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Based on observation, interview and record review, the facility failed to ensure nursing staff provided care and services for 12 of 38 sampled patients (Patient #s 11, 13, 41, 24, 27, 23, 31, 66, 60,61, 1, and 2 ). Nursing staff failed to implement physician orders and follow facility policies for: weighing patients daily, application of compression stockings, implementing fluid restriction, ensuring availability of food for medication required to be given with food, administration of medication, and dating of IV sites.
Findings:

Patient #11

Patient # 11 was observed in his room on 06/10/2015 at 9:25 a.m; The Patient had a Foley catheter to bedside drain and was receiving oxygen via nasal cannula

Review of the Patient's clinical record ( History and Physical) revealed Patient #11 was admitted to the Facility on 06/06/2015 with admitting diagnosis of Chronic Renal Failure, Hyponatremia and Coronary Artery Disease.

Review on 06/10/ 2015 of Patient # 11's clinical record located in the computer system revealed a physician's order dated 06/07/2015 to " Weigh Patient Daily. "

Review of the Patient's clinical record (progress notes and patient's weight record) revealed the recorded weight of the patient was dated 06/07/2015. The physician's order was not followed for daily weight.

During an interview on 06/10/2015 at 11:30 a.m with the Units's Assistant Nurse Manager revealed the only weight done on the Patient was dated 06/07/2015.

Patient #13

On 06/11/2015 at 9:39 a.m Patient #13 was observed in her room on the 9th floor of the facility. The Patient was alert and had oxygen in progress via nasal canula. The Patient had a left triple lumen catheter in place. The Patient was observed with generalized edema.

Interview on 06/11/2015 at 9:39 a.m with (Registered Nurse T58) revealed the Patient was admitted to the Facility on 05/10/2015 with diagnosis of Chronic Kidney disease on hemodialysis three times weekly.

Review of the Patient's clinical Record ( History and Physical) located in the computer revealed the Patient was admitted to the Facility on 05/10/2015 with diagnosis of Hypertension, Chronic Kidney Disease, Congestive Heart Failure and Hypercalcemia.

Review on 06/10/ 2015 of Patient # 13's clinical record located in the computer system revealed a physician's order dated 05/11/2015 for " Weigh Patient Daily. "

Review of the Patient's record (Progress notes and Patient's Weight Record) revealed the physician's order was not followed for daily weight. There was no weight documented for the following dates:
05/30/2015, 05/31/2015, 06/01/2015, 06/02/2015, 06/07/2015 and 06/09/2015

During an interview on 06/10/2015 at 11:30 a.m with the Unit's Assistant Nurse Manager revealed the weight was not done on the Patient as ordered by the physician.

Patient 41

Patient # 41 was observed in his room in the intensive care unit 7 South 4 on 06/11/2015 at 8:48 a.m. The Patient was alert and oriented.

Interview with Registered Nurse (O27) on 06/11/2015 at 8:48 a.m revealed the Patient was admitted to the Facility on 06/05/2015 with diagnosis of Pneumonia and End Stage Renal Disease.

Review of the Patient's clinical record (Hemodialysis Treatment Sheet) located in the computer revealed documentation which indicated the Patient received hemodialysis at the Facility on 06/06/2015, 06/07/2015, 06/08/2015 and 06/10/2015.

Review on 06/11 2015 of Patient # 41's clinical record in the computer system revealed a physician's order dated 06/06/2015 for " Check Weight on admission and daily "

Review of the Patient's record (Progress notes, Dialysis Treatment Sheets and Patient's Weight Record) revealed the recorded weight on the patient was dated 06/06/2015 at 68 kg. The physician's order was not followed for daily weight.

Review of the Patient's clinical record revealed a progress notes from the Registered Dietician dated 06/10/2015 which documented the following:
Malnutrition evaluation, unable to complete malnutrition evaluation at this time. Weight loss: unable to evaluate. "

During an interview on 06/11/2015 at 12:02 p.m. with the Unit's Nurse Manager revealed the only weight done on the Patient was 06/06/2015.

During an interview on 06/11/2015 at 12:06 p.m., The Surveyors requested evidence of daily weight from the Staff Nurse (O27) assigned to the Patient # 41. Staff Nurse (O27) stated " I have not done a weight on the Patient. His bed has a scale I will do it now. " The Staff nurse weighed the Patient which indicated a weight of 74.63 kg.

Patient #11

Patient # 11 was observed in his room on 06/10/2015 at 9:25 a.m; The Patient had a Foley catheter to bedside drain and was receiving oxygen via nasal cannula. The Patient was not wearing a pair of compression stockings.

Review on 06/10/2015 of the Patient's clinical record revealed a physician's order dated 06/07/2015 for Compression Stockings.

On 06/10/2015 at 11:50 a.m the Surveyor requested evidence that the patient was provided with the compression stockings. The Registered Nurse stated that the compression stocking was available and that the facility's staff was currently imputing the order for the compression stockings


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FLUID RESTRICTION

11 Tower Patient #24

Observation on 6/9/15 at 10:30 a.m. with RN Assistant Vice-President Z26 revealed a sign on the name plate outside Patient #24's room that alerted staff he was on 1500 cubic centimeter (cc) fluid restriction. Interview with the patient's family members in the room they said they used a plastic cup filled from the water pitcher in the room and would tell the staff how many the patient drank. The PCA (Personal Care Attendant) in the room said he would document in the computer how much the patient drank off his meal tray and how many glasses of water the family said he drank.

Interview at this time with RN C29, she said the patient was on fluid restriction for a low sodium level. She said the staff and family members worked together to document how much fluid the patient drank. When she was asked how much each shift was responsible for, she said she would check the patient's water pitcher and if it was at a certain point she knew it was 800 cc and if it was to the rim it was 1000 cc. She did not know how much fluid was given from dietary on his food tray.

Record review and further interview with RN C29, she said fluid restriction was usually in the dietary note. Review of the dietary note revealed nothing about fluid restriction.

Record review of the patient's Physician's Orders revealed on 6/7/15 an order for 1500 cc fluid restriction in 24 hours.

Record review of Patient #24's Intake and Output record revealed he was admitted on 6/1/15 and the following intake was noted:

6/5 to 6/6/15 - 7 a.m. to 7 p.m. 700 cc
7 p.m. to 7 a.m. 0 cc

6/6 to 6/7/15 - 7 a.m. to 7 p.m. 450 cc
7 p.m. to 7 a.m. 0 cc

6/7 to 6/8/15 - 7 a.m. to 7 p.m. 400 cc
7 p.m. to 7 a.m. 120 cc
Total: 520 cc

Record review of Patient #24's Sodium levels revealed the following:
6/7/15 - 133
6/8/15 - 137
6/9/15 - 139
6/10/15 - 137

The normal range for sodium was 136 - 145 mg/Liter.

Further interview with RN C29, she was asked what was done when the patient's intake was so low for three days and would there be a concern for the patient being dehydrated. She said the patient's family member said he did not like to drink much fluids. She did not offer anything else.

On 6/11/15 at 9:00 a.m. the facility was asked for a Policy and Procedure (P&P) for Fluid Restriction. A P&P was given for Intake and Output (I&O). Record review of this P&P revealed it did not cover fluid restriction. The facility did not provide a P&P for Fluid Restriction by the time of exit on 6/12/15 at 4:00 p.m.

MEDICATION

15 Tower Patient #27

Observation on 6/9/15 at 11:45 a.m. revealed RN (Registered Nurse) E31 was giving Patient #27 her medications. She tapped three capsules of Creon into her gloved hand and put them in a plastic medicine cup. Patient #27 informed the nurse that she did not want to take the capsules because they needed to be given with food and she had not ordered her meal yet. She said it would be 45 minutes to one hour before the food came. RN E31 said she would hold her medication until the patient received her meal. RN E31 gave the patient her meal menu to order from dietary. RN E31 said she would keep the patient's medications with her on the shelf of the rolling computer stand.

Record review of Patient #27's Physician's Orders revealed Creon 3 capsules by mouth three times a day with meals. The first dose was given on 6/8/15 at 9 p.m.

Record review of the facility's Policy and Procedure for Medication Administration Policies - Medication Management, Number 2.50.033 dated 5/2011 revealed the following:

"PROCEDURES...
1.05 The medication is verified using the seven rights of medication administration: right patient, right medication, right dose, right route, right time, right monitoring, and right documentation ..."

IV (Intravenous) SITES

11 Tower Patient #23

Observation on 6/9/15 at 10:50 a.m. revealed Patient #23 had a peripheral IV that was not dated.

Interview at this time with RN Unit Manager V60, she acknowledged the IV was not dated and said the patient had a heparin lock IV that would be changed every 3 days.

16 Tower Patient #31

Observation on 6/9/15 at 1:50 p.m. with RN Charge Nurse F32 revealed Patient #31 had an IV that was not dated. The patient said it was the same IV he got on Saturday evening (6/6/15) in the Emergency Room.

Interview at this time with RN F32, she said he had a peripheral IV and the dressing would be changed every 96 hours (4 days). She said the dressing was due to be changed today.

Record review of the facility's Policy and Procedure for Peripheral IV Cannula Insertion number 2.60.020 dated 3/2014 revealed the following:

"PROCEDURE...

15. IV dressings will be changed every four days and as needed. Dressing will be changed immediately if they become wet or soiled. Dressing will be labeled with the date of insertion size of needle, time, date, and initials of nurse changing the dressing."



17028


Medication Administration Unit 6C

Patient # 60

Observation on 6/10/2015 9 :35 am on Unit 6C revealed Staff (N52) RN was preparing medication for Patient (#60) in his room. The staff pulled up medication from a vial into a syringe, came to the door way to patient ' s room and asked staff (I 73) Registered Nurse to verify the medication.

Staff (I 73) did not verify the orders or the patient. She looked at the syringe of medication and said it was 8 units of medication in the syringe. Staff (N52) proceeded to administer the medication by subcutaneous injection to Patient (#60).

During an interview on 6/10/2015 at 10:10 am with Staff (I 73) The Surveyor asked her the name of the medication she verified. The Staff stated 'I think it was Lovenox' (anticoagulant medication) but I'm not sure", she stated she knew it was 8 units.

Review of medication administration Record for Patient (#60) revealed the patient was given 8 units of insulin on 6/10/2015 at 9:40. There was no documentation that the medication was verified.

During an interview on 6/10/2015 at 11:12 am with Staff (N52) RN, she stated insulin is classified as a verifiable medication but there is no capability in the electronic medical record (E-MR) to have a second signature.

According to Staff (N52) staffs are able to free text on the E-MR but it is not always done.

Review of the facility ' s Medication Administration Policy/ Procedure # 2.50.033 dated May, 2014 gave the following information:

'High alert Medications require specific procedure to ensure patient safety.
The following medications require verification by second authorized professional staff that is approved to administer that medication.

Insulin for subcutaneous use requires visual double check by two licensed caregivers of all doses prepared prior to administration.

The medication is verified using the seven rights of medication administration:
Right patient, right medication, right dose, right route, right monitoring and right documentation".

Staff (I 73) did not observe the seven rights when she verified the medication for Patient (#60).

Physician Orders

Patient #61

Observation on 6/10/2015 at 11:30 am on unit 6 C Room 17 revealed Patient (#61) was observed receiving continuous renal replacement therapy.
Review of medical record for the Patient revealed he was diagnosed with ESRD(End Stage Renal Disease) and was on Continuous Renal Replacement Therapy.

Patient(#61) had a triple lumen catheter in his left femoral vein for his renal therapy and a double lumen in his right arm.

Review of the physician ' s orders dated 6/7/2015 revealed an order for weights on admission and daily.

Review of weight charts revealed no documentation weights were done 6/8, 6/9 and 6/10.

During an interview on 6/10/2015 at 12:15 pm with the unit manager she stated there was no reason for not weighing the patient because there is a bed scale.



23032


Implementation of Physician Orders:

21 Tower Patient # 1

Record review on 06-11-15 of the clinical record of Patient # 1 revealed he was 57 years old and admitted to the facility on 06-02-15 with diagnoses of poorly controlled Diabetes and status-post left toe amputation with infection.

Continued review of Patient #1's clinical record revealed a physician order dated 06-02-15 that read: "sequential compression device" (compression stockings). Review of Patient # 1's record with RN # W-61 failed to reveal documentation the patient was ever provided the compression stockings per order dated 06-02-15.

Continued review of Patient #1's clinical record revealed a physician order dated 06-02-15 that read: "weigh daily." Review of the record with RN # W-61 revealed Patient # 1 was not weighed on the following dates :

06-03-15
06-04-15
06-07-15
06-08-15

Record review of facility policy titled "Physician orders: Processing-Patient Care," dated March 2014, read: "Scope: ..Departments: Nursing & Pharmacy...4. Processing of Orders: a. All orders will be taken off by qualified personnel. b. The RN accountable for the patient's care on each shift must acknowledge all orders in the EMR. c. New orders should be reveiwed by two RNs each shift or with change of the caregiver by reviewing the active orders list in the EMRs..."

Intravenous (IV) Sites :

21 Tower Patient # 2

Record review of Patient # 2's clinical record revealed she was a 66 year old female admitted to the facility on 05-31-15 with diagnosis of Common Bile Duct Stones.

Observation on 06-09-15 revealed Patient # 2 laying in bed. Further observation of Patient # 2 revealed she had a Peripherally Inserted Central Catheter (PICC) line to her left arm. The dressing site was not dated.


24 Tower Patient # 14

Record review of Patient # 14's clinical record revealed she was a 53 year old female admitted to the facility on 06-03-15 with diagnosis of Cystic Fibrosis exacerbation. Patient # 14 was placed on modified Contact Isolation Precautions.

Observation on 06-10-15 at 10:15 a.m. revealed RN # O-15 performed a sterile dressing change of Patient # 14's PICC line. Further observation revealed the existing PICC line dressing removed by the nurse was undated. Interview with RN # O-15 at the time of obsrvation, she stated that all IV site dressings were to be dated when changed.




33438

20 Tower Patient #66

Observation on 06/10/2015 at 09:10 a.m. of Patient #66 revealed she was coherent, and awake. The Surveyor noted a right hand Peripheral Intravenous needle locked and taped. The Surveyor asked the patient when it was inserted; she answered, "I cannot recall. I think a few days ago since I am just waiting for my doctor today. He is okay to discharge me."

An interview was made with the assigned Registered Nurse #A.65 on 06/10/2015 at 09:15 a.m. The Surveyor notified her that the label for Patient #66's IV could not be identified. She said "I am her nurse for today. I was not assigned to her before. This is my first time to be with her and I do not know when the IV was inserted. Let me look at the computer for her file."

Reviewed Patient #66's medical records on 06/10/2015 revealed the patient was admitted to the facility on 06/03/2015 due to Amputation below the knee. The Peripheral Intravenous needle (PIV) was inserted on 06/08/2015.

Based on observation, interview and record review, the facility's biomedical staff failed to follow manufacturer's instruction for the use of Diasafe Filter in 2 of 2 hemodialysis machines in use in the Facility with Diasafe filters. Hemodialysis Machines M 13 and N 13

Findings:

On 06/09/2015 at 11:28 a.m, Fresenius K hemodialysis machine #s M 13 and N 13 were observed in use on the dialysis unit 7 South 6, in room 1. The hemodialysis machines had two Diasafe Filters Plus attached to the back of the hemodialysis machines. Observation of the filters attached to the back of the hemodialysis machines label;ls which indicated the filters were replaced on the following dates:
Hemodialysis M 13 Diasafe Filter Plus replaced on 02/24/2015
Hemodialysis N 13 Diasafe Filter Plus replaced on 01/2/2015

During an interview on 06/09/2015 at 11:28 a.m with Registered Nurse ( D 4,) the Surveyor asked the Registered Nurse how often the Diasafe Filters Plus should be replaced. She stated " Every six months. "

Review of the Manufacturer's Instruction for use directs users as follows: " Filter Life Time; Diasafe plus must be exchanged after 12 weeks or 100 treatments (Online plus) or earlier if the filter fails the integrity test.

The Facility did not replaced Diasafe filters in use based on the Manufacturer's instructions.

Based on observation, interview and record review the facility failed to maintain an effective system to prevent and control the transmission of infections. Widespread infection control issues were identified throughout the facility.

These system failures placed all patients at risk for the development of serious; possibly life-threatening, healthcare-associated infections.

A. The facility failed to ensure a sanitary environment in 5 of 21 patient units/departments observed ( Main operating rooms (OR) , outpatient surgery center, sterile processing, Cardiovascular recovery area, 16 Tower) .

B. The facility failed to ensure hinged surgical instruments were sterilized in the open position.

C. The facility failed to ensure staff performed appropriate hand hygiene on 11 of 21 patient units/departments ( Main OR; outpatient surgery center; 6 South; Unit 6 C ; 7 South ( 1 & 2); 7 South ( 3& 4); 7 South 6; 14 Tower; 18 Tower; 22 Tower; and outpatient community ER)

D. The facility failed to ensure staff utilized appropriate personal protective equipment(PPE) when caring for patients on dialysis; patients on isolation precautions; when administering intravenous (IV) medication; when handling urinary drainage bag; and performing venipuncture.

E. The facility failed to ensure staff cleaned patient equipment appropriately ( dialysis machine, glucometers, electronic thermometer, blood pressure cuff, medication refrigerators, microwave for patient use, and rolling computer carts taken into multi-patient rooms)

F. The facility failed to ensure staff utilized appropriate Hair covering in the OR.

G. The facility failed to ensure that single use oxygen extension tubing was not used on multiple patients.

Refer to TAG F-0749

Based on observation, record review and interview, the facility failed to implement an effective system to prevent and control infections in 15 of 21 units/departments (Tower 11, 14, 15, 16, 18, 21, 22, 24 , 7 South (1 & 2) , 7 South (4 & 5) , 7 South 6, Main OR (Operating Room), Out-patient Ambulatory Surgery Center, Out-patient Emergency Room, and CV (Cardiovascular) recovery room and to ensure TB monitoring of personnel was conducted for 6 of 12 staff (RN C3, RN F18, Endo Tech T6, Rad Tech Z38, PCA D30; and RN Y25) as evidenced by:

-Hand Hygiene practices were not followed
-Hair was not covered in the OR (Operating Room)
-Hinged instruments were not sterilized in the open position
-Intravenous(IV) and irrigation bags were put in a warmer without being dated
-Dust, grime and tape residue were found on equipment and in the environment
-Linen was not stored or handled appropriately
-Glucometers were not cleaned and sharps were not disposed of properly
-Appropriate use of PPE (Personal Protective Equipment) was not followed
-Terminal cleaning of Hemodialysis equipment was not performed
-Use of single use oxygen tubing on more than one patient
-Dressing change for PICC (Peripherally Inserted Central Catheter) was cross contaminated
-IV site dressings were not dated per facility policy
-Annual TB screening and PPDs (Purified Protein Derivative, a screening test for TB) were not conducted on 6 staff for 3 years

Findings include:

MAIN OR (OPERATING ROOM),
PACU (POST ANESTHESIA CARE UNIT)
PRE-OPERATIVE UNIT

Hand Hygiene

Observation on 6/10/15 at 10:20 a.m. with RN Director of Main OR, P2, revealed Dr. H46 was putting Patient 20 to sleep for her procedure in OR #7. The doctor was seen taking off gloves and putting on gloves without performing hand hygiene. No hand sanitizing gel was seen by the anesthesia area and the doctor did not leave the area to get gel from the only dispenser in the room.

Interview on 6/10/15 at 11:45 a.m. with Dr. H46, he acknowledged there was no hand sanitizing gel in the anesthesia area and he did not use the gel when he changed his gloves.

Observation on 6/12/15 at 9:30 a.m. revealed Scrub Tech U59 was helping to turn OR #17 over for the next case. She was seen taking off her gloves and going into the central core to get an instrument tray. A hand gel sanitizing dispenser was near the door.

Interview with RN Director of Main OR, P2, who was present at this time, she said she was hoping the incident had not been seen by the surveyor. She said Scrub Tech U59 should have performed hand hygiene before she entered the central core area.

Hair covering

Observation on 6/10/15 at 10:20 a.m. with RN Director of Main OR P2 in OR #7 revealed Dr. K37 and a resident were performing surgery on a patient with disposable scull cap hair coverings that did not fully cover the hair on the back of the head. Scrub tech M39 had a bouffant cap on that was rolled up in the back leaving his hair uncovered.

Interview at this time with RN Director of Main OR P2, she said Dr. K37 would not wear any other type of hair covering. She said all hair should be covered.

Record review of AORNs (Association of periOperative Registered Nurses) 2012 Edition of Perioperative Standards and Recommended Practices on page 62 revealed the following:
"Recommendation IV
All personnel should cover head and facial hair, including sideburns and the nape of the neck when in the semirestricted and restricted areas....Head coverings designed to contain hair and scalp skin will minimize microbial dispersal. Skull caps may fail to contain the side hair above and in front of the ears and hair at the nape of the neck..."

Hinged Instruments

Observations on 6/10/15 at 11:00 a.m. with RN Director of OR, P2, revealed the following
-Pod A core sterile equipment storage: Laparoscopy hinged forceps in the closed position
-Urology core sterile equipment storage: Hinged forceps in closed position
-Orthopedic core sterile equipment storage: Hinged needle holders and scissors in the closed position.

Interview at this time with RN P2, she said she did not know if the instruments were required to be in the closed position.

Interview on 6/10/15 at 11:40 a.m. with Director of Sterile Processing, N 40, he said all the individually wrapped hinged instruments would probably not be in the open position, because he did not know they needed to be. He said they processed hinged instruments in the open position in trays and sets on stringers, but did not have any way to keep the instruments individually wrapped in the open position.

Record review of AORN's (Association of periOperative Registered Nurses) Perioperative Standards and Recommended Practices 2012 Edition page 522 revealed the following:
"Recommendation XII
Cleaned surgical instruments should be organized for packaging in a manner to allow the sterilant to contact all exposed surfaces ....

XII.c. Instruments with hinges should be opened and those with removable parts should be disassembled when placed in trays designed for sterilization ...Sterilization occurs only on surfaces that have direct contact with the sterilant ...

XII.c.1 Instruments should be kept in the open and unlocked position using instrument stringers, racks, or instrument pegs designed to contain instruments ...

XII.d. Delicate and sharp instruments should be protected using a device such as a tip protector. The tip protector should be used according to the manufacturer's instructions.

IV and Irrigation bags

Observations on 6/10/15 from 8:45 a.m. to 12:00 p.m. with RN Director Main OR, P2, revealed IV solutions in the warmer in Pod A core. Three sodium chloride (NaCl) 3000 cc irrigation bags and one Lactated Ringers 1000 cc IV bag were in the warmer without being dated. There was a sign outside the warmer door that instructed staff to label solutions for two weeks with date/time and initial of person dating the item.

In the Urology core the warmer had three 3000 cc bags of water, three 3000 cc bags of glycine and three 3000 cc bags of NaCl that were not dated, timed or initialed.

Record review of the facility's Policy and Procedure for Warmers for Blood and Intravenous fluids - Patient Care number 2.60.177 dated 10/2014 revealed the following:

"PROCEDURES...

7. AMSCO Warming Cabinet by STERIS Corporation
a. Temperature is monitored on a daily basis and documented.
b. Temperature readings should not exceed 122 degrees Fahrenheit or 50 degrees Celsius..."
There was nothing in the policy about warming IV bags.

Record review of an on-line site for AORN Environment of Care Questions and Answers revealed the following:

"How long can fluids remain in the warmer?
Answer:
Contact the solution manufacturer for maximum temperature and length of time that the fluids may remain in the warming cabinet. The stability of the fluids will vary by the type of solution and the storage container. Post the temperature and length parameters on the cabinet for ready reference. Label and date the fluids with either the date into the warmer or the date the fluids should be removed, according to your institution policy." This statement was updated on 1/28/13.

Environment

Observations on 6/10/15 from 8:45 a.m. to 12:00 p.m. with RN Director of Main OR, P2, revealed the following:
- an emergency cart in the Pre-Operative area with tape residue on the top.
-an emergency cart in PACU (Post Anesthesia Care Unit) with tape residue on the top.

Observations on 6/10/15 at 11:00 a.m. with RN Director Main OR, P2, revealed tape residue was on the top of the emergency carts in Pod A, Urology core and Orthopedic core sterile equipment storage areas.

Observations on 6/12/15 from 8:45 a.m. to 9:30 a.m. with RN Director of Main OR, P2, revealed the following:

OR #9 - dust on the electronic monitor and computer equipment on the wall. The rolling computer stand legs had a layer of dust. One arm board had an accumulation of tape and tape residue. Outside the OR was a day surgery gurney with a thick layer of dust on the shelf underneath the bed. There was tape residue on a C-arm in the hall.

OR #16 - there was a layer of dust on a shelf over the scrub sink that held boxes of scrub brushes.

OR #15 - the anesthesia cart had tape residue.

OR #19 - An airway cart by OR 19 had tape residue. There was dust on the shelf over the scrub sink that held boxes of scrub brushes.

OR #25 - the anesthesia cart had tape residue. The intergration equipment for the robotic system had a layer of dust along with an electrical box and a Storz box. A solution warming unit was rusted.

Interview on 6/12/15 at 9:25 a.m. with RN Director of Main OR, P2, she said housekeeping did the high dusting and terminal cleaning and the PCAs and OR assistants turned rooms over between cases.

Linen

Observation on 6/10/15 at 11:50 a.m. in the Main PACU with RN Director of Main OR, P2, revealed the nurse in Bay 18 put the patient's used blanket, sheets and gown on the floor.

Interview at this time with RN P2, she said PACU did not have a lot of room so kept the linen hampers outside the unit. At this time another nurse brought a linen hamper to Bay 18. The nurse in Bay 18 picked the linen off the floor and put it in the hamper.


JAMAIL AMBULATORY SURGERY CENTER - OUT PATIENT


Hand Hygiene

Observation on 6/11/15 at 9:20 a.m. revealed PCA S31 put on a pair of gloves to perform a finger stick blood sugar test on Patient #44. She did not perform hand hygiene before putting on the gloves.

During an interview at this time with Jamail Ambulatory Surgery manager, RN Q29, she was informed of the above observation. She said the PCA should have performed hand hygiene before putting on gloves.


Glucometer use

Observation on 6/11/15 at 9:20 a.m. revealed PCA S31 cleaned a glucometer with a 70% alcohol swab. She then connected the glucometer to the computer where a second glucometer was connected. PCA S31 then picked up a glucometer to use on Patient 44. After she got the reading, she got another 70% alcohol swab and cleaned the glucometer with her contaminated gloves on. She connected the glucometer to the computer and then took off her gloves.

Interview at this time with the Jamail Ambulatory Surgery manager, RN Q29, she said the glucometer should be cleaned between patients with either Oxycite solution or the approved purple topped sanitizing wipes.

Environment

Observations on 6/11/15 at 10:00 a.m. with Director of Sterile Processing N40 revealed dust and grime on the following items:
-top ledge of hand scrub sinks between ORs (Operating Room) 6 & 5, 5 & 4, 3 & 2 and 1.
-paper towel dispenser between ORs 5 & 4
-top of 2 gel dispenser
-bottom legs of emergency cart
-window ledge outside OR
-top of wall rail in hallways
-top of two gas gage panels

Interview at this time with Director of Sterile Processing, N40, he acknowledged there was a problem with the cleanliness of the facility by saying they needed to contact the cleaning company.

In Sterile Processing there was a thick layer of dust on top of two steam sterilizers. The top of the gas sterilizer had a layer of dust and on the shelves of the sterilizer cart. The pediatric anesthesia cart in SP (Sterile Processing) had a layer of dust on the legs.

During an interview at this time with Sterile Processing techs (SPT) T32 and U33, they were asked how they cleaned the area. They said they mainly wiped the counter tops with wipes from the purple topped sanitizer.

Continued observations on 6/11/15 at 10:40 a.m. revealed a thick layer of dust on top of a suction canister in G bay in PACU (Post Anesthesia Care Unit). A rolling computer cart by bay F had a thick layer of dust on the legs and shelf under the key board. In Pre-Operative area some rolling computers were being stored. Two of them had a layer of dust on the legs and the shelf under the key board. A vital sign rolling cart had a layer of dust on the legs.

Interview at this time with Jamail Ambulatory Surgery manager, RN Q29, she said her staff was responsible for cleaning in the bay areas and the ORs. She said a contract company was responsible for cleaning surface areas like counter tops and to mop the floors. She said they were responsible for cleaning in the hallways by the ORs.

Interview with PCA (Patient Care Attendant) Y37, he said he cleaned the ORs and the contract company cleaned the hallways, the floors and the bathrooms. He said they came around 5 to 6 p.m. He said he had only seen them clean the floors and the bathroom.

Record review of the Jamail Ambulatory Surgery Center "Surgical Center Checklist" revealed the Contracted Housekeeping company was responsible for the following items:
"Entry Hall, Support Hall to Back entry, OR Hallway, Nurses Station Side A, Recovery, Holding, Back service hall, Patient Bays, Side B Entry and Halls, Nurses Station ..."

Interview on 6/11/15 at 2:35 p.m. with Director of Infection Control, W23, and Infection Control Department member, W9, they said a couple of months ago the Infection Control Department identified improper cleanliness throughout the facility as a Performance Improvement for 2015-2016. They said that came about when they checked rooms that had been cleaned by the contract housekeeping company that were "patient ready." They found that high touch areas, over bed tables and beds were still dirty. The intent was to improve cleanliness of the facility and increase patient satisfaction scores for room cleanliness. Infection Control member W9 said the department knew they had a problem with cleanliness and that was why it was on top of the list.


15 Tower

Glucometer use

Observation on 6/9/15 at 11:35 a.m. revealed PCA (Patient Care Attendant) D30 performed a finger stick blood sugar for Patient #26 in her room. After she got the result, she threw the sharp lancet into the trash.

Interview at this time with PCA D30, she said she had thrown the sharp into the patient's trash. She said she should have thrown it in the sharps container.

16th Floor Tower

Environment

Observations on 6/9/15 at 10:00 a.m. with RN (Registered Nurse) Assistant Vice President Z26 revealed tape residue on the top of the emergency cart.

CV (Cardiovascular) Recovery
2nd Floor ICU Cooley

Environment

Observations on 6/9/15 at 1:15 p.m. with RN (Registered Nurse) Assistant Vice President Z26 revealed tape residue on the top of three emergency carts. There was a medication cart at a nursing station with multiple drawers and each drawer had tape residue on the front. There was a rolling tray table with a thick layer of tape residue.

IV (Intravenous) SITES

11 Tower

Observation on 6/9/15 at 10:50 a.m. revealed Patient #23 had a peripheral IV that was not dated.

Interview at this time with RN Unit Manager V60, she acknowledged the IV was not dated and said the patient had a heparin lock IV that would be changed every 3 days.

16 Tower

Observation on 6/9/15 at 1:50 p.m. with RN Charge Nurse F32 revealed Patient #31 had an IV that was not dated. The patient said it was the same IV he got on Saturday evening (6/6/15) in the Emergency Room.

Interview at this time with RN F32, she said he had a peripheral IV and the dressing would be changed every 96 hours (4 days). She said the dressing was due to be changed today.

IMMUNIZATION RECORDS

Record review of the following personnel immunization records with Director of Occupational Health, D68, revealed the following for TB (Tuberculosis) testing:

-RN C3. Date of Hire (DOH) 7/21/03
Last negative PPD - 5/3/12
No screening
-RN F18. DOH - 3/4/02
Last negative PPD - 11/6/12
No screening
-Endoscopy
Tech. T6. DOH - 7/9/12
Last negative PPD - 2/28/12
No screening

-Radiology
Tech Z38. DOH - 7/9/12
Last negative PPD - 2/28/12
No screening

The above staff had not received a PPD for 2 1/2 to 3 years.

The following personnel had positive PPD with chest x-ray:

-PCA D30. DOH - 6/15/09
Last chest x-ray - 10/31/11
No screening

-RN Y25. DOH - 9/11/06
Last positive PPD - 7/19/11
Last chest x-ray - 8/11/11
No screening

The above staff had not received annual screening or repeat chest x-ray for 3 years.

Interview at this time with Director of Occupational Health, D68, she said she started her position in January 2013. She said she found boxes of patient health care information that had not been entered into the computer system. She said she, her two employees and any one else she could find to help spent until September 2014 entering data. At that time it was discovered that immunizations were not current. She said the first thing her department did was get staff caught up with PPD and mask fit testing. She said the next thing she needed to do were TB screenings.

Record review of the facility's Policy and Procedure for Employee Tuberculosis Screening number 1.01.25.80.007 dated January 2012 revealed the following:

"PROCEDURES...

2. Current Employees.
a. Current employees who have a history of negative TB skin tests and who have patient contact must receive an annual TB skin test....
b. Current employees who have a history of a positive TB skin test will complete the symptom screen annually. They will also be given the choice of a chest x-ray or a blood test every 3 years..."


10802

Unit 7 South 6

Hand Hygiene

On 06/09/2015 at 10:32 a.m Registered Nurse (C 3) was observed on the dialysis unit, room #, 7 South 6. The Registered Nurse was observed terminating hemodialysis treatment on Patient # 6.
Observation revealed Registered Nurse (C 3) donned two pairs of gloves (double gloved), disconnected the Patient's vascular access needles from the patient's left arm arteriovenous graft and placed the contaminated needles directly on the patient's bed. The sharps container available in the patient's room was filled and sealed. It could not hold any sharps. Registered Nurse (C#3) walked from the room to the nurses' station and discarded the vascular access needles in a sharp container. On leaving the room, Registered Nurse C 3's gown was observed with droplet of blood on the sleeve.

On re-entering the Patient's room, Patient #6's vascular access ( Artero venous Graft) began bleeding. Registered Nurse (C 3) removed the contaminated gloves she had used to discard the vascular access needles and picked up two pairs of gloves from a box of the clean gloves stored in the patient's room and donned two pairs of gloves (double gloved). The Patient then requested to apply pressure to his vascular access. Registered Nurse (C 3) removed the bloody dressings from the Patient's vascular access, and applied clean dressings. The Patient then held his vascular access site with his ungloved hand. Registered Nurse (C 3) discarded the bloody dressings, removed one pair of gloves while one pair remained on her hands. She then used her contaminated gloved hand to pick up clean gloves from boxes of gloves stored on the wall in the patient's room. The Registered Nurse was still wearing one pair of the contaminated gloves used to remove the Patient's contaminated bloody dressings.

Registered nurse (C 3) did not remove her contaminated gloves and wash/ sanitize her hands after removing the Patient's bloody dressings. The Patient was not encouraged to wash/sanitize his contaminated hands used to hold his vascular access site. This room is shared by two patients receiving hemodialysis treatment.

On 06/09/2015 at 11:55 a.m the Surveyor notified Registered nurse (C 3) that she was wearing double gloves and that she did not remove her contaminated gloves and wash/sanitize her contaminated hands after removing the Patient #6's vascular access needles and reinforcing the patient's bleeding vascular access dressings. Registered Nurse (C 3) stated " Even although I removed one. " She was refer to the process of double gloving.

7 South 6

On 06/09/2015 at 11:00 a.m Registered Nurse (D 4) was observed on the dialysis unit, room 1, 7 South 6. Observation revealed Registered Nurse (D 4), donned a pair of gloves, removed Patient # 7's bloody external blood line and discarded the bloody external blood lines.

She then removed her contaminated gloves, walked over to the computer and entered information in the computer, then secured clean gloves from boxes of gloves stored on the wall with her contaminated hands.

On 06/09/2015 at 11:05 a.m, the Surveyor notified Registered Nurse (D 4) that she did not wash/ sanitize her hands after removing her contaminated gloves.

Registered Nurse (D 4) stated " I should have. "

7 South 1 and 2

On 06/10/2015 at 9:45 a.m Registered Nurse (L 12) was observed at the bedside of Patient # 11. Observation revealed Registered Nurse (L 12) picked up the Foley bag and tubing of Patient #11 who had a Foley Catheter in place to bedside drain. The Foley bag and tubing was draining clear amber urine. Registered Nurse L 12 was estimating the total volume of the Patient's urinary out-put by suspending it in the air with her un-gloved hands. The Registered Nurse was not wearing a pair of gloves. After touching the Patient's contaminated Foley tubing and bag with her ungloved hand, Registered Nurse (L 12) walked over to the clean glove box on the wall and picked a pair of clean gloves with her contaminated hands. She did not wash/sanitize her contaminated hands after touching the Patient's contaminated Foley tubing and bag.

During an interview on 06/10/2015 at 9:57 a.m the Surveyor informed the Registered Nurse ( L 12) that she had touched the Patient's contaminated Foley catheter tubing and bag with her ungloved hands and that she had not washed/ sanitize her hands prior to securing gloves from the clean glove box. She stated " OK "

Review on 06/10/2015 of Patient #11's clinical record ( Patient History and Physical and Progress Notes ) revealed a diagnosis of Urinary Tract infection. Review of a laboratory report dated 6/08/2015 revealed a positive urine culture for Candida Albicans greater than 100,000 cfu.

7 South 1 and 2

On 06/09/2015 at 12:10 p.m. Registered Nurse V 8 was observed at the bedside of patient #8. on 7 South 1 and 2. Observation revealed the Registered Nurse V 8 donned a pair of gloves, examined the patient's chest and legs. After examining the Patient, the nurse removed her contaminated gloves. She did not wash/sanitize her contaminated hands. Registered Nurse V 8 went over to the computer and entered information in the computer. She picked up clean gloves with her contaminated hands from a box of clean gloves then applied them and then proceeded to hang intravenous antibiotic of Microfungin on the Patient. She then drew blood from the Patient's intravenous port for glucose testing.

During an interview on 06/09/2015 at 12:20 p.m. , the Surveyor notified Registered Nurse V 8 that she did not wash/sanitize her hands after examining and touching the Patient's chest and legs, that she had used her contaminated gloved hands to hang intravenous antibiotic and draw blood on the Patient # 8.
Registered Nurse V 8 stated " I changed my gloves."

7 South 1 and 2
On 06/09/2015 at 12:25 p.m. Patient Care Assistant J 74 was observed at the bedside of Patient #8. on 7 South 1 and 2. Observation revealed the Patient Care Assistant donned a pair of gloves and collected a sample of blood from Registered Nurse (V 8) for blood glucose testing of Patient #8.
After testing the Patient's blood glucose level with the glucose testing meter, the Patient Care Technician left the room, placed the contaminated meter under his arm and proceeded to remove his contaminated gloves and sanitize his hands.. The contaminated meter was in direct contact with the patient Care Assistant clothing and arm .

During an interview with Patient Care Technician J 74 at the time the Surveyor notified him that he had placed the contaminated glucose testing meter under his arm and directly against his clothing and arm. He stated " I was not thinking"

7 South 4 and 5

Hand Hygiene Medication Administration

On 06/11/2015 at 8:58 a.m Patient #42 was observed in his room on 7 South 4, room # 6. Registered Nurse P 28 was observed administering intravenous medication, subcutaneous medications and drawing blood specimen from Patient # 42 intravenous lines.

Observation revealed Registered Nurse (P 28) was observed wearing a pair of gloves. The Licensed nurse picked up intravenous administration supplies, blood tubing, syringes and a medication vial which he placed directly on the contaminated bed linen of the Patient #42. Registered Nurse P 28 sat directly on the Patient's bed and proceeded to flush the Patient's intravenous line. Wearing the same contaminated gloves the Licensed Nurse picked up the vial of Heparin that was on the Patient's bed linen and pulled up 5000 units of Heparin from the Vial. The Registered Nurse did not clean the septum of the vial before entering it with the needle. After pulling up the Heparin he walked outside the room and requested verification of the dosage with another nurse. He returned to the room and administered the medication to the patient subcutaneous.

After administering the Medication of Heparin into the Patient, the Licensed Nurse removed his contaminated gloves and then retrieved clean gloves from a box of clean gloves. The Licensed Nurse did not wash/sanitize his hands. He then collected a sample of blood from the intravenous port and threw the blood and tube on the Patient's bed.

He then went over to the clean supply cart wearing his contaminated glove and picked up another blood tube from a drawer in the clean supply cart. He collected another sample of blood which he placed on top of the clean supply cart, removed his gloves, sanitized his hands and picked up the blood tubing with his un-gloved hands.

During an interview on 06/11/2015 at - with Registered Nurse P 28, the Surveyor notified him that he had used one pair of gloves to gather supplies, administer intravenous and subcutaneous medication, that he had not used a clean area to prepare medication and that he did not clean the septum of the vial of Heparin. He stated " OK "
7 South 4

On 06/06/2015 at 9:15 a.m Patient #43 was observed on 7 South 4, room 5. Observation revealed the Patient was observed with dressing to her abdomen. Observation revealed Registered Nurse (P 28) donned a pair of gloves, and removed the dressing from the Patient's wound. Observation revealed the wound was draining. The Registered Nurse removed the dressing from the wound with his gloved hands. After examining the Patient's draining wound, the Registered Nurse removed his contaminated gloves, then walked to the computer station and entered information in the Patient's computer.

The Units Manager who was present said to Registered Nurse (P 28) " You did not wash your hands before you touched the computer. " Registered Nurse ( P 28) stated "I did not."

PPE

7 South 6

On 06/09/2015 at 11:10 a.m Registered Nurse (C 3) was observed on the dialysis unit, room 1 Station 7 South 6. Observation revealed Registered nurse (C 3) donned a pair of gloves, removed the Patient's bloody external blood lines. The bloody external blood lines touched Registered Nurse clothing. She was not wearing a protective gown.

During an interview on 06/09/2015 at 11:12 a.m, with Registered Nurse (C 3), the Surveyor notified Registered Nurse (C 3) that she did not wear protective gown when removing the blood external blood line which touched her clothing. Registered Nurse (C 3) stated " OK "

Terminal cleaning of Hemodialysis machine Station 7 South 6

On 06/09/2015 at 11:30 a.m Patient Care Assistant (E 5) was observed on the hemodialysis unit, room #1, 7 South 6. Observation revealed Patient Care Associate (E 5) cleaned the front of hemodialysis machine M 13 which was previously used by a patient for hemodialysis treatment. The Patient Care Associate did not clean the drain bucket or the Hanson Connector of the hemodialysis machine.

The Patient Care Assistant picked up the contaminated drain bucket walked over to the clean supply area and picked up clean supplies in preparation of an oncoming patient. The Patient Care Associate comingled the contaminated drain bucket with the clean supplies to be used for the on -coming patient.

Review of the Facility' s current Policy and Procedure on Disinfection of Hemodialysis Equipment and immediate Environment _ Dialysis # 2.230.013 directs staff as follows: " All dialysis machines, ancillary equipment and other items will be disinfected after each use. Spilled contaminants such as blood, ultrafiltrate, or peritoneal fluids will be cleaned immediately. Dialysis unit personnel performing cleaning shall wear appropriate personal protective equipment (PPE).

" The surface of all dialysis, apheresis and ancillary equipment must be wiped down with 10% bleach or hospital -approved disinfectant after use. Any surface that has been touched or anticipated to have been touched during Patient Care must be cleaned, decontaminated, and disinfected. "

Review on 06/12/2015 of Patient Care Assistant Personnel Training record revealed documentation which indicated that her last Skills/ assessment training on Hemodialysis Pre/ Post cleaning was done on March 2012.


33438

18 Tower

Hand Hygiene
Observation by Surveyor with Emergency Room Director of Nursing #T.20, Cooley B Director #K.49, and Assistant Nurse Manager #Z.64 on 06/09/2015 at 12:25 p.m., Registered Nurse #B.2 was holding an alcohol swab while pointing her right index finger to the screen of the Acudose-Rx and getting a medication. The Surveyor followed her towards a patient room. At 12:30 p.m., she entered the room of Patient #5 and took a medication cup from her mobile computer station; opened 2 sealed oral tablets gave to Patient #5, and left the room without washing hands.

Interviewed Registered Nurse #B.2 on 06/09/2015 at 12:27 p.m., the Surveyor verified with her the purpose of an alcohol swab that was used while pointing her finger on the screen of the medication dispenser. She said "Oh, I'm using this to protect myself from germs; you know staff members are exposed to different types of microorganisms." Subsequent interview with her at 12:31 p.m., the Surveyor notified her of the observation while giving medication without performing hand hygiene. The Surveyor verified also the medication that was given and she said "I gave 2 tabs of Norco to her. I'm sorry, but I can't wash my hands. I do have sensitive skin (she showed her both hands with big open wounds to Surveyor and her Assistant Nurse Manager #Z.64), even the hand gel I cannot use because it irritates more."
Community Emergency Center Registered

Hand Hygiene

Observation by Surveyor with Emergency Room Director of Nursing #T.20, and Cooley B Director #K.49 on 06/11/2015 at 09:25 a.m., Registered Nurse #D.42 was in Patient #50's room. She worn a glove on right hand, while the left hand was ungloved. She inserted a PIV (Peripheral Intravenous) needle on Patient #50's right forearm using that right gloved hand, while her ungloved hand was performing a skin taut. Registered Nurse #D.42 immediately put a clean glove on her left hand, then pulled tape to secure patient's PIV site. She collected blood to green top tube, removed her gloves, then placed that green top tube on the bedside table. She removed her gloves and placed the green top tube inside a plastic bag without wearing gloves.

Interview with Registered Nurse #D.42 on 06/11/2015 at 09:40 a.m. while at the presence of Emergency Room Director of Nursing #T.20, Cooley B Director #K.49, the Surveyor notified her about the PIV insertion with no gloves on both hands, she said "I usually do it to palpate the site for vein, but I forgot that I'm supposed to wear gloves on both hands."

Community Emergency Center

Hand Hygiene

Observation with Emergency Room Director of Nursing #T.20, and Cooley B Director #K.49 on 06/11/2015 at 12:00 noon., Registered Nurse #G.45 was in a Triage Room ,she applied blood pressure cuff to Patient Patient #51's left arm. The Surveyor noted that there was no visible nor easily accessible disinfectant solution inside the room to clean a blood pressure cuff. After assessment, the nurse left the room with the patient and his mother, brought them to another room without performing hand hygiene.

Interview with Registered Nurse #G.45 on 06/11/2015 at 12:08 p.m while at the presence of Emergency Room Director of Nursing #T.20, Cooley B Director