HospitalInspections.org

Based on review of medical records, observations, hospital policy, and interviews it was determined the hospital failed to ensure:

1. Patients were cared for in a safe environment.
2. Patients were free from harm due to ligature risks and hazards,
3. Patients were assessed for the need for restraints and physician's orders were obtained prior to or immediately after the application of restraints.
4. Orders for the use of restraints were not enacted on as needed basis.
5. Orders for the use of restraints were specific for duration and the type of restraint to be used.
6. Orders were renewed every four hours for patients with violent/self destructive behavior.
7. Restraint alternatives or other less restrictive interventions attempted were documented.
8. A written modification to the patient's plan of care for the use of restraints was documented.
9. Restraint justification and rationale for continued use of restraints were documented.

Refer to tags; A-144, A-165, A-166, A-168, A-169, A-171, A-174, and A-175.

Based on facility tour observations and staff interviews, it was determined the facility failed to ensure patients were cared for in a safe environment.

These deficient practices had the potential to negatively affect all patients admitted to the Geriatric Behavioral Health unit.

Findings include:

1. During a tour of the Geriatric Behavioral Health unit on 7/25/23 at 1:30 PM, with Employee Identifier (EI) # 3, Chief Nursing Officer, the following ligature risks were identified:

a. Five out of five semi-private patient rooms and the seclusion room entry door hinges were not rounded or piano hinge style and could be used to support a rope or other ligature for hanging or strangulation.

b. Five out of five semi-private patient rooms bathroom door hinges were not rounded or piano hinge style and could be used to support a rope or other ligature for hanging or strangulation.

c. Five out of five semi-private patient rooms bathroom doorknobs were not breakaway and could be used to support a rope or other ligature for hanging or strangulation.

d. Five out of five semi-private patient room bathrooms and the seclusion room bathroom had exposed plumbing under the sink, which could be broken off and used for self-harm or harm to others or pose as a ligature risk.

e. Five out of five semi-private patient room bathrooms and the seclusion room bathroom sink faucet and knobs were not recessed and could be used to support a rope or other ligature for hanging or strangulation.

f. Five out of five semi-private patient rooms bathroom shower faucet and knobs were not recessed and could be used to support a rope or other ligature for hanging or strangulation.

g. Five out of five semi-private patient room showers contained a recessed metal soap holder, each end of the recessed metal soap holder contained a metal post which extended from the recessed holder approximately 1 to 1 1/2 inches. The posts could be broken off and used for self-harm or harm to others and could be used to support a rope or other ligature for hanging or strangulation.

h. Five out of five semi-private patient rooms contained rolling bedside tables which could be picked up and used to break bedroom windows or thrown to harm self or others.

i. Five out of five semi-private patient rooms and the seclusion room contained uncovered regular windows which could be broken and used to harm self or others.

j. Patient room 23 contained an air conditioner with an approximately two feet of the center of the vent cover torn off, which could be used to harm self or others.

k. Patient room 24 bathroom contained area where the emergency cord and bracket had been removed exposing the electric wires, which could be used to harm self.

l. The seclusion room contained an electrical outlet with an approximately two and a half foot cord cover with a hard plastic shell which was detached from the wall exposing the plug's electric wires and could be used to harm self or others.

An interview was conducted during the tour with EI # 3, who confirmed the ligature risk findings and hazards.

Based on review of medical records, hospital policy, and interviews it was determined the hospital failed to ensure restraint alternatives or other less restrictive interventions attempted were documented.

This deficient practice affected one of four patients reviewed with restraints including Patient Identifier (PI) # 8 and had the potential to affect all patients requiring restraints admitted to this hospital.

Findings include:

Hospital policy: Restraint or Seclusion

Policy number: Not included

Date: 1/2022

...Standard:

...Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time...

B. Medical - Surgical Restraint.

...2. Documentation of initial assessment and ongoing daily assessments:

a. Clinical justification of restraint...

b. Alternatives or other less restrictive interventions attempted.

1. PI # 8 was admitted to the hospital on 7/23/23 with diagnoses including Acute Hypoxic and Hypercarbic Respiratory Failure and Chronic Obstructive Pulmonary Disease Exacerbation.

Review of the nursing notes dated 7/23/23 and 7/25/23 revealed the nurse documented restraints as a safety intervention. There was no documentation of a physician's order for restraints.

Further review of the nursing notes dated 7/23/23 to 7/25/23 revealed no documentation of the clinical justification of the restraints, alternatives or other less restrictive interventions attempted.

An interview was conducted on 7/25/23 at 11:34 AM with Employee Identifier (EI) # 10, Registered Nurse for PI # 8, and EI # 7, Assistant Chief Nursing Officer. EI # 10 verbalized PI # 8 had been in restraints, and he/she removed the restraints on 7/25/23 around 7:00 am. EI # 7 confirmed there was no documentation of the clinical justification of the restraints, alternatives or other less restrictive interventions attempted.

Based on review of medical records, hospital policy, and interviews it was determined the hospital failed to ensure a written modification to the patient's plan of care for the use of restraints was documented.

This deficient practice affected one of four patients reviewed with restraints including Patient Identifier (PI) # 8 and had the potential to affect all patients requiring restraints admitted to this hospital.

Findings include:

Hospital policy: Restraint or Seclusion

Policy number: Not included

Date: 1/2022

...Standard:

...Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time...

A. Plan of Care.

The use of a restraint...must be documented in the patient's plan of care or treatment plan based on an assessment and evaluation of the patient. The plan of care or treatment plan should be reviewed and updated within 24 hours following the initiation of restraint...and daily thereafter.

1. PI # 8 was admitted to the hospital on 7/23/23 with diagnoses including Acute Hypoxic and Hypercarbic Respiratory Failure and Chronic Obstructive Pulmonary Disease Exacerbation.

Review of the nursing notes dated 7/23/23 and 7/25/23 revealed the nurse documented restraints as a safety intervention. There was no documentation of a physician order for restraints.

Review of the Plan of Care revealed no documentation the patient's plan of care was modified for the use of the restraints.

An interview was conducted on 7/25/23 at 11:34 AM with Employee Identifier (EI) # 10, Registered Nurse for PI # 8, and EI # 7, Assistant Chief Nursing Officer. EI # 10 verbalized PI # 8 had been in restraints, and he/she removed the restraints on 7/25/23 around 7:00 am. EI # 7 confirmed there was no documentation of a modification to the patient's plan of care for the use of restraints.

Based on review of medical records, hospital policy and procedure, and interviews it was determined the hospital failed to ensure a physician's order was obtained and written each time a patient was placed in restraints.

This deficient practice affected two of four patients reviewed with restraints including Patient Identifier (PI) # 7, PI # 8 and had the potential to affect all patients admitted to this hospital.

Findings include:

Hospital policy: Restraint or Seclusion

Policy number: Not included

Date: 1/2022

...Standard:

...Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time...

III. Ordering Guidelines...

A. Requirements for ordering restraint or seclusion for any reason.

1. The physician responsible for the care of the patient orders restraint or seclusion prior to the application of restraint or seclusion.

2. In emergent situations, an RN (Registered Nurse)...The order must be obtained either during the emergency application of the restraint or seclusion, or immediately (within a few minutes) afterwards...

B. Requirements for ordering medical/surgical restraint.

1. Orders obtained to address a patient's medical care-related needs (safety) that are evidenced by non-violent or non-destructive behavior is considered in effect for one calendar day.

...3. If the patient remains in restraints for more than one calendar day a new order must be obtained for each calendar day in restraint.

C. Requirements for ordering Violent or Self Destructive Behavior Restraint or Seclusion: (VSDRS)

...2. Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be obtained and renewed in accordance with the following limits for up to a total of twenty-four hours:

a. Up to four (4) hours for adults aged 18 and older...

3. At the end of the time frame, if the continued use of restraint or seclusion to manage violent or self destructive behavior is deemed necessary...a RN must contact the physician to report the results of his or her most recent assessment and request that the original order be renewed...

1. PI # 7 was admitted to the hospital on 6/16/23 with a diagnosis of Schizoaffective Disorder, Bipolar Type.

Review of the Geriatric Behavioral Nursing Notes dated 6/17/23 at 9:21 PM revealed the nurse documented PI # 7 was combative with staff and security.

Review of the physician's order dated 6/17/23 at 9:45 PM revealed orders for restraints once. There was no description of the type of restraints to be used or the duration of restraints.

Review of the Intensive Care Unit (ICU) Nursing Note dated 6/17/23 at 9:54 PM revealed the patient was received in ICU and placed in four point restraints and Posey vest.

Review of the Restraint Observation (RO) Flowsheet dated 6/17/23 revealed PI # 7 was in restraints from 9:45 PM until 7:00 AM on 6/18/23.

There was no documentation the order for the restraints was renewed every four hours per policy.

Review of the Nursing note dated 6/18/23 at 6:00 PM revealed the nurse documented the patient was agitated and attempting to remove leg restraints. There was no documentation of a physician.s order for restraints on 6/18/23.

Review of the Nursing Notes dated 6/19/23 at 6:00 PM revealed the nurse documented the restraints were in place. There was no documentation of a physician's order for restraints on 6/19/23.

Review of the Nursing Notes dated 6/20/23 at 5:35 AM revealed the nurse documented PI # 7 was in four point restraints. There was no documentation of a physician's order for restraints on 6/20/23.

Further review of the 6/20/23 Nursing Note revealed the restraints were removed at 6:00 PM

Review of the RO Flowsheet dated 6/22/23 revealed PI # 7 was in four point leather restraints for assaulting staff from 7:15 AM until 7:00 AM on 6/23/23. There was no documentation of a physician's order for restraints on 6/22/23.

Review of the RO Flowsheet dated 6/23/23 revealed PI # 7 was in four point psychiatric restraints for behavior and medical device safety from 7:00 PM until 7:00 AM on 6/24/23. There was no documentation of a physician's order for restraints on 6/23/23.

Review of the RO Flowsheet dated 6/24/23 revealed the nurse documented PI # 7 was in locked wrist restraints from 7:00 PM until 9:00 PM and placed back in restraints from 5:00 AM until 7:00 AM on 6/25/23. There was no documentation of a physician's order for restraints on 6/24/23.

Review of the RO Flowsheet dated 6/25/23 revealed the nurse documented PI # 7 was in locked wrist restraints from 8:00 PM until 11:00 PM and placed back in restraints from 6:15 AM until 7:00 AM on 6/26/23. There was no documentation of a physician's order for restraints on 6/25/23.

An interview was conducted on 7/27/23 at 3:32 PM with Employee Identifier (EI) # 3, Chief Nursing Officer (CNO), who confirmed the hospital staff failed to ensure a physician's order was obtained for each time the patient was placed in restraints.






40119

2. PI # 8 was admitted to the hospital on 7/23/23 with diagnoses including Acute Hypoxic and Hypercarbic Respiratory Failure and Chronic Obstructive Pulmonary Disease Exacerbation.

Review of the nursing notes dated 7/23/23 and 7/25/23 revealed the nurse documented restraints as a safety intervention.

Review of the MR revealed no documentation of a physician's order for restraints.

An interview was conducted on 7/25/23 at 11:34 AM with EI # 10, Registered Nurse for PI # 8, and EI # 7, Assistant CNO. EI # 10 verbalized PI # 8 had been in restraints, and he/she removed the restraints on 7/25/23 around 7:00 am. EI # 7 confirmed there was no documentation of a physician's order for restraints.

Based on review of medical records, hospital policy, and interviews it was determined the hospital failed to ensure orders for restraints were not used as a standing order.

This deficient practice affected one of four medical records of patients in restraints including Patient Identifier (PI) # 7 and had the potential to affect all patients admitted to this hospital.

Findings include:

Hospital policy: Restraint or Seclusion

Policy number: Not included

Date: 1/2022

...Standard:

...Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time...

III. Ordering Guidelines...

D. PRN (as needed) Ordering of Restraint & Seclusion

1. Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis...

2. Staff cannot discontinue a restraint or seclusion intervention and then re-start it under the same order. This would constitute a PRN order. A "trial release" constitutes a PRN use of restraints...

1. PI # 7 was admitted to the hospital on 6/16/23 with diagnosis of Schizoaffective Disorder, Bipolar Type.

Review of the Restraint Observation (RO) Flowsheet dated 6/24/23 revealed the nurse documented PI # 7 was in locked wrist restraints from 7:00 PM and released at 9:00 PM.

Further review of the RO Flowsheet dated 6/24/23 revealed PI # 7 was placed back in restraints at 5:00 AM until 7:00 AM on 6/25/23.

There was no documentation the physician was contacted for a new order for restraints.

Review of the RO Flowsheet dated 6/25/23 revealed the nurse documented PI # 7 was in locked wrist restraints from 8:00 PM and released at 12:00 AM on 6/26/23.

Further review of the RO Flowsheet dated 6/25/23 revealed PI # 7 was placed back in restraints at 6:15 AM until 7:00 AM on 6/26/23.

There was no documentation the physician was contacted for a new order for restraints.

An interview was conducted on 7/8/23 at 10:30 AM with Employee Identifier (EI) # 21, Medical Director, who stated the restraint orders are written as general orders and the discretion is on the nursing staff to what type of restraint is needed.

An interview was conducted on 7/27/23 at 3:32 PM with EI # 3, Chief Nursing Officer, who confirmed the hospital policy for ordering restraints was not followed and the staff failed to contact the physician for a new order when the restraints were reapplied.

Based on medical record review, hospital policy, and interviews it was determined the hospital failed to ensure an order for the continued use of restraints for violent/self destructive behavior was obtained every 4 hours.

This deficient practice affected one of four medical records of restraint use including Patient Identifier (PI) # 7 and had the potential to affect all patients admitted to this hospital.

Findings include:

Hospital policy: Restraint or Seclusion

Policy number: Not included

Date: 1/2022

...Standard:

...Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time...

III. Ordering Guidelines...

A. Requirements for ordering restraint or seclusion for any reason.

1. The physician responsible for the care of the patient orders restraint or seclusion prior to the application of restraint or seclusion.

2. In emergent situations, an RN (Registered Nurse)...The order must be obtained either during the emergency application of the restraint or seclusion, or immediately (within a few minutes) afterwards...

C. Requirements for ordering Violent or Self Destructive Behavior Restraint or Seclusion: (VSDRS)

...2. Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be obtained and renewed in accordance with the following limits for up to a total of twenty-four hours:

a. Up to four (4) hours for adults aged 18 and older...

3. At the end of the time frame, if the continued use of restraint or seclusion to manage violent or self destructive behavior is deemed necessary...a RN must contact the physician to report the results of his or her most recent assessment and request that the original order be renewed...

1. PI # 7 was admitted to the hospital on 6/16/23 with a diagnosis of Schizoaffective Disorder, Bipolar Type.

Review of the physician's orders dated 6/17/23 at 9:45 PM revealed orders for restraints once. The order did not include the duration of the restraints.

Review of the Restraint Observation (RO) Flowsheet dated 6/17/23 at 9:45 PM revealed PI # 7 was placed in restraints for assaultive, violent, and psychotic behavior.

Further review of the RO Flowsheet dated 6/17/23 revealed PI # 7 remained in wrist and ankle restraints with a Posey vest (upper body restraint) and siderails up x 4 until 6/18/23 at 7:00 AM, which was 9 hours and fifteen minutes.

Review of the RO Flowsheet dated 6/22/23 revealed PI # 7 was in four point leather restraints for assaulting staff from 7:15 AM until 6/23/22 at 7:00 AM, which was eleven hours and fourty-five minutes.

Review of the physician's order dated 6/27/23 at 7:00 AM revealed orders for restraints once. The order did include the duration of restraints.

Review of the physician's order dated 6/29/23 at 7:05 AM revealed orders for restraints once. The order did not include the duration of restraints.

Review of the physician's order dated 6/30/23 at 7:15 AM revealed orders for restraints once. The order did not include the duration of restraints.

Review of the RO Flowsheets dated 6/26/23, 6/27/23, and 6/30/23 revealed PI # 7 was in soft wrist and ankle restraints for patient/employee safety continuously from 7:15 AM until 7:00 the next day, which was eleven hours and fourty-five minutes each day.

There was no documentation the orders for the restraints were renewed every four hours per policy.

An interview was conducted on 7/27/23 at 3:32 PM with Employee Identifier (EI) # 3, Chief Nursing Officer, who confirmed the hospital policy for writing restraint orders and renewing the restraint orders were not followed.

Based on review of medical records, hospital policy, and interviews it was determined the hospital failed to ensure restraint justification and rationale for continued use of the restraint were documented.

This deficient practice affected one of four patients reviewed with restraints including Patient Identifier (PI) # 8 and had the potential to affect all patients requiring restraints admitted to this hospital.

Findings include:

Hospital policy: Restraint or Seclusion

Policy number: Not included

Date: 1/2022

...Standard:

...Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time...

B. Medical - Surgical Restraint.

...2. Documentation of initial assessment and ongoing daily assessments:

a. Clinical justification of restraint...

k. Restraint justification.

...m. Patient's response to the interventions(s) used, including the rationale for continued use of the intervention.

1. PI # 8 was admitted to the hospital on 7/23/23 with diagnoses including Acute Hypoxic and Hypercarbic Respiratory Failure and Chronic Obstructive Pulmonary Disease Exacerbation.

Review of the nursing notes dated 7/23/23 and 7/25/23 revealed the nurse documented restraints as a safety intervention.

Further review of the nursing notes dated 7/23/23 to 7/25/23 revealed no documentation of the clinical justification of the restraints and the rationale for continued use of the restraint.

An interview was conducted on 7/25/23 at 11:34 AM with Employee Identifier (EI) # 10, Registered Nurse for PI # 8, and EI # 7, Assistant Chief Nursing Officer. EI # 10 verbalized PI # 8 had been in restraints, and he/she removed the restraints on 7/25/23 around 7:00 am. EI # 7 confirmed there was no documentation of the clinical justification of the restraints and the rationale for continued use of the restraint.

Based on review of medical records, hospital policy, and interviews it was determined the hospital failed to ensure the staff assessed, monitored, and documented the patient condition while in restraints.

This deficient practice affected one of four medical records of patient in restraints including Patient Identifier (PI) # 7 and PI # 8 and had the potential to affect all patients admitted to the hospital.

Findings include:

Hospital Policy: Restraint or Seclusion

Policy number: not provided

Date: 1/2022

...Standard:

...Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time...

B. Medical - Surgical Restraint.

...3. Frequency of monitoring and documentation for patients placed in medical-surgical restraint:

a. Every two (2) hours...:

Observation.
Circulation.
Safety checks.
General care needs (...eating, hydration, tolieting, position change, skin integrity, and range of motion exercises).
...Individual patient assessments and reassessments.
Mental status.
Restraint justification.
Patient's response to the intervention(s) used, including the rationale for continued use of the interventions...

...Violent/Self Destructive Restraint/Seclusion

...a. Every 15 minutes by RN (Registered Nurse), LPN (Licensed Practical Nurse) CT (Certified Technician), or UAP (unlicensed assisted personnel)

1. Observation, circulation, and safety checks

2. Behavior observations

b. Every 1 (one) hour by RN, LPN, CT, or UAP

1. General care needs

...f. Every 2 (two) hours by RN or LPN

1. Individual patient assessments and reassessments
2. Mental status
3. Restraint or seclusion justification
4. Patients response to the intervention(s) used, including the rationale for continued use of the intervention...

1. PI # 7 was admitted to the hospital on 6/16/23 with a diagnosis of Schizoaffective Disorder, Bipolar Type.

Review of the Geriatric Behavioral Nursing Notes dated 6/17/23 at 9:21 PM revealed the nurse documented PI # 7 was combative with staff and security.

Review of the Nursing Note dated 6/18/23 at 1:19 PM revealed the nurse documented "...when questioned, (patient) states that (he/she) will not hit staff today, remains in Posey vest and ankle restraints".

Review of the Nursing Note dated 6/19/23 at 6:00 PM revealed the nurse documented "...restraints in place...some verbal aggression...".

Review of the Nursing Note dated 6/20/23 at 6:00 PM revealed the nurse documented "...resting in bed in 4 (four) point restraints...".

There were no Restraint Observations (RO) Flowsheets provided for 6/18/23, 6/19/23, or 6/20/23 and no documentation the staff had performed the every 15 minute patient observations, every one hour general care needs, or every two hour patient assessments.

Review of the Nurses Note dated 6/23/23 revealed the nurse documented PI # 7 was in restraints x 4 and extremely combative and hostile.

Review of the RO Flowsheet dated 6/23/23 revealed the nurse documented patient was in wrist and ankle restraints for behavior and documented circulation checks at 7:00 PM and 9:00 PM.

There was no documentation of every 15 minute checks per policy.

An interview was conducted on 7/27/23 at 3:32 PM with Employee Identifier (EI) # 3, Chief Nursing Officer (CNO), who confirmed the staff failed to follow hospital policy for documenting patient assessments for patients with violent and destructive behavior.




40119

2. PI # 8 was admitted to the hospital on 7/23/23 with diagnoses including Acute Hypoxic and Hypercarbic Respiratory Failure and Chronic Obstructive Pulmonary Disease Exacerbation.

Review of the nursing notes dated 7/23/23 and 7/25/23 revealed the nurse documented restraints as a safety intervention.

Further review of the nursing notes dated 7/23/23 to 7/25/23 revealed no documentation the following was observed and/or assessed related to the restraint use: observation, circulation, safety checks, general care needs, individual patient assessment and/or reassessment, mental status, restraint justification and the patient's response to the restraint including the rationale for continued use of the restraint.

An interview was conducted on 7/25/23 at 11:34 AM with EI # 10, Registered Nurse for PI # 8, and EI # 7, Assistant CNO. EI # 10 verbalized PI # 8 had been in restraints, and he/she removed the restraints on 7/25/23 around 7:00 am. EI # 7 confirmed the hospital staff failed to document the monitoring of the restraint per hospital policy.

Based on review of medical records (MR), hospital policies and procedures, and interviews with staff, it was determined the hospital failed to ensure care of central lines and wound assessments were documented per hospital policy.

This deficient practice affected two of two patients with central lines, and one of one patients with wounds including Patient Identifier (PI) # 7, PI # 12, and PI # 9, and had the potential to affect all patients admitted to this hospital.

Findings include:

Hospital Policy: Central Line: Procedure for Insertion and Care

Policy number: not provided

Revised: 3/11

... Procedure for Dressing Change

1. ...Change dressing: Monday, Wednesday, Friday at 0600 (6:00 AM), and PRN (as needed).

...3. Remove old dressing...observe the insertion site for redness and/or swelling...

4. ...cleanse the site with Betadine swabs...topically apply Betadine ointment.

5. ...apply clear dressing to cover the catheter.

6. Clean each catheter hub with a 70 % (percent) alcohol prep...

...8. Document dressing changes in the electronic medical record, indicating:

a. Dressing change

b. Appearance of the site

Facility Policy: Wound Care Management
Policy Number: None
Revised Date: 07/22

Admission Wound Assessment:

...Nursing service will perform daily wound care as ordered and document.

Prevention:

...10. Report and chart the first evidence of pressure sores. Documentation within the EMR (electronic medical record) should include staging, drainage (color and amount if present), areas involved, and interventions performed.

1. PI # 7 was admitted to the hospital on 6/16/23 with a diagnosis of Schizoaffective Disorder, Bipolar Type.

Review of the Nursing Note dated 6/27/23 at 6:00 PM revealed the TLC (Triple Lumen Catheter) Central Line was in place to the right Internal Jugular.

Review of the IV (Intravenous)/Invasive Line Assessment revealed the Central Line care was provided on 6/30/23. The next central line care was documented on 7/6/23 which was six days since the last dressing change.

Further review of the Nursing Notes revealed the Central Line was pulled out per patient on 7/8/23. There was no other documentation of central line care provided.

An interview was conducted on 7/27/23 at 3:32 PM with Employee Identifier (EI) # 3, Chief Nursing Officer, (CNO), who confirmed the care of the central line was not provided per hospital policy.



41624

2. PI # 12 was admitted to the facility on 7/10/23 with a diagnosis of AKI (Acute Kidney Injury) with acute tubular necrosis.

Review of the 7/15/23 6:20 PM Nursing Note revealed the Skilled Nurse (SN) documented, "Dressing to vascath (central line) right neck changed using sterile technique."

There was no documentation of site appearance, what was utilized for skin anti-sepsis, or what dressing was utilized with the dressing change.

An interview was conducted on 7/28/23 at 2:24 PM with EI # 7, Assistant Chief Nursing Officer, who confirmed the dressing change was not documented per facility policy.

3. PI # 9 was admitted to the facility on 7/23/23 with diagnoses including Respiratory Failure and Sepsis from Pneumonia.

Review of the Wound Consult Note dated 7/25/23 by EI # 20, Registered Nurse (RN) revealed EI # 20 documented PI # 9 had a new stage two pressure wound to the right hip. The consult note included orders for wound care every other day to cleanse with Vashe, and apply hydrocolloid dressing.

Review of the 7/26/23 9:00 AM SN Assessment Note revealed the SN documented under Clean Wound, "Yes." There was no documentation of what was utilized to clean the wound and what dressing was applied. There was no documentation of the wound site, including appearance, drainage or odor.

An interview was conducted on 7/28/23 at 2:08 PM with EI # 3 who confirmed the SN did not document the wound appearance and wound care per policy.

Based on observation, hospital policies, Centers for Disease Control and Prevention (CDC) Injection Safety, and interview, it was determined the facility failed to ensure:

1. Opened medication vials and solutions were labeled with the date opened.

2. Single use vials were not opened, stored and available for future use.

3. Expired medications were not available for patient use.

4. Medications were not used after the expired date.

This deficient practice had the potential to affect all patients receiving care at this hospital.

Findings include:

Hospital Policy: Multi-Dose Vials

Policy number: not provided

Revised: 9/19

Multi-Dose Vials.

It is a policy of Whitfield Regional Hospital that all multi-dose vials have the date initially used noted on the vial...

Hospital Policy: Monitoring Monthly of Expiration Dates

Policy number: not provided

Revised: 3/22/21

All drugs in the hospital will be checked for appropriate dating and integrity at least monthly... If an out-of-date drug is discovered, it is pulled from the shelf immediately...

CDC Injection Safety

Reviewed: 6/20/19

Questions about Single-dose/Single-use Vials

A single-dose or single-use vial is a vial of liquid medication intended for parenteral administration (injections or infusion) that is meant for use in a single patient for a single case, procedure, injection.

Single-dose or single-use vials are labeled as such by the manufacturer and typically lack an antimicrobial preservative...Vials that are labeled as single-dose or single-use should be used for only a single patient as part of a single case, procedure, injection...

If a single-dose or single-use vial has been opened or accessed (e.g., needle-punctured) the vial should be discarded... It should not be stored for future use.




40119

1. During a tour of the Geriatric Behavioral Health unit on 7/25/23 at 1:30 PM, with Employee Identifier (EI) # 3, Chief Nursing Officer, the following was identified:

a. Vashe wound solution 250 milliliters (ml) opened without a date.

b. Hydrogen Peroxide 3 % 473 ml opened without a date.

c. 0.9 % Sodium Chloride injection 20 ml, labeled as a single dose vial, was opened without a date, expired 6/1/23, and stored for future use.

d. 0.9 % Sodium Chloride injection 20 ml, labeled as a single dose vial, was opened 6/25/23, expired 6/1/23, and stored for future use.

e. 0.9 % Sodium Chloride injection 20 ml expired 6/1/23.

f. Bacteriostatic water for injection, 0.9 % benzyl alcohol added 30 ml vial opened without a date.

An interview was conducted during the tour with EI # 3, who confirmed the above opened medication vials and solution without the date opened, storage of a single use vial for future use, use of expired medications, and expired medication available for patient use were against the hospital policy.

Based on observations, review of hospital policies and procedures, and interviews with staff it was determined the hospital failed to ensure:

1. Freezer temperatures were monitored and action taken when above zero degrees.

2. Dietary service equipment and work areas were clean and kept free of encrusted grease deposits and/or accumulated soil.

This had the potential to affect all patients admitted to the hospital.

Findings include:

Hospital Policy: 5.17 Equipment Temperatures
Section: Sanitation and Infection Control
Revision Date: 12/2016

Policy: Equipment Temperatures

Department ... freezer... temperatures are checked and recorded twice daily.

Procedure:

1. All department...freezers and reach-in...temperatures are recorded utilizing the ... Freezer Temperature Log...

...4. Freezer storage temperatures are at or below 0 degrees (F) Fahrenheit

...6. Any discrepancies in temperature must be reported immediately to the general manager/director of dining services.

Policy: 7.3 Surface: Cleaning...
Revision Date: None

Policy:

Team members must maintain the food service operation in a clean and sanitary manner.

Procedure:

Clean surfaces.

Non-Food Contact Surfaces. Must be cleaned and rinsed.

Examples: ...floors,... equipment exteriors...

When: as necessary

Steps to Clean, Rinse... in the following order:

Remove food particles from the surface areas.

Wash the surface utilizing an approved cleaner and cleaning tool.

Rinse the surface with clean water, utilizing the correct cleaning tool,...

A tour of the dietary department was conducted on 7/25/23 at 10:07 AM with Employee Identifier (EI) # 4, Director of Administration and EI # 5, Dietary Director. The following deficient practices were observed.

a. During the tour, an observation of the Walk-In (WI) freezer temperature reading was 9 degrees F. Review of the Daily Temperature Logs (DTL) dated May 1, 2023 to July 24, 2023 revealed the WI freezer temperatures were consistently above zero degrees F with no documentation of decrepanices reported to the general manager or director of dining services.

Further review of the DTL revealed the Reach In (RI) freezer daily temperature readings dated June 12, 2023 to July 24, 2023 a temperature above zero degree F each day with no documentation of decrepanices reported to the general manager or director of dining services.

EI # 5, who was present on the tour, confirmed the out of range temperatures had not been reported to anyone. The staff failed to ensure freezer temperatures were maintained at zero degrees or below.

b. Observation of the cooking area revealed two (2) gas stovetops (Range); the first was a ten (10) burner gas stovetop with only six (6) burners available for use. There were crumbs with build up of encrusted grease and grime on the stovetop and the oven had rust buildup. The second, was a six (6) burner gas stovetop with two (2) burners available for use. The oven had encrusted grease deposits and/or accumulated soil buildup inside the oven and on the interior side of the door. EI # 5 reported the gas stove oven has not been in use since his/her date of hire in 2019.

There was a black grime and grease buildup in between the tile sections and on the outline of the floor mats on the floors in the cooking area.

Review of the Food Safety and Sanitation Audits dated May 24, 2023 to July 24, 2023, conducted by EI # 19, Dietitian, revealed on 5/24/23 maintenance was made aware of floors needing deep cleaning and Range with grease build-up was out of compliance on 7/24/23.

There was no documentation the stovetop burners and gas oven were reported as needing repair.

An interview was conducted on 7/26/23 at 9:30 AM with EI # 4, EI # 5 and EI # 19, who confirmed the listed observations were deficient practices and not in accordance with hospital polices.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations, and A 724 for findings.

Based on observations, Labor and Delivery crash cart log, hospital policy and procedure, and interviews, it was determined the staff failed to:

1. Check, test and document the defibrillator on was ready to use daily.

2. Ensure expired supplies were not available for patient use.

3. Ensure sterile supplies were stored unopened to maintain sterility.

This deficient practice had the potential to affect all patients receiving care at this hospital.

Findings include:

Hospital Policy: Crash Cart Checks and Inventory Control
Policy Number: None listed
Revised date: 9/19

Emergency carts are standardized throughout Whitfield Regional Hospital to enhance staff response time during code situations, ensure availability of drugs, equipment and supplies necessary to initiate advanced life-support measures...

To ensure the carts are always stocked and ready for use:

-The defibrillator and cardiac monitor shall be checked and appropriately documented for performance on both battery and electrical current once every 24 hours except when the unit is closed...

The following responsibilities are designated:

Designated licensed personnel are responsible to ensure:

...Defibrillator check, plugged and unplugged, to ensure proper working order. If the defibrillator is not in working condition (both plugged and unplugged), bio-med and the nursing supervisor is to be contacted immediately.

1. A tour of the Labor and Delivery Unit (L&D) was conducted on 7/25/23 at 1:24 PM, accompanied by Employee Identifier (EI) # 9, Director of L&D and Emergency Department. The following items were expired and available for patient use:

a. Observed in the baby supply room were 15 yellow-topped microtainer's with an expiration date 5/31/23, used for Phenyl (PKU) testing collection available for patient use.

b. Observed in the soiled utility room was a single 20 milliliter (ml) syringe with 1 and 1/2 inch needle attached, out of its sterile packaging, in a utility cart drawer, available for patient use.

Review of the crash cart log revealed no documentation the defibrillator/crash cart had been checked for the following dates:

7/21/2023
7/22/2023
7/23/2023
7/24/2023
7/25/2023

An interview was conducted on 7/25/2023 at 1:24 PM, with EI # 9, who was also present during the tour, confirmed the crash cart log was not initialed on those dates and it appeared staff failed to check, test and document the crash cart/defibrillator every 24 hours for the above listed dates and confirmed the expired supplies were available for patient use.

2. A tour of the Post-Anesthesia Care Unit was conducted on 7/26/23 at 9:26 AM, accompanied by EI # 8, Director, Perioperative Services. The following items were expired and available for patient use in the malignant hyperthermia cart.

a. One Intravenous (IV) Administration set with an expiration date of 8/23/21 available for patient use.

b. One IV extension set with an expiration date of 10/31/20 available for patient use.

c. One Becton-Dickinson (BD) Pro Edge three ml luer lock (ll) syringe with 20 gauge 1 and 1/2
inch needle with a tear in its sterile packaging available for patient use.

An interview was conducted on 7/26/23 at 9:26 AM with EI # 8, who was present during the tour, confirmed the items were expired and available for patient use.



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3. During a tour of the Geriatric Behavioral Health unit on 7/25/23 at 1:30 PM, with EI # 3, Chief Nursing Officer, the following supplies were observed and available for patient use:

a. Six opened Silvercel non-adherent antimicrobial alginate sterile dressing 2 x 2 (two by two), which expired on 10/31/22.

b. Two opened Aquacel Ag advantage 2 x 2 sterile dressings.

c. Opened package of one sterile 4 x 4 gauze.

d. Opened package of one sterile 8 x 10 abdominal pad dressing.

e. Opened Drawtex hydro conductive sterile 4 x 4 wound dressing.

An interview was conducted with EI # 3, Chief Nursing Officer, who was present during the tour, who confirmed opened and/or expired supplies should not be available for patient use.

Based on observations, United States (US) Federal Drug Administration (FDA) Guidelines for Sharps Containers in Health Care Facilities, Centers for Disease Control and Prevention (CDC): Frequently Asked Questions (FAQs) regarding Safe Practices for Medical Injection, CDC: Guidelines for the Prevention of IV Catheter-Related Infections, CDC: Best Practices for Environmental Cleaning in Healthcare Facilities, Medical Staff Executive Committee Minutes, Sanderling Renal Services Policy and Procedures for Acute Dialysis Services, hospital policy and procedures, and interviews, It was determined the facility failed to ensure staff:

a. Care and dressing changes were provided for patients with Central Line Catheters.
b. Disposed of sharps containers per US FDA Guidelines for Sharps Containers in Health Care Facilities.
c. Cleaned the rubber septum of the vial of medication in an aseptic manner per CDC guidelines.
d. Performed hand hygiene per hospital policy.
e. Performed antisepsis per policy prior to cannulation of an AVG (ArterioVenous Graft).
f. Cleaned the access port of the needleless Intravascular (IV) catheter or tubing prior to medication administration.
g. Disinfected the accucheck machine and stethoscope after patient use.

Refer to tag A 0749 for findings.

Based on observations, United States (US) Federal Drug Administration (FDA) Guidelines for Sharps Containers in Health Care Facilities, Centers for Disease Control and Prevention (CDC): Frequently Asked Questions (FAQs) regarding Safe Practices for Medical Injection, CDC: Guidelines for the Prevention of IV Catheter-Related Infections, CDC: Best Practices for Environmental Cleaning in Healthcare Facilities, Medical Staff Executive Committee Minutes, Sanderling Renal Services Policy and Procedures for Acute Dialysis Services, hospital policy and procedures, and interviews, It was determined the facility failed to ensure staff:

a. Care and dressing changes were provided for patients with Central Line Catheters.

b. Disposed of sharps containers per US FDA Guidelines for Sharps Containers in Health Care Facilities.

c. Cleaned the rubber septum of the vial of medication in an aseptic manner per CDC guidelines.

d. Performed hand hygiene per hospital policy.

e. Performed antisepsis per policy prior to cannulation of an AVG (ArterioVenous Graft). This did affect one of one observations of inpatient hemodialysis, including Patient Identifier (PI) # 14.

f. Cleaned the access port of the needleless Intravascular (IV) catheter or tubing prior to medication administration.

g. Disinfected the accucheck machine and stethoscope after patient use.

These deficient practices affected one of two patients with central line catheters including PI # 7, one of one observations of inpatient hemodialysis including PI # 14, three of eleven observations of care including PI # 11, PI # 20, Unsampled Patient (UP) # 1, and had the potential to negatively affect all patients admitted to the facility.

Findings Include:

Hospital Policy: Central Line: Procedure for Insertion and Care

Policy number: not provided

Revised: 3/11

... Procedure for Dressing Change

1. ...Change dressing: Monday, Wednesday, Friday at 0600 (6:00 AM), and PRN (as needed).

...8. Document dressing changes in the electronic medical record, indicating:

a. Dressing change

b. Appearance of the site

US FDA Sharps Disposal Containers in Health Care Facilities.
Date: 4/29/21

Sharps disposal containers are made from rigid puncture-resistant plastic or metal with leak-resistant sides and bottom..."Sharps" is a term for objects with sharp points or edges that can puncture skin or cut skin such as needles, syringes, lancets, auto injectors, infusion sets, and connection needles...

Disposal of Sharps Disposal Containers

Sharps disposal containers are marked with a line to indicate when the container is about three-fourths (3/4) full...close and seal sharps disposal containers when about 3/4 full...

CDC: FAQs Regarding Safe Practices for Medical Injections:

Medication Preparation Questions

1. How should I draw up medications?

Parenteral medications should be accessed in an aseptic manner (free from contamination caused by harmful bacteria, viruses, or other microorganisms).This includes using a new sterile syringe and sterile needle to draw up medications while preventing contact between the injection materials and the non-sterile environment... the rubber septum should be disinfected with alcohol prior to piercing it.

CDC: Guidelines for the Prevention of IV Catheter-Related Infections, 2011

...Needleless IV Catheter Systems.

Recommendations:

...4. Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70 % alcohol) and accessing the port only with sterile devices...

CDC: Best Practices for Environmental Cleaning in Healthcare Facilities
Reviewed Date: 4/21/2020

...4. Environmental Cleaning Procedures.

...4.7 Noncritical patient care equipment...noncritical patient care equipment includes...stethoscopes. Theses high-touch items are:

Used by healthcare workers to touch patients (i.e., stethoscopes)...often shared between patients.

...Recommended selection and care of noncritial patient care equipment.

Type of equipment...shared (e.g. general inpatient wards)...before and after each use..clean and disinfect...

Facility Policy: Infection Control -Hand Hygiene
Page Number: 20
Revised Date: 3/2020

Policy:

A. Objective:

The purpose of this policy is to outline indications for and methods of hand hygiene for personnel in a patient care setting at Whitfield Regional Hospital. Hand Hygiene measures are the single most important prevention strategy for avoiding healthcare-associated infections (HAI)...All staff will adhere to this policy to reduce the transmission of microorganisms to patients and other personnel.

Procedure:

A. Hand Hygiene Indications

1. Hand hygiene with either waterless hand sanitizer or soap and water is required:

...- Before donning and after removing gloves
- Before handling an invasive device (regardless of whether or not gloves are used)
- ...Before handling...oral medications.

...C. Routine Hand Hygiene Techniques.

...2. Handwashing with soap and water requires a minimum of 15 seconds to be effective. It can be accomplished in the following manner:

...b. Apply soap.
c. Vigorously rub together all surfaces of lathered hands for 15 seconds.
...f. Use a dry paper towel to turn off faucets to avoid recontamination.

Facility Medical Staff Executive Committee Minutes:
Date: June 18, 2019

BWWMH (Bryan W. Whitfield Memorial Hospital) will be rolling out the new inpatient dialysis program effective July 1st...

Motion: Medical Staff approval of the adoption of Sanderling's dialysis policies and procedures for our hospital's dialysis program.

Motion Carried.

Sanderling Renal Services Policy: Adoption of Hospital Policies and Procedure For Acute Dialysis Services
Policy Number: None
Revision Date: April 30, 2019

II. Purpose:

To provide acute dialysis services within compliance of hospital policies and procedures.

III. Responsibility:

All acute program dialysis qualified patient care staff

IV. Procedure:

1. A hospital representative will in-service the Acute Nurse Manager on general hospital policies and procedures...

...6. All dialysis clinic staff members who administer acute dialysis treatments within the hospital will be educated on adopted hospital policies and procedures...

Sanderling Renal Services Policy: Cannulation with Safety Needle Device
Policy Number: None
Creation Date: 11/02/12

Policy:

1. Chloroprep is the preferred cleansing agent for vascular access site care...Approved alternative cleansing agents:

...b. 70% (percent) Alcohol: clean site for one minute using multiple swabs per site...

Supplies:

PPE (Personal Protective Equipment)

ALABAMA DEPARTMENT OF PUBLIC HEALTH

BLOODBORNE PATHOGENS EXPOSURE PLAN INFECTION PREVENTION

BUREAU OF COMMUNICABLE DISEASE

Revised: 2/2013

... Sharps Containers 1. Immediately, or as soon as possible after use, contaminated sharps will be placed in appropriate containers until properly processed. These containers are:

...d. easily accessible to personnel, but out of reach of clients

e. located as close as possible to area of use

...g. not allowed to overfill

Hospital Policy: Cleaning and Disinfecting the Accu-Check Inform II System Components

Policy number: not provided

Policy date: not provided

... The FDA (Food and Drug Administration) recommends that Point of Care testing devices, such as blood glucose meters, should be used on one patient and not shared. If dedicating blood glucose meters to a single patient is not possible, the meters must be properly cleaned and disinfected after every use ...

1. PI # 7 was admitted to the hospital on 6/16/23 with diagnosis of Schizoaffective Disorder, Bipolar Type.

Review of the Nursing Note dated 6/27/23 at 6:00 PM revealed the TLC (Triple Lumen Catheter) Central Line was in place to the right Internal Jugular.

Review of the IV (Intravenous)/Invasive Line Assessment revealed the Central Line care was provided on 6/30/23. The next documented dressing change was on 7/6/23 which was six days since the last dressing change.

Further review of the Nursing Notes revealed the Central Line was pulled out per patient on 7/8/23. There was no other documentation of central line care provided.

An interview was conducted on 7/27/23 at 3:32 PM with Employee Identifier (EI) # 3, Chief Nursing Officer, CNO, who confirmed the care of the central line was not provided per hospital policy.

2. A tour of the surgical suites was conducted on 7/25/23 at 10:40 AM, accompanied by Employee Identifier (EI) # 8, Director of Perioperative Services.

Upon entering Operating Room (OR) # one, a disposable sharps container was observed to be above the 3/4 line, full and still in use.

An interview was conducted on 7/25/23 at 10:40 AM with EI # 8, who was present during the tour, confirmed the sharps container was above the 3/4 line, full and should have disposed.

3. A tour of the hospital's Med Surg (Medical Surgical) unit area was conducted on 7/25/23 at 1:10 PM with EI # 17, Registered Nurse (RN), House Supervisor. The surveyor observed one overflowing biohazard sharps container box, filled above the empty line attached to the crash cart.

An interview was conducted on 7/25/23 at 1:10 PM with EI # 17, who was present during the tour, confirmed the biohazard sharps container box was filled above the empty line.

4. A tour of the Labor and Delivery (L&D) Unit was conducted on 7/25/23 at 1:24 PM, accompanied by EI # 9, Director of L&D and the Emergency Department.

Upon entering the soiled utility room, a disposable sharps container was observed to be above the 3/4 line, full and still in use.

An interview was conducted on 7/25/23 at 1:47 PM with EI # 9, who confirmed the sharps container was full and should have been disposed.

5. An observation was conducted on 7/25/23 at 2:30 PM with EI # 11, RN, to observe oral medication administration.

During the observation, EI # 11 failed to perform hand hygiene prior to handling oral medications.

An interview was conducted on 8/8/23 via phone at 11:30 AM with EI # 3, Chief Nursing Officer (CNO), who confirmed EI # 11 failed to follow the hospital policy for hand hygiene.

6. An observation of wound care on the Med Surg unit was conducted on 7/25/23 at 3:42 PM with EI # 20, RN. EI # 20 rolled Patient Identifier (PI) # 11 to the left side, removed the diaper, removed the gauze, and measured the wound.

EI # 20 then removed the gloves, failed to perform hand hygiene, then reached inside his/her uniform pocket, took out a personal cell phone and called the physician to report wound care status and received verbal orders for patient wound care. EI # 20 applied a clean pair of gloves without performing hand hygiene. EI # 20 provided wound care, removed gloves, washed hands at bathroom sink and used wet left hand to turn off sink faucet.

An interview was conducted on 7/26/23 at 2:37 PM with EI # 6, RN Clinical Program Director, confirmed hand hygiene was not performed per hospital policy.

7. An observation was conducted on 7/26/23 from 6:51 AM to 10:14 AM in OR # 1, to observe a Right Carpel Tunnel on PI # 20. EI # 8 was also present in the OR.

Upon entering OR # 1 at 7:43 AM, EI # 16, Certified Registered Nurse Anesthetist (CRNA), was observed drawing up medicine in preparation for the upcoming surgery. The following was observed during medication preparation:

a. Fentanyl Citrate 100 micrograms (mcg). Staff failed to disinfect the septum of the vial of Fentanyl with an alcohol prep pad prior to inserting the needle, per CDC guidelines.

b. Glycopyrrolate 0.4 milligrams (mg). Staff failed to disinfect the septum of the vial of Glycopyrrolate with an alcohol prep pad prior to inserting the needle, per CDC guidelines.

c. Zofran 4 mg. Staff failed to disinfect the septum of the vial of Zofran with an alcohol prep pad prior to inserting the needle, per CDC guidelines.

d. Dexamethasone sodium phosphate 4 mg. Staff failed to disinfect the septum of the vial of Dexamethasone sodium phophate with an alcohol prep pad prior to inserting the needle, per CDC guidelines.

e. Midazolam 2 mg. Staff failed to disinfect the septum of the vial of Midazolam with an alcohol prep pad prior to inserting the needle, per CDC guidelines.

f. Propofol 200 mg. Staff failed to disinfect the septum of the vial of Propofol with an alcohol prep pad prior to inserting the needle, per CDC guidelines.

An interview was conducted on 7/26/23 at 9:26 AM with EI # 8, who confirmed staff failed to disinfect the septums of the vials of medications per CDC guidelines.

8. An observation was conducted on 7/26/23 at 8:23 AM with EI # 12, RN, to observe an IV placement.

During the observation, EI # 12 failed to perform hand hygiene twice, prior to donning gloves, and once after removing gloves.

An interview was conducted on 8/8/23 via phone at 11:30 AM with EI # 3, CNO, who confirmed EI # 12 failed to follow the hospital policy for hand hygiene.

9. An observation was conducted on 7/26/23 at 9:00 AM with EI # 13, RN, to observe an IV medication administration.

During the observation:

EI # 13 performed hand hygiene using soap and water three times. EI # 13 applied soap and lathered for two seconds the first time hand hygiene was performed and lathered for three seconds the next two times. EI # 13 failed to lather hands for 15 seconds per hospital policy.

EI # 13 used his/her bare hand to turn the faucet off after performing hand hygiene in each of the three times hand hygiene was performed.

EI # 13 failed to disinfect rubber septum of Lasix vial with alcohol prior to piercing it.

EI # 13 failed to disinfect needleless IV catheter hub prior to administering Lasix via IV push method.

EI # 13 failed to disinfect needleless IV catheter hub prior to connecting the Vibramycin IV administration tubing and starting the IV administration.

An interview was conducted on 8/8/23 via phone at 11:30 AM with EI # 3, CNO, who confirmed EI # 13 failed to follow the hospital policy for hand hygiene, CDC Safe Practices for Medical Injection and CDC Guidelines for the Prevention of IV Catheter-Related Infections.

10. An observation was conducted on 7/26/23 at 11:25 AM with EI # 15, Patient Care Technician, to observe the monitoring of a blood glucose using the Accucheck machine.

During the observation, EI # 15 failed to clean the Accucheck machine prior to and after obtaining the patient's blood glucose. After use of the Accucheck machine, EI # 15 placed the machine at the nurses station to be available for use on other patients.

An interview was conducted on 8/8/23 via phone at 11:30 AM with EI # 3, CNO, who confirmed EI # 15 failed to follow the hospital policy for the disinfection of the Accucheck machine.

11. An observation was conducted on 7/26/23 at 1:14 PM with EI # 14, Respiratory Therapist, to observe the administration of a nebulizer treatment.

During the observation, EI # 14 used a stethoscope hanging around his/her neck to assess the patient's lung sounds prior and post nebulizer treatment. EI # 14 failed to disinfect the stethoscope prior to and after patient use.

An interview was conducted on 8/8/23 via phone at 11:30 AM with EI # 3, CNO, who confirmed EI # 14 failed to follow the CDC's recommendations for the disinfection of a stethoscope.

12. An observation of wound care on the Wound Care Clinic unit was conducted on 7/26/23 at 2:31 PM with EI # 6 on an unsampled patient. EI # 6 removed bandage from patient's left foot and disposed soiled bandage in biohazard waste trash can. EI # 6 used dirty gloves to open sterile gauze and wound cleaner. EI # 6 failed to removed gloves and perform hand hygeine after handling soiled dressing.

With same dirty gloves EI # 6 cleaned wound site. EI # 6 removed gloves, applied clean gloves and obtained the patient's vital signs. EI # 6 failed to perform hand hygiene after removing gloves.

EI # 6 removed gloves, applied clean gloves and measured patient's wound. EI # 6 failed to perform hand hygeine after removing gloves.

An interview was conducted on 7/26/23 at 2:37 PM with EI # 6, RN, Clinical Program Director, confirmed hand hygiene was not performed per hospital policy.

13. An observation was conducted on 7/28/23 at 8:15 AM to observe hemodialysis provided to PI # 14 by EI # 22, Certified Clinical Hemodialysis Technician (CCHT).

During the observation, EI # 22 performed hand hygiene, applied gloves, and opened two needles in preparation for cannulation. EI # 22 then performed anti-sepsis to the arterial side of PI # 14's AVG with a 70 % (percent) alcohol pad for a total of eight seconds, then picked up a needle wearing the same gloves and successfully cannulated and secured the needle to the arterial side of the AVG.

EI # 22 proceeded to perform antisepsis to the venous side of the AVG for a total of eight seconds utilizing a 70 % alcohol pad, and attempted unsuccessfully to cannulate the venous side of the AVG still wearing the same gloves.

EI # 22 then proceeded to remove his/her gloves, performed hand hygiene, applied new gloves, and performed anti-sepsis to the venous side of the AVG with a 70 % alcohol pad for a total of six seconds. EI # 22 picked up the needle, successfully cannulated and secured the needle to the venous side of the AVG, and connected the dialysis machine lines, still wearing the same gloves.

EI # 22 failed to follow facility policy to perform hand hygiene prior to handling an invasive device, and failed to follow Sanderling Renal Services policy to perform anti-sepsis for one minute prior to cannulation.

These observations were confirmed on 7/28/23 at 4:00 PM with EI # 3.



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Based on review of medical records (MR), facility policy, and interviews staff it was determined the facility failed to ensure the discharge evaluation was documented and in the patient's MR. This affected two of three discharged MR's reviewed, and did affect Patient Identifier (PI) # 12, and PI # 6, had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy: Discharge Planning
Policy Number: None
Revised Date: 5/21

Policy:

...The assessment may begin prior to admission, but in no event later than at the time of the admission assessment.

...The purpose of discharge planning is to identify a patient's unique need for continuing...needs and to arrange services to meet those needs.

Procedure:

...Each discipline assesses needs for after care as part of their ongoing assessment and reassessment process...All pertinent information shall be documented in the EMR (electronic medical record). The discharge planning evaluation must include an evaluation of the likelihood of a patient needing post-hospitalization services and the availability of the services. The discharge planning evaluation must be in the patient's medical record for use in establishing an appropriate discharge plan. There must be documentation of discussion of the results of the evaluation with the patient or the individual acting on his or her behalf.

1. PI # 12 was admitted to the facility on 7/10/23 with a diagnosis of AKI (Acute Kidney Injury) with acute tubular necrosis, and discharged on 7/23/23.

Review of the MR revealed there was no documentation of a discharge planning evaluation.

In an interview on 7/28/23 at 2:24 PM with EI # 7, Assistant Chief Nursing Officer, EI # 7 provided a Social Services Note dated 7/11/23 at 8:49 AM which documented, "Will continue to assess dc (discharge) needs." The surveyor requested documentation of the discharge needs assessed/discharge evaluation, and EI # 7 was unable to provide the requested documentation.

2. PI # 6 was admitted to the facility on 7/24/23 with a diagnosis of suicidal ideation, and discharged on 7/27/23.

Review of the MR revealed no documentation of a discharge planning evaluation.

In an interview on 7/28/23 at 2:24 PM with EI # 7, the surveyor asked for documentation of discharge planning. EI # 7 provided several late entries dated 7/27/23, the date PI # 6 was discharged, for a discharge plan follow up appointment, but was unable to provide a discharge planning evaluation.

Based on review of medical records (MR), facility policy, and interview, it was determined the facility failed to document a list of Home Health Agencies (HHA) available to the patient was provided to the patient and caregiver prior to discharge from the facility.

This affected one of one MR's reviewed with a HHA referral, and did affect Patient Identifier (PI) # 12, and had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy: Discharge Planning
Policy Number: None
Revised Date: 5/21

Policy:

...The purpose of discharge planning is to identify a patient's unique need for continuing physical,...needs and to arrange services to meet those needs. Discharge services may include:

...Home Health Services

Procedure:

...All pertinent information shall be documented in the EMR (electronic medical record). The discharge planning evaluation must include an evaluation of the likelihood of a patient needing post-hospitalization services and the availability of the services...There must be documentation of discussion of the results of the evaluation with the patient or the individual acting on his or her behalf.

1. PI # 12 was admitted to the facility on 7/10/23 with a diagnosis of AKI (Acute Kidney Injury) with acute tubular necrosis, and discharged on 7/23/23.

Review of the 7/24/23 9:34 AM note by Employee Identifier (EI) # 23, RN (Registered Nurse) Case Manager, revealed EI # 23 documented PI # 12 was discharged on 7/23/23 with a need for HHA services, and had contacted PI # 12 that morning regarding his/her choice for home health care.

There was no documentation PI # 12 had been provided a list of the HHA in his/her geographic region that were available to him/her.

In an interview on 7/28/23 at 2:24 PM with EI # 7, Assistant Chief Nursing Officer, EI # 7 confirmed it was facility policy to provide patients with a form that outlined HHA choices and affiliations, and there was no documentation the form was provided to the patient.