HospitalInspections.org

Based on policy/procedure and medical record review, and staff interviews, the hospital failed to ensure documentation that inpatients were informed of their visitation rights including the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including same-sex domestic partner) and another family member or friend for 10 of 13 open inpatient records reviewed. (Patients # 4, 5, 9, 10, 16, 17, 18, 19, 20, and 21) The hospital administrative staff reported a current census of 85 patients at the beginning of the survey.

Failure to ensure all inpatients were provided patient visitation rights information could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person present when they are provided any type of care services or treatment modalities.

Findings include:

1. Review of policy/procedure titled "Visitation Rights for Patients", dated April 2014, revealed a lack of requirement to document the patients were informed of their visitation rights.

2. Review of inpatient medical records on 12/12/16 at 2:00 PM revealed a lack of documentation that Patients # 4, 5, 9, 10, 16, 17, 18, 19, 20, and 21 were informed of their visitation rights.

3. During an interview and inpatient medical record review on 12/12/16 at 2:00 PM, Staff I, Director of Acute Care, provided a document titled "An Important Message From Medicare About Your Rights". Staff I confirmed the document failed to explain the visitation rights.

During an interview on 12/14/16 at 3:45 PM, Staff G, Director Quality, acknowledged the hospital did not have a mechanism for patients to sign the document in the patient's medical record that they were informed of their visitation rights.

Based on observations, policy review, and staff interviews, the hospital staff failed to secure and protect patient information from unauthorized users. The problem was identified for 2 of 5 departments with hard copy patient medical records (Obstetrics and Diagnostic Imaging).

The Obstetrics staff identified approximately 535 births per year with delivery room records that contained patient personal health information from January 2013 to December 2016 stored on an unsecured shelf.

The Diagnostic Imaging staff identified approximately 15,750 patient film jackets that contained patient personal health information on unsecured shelves in a supply room.

Failure to secure the patient information could potentially cause a misuse of patient information and/or stolen identity for the individual patients.

Findings include:

1. Review of hospital policy titled "Protection and Availability of Medical Records", dated October 2013, revealed in part, ". . . All required records, either as original hard copy, electronic, microfilm/DVD/CD or recordings, and the content of such originals, shall be legibly maintained and readily available upon request on a 'need to know' basis. Access to medical records is restricted to authorized personnel and medical staff. . . Any area or equipment maintaining PHI [protected health information] shall remain secured and/or locked at all times when unsupervised by authorized personnel. . . ."

2. Observation during tour of the Obstetrics department on 12/12/16 at 1:40 PM with Staff E, Clinical Facilitator Women's Health, revealed 2 of 2 delivery room log books, one book with patient deliveries from January 2013 to March 2015 and one book with patient deliveries from April 2015 to December 2016, stored on an open shelf in the Obstetrics nurse's station.

During an interview on 12/12/16 at 1:40 PM, Staff E confirmed the patient information in the 2 delivery room log books stored on an open shelf in the Obstetrics nurse's station were unsecured when the department had no patients. Staff E acknowledged the housekeeping staff have access to the department when no Obstetrics staff were present and allowed for the potential of unsupervised access to patient personal health information contained in the unsecured delivery room log books.

3. Observation during tour of the Diagnostic Imaging department on 12/13/16 at 3:10 PM with Staff H, Manager Diagnostic Imaging, revealed 45 open shelves with approximately 350 patient film jackets that contained patient personal health information in the supply room.

During an interview on 12/13/16 at 1:40 PM, Staff H confirmed the patient information in the patient film jackets were stored in a store room with code access and the store room staff have access to the supply room when no Diagnostic Imaging staff were present. Staff H acknowledged the store room staff know the access code and have access to the supply room when no Diagnostic Imaging staff were present and allowed for the potential of unsupervised access to patient personal health information contained in the unsecured patient film jackets.

Based on review of medical records and staff interview, the hospital failed to ensure the physician order for the patient's hemodialysis treatment included the gauge size for the needles used to cannulate (insert needles into a vascular access) the patient's AV Fistula (arteriovenous fistula; a hemodialysis vascular access created by surgically connecting an artery and a vein beneath the skin of an arm or leg to provide access to the patient's blood. During the dialysis treatment the access is used to withdraw blood from the patient, circulate the blood through the hemodialysis machine to remove excess fluid and toxins and then return the blood to the dialysis patient) for the patient's hemodialysis treatment.

The physician order is the prescription used by staff to provide the patient's hemodialysis treatment. Failure to ensure the order included the gauge size for the vascular access needles could potentially result in staff using a needle size that was not the correct size for the patient's AV Fistula which could result in adverse outcomes or harm to the patient's fistula and inability to receive an effective dialysis treatment.

At the time of the survey, the hospital staff reported a hemodialysis patient census of 2. Findings for 1 of 2 hemodialysis medical records reviewed (Patient D1) include:

1. Review of Patient D1's medical record and interview with Dialysis RN (Registered Nurse) DA on 12/14/16 at 11:30 AM showed Patient D1 received the first dialysis treatment using the patient's AV Fistula on 12/12/16.

The medical record for Patient D1 included a physician order dated 12/12/16 for a BFR (Blood Flow Rate) of 200 and "Run BFR as high as possible to complete tx [treatment/time] (max 400 ml/min [milliliter/minute])." The physician order did not include a specific order for the gauge of needles for the patient's dialysis treatment.

2. The hospital had a policy and procedure titled "DIALYSIS VASCULAR ACCESS," with the last Revision Date of 9/2016, which included in part, "PURPOSE To provide hemodialysis treatment utilizing the patient's vascular access. POLICY To gain access to a patient's vascular access minimizing the possibility of infection, occlusion, thrombosis, infiltration and other trauma... CANNULATION OF NEW VASCULAR ACCESS PURPOSE To successfully cannulate new vascular access and prevent infiltration... AV Fistula Week One... Recommended blood flow rate is 250; reduce to 200 if unable to tolerate... Use 17 gauge needles... Blood Flow Rate to Needle Gauge Chart... BLOOD FLOW RATE 200-250 ml/min... NEEDLE GAUGE 17 gauge..."

3. Review of the dialysis treatment sheet documentation dated 12/12/16 showed staff used 17 gauge needles for Patient D1's dialysis treatment with the BFR during the dialysis treatment of 200.

4. During an interview on 12/14/16 at 11:30 AM, RN DA, the Director for Dialysis, and the Manager for Dialysis acknowledged and verified the physician order should include the gauge of needles for the patient dialysis treatment.

Based on observation, policy review, and staff interview, the hospital failed to ensure 1 of 4 radiation exposure cords were secured to not allow staff access into the x-ray room during testing of patients. The Diagnostic Imaging staff reported completing an average of 3000 x-ray's per month.

Failure to secure radiation exposure cords could allow staff access to the x-ray room while performing a procedure and exposing staff to unnecessary radiation.

Findings include:

1. During tour of the Diagnostic Imaging department on 12/13/16 at 2:50 PM with Staff H, Manager Diagnostic Imaging, revealed 1 of 4 radiation exposure cords in general x-ray room 1 was not secured and reaching approximately 6 feet into the x-ray room. This would allow staff access to the x-ray room during the procedure.

2. Review of undated Diagnostic Imaging Policy/Procedure titled "DI Departmental Safety Policy" revealed in part ". . . The radiological technologist shall always stand in the lead-lined control booth when making an exposure. . . ."

3. During an interview on 12/13/16 at 2:50 PM, Staff H, Manager Diagnostic Imaging, agreed the radiation emitting cord was not secured and would allow staff access to the x-ray room during x-ray procedures. Staff H acknowledged the cords should be secured at a short length to not allow staff access to the x-ray room during procedures.

Based on observation and staff interview the Clinical Nutrition Services Supervisor failed to plan a standard non-select menu for patients unable to or choosing not to make their own menu selections. The Director of Food and Nutrition Services (FNS) reported the department served an average of 188 patient meals daily. The hospital administrative staff identified a census of 85 residents.

Failure to have a planned menu, approved by the dietitian, for patients unable to or choosing not to make their own menu selections, could potentially result in meals that failed to meet their nutrient needs

Findings include:
During an interview on 12/12/16, at 12:40 AM, Staff A, Director of FNS, reported patients are provided a select menu to make their own menu choices, based on their diet order and provided select menus for each diet type. She reported the Food and Nutrition Services department did not have a standard or house menu or therapeutic spread sheets for use when a patient failed to make their own selections. She did not know if the diet techs had a template or reference sheet to guide them in making choices, in order to meet the patient's nutrient needs, but would check with one of the diet techs.

During an interview on 12/13/16, at 8:00 AM, Staff D, Registered Dietitian/Clinical Nutrition Supervisor, confirmed the department lacked a standard or house menu to identify the items to provide a patient unable to or unwilling to make their own selections, in order to provide the patient with meals that would meet their nutrient needs.

During an interview on 12/13/16, at 10:40 AM, Staff J, Diet Tech, reported the diet techs did not have any set guidelines or reference sheets to make selections for patients unable to or chose not to make their own menu selections. She reported she would consider their age and any known preferences and make selections from the options in the menu categories, identified on the select menus for the patient's diet type.

I. Based on review of manufacturer's recommendations, facility documents, and staff interview, the hospital failed to ensure documentation that reflected staff verified the absence of the residual disinfectant used to sanitize the portable RO (Reverse Osmosis) systems used for acute hemodialysis prior to utilizing the units for patient treatments.

Hospital dialysis units often utilize portable RO units to produce the dialysis quality water required for acute hemodialysis services. Portable RO units are often required, by manufacturer's recommendations, to be periodically disinfected internally with chemical products. Failure to ensure verification for the absence of residual disinfectant in the portable RO units, prior to beginning dialysis treatments at the facility, could potentially lead to patient exposure to residual disinfectants in the water produced by the RO units leading to poor patient outcomes including illness and death.

The hospital staff reported a census of 2 hemodialysis patients. Findings for review of 4 of 4 (units #8350, #9236, #10624 and #10625) portable RO units used for dialysis for the months of September 2016, October 2016, and November 2016 include:

1. Review of the manufacturer's directions for use titled, "Mar Cor Purification MILLENIUM REVERSE OSMOSIS UNIT Operation and Maintenance Manual", Document number 1236572 Revision G, included in part, "...WARNING: Label the machine with appropriate warning signs such as DO NOT USE/CONTAINS RENALIN" to prevent use of the RO unit until it is properly rinsed ..."

2. Review of the manufacturer's directions for use titled, " Mar Cor Purification MILLENIUM HX REVERSE OSMOSIS UNIT Operation and Maintenance Manual, dated 10 APR 15, included in part, "...WARNING: Label machine with appropriate warning signs such as "DO NOT USE/CONTAINS SANITIZER" to prevent use of the RO until it is properly rinsed...ALWAYS RINSE AND TEST PRODUCT WATER AFTER ANY CHEMICAL PROCESS! NEVER DIALYZE WITHOUT RINSING AND TESTING FIRST! ..."

3. The hospital staff provided the surveyors with the disinfection logs for the facility's 4 portable reverse osmosis units for the months of September 2016, October 2016, and November 2016. Closer evaluation of the logs showed the following:

a. RO unit # 8350 was chemically disinfected on 9/12/16, 9/26/16, 10/9/16, 10/31/16, 11/7/16, and 11/21/16. Closer review of the log lacked documentation that staff verified the absence of disinfectant after completion each chemical disinfection procedure.

b. RO unit # 9236 was chemically disinfected on 10/3/16, 10/10/16, 10/17/16, 11/7/16, 11/14/16, 11/21/16, and 11/28/16. Closer review of the log lacked documentation that staff verified the absence of residual disinfectant after completion of each chemical disinfection procedure.

c. RO unit # 10624 was chemically disinfected on 10/14/16 and 11/7/16. Closer review of the log lacked documentation that staff verified the absence of residual disinfectant after completion of each chemical disinfection procedure.

d. RO unit #10625 was chemically disinfected on 10/13/16 and 11/17/16. Closer review of the log lacked documentation that staff verified the absence of residual disinfectant after completion each chemical disinfection procedure.

4. During an interview on 12/13/16 at beginning at approximately 12:50 PM, the Biomedical Technician in charge of the portable RO units acknowledged the findings and reported to the surveyor that the facility did not document verification of residual chemical disinfectant in the portable RO units. The Biomedical Technician reported to the surveyors that the residual test was being done but not documented. The Biomedical Technician agreed that documentation should reflect that the RO units used for dialysis are free of residual disinfectant to ensure all staff is aware that each unit is safe for use.



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II. Based on review of policies and procedures, observation, and staff interview, the hospital failed to ensure a written policy and procedure that addressed the procedure for staff to obtain RO (reverse osmosis; purified dialysis quality water) water for use with the Hydra meter (a hand held meter used to verify the conductivity, pH, and temperature of the dialysate from the dialysis machines).

Written policies and procedures provide guidance to staff, serves as a resource for staff in the performance of procedures, and facilitates consistency in staff practices. Failure to have a written policy and procedure addressing the procedure for staff to obtain RO water for use with the Hyrdra meter could result in staff performing the procedure incorrectly or inconsistently which could result in contamination of the RO water used for the patient dialysis treatment and cause patient illness or adverse patient outcomes.

At the time of the survey, the hospital staff reported a hemodialysis patient census of 2. Findings for 1 of 1 observation of staff obtaining water from the RO unit (the device that purifies water to produce dialysis quality water for the patient dialysis treatment) (RN [Registered Nurse] DA on 12/12/16) for use with the Hydra meter include:

1. The hospital had a dialysis policy and procedure titled "DIALYSATE CONDUCTIVITY TESTING WITH HYDRA METER," with the last Revision Date of 9/2016, which included using RO water collected at the beginning of the day to rinse the syringe barrel of the Hydra meter when performing the Initial Set-Up of the Hydra meter and Level 1 Calibration of the Hydra meter.

2. During an interview and observation on 12/12/16 at approximately 11:30 AM, Dialysis RN DA reported staff changed the RO water, in the bottle holding RO water for the Hydra meter, prior to use of the Hydra meter each day. Further interview and observation with RN DA on 12/12/16 at 12:40 PM showed the dialysis staff collected RO water for the Hydra meter every day prior to use of the Hydra meter from the RO unit's product water line, by separating the product water line at the "quick disconnect/quick connect" section of the product water line. Observation and interview with RN DA showed staff wore a face mask, face shield, and clean gloves when collecting the RO water from the RO product water line.

3. Review of the hospital's policy and procedure titled "DIALYSATE CONDUCTIVITY TESTING WITH HYDRA METER," referenced above, showed the policy and procedure did not reflect the facility's system for collecting the RO water for the Hydra meter.

4. During an interview on 12/14/16 at 11:30 AM with RN DA and on 12/15/16 at 9:15 AM with the Director for Dialysis, the staff acknowledged the findings and acknowledged the hospital should have a written policy and procedure addressing the facility's procedure for collecting the RO water for use with the Hydra meter.

III. Based on review of manufacturer's information, employee records, documentation, observation, and staff interview, the hospital failed to have a system in place that identified each employee's ability to discern colors when performing critical safety checks to ensure the safe provision of dialysis quality water and the safe provision of the patient hemodialysis treatment.

Failure to complete a color vision evaluation could result in failure to identify a problem with the staff's ability to distinguish differences in colors needed to determine test results when staff used test strips for the critical safety test of total chlorine (for the water used for the patient hemodialysis treatment) and the critical safety test of residual chemical disinfectant (for the RO machines). Failure to identify an elevated total chlorine level in the water used for the patient hemodialysis treatment could potentially result in patient harm and patients becoming severely ill, hemolysis (the rupture of red blood cells), and/or patient death. Failure to identify chemical disinfectant remaining in the RO machine at unsafe levels could potentially result in patient harm or severe patient illness with use of the RO machine for the patient dialysis treatment.

At the time of the survey, the hospital staff reported a hemodialysis patient census of 2. Findings for 2 of 4 staff reviewed with responsibilities that included performing the total chlorine test and/or the residual chemical disinfectant test using test strips (PCT [Patient Care Technician] DC and the Biomedical Technician) include:

1. Interview and observation on 12/12/16 at 11:30 AM with Dialysis RN DA showed staff used Ultra-Low Total Chlorine Test Strips to test the water for the RO for the patient's hemodialysis treatment. During the interview and observation, RN DA reported the facility's system included routinely checking the water for the RO after the first carbon tank prior to each patient treatment and every 4 hours during the patient's dialysis treatment if the dialysis treatment extended greater than 4 hours. During the observation, RN DA performed the total chlorine test using the Ultra-Low Total Chlorine Test Strips. Observation of the procedure, interview with RN DA, and review of the manufacturer's information for the test strips showed staff determined the results of the total chlorine test by comparing the color of the test strip (after removing the test strip from the sample of water and waiting the amount of time specified by the manufacturer) to a color chart provided by the manufacturer. Review of the manufacturer's information showed the color chart had 7 numerical values, ranging from 0.0 ppm (parts per million) to 0.2 ppm, and each numerical value had a color. The manufacturer's information included to compare the reagent pad color on the test strip with the color chart to determine the level of total chlorine in the water.

Review of the portable RO machine logs (RO units #8350, #9236, #10624, and #10625) for the months of 10/2016 and 11/2016 showed staff completed chemical disinfection of the RO machines from 1 to 4 times a month. Interview and observation on 12/14/16 at approximately 9:30 AM with Dialysis PCT DC showed staff used Minncare Residual Test Strips to test for residual disinfectant, to verify the absence of the disinfectant, at the end of the disinfection procedure/rinsing procedure. Review of the manufacturer's information on the bottle of Minncare Residual Test Strips and interview with PCT DC showed staff determined the results of the residual chemical test by comparing the color of the test strip (used to test the rinse water) to a color chart provided by the manufacturer on the bottle. Review of the color chart on the bottle of Minncare Residual Test Strips showed the color chart had 6 numerical values, ranging from 0 ppm to 100 ppm, and each numerical value had a color.

2. During an interview on 12/15/16 at approximately 9:30 AM, PCT DC reported having responsibilities that included performing the total chlorine test of the water for the RO machine for the patient dialysis treatment and disinfection of the RO machines, including testing for the residual chemical disinfectant.

During an interview on 12/13/15 in the afternoon, the Biomedical Technician reported responsibilities that included performing the chemical disinfection procedure for the RO machines, including testing for the residual chemical disinfectant.

3. In the morning on 12/15/16, the surveyor requested the color blindness test results for 4 staff including PCT DC and the Biomedical Technician. The hospital staff provided the color blindness test results for 2 of the staff. However, the hospital staff reported the hospital did not have documentation of providing a color blindness test to PCT DC and the Biomedical Technician.

4. During an interview on 12/15/16 at 9:15 AM, the Director of Dialysis acknowledged the findings for PCT DC and the Biomedical Technician and verified that PCT DC and the Biomedical Technician should have a test to ensure they could discern colors.

IV. Based on interview with staff and review of documentation, the hospital failed to ensure staff evaluated or followed up regarding a staff reported "typo" (error) in a chart used by the staff to set up the dialysis machine with the patient's hemodialysis prescription which failed to ensure delivery of the patient hemodialysis treatment in accordance with the physician order.

Failure to set up the dialysis machine accurately and/or in accordance with the physician prescription could put the patient at risk for harm and result in adverse patient outcomes.

At the time of the survey, the hospital staff reported a hemodialysis patient census of 2. Findings for 1 of 1 chart (titled "Dialog Plus Hemodialysis System Conductivity, Bicarbonate and Sodium Comparison) used by staff to set up the patient dialysis machines include:

1. During an interview and observation on 12/12/16 in the afternoon, Dialysis RN DA reported the hemodialysis staff used a chart titled "Dialog Plus Hemodialysis System Conductivity, Bicarbonate and Sodium Comparison," with columns containing numbers with the headings of "Machine Bicarb Setting (mS/cm)" (millisiemens/centimeter), "Desired Bicarb (mmol/L)" (millimoles/liter), "Desired Sodium (mmol/L)," and "Suggested Machine Final Conductivity Setting (ms/cm)" to set up the dialysis machine with the patient's prescription for the dialysis treatment. During the interview and review of the chart, RN DA reported the chart had a "typo" (error) for one of the values for the Suggested Machine Final Conductivity Setting and that the value specified on the chart should be higher. During the interview, RN DA reported the chart was from the manufacturer of the dialysis machine and that staff had not further evaluated or followed up with the manufacturer regarding the staff stated "typo" on the chart.

2. During an interview on 12/13/16 at approximately 4:20 PM, the Director of Dialysis reported after the above interview, the staff had contacted the dialysis machine manufacturer and obtained the most current chart titled "Conductivity, Bicarbonate and Sodium Comparison Chart" from the manufacturer. During further interview on 12/15/16 at 9:15 AM, the Director of Dialysis reported the staff were now in the process of evaluating the Conductivity, Bicarbonate and Sodium Charts and the Dialysis Director reported the chart observed on 12/12/16 was accurate and did not have a typo as reported by staff on 12/12/16.


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Based on observations, document review, and staff interviews, the hospital failed to ensure outdated baby formula was removed from 2 of 2 inpatient nursing areas (Obstetrics and Pediatrics). The hospital obstetrics staff reported 8 babies in obstetrics at the time of the survey and reported 1 pediatric patient at the time of the survey.

The failure to remove outdated patient supplies from the hospital's supplies located in the patient care areas following the date a manufacturer determined the supplies are no longer considered appropriate for patient care use can lead to potential complications.

Findings include:

1. Observation during tour of the Nursery clean store room on 12/12/16 at 2:10 PM with Staff E, Clinical Facilitator of Women's Health, revealed 24 of 24 - 2 fluid ounce bottles of Enfamil Newborn Formula with an expiration date of November 1, 2016.

Observation during tour of the Pediatric inpatient clean store room area on 12/12/16 at 2:40 PM with Staff F, Director Women/Family, revealed 17 of 35 - 2 fluid ounce bottles of Enfamil Infant Formula with an expiration date of November 1, 2016 and 7 of 7 - 8 ounce bottles of Enfamil Infant formula with an expiration date of November 1, 2016.

2. Review of hospital policy/procedure titled "Outdate/Expiration Process (Supplies, Medications, Food)", dated September 2016, revealed in part, ". . . Each Department, Clinic, Unit, etc. is responsible for checking outdates of all supplies, products, medications and food in all locations in their area. Additional checks will be performed by: Stores will check all storerooms they directly stock. . . When outdated items are found, they should be clearly marked as "Outdated" and disposed of by: . . . Supplies or product should be returned to Stores. . . ."

Review of document titled "Supply Cart Outdate Sheet" provided by Staff G, Director Quality, revealed the 'Stores - Store Room Checklist' last checked OB and Peds August 2016.

3. During an interview on 12/12/16 at 2:10 PM, Staff E, Clinical Facilitator of Women's Health, verified the outdated Enfamil Newborn Formula in the Nursery clean store room. Staff E acknowledged the outdated patient care supplies were available for patient care use. Staff E stated store room staff were responsible for checking and removing outdated patient care supplies in the Nursery clean store room.

During an interview on 12/12/16 at 2:40 PM with Staff F, Director Women/Family, verified the outdated Enfamil Infant Formula in the Pediatric clean store room. Staff F acknowledged the outdated patient care supplies were available for patient care use. Staff F stated store room staff were responsible for checking and removing outdated patient care supplies in the Nursery clean store room.

During an interview on 12/13/16 at 7:20 AM, Staff G, Director Quality, verified the store room staff last checked OB and Peds August 2016 per the 'Stores - Store Room Checklist'.

I. Based on review of Centers for Disease Control (CDC) standards of practice guidelines and facility policies and procedures, observations, and staff interviews, the facility did not ensure staff members' consistency regarding hand hygiene practices at the hemodialysis (HD) unit.

Failure to ensure all staff members were consistent with the performance of hand hygiene before donning gloves, after removing gloves, and as needed during initiation of dialysis treatments could potentially result in the transmission of infectious agents to objects such as medical equipment, environmental surfaces, patients, staff and/or visitors. This could potentially result in illness to those exposed to the infectious agents.

The hospital staff reported a hemodialysis census of 2 patients. Findings for 1 of 2 HD patients (Patient D1) observed during initiation of HD treatment thru arteriovenous fistula (AVF) include:

1. The facility did not follow the guidelines for standards of practice, and facility's own policies and procedures, as follows:

a. The CDC recommendations as reiterated under the APIC (Association for Professionals in Infection Prevention), Guide 2010 titled, "Guide to the Elimination of Infections in Hemodialysis" (www.apic.org), provided that hand hygiene is "the single most important intervention in preventing infections in health care" including dialysis units in hospitals. The APIC Guide 2010 also identified "important times" of when to perform hand hygiene that included "after gloves are removed."

b. The facility's policy number 4025, titled, "Infection Control Policies & Procedures" dated August 1999, directed "employees" to follow evidence based standard precautions in order to "eliminate or minimize transmission of infectious diseases." The policy also provided that "hands must be washed immediately after gloves are removed."

c. The facility's policy number 4004, titled, "HAND HYGIENE" with last review and revision date of December 2013, provided that "staff will utilize the basic principles of hand hygiene as outlined in this policy in an effort to prevent the transmission of infection." In addition, Procedure number 2 indicated that all personnel must wash their hands during given times, including "after contact with body fluids" and "after removing gloves."

2. During observation for the initiation of HD treatment thru an AVF on 12/13/16 starting at 9:57 AM to 10:45 AM, a series of instances where there was failure to perform hand hygiene was observed, as follows:

a. RN (Registered Nurse [DB]) was in HD Room #2 working with Patient D1 to start HD treatment with the use of Patient D1's AVF. After RN DB successfully placed the first needle and attached the HD tubing from the HD machine, RN DB changed gloves without performing hand hygiene, and then started working to place the 2nd needle.

b. After the 2nd needle was placed, RN DB was observed alternately touching the HD machine and Patient D1's 2nd HD needle/site. Without changing gloves, RN DB went towards the supply counter, opened a drawer, took out a syringe, and then went back to work with the 2nd needle. RN DB's gloves were then observed to be bloody as RN DB continued to work on the 2nd needle.

c. RN DB changed the blood-soiled gloves without doing hand hygiene. RN DB went to Room # 2's supply storage cabinet, took out a Y connector, and then went back to use the Y connector for Patient D1's HD access. RN DB's gloves were observed to be blood-soiled after connecting the two needle catheters. RN DB again changed the blood soiled gloves without hand hygiene. RN DB was observed holding Patient D1's HD needle sites to establish hemostasis.

d. While RN DB was in the process of holding Patient D1's HD access site, RN DB's phone rang. RN DB answered the phone while gloves were still on, put the phone back in pocket, and then resumed holding Patient D1's HD access site. RN DB did not do hand hygiene and did not change gloves. The phone rang a second time while RN DB was still touching Patient D1's HD access site, RN DB took the phone out while wearing gloves, and then handed the phone to RN DA, who answered the phone call.

e. RN DB was observed touching and moving Patient D1's blood-stained pillows. RN DB changed gloves without doing hand hygiene, removed the pillow cases, and put them in the soiled linen bin.

3. During interview on 12/13/16 at 4:45 PM, RN DB enumerated the times where hand hygiene was expected to be performed including "before putting on gloves, after removing gloves, and changing gloves when soiled."

4. During interview on 12/15/16 at 9:45 AM, the Director for Dialysis acknowledged the findings and stated expectations that all staff members follow the guidelines and facility policies for hand hygiene.



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II. Based on review of policies and procedures, observation, and staff interview, the hospital failed to ensure the dialysis staff changed gloves and/or performed hand hygiene in accordance with the hospital's policies and procedures and did not ensure the separation of clean and dirty areas or items.

Failure to ensure staff changed gloves and/or performed hand hygiene in accordance with the hospital's policies and procedures and failure to ensure the separation of clean and dirty areas or items could potentially result in the transmission of infectious agents or cross-contamination to objects such as medical equipment, environmental surfaces, common supplies, and to patients, staff, and/or visitors which could result in illness and/or adverse outcomes to those exposed to the infectious agents.

At the time of the survey, the dialysis staff reported a hemodialysis patient census of 2. Findings for 1 of 2 observed discontinuations of a patient's hemodialysis treatment and for 1 of 1 observed cleaning and disinfection of the treatment area, equipment, and items (RN DA after Patient D2's hemodialysis treatment) include:

1. The hospital had a policy and procedure titled "Infection, Prevention, Water Composition and Dialysate Standard," with the last Revision Date of 8/16, which included in part, "PURPOSE To maintain a safe environment for patients and staff by following infection procedures in the hemodialysis unit. This can be accomplished through the use of aseptic technique, strict procedural adherence and knowledgeable, well-trained staff... INFECTION GUIDELINES... 2) During the process of hemodialysis, exposure to blood and potentially contaminated items can be routinely anticipated; thus, gloves are required whenever caring for a patient or touching the patient's equipment... 4) All equipment must be cleaned between patients... 5)... Clean areas should be dedicated for preparation, handling and storage of medications and unused supplies or equipment. 6) Clean and dirty areas should be separated. 7) Do not handle or store medications or clean supplies in the same or adjacent area to where used equipment... are handled..."

The hospital had a policy titled "HAND HYGIENE," with the last Review and Revision Date of December 2013, which included in part, "PURPOSE: The purpose of hand washing is to remove dirt, organic material and transient microorganisms from the hands to reduce the risk of cross contamination. POLICY: Staff will utilize the basic principles of hand hygiene as outlined in this policy in an effort to prevent the transmission of infection. BACKGROUND: 1) Studies have shown that hand washing causes a reduction in the carriage or potential pathogens on the hands. 2) Microorganisms proliferate on the hands within the moist environment of gloves. 3) The Centers for Disease Control and Prevention states that hand washing is the single most important procedure for preventing health care acquired infections... PROCEDURE:... 2) All personnel... must wash their hands at the following times:... * When hands are visible dirty or contaminated with blood or other body fluids * Before and after direct contact with the patient... * After contact with body fluids, excretions, mucous membranes, nonintact skin... * After contact with equipment or furniture in patient room * After removing gloves... 4) The use of alcohol gel rub products instead of hand washing is acceptable in situations where hands are not visibly soiled (i.e. showing visible dirt or visibly contaminated with proteinaceous material, blood or body fluids...)..."

The hospital had a policy and procedure titled "Isolation and Standard Precautions," which included in part, "PURPOSE: To aid in the elimination or minimize transmission-based exposure to infectious diseases... PROCEDURE... 4) Standard (Universal Precautions) Standard precautions are used to place a protective barrier between potentially infectious body substances and the caregiver. There is a potential of infection when contact is made with body fluid/blood components from an individual other than oneself. Precaution to prevent transmission of potentially infectious agents should be practiced for all patients, not only those who have diagnosed infectious diseases... b) Hands must be washed after contact with blood, body fluids, secretions, excretions and contaminated items whether or not gloves have been worn. i) Hands must be washed immediately after gloves are removed, between patient contacts and when otherwise indicated to avoid transfer of microorganisms to other patients or environments... iii) Use plain soap or alcohol based hand gel for routine hand washing... c) All personnel must routinely use protective equipment when there is a potential for exposure to blood or other infectious body materials... i) Gloves must be worn when there is a potential to have direct skin contact with blood, other potentially infectious materials... non-intact skin and contaminated items. (a) Disposable single-use gloves must be changed as soon as possible when visibly soiled... (c) Gloves must be changed after use, before touching uncontaminated items and environmental surfaces... i) All noninvasive equipment, environmental and working surfaces shall be properly cleaned and disinfected after contact with blood or other potentially infectious materials..."

2. Observation on 12/13/16 at 12:25 PM showed Dialysis RN DA discontinuing the dialysis treatment for Patient D2. Observation showed RN DA, wearing gloves used to remove the vascular access needle and hold pressure over the gauze covered needle puncture site, touched gauze on the bedside table to obtain gauze for the care of the patient. RN DA obtained the gauze from a stack of gauze on the bedside table. Continued observation showed after RN DA removed gloves and performed hand hygiene, RN DA touched the gauze remaining on the bedside table with ungloved hands (potentially contaminating hands), did not perform hand hygiene, obtained gloves from a common glove box, and donned the gloves.

Further observation showed after removing gloves, performing hand hygiene, and donning gloves, RN DA obtained gauze, wet the gauze with water and soap, used the gauze to wipe blood from the patient's arm, removed a glove and placed the ungloved hand on the patient's arm, near or over part of the patient's vascular access. Continued observation showed RN DA assisted the patient to a sitting position, touched the vital signs monitor, did not perform hand hygiene and touched a pen and paper on the counter by clean items such as inverted prime containers and hemostats/clamps on a white paper-like sheet (which did not ensure the separation of clean and potentially contaminated areas/items). Continued observation showed RN DA then took the patient's temperature and set the thermometer on the counter described above, touched the vital signs monitor, touched the paper and pen on the counter, and picked up the phone from the water log notebook on the counter. Further observation showed after touching the vital signs monitor, the blood pressure cuff, and assisting the patient to obtain a standing weight on the scale, RN DA touched the pen and paper on the counter and performed hand hygiene. Further observation showed RN DA did not disinfect the phone and placed the phone in RN DA's pocket.

Observation of RN DA cleaning and disinfecting the dialysis treatment area after Patient D2's dialysis treatment showed RN DA did not disinfect the outside of the biohazard sharps waste container prior to placing the container on the bottom shelf of the supply storage cupboard. Observation showed the other shelves in the cupboard contained clean supplies used in the provision of patient care.

Continued observation showed RN DA wearing gloves removed some of the used blood lines from the dialysis machine and placed the blood lines in the trash. Observation showed RN DA wearing the same gloves, picked up the paper from the counter (described above) took the paper outside of the treatment room, and placed the paper on a counter outside of the room, located between the 2 rooms used to provide patient dialysis treatments.

Observation showed the cupboard, in the patient treatment room storing the clean supplies used in the provision of patient care and the biohazard sharps waste container, also had a container of disinfectant wipes and a bottle of disinfectant solution present. Observation during the cleaning and disinfection of the dialysis treatment area including equipment and items showed RN DA, wearing gloves used to disinfect equipment and items or after removing the gloves used to disinfect equipment and items and not performing hand hygiene, touched the handle of the cupboard to open the door and obtained the bottle of disinfectant solution and disinfectant wipes from the container in the cupboard for disinfection of the equipment and items.

3. During an interview on 12/15/16 at 9:15 AM, the Director for Dialysis acknowledged the findings and verified in the above instances, the staff had not followed the hospital's policies and procedures for infection control. During the interview, the Director for Dialysis reported the staff should not store the biohazard sharps waste container in the same cupboard that held the clean patient supplies for patient care.


30076

Based on observation, policy review and staff interview the hospital food and nutrition services staff failed to use sanitary practices in order to reduce the risk of contamination and food-borne illness. The Director of Food and Nutrition Services (FNS) reported the department served an average of 188 patient meals daily. The hospital administrative staff identified a census of 85 residents.

Failure to use sanitary practices could potentially result in contamination of the patient's food leading to foodborne illness.

Findings include:

Observation on 12/13/16, from 7:45 AM to 8:00 AM, revealed Staff B, FNS Supervisor stationed at the end of the trayline to check trays and place english muffins, bagels, mini muffins etc. on patient trays as ordered. Staff B had gloved hands at the beginning of the observations and continued with the same gloves throughout the observation. Staff B touched multiple surfaces with the gloved hands , but not limited to, carts, trays, portable telephone and menu slips. Staff B handled 10 toasted english muffins, for patient trays, with the contaminated gloves.

Observation on 12/13/16, from 11:10 AM to 12:00 PM and again from 12:15 PM to 12:22 PM revealed Staff C, FNS Supervisor stationed at the end of the trayline to check trays and place hamburger buns on the patient trays as ordered. Staff C had gloved hands at the beginning of the observations and continued with the same gloves throughout the observation. Staff C touched multiple surfaces including but not limited to carts, trays, portable telephone and menu slips. Staff C handled 15 hamburger buns, for patient trays, with the contaminated gloves.

During an interview on 12/13/16, at 12:40 PM, Staff A, Director of FNS, reported she expected dietary staff to wear gloves if they were going to touch ready-to-eat food and would then need to remove the gloves if they touched other surfaces, wash hands and put on clean gloves. Staff A acknowledged the gloves would be considered contaminated if other surfaces were touched.

Review of a hospital policy titled Infection Control and Sanitation, reviewed 4/2011, identified gloves may be worn to handle prepared foods, but gloves need to be changed, and hands washed frequently. The policy failed to identify the need to change gloves when changing tasks and/or when the gloves become contaminated.

Review of an electronic education session titled "Safe Food Handling", assigned to FNS staff annually, identified staff are to change gloves when beginning a different task.

The 2013 Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry requires gloves must be used for only one task, such as working with ready-to-eat food and for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.