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2. A review of Patient 8's clinical record revealed he was admitted to the facility on April 22, 2013, with diagnosis of appendicitis. On admission, the Consent or Refusal for Blood Transfusion was provided to the patient. However, the section under Physician Certification that "A Patient's Guide to Blood Transfusion" concerning the advantages, disadvantages, risks and benefits of autologous blood and of directed and non-directed homologous blood from volunteers was not signed by the physician.

During an interview with RN 6 on April 24, 2013, at 9:45 a.m., she stated the section on Physician Certification should have been signed by the physician.

A review of the facility's policy on Paul Gann Blood Safety Act stipulated the physician must note in the patient's medical record that the standardized written summary was given to the patient or patient's legal representative.

3. On April 22, 2013, at 10:15 a.m., Patient 6's medical record was reviewed. The Admission/ Registration form indicated the patient was admitted to the facility on April 22, 2013 at 6:04 a.m., for alcohol intoxication.

A review of the Conditions of Admissions form revealed under Patient/ Parent/ Conservator/Guardian signature was blank. Patient 6 was unable to sign and a witness signed and dated the form.

The nurses notes dated 4/22/13 at 11:43 a.m., indicated the patient was discharged to home in stable condition, written and verbal after care instructions given and verbalizes understanding of instruction.

During a concurrent interview, Admin 4 stated the Conditions of Admission form should be signed by the patient when they are in stable condition before discharged. The RN would notify admitting office when the patient is ready for discharge.


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Based on record reviews and interviews, the facility failed to ensure the patient/his or her representative has the right to make decisions regarding his or her care. For Patient 2, the medical record failed to indicate that the physician had discussed the procedure's risk and benefits with Patient 2's representative, and obtained a signed informed consent for a peripherally inserted central catheter (PICC - a form of intravenous access that can be used for a prolonged period of time). For Patient 8, the section Physician Certification for the Consent or Refusal for Blood Transfusion was not signed by the physician. For Patient 6, the Conditions of Admission form was not signed by the patient or patient representative.

Findings:

1. The clinical record for Patient 2 was reviewed on April 24, 2013, at 8 a.m., with Registered Nurse (RN) 3. The "Admission/Registration" sheet indicated Patient 2 was admitted to the facility on April 9, 2013 with the admitting diagnosis of pneumonia.

The form "Peripherally Inserted Central Catheter Informed consent" dated April 16, 2013, at 8:30 a.m., indicated telephone consent was obtained from Patient 2's family member, and witnessed by 2 RNs. However, the form was not signed by the physician who obtained the consent from Patient 2's family member.

During a concurrent interview, RN 3 stated the physician was supposed to sign the consent form.

The facility policy titled "Consent, Informed" revised January 2010 indicated "4. The Informed Consent must consist of: ... 4.1.12. The anesthesiologist and/or physician obtaining the consent signs, dates and times in the appropriate location."

Based on observation, record review and interview, the facility staff failed to ensure a registered nurse supervises the nursing care for each patient. Patient 7 was wearing a diaper while using a specialty mattress. Patient 18 was not receiving oxygen as per physician order.

Findings:

On April 23, 2013, at 11:05 a.m., during the tour of the unit with RN 3, the following were observed:

1. Patient 7 was lying in a specialty mattress (low air loss), with an indwelling catheter in place. Upon closer observation of the patient, it was noted that the patient was wearing a diaper, a disposable Chux and a single linen underneath his buttock. On the patient's bedside was a hydrogel and Mepilex dressing used for wound care treatment.


A review of the Admission/Registration Form indicated Patient 7 was admitted to the facility on April 21, 2013, for intractable pain. The initial physical assessment on admission revealed the patient had a pressure ulcer on the right buttock, measures 5 cm by 4 cm by 1 cm, with serosanguineous drainage and re wound color.

During a concurrent interview, the certified nurse assistant (CNA) 1 stated when patient is on a specialty mattress/bed there should only be a Chux underneath the patient's buttock.

On April 24, 2013, at 8:45 a.m., during an interview, RN 3 stated the night nurse left the hydrogel/Mepilex at the patient's bedside.

The facility's policy on Bedside Medications and Self Administration stipulated the following: (a) Only certain categories of drugs, upon written orders by the physician are allowed for self-administration. The only medications which patients are allowed to self-administer were topical ointments, creams and lotions; (b) Bedside medications are kept away (secured) from other patients/ visitors to have access to these medications.

A review of the facility's policy on Skin Integrity stipulated removing adult brief and reducing as much linen would optimize the therapeutic effects of the bed is recommended.

2. Patient 18 was observed sitting in a chair and receiving oxygen four liters (4) via nasal cannula.

A review of the Admission/Registration Form revealed the patient was admitted to the facility on April 21, 2013, for abdominal pain.

On April 23, 2013, the physician ordered oxygen three (3) liters via nasal cannula.

During a concurrent interview, while reviewing the clinical record, RN 3 stated the physician ordered 3 litters of oxygen and it should have been followed.

Based on record reviews and interviews, the facility failed to ensure the nursing staff develops, and keeps current, a nursing care plan for each patient. Patient 2 was receiving hemodialysis treatments at the bedside and did not have an individualized plan of care addressing the hemodialysis treatments. Patient 3 was on soft mittens restraints and did not have a plan of care for its use.

Findings:

1. The clinical record for Patient 2 was reviewed with Registered Nurse (RN) 3 on April 24, 2013, at 8 a.m. The clinical record indicated Patient 2 was receiving hemodialysis (a therapy that filters waste, removes extra fluid and balances electrolytes) at the bedside. Patient 2's care plans were reviewed with RN 3.

During the concurrent interview with RN 3, she was unable to find documentation of a plan of care addressing Patient 2's hemodialysis treatments and cares.

2. During the tour of the Intensive Care Unit (ICU) on April 23, 2013, at 12:05 p.m., Patient 3 was observed to have bilateral soft wrist restraints.

The clinical record for Patient 3 was reviewed with Admin 2, Director of ICU, on April 24, 2013, at 2:20 p.m. The clinical record indicated bilateral soft wrist restraints were ordered for Patient 2 on April 21, 2013, at 6:30 a.m. The restraints were ordered due to Patient 2 was attempting to pull out tubes, drains, or other lines medically necessary for treatment. The order indicated "Note restraint use on the patient's plan of care." The order for the restraints was renewed on April 21, 2013, at 7:02 p.m., on April 22, 2013, at 7 p.m., and April 23, 2013, at 7:05 p.m.

During the concurrent with Admin 2, she reviewed the electronic clinical record and stated she was unable to find documentation an individualized plan of care regarding the use of the bilateral soft wrist restraints.

The facility policy and procedure titled Patient Assessment and Care Planning Interdisciplinary revised February 2013 indicated, "A Registered Nurse will identify the Nursing care needs/problems based upon admission assessment data and initiate the plan of care. The plan of care will be reviewed for appropriateness, evaluated and updated daily as needed."

Based on record reviews and interviews, the facility failed to ensure the medication frequency order was followed for Patient 5 and for Patient 6, a medication was administered with no documented indication for use. Dilaudid (a narcotic pain reliever used to treat moderate to severe pain) was ordered to be given every 10 minutes to Patient 5. The nurse gave Dilaudid within 8 minutes from the previous dose. Patient 6 was assessed as having no pain, and was given Ibuprofen (medication use for minor pain relief and swelling).


Findings:

1. The clinical record for Patient 5 was reviewed on April 23, 2013, at 1:10 p.m. Patient 5 was admitted to the facility on April 23, 2013 for a laparoscopic cholecystectomy (a surgery to remove gallbladder and gallstones through several small incisions in the abdomen).

The "Post Anesthesia Care Unit Orders and Post Recovery Day Surgery Orders" dated April 23, 2013 indicated an order for "Hydromorphone/Dilaudid 1 milligram (mg) intravenous push every 10 minutes for severe pain. May repeat x 2."

The "PACU Nursing Record" dated April 23, 2013 indicated Dilaudid 1 mg was administered to Patient 5 at 8:50 a.m., 8:58 a.m., and 9:10 a.m.

During an interview with Registered Nurse (RN) 2 on April 23, 2013 at 1:20 p.m., RN 2 stated the CRNA (certified registered nurse anesthetist) who wrote the order usually writes the Dilaudid order frequency for every 5 minutes, instead of the actual order of every 10 minutes. RN 2 stated "I didn't check. The order is for every 10 minutes. I gave it 2 minutes early."

The facility policy titled "Medication Administration Procedure" revised October 2011 indicated the RN, LVN or student nurse may administer medication in accordance with the Six Rights of medication administration, of which included "right time".



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2. A review of Patient 6's clinical record revealed he was admitted to the Emergency Room on on April 22, 2013, at 6:09 a.m., for alcohol intoxication.

The nursing documentation during triage assessment indicated the patient had no pain. On the succeeding vital sign assessment at 6:26 a.m., 7:22 a.m., 8:27 a.m. and 10:16 a.m., the documentation indicated the patient was not experiencing pain (0/10).

At 7 a.m., it the documentation indicated the patient was administered 400 mg of Ibuprofen orally (by mouth). The medical record failed to show documentation why Ibuprofen was administered. Further review of the record revealed a physician order for Ibuprofen 400 mg (milligram) tablet P.O. (oral) with no indication for use.

During a concurrent interview with LVN 1, he concurred the medical record failed to show why Ibuprofen was administered when the patient was not experiencing pain.

Based on record reviews and interviews, the facility failed to ensure all orders for drugs and biologicals were documented and signed by an authorized practitioner, the orders were noted and signed by the noting registered nurse (RN).

Findings:

a. The clinical record for Patient 3 was reviewed with Registered Nurse (RN) 3 on April 24, 2013, at 10:12 a.m. The "Admission/Registration" sheet indicated Patient 3 was admitted to the facility on April 21, 2013 with respiratory failure.

A review of the "Physician Order Sheet" revealed telephone orders which were not signed by the practitioner within 48 hours as follow:

1. Telephone orders on April 21, 2013 @7 a.m. to admit Patient 3 to the Intensive Care Unit (ICU), intravenous orders, bilateral soft wrist restraints, continue ventilator settings, SCD's (Sequential Compression Devices-designed to limit the development of deep vein thrombosis and peripheral edema in immobile patients) and medications - Tylenol, Zofran, Protonix, Rocephin, Levaquin, Albuterol/Atrovent, and Diprivan.
2. Telephone orders on April 21, 2013, at 9 a.m., to start ventilator associated pneumonia reduction protocol.
3. The orders on April 23, 2013, untimed, for intraoperative orders were not signed by the physician.

During a concurrent interview, RN 3 stated the above telephone orders were not signed by the ordering physician. RN 3 cross-referenced the above orders with the electronic medical record and was unable to find documentation of physician signature of the orders.

b. The clinical record for Patient 2 was reviewed with RN 3 on April 24, 2013, at 8 a.m. The Admission/Registration sheet indicated Patient 2 was admitted to the facility on April 9, 2013 for pneumonia.

A review of the physician orders indicated for the dates below, the following orders were not signed by the practitioner within 48 hours:

1. A telephone order from a Physician Assistant (PA) on April 9, 2013, at 9:41 p.m., to give 20 units of Regular Insulin subcutaneously, and to check the patient's blood sugar via Accucheck machine every 4 hours with an aggressive sliding scale.

2. An untimed telephone order on April 12, 2013 for hemodialysis for that day and to set the ultrafiltration rate as tolerated.

3. An untimed telephone order on April 26, 2013 for peripherally inserted central catheter placement (PICC) and for lidocaine 1% 0.5 milliliters (ml), titrate up to 5 ml subcutaneous with PICC line insertion.

4. A telephone order from a Nurse Practitioner (NP) on April 16, 2013, at 12:40 a.m., to transfer Patient 2 to the ICU with BiPAP (Bi-level Positive Airway Pressure, is a machine that helps users breathe more easily.), handheld respiratory treatments with albuterol 2.5 milligrams (mg) plus Atrovent 0.5 mg every 4 hours as needed for respiratory distress.

5. A telephone order from an NP on April 16, 2013, at 2 a.m., to keep Patient 2 NPO (nothing by mouth) , may use the Quinton for intravenous access overnight, and to change the albuterol/Atrovent. The space for the noting RN's signature, date and time were left blank.

6. A telephone order from an NP on April 16, 2013, at 3:40 a.m., to start a Levophed (functions as a peripheral vasoconstrictor and as an inotropic stimulator of the heart and dilator of coronary arteries.) drip and titrate the medication to keep the systolic blood pressure above or equal to 90. The space for the noting RN's signature, date and time were left blank.

7. A telephone order from a PA on April 18, 2013, at 11 a.m., for insulin drip sliding scale.

During a concurrent interview with RN 3, she stated the above telephone orders were not signed by the ordering physician. RN 3 cross-referenced the above orders with the electronic medical record and was unable to find documentation of physician signature of the orders. RN 3 stated the orders should be signed by the physician within 48 hours. RN 3 stated the nurse receiving the orders should note the orders.

c. During the review of the "Vasoactive Intravenous Infusion Orders" dated April 16, 2013, at 2 p.m., the form indicated the orders to keep central line open with normal saline at 10 ml per hour, initiate infusion of Levophed (16 micrograms (mcg) per ml concentration) at 5 mcg per minute, and initiate infusion of NeoSynephrine (80 mcg/ml concentration) at 50 mcg per minute. There was no documentation on the form of who gave the telephone order, only an RN signature of receiving a telephone order/read back order.

During an interview with Admin 2, Director of ICU, and the Director of Pharmacy (DOP), on April 25, 2013, at 2 p.m., they both reviewed the paper and electronic clinical record. The DOP explained the order for Levophed was done at 3:40 a.m. by a physician assistant. Admin 2 reviewed the Nurse's Notes and was unable to find documentation the nurse spoke to the ordering physician to clarify the order. Admin 2 and the DOP stated the nurse needed to write on the form that it was a clarification of the titration order and the ordering practitioner's name who she received the clarification from.

The facility policy titled "Orders, Physician's Orders Guidelines/Readback Policy and Review of Physician Orders, Inpatient" revised December 2011 indicated a telephone order transmitted by practitioner must include date and time written, the order, indication of how transmitted (telephone order), the name of the practitioner giving the order, and the name and title of the person receiving the order. The prescribing physician must countersign the order within 48 hours, and the prescribing physician assistant/nurse practitioner must countersign the order within 24 hours.

Based on record reviews and interviews, the facility failed to ensure Patient 2 had properly executed informed consent forms for procedures and treatments performed on him.

Findings:

The clinical record for Patient 2 was reviewed on April 23, 2013, at 1:40 p.m., with Admin 2, Director of Intensive Care Unit. The "Admission/Registration" sheet indicated Patient 2 was admitted to the facility on April 9, 2013 with the admitting diagnosis of pneumonia.

The "Authorization For and Consent to Surgery or Special Diagnostic or Therapeutic Procedure" form dated April 22, 2013, at 2:30 p.m., indicated an informed consent was obtained for a tracheostomy (an operation to cut a hole in the trachea) placement. The form indicated a hand-written family member's name with "(sister)" next to the name under the signature line and had 2 Registered Nurse (RN) signatures under the Witness line.

The "Peripherally Inserted Central Catheter Informed Consent" form dated April 22, 2013, at 3:30 p.m., indicated consent was obtained for a placement of a peripherally inserted central catheter (PICC - a form of intravenous access that can be used for a prolonged period of time). The form indicated a hand-written family member's name with "(sister)" next to the name under the signature line and had 2 Registered Nurse (RN) signatures under the Witness line.

The "Consent for Anesthesia/Moderate Sedation Services" form dated April 22, 2013, at 7 p.m., indicated consent was obtained for the use of general anesthesia during the tracheostomy placement. Under the "Patient's Signature" line was a hand-written "unable/xxx (sister)" and had 2 RN signatures under the Witness line.

During a concurrent interview with Admin 2, Admin 2 stated two signatures on an informed consent form on the Witness line means the consent was obtained via telephone. Admin 2 stated the nurses who were witnessing the oral consent should have written on the form the consent was obtained by telephone.

The facility policy titled "Consent, Informed", revised January 2010, indicated if a telephone consent was obtained a hospital personnel should verify the patient's legal representative has in fact given consent. A third person listens to the conversation and serves as a witness to the oral consent. Obtain a written consent as soon as possible, when person consenting is available. However, the policy failed to address neither the need to write the consent was obtained via telephone nor the staff not signing the family member's name as if the consent was not obtained via telephone.

Based on interview, observation, and document review, the facility failed to ensure accountability procedures were in place to control the use of all controlled substances (CS).


Findings:

On 4/23/2013, at 2:33 p.m., during a discussion of CS use monitoring of non-profiled automatic dispensing cabinets (ADC) called Pyxis, which were used in departments, such as Emergency Department (ED) and the Operation Rooms (OR), the director of pharmacy (DOP) stated there was no retrospective review for any ED orders, including CS. The DOP stated in the ED, after physicians order medications, the nurses would remove the medications from the ADC, but there was no pharmacy review for the appropriateness of therapy.

On 4/24/2013, at 9:50 a.m., during an inspection of the anesthesiologist (a physician trained in anesthesia and perioperative medicine) medication tray, Pharmacist 1 explained that if anesthesiologists anticipated the need for narcotics, they would retrieve the narcotics from the non-profiled ADC (the ADCs were not programmed to be patient-specific which allowed users to remove medications at will) before the surgery. Pharmacist 1 stated anesthesiologists would document the usage on the anesthesiology record and the unused amount would be returned to the ADC, usually by another authorized staff, such as nurses.

During a concurrent interview, the DOP stated the pharmacy department did not reconcile narcotic usage from the non-profiled ADCs and there was no policy to reconcile non-profiled ADCs. The DOP also acknowledged that there could be potential discrepancies, drug diversions, as well as missed opportunities to identify medication errors.

Reference A500; Pharmacists failed to ensure that medications removed from non-profiled ADCs were appropriate to ensure patient safety.

Based on observation, interviews, and document reviews, the facility failed to ensure that medications removed from non-profiled ADCs were appropriate and controlled medications ordered by the physician were administered as prescribed; and unused controlled medications were returned to pharmacy after the patient was discharged for 1 of 1 patient (Patient 31).


Findings:

1. On 4/23/2013, at 11:15 a.m., during a discussion of the CS use monitoring of non-profiled ADCs that were being used in departments, such as Emergency Department (ED) and Operation Rooms (OR), the DOP stated there were no retrospective reviews for any ED orders. The DOP stated in the ED, after physicians order medications, the nurses would remove the medications from the ADC and there was no pharmacy review for the appropriateness of the medication therapy. The DOP further stated only a few orders from a selected list of medications would be sent to the pharmacy for prospective review during pharmacy hours.

At 2:15 p.m., Pharmacist 1 presented a list of patients who had morphine injectable (a narcotic, controlled substance, and potent pain relief) orders originated in the ED for the past seven days. The evaluator randomly selected Patient 25 from the list. The clinical record of Patient 25 indicated the ED physician ordered morphine 4 milligram (mg) intravenously for one dose and the administering nurse documented 4 mg was given. However, the ADC transaction record showed the nurse removed one syringe of morphine 2 mg, not 4 mg as ordered by the physician.

During a concurrent interview, both the DOP and Pharmacist 1 agreed that was a medication error.

On 4/24/2013, at 11 a.m., during a discussion of ED admission rate, the DOP presented a report that indicated approximately 20 percent (%) of the ED patients were admitted to the hospital in the previous month. The DOP stated the pharmacy only reviewed ED medication usage for those patients that were admitted to hospital.

During a concurrent interview, DOP acknowledged that approximately 80% of ED orders were not reconciled or retrospectively reviewed by pharmacists for appropriateness, and the pharmacy department missed opportunities to identify medication errors, and potential diversion, or drug loss.

The DOP also stated there was no policy and procedure to reconcile non-profiled ADCs.

According to a nationally recognized professional association, American Society of Health-System Pharmacists (ASHP, which published numerous authoritative guidelines in pharmacy practice referred by the industry as the standard of practices), the guideline titled, " Minimum Standard for Pharmacies in Hospitals, " dated 4/13/2012, indicated all medication orders shall be prospectively reviewed by a pharmacist and assessed in relation to pertinent patient and clinical information before the first dose is administered or made available in an automated dispensing device, except in emergent situations ... There shall be a procedure for retrospective review of these orders. The guideline further suggested the use of [ADC] shall be structured so as to not hinder the pharmacist ' s review of (and opportunity to intervene in) medication orders before the administration of first doses ...

According to the California Code of Regulation, title 22, section 70263(c)(1), the pharmacy and therapeutics committee shall be responsible for the development and implementations of policies and procedures for procurement, storage, distribution, dispensing, and use of drugs.




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2. On 4/24/2013, at 10:30 a.m., a review of a controlled substance " Outstanding Transaction " report with Pharmacist 1 indicated that 10 units of Methadone, a controlled medication used to relieve pain; 5 milligrams (mg)/5 milliliters (ml) were sent to the Medical Surgical Unit 1 (MedSurg1) on 4/19/2013 for a patient (Patient 31). Pharmacist 1 reviewed Patient 31 ' s electronic Medication Administration Record (eMAR) and stated, Patient 31 ' s Methadone medication was externally stored in a double locked wall safe outside of the ADC called Pyxis on MedSurg 1. The eMAR indicated Patient 31 had received two doses of Methadone 15 mg/ 15 ml.

During a concurrent interview, Pharmacist 1 discovered Patient 31 had been discharged home and stated, " The patient (Patient 31) was discharged home on 4/20/2013 and the medication (Methadone) should have been pulled on 4/21/2013. " Pharmacist 1 acknowledged that the Methadone for Patient 31 was not pulled from the external storage until 4/24/2013 by Pharmacist 2, four days after Patient 31 was discharged from the hospital.

The clinical record of Patient 31 indicated the physician ordered Methadone 15 milligrams (mg) solution twice a day and the administering nurse documented 15 mg was given on 4/19/2013, at 5:13 p.m.
However, the administering nurse documented on the controlled substance administration record that 5 mg/ 5 ml of Methadone was administer to Patient 31 and not the physician ordered dose of 15 mg.

On 4/24/2013, at 11:10 a.m., during an interview, Pharmacist 2 stated, " I ran a report this morning (4/24/2013) and picked up the medication (Methadone) because the patient (Patient 31) was discharged. I saw a discrepancy in the dosage of Methadone and was going to check on it. Patient 31 should have been given one dose, which would have been three syringes of 5 mg / 5 ml each, but the patient was only given one syringe of 5 mg/5 ml, but it was documented as given 15 mg/ 15 ml of Methadone. "

A review of the hospital ' s policy and procedure titled, " Management of Controlled Medications/Pharmacy Manual, Nursing Manual, " dated 12/2011, indicated CSAR (controlled substance administration record) is used for both accountability in delivery and administration. For unit were controlled medication is usually not stock/ not kept, to fulfill the patient ' s need, the pharmacy sends a single sheet CSAR. All documentation are done on that sheet and returned to pharmacy after use on the same day.

Based on record review and interview, the facility failed to prescribed the therapeutic diets for Patient 17 and 20 as recommended by the registered dieticians.

Findings:

1. A review of the medical record indicated Patient 17 was admitted to the facility on March 22, 2013, with diagnoses that included chronic ventilator dependent respiratory failure and end stage renal disease on hemodialysis.

On April 24, 2013, a review of the nutritional assessment dated March 25, 2013, indicated the patient was a high nutritional risk. There was a registered dietician recommendation to recheck pre-albumin and C- reactive protein for trend.

A review of the laboratory results from March 26, 2013-April 24, 2013, indicated no results for pre-albumin and C-reactive protein.

During an interview on April 24, 2013, at 8:44 a.m., the registered dietician stated the recommendation should have been followed up. After reviewing the medical record, the registered dietician stated there was no physician order for pre-albumin and C-reactive protein determination after March 25, 2013.

A review of the facility's policy and procedure titled Nutritional Assessment revised September 2011, indicated a notation will be made in the patient's chart to alert the physician of such recommendations.

2. A review of the medical record revealed Patient 20 was admitted to the facility on April 21, 2013, with diagnoses that included urosepsis, dysphagia and moderate caloric protein malnutrition.

A review of the nutritional assessment dated April 22, 2013, indicated the patient was a high nutritional risk. There was a recommendation for health shake twice a day. However, the documentation did not indicate the physician had prescribed health shake for Patient 20.

Based on observation, interview and record review, the facility failed to maintain an environment to assure the safety and well-being of the patients. Ceiling vents had an accumulation of dust. The emergency water supply was short of 100 gallons. There was no documentation of temperature and humidity monitoring in the intensive care unit and recovery room.

Findings:

During a tour of the facility on April 23, 2013, from 10:47 a.m.-11:40 a.m., the following were observed:

1. THIRD FLOOR
In the restrooms of 20 patient's rooms, the ceiling exhaust vents were thickly covered with dust.
At the same time, during an interview, the environmental services supervisor stated the vents should be cleaned daily.

A review of the facility policy and procedure titled Daily Cleaning Seven Step Process revised on September 1, 2010, indicated to high dust all vents or ventilation ducts in the area.
A review of the facility's policy and procedure titled Vent Cleaning revised in October 2008, indicated if the dust is excessive, use the vacuum cleaner first to remove the loose dust. If vent can be removed, vacuum the inside of the cover. Take the vent outside to be cleaned, especially if it requires soaking. If the vent cannot be removed, wet a cleaning cloth in the cleaning/germicidal solution and wring it out. Have several dry cloths available. Wipe the outside with a damp cloth removing all the dirt. Carefully dry and replace the vent.

The facility was not able to provide the survey team with a cleaning schedule.

2. During a tour of the kitchen on April 23, 2013, at 10:30 a.m., in the dry goods storage area, there were two pipes above the food items.

At the same time, during an interview, the supervisor for facility operations stated the pipes were drain pipes and dirty water flowed through the pipes.

A review of the facility's policy and procedure titled Food Storage formulated on April 23, 2011, indicated the dry storage area must be designed to control/prevent the invasion of pests and rodents as well as the seepage of dust, water or any other source of contamination.

3. During a tour of the facility on April 25, 2013, at 8:30 a.m., there were 96 five gallon emergency water supply and emergency food supply located in the first floor southwest section of the building adjacent to the main hospital.

During an interview on April 25, 2013, at 9:16 a.m., the disaster planner stated aside from the 96 five gallon water they had other sources of water available. However, the facility was short of 100 gallons emergency water. She had made the chief nursing officer and facilities supervisor aware of the shortage end of last year.

A review of the facility's Disaster Inventory of food items indicated the list was based on 100 staff, 75 patients, 25 visitors, a total of 200 individual.

At the same time, during an interview, the disaster planner stated disaster inventory was based on 950 individuals and not 200 individuals.

A review of the facility's policy and procedure titled Failure of Potable Water System indicated storage of potable water shall be based on FEMA guidelines of 1 gallon of water per person per day. The storage for storage of water is determined as follows:
Ratio of Staff: Maximum census 4:1
Maximum census 170
Maximum staff 680
Allowance for visitors and community needs 100
Minimum storage of water required per day 950 gallons
Emergency water shall be used for drinking purposes only.

4. On April 24, 2013, at 10:15 a.m., a review of the QAPI (Quality Assurance and Performance Improvement) meeting minutes for 4 quarters of 2012 indicated there was no environment of care indicators included.

During an interview on April 25, 2013, at 9:40 a.m., the performance improvement director stated the environment of care indicators for 2012 was not presented during the QAPI meeting. The data for environment of care indicators for 2012 was only presented to the performance improvement committee.

5. During a tour of the intensive care unit on April 23, 2013, at 1:15 a.m., a temperature/ humidity monitoring device was observed attached to the wall in the nurses' station. The temperature was 71 degrees Fahrenheit and the humidity was 37 %. There was no temperature/humidity log.

At the same time, during an interview, the supervisor for facility operations stated there was no temperature/ humidity log for the intensive care unit and recovery room. He further stated there was a temperature/ humidity log for the operating rooms.

A review of the operating room log dated January 2012-April 23, 2013, indicated the acceptable humidity range on the form was either 30-60 or 20-60 or 35-60. The actual documented readings were from 44-69. There was no acceptable temperature range on the form. The actual documented temperature readings were from 58-71.

A review of the facility's policy and procedure titled Humidity Control Systems indicated humidity controls are provided in the following areas: operating rooms, intensive care unit rooms, nursery areas and recovery rooms. The range required is 20-60%.

A review of the temperature/humidity log from January, 2013-April, 2013 for the cardiac catheterization lab indicated the acceptable temperature range as 60-70 degrees Fahrenheit and the acceptable humidity range as 20-60 %. The actual documented temperature readings were from 60-68 degrees Fahrenheit and the actual documented humidity readings were from 20-48%.

A review of the 2010 California Mechanical Code indicated the temperature range for the operating room was 68-75 degrees Fahrenheit and the temperature range for the cardiac catheterization lab, post anesthesia care unit and intensive care unit was 70-75 degrees Fahrenheit.

The relative humidity range for the operating room and the cardiac catheterization unit was 20-60%. The relative humidity range for the post anesthesia care unit and intensive care unit was 30-60%.

Based on observation, interview and record review, the facility failed to implement its policy on infection control to prevent the potential spread of infections and communicable diseases. In addition, the facility failed to provide RN 1 the hepatitis B vaccine he requested from the facility. Per facility policy, if the employee wishes to receive the hepatitis B vaccine, the vaccine was to be given to the employee free of charge.

Findings:

On April 23, 2013, between 9 a.m. through 2 p.m., during the initial tours of the different units with CNO, the following was observed:

1. In Room 116, there was an oxygen tubing exposed hanging on the flowmeter. There were two (2) patients in the room and both patients were receiving oxygen via nasal cannula.

2. In Room 118, Patient 7 was lying on a KCI low air loss mattress with an indwelling catheter in place. When RN 3 was asked how much urine output and the urine characteristic, RN 3 proceeded to handle the indwelling catheter and without washing her hands, RN 3 went to touch the patient and straighten the linen.

During a concurrent interview, RN 3 stated she should have washed her hands after handling the indwelling catheter.

A review of the facility's policy stipulated washing hands as promptly and thoroughly as possible between patient contacts and after contact with blood, body fluids, secretions and equipment or articles contaminated by them is an important component of infection control.

3. In Room 310-2, a patient was in bed and the patient's oxygen tubing was on the floor. LVN 2 was observed picking up the oxygen tubing and placed it back on the bed for patient's use.

During a concurrent interview, LVN 2 stated the contaminated oxygen tubing should have been discarded rather than placing it back on the bed for potential use of the patient.

4. In Room 313, Patient 10 was observed lying in bed and was on ventilator. The tidal volume was 600, assist control of 18, Peep was 5 and FIO2 of 40. Upon closer observation, it was noted the ventilator circuit had no date when it was placed. There was also a bottle of 0.9% Sodium Chloride opened and undated.

A review of the facility's policy on Changing and Disposal of Respiratory Equipment stipulated ventilator breathing circuits every 7 days.

5. In Room 315-2, a patient had tracheal tubing in place. The Cool Aerosol Tubing did not have label as to the date it was placed. There was also a bottle of Sterile water opened and undated.

A review of the facility's policy on Irrigation Solutions stipulated for normal saline or sterile water without any medication or add mixture, the solution must comply with infection control guidelines,
a. Date that the bottle is opened.
b. Dispose opened bottle with or without remaining solution within 24 hours.

6. In Room 320, Patient 19 had a heplock on the left wrist. The heplock did not have a label to indicate the date/time the access site was placed.

A review of the facility's policy on IV Therapy Protocol stipulated change IV site every 96 hours unless otherwise ordered by the physician. Also to change dressings 96 hours and PRN, if soiled. Dressing change should be dated and timed.



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7. The personnel and health file for RN 1 was reviewed with Admin 1, Director of Human Resources, on April 25, 2013, at 1:18 p.m. The undated "Hepatitis B Virus Vaccine Acceptance OR Declination Form" found in RN 1's health file indicated that RN 1 wished to receive the hepatitis B virus vaccine. The portion of the form indicating the date of administration of the three doses of the hepatitis B virus vaccine was blank.

During the concurrent interview, Admin 1 stated the form was signed in 2006, when RN 1 was originally hired. Admin 1 stated she was unable to locate proof in RN 1's health file of RN 1 receiving the hepatitis B virus vaccine.

The facility policy titled "Hepatitis B Vaccine Program" reviewed on January 2008 indicated the hepatitis B vaccine is offered to all at-risk employees. The employee will receive information regarding the vaccine and will be asked to sign an informed consent prior to vaccination.



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8. On 4/23/2013, at 11 a.m., during an observation of a medication pass located on the second floor on the Intensive Care Unit (ICU), RN 4 stated, Patient 22 was in isolation for clostridium difficile, a bacteria that causes diarrhea, hepatitis, an infection of the liver, and positive for human immunodeficiency virus (HIV), a condition that gradually destroys the immune system, which makes it harder for the body to fight infections. RN 4 was observed putting on a blue gown, mask, and gloves, and entered Patient 22's room. RN 4 removed the gown, mask, and gloves upon exiting Patient 22's room. RN 4 stated, "I was confirming Patient 22's date of birth and name on the arm bracelet to the label I carried in my pocket and scanned, because Patient 22 is in isolation and I cannot take the computer into the room." RN 4 scanned the labeled intravenous (IV) medication, put on a new gown, mask, and gloves, and reentered Patient 22's room, proceeds to administer the IV medication, Vancomycin, used to treat colitis (inflammation of the intestine caused by certain bacteria). RN 4 removed the gown, mask, and gloves upon exiting Patient 22's room, and used the hand sanitizer. However, RN 4 was not observed washing hands before entering or reentering Patient 22's room.

During a concurrent interview, RN 4 acknowledged that hand washing should be done especially for patients in isolation. When asked if she should have washed her hands prior to putting on the gloves, RN 4 stated, "I've been doing it a long time and haven't gotten sick."

A review of two signs posted outside the room of Patient 22 indicated: a) Isolation- hands must be washed after contact with patient or patient ' s environment b) Contact Precaution- hands must be clean with soap and water before and after contact with patient, with objects in the room and/or glove use.

On 4/23/2013, at 11:30 a.m., during an interview, RN 5 stated, "Hand washing is done before and after medication administration."

On 4/25/2013, at 8:50 a.m., during an interview, Infection Control/Infection Prevention (Admin 3) stated, "Hand washing before and after passing any medication thoroughly is the right way, and they must use gloves. Gloves are not a replacement for hand washing. Hand washing is preferred for clostridium difficile. Nothing replaces hand washing with soap and water. The policy is very clear; there is no substitution for hand washing before and after coming in contact with a patient."

A review of the hospital's policy and procedure titled, "Hand Hygiene," revised 3/2012, indicated, "Hand washing is the single most effective deterrent to the spread of infection. Hospital personnel shall wash their hands, to prevent the spread of infections: ...before applying and after removing gloves, between handling of individual patients, before passing medications to patients, on leaving isolation area or after handling articles from an isolation area ..."
A review of the hospital's policy and procedure titled, "Isolation Precautions," revised 4/2013, indicated, wearing gloves does not replace the need for hand washing because gloves may have small, in-apparent defects or may be torn during use, and hands can become contaminated during removal of gloves.

Based on interviews and record reviews the facility failed to ensure the infection control preventionist was aware of the number and types of infections that has occurred as a result of transfusion of blood that has been reported to be at an increased risk of transmitting infectious diseases.

Finding:

During an interview on 4/25/13 at 10:30 a.m., with the Director of Laboratory Services (Admin 5) was asked to whom does she report the data from the "Lookback Report" (the process that is followed when the hospital is informed by the vendor for blood and blood components that units that the facility has received are at increased risk of transmitting infectious diseases). Admin 5 replied that the report is forwarded to the Laboratory Medical Director for review. When asked if she (Admin 5) reports the data to the infectious control preventionist she stated "No."

On 4/25/13 at 11:30 a.m., the Infection Control Preventionist (Admin 3) was interviewed. When asked if he received any data from the Director of Laboratory Services or the Laboratory Medical Director regarding the number of cases and infectious agents involved in the Lookback report, Admin 3 replied "No." When asked if he thought that this was information that should come to him and be discussed in the infection control committee meeting he stated "Yes."