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Based on observation, interview and document review, the facility failed to ensure nursing staff followed the skin/wound plan of care as prescribed for 1 (#45) of 3 patients reviewed with alterations in skin integrity out of a total of 45 sampled patients resulting in the potential for the less than optimal outcomes for the patients. Findings include:

On 4/19/18 at approximately 0930 a wound care observation for patient #45 was performed by Registered Nurse Staff DDD. Clinical Nursing Educator Staff O was present for the wound care observation. Staff DDD explained the patient had a wound on her "bottom". Staff DDD was observed as she removed a foam dressing from the patient #45's sacral (bony area at bottom of the spine) wound. A saturated gauze dressing with a large amount of bloody drainage was observed. The wound bed was observed covered with grayish-black eschar (leathery dead tissue) with small amounts of pink granulation tissue. The wound edges and surrounding tissue were irregular and varied in color from pink, dark red and purple. There was tunneling (a narrow opening underneath the skin) noted within the wound. The patient's left inner buttock was observed excoriated with reddened blisters in various stages of healing.
Staff DDD was observed as she irrigated the wound with sterile water, cleansed the wound with a sterile water moistened gauze, packed the wound with an alginate (absorbent) dressing and secured the wound with a foam dressing.

On 4/19/18 at 0940 a review of the medical record for patient #45 was conducted with Staff DDD. Staff DDD explained that was the first time that she was assigned to patient #45.
A review of the skin/wound care plan treatment order dated 4/18/18 at 1209 documented the following:
Irrigate wound with normal saline. Apply Santyl (ointment used to remove dead tissue from a wound) nickel thick (amount) to wound bed using a tongue depressor pack with a normal saline moistened gauze and cover with Optilock (plastic dressing) secure with medical tape.

At that time Staff DDD was asked to explain why she did not follow the wound care plan treatment order dated 4/18/18 when changing patient #45's wound care dressing. Staff DDD stated, "I was nervous." When asked to explain if she reviewed the order prior to performing the wound care, Staff DDD said that she did.

On 4/19/18 at 0945 Staff O was overheard as she explained there was a shortage of saline and therefore Staff DDD used sterile water. Staff O was asked to explain if the Santyl ointment was available and if the manufacturer's recommendations for Santyl included the use of sterile water for cleansing and dressing the wound. Staff O said she would have to find out.

On 4/19/18 at 0950 an interview and record review for patient #45 was conducted with Nurse Manager Staff K.
A review of the medical record documented the following:
According to the admission face sheet patient #45 was admitted to the facility on on 4/8/18 with a diagnosis of infection.
A review of the "Skin/Wound" plan of care dated 4/9/18 revealed the patient was admitted with a 3 centimeter (cm) x 3 cm unstageable (full thickness tissue loss in which the base is covered by slough (yellow, tan, gray, green or brown in the wound bed) decubitus ulcer, to the coccyx. Dressing change twice per day, treatment as ordered by the physician.

On 4/19/18 at 1120 an interview was conducted with the Chief Nursing Officer Staff E and the Director of Nursing Staff CC. Staff E said she was aware of the aforementioned wound care observation. She said that should not have happened.
At 1125 on 4/19/18 Staff CC said, we just recently completed staff education for all nursing staff regarding obtaining and following physician's orders for wound care. She said, that's not good.
Staff CC explained they were monitoring staff and performing chart audits to ensure wound care orders and wound care treatments were documented accordingly in the clinical records.

On 4/19/18 at 1230 a review of the facility's "Nursing Plan of Care" policy dated 3/31/18 documented: "...V. Provisions...E. the RN is responsible for reviewing, evaluating, and documenting the progress toward established plan of care goals and updates the plan of care accordingly...".
A review of the manufacturer's dosage and administration instructions for Santyl ointment dated 2016 documented:
1-Prior to application the wound should be cleansed of debris and digested material by gently rubbing with a gauze pad saturated with normal saline solution, or with the desired cleansing agent compatible with Santyl, followed by a normal saline solution rinse.

On 4/19/18 at 1300 during an interview with the Director of Regulatory Compliance Staff A stated, "We don't have a policy for following wound care treatment orders."

Based on observation, interview and document review, the facility failed to ensure nursing staff observed during medication pass observations prepared blood thinner injection medication in a clean and sanitary manner prior to administering to 1 (#23) of 3 patients observed during medication pass observation, resulting in the potential for less than optimal outcomes. Findings include:

On 4/17/18 at 1420 patient #23 was observed in bed. The patient was agreeable to the medication observation.

On 4/17/18 at 1425 Staff GG was observed as she prepared the patient's heparin (medication used to prevent blood clots). Staff GG was observed as she removed the plastic cap seal from the heparin vial. Staff GG was observed as she inserted the syringe/needle into the rubber septum and withdrew the heparin without cleaning prior to accessing the vial.

Staff GG then proceeded with cleaning the patient's abdomen with an alcohol swab and injected the patient's heparin.

On 4/17/18 at 1435 Staff GG was asked to explain if it was necessary to clean the rubber septum of the heparin vial prior to accessing and removing the medication. Staff GG stated, "Yes. I didn't do that. I usually do."
A review of the facility's "Multi-Use Vials and Medication Packaging Available in Patient Care Areas" policy Number 2 MEDS 113 dated 7/15/2017 documented:
Procedure:
C. For all vials (single-dose/single use and multiple dose):
1. Disinfect the vials rubber septum before piercing by wiping (and using friction) with a sterile 70 percent isopropyl alcohol swab. Allow the septum to dry before inserting a needle or other device into the vial.

Based on observation and interview the facility failed to ensure the physical environment was developed and maintained to ensure the safety of the patient resulting in the potential for harm to all patients served by the facility. Findings include:
See specific tags:

A-0701 - Failure to ensure the physical environment of the hospital was developed and maintained to assure the safety and well-being of patients

A-0710 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code

Based on observation and interview the facility failed to maintain proper ventilation system to assure the safety and well being of patients resulting in less than optimal air quality for all 321 patients. Findings include:

On 4/17/2018 at approximately 1400 it was observed that the magnehelic gauges serving final air filters (90% efficiencies) of air handling units, located on the 6th floor East Penthouse, were not calibrated to show accurately the static pressure differential to determine the cleanliness of the air filters. This finding was confirmed in an interview with the facility maintenance director at the time of observation.

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated April 19, 2018
K-0222
K-0225
K-0226
K-0291
K-0321
K-0341
K-0351
K-0355
K-0363
K-0371
K-0511

Based on observation, interview and record review, the facility failed to ensure that Infection Control policy was followed for handwashing after glove removal for one of one observations of a blood spill clean up, mobile computer (WOW) disinfection after leaving an isolation room for one (#46) of three patients observed for isolation precautions out of a total sample of 46, and for cleaning of nursing unit medication storage refrigerators for one of twelve medication refrigerators inspected, out of a total of 12 nursing units, resulting in the potential for transmission of infectious illness. Findings include:

On 4/17/18 at approximately 1000, an unidentified man was observed in the main lobby, bleeding from his left wrist. The patient stated, "I knew this would happen, I told that nurse she had to wrap up my IV (intravenous access) better than that before she discharged me." The patient was transferred to the Emergency Department by wheelchair, still bleeding from his left wrist, and dripping blood onto the floor. There was an approximately 10 centimeter (cm) puddle of blood with surrounding blood spatters and drops of blood on the lobby floor between the reception desk and the metal detector screening station.

Security guard Staff Z was already wearing protective disposable gloves to screen patients at the metal detector. Staff Z took a handful (four to five towelettes/wipes) of (brand name of hospital grade disinfectant quarternary ammonium compound impregnated disposable towelettes) and used them to mop up the blood spill on the lobby floor. Staff Z used two additional handfuls of disinfectant wipes to mop up the blood spill. A rust colored smear remained on the lobby floor where the blood spill was. Staff Z then removed his contaminated gloves and put on a new pair without washing or disinfecting his hands. Staff Z then picked up a woman's purse and handled the contents as he searched her purse while she went through the metal detector. Staff Z then handed a male guest a plastic container for him to put his cell phone and keys in while he went through the metal detector. Staff Z touched the container's contents with his gloves as he checked them for contraband.

At approximately 1010 Staff Z was interviewed regarding hand sanitization and blood spill clean up procedures. Staff Z stated that he didn't know that he had to sanitize his hands between glove changes after cleaning up blood.

Staff A, who was present from 1005 through 1010 stated, "I'm sorry you had to see that. He (Staff Z) should have known better. He has hand sanitizer at his station and should have used it between glove changes. I'll call housekeeping to come clean up the area.'

On 4/19/18 at approximately 1300 Staff Z's personnel file was reviewed and revealed that he had completed annual training on Infection Control, Handwashing, and Blood Borne Pathogens in 2017.

On 4/19/18 at approximately 1330, review of the facility policy entitled, "Infection Control Committee", dated 11/1/17 revealed the following statement, "Perform Hand Hygiene before and after gloving."

On 4/17/18 at approximately 1440, Staff KK was observed in Patient #46's room wearing (PPE) a disposable protective gown, disposable mask, and disposable gloves. The Portable computer (WOW) was in the room on the left side of the patient's bed. Staff KK was observed as she scanned the patient's armband with the WOW scanner and then gave Patient #46 an injection. Staff KK then removed her gown, mask and gloves, and sanitized her hands. Staff KK then pushed the WOW out of the room, down the hallway and to the nursing station with her bare hands. A pen, two pieces of paper with writing, and two syringes were observed on the desk top surface of the WOW. Staff KK then took the syringe off the top of the WOW, and without sanitizing her hands or the WOW she unlocked the door of the Medication Room and entered it with the syringe. Signs on the door of Patient #46's room noted that two types of isolation precautions were in effect, Droplet Precautions (respiratory disease spread by droplets) and Contact Precautions (spread by touching contaminated surfaces or objects).

On 4/17/18 at approximately 1500, Staff KK was interviewed and asked about the syringe she took out of Patient #46's room and placed on top of the WOW station and then took into the Medication Room. Staff KK reported that it was an empty syringe that she had used to give Patient #46 a heparin injection. When asked why she didn't discard the used syringe in the sharps box in the patient's room, Staff KK declined to answer. When asked whether she should disinfect the WOW station before returning it to the nursing station, Staff KK declined to answer.

On 4/17/18 at approximately 1505, the Unit manager, Staff II was interviewed. Staff II stated that the WOW station should be disinfected in the alcove of the isolation room. Staff II stated that there should be a container of disinfectant wipes in the alcove for this purpose. At approximately 1506, the alcove of Patient #46's room was inspected with Staff II, and there were no disinfectant wipes there, or in the patient's room.

On 4/17/18 at approximately 1510, Patient #46's clinical record was reviewed and revealed the following:
Patient #46 was a 62 year old female who was admitted on 4/15/18 for diagnoses of Cough, Difficulty Breathing, and Diarrhea. A Physician order dated 4/15/18 noted "Contact Precautions" was ordered for rule out (presumptive) C-diff (Clostridium difficile infection - a potentially life-threatening infectious diarrhea). A Physician's order dated 4/15/18 noted "Droplet Precautions" was ordered for laboratory confirmed infection with RSV (Respiratory Syncytial Virus).

On 4/19/18 at approximately 1430, review of the facility policy entitled, "Infection Control in the Environment of Care", dated 11/14/16 revealed the following statements, "Bedside computers, handheld devices and Bar Code Scanners may be taken into isolation rooms providing that gowns and gloves are removed and hand hygiene is performed prior to accessing the device. The devices will be disinfected with the hospital approved disinfectant wipes upon exit from the isolation room."


28775

On 4/17/18 at approximately 1000 a tour of the 6 East Nursing unit was conducted with Nurse Manager Staff EE. During the tour the medication refrigerator was observed. There were two shelves with Intravenous (IV) solutions observed refrigerated. The shelves were were lined plastic liners. There were large amounts of white flakes observed on the top shelf and the bottom shelf liners. The white flakes were observed in contact with the IV solutions. Staff EE was asked to explain what the white flake like substances were. Staff EE said she did not know. She confirmed the medication refrigeration was not clean. She explained pharmacy staff were responsible for cleaning the refrigerator.

A review a of the facility's 2018 "Cleaning Responsibility Grid" documented the following:
Item: Medication Refrigerators
Standard: Visibly soiled
Cleaning Method: Disinfectant wipes Wipe with disinfectant (EVS)
Verification of cleaning method: (left blank)
Responsible group or person: Pharmacy: inside. EVS: outside. User if spill clean up required





27986

On 4/19/18 at 1344 during a tour of the pharmacy and interview with the pharmacy director staff NN, he stated that Pharmacy is responsible for the cleaning the inside of all the medication refrigerators. He stated there was not a schedule for timing of the cleanings, they were cleaned whenever necessary. Staff NN stated he looked at the refrigerator that was found dirty and stated it looked like the dust from drilling when drug boxes were installed about one month ago.