 at 2 PM.

No hospital policy on terminal cleaning of the perioperative areas was presented upon request prior to the end of the survey.

On 2/16/16, during an interview with the Infection Control (IC) at 9:30 AM, he stated that the hospital has adopted the Association of periOperating Registered Nurses Guidelines (AORN) Guidelines for Perioperative Practice as one of the hospital's nationally recognized infection control standards.

According to AORN Guidelines for Perioperative Practice, Guideline for Environmental for Environmental Cleaning, Section V.,Terminal cleaning and disinfection of perioperative areas, including sterile processing areas, should be performed daily when the areas are being used.

AORN Guidelines for Perioperative Practice, Guideline for a Safe Environment of Care, Part 2, Section IIb states that the HVAC (heating, ventilation, air conditioning), surgical attire, and traffic pattern requirements of the surgical suite are designed to be more stringent as one moves from unrestricted to restricted areas. The progression of restrictions is intended to provide the cleanest environment in the restricted area. The designated areas should be separated by ... doors separating the restricted area from the semi-restricted area; and doors, signage, or a line of demarcation to identify the separation between the unrestricted and semi-restricted areas. The doors provide a physical barrier to assist in maintaining control of the HVAC.

2. On 2/16/16 at 9:23 AM, in the decontamination room, clean equipment (sequential compression devices [equipment used to mobilize the knee] wrapped in plastic) were observed to be piled two high on the horizontal surface adjacent to the decontamination area sink.

During an interview with the IC at 9:30 AM, he stated the hospital has adopted the Association of periOperating Room Nurses Guidelines for Perioperative Practice as one of the hospital's nationally recognized infection control standards.

On 2/17/16 at 1:35 PM during a tour of the second decontamination room, it was noted that both decontamination and sterilization were performed in the same room without an additional sink for handwashing.

The hospital policy entitled "Separation of Clean and Contaminated Items", dated 2/2/16, indicated: "no clean items will be stored in the decontamination area of central services or the contaminated utility room /area ...at no time will the clean/sterile items go through the decontamination areas of the dirty/contaminated items go through the clean sterile areas."

According to AORN, Guidelines for Perioperative Practice, Guideline for Cleaning and Care of Surgical Instruments states that Instruments should be cleaned and decontaminated in an area separate from locations where clean items are handled. Physical separation of decontamination areas from areas where clean items are handled minimizes the risk of cross-contamination. Droplets and aerosols created during cleaning of soiled instruments can cause cross-contamination of any nearby clean items or surfaces. The sterile processing area should have separate clean and decontamination spaces, which may be rooms or areas; decontamination and clean spaces that are separated by one of three methods: a wall with a door or pass-through, a partial wall or partition that is at least 4 ft high and at least the width of the counter, or a distance of 4 ft between the instrument washing sink and the area where the instruments are prepared for sterilization; separate sinks for washing instruments and for hand hygiene.

3. During an interview with the Administrator 1 on 2/17/16 at 11:30 AM the annual air balance and certification report dated, 9/1/15, was reviewed. Under the section Crucial Area Validation Testing, OR 2 was noted to have "failed". According to the report this meant that the air exchanges per hour and space pressurization requirements found in the California Mechanical Code were not met. The additional rooms that failed testing were ICU 2, Isolation 104 and SPD Clean/Dirty. Administrator 1 he stated that recommended maintenance, detailed in the report, and re-testing had not been performed since the receipt of the report in 9/2015.

During an observation and interview on 2/16/16 at 9:15 AM in OR 2, five peel packs (paper packages that contain sterilized small surgical instruments) were opened. In four out of the five packs opened, the instruments inside were in the closed and locked position. ORT 1 commented that the instruments were not processed correctly and the instrument technician who packaged them (ORT 2) should have known better.

4. During an interview with the IC on 2/16/16 at 9:30 AM, he stated the hospital has adopted the AORN Guidelines for Perioperative Practice as one of the hospital's nationally recognized infection control standards.

According to AORN, Guidelines for Perioperative Practice, Guideline for Selection and Use of Packaging Systems for Sterilization, V.h. Items to be sterilized should be placed in the package or tray in an open or unlocked position. The open or unlocked position facilitates sterilant contact of all surfaces of the item.

5. On 2/16/16 at 11:44 AM during an observation of RN 29 performing a glucose test for Patient 53 and Patient 49, it was noted that the glucometer was not cleaned and disinfected between patients and according to the manufacturer's instructions.

During an interview and observation of the area outside of the emergency room with RN 16, on 2/16/16, at 8:53 AM, there were two containers on the wall. One container with a purple lid, had the manufacturer's label that read "MICRO-KILL ONE...GERMICIDAL ALCOHOL WIPES" and read, in part, "To disinfect hard, non-porous surfaces, use one or more wipes, as necessary to thoroughly wet the surface to be treated. Treated surface must remain visibly wet for one minute to achieve complete disinfection of all pathogens listed..." A second container, with a light blue lid, the label read, "MICRO-KILL Bleach GERMICIDAL BLEACH WIPES" and the product label read, in part, for hospital disinfection, "...Remove pre-saturated 7 in x 8 in wipe...Apply pre-saturated towelette and wipe desired surface to disinfect...CONTACT TIME [amount of time the item should remain visibly wet to kill the listed pathogens]: Allow surface to remain wet for 30 seconds to kill HBV and HCV, for 3 minutes to kill Clostridium difficile sores and 5 minutes to kill HIV..." RN 16 stated she uses the "MICRO-KILL Bleach GERMICIDAL BLEACH WIPES" to disinfect the glucometers (ACCU CHEK Inform II is a medical device that is used to determine the appropriate concentration of glucose [sugar] in the blood) and she stated the contact time is a 30 second contact time. She then indicated the kill/contact time was 3 minutes for these wipes. Although she uses "MICRO-KILL Bleach GERMICIDAL BLEACH WIPES" she was instructed to use "MICRO-KILL ONE...GERMICIDAL ALCOHOL WIPES".

During an observation and interview with RN 28 (Charge Nurse for the Intensive Care Unit [ICU] and the telemetry unit), on 2/16/16, at 9:47 AM, she stated there are two glucometers in the ICU and she disinfects them using the "MICRO-KILL ONE...GERMICIDAL ALCOHOL WIPES" and she stated, she is the staff who is responsible for disinfecting the devices. She disinfects the glucometers once on her shift (morning) and then the night shift staff will disinfect the devices once on their shift. She was asked how many times are the glucometers being used currently and she stated approximately six times on the morning shift. She then proceeded to demonstrate how she wipes the devices and allows them to remain visibly wet for two minutes. She was again asked, how many times are the devices disinfected, and again she stated once on her shift. No further information was provided.

The hospital policy and procedure titled, "ACCU-CHEK Inform Glucose Meter" effective date 2/19/14, indicated in part for the Cleaning/Disinfecting of the meters use "Super Sani-Cloth Wipes or 10% bleach...Frequency 1. In between every patients...3. Whenever there is suspected or true contamination...How to Clean Meters, Bases and Supply Cases 1. Meter...remove a wipe from the PDI Super Sani-Cloth or Clorox wipe tub and close the lid...Allow to air dry before use: 2 min for Sani-Cloth"

The "ACCU-CHEK Inform II" Operator's manual Version 3.0, Revision dated 3/2013, with changes that included "Update cleaning and disinfecting chapter" was reviewed. Page 124 through page 131 indicated in part, "Cleaning and disinfecting the exterior surface of the meter is, at minimum, recommended daily for dedicated patient devices. Meters used with multiple patients may require more frequent cleaning and disinfecting...The meter should be cleaned and disinfected between each patient use...Acceptable active ingredients and products for cleaning and disinfecting are...Clorox Germicidal Wipes...Super Sani-Cloth Germicidal Disposable Wipes...Always use Clorox Germicidal Wipes...or Super Sani-Cloth Germicidal Disposable Wipes...to clean and disinfect the meter. Do not use any other cleaning or disinfecting solution. Using solutions other than Clorox Germinal Wipes...or Super Sani-Cloth Germicidal Disposable Wipes...could result in damage to the system components..."

6. On 2/16/16 at 1:15 PM, during a review of employee health records, three out of three files did not have complete vaccination records (RN 29, ORT 2, Environmental Services Manager [EVS] 1). RN 29 did not have evidence of tDap (Tetanus (a serious illness caused by bacteria that can enter the body through a deep cut) Diphtheria (a serious bacterial infection), and Pertussis (commonly known as Whooping Cough, an infectious bacterial disease that causes uncontrollable coughing) or varicella (Chickenpox) immunity. ORT 2 did not have evidence of mumps immunity and EVS 1 did not have evidence of tDap and Varicella.

The hospital policy entitled Immunizations for Healthcare Workers dated 2/2012 was reviewed on 2/16/16 at 2:30 PM. It states that as part of the preemployment evaluation, employees will be required to complete a questionnaire regarding prior vaccinations for, or exposure to communicable vaccine-preventable diseases. In situations where immunity is questionable or undetermined from the questionnaire the employee will be tested to determine his/her immune status.