HospitalInspections.org

Based on observations, review of medical record, facility policy and procedure, facility occurrence investigation, Daily MHT (mental health technician) Assignments, invoice documentation and staff interviews, it was determined the facility failed to ensure all patients were in a secure and safe environment and all occurrences were accurately and thoroughly investigated.

This affected 1 of 3 active patient records reviewed that included Patient Identifier (PI) # 1. This had the potential to affect all patients admitted to the geriatric behavioral hospital.

Findings include:

Unity Psychiatric Care-Huntsville Administrative Policy and Procedure
Title: Occurrence Reporting
Revised-5-2015

"...Procedure:

Definitions: Incidents or Occurrences...A patient safety event...whether or not the patient was harmed...

1. The hospital will maintain a system for reporting and follow-up of incidents. The incident report serves to:

a. Prevent critical incidents from occurring.
b. Detect problems early.
c. Provide a mechanism to prevent future problems.
d. Provide a system to monitor treading of incidents.

...c. Gather written statements from all witnesses and involved parties following...critical incidents, or occurrences that took place during patient care.

c. The Occurrence Investigation...submitted to DON (director of nurses)...for review...further investigation...
e. Appropriate intervention must be implemented...by the charge nurse immediately to prevent reoccurrence.

5. The investigation will be conducted in a systematic approach:

a. What are the details of the event? Review all statements collected...
b. Why did occurrence occur/happen?
c. What systems were in place? Were the systems effective...carried out as intended...staff properly trained, qualified? Staff level appropriate for level of patient care?
d. Did environment, equipment, or other factors contribute to occurrence? Controllable equipment factors contribute to occurrence?
e. Policies and procedures in place...
g. Care standards were acceptable?
i. Any other factors that contributed to the outcome?...
j. All occurrences will be tracked and monitored for trends...

6....part of the hospital's Quality Assurance Plan..."

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1. During a tour of the facility on 5/21/18 at 10:30 AM, the surveyor observed the handrails located through out the main halls of the facility, to have clearance from the wall, and pose a ligature risk.

An interview was conducted on 5/23/18 at 12:23 PM with Employee Identifier (EI) # 2, Director of Nursing who confirmed the above finding.



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2. During a facility tour on 5/21/18 at 10:45 AM, EI # 3, the Risk Manager reported the last facility elopement occurred on 5/18/18. EI # 3 described the series of events that contributed to the elopement as "the perfect storm".

EI # 3 reported the court yard exit door sensor was not working, the court yard door which exited to the court yard was not locked by staff and the court yard gate was not locked the afternoon of 5/18/18. EI # 3 reported the patients had been in the court yard earlier that day.

The surveyor requested all facility documentation of the occurrence, investigation, findings and corrective actions.

1. PI # 1 was admitted to the facility on 5/17/18 with diagnoses including Major Neurocognitive Disorder, and Alzheimer's Type Dementia, Moderate, Bipolar Disorder, Manic, Severe with Psychotic Features.

On 5/21/18, the surveyor reviewed PI # 1's medical record which contained a Special Precautions-Special Monitoring document dated 5/18/18. On 5/18/18, from 3:00 PM to 3:45 PM, PI # 1's location code was GR (group room).

The location of PI # 1 from 3:30 PM to 3:45 PM had been marked through, a line drawn over the times and a new location code inserted. At 3:30 PM, PI # 1's location was changed from GR to O (outside). At 3:45 PM, PI # 1's location was changed from GR to H (hallway).

There was no documentation when the patient location codes were changed, who made the changes to the medical record and why the changes were made.

On 5/22/18 at 1:00 PM, the surveyor reviewed the facility documentation titled, Interdisciplinary Team Occurrence Investigation Worksheet, Conclusion and Action Plan, Type of Occurrence: Elopement, date 5/18/18.

The facility documentation contained the Registered Nurse (RN)'s description of the root cause of the occurrence documented as: the MHT notified the RN the patient, (Patient Identifier # 1) was outside, PI # 1 was agitated and was retrieved by staff, assisted to the patient room with one staff to monitor.

The facility occurrence root cause included the following documentation:

The Patient Interview revealed he/she wanted to go home, the family wanted PI # 1 to remain in the facility.

The Facility Video review revealed on 5/18/18 the following events:

At 2:03 PM, the lawn care company (employee) at the court yard gate, the court yard gate was open.
At 2:08 PM, the lawn care employee at the court yard gate, the court yard gate was closed.
At 3:07 PM, the lawn care employee at the court yard gate, the court yard gate was closed.
At 3:29 PM, PI # 1 was at the court yard gate, the court yard gate was open.
At 3:30 PM, PI # 1 was outside the facility in the far corner parking lot, the nurse was outside the front door.

The facility review of PI # 1's chart as part of the occurrence investigation revealed the following:

PI # 1's medical history included Hypertension, Pre-Diabetes, Dementia with behavioral disturbances. According to the patient's family, PI # 1 had a diagnoses of Advanced Dementia, a history of violence towards family members, increased sexual behaviors and was getting into cars with strangers.

The facility patient monitoring precaution levels were fall, activities of daily living, elopement, sexual and assault precautions at the time of the elopement as reflected on the Psychiatric Nursing Assessment and Special Precautions/Special Monitoring documentation. PI # 1 was last toileted by staff at 1:30 PM prior to the (3:29 PM) occurrence. Urinalysis collected on 5/18/18 showed 50,000 CFU/ML (colony forming unit per milliliter) Streptococcus Gallolyticus Group (a bacterial infection of the urinary tract).

Prior to the elopement, PI # 1 was in treatment team, agitated, angry with escalating behaviors and demanded to go home. Staff attempted to redirect/reorient and the patient grabbed belongings, insisted to leave (the facility). Behaviors continued to escalate, PI # 1 refused oral Seroquel (medication for behavior management). While EI # 3 attempted to obtain an intramuscular prn (as needed) medication, PI # 1 was seen by a MHT outside the facility. PI # 1 ran across the facility driveway, as staff approached PI# 1 sat down on the sidewalk. After several minutes of therapeutic communication, PI # 1 was assisted back inside the facility by 2 staff members. No injury was observed.

The facility staff documented PI # 1 had a Wander Guard in place, however the court yard door was not equipped with a Wander Guard alarm sensor. Root cause: 1) Anger/Severe Agitation. 2) Exit Seeking. 3) Court yard door was unlocked. 4) Court yard gate was left unlocked by lawn care staff.

Intervention (s) put in place: 1) LOS (line of sight monitoring precautions) while awake. 2) All outdoor activities are suspended, until repairs made to court yard door. 3) Lawn company no longer maintains a court yard gate key. 4) Court yard door will remain manually locked at all times, until door is repaired.

On 5/22/18 at 1:20 PM, the surveyor reviewed the 5/18/18 MHT Daily Assignments documentation. The daily assignment documentation for 7:00 AM to 3:00 PM revealed one RN, EI # 8 was on duty with 2 MHT's assigned to care for six patients. Five of the six patients were identified as elopement risks on the monitoring precautions documentation.

Further review of the 5/18/18 MHT Daily assignments for 7:00 AM-3:00 PM revealed no documentation staff was assigned as Hall Monitor.

Review of the 5/18/18 MHT Daily Assignment for shift 3:00 PM to 11:00 PM contained documentation seven patients were on census, the additional newly admitted patient was on "1:1" (one staff to one patient monitoring).

There was no documentation on the MHT Daily Assignments for the monitoring precautions of the other six patients. There was no assigned staff for Hall Monitor.

On 5/22/18 at 3:45 PM, the surveyor interviewed EI # 7, the MHT assigned to care for PI # 1 from 3:00 PM to 11:00 PM on 5/18/18.

EI # 7 reported she was late to work on 5/18/18, arrived around 3:15 PM and did not know at the time of the elopement she was assigned to care for PI # 1 that day. EI # 7 verified the Daily MHT assignment for Hall Monitor was to ensure patients with exit seeking behavior were identified and redirected as needed. EI # 7 confirmed no assignment for Hall Monitor was documented on the 5/18/18 MHT assignments.

EI # 7 reported she was not involved in retrieving PI # 1 back into the facility, but sat with PI # 1 in the patient room to help calm the patient following the elopement. EI # 7 reported PI # 1 exited the facility from the court yard door which was left unlocked. EI # 7 reported she was aware the court yard door sensor alarm was not working and manual lock with a key was required.

On 5/23/18 at 7:15 AM, the surveyor interviewed EI # 8, the RN on duty on 5/18/18 for 7:00 AM to 7:00 PM. EI # 8 confirmed RN responsibilities included daily MHT assignments which included Hall Monitor for each shift. EI # 8 confirmed no Hall Monitor was assigned on 5/18/18 for the 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM shifts.

The surveyor asked if staff were assigned to monitor the continuous video camera at the nurse station, EI # 8 reported no staff were assigned to monitor the video.

EI # 8 reported the shift got chaotic around 2:00 PM, there was treatment team and visiting hours and a new patient was admitted who required 1:1 monitoring. EI # 8 reported PI # 1 was agitated after treatment team and the assistance of another RN staff, EI # 3, Risk Manager was required.

EI # 8 reported she was aware the court yard exit door sensor was not working for more than one week and staff were to manually lock the court yard door with a key.
EI # 8 reported she was not aware the patients were taken out into the court yard on 5/18/18.

EI # 8 reported MHT's were supposed to check the exit doors each shift for the wing of the hall they were assigned. EI # 8 reported she did not know where the MHT's documented completion of this task.

EI # 8 reported no staff were assigned to conduct environmental safety rounds at the beginning of the shifts to include monitoring for locked exits. There was no documentation staff completed safety rounds on 5/18/18 prior to the elopement.

During an interview on 5/23/18 at 8:08 AM, EI # 6, Maintenance Supervisor reported the court yard door sensor alarm had been broken by a patient sometime in April. EI # 6 reported that he notified the door company, a representative in the area came by and had the repair part with him and left the part to repair the sensor alarm at the facility. EI # 6 reported he had not attempted to repair the court yard door despite having the part available since the end of April. The surveyor asked for the repair request documentation.

On 5/23/18 at 9:08 AM, EI # 6 presented the surveyor with an invoice dated 4/26/18 for "1 door contact" ordered and shipped on 4/26/18. EI # 6 verified the part to repair the court yard exit door had been at the facility since 4/26/18 and he was "getting to it".

EI # 6 reported he completed weekly environment checks and documented the monitoring on the Life Safety Checklist document.

Review of the Life Safety Checklist dated 5/11/18 which was completed the week before the elopement, revealed the following documentation: "all self-closing doors in compliance (closed)."

In an interview on 5/23/18 at 9:58 AM, EI # 3 reported all staff present on 5/18/18 during the occurrence were interviewed separately, some were interviewed while on duty in the hallway and at the nurse station and all completed an occurrence investigation statement prior to the end of their shift.

EI # 3 confirmed as part of the occurrence investigation, she failed to review facility staffing and the MHT Daily Assignment documentation and she was not aware there was no Hall Monitor assigned on 5/18/18. EI # 3 verified this was not identified during staff interviews.

EI # 3 reported she was not aware the "part" to repair the court yard door sensor had been at the facility since 4/26/18 and that facility staff had failed to repair the court yard exit door.

EI # 3 reported she had not determined when the court yard door last was opened by staff, reporting the video was not clear and did not know how long the court yard door was left unlocked. EI # 3 reported the video review did show the patients were last in the court yard on 5/17/18, the day prior to the elopement.

EI # 3 also reported she changed PI # 1's medical record documentation. EI # 3 verified MHT'S originally completed the Special Precautions-Special Monitoring for PI # 1's location on 5/18/18 at 3:30 PM and 3:45 PM.

EI # 3 reported she was at the facility when the elopement happened and she knew the patient locations were not correct as documented by MHT staff.

EI # 3 confirmed as part of the occurrence investigation, she had not identified EI # 6, the Maintenance Supervisor, had the "part" to to repair the court yard door sensor for the past 23 days. As of the 5/23/18 at 9:58 AM, the repair to the court yard door had not been completed.

EI # 3 reported the facility did not have a policy for daily environmental safety rounds completion. EI # 3 reported there was no documentation the staff completed safety rounds completed on 5/18/18 which may have identified an unlocked door.

On 5/23/18 at 10:55 AM, EI # 3 confirmed the facility occurrence investigation failed to identify facility factors that contributed to the elopement including identifying how/ when the court yard door was left unlocked by staff, failure of RN to complete all 5/18/18 daily patient care assignments which included Hall Monitor and prompt repair of the court yard door by maintenance staff.

The facility staff failed to complete an accurate and thorough occurrence investigation and implement appropriate changes to prevent future elopements from this facility. The facility failed to conduct daily environmental safety rounds which would have identified an unlocked exit door.

Based on review of medical records (MR), facility policies and procedures, and interview, it was determined the facility failed to ensure:

1. The patients received oral nutritional supplements and TED (ThromboEmbolic Disease) Hoses according to physician's orders.

2. The patient's personal hygiene (bathing) needs were met per the facility policy.

This affected Patient Identifier (PI) # 2, # 7, # 8, # 1, 4 of 6 records reviewed and had the potential to negatively affect all patients served by this facility.

Findings include:

Facility & (and) Procedure: Prescribing or Administering of Medications
Revised: 3-10

"Policy: It is the policy of BHC to prescribe or administer medication to patients as determined by the doctor...

Procedure:

... 4. Each dose must be properly recorded in the medication administration record."

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Facility Policy: Personal Hygiene Standards
Revised: 11-09

"Policy: Quality standards of personal hygiene and grooming shall be taught and maintained in accordance with the needs of the patients served... Patients shall be provided with the necessary supplies to achieve these goals or shall receive assistance from clinical staff. ...patients shall be cleaned and bathed with the utmost respect to privacy and dignity."

********

1. PI # 2 was admitted to the facility on 5/3/18 with diagnoses including Dementia with Behavioral Disturbances.

Review of the telephone Admission order's dated 5/2/18 and transcribed on 5/3/18 revealed an order for:

PRN (as needed) Medications:

...Ensure 240 ml (milliliters) PO (by mouth) TID (three times a day) if meal intake is < (less than) 50% (percent) as Supplement.

Review of the May Medication Administration Record (MAR) and the Graphic/Intake & Output Record revealed no documentation the patient received:

Ensure 240 ml on:

5/6/18 supper - 0 % consumed
5/7/18 supper - 25 % consumed
5/8/18 breakfast and supper - 0 % consumed
5/9/18 supper - 25 % consumed
5/10/18 supper - 0 % consumed
5/11/18 breakfast - 25% consumed
5/16/18 breakfast and supper - 0 % consumed
5/18/18 breakfast - 0 % and supper - 25% consumed

Further review of the Graphic/Intake & Output Record dated 5/12/18 revealed, lunch: 25 % consumed. Enteral (supplement): 120 (ml). There was no documentation why PI # 2 failed to receive the 240 ml's as ordered.

Personal Care Needs:

Review of the Psychiatric Nursing Assessment Notes revealed there was no documentation the patient was provided or assisted with a bath on 5/4/18, 5/5/18, 5/6/18, 5/7/18, 5/8/18, 5/11/18, 5/12/18, 5/13/18, 5/15/18, 5/17/18, 5/18/18, 5/19/18, 5/20/18, and 5/21/18, which was 14 of 18 days while being admitted in the facility.

An interview was conducted on 5/23/18 at 11:50 AM with Employee Identifier (EI) # 2, Director of Nursing (DON), who verified there was no documentation the staff administered the nutritional supplement as ordered. EI # 2 verified there were no showers or tubs in the patient rooms and that a staff member must assist a patient with a bath.

2. PI # 7 was admitted to the facility on 3/20/18 with diagnoses including Alzheimer's Type Dementia with Behavioral Disturbances.

Review of the MR revealed PI # 7 was discharged from the facility on 4/3/18.

Review of the Psychiatric Nursing Assessment Notes revealed there was no documentation the patient was provided or assisted with a bath on 3/21/18, 3/22/18, 3/23/18, 3/26/18, 3/27/18, 3/29/18, 3/30/18, and 4/2/18, which was 8 of 13 days while being in the facility.

An interview was conducted on 5/23/18 at 11:50 AM with EI # 2 who verified the aforementioned findings.



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3. PI # 8 was admitted to the facility on 4/9/18 with diagnoses including Major Neurocognitive Disorder, and Alzheimer's Type Dementia, Severe, with Behavioral Disturbances.

A review of the Admission Orders revealed the following order: "Ensure 240 ml PO TID if meal intake < 50% as Supplement."

Review of the April Medication Administration Record (MAR) and the Graphic/Intake & Output Record revealed no documentation the patient received:

Ensure 240 ml on:

4/16/18 supper- Refused, 0 % consumed
4/18/18 breakfast- 0 % consumed
4/27/17 breakfast- 25 % consumed

Review of the Psychiatric Nursing Assessment Notes revealed there was no documentation the patient was provided or assisted with a bath on 4/9/18, 4/10/18, 4/11/18, 4/12/18, 4/13/18, 4/14/18, 4/15/18, 4/16/18, 4/17/18, 4/18/18, 4/19/18, 4/21/18, 4/22/18, 4/23/18, 4/24/18, 4/25/18, 4/26/18, and 4/27/18, which was 18 of 19 days while being admitted in the facility.

Review of the MR revealed the following physician's order dated 4/14/18, "Bilateral knee high compression hose 20-30 mmHg (millimeters of Mercury) bilateral legs for edema on in AM and off at bedtime."

Further review of the MR revealed the following documentation in the physician progress notes:

4/15/18: "...No compression hose on today."

4/19/18: "...He does not have compression hose on and swelling has increased slightly from yesterday."

4/20/18: "...Ext (Extremities): Chronic edema bilateral legs...No compression hose on."

An interview was conducted on 5/23/18 at 12:23 PM with EI # 2, who confirmed the above findings, and confirmed there was no documentation in the MR to explain why the patient was not wearing the compression hose as ordered.



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4. PI # 1 was admitted to the facility on 5/17/18 with diagnoses including Major Neurocognitive Disorder, and Alzheimer's Type Dementia, Moderate, Bipolar Disorder, Manic, Severe with Psychotic Features.

Review of the Psychiatric Nursing Assessment Notes revealed documentation oral care and peri care was completed. There was no documentation PI # 1 was provided or assisted with a bath on 5/17/18, 5/18/18, 5/19/18, 5/20/18 and 5/21/18, which was 5 of 5 days since admitted in the facility.

An interview was conducted on 5/23/18 at 12:00 PM with EI # 2, who confirmed the above findings.

Based on review of facility policy, medical record and staff interviews, it was determined the facility failed to ensure all medical record documentation was legible and corrected entries were completed according to facility policy.

This affected Patient Identifier (PI) # 1, 1 of 3 active records reviewed and had the potential to affect all patients admitted to the facility.

Findings include:

Behavioral Healthcare Center Administrative Policy and Procedure
Subject: Medical Records Standard
Revised 3-2015

...Procedure:

...Each medical record shall contain...accurate information to...document...course, results, and promote continuity of care...

b. Long Hand Medical Record-Any medical record...in a hand written format. Information is entered by writer on paper...

2. Authentication...shows authorship and assigns responsibility for an act, condition, opinion, or diagnosis. All entries in a medical record must be authenticated...

b....Staff authorized to make entries in the medical record shall sign and date the entries whether hand written or typed.

3. Legible and Complete Documentation-Medical Record entries will be clear and able to be read....Late entries and addendums must reflect the date, time, and signature of the author. Entries must not give the appearance that the entry was made on a previous date or earlier time. Late entries and addendums must refer to the circumstances for which it was written or added...

b. Hand written Documentation entries will be timed, dated, and signed on each entry...

4. Correction and Amendments...Errors...made in a medical record entry, the original entry must not be obliterated, and the inaccurate information should still be accessible. The correction must indicate the reason for the correction, and the correction entry must be dated and signed by the person making the revision...

a. Paper format...

2) If information must be corrected or revised, draw a line thorough the incorrect entry and annotated the record with the date and the reason for revision noted, and signature of the person making the revision....

1. PI # 1 was admitted to the facility on 5/17/18 with diagnoses including Major Neurocognitive Disorder, and Alzheimer's Type Moderate,Bipolar Disorder, Manic Severe with Psychotic Features.

Review of the Psychiatric Nursing Assessment Note dated 5/18/18 contained a medical record entry made between 2:00 PM and 3:20 PM. The time of the nurse medical record entry was not clear or legible. The entry time had been written over, which was during the time of PI # 1's elopement from the facility.

Review of the Special Precautions-Special Monitoring documentation dated 5/18/18 completed by the MHT (mental health technician) revealed at 3:30 PM, PI # 1's location code was the group room (GR). A line was drawn thorough GR and an O (outside) inserted. At 3:45 PM, the patient location code GR was lined thorough and H (hallway) was inserted.

There was no documentation who made the medical record changes, no reason documented why the medical record was changed and no documentation when the medical record changes were made.

In an interview on 5/23/18 at 10:40 AM, EI # 3, the Risk Manager reported she was present on 5/18/18, had made the medical record changes to the Special Precautions-Special Monitoring documentation and not spoken to the MHT's who made the original entries. EI # 3 reported to the surveyor she knew the patient locations were not correct as documented by MHT staff.

An interview was conducted on 5/23/18 at 12:08 PM with EI # 2, Director of Nursing who confirmed the staff failed to follow the policy for medical record documentation.

Based on observations, review of Centers for Disease Control (CDC) hand hygiene guidelines for healthcare settings, facility policies and procedures and interview, it was determine the facility failed to ensure the staff:

1. Performed hand hygiene per policy.

2. Maintained clean surfaces in the facility medication cart after contact with contaminated equipment.

3. Wore appropriate personal protective equipment (gloves) when cleaning contaminated equipment.

4. Properly disposed used of sharps.

This affected Patient Identifier (PI) # 3 and 2 (two) unsampled patients and had the potential to negatively affect all patients served by this facility.

Findings Include:

Facility Policy: Hand Hygiene
Revised: 5/16

"Policy:

Hand hygiene is a critical component of patients' safety and saves lives in health care settings.

Procedure:

...Improved adherence to hand hygiene (i.e. {that is} hand washing or use of alcohol-based hand rubs has been shown to terminate outbreaks in healthcare facilities, to reduce transmission of antimicrobial resistant organisms ... and reduce overall infection rates.

...The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves. Gloves reduce hand contamination by 70 percent to 80 percent; prevent cross-contamination and protect patients and health care personnel from infection. Hand rubs should be used before and after each patient just as gloves should be changed before and after each patient."

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CDC Guidelines to Hand Hygiene Volume 51, Published 2002

Recommendations

"1. Indications for handwashing and hand antisepsis

B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C-J. Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items 1C-J.

C. Decontaminate hands before having direct contact with patients.

F. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient).

G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled.

H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care.

I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

J. Decontaminate hands after removing gloves ..."

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Policy: Infections and Hazardous Waste
Date Revised: 1-2008

"Policy: The hospital will define what is infectious or hazardous waste...

Procedure: The following waste shall be considered to be infectious waste:

...2. Waste human blood and any blood products;
...4. All discarded sharps..."

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Policy: Infection Control
Date Revised: 5-2016

"Policy: All Unity employees and contracted workers are responsible for infection control and prevention.

Procedure:

5....a) Standard Precautions-...The principles of Standard Precautions assumes that every patient is potentially infected... All patients require standard precautions...

...e). ...Dressings and other disposable articles are to be placed in plastic bags and disposed of in covered waste recepticle..."

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1. An observation of care was conducted on 5/22/18 at 8:30 AM to observe Employee Identifier (EI) # 4, Licensed Practical Nurse (LPN) perform a blood glucose testing and administer medications to an unsampled patient. EI # 4 performed the blood glucose testing, removed his/her gloves and proceeded to the medication cart and retrieved supplies from medication cart without performing hand hygiene. EI # 4 then proceeded to disinfect the blood glucose machine without applying gloves as directed per the facility policy to prevent contamination.

An interview was conducted on 5/23/18 at 1:53 PM with EI # 2, the Director of Nursing, who verified the aforementioned finding's.



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2. On 5/22/18 at 7:30 AM the surveyor observed care performed by EI # 4, on an unsampled patient. Medication was administered and a fingerstick blood glucose was obtained by EI # 4.

Following the procedure, EI # 4 cleaned the glucose monitor with ungloved hands. EI # 4 then gathered all the used supplies, including the contaminated lancet used to stick the patient and the used reagent strip containing the patient's blood, and placed them in the open garbage can lined with a paper bag.

An interview was conducted on 5/23/18 at 1:53 PM with EI # 2, who confirmed the above findings.

3. PI # 3 was admitted to the facility on 5/5/18 with diagnoses including Dementia with Behavioral Disturbances and Diabetes Mellitus.

On 5/22/18 at 8:00 AM the surveyor observed EI # 4 perform a fingerstick blood glucose and administer medications on PI # 3.

Following the procedure, EI # 4 removed his/her gloves and then cleaned the glucose monitor. EI # 4 then left the room without performing hand hygiene.

An interview was conducted on 5/23/18 at 1:53 PM with EI # 2, who confirmed the above findings.



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On 5/22/18 at 9:40 AM, the surveyor observed the Physical Therapist, EI # 5 complete therapy evaluations on two patients. While in the group room, EI # 5 performed an evaluation of the first patient which began with lower extremity strength assessment. EI # 5 then applied a gait belt and ambulated the patient up and down the hallway. EI # 5 added a rolling walker to the gait assessment and completed the therapy evaluation.

EI # 5 returned the patient to the group room, then EI # 5 cleaned the walker with a Purell sanitizing wipe, returned to the nurse station and completed medical record documentation.

EI # 5 failed to perform hand hygiene after patient contact.

EI # 5 entered to the group room, performed the physical therapy evaluation on the second patient which included gait training up and down the hallway. EI # 5 returned the patient to the group room then exited to the nurse station and completed the medical record documentation.

EI # 3 failed to completed hand hygiene after patient contact.

In an interview on 5/23/18 at 1:30 PM, EI # 2 confirmed staff failed to complete follow the facility infection control policy.