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Based on observation, interview, record review, and policy review the facility staff failed to follow facility policies for hand hygiene (wash hands with soap and water or sanitize hands with gel or foam) in the following:
-When entering patient rooms;
-Before and after glove use;
-Before medication administration in five (#10, #11, #17,#49, and #50 of six patients observed.
The facility census was 18.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene," reviewed on 12/11 showed, health care workers shall decontaminate hands using either soap and water or alcohol based hand hygiene products in the following situations:
-Before having direct contact with patients;
-Before donning (applying) sterile gloves when inserting a central or peripheral intravascular catheter (a long catheter that can be inserted in the arm and threaded toward the heart for long term use), indwelling urinary catheter, or other invasive devices that do not require a surgical procedure and surgical scrub;
-After contact with a patient's intact skin, non-intact skin, body fluids, or excretions, mucous membranes and wound dressings if hands are not visibly soiled (if hands are visibly soiled must wash hands and may not use hand hygiene products);
-After removing sterile or non-sterile gloves;
-If moving from a dirty body site to a clean body site on the same patient;
-After contact with inanimate objects (including medical equipment and computer keyboards) in the immediate vicinity of the patient.

Record review of the facility's policy titled, "Standard Precautions," reviewed 02/12, showed that hand hygiene was the single most important strategy to reduce risk of transmitting organisms from person to person or site to site on the same person.

2. Record review of the facility's document titled, "Infection Prevention Minutes" dated 01/09/13, showed a hand hygiene surveillance compliance rate of 39% for the month of December, that there were very few visual reminders posted for staff to use hand hygiene, and that staff were being made aware that data was being collected for hand hygiene surveillance.

3. Observation in Patient #9's room on 03/19/13 at 9:35 AM showed Staff P, Registered Nurse (RN), entered Patient #9's room and failed to perform hand hygiene. Staff P donned gloves, obtained, and assisted the patient on to a bedpan. Staff P failed to perform hand hygiene prior to putting the gloves on.

Record review of Patient #9's medical record showed Patient #9 diagnoses included urinary tract infection (infection in one or more of the urinary systems structures)

4. During an interview on 03/19/13 at 7:31 PM, Staff P, stated that as long as she used hand hygiene when she entered and exited a patient's room she could donn and remove gloves without hand hygiene between glove changes.

5. Observation in Patient #50's room on 03/19/13 at 9:43 AM showed Staff P entered Patient #50's room and failed to perform hand hygiene.

6. Observation in Patient #10's room on 03/19/13 at 10:11 AM showed Staff N, RN donned gloves to assist phlebotomist (a staff member that draws blood for lab tests) with a blood draw. Staff N failed to use hand hygiene prior to putting the gloves on.

Observation on 03/19/13 at 10:35 AM showed Staff N, RN entered Patient #10's room to administer medication. Staff N touched the Computer on Wheels (COW) and looked up medications on the computer. Staff N then placed Carafate (a stomach medication) in her ungloved, contaminated hands to break the pill in half and then placed the pill in the medication cup. Staff N failed to use hand hygiene after she touched the COW and before medication administration. Staff N left Patient #10's room and failed to perform hand hygiene prior to leaving Patient #10's room.

7. During an interview on 03/19/13 at 7:26 PM Staff N, RN, stated that as long as she used hand hygiene when she entered and exited a patient's room she could donn and remove gloves without hand hygiene between glove changes. If the gloves were heavily soiled, then she performed hand hygiene after gloves were removed.


8. Observation on 03/19/13 at 2:10 PM showed Staff S, RN completed hooking the intravenous (IV) tubing into Patient #49's PICC line. Staff S removed gloves, picked up a pen, and touched the COW. Staff S failed to perform hand hygiene after he removed his gloves.

9. During an interview on 03/19/13 at 2:15 PM, Staff S, stated that he typically removed his gloves, operated the COW, and then performed hand hygiene on his way out of the room.

10. Observation on 03/20/13 at 11:15 AM showed Staff W, RN, failed to wash hands or use gel sanitizer when entering the room of Patient #17. She donned gloves and de-accessed a venous access port (removal of needle and tubing from an implanted device) of Patient #17. Staff W failed to use hand hygiene before she donned gloves and performed the procedure.

11. During an interview on 03/20/13 at 11:23 AM, Staff W, stated that she did not recall if she used hand sanitizer when entering room and knew that hand hygiene was standard procedure.

12. During an interview on 03/21/13 at 1:30 PM, Staff G, RN Supervisor, stated that Staff W should have used hand hygiene before she donned gloves and performed the procedure on Patient #17.

13. Record review of the facility's policy titled, "Foley catheter (a tubing inserted into the bladder to remove urine-a sterile procedure) insertion and Care,"reviewed 10/09, showed most urinary tract infections (UTIs) were caused by instrumentation of the urinary tract, including indwelling catheters.

14. Record review of facility-provided staff meeting minutes for the medical/surgical (med/surg) unit, dated 03/07/13 showed a reminder to staff to "Gel in and Gel out" (sanitize).

15. Record review of Patient #11's History and Physical (H & P) dated 03/19/13 showed the patient was admitted on 03/19/13 with a history of COPD.

Record review of Patient #11's Physician's Orders dated 03/19/13, showed a written order for an indwelling urinary catheter.

16. Observation on 03/19/13 at 4:45 PM showed Staff N, RN, failed to sanitize her hands between glove changes (from standard gloves to sterile and back to standard) while inserting the indwelling urinary catheter.












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31891

Based on observation, interview and record review, the facility's Director of the Dietary Services failed to maintain a sanitary environment in a kitchen where hot meals are prepared and served three times daily, affecting the facility census and multiple staff. The facility census was 18.

Findings included:

1. Observation on 03/20/13 at 2:50 PM showed brown and white residue dried on the blade of the large table-top can opener, and black carbonized (burned and blackened) food residues around the rolled edges of 21 of 21 large flat baking pans and six of six muffin pans which were stacked inverted, one on top of the other on a wheeled cart.

Two of two strips of the heat weld (bonds and seals two sections of floor covering together) between large sections of the sheet vinyl floor were peeled and split, and created a rough floor surface that was not easily cleanable.

2. During an interview on 03/20/13 at 2:50 PM, Staff E, Director of Dietary Services, stated that the can opener was cleaned on an irregular basis, which is usually if staff notice it has food product on it. She stated that there was currently no specific policy or regular cleaning schedule that included or specified the can opener or specific cooking utility such as deep cleaning of baking pans.

3. Record review on 03/20/13 of a cleaning assignment sheet titled, "Daily Check List" showed a balance of cooking and cleaning duties spread across the daily and weekly schedules, supported by a policy dated 07/01/00 which addressed the cleaning responsibilities of kitchen staff more general to work areas such as "ovens and ranges free of debris" and "clean work table/shine."

Based on interview, record review, and policy review the facility failed to ensure facility patient care policies were reviewed annually in seven of ten patient care areas observed. The un-reviewed policies have the potential to affect all patients. The facility census was 18.

Findings included:

1. Record review of the facility's policy titled, "Document and Data Control," revised on 10/12, showed that all policies and procedures must have final approval and be signed off by the appropriate facility's Chief Executive Officer (CEO) or designee. The designee who has final approval authority for this facility is the Administrative Services Director. Policies and Procedures shall be reviewed no less than annually.

2. Record review of random facility policies showed the following policies that were not reviewed annually:
-"Dispensing of Medication to E.D. (Emergency Department) Patient," reviewed on 02/2008;
-"Arterial Puncture-ICU (Intensive Care Unit) and TCU (Transitional Care Unit)," revised on 06/2011;
-"Code Blue Procedure," reviewed on 09/2011;
-"Blood to OR (Operating Room), ICU, Trauma," reviewed on 02/2009;
-"Identification of Patient for Blood Bank Specimens," revised on 03/2010;
-"Emergency Issue of Blood Products," reviewed on 02/2009;
-"Isolation Procedure in the Emergency Room," revised on 10/2010;
-"Patient Care Plans," revised on 09/2010;
-"Regulations for Institutional Pharmacy Practice," reviewed on 08/2011;
-"Adverse Drug Reactions Reporting," reviewed on 08/2011;
-"Steps to Take In Case of Adverse Reaction," reviewed on 08/2011;
-"Dispensing Controlled Substance IM (intramuscular) /IV (intravenous)," reviewed on 05/2011;
-"Oral Contrast Prep and Delivery," reviewed on 08/2011;
-"Contact Precautions," reviewed on 09/2010;
-"Hand Hygiene," reviewed on 12/2011;
-"Standard Precautions," reviewed on 02/2012.

3. Record Review of the facility's Quality Council Meeting Minutes, dated January 27, 2012, showed that no significant trends were noted last year with the exception of managers being current with updated policies and procedures.

4. Record review of the facility's document titled, "Corrective Action Overview," dated 03/21/12 showed the ED department had a policy that needed to be reviewed/updated regarding transport of the ED patient. This was an ED policy that was not updated annually.

5. Record review of the facility's Quality Improvement Committee minutes, dated January 9, 2013, showed that audits continued to show the same issue with not being able to keep policies and procedures updated house wide.

6. During an interview on 03/20/13 at 8:35 AM Staff NN, Director of Pharmacy, stated that policies and procedures should be reviewed annually.

7. During an interview on 03/20/13 at approximately 2:30 PM Staff T, Lab Supervisor, stated that policies and procedures should be reviewed annually.

8. During an interview on 03/20/13 at 3:40 PM Staff Q, Lead Technician Coordinator Radiology, stated that policies and procedures should be reviewed annually.

9. During an interview on 03/21/13 at 8:50 AM Staff A, Administrative Services Director, stated that she was not aware that policies and procedures were not reviewed annually. She stated that the policies and procedures, that needed to be reviewed/updated each year, were too cumbersome to find on the computer.

Based on interview, record review, and policy review, the facility failed to ensure two of three patients (#13 and #14) reviewed, admitted to their Swing Bed (a specific portion of the hospital that provided skilled services and receive a different reimbursement based on that level of care) services, received notification of patients' rights. This had the potential to affect all Swing Bed patients admitted. The facility Swing Bed census was five.

Findings included:

1. Record review of the facility's policies titled, "Resident's Rights," reviewed 06/09, and "Welcome Booklet (Patient Rights and Responsibilities, Patient Safety, AMD [unknown acronym], General Information)," reviewed 11/11, showed the following:
-Each person admitted to the Swing Bed unit, or their responsible party, is informed, both orally and in writing of rights;
-A statement which indicated that the resident or family understood the rights will be signed and maintained in the medical record;
-The admission representative will give a copy of the Welcome Booklet to all patients being admitted;
-The Welcome Booklet contained the Patient Rights.

2. Record review of Patient #13's History and Physical (H & P) dated 03/14/13, showed the patient was admitted to the Swing Bed unit on 03/13/13. The patient had been transferred from a sister facility where she received more acute-type care.

During an interview on 03/19/13 at 10:04 AM, Patient #13 stated that she did not receive an admission/welcome booklet when admitted. Patient #13 stated that she did not remember reading, or being told about, any patient rights information.

Record review of Patient #13's record showed facility staff failed to document provision of patient rights to the patient.

3. Record review of Patient #14's H & P dated 03/08/13, showed the patient was admitted to the Swing Bed unit on 03/07/13. The patient had been transferred from a network facility where she received more acute-type care.

Record review of Patient #14's record (with the assistance of staff) showed facility staff failed to document provision of patient rights to the patient.

4. During an interview on 03/19/13 at 1:36 PM, Staff G, Registered Nurse Supervisor, stated that there was no documentation showing evidence either Patient #13 or #14 received their patient rights information. Staff G stated that they had identified, since surveyor inquiry, a failure to provide this information to those patients transferred from their network facility.

Based on interview and record review the facility failed to provide written notification of possible charges incurred during a Swing Bed (a specific portion of the hospital that provide skilled services and receive a different reimbursement based on that level of care) stay for three of three patients reviewed (#12, #13, and #14). This had the potential to affect all Swing Bed patients admitted. The facility Swing Bed census was five.

Findings included:

1. Even though requested, the facility failed to provide a policy regarding this requirement.

2. Record review of Patient #12's History and Physical (H & P) dated 02/26/13, showed the patient was admitted to the Swing Bed unit on that date with a diagnosis of lung cancer.

Record review of the patient's record showed staff failed to provide written notification of potential charges while a Swing Bed patient.

During an interview on 03/19/13 at 9:20 AM, Patient #12 stated that she had not received any written notification of possible charges while a Swing Bed patient. Patient #12's spouse also stated he had not received any such notification.

3. Record review of Patient #13's H & P dated 03/14/13, showed the patient was admitted to the Swing Bed unit on 03/13/13 with a diagnosis of pneumoperitoneum (the presence of air/gas within the abdominal cavity). The patient had been transferred from a sister facility where she received more acute-type care.

Record review of the patient's record showed staff failed to provide written notification of potential charges while a Swing Bed patient.

During an interview on 03/19/13 at 10:04 AM, Patient #13 stated that she had not received any written notification of possible charges while a Swing Bed patient.

4. Record review of Patient #14's H & P dated 03/08/13, showed the patient was admitted to the Swing Bed unit on 03/07/13 with cardiac issues and a urinary tract infection (an infection in one or more of the urinary structures). The patient had been transferred from a network facility where she received more acute-type care.

Record review of the patient's record showed staff failed to provide written notification of potential charges while a Swing Bed patient.

5. During an interview on 03/20/13 at 10:25 AM, Staff A, Director of Administrative Services, stated that she was sure the facility did not provide written notification of potential charges to Swing Bed patients prior to admission, or periodically during stay.

6. During an interview on 03/20/13 at 11:06 AM, Staff X, Director of Financial Services, stated that, historically, billing for Swing Bed patients did not show anything billed that Medicare/Medicaid did not pay for. Staff X stated that a patient-requested private room would be discussed prior to surprise billing; however, no written notification of this, or other potential charges had ever been provided to Swing Bed patients.