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Based on observation, interview and policy review, the facility failed to:
- Ensure crash carts (mobile cart which contains emergency medical supplies and medications) were secured and monitored in a manner to maintain emergency supplies and/or medications for one crash cart (Operating Room [OR] adult) of five crash carts observed.
- Ensure storage areas which contained patient supplies were secured in a manner to prevent unauthorized access for one patient care area (Medical Unit) of two patient care storage areas observed.
- Ensure outdated supplies and medications were removed from potential patient use for three Emergency Department (ED) crash carts (one pediatric and two adult) of five total crash carts reviewed. These failures had the potential to allow unauthorized access to emergency supplies and medications, as well as allow expired supplies and/or medications to be used during patient care, and could affect all patients. The facility census was five.

Findings included:

1. Review of the facility's policy titled, "Crash Cart Check," reviewed 01/2018, showed directives for staff to perform the following:
- The crash cart is to be checked once a day when patient care is provided to verify that it is locked.
- The keys (plastic locks) to the crash carts will be maintained by Pharmacy.
- Each department will have ten keys to keep locked up in the automated medication dispensing system.
- All crash cart keys will be red and in numerical order.

Observation and concurrent interview on 11/28/18 at 2:15 PM, in the Surgery Operating Room (OR) hallway, showed a crash cart with eight red plastic locks in the top drawer. Staff II, Lead Surgical Registered Nurse (RN), stated that the locks were always kept in the top drawer of the crash cart, and the OR staff would get more from the Pharmacy when needed.

The unsecured plastic locks had the potential to allow staff to access the medications in the crash cart without accountability. This rendered the medications unsecured.

2. Observation on 11/26/18 at 10:30 AM, of the Medical Unit supply area, showed a supply cabinet with a broken padlock, which left the cabinet unsecured and accessible. The supply cabinet contained needles, syringes and other sterile items used for patient care.

During an interview on 11/26/18 at 10:40 AM, Staff L, RN, stated that two work orders had been submitted for maintenance to address the broken padlock, and that she had personally reached out to maintenance to get this broken padlock replaced.

During an interview on 11/29/18 at 11:00 AM and 11:07 AM, Staff A, Chief Nursing Officer (CNO), stated that it was her expectation that the supply cabinet which contained needles, syringes and other sterile items used for patient care, was kept locked and secured at all times, and that all supplies should be secured to prevent unauthorized access. Staff A was unable to locate the two work orders submitted to replace the broken padlock.

3. Review of the facility's policy titled, "Central supply," revised 12/2016, showed that items distributed to nursing units or departments shall be checked monthly to monitor for outdated supplies. Outdated supplies shall be replaced and returned to central supply for proper disposal or disposition.

Observation on 11/27/18 at 11:52 AM of the ED adult crash cart, showed a central line catheterization kit (long, thin, flexible tube inserted into the arm or chest to administer medications or fluids) with an expiration date of 09/2018.

Observation on 11/27/18 at 11:55 AM of the ED pediatric crash cart, showed a disposable scalpel (sharp blade instrument used to cut) with an expiration date of 10/2018.

Observation on 11/27/18 at 11:58 AM of a second ED adult crash cart, showed a intraosseous needle (small metal tube inserted into a bone to deliver medications or fluids) with an expiration date of 06/2018.

During an interview on 11/27/18 at 12:00 PM, Staff B, Inpatient and ED Director, acknowledged the expired supplies and stated that the expired supplies should be removed from patient use.

During an interview on 11/29/18 at 11:07 AM, Staff A, CNO, stated that it was the responsibility of all staff to check for expired supplies and remove the items from patient use.



39562











40710

Based on observation, interview, record review, policy review and review of the United States Pharmacopoeia (USP) Chapter 797 the facility failed to:
- Ensure that staff followed the infection prevention standards for the USP for compounded sterile preparations. (C-276)
- Ensure that staff followed infection control policies and infection prevention standards. (C-278)
- Ensure that staff followed the standard of practice and provide consistent cardiac (heart) monitoring for two patients (#6 and #10) of two patients who were monitored by cardiac telemetry (a monitor that provides real time measurement of a patient's heart rate and rhythm). (C-294)
- Ensure that staff implemented a care plan for chronic pain, diabetic management, and/or fall risk for three patients (#6, #7 and #8) of five patients reviewed. (C-298)

The cumulative effect of these failures resulted in non-compliance with 42 CFR 485.635 Condition of Participation.


Refer to the 2567 for additional information.

Based on observation, interview, record review and review of the United States Pharmacopoeia (USP) Chapter 797 for compounded sterile preparations (CSPs, medications or solutions that are prepared in a way to prevent contamination), the facility failed to ensure that staff followed the infection prevention standards when they failed to:
- Document and clean the buffer area (sterile zone in the pharmacy where CSPs are prepared) on days that medications were compounded.
- Have a documented growth media (test to ensure proper cleaning technique) sampling.
- Have a documented proper garbing/procedure (shoe covers, hair and beard covers, mask, gown, gloves) including successful glove fingertip test (test to ensure staff who process CSPs were able to prevent contamination of the CSP).
- Have a written record or log that demonstrates that the CSP was performed properly.

These failed practices had the potential to increase the risk of cross contamination in CSPs that may result in patient harm and/or death. The facility performs approximately 10 to 20 CSPs per month. The facility census was five.

Findings included:

1. Review of the USP, Chapter 797, dated 2013, showed that:
- The buffer area floors should be cleaned daily, and walls, ceilings and storage shelving cleaned monthly, and documented on a cleaning log.
- Sampling plans that included surface disinfection sampling (growth media requirements) should be performed on a periodic basis, at a minimum of every six months.
- Low risk compounding required proper garbing/procedures (shoe covers, hair and beard covers, mask, gown, gloves) including successful glove fingertip test.
- A documented log or written record that the CSP was performed properly, should be easily accessible.

Review of the facility's policy titled, "Intravenous (IV, in the vein) admixture" revised 10/2015, showed no general operational guidelines for the compounding of non-hazardous drugs that followed the recommended guidelines by USP Chapter 797, which are enforceable by regulation.

Observation on 11/27/18 at 3:45 PM, in the pharmacy, showed the following:
- A barrier isolator (provides a physical barrier for compounding CSPs) within the pharmacy;
- Staff N, Pharmacist, with two CSPs in his hand;
- No documented cleaning log of the buffer area; and
- No documented written record or log that demonstrates that the CSP was performed properly.

Review of the facility's recertification of the devices and room report dated 10/02/18, showed a buffer room that contained both a positive pressure (air pressure is higher than the surrounding area) and negative pressure (air pressure is lower than the surrounding area) isolator. The room shall be thoroughly cleaned on a regular basis, including under the work surfaces.

During an interview on 11/27/18 at 4:00 PM, Staff N, Pharmacist, stated that he:
- Just completed the two CSPs he had in his hand;
- Prepared approximately 10 to 20 CSPs per month;
- Did not have a log of the CSPs that were prepared;
- Did not garb when he prepared CSPs;
- Did not have documented growth media sampling;
- Did not have a documented successful glove fingertip test; and
- Did not have a cleaning log for the buffer area.

Based on observation, interview, record review and policy review, the facility failed to ensure that staff followed infection control policies and infection prevention standards when they failed to:
- Perform hand hygiene before and after glove use, after touching inanimate objects (non-living objects, such as keyboards, tables, etc.), and between patient tasks for six patients (#5, #8, #10, #11, #12 and #14) of six patients observed.
- Ensure cleanliness of the Workstation on Wheels (WOWs, computer and supplies on wheels) for seven patients (#5, #7, #8, #10, #11, #12 and #14) of seven patients observed.
- Ensure items which were not disposable, and intended for use on multiple patients, were properly packaged to maintain sterile conditions in one crash cart (mobile cart which contains emergency medical supplies and medications) of five crash carts reviewed.
- Ensure that the receiving date and used by date were placed on food packages in the kitchen freezers, refrigerators, and dry storage area.
- Ensure refrigerated food was dated to provide notice of when to discard and ensure expired food was discarded from the patient nourishment refrigerator on the Medical Unit.
- Ensure patient nutrition items were stored separately from staff food preparation items in the Medical Unit break room.
- Ensure the ice/water machine used for patients was clean and free from debris in the Medical Unit break room.
These failed practices had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The facility census was five.

Findings included:

1. Review of the facility's policy titled, "Hand Hygiene Program," reviewed 01/2018, showed the following:
- Hand hygiene is the single most important strategy to reduce the risk of transmitting organisms (germs) from one person to another, or from one site to another, on the same patient.
- Cleaning hands promptly and thoroughly between patient contact and after contact with blood, body fluids, secretions (discharged substance from the body), excretions (expelled waste), equipment and potentially contaminated surfaces is an important strategy for preventing healthcare-associated infections.
- Effective hand hygiene removes microorganisms (bacteria, virus or fungus), dirt and material from the hands and decreases the risk of cross contamination from patients, patient care equipment and the environment.

2. Review of the facility's policy titled, "Disinfection of Computer Devices," reviewed 01/2018, showed directives for staff to perform the following:
- It is the responsibility of all staff to minimize the risk of transmission of pathogens by following principles of hand hygiene and the cleaning of devices with manufactured approved products.
- All patient care computer devices will be cleaned and disinfected in order to prevent cross contamination and the transmission of pathogens throughout the facility.
- Computer devices include but are not limited to computer keyboards, mice and bar code scanners.
- All staff must clean their hands after patient contact and prior to using the computer equipment.
- All gloves must be removed and hands cleaned prior to using the computer equipment.
- Computer equipment that is stored on rolling stands (WOWs), should be cleaned with a disinfectant wipe by the user prior to entrance and upon exit of a direct patient care area/room.

Observation on 11/28/18 between 9:00 AM and 9:30 AM on the Medical Unit, showed Staff U, Registered Nurse (RN), entered the room of Patient #5 to apply a dressing to Patient #5's left foot wound. Staff U failed to:
- Perform hand hygiene and failed to put on gloves before she opened the dressing supplies and began to wipe the wound with gauze.
- Perform hand hygiene and failed to put gloves on, and applied an ointment to the dressing, and placed the dressing over the patients wound.
- Failed to clean the WOW between patients.

Observation on 11/28/18 between 8:45 AM and 10:00 AM, on the Medical Unit, showed Staff M, RN entered the rooms of Patient #8, #10, #11, #12 and #14 with the WOW to administer medications. Staff M:
- Failed to clean the WOW before she entered, or after she exited, the patients' rooms.
- Put on gloves when she entered each room, and touched the computer keyboard, mouse, scanner, and other inanimate objects.
- Failed to change gloves or perform hand hygiene between tasks and before she administered medications.

Observation on 11/28/18 between 9:00 AM and 9:30 AM, on the Medical Unit, showed Staff U, RN, entered the rooms of Patient's #5 and #7 with the WOW to administer medications. Staff U failed to:
- Clean the WOW before she entered or after she exited the patients' rooms;
- Put on gloves during the medication administration; and
- Perform hand hygiene between tasks.

During an interview on 11/29/18 at 11:00 AM, Staff CC, Infection Prevention Coordinator, stated that staff were to:
- Perform hand hygiene and wear gloves when they applied a dressing;
- Change gloves after they touched inanimate objects and before medications were administered; and
- Clean the WOWs between each patient use.

3. Review of the facility's policy titled, "Sterility Assurance of Patient Care Items," reviewed 01/2018, showed that all items processed for sterilization will be properly wrapped and processed in such a manner so as to provide an effective barrier to microorganisms (bacteria, virus, and fungus).

Observation on 11/28/18 at 2:30 PM, in the Operating Room (OR) crash cart, showed two unpackaged angled forceps (used to remove foreign bodies from the throat) inside the cart.

During an interview on 11/29/18 at 10:50 AM, Staff CC, stated that any instrument that entered a patients body must be cleaned and packaged according to current standards of practice. Instruments utilized for patient use should not lay in a drawer unpackaged.

4. Review of the facility's nutritional services policy titled, "Storage of Food," revised 02/2014, showed to use First-in-First-Out (FIFO) rotation of products in all storage areas, to assure that oldest products are used first. All goods are to be dated with a receiving date (date the product was received by the facility) and a use by date.

Observation on 11/28/18 at 1:30 PM, in the dietary dry storage room, showed the following:
- Three thickened (liquid thickened by added powder, to decrease the risk of chocking) liquid orange juice bottles, with no received date.
- Five thickened apple juice bottles with no received date.
- One repackaged bag of pasta noodles with no use by date.
- One repackaged bag of macaroni noodles with no use by date.

Observation on 11/28/18 at 1:45 PM, in the dietary reach in refrigerator, showed the following:
- Three slices of cheese with no use by date.
- One repackaged butter with no use by date.
- One repackaged bag of hamburger with no use by date.
- One repackaged bag of turkey with no use by date.
- One repackaged bag of boiled eggs with no use by date.
- One repackaged bag of sausage/bacon with no use by date.

Observation on 11/28/18 at 1:55 PM, in the dietary reach in freezer located in the kitchen, showed the following:
- One bag of hash browns with no received or use by date.
- One bag of country fried steak with no received or use by date.
- One bag of hot dogs with no received or use by date.
- Two bags of french toast with no received or use by date.
- One bag of beef patties with no received or use by date.

Observation on 11/28/18 at 2:15 PM, in the dietary walk in freezer, showed two bags of breaded mushrooms and one bag of bagels with no received date.

During an interview on 11/28/18 at 2:30 PM, Staff X, Dietary Manager, stated that staff were to label and date all foods that were stored in the dry storage area, kitchen, refrigerators and freezers.

5. Review of the facility's policies showed there were no policies which directed staff to clean and sanitize the ice/water machine or the counter tops daily.

Observation on 11/28/18 at 11:00 AM, in the Medical Unit break room showed the following:
- A packet of salad dressing with an expiration date of 07/11/18 in the patient nourishment refrigerator.
- Two plastic bags filled with packets of tartar sauce and ranch dressing dated 07/20/18 in the patient nourishment refrigerator.
- A container filled with packets of margarine and condiments with no expiration dates in the patient nourishment refrigerator.
- A canister of thickener ( a powder used to thicken food and beverages) for patient use was on a counter with food crumbs next to a stove with a dirty pot that staff used to pop popcorn.
- The ice/water machine used for patients had a large amount of white, hard water scaling build up throughout the drain area and water standing in the drain.

During an interview on 11/29/18 at 11:00 AM, Staff CC, Infection Prevention Coordinator, stated that:
- Condiments should not be stored in the patient nourishment refrigerators.
- Expired foods in the refrigerator should be removed from patient use.
- Food intended for patient use should not be stored next to the staff food prep area.
- The ice/water machines should be taken out of service until they were cleaned appropriately.









37921




40710

Based on observation, interview, record review and policy review, the facility failed to follow the standard of practice and provide consistent cardiac (heart) monitoring for two patients (#6 and #10) of two patients who were monitored by cardiac telemetry (a monitor that provides real time measurement of a patient's heart rate and rhythm). This failure had the ability to affect all patients on cardiac telemetry, when the potential for abnormal changes in the heart's rhythm could go unnoticed. The facility census was five.

Findings included:

1. Review of the facility's policy titled, "Telemetry," reviewed 01/2018, showed that the purpose of telemetry was to monitor patients with potential heart arrhythmia's (abnormal heart rhythms). Telemetry patients were to be assigned to Registered Nurses (RNs) or Licensed Practical Nurses (LPNs) who have had a basic dysrhythmia (abnormality in rhythm) course and were competent at interpreting rhythm strips.

Observation on 11/27/18 at 12:35 PM, in the Medical Unit nurse's station, showed that Patient #6's heart rhythm was displayed on the cardiac telemetry monitor. No staff were at the nurses' station, and the patient's heart rhythm was not monitored.

Review of the physician's orders and History and Physical (H&P) for Patient #6, dated 11/26/18, showed an order for cardiac monitor/telemetry. Patient #6 was a 79 year old female admitted to the Medical Unit with dyspnea (shortness of breath), due to cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), coronary (heart) artery disease, chronic kidney disease, insulin dependent diabetic, and hypertension (high blood pressure).

Review of the physician's orders and H&P for Patient #10, dated 11/27/18, showed an order for cardiac monitor/telemetry. Patient #10 was a 68 year old male admitted to the Medical Unit with syncope (fainting, or a sudden temporary loss of consciousness). He had a past medical history of coronary artery disease (blockage in the heart's major blood vessels), coronary artery bypass graft surgery (a surgical procedure to restore normal blood flow to an obstructed heart artery) on 09/03/18, high blood pressure, and hyperlipidemia (high levels of fat in the blood).

Observation on 11/28/18 at 9:10 AM and again at 10:00 AM, in the Medical Unit nurse's station, showed that Patient #6 and Patient #10's heart rhythms were displayed on the cardiac telemetry monitor. Patient #10's heart rate was 129 beats per minute. A normal resting heart rate for adults was 60 to 100 beats per minute. No staff were at the nurses' station, and the patients' heart rhythms were not monitored.

During an interview on 11/28/18 at 10:05 AM, Staff M, RN, stated that telemetry was not monitored continuously by staff. If a patient was critical, they would be monitored at all times. The Emergency Department (ED) had the capability to view Medical Unit telemetry if needed.

During an interview on 11/28/18 at 11:35 AM, Staff B, Inpatient and ED Director, stated that her expectation of staff was that someone should watch the cardiac monitors at all times.

During an interview on 11/28/18 at 11:30 AM, Staff HH, Physician, stated that his expectation of nursing staff was that someone should watch the cardiac monitors at all times.

During an observation and concurrent interview on 11/29/18 at 10:45 in the ED, showed that the Medical Unit patients were not displayed on the cardiac monitor in the ED (Patient #10 was not monitored while on telemetry). Staff GG, ED RN stated that there was no one designated to watch the telemetry monitor in the ED and there was not a way to view the Medical Unit telemetry and the ED telemetry at the same time. Staff GG added that she was never requested to watch Medical Unit telemetry while Medical Unit staff stepped away from the nurses' station.

Based on interview, record review and policy review, the facility failed to implement a care plan for chronic pain, diabetic management, and/or fall risk for three patients (#6, #7 and #8) of five patients reviewed. This failure had the potential to affect all patients admitted to the facility when individualized care needs were identified, but were not addressed in the Care Plan. The facility census was five.

Findings Included:

1. Review of facility policy titled, "Nursing Care Plans," reviewed 09/2016, showed that:
- A care plan was used to develop a plan of care based on the assessment of the patient's physiological, psychosocial and environmental needs.
- The care plan will be initiated by the admitting Registered Nurse (RN) after admission, or within 24-hours of admission.
- Each care plan must be individualized for the patient by choosing options that were available for outcomes, indication and interventions.
- Review of the care plan shall be made by the caregiver every shift, and shall be documented and made a permanent part of the patient's medical record.
- Any revision of care plans completed by a Licensed Practical Nurse (LPN) must be co-signed by an RN.

Review of Patient #6's History and Physical (H&P) showed that she was a 79 year old female admitted to the facility on 11/26/18 with dyspnea (shortness of breath), due to cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), coronary (heart) artery disease, chronic kidney disease, insulin dependent diabetic, and hypertension (high blood pressure). Patient #6 was also placed on telemetry (continuous heart rhythm monitor).

Review of Patient #6's Care plan dated 11/26/18 through 11/28/18 showed that the patient problems/goals were impaired gas exchange, safety risk for injury, fluid volume excess and discharge plan of care. There was no documentation in the care plan of the patient being diabetic, to monitor telemetry, or to monitor hypertension. Patient #6 did not have an individualized diabetic or cardiac care plan.

Review of Patient #7's medical records on 11/28/18 showed that the patient was treated for chronic pain, intermittent, and generalized body weakness/aches related to a recent cerebrovascular accident (CVA, a condition in which blood flow to a part of your brain was stopped either by a blockage or the rupture of a blood vessel), in which he rated five out of 10 (zero was no pain, 10 was worse pain) on 11/16/18, and four out of 10 on 11/26/18 in the medical record flowchart nurses notes. The patient required as needed (PRN) narcotic analgesic (strong and addictive drug) pain medication prescribed to help manage pain symptoms. Additionally, the medication administration flowchart showed that the patient received PRN narcotic analgesic medication to help manage pain symptoms on 11/21/18, 11/22/18, 11/24/18, 11/25/18, and 11/27/18 in which the pain level at time of administration was not documented in the medical record. Patient #7's medical record did not have an individualized pain management care plan.

Review of Patient #8's Medical Record showed that she was a 91 year old female admitted to the facility on 11/26/18 at 8:58 AM with a wound infection of the breast. A fall risk assessment was completed and she was placed on fall precautions.

Review of Patient #8's Care plan dated 11/26/18 through 11/28/18 showed no documentation of high risk for injury related to falls until 11/28/18 at 11:04 AM, over 48 hours since admission.

During an interview on 11/29/18 at 11:00 AM Staff A, Chief Nursing Officer (CNO), stated that the care plans should be initiated within 24-hours of admission, upon change of condition, and that each care plan was individualized to meet the specific needs of the patient.







40710

Based on observation, interview, record review, policy review and review of the Association of periOperative Registered Nurses (AORN) and the Association for the Advancement of Medical Instrumentation (AAMI), the facility failed to follow policies and guidelines for surgical services when they failed to:
- Eliminate the residue and debris in three large sterilizers (machines that use high heat and steam to kill harmful organisms) in the operating room (OR) sterile processing clean room (area designated to clean and sterilize surgical instruments).
- Terminally clean (a cleaning method used in hospitals to control the spread of infection) the OR sterile processing clean and dirty room (area designated for dirty surgical instruments to be cleaned before they are sterilized) every day, which processes instruments used in all OR suites.
- Ensure three visibly dirty, unfiltered wall vents, which vented into the clean room, were free of dust, debris and drainage pipe steam.
- Maintain a sterile field after touching unsterile items and walking in and out of the OR room with sterile garb on.
- Perform an appropriate preparation of the operative site.
- Ensure that a History and Physical (H&P) was current and updated in the medical record prior to the start of the procedure for one discharged patient record ( #15) of seven discharged patient records reviewed.
- Ensure that an informed consent was signed by the physician prior to the start of the procedure for one discharged patient record (#16) of seven discharged patient records reviewed.
These failed practices had the potential to compromise the safety and health of all patients undergoing procedures at the facility. The facility performed 20-30 procedures per month. The facility census was five.

The cumulative effect of these failures resulted in non-compliance with 42 CFR 485.639 Condition of Participation (COP): Surgical Services.

Findings included:

1. During an interview on 11/28/18 at 2:00 PM, Staff V, Surgical Services Director, stated that the department followed he AORN and the AAMI guidelines.

Review of the AAMI ST79:2017 Guidelines, showed the following:
- Sterilizers should be inspected and cleaned daily to include door gaskets (rubber seal), the chamber drain screen (screen to trap debris when water exits through the drain), the internal chamber (inside of the sterilizer), and external surfaces.
- Weekly or other prescribed inspection and cleaning should be performed as specified by the manufacturer.
- Inspection and cleaning reduce the frequency of equipment malfunction and the risk of accidental contamination of sterile items.
- Sterilization is a complex process requiring environmental controls (e.g., controlled air changes, heating, ventilation and air conditioning [HVAC] parameters to facilitate effective and efficient processing, promote personnel safety and standardization of procedures, minimize environmental contamination, and maintain the sterility of processed items.
- Separating "clean" and "dirty" areas limits environmental contamination and, therefore, the amount of bioburden (number of bacteria living on a surface that has not been sterilized) on devices to be sterilized.

Review of the facility's policy titled, "Steam Sterilizer Maintenance," reviewed 01/2018, showed that the sterilizers will be serviced by a qualified technician to ensure safety and proper function of equipment.

Review of the facility's undated document from the service contractor titled, "Sterilizer Chamber Cleaning Instructions," showed directives for staff to perform the following:
- Wipe the interior down with mild soap and water with a lint free cloth.
- Wipe around the door gasket and gasket mating surface (opposing surface that presses against the gasket, to form a seal).
- Rinse with clean water or a cloth to get all soap residue off of the metal and door gasket.
- This shall be repeated monthly.

Observation on 11/28/18 at 3:00 PM, in the Sterile Processing Department (SPD) clean room, showed two large sterilizers (A1 and A2). In an enclosed room next to the SPD was the Immediate Use Steam Sterilizer (A3). Observation showed the following:
- The inside chamber of the A1 Sterilizer had green stains, rust colored stains, and white hard water deposits on the bottom of the sterilizer.
- The inside chamber of the A2 Sterilizer had rust colored stains on the bottom of the sterilizer and dust on top of the sterilizer door.
- The inside chamber of the A3 Sterilizer had rust colored stains on the bottom and sides of the sterilizer.

During an interview on 11/28/18 at 3:10 PM, Staff Y, Central Supply Technician, stated that she had worked at the facility for two years and had never cleaned the inside of any of the sterilizers.

During an interview on 11/29/18 at 10:00 AM, Staff Z, Lead Central Supply Technician, stated that she cleaned the inside of the sterilizers monthly, but did not have a cleaning log.

During an interview on 11/29/18 at 11:00 AM, Staff CC, Infection Prevention Coordinator, stated that her expectation of staff was to clean the sterilizers following recommended AAMI guidelines and to document when the cleaning was completed.

2. Review of the 2017 AORN guidelines showed that terminal cleaning and disinfection of sterile processing areas should be performed daily when the areas are being used. Sterile processing areas where decontamination occurs have some of the highest risks for environmental contamination of all perioperative areas. Environmental cleaning in sterile processing areas is critical for reducing the risk of disease transmission from microorganisms (bacteria and viruses) in the decontamination environment.

Even though requested, the facility failed to provide a terminal cleaning policy for the Sterile Processing Department.

During an interview on 11/29/18 at 10:30 AM, Staff BB, Housekeeping Director, stated that the housekeeping staff did not perform a terminal cleaning in the Sterile Processing Department and she was unaware that it should be done.

3. Observation on 11/29/18 at 11:30 AM, in the OR sterile processing clean room, showed three unfiltered wall vents that had steam from a drainage pipe entering the sterile processing clean room. Through the unfiltered wall vents was visible dust and debris.

During an interview on 11/29/18 at 11:35 AM, Staff AA, Material Management Director, acknowledged the unfiltered wall vents, visible dust, debris and the steam from the drainage pipe, and stated that the unfiltered vents should not be vented into the sterile processing clean room.

During an interview on 11/29/18 at 11:40 AM, Staff CC acknowledged the unfiltered wall vents, visible dust, debris, and the steam from a drainage pipe, and stated that the unfiltered vents vented into the sterile processing clean room was an infection control issue.

4. Review of the facility's policy titled, "Aseptic (free from contamination) Practice," reviewed 01/2018 showed the following:
- Aseptic practices are implemented preoperatively, intraoperatively, and postoperatively to minimize wound contamination.
- Scrubbed persons function within a sterile field.
- Items used within the sterile field should be sterile.
- All items introduced to a sterile field should be opened, dispensed, and transferred by methods that maintain sterility and integrity.
- All personnel moving within or around a sterile field should do so in a manner that maintains the sterile field.

Review of the facility's policy titled, "Sterilization Indicators," reviewed 01/2018, showed that if the indicator strip in any sterile item has not turned the appropriate color indicating that it has not been exposed to the correct sterilization parameters, then the item cannot be considered sterile and must be sterilized again before use.

Review of the AORN Guidelines for Perioperative Practice, 2017 edition, showed the following:
- Scrubbed team members should remain close to the sterile field and touch only sterile areas or items.
- Walking outside the periphery of the sterile field or leaving and then returning to the OR in sterile attire increases the potential for contamination.
- Scrubbed team members should not leave the sterile field to retrieve items from the sterilizer.
- Rigid sterilization containers should be inspected and opened on a clean, flat, dry surface by a perioperative team member.
- The scrubbed team member should avoid contacting the unsterile surfaces of the container while lifting the inner basket out and above the container.
- Sterile gloves that have contacted unsterile items may transfer microorganism or other unsterile particulates to the sterile field.

Observation on 11/29/18 at 11:20 AM in the OR suite showed the following:
- Staff FF, Surgical technician, gowned and gloved and stood next to the sterile field.
- Staff EE, Surgical technician, opened the door for Staff FF to leave the OR suite to retrieve a container from the immediate use steam sterilizer.
- Staff FF, returned to the OR suite and placed the rigid sterilization container on the sterile field.
- Staff FF, opened the rigid sterilization container and noticed the indicator strip had not turned the appropriate color (all items were considered unsterile).
- Staff FF did not change her gown or gloves after touching unsterile items.
- Staff EE opened up items in a sterile fashion for Staff FF to set up the sterile field again (Staff FF touched sterile items with contaminated gloves).
- At 11:40 AM, Staff FF left the OR suite a second time to retrieve a container from the immediate use sterilizer.
- Staff FF returned to the OR suite and placed the rigid sterilization container on the sterile field.
- Staff FF opened the rigid sterilization container, checked the indicator strip, lifted the sterile items out of the container and placed them on the sterile field.

5. Review of the facility's policy titled, "Preparation of the Operative Site," reviewed 01/2018 showed directives for staff to begin scrubbing at the site of the incision and move outward in a circular motion to the periphery of the prepped area. Do not return sponge to the center, but discard.

Observation on 11/29/18 at 11:45 AM, in the OR suite, showed Staff II, Lead Surgical RN, performed preparation of the patient's right knee for surgery. Staff II began her surgical scrub (cleaning of skin) at the knee using an antiseptic skin applicator and progressed down the leg to the patient's ankle and then using the same applicator wiped around the knee area again (contaminating the operative site).

During an interview on 11/29/18 at 12:15 PM, Staff V, Surgical Services Director, stated that her expectation of the OR staff was that the sterile field should be maintained at all times. Gown and gloves should be changed if contaminated. When the operative site was prepped, clean the area from the inside and go out. Do not reapply the same applicator to the operative site after touching outside areas of the body.

6. Review of the facility's "Medical Staff Rules and Regulations," amended 07/2018, showed that a complete history and physical (H&P) examination must be recorded in the chart up to 30 days before a patient's admission. The attending practitioner must personally write an admission note within 24 hours of admission, indicating the reason for hospitalization and the diagnostic/therapeutic plan.

7. Review of the facility's policy titled, "Informed Consent," reviewed 01/2018, showed that the patient's physician bears the responsibility for obtaining the patient's consent to treatment. In order to obtain informed consent, the physician must first discuss the proposed treatment with the patient. The completion of the consent form requires the signature of the physician who obtained the consent and the persons who witnessed the granting of such consent.

Review of discharged Patient #15's medical record, showed that he had an incision and drainage of right axilla (armpit) on 07/23/18. The H&P noted in the medical record was dated 04/10/18, greater than 30 days from the date of admission.

Review of discharged Patient #16's medical record showed that he had an open reduction internal fixation (a type of surgery used to fix broken bones) right fifth metatarsal (the long bone on the outside of the foot that connects to the little toe) on 09/13/18. A consent form dated 09/13/18 was signed by the patient and witnessed by an RN. There was no physician signature.

During an interview on 11/29/18 at 12:15 PM, Staff V, Surgical Services Director, stated that her expectation of staff was to make sure an updated H&P was in the patient's chart and the consent was signed by the physician prior to the patient going into surgery.







37921

Based on observation, interview, record review and policy review, the facility failed to provide a comprehensive activity program for two Swing-bed patients (#5 and #7) of two Swing-bed patients reviewed. This had the potential to negatively impact the quality of life for the swing bed patient during their admission to the facility by failing to individualize activities to each patient's preference. The facility census was five with two of those in Swing-bed status (Medicare program in which a patient can receive acute care, then if needed, Skilled Nursing care in the same facility).

Findings included:

Review of the facility's policy titled, "Patient Activities Program-Swing-bed," reviewed 09/2016, showed the following:
- The activity program is designed to meet the needs, interests and abilities of the Swing-bed patients.
- Activities will be provided in both group and individual settings for both ambulatory and non-ambulatory patients by the nursing staff and the activities department of the Convalescent Center (lower level extension of hospital care).
- Activities were personalized for each patient.
- The schedule is communicated to patients who have difficulty reading.
- A Swing-bed activity flow sheet is present in each patient's electronic medical record (EMR).
- Activity Care Plan will be initiated by the activity director.

Review of the facility's undated job description titled, "Activity Director," showed the activities director:
- Plans, coordinates, and implements a therapeutic activity program on a daily basis to meet the individual patient needs and interest.
- Meets the qualifications of activity aide certified certification and Cardiopulmonary Resuscitation (CPR) certification every two years.
- Organizes and directs programs in accordance with the patient needs, abilities, and interests.
- Completes activity assessments within seven days of admission.
- Records attendance and logs activity participation.
- Composes monthly activities schedule and newsletter.
- Provides diversion activities to those confided to bed.

Observation on 11/27/18 at 12:00 PM showed Patient #5 did not have an activities calendar posted in her room.

During an interview on 11/27/14 at 12:00 PM, Patient #5 stated that she was not aware of an activities program in the facility and did not recall any activities being offered to her anytime during her stay.

Review of Patient #5's medical record, showed that the patient was an 82 year old, admitted to the facility swing-bed program on 11/09/18 for ongoing physical therapy and intravenous (IV, in the vein) antibiotic therapy, related to a previous fall, weakness, cellulitis (a common, potentially serious bacterial skin infection) to left lower extremity (LLE), and wound therapy to ulceration (open wound cause by continuous pressure or poor blood circulation) on left foot.

Review of Patient #5's activity documentation on 11/27/18 at 10:30 A.M., revealed no initial comprehensive activity assessment completed. There were no activities documented as completed for this patient for the 18 days since her admission.

Review of Patient #5's care plan on 11/27/18 at 10:40 AM, revealed no activity entry.

During an interview on 11/27/14 at 12:20 PM, Patient #7 stated that he was not aware of an activities program in the facility and did not recall any activities being offered to her anytime during his stay.

Review of Patient #7's medical record, showed that the patient was an 87 year old, admitted to the facility swing-bed program on 11/14/18 for ongoing physical therapy related to status post cerebrovascular accident (CVA, a condition in which blood flow to a part of your brain was stopped either by a blockage or the rupture of a blood vessel).

Review of Patient #7's activity documentation on 11/27/18 at 11:30 A.M., revealed no initial comprehensive activity assessment completed. There were no activities documented as completed for this patient for the 13 days since his admission.

Review of Patient #7's care plan on 11/27/18 at 11:40 AM, revealed no activity entry.

During an interview on 11/29/18 at 9:54 AM, Staff DD, Activities Director, stated that:
- She worked both the convalescent side and the acute side for Swing-bed patients.
- The nursing staff would communicate to her via phone or email when a patient has been admitted to a acute side Swing-bed.
- She would interview swing-bed patients on activity preferences and complete an activities assessment within four to five days of admission.
- Patients #5 and #7 did not have an activities assessment or care plans completed, as she has not been able to complete them.

During an interview on 11/29/18 at 11:00 AM, Staff A, Chief Nursing Officer (CNO), stated that:
- The activities on the Swing-bed patients should be Individualized and comprehensive for the patient's individual activity needs.
- The activity assessments needed to be completed on time, per policy.
- The activity calendars should be placed in the patient's room and updated monthly.