HospitalInspections.org

Based on observations of care, review of medical records which included Patient Identifier (PI) # 11 and # 12, 2 of 2 Geropsychiatric Unit (GPU) records reviewed, the GPU policy and procedure manual, GPU hospital contract and interviews with Employee Identifier (EI) # 27, GPU, Medical Director and EI # 1, Hospital Administrator, the hospital failed to develop policies and procedures for use of telemedicine in the GPU unit.

This affected Patient Identifier (PI) # 11 and # 12 and had the potential to affect all patients treated on the hospital GPU.

Findings include:

On 1/23/18 at 1:40 PM in the GPU, the surveyor observed the treatment team that included a Registered Nurse, Certified Nurse Practitioner (CRNP), Social Worker and Medical Director complete treatment team meeting on an unsampled patient via telemedicine.

During a telephone interview on 1/23/18 at 1:50 PM, Employee Identifier (EI) # 27, GPU Medical Director reported the GPU was currently evaluating processes that included the psychiatrist onsite frequency, physician signature on orders and other required documentation and physician progress note documentation.

EI # 27 reported the GPU would begin to scan documentation for physician signature. EI # 27 reported that until a couple of weeks ago a psychiatrist visited the GPU twice weekly. EI # 27 reported now a CRNP sees the patients 5 days a week.

On 1/23/18 the surveyor reviewed the hospital GPU policy and procedure manual and on 1/24/18 the Psychiatry Services Agreement which was effective on 3/15/17. There was no documentation regarding the use of telemedicine on the GPU.

On 1/24/18 at 9:15 AM, EI # 1, Hospital Administrator confirmed the hospital had not developed policies and procedures for telemedicine in the GPU unit.

Refer to A 407 and A 449 for individual findings.

Based on observations in the Geropsychiatric Unit (GPU), facility policy, Environmental Safety Check Log documentation and interviews it was determined the staff failed to ensure all patients were in a safe environment and:

1) all doors were able to be secured.

2) the seclusion room was available for patient use.

3) all patient bathroom call lights were functional.

4) handicap bars in all patient bathrooms were ligature proof.

5) all sheetrock, wallpaper and bathroom ceilings were intact.

6) the unit fire extinguisher case was locked.

7) all exposed doorknobs were unable to support patient weight.

8) electrical cords were less than eighteen inches long in patient areas.

9) portable heaters were not used in the GPU.

This affected Patient Identifier (PI) # 12 and all patients admitted to the GPU.

Findings include:

Policy Number: 006.003
Subject: Unit Safety Checks
Revised: 02-14-17

I. Purpose: To ensure a safe patient environment and the safety of each patient of (on) the unit.

II. Policy: The charge RN (Registered Nurse), or designee, at the beginning of the shift will inspect the entire unit. A log will be kept...as well as any deficiencies or contraband found...

III. Procedure:
a...walk the entire unit.
b....inspection will include all the area of the unit.
c. Any contraband...to include...not limited to sharps...lighters, cords...removed immediately...and noted on the log.
d. Any other deficiencies (such as housekeeping issues, maintenance problems...must also be noted on the log...
f. Any deficiencies will be immediately corrected...
g...issues identified on a recurring basis will be addressed as part of the programs CQI (continuous quality improvement) process.

****

On 1/22/18 the following observations were made on the nine bed GPU unit during the initial tour and during care observations from 10:45 AM to 3:00 PM:

The exit door located in the entrance hallway was not secured at the bottom of the door which enabled the surveyor to be able to insert her foot and lower leg between the door and door facing.

The seclusion room entrance was blocked by a hoyer lift, a large blue pad and an empty portable electric heater box. There was no light in the seclusion room.

Handicap bars in all patient bathrooms were not secured which was a ligature risk.

Patient Room 301 bathroom call light not functional, peeling paint, separated wallpaper beneath the window and along the door, exposed sheetrock, a hole in the bathroom ceiling. Patient Identifier (PI) # 12 occupied this patient room.

Patient Room 302, separated wallpaper.

Exposed sheetrock, hole in ceiling in the TV (television) room.

Fire Extinguisher cabinet was unlocked.

Patient Room 304, no functioning bathroom call light.

Patient Room 305, medical bed electrical cord greater than 3 feet long. This was immediately removed.

Patient Room 301, bathroom and two closet door knobs were able to support patient weight, a ligature risk.

Review of the GPU Environmental Safety Check Log dated 1/22/18 7:00 AM-7:00 PM failed to include the above patient safety concerns and no documentation the safety concerns were reported to maintenance and/or management.

****

At 10:55 AM on 1/22/18, staff escorted a new patient into the GPU. The patient asked staff if she/he could have his/her same room back and the "little heater?"

On 1/22/18 between 11:00 AM and 2:50 PM, interviews with GPU employees, Employee Identifier (EI) #14, RN, EI # 15, Social Worker and EI # 25, Licensed Practical Nurse all confirmed portable heaters were used in the GPU during the recent cold weather/snow event.

On 1/24/18 at 9:55 AM, EI # 17, Maintenance Technician confirmed there were boiler problems which affected the GPU and staff used portable electric heaters during the recent cold weather late December 2107 and early January 2018. EI # 17 confirmed there was heat on the GPU, however the boiler had been "taxed". EI # 17 reported the facility was currently working on the problem and submitted electronic mail documentation to confirm the status.

The staff failed to ensure a safe environment was maintained on the GPU.

Based on review of facility policy, Geropsychiatric Unit (GPU) personnel records and staff interviews, it was determined the hospital staff failed to ensure all GPU staff were trained on the application and use of all types of restraint and seclusion. This affected 3 of 4 GPU staff personnel training records reviewed and has the potential to affect all patients admitted to the GPU.

Findings include:

Policy: 003.021
Subject: Restraint and Seclusion
Revised: 06-21-2017

" I. Purpose...of this policy is to provide guidelines for the management and use of restraint or seclusion...

IV. Definition of Terms

...n. Authorized staff-staff members that have been trained and have demonstrated competency in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion.

V. Policy-It is the policy of Southern Oaks that:

a. Restraint or seclusion will only be used to protect the immediate physical safety of the patient, staff or others...
h. Non-physical interventions are the preferred interventions. Restraint or seclusion will only be used when clinically justified...or other (if less restrictive interventions have been ineffective).

VI: Procedures:

...xiii. Use verbal redirection techniques.
xiv. De-escalation techniques such as non-violent crisis prevention.
xv. Assess environment and decrease stimuli...

j. Staff Education
i. Staff must be trained and able to demonstrate competency in the safe application of restraints, implementation of seclusion...before providing care for a patient requiring restraint or seclusion at orientation and in ongoing education (annual)...."

During observations of care on the GPU on 1/22/18 between 8:30 AM and 11:40 AM, Employee Identifier (EI) # 14, Registered Nurse (RN) was interviewed. EI # 14 reported crisis prevention interventions (CPI) education was completed by a consulting company every 2 years. EI #16, Mental Health Technician (MHT) reported he/she was hired in September 2017 but a CPI class had not been offered.

Personnel files which included GPU staff education and training records were reviewed on 1/24/18 at 9:00 AM. There was no documentation GPU staff members EI # 14, RN, date of hire 2/14/05 and EI # 23, Recreational Therapist, date of hire 6/2/03, had annual CPI training.

There was no documentation EI #16, a MHT hired on 9/29/17 had initial CPI training.

In an interview on 1/24/18 at 11:05 AM, EI # 29, Administrative Assistant confirmed the aforementioned findings.

Based on review of the facility's policy and procedures, medical record (MR) and interview with the staff, it was determined the staff failed to perform wound care according to the physician's order and to provide wound management.

This affected 3 of 4 wound records reviewed including Patient Identifier (PI) # 21, # 13, # 22 and had the potential to affect all patients served in this facility.

Findings include:

Facility Policy:
Subject: Management of Wounds and Pressure Ulcer
Reference # 9202

Policy
Grove Hill Memorial Hospital shall ensure that all patients admitted to the hospital receive a complete head-to-toe assessment, at which time a thorough examination of the skin will be done.

Any pressure ulcer and/ or other wound present at the time of admission will be identified.

Any pressure ulcer and/ or other wound developed after admission will be identified.

Daily monitoring of pressure ulcer/ wounds includes:

With each dressing change, or at least weekly, the pressure ulcer wound will be assessed and documented.
Date
Location of ulcer and staging
Size (perpendicular measurement of the greatest extent of length and width of the ulceration).
Depth of the pressure ulcer.

Documentation
Document interventions used to prevent the development of pressure ulcers.
Pressure Ulcer/ Wound Documentation:

Size of the pressure ulcer (length and width)
The depth: Base of wound to skin in centimeters.
...Exudate: type, amount, color and odor...

Note any change in the condition or size of the ulcer and any elevation of skin temperature in the medical record.
...

Procedure:

...Daily Monitoring of Pressure Ulcer/Wounds includes:

Evaluate the ulcer/wound if no dressing is present
Evaluate the dressing if present; dressing intact, drainage present
Evaluate the area surrounding the...wound
With each dressing change, or at least weekly, the pressure ulcer/wound will be assessed and documented:
Date, Location...Depth of the pressure ulcer/wound...Presence of exudate: Type: purulent/serous, Color, Odor...Description of wound edges and surrounding tissue...


1. PI # 21 was admitted to the hospital on 12/1/17 with the diagnosis of Pressure Ulcer of Sacral Region, Stage IV.

Review of the Physician Order 12/2/17 revealed the following wound order: Clean wound with Normal saline (NS), apply wet to dry dressing, cover abdominal gauze pad (ABD) 2 times a day.

Review of the Nurse Note (NN) 12/3/17, 12/4/17, 12/5/17 and 12/6/17 revealed documentation the wound care and dressing was provided by the licensed practical nurse (LPN) during the day shift but failed to measure the wound size. Further review of the NN note revealed the evening shift LPN performed wound care and dressing but failed to measure the wound according to the hospital policy and procedures.

Review of the day and night shift NN 12/7/17 revealed the staff failed to document wound care and management.

In an interview conducted on 1/4/18 at 3:00 PM with Employee Identifier (EI) # 2, Director of Nursing (DON) who confirmed the above mentioned findings.



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2. PI # 13 was admitted to the hospital on 1/20/18 with diagnoses including large right axilla abscess.

Review of the physician orders dated 1/20/18 included apply warm compresses bid (two times a day) to right axilla area. There was no documentation staff applied warm compresses bid as ordered.

Further review of physician orders dated 1/20/18 revealed clean R (right) axilla with NS (normal saline), pat dry, apply Bactroban ointment and cover with abd (abdominal) pad bid. There was no documentation the dressing change was performed two times on 1/20/18 as ordered.

Written questions were submitted to EI # 2, Director of Nursing on 1/23/18 at 2:45 PM. Written responses received on 1/24/18 at 8:00 AM confirmed the above findings.



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3. PI # 22 was admitted to the facility on 8/30/17 with diagnoses including Hypotension and Sepsis.

Review of the Initial Physical Assessment dated 8/30/17 at 9:45 PM, revealed the following documentation by the RN: "...Duoderm removed from buttock area Stage 2, 10 cm (centimeter) diameter of redness. Open area is 5 cm x 6 cm."
The nurse failed to document the depth of the wound, per hospital policy and procedure.

During an interview on 1/24/18 at 11:00 AM, with EI # 2, DON, the above findings were confirmed.

Based on hospital policy, record review and interviews the hospital failed to assure the plan of care for Patient Identifier (PI) # 12 was followed for individual therapy, education and activities. This affected 1 of 2 Geropsychiatric Unit (GPU) records reviewed and had the potential to affect all patients served.

Findings include:

Policy Number: 001.007
Subject: Program Narrative
Revised: 06-21-2017

IX. ADMISSION:

A. Every patient will receive a nursing assessment upon admission. Other assessments are ordered by the admitting physician...who determines the degree of assessment and care based on the patient's individual needs...


1. PI # 12 was admitted to the facility 1/09/18 with diagnoses including Suicidal Ideations and Dementia with Behavioral Disturbances.

Medical record review revealed Admission Orders dated 1/09/18 for Therapeutic Activities which included Individual therapy BID (twice daily), Nursing education BID and Sensory stimulating activity therapy (Recreation Therapy) BID.

The Master Treatment Plan dated 1/9/18 included interventions for nursing education for medications, fall prevention and diagnosis, individual counseling and therapeutic recreation.

Record review revealed the Social Worker completed the Psychosocial Assessment on 1/11/18. One Individual therapy session was documented on 1/11/18, 1/12/18, 1/21/18, 1/22/18 and 1/23/18. There were no individual therapy sessions documented from 1/13/18 to 1/20/18.

There was no documentation twice daily Individual therapy was provided per the 1/09/18 Admission orders.

Further record review revealed Nursing education was completed only one time a day on 1/10/18, 1/12/18, 1/15/18, 1/16/18, 1/18/18, 1/19/18, 1/20/18 and 1/22/18. There was no documentation Nursing education was completed on 1/17/18.

The medical record contained a Comprehensive Therapeutic Recreational Activity Evaluation dated 1/10/18, short term goal included daily sensory stimulation programs.

Record review revealed on 1/10/18 PI # 12 did not attend the morning and afternoon sensory stimulation (recreation) activity sessions "to avoid contact with persons exposed to flu-like symptoms." There was no documentation staff provided PI # 12 with any Sensory stimulation activities on 1/10/18.

There were no Sensory stimulation activity sessions documented from 1/12/18 to 1/20/18. Staff failed to provide and document Sensory stimulating activity therapy BID as ordered.

In an interview on 1/24/18 at 10:50 AM, Employee Identifier (EI) # 23, Recreation Therapist reported she/he was out sick for one week.

During an interview on 1/24/18 at 11:00 AM, EI # 18, Registered Nurse, Geriatric Psychiatric Unit confirmed the GPU staff failed to provide and document therapies, education and activities as ordered on the plan of care.

Based on observation, medical record (MR) review, staff interview, and hospital policy it was determined the staff failed to obtain a physician's order for all drugs and biologicals administered to patients. This affected 1 of 2 patients reviewed with tube feedings, and did affect Patient Identifier (PI) # 24.

Findings include:

Policy: Medication Administration
Reference # 3017
Effective: 6/08/10

"Medications will be administered only upon the order of physicians...
...Medication Administration Record will be compared with the Kardex prior to preparation of any medication at least one time each shift. The individual administering the medication will verify the medication selected for administration is the correct medication based on the medication order..."

*****

PI # 24 was admitted to the facility on 1/18/18 with diagnoses including Right Lower Lobe Pneumonia and Weakness.

On 1/23/18 at 8:45 AM the surveyor observed Employee Identifier (EI) # 9, RN (Registered Nurse) administer routine medications to PI # 24. EI # 9 administered Jevity 1.5 Calorie Liquid, 237 ml (milliliters), via PEG (Percutaneous Endoscopic Gastrostomy) tube, and flushed with water.

A review of PI # 24's MR revealed no physician's order for the Jevity. A review of the Medication Record, dated 1/19/18 to 1/23/18, revealed during PI # 24's admission, he/she received 27 doses of Jevity prior to the verbal order written on 1/23/18 at 9:44 AM, following the surveyor's request to see the physician's order for the Jevity.

During an interview on 1/23/18 at 10:00 AM with EI # 9, the above findings were confirmed.

Based on review of the Geropsychiatric Unit (GPU) Physician Orders policy, medical record review and staff interview, it was determined the hospital failed to ensure staff followed the policy and:

1) all telephone orders were signed by the physician within 24 hours.

2) all verbal and telephone orders must be read back to the physician to ensure accuracy and marked "RBV" to indicate they have been "Read Back and Verified."

This affected Patient Identifier (PI) # 11 and # 12, 2 of 2 GPU patient records reviewed and this had the potential to affect all patients admitted to the GPU.

Findings include:

Policy Number: 003.002
Subject: Physician Orders
Revised: 08-16-2016

...II. Procedure:

...d. All verbal, telephone, and faxed orders must be signed by the physician within 24 hours.
e. All verbal and telephone orders must be read back to the physician to ensure accuracy, and must be marked "RBV" to indicate they have been "Read Back and Verified."


1. PI # 12 was admitted to the facility 1/09/18 with diagnoses including Suicidal Ideations and Dementia with Behavioral Disturbances.

Record review on 1/22/18 included physician order sheet documentation dated 1/09/18, 1/10/18 and 1/12/18 which were telephone orders for medications. There were no physician signatures on the telephone orders which were greater than 24 hours. There was no documentation staff completed the "RBV" for order accuracy per policy.

Written questions were submitted to Employee Identifier (EI) # 2, Director of Nursing on 1/23/18 at 2:45 PM. Written responses received on 1/24/18 at 8:00 AM confirmed the findings above.

2. PI # 11 was admitted to the facility 1/18/18 with diagnoses including Dementia without Behavioral Disturbances.

Record review on 1/22/18 revealed Admission Orders (pre-printed) dated 1/18/18 and physicians' order sheet documentation dated 1/18/18 and 1/20/18 that included telephone orders for medications. There were no physician signatures on the telephone orders which were greater than 24 hours. There was no documentation staff completed the "RBV" for order accuracy.

During a telephone interview on 1/23/18 at 1:50 PM, Employee Identifier (EI) # 27, GPU Medical Director reported the GPU was evaluating processes currently including psychiatrist onsite visit frequency and would begin to scan medical record documentation including orders to the physician for signature.

Written questions were submitted to EI # 2 on 1/23/18 at 2:45 PM. Written responses received on 1/24/18 at 8:00 AM confirmed the findings above.

Based on review of medical records, policies and procedures and interviews with staff, it was determined the staff failed to ensure the medical record for each patient was complete and:

1) All Psychiatric Evaluations included past and current medical history, patient strengths and weakness, clinical assessment, and an initial treatment plan.

2) All Master Treatment Plans and Treatment Plan Review contained the psychiatrist signature.

3) All Special Observation Flowsheet documentation contained the level of patient monitoring and the appropriate level of patient monitoring was completed for suicide precaution and fall precaution monitoring.

4) Included Physical Therapy treatments as ordered.

This did affect Patient Identifier (PI) # 11 and # 12, 2 of 2 Geropsychiatric Unit (GPU) records reviewed and had the potential to affect all patients treated in the GPU.

Findings include:

Policy Number: 003.016
Subject: Psychiatric Evaluation
Revised: 09-16-2016

I. Purpose: To ensure that a physical and psychiatric needs of the patient are assessed by a psychiatrist.

II. Policy:
a. The psychiatric evaluation is complete and on the patient's chart within 60 hours of admission.
c. Includes assessment of the following:
xiii. Assets and liabilities...
d. Notes the onset of illness and circumstances leading to admission.
e. Documents justification for admission...

****

Policy: 001.002
Subject: Program Narrative
Revised: 06-21-2017

Purpose...

k. To improve continuity of psychiatric care for patients...

g. Psychiatric Evaluation

i. Performed by the psychiatrist, the psychiatric evaluation is a comprehensive assessment which includes:

2. Present illness and severity of illness
5. Past medical history
11. Patient Strengths and weaknesses
13. Initial treatment plan...

****

Policy Number: 003.020
Subject: Treatment Team Meetings
Revised: 09-16-2016

II. Procedure:

a. The multidisciplinary treatment team, led by the patient's attending physician, will formally update the treatment plan weekly at the patient staff meeting.
c. The review of the treatment plan will include...evaluation of the patient's progress...Treatment team recommendations...medication review...review of the discharge plan...
e. Each member of the treatment team in attendance, including all others involved in the plan...shall sign the treatment plan review form.

****

Policy Number: 002.011
Subject: Special Observations
Revised: 06-21-2017

I. Policy: All patients admitted to the unit will be monitored by direct visual observation at a minimum of every 15 minutes unless there is a need for special intensive therapeutic interaction....

a....Patients in need of special observations include...
i. Patient at risk for self harm, including suicide.
iv. Patients at risk for falls...

b. Special Observations Status...defined as follows:
i. Close Observation: Patients will be monitored by direct visual contact a minimum of every 10 minutes. Documentation must reflect the direct visual observation.
iii. One-to-One Observation: Patient will be monitored by a staff who is within arm's length length reach at all times...document observations a minimum of every 15 minutes...
...Observation directives will be documented on the Special Observation Flowsheet...

****
Policy Number: 003.012
Subject: Falls and Prevention
Revised: 06-21-2017

I. Purpose: To prevent falls and resulting injury...

f. Implement interventions based on appropriate level...
i. Green...

ii. Yellow...

iii. Red

1. All of the above Green and Yellow interventions...
2. Initiate special observations as ordered (line-of-sight, one-to-one, etc)...

****

Policy Number: 003.019.
Subject: Suicide Assessment and Precautions
Revised: 06-21-2017

...Procedure:
a. Suicide precautions will be implemented utilizing the following levels"
i. Suicide I- patient at high risk or has the potential for imminent self-harm. This patient requires on-to-one observation...
ii. Suicide II- patient is at increased risk for suicide...requires direct visual observation every 10 minutes...

c.... physician must be notified immediately...must be a written order for suicide precautions in the medical record within one hours of initiation.
d. The physician will assess the need for continued suicide precautions every 72 hours...only a physician can discontinue the suicide precautions...

****

1. PI # 11 was admitted to the facility 1/18/18 with diagnoses including Dementia without Behavioral Disturbances.

Medical record review included a Psychiatric Evaluation dated 1/18/18 at 5:15 PM. The Psychiatric Evaluation failed to include documentation of PI # 11's past medical history, current medical history (to include medications), strengths and weakness, clinical assessment (to include patient's status and expectation for improvement due to treatment) and an initial treatment plan (to include intervention of MD [medical doctor] and staff which will address the goals for the patient).

Review of the Master Treatment Plan revealed the plan was completed and signed by the Registered Nurse (RN), Certified Nurse Practitioner (CRNP) Social Worker (SW) on 1/19/18 and the Recreational Therapist (RT) on 1/22/18. The Master Treatment Plan did not contain the psychiatrist signature.

Review of the Special Observation Flowsheet documentation dated 1/18/18 revealed PI # 11 was on close, one-to-one, eyesight, admission and falls prevention observation.

Review of the Special Observation Flowsheet documentation on 1/19/18 and 1/20/18 failed to include the type observation provided.

The GPU staff progress note dated 1/20/18 at 3:55 AM revealed PI # 11 attempted to get out of bed unassisted and fell to the floor.

Written questions were submitted to Employee Identifier (EI) # 2, Director of Nursing on 1/23/18 at 2:45 PM. Written responses received on 1/24/18 at 8:00 AM confirmed the above findings.

In a telephone interview on 1/23/18 at 1:50 PM, Employee Identifier (EI) # 27, GPU Medical Director reported the GPU was evaluating processes which included the psychiatrist onsite frequency. EI # 27 reported staff would begin to scan documentation for physician signature. EI # 27 reported that until a couple of weeks ago a psychiatrist visited the GPU twice weekly. EI # 27 reported now a CRNP sees the patients 5 days a week.

2. PI # 12 was admitted to the facility 1/09/18 with diagnoses including Suicidal Ideations and Dementia with Behavioral Disturbances. The history and physical chief complaint documentation was "voicing suicide".

The medical record contained a Fall Prevention Protocol assessment dated 1/9/18 which revealed the level of special observation required for "RED" was "close observation". The Suicide Risk Assessment dated 1/9/18 revealed the physician was notified and suicide precautions were initiated.

Review of the Special Observation Flowsheet documentation (not dated) for 1/9/18 revealed PI # 12 was monitored close observation every 10 minutes from 4:40 PM to 1/10/18 at 6:50 AM.

Review of the Special Observation Flowsheet documentation dated 1/10/18 at 7:00 AM to 1/22/18 revealed monitoring every 15 minutes. There was no documentation of the level of monitoring (one-to-one, close observation and/or suicide precautions) on PI # 12's Special Observation Flowsheet.

Record review revealed an Initial Physical Therapy Examination completed on 1/10/18 that revealed the chief complaint, weakness, decreased range of motion and decreased ability to ambulate safety. The physical therapy plan was therapeutic exercises "QD", (every day) for 1 week from 1/10/18 to 1/16/18. There was no documentation physical therapy was provided from 1/11/8 to 1/16/18.

Medical record review revealed a Psychiatric Evaluation dated 1/9/18. There was no documentation of PI # 12's strengths and weakness and no clinical assessment (to include patient's status and expectation for improvement due to treatment).

Review of the Master Treatment Plan completed and signed by the RN and SW on 1/12/18 and the CRNP and RT on 1/18/18. There was no Psychiatrist signature on the Master Treatment Plan.

Review of the Treatment Plan Review documentation contained Treatment Team members signatures by the RN on 1/18/18, signed by CRNP and SW on 1/9/18 and the RT on 1/22/18. There was no Psychiatrist signature on the Treatment Plan Review.

Written questions were submitted to EI # 2 on 1/23/18 at 2:45 PM. Written responses received on 1/24/18 at 8:00 AM confirmed the above findings.

Based on facility policy, medical record review and written responses from the facility, it was determined the facility failed to ensure all history and physicals (H&P) were completed within 24 hours and included a neurological examination per facility policy. This affected Patient Identifier (PI) # 12, 1 of 1 active Geropsychiatric Unit (GPU) records reviewed and had the potential to affect all patients treated on the GPU.

Findings include:

Policy Number: 001.007
Subject: Medical Services
Revised: 07-11-2016

Policy: The medical staff...offers physician services available to the unit 24 hours a day to ensure that each patient's physical status is assessed and the patient maintains medical stability during...inpatient admission...

Procedure:

1. A completed medical history and physical examination will be performed...within 24 hours of admission to the unit. This examination must also include a basic neurological examination that include cranial nerves, sensory and motor functions, coordination, and deep tendon reflexes...

****

1. PI # 12 was admitted to the facility 1/09/18 with diagnoses including Suicidal Ideations and Dementia with Behavioral Disturbances.

Medical record review revealed a H&P dated 1/9/18, dictated 1/10/18 and transcribed 1/11/18. The H&P was not signed by the Certified Nurse Practitioner or the physician.

There was no documentation a neurological examination that included cranial nerves, sensory and motor functions, coordination, and deep tendon reflexes was completed.

Written questions were submitted to Employee Identifier # 2, Director of Nursing on 1/23/18 at 2:45 PM. Written responses received on 1/24/18 at 8:00 AM confirmed the above findings.

Based on observations, review of facility policies and procedures and interview, it was determined the staff failed to:

a) Follow facility policy for multi-dose vials use.

b) Ensure all medications available for patient use were not expired.

c) Store medications and solutions according to facility policy.

This had the potential to negatively affect all patients served by this facility.

Findings include:

Policy Number: 005.019 and
Subject: Multi-Dose Vials
Revised: 02-14-2017

I. Purpose: To have established procedures for use of multi-dose vials.

II. Procedure:
a. Upon opening, all multi-dose vials will be initialed by the nurse and dated.
b. All vials will be used for 30 days after opening.
c. After 30 days, vials will be sent to the pharmacy to be destroyed...

Policy Number: 005.017
Subject: Medication Room
Revised: 02-13-2017

II. Procedure
...h. Outdated medications or otherwise unusable drugs shall be identified and returned to pharmacy...
m. Monthly documentation of medicine room inspections are noted on the nursing station unit review form and kept in the pharmacy...

****

Subject: Storage of Medications and Solutions in Patient Care Areas
Reference # 7013
Effective: 6/14/11

"Policy:

It is the responsibility of the Pharmacy to assure that all chemicals, drugs, medications, disinfectants and germicides are sorter at the nursing stations in a manner to assure accuracy of administration, prevent degradation ...

Procedure:

... All drugs shall be stored in their original container as issued from the Pharmacy...

... Saline and sterile water for irrigation must be dated when opened and discarder after 24 hours...

... Record open and discard dates on solution bottles."

********

1. On 1/22/18 from 12:45 PM to 1:15 PM observations were conducted in the medication room on the Geropsychiartric unit.

Humalog Insulin 100 U (units), 10 milliliter (ml) vial opened 10/2/17.
Humalog Insulin 75/25 Mix 100 U, 10 ml vial opened 12/2/17.
Humulin Insulin 70/30 10 ml vial, opened 8/8/17.

Risperadol oral 1 milligram (mg)/ml, open and not labeled.
Guaifenesin oral solution 200 mg/10 ml, expired 11/2017.
Haldol oral solution 10 mg/5 ml, expired 9/2017.

In an interview on 1/22/18 at 1:15 PM, Employee Identifier (EI) # 25, Licensed Practical Nurse confirmed the medications were available for patient use and should have been removed from the unit.



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2. A tour of the Recovery Room was conducted on 1/22/18 at 11:00 AM with EI # 26, Operating Room/ Recovery Room (OR/RR) Registered Nurse (RN). The surveyor requested EI # 26 to open the emergency crash carts to review the medications, supplies and equipments.

The following items (supplies and drugs) were found to be out of date in Procedure Room:
1. 50 % Dextrose 25 gram (gm) x 2 bottle expired: 12/2017
2. Furosemide Injectable 40 milligram (mg)/ 4 milliliter (ml) 10 mg/ ml x 4 vials expired: 9/2017
3. Unifusor 500 cc drip Unifusor II - expired: 10/2015
4. 100 cubic centimeters (cc) Sterile Water x 2 expired 9/2017

The following items (supplies and drugs) were found to be out of date in the RR:
1. Adenocard 6 mg/ 2 ml x 1 - expired 12/2017
2. Dopamine Hydrochlorothiazide (HCL) 400 mg/ 250 ml x 1 expired 8/2011
3. Size 4 and 5 laryngeal mask expired 9/2015
4. Pediatric Colorimetric Oxygen Detector for 1 kilogram (kg) to 5 kg x 1 expired 1/2017; greater than 5 kg x 1 expired 7/2016
5. Intubation Stylet 5.0 to 7.0 x 2 expired 3/2017
6. Partex nasopharngeal airway size 7.0 expired 5/2016

In an interview conducted on 1/22/17 at 2:30 PM with EI # 26 who confirmed the above mentioned findings.



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3. A tour of the Medical Surgical floor was conducted on 1/23/18 at 10:05 AM.

A review of the Crashcarts revealed the following expired medications:

Adult Crashcart-
3- Dobutamine 250 mg (milligrams)/ 250 ml (milliliters), expired 11/17.
1- Dobutamine 400 mg/ 250 ml, expired 11/17.
1- Phenergan 25 mg/ml, brown stain/ leak on label.

Pediatric Crashcart-
1- Adenocard 6 mg/ 2 ml, expired 12/1/17.

During an interview on 1/23/18 at 10:45 AM with EI # 20, RN, the above findings were confirmed.

4. During the tour of the medical surgical floor on 1/23/18 at 1:00 PM, the following expired medications were observed in the narcotics cabinet. EI # 10, RN was also present.

3- Butorphanol Tartrate (Stadol) 2 mg/ ml, expired 7/17.

During an interview on 1/23/18 at 1:10 PM, with EI # 10, the above findings were confirmed.



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5. During a tour of the Obstetric (OB) Unit on 1/23/18 at 7:11 AM by the surveyor and EI # 4, Manager L & D (Labor and Delivery) and Nursery the following observations were identified:

Newborn Emergency Cart:

1 - 1 cc (cubic centimeter) syringe (no needle) filled with a clear substance. There was no label identifying the contents of the syringe. The surveyor asked EI # 4 what was in the syringe. EI # 4 stated, "I think Normal Saline (NS)". The surveyor asked, "How do I know that and when was the NS prepared?" EI # 4, stated, "You don't because there is no label. I believe one of the Neonatal Intensive Care (NICU) nurses told us we needed to start using them (1 cc NS syringes). It is one they left here and I guess one of our nurses stuck it in there (in the cart)."

1 - bottle of Similac Sterilized Water for oral use only: expired 1/1/18.

L & D Room 124:

1 - bottle 0.9 % (percent) Sodium Chloride Irrigation 1000 ml (milliliters): opened and not dated.

An interview was conducted on 1/24/18 with EI # 2, Director of Nursing, who verified the aforementioned findings.

Based on a tour of the dietary department, interview, and facility policies, it was determined the facility failed to:

1. Store food in a safe and sanitary manner.
2. Discard expired food.
3. Ensure the Auto-Chlor dish sanitizer was functioning properly.

This had the potential to affect all persons served by the facility.

Findings include:

Policy: Receiving and Storage
Review date: None listed, copied from Dietary Training Manual on 1/22/18.

"...Keep storage area clean...
Date goods upon receipt...
All goods should be stored in a clean, properly wrapped and dated containers.
...Store opened packages in closed and labeled containers."

*****

During a tour of the dietary department on 1/22/18 at 11:00 AM, the following items were observed in the dry storage area:

1 large plastic bin containing white powder, not labeled with contents or date.
1 large bag elbow pasta, opened with no date.
1 large storage bin of rice, not labeled with contents or date.
50- 1/2 oz (ounce) cranberry sauce packets, expired 8/9/17.
2 large plastic containers of white and yellow particles, not labeled with contents or date. Containers had brown sticky substance on exterior.
1 liter caramel syrup, opened with no date.
1- 32 oz imitation vanilla flavoring, opened with no date.
1 liter almond syrup, opened with no date.
1- 16 oz pure lemon extract, opened with no date.
1- 16 oz can Crisco shortening, opened, expired 11/5/17.
1- 48 oz can Crisco shortening, opened with no date.
1 gallon Pan and Grill shortening, opened, expired 9/29/17.
1- 10 oz bottle dried parsley flakes, opened with no date.
1- 48 oz carton dehydrated chopped onion, opened with no date.
1- 14 oz box baking soda, opened with no date.
1- 20 oz onion powder, opened with no date.
1- 32 oz bottle browning sauce, opened with no date. Bottle has brown substance running down all sides.
1 gallon teriyaki sauce, opened with no date.
1- 16 oz Alfredo sauce mix, opened with no date.
2 large bags spaghetti noodles, opened with no date.
2 large bags rotini pasta, opened with no date.
2- 11.3 oz turkey gravy mix, opened with no date.

In the kitchen area near the stove the following was observed:

1 large plastic storage bin containing a white substance, unlabeled, no date, and metal scoop left inside.
1 large plastic storage bin, labled 'Self-rising flour,' no date, and metal scoop left inside.
1 large plastic storage bin labeled 'Self-rising meal,' no date, and metal scoop left inside.
All large spice bottles near the stove, opened with no date.
Large can opener dirty, covered in grime, tiny pieces of paper sticking to blade area.

The following was observed in the freezer:

1/2 bag frozen brown items, not labeled with contents or date.
1/2 bag hash browns, undated.

Employee Identifier # 12, Dietary Manager, who was also present during the tour, stated "...these two items should have been thrown out."

During the tour on 1/22/18, the surveyor observed a puddle of clear red liquid on the floor in the freezer area. On day 2 (1/23/18) of the survey, the puddle remained.

Also during the tour on 1/22/18 at 1:00 PM, the surveyor observed the dish sanitizing process. The surveyor observed EI # 12 test the effectiveness of the sanitizer concentration two times. Both times, the test strips tested at a level of 10 ppm (parts per million), and not the correct 100 ppm per EI # 12. The surveyor observed dust, white, and black particles on top of the dish sanitizer.

During an interview on 1/22/18 at 1:30 PM, with EI # 12, the above findings were confirmed.

Based on review of the policy and procedure manual of the dietary department, observation and interviews, it was determined the staff failed to use the current dietary manual in day to day practice. This had the potential to affect all consumers served by the dietary department.

Findings include:

During a tour of the Dietary Department on 1/22/18 at 10:45 AM, the surveyor requested the therapeutic diet manual. Employee Identifier (EI) # 12, Dietary Manager, informed the surveyor the diets were listed on his/her computer. EI # 12 opened the computer file containing therapeutic diets and the surveyor observed the 1200 calorie ADA (American Diabetes Association) diet was last reviewed in 2011.

During an interview on 1/23/18 at 12:15 PM, with EI # 11, Registered Dietician, the above findings were discussed. EI # 11 stated there is a new policy and procedure manual for the dietary department, dated 6/13/17, that contains all current therapeutic diets, and confirmed EI # 12 should not be using the diets listed on the computer.

A review of the policy and procedure manual for the dietary department revealed EI # 11's signature approving the manual on 6/13/2017.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations

Based on observations, review of facility policies, Defibrillator and Crashcart Checklist and interviews with facility staff it was determined the facility failed to ensure:

a) Supplies and equipment available for patient use were stored per policy, not expired and functional.

b) Equipment was monitored to maintain safety of patients and staff.

c) Defibrillator and Crashcarts were checked every shift as directed.

This had the potential to affect all patients served by this facility.

Findings Include:

Defibrillator and Crashcart Checklist

Registered Nurse, Licensed Practical Nurse or Respiratory Technician checks the defibrillator and the crash cart every shift to ensure that all supplies are available and in working order.

... Pharmacy is responsible for checking the expiration dates and assuring that the medications remain appropriately dated.

********

Subject: Compressed Gas and Oxygen Use
Reference # 2015
Effective: 6/14/11

Policy:

Personnel that handle medical gases shall be educated about the possible hazards associated with medical gas use...

Procedure:

General Standards:

All personal handling medical gases will be trained to recognize various types of medical gas labels.

...With use of 360-degree wrap-around labels to designate medical oxygen provided on oxygen cylinders from the medical gas supplier, personnel will be trained to assure that each vessel to be connected to oxygen systems bears the 360-degree-wrap-around label.

Cylinders must be secured at all times so they cannot fall."

********

Subject: Under the Sink Storage Policy
Effective: 12/12/16


"The following are items that are prohibited for Under Sink Storage:

... No under the sink storage in any patient rooms."

********

Policy Number: 005.013
Subject: Emergency Medications
Revised: 02-03-2017

"I. Policy:

a. Emergency drugs shall be kept in adequate supply.
b. An emergency box that meets the following requirements shall be maintained:
i. The emergency box shall be readily available to staff...
ii...contents appropriate to the needs of the clients.
iii....inspected after use...and at least monthly to...assure completeness of contents....

II. Procedure:

a. An emergency box... located in the medication room of GPU (geropsychiatric unit)...maintained by the Pharmacy department.
b...inspected for missing...and out-of-date drugs...
c. A list of all emergency medications available in the emergency box...maintained...

III. List of Medications

a. Epipen 0.3 mg (milligram) Auto-injector...
i. Indications...To relieve/reverse bronchospasm...2. Treatment of hypersensitivity reactions...3. Shock...

c. Narcan (Naloxone)
i. Indications...complete or partial reversal of narcotic depression...

d. Nitrostat (Nitroglycerin) Sublingual
i. Indications...Acute angina and angina prophylaxis...

e. Diastat (Diazepam) Rectal gel
i. Indications...Seizure..."


1. A tour of the Emergency Department was conducted on 1/22/18 at 10:45 AM.

At 10:50 AM the surveyor reviewed the (ER) Emergency Room Defibrillator and Crashcart Checklist for December 2017 and January 2018. There was no documentation the Defibrillator and Crashcart were checked on the following shifts as directed per the facility checklist:

"Lifepak (Defibrillator)":

7 AM - 7 PM: 12/2/17, 12/5/17, 12/19/17, 12/21/17, 12/23/17, 12/24/17, 12/29/17, 1/12/18, 1/17/18 and 1/20/18.

7 PM - 7 AM: 12/14/17, 12/27/17, 1/2/18. 1/3/18, 1/10/18 and 1/15/18.

7 AM - 7 PM & (and) 7 PM - 7 AM: 12/3/17, 12/20/17 and 1/14/18.

"Zoll" (Defibrillator):

7 AM- 7 PM: 12/1/17, 12/2/17, 12/13/17, 12/21/17, 12/29/17, 1/1/18, 1/12/18 and 1/17/18.

7 PM - 7 AM: 1/4/18, 1/14/18, 1/18/18, 1/25/18 and 1/27/18.

7 AM - 7 PM & 7 PM - 7 AM: 12/3/17, 12/5/17, 12/19/17, 12/20/17, 1/3/18, 1/13/18 and 1/14/18.

"Peds" (Pediatric {Defibrillator}):

7 AM- 7 PM: 12/2/17, 12/13/17, 12/21/17, 12/29/17 and 1/1/18.

7 PM - 7 PM: 12/4/17, 12/14/17, 12/27/17, 1/2/18 and 1/10/18.

7 AM - 7 PM & 7 PM - 7 AM: 12/1/17, 12/3/17, 12/5/17, 12/20/17 and 1/3/18.

At 11:10 AM the surveyor observed two Oxygen (O2) tanks standing upright in a hallway cubical next to the pediatric Emergency Crashcart maintaining the pediatric defibrillator. The O2 tanks were not secure as directed per the facility policy to keep from falling.

An interview was conducted with Employee Identifier (EI) # 7, Registered Nurse (RN), who verified the aforementioned findings.

2. A tour of the Magnetic Resonance Imaging (MRI) system was conducted in the Radiology Department on 1/22/18 at 2:15 PM with EI # 21, Director of Radiology. The surveyor observed that the right bottom rail (side) of the MRI table was broken and covered with tape. The tape was peeling off and revealed cloth like material underneath.

The surveyor asked EI # 22, Radiology Technician, how long the table had been broken. EI # 22 stated, "A long time". The surveyor asked EI # 21 if he/she was aware the MRI table was broken. EI # 21, stated, "No, ... because I never come out here."

An interview was conducted on 1/24/18 with EI # 2, Director of Nursing, who verified the aforementioned findings.

3. During a tour of the Labor and Delivery (L& D) Room 124 on 1/23/18 at 7:30 AM the surveyor observed the following:

Supplies stored under the sink:

Disinfecting Wipes (Clorox wipes) x (times) 2 bottles
Lysol Disinfectant Spray x 2 cans
Hibiclens Solution 4.0% (percent) expired (exp) 12/10 x 1 bottle
Virex Disinfectant Cleanser x 1 bottle
Red biohazard bags
Wire basket
Bed stirrups

At 7:30 AM the surveyor toured the nursery with EI # 24, Manager L & D and Nursery. The surveyor observed a Bili Lite which revealed a Preventive Maintenance (PM) sticker that was "Blank". There was no date of when the last of the last PM was performed on the sticker. The surveyor asked EI # 24 when was the last time a PM was performed on the Bili Lite. EI # 24 stated, "I don't know, we don't use it that much. "There was no current PM submitted for the Bili Lite used in the nursery.

An interview was conducted on 1/23/18 at 8:00 AM with EI # 24 who verified the aforementioned findings and stated, "It should be done annually".




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4. On 1/22/18 from 12:45 PM to 1:35 PM observations were conducted in the Geropsychiartric unit (GPU) Medication Room and Nurses Station.

The emergency drug box on the GPU did not include Epipen, Narcan, Nitrostat Sublingual and Diastat rectal gel as per policy.

The respiratory emergency kit contained a laryngoscope and multiple blades, but there were no batteries. The GPU laryngoscope was not functional.

In an interview on 1/22/18 at 1:50 PM, EI # 25, GPU, Licensed Practical Nurse and EI # 14, GPU, Registered Nurse confirmed all emergency medications were not available for patient use and all emergency equipment was not functional.



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5. A tour of the Dietary Department was conducted on 11/22/18 at 1:00 PM.

PM stickers were observed on the following equipment, with due dates listed:

Refrigerator # 1, date due 11/20/16.
Refrigerator # 2, date due 11/20/16.
Freezer # 1, date due 11/20/16.
Freezer # 2, date due 11/20/16.
Ice Maker, date due 10/16/16.
Dinex Heating unit, date due 10/15 (month and year listed).

During an interview on 1/24/17 at 12:05 PM, with EI # 12, Dietary Manager, the above findings were confirmed.

6. A tour of the Medical Surgical floor was conducted on 1/23/18 at 10:05 AM.

A review of the Defibrillator and Crashcart Checklists, dated December 2017 and January 2018, located on both the adult crashcart and pediatric crashcart, revealed no documentation on the following dates the defibrillator and crashcart had been checked according to policy:

Adult Crashcart-
7 AM to 7 PM:
12/8/17, 12/9/17, 12/11/17, 12/24/17, 12/25/17, 1/4/18 and 1/9/18.

7 PM to 7 AM:
12/1/17, 12/2/17, 12/7/17, 12/14/17, 12/24/17, 12/26/17, 12/29/17, 12/30/17 and 1/4/18.

Pediatric Crashcart-
7 AM to 7 PM:
12/8/17, 12/11/17, 12/18/17, 12/24/17, 12/25/17, 1/4/18, 1/9/18 and 1/22/18.

7 PM to 7 AM:
12/1/17, 12/2/17, 12/3/17, 12/11/17, 12/14/17, 12/24/17, 12/26/17, 12/29/17, 12/30/17 and 1/4/18.

A review of the items located in the crashcart revealed the following:

Adult Crashcart-
1- 18 Gauge biopsy needle, expired 4/30/16.

During an interview on 1/23/18 at 10:45 AM with EI # 20, RN, the above findings were confirmed.

Based on review of facility policy and procedures, observations and interviews with the staff it was determined the facility failed to ensure the staff:

a) followed the facility policy and procedure for proper hand washing and glove changes.

b) followed the facility policy and procedure for standard precautions and disinfection of medical equipment used during patient care.

c) cleaned scissors/hemostats used between wound packing during a dressing change.

d) discarded contaminated wound dressing into red bag for disposal.

This had the potential to negatively affect all patients served by this facility.

Findings include:

Subject: Hand Hygiene - CDC (Centers for Disease Control) Guidelines
Reference # 4002
Revised: 8/4/14

"Purpose:

To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs and infections.

Policy:

All personnel will use the hand-hygiene techniques, as set forth in the following procedure. The CDC has recommended guidelines on when to use non-antimicrobial soap and water, an antimicrobial soap and water or an alcohol-based hand rub.
... Before each patient encounter
... After coming in contact with patient's intact skin, i.e. (such as), taking a patient's blood pressure, pulse, lifting/moving the patient
... After contact with medical equipment/supplies in patient areas
...Always after removing gloves...

Procedure:

...Wash hands thoroughly..
Rinse hands and wrists...
Dry hands with clean paper towel..
Turn off faucets with used paper towel and discard..."

********

Subject: Standard Precautions
Reference # 4003
Effective: 6/08/10

"Purpose:

To provide guidelines for interactions between patients and healthcare providers to prevent the transmission of infections (infectious) agents associated with healthcare delivery.

Standard Precautions include:

...Gloves: ... Hands are to be washed after removing gloves.

...Patient Care Equipment: ... Surfaces that are likely to be contaminated with pathogens, including those that are in close proximity to the patient (... bed rails...) ... shall be cleaned and disinfected..."

********

Subject: Infection Control
Reference # 5026

"Purpose:

To develop measures necessary to prevent infection and cross infection in patients, visitors and staff.

Patient Care Equipment and Supplies:

Clean and contaminated supplies/equipment are stored separately.

...Reusable equipment/supplies: Clean with disinfectant solution...

Equipment and Cleaning of:

Machines:
Damp wipe with approved disinfect and daily and prn (as needed)

Exam tables:
Wipe with disinfectant between patients by Imaging/Radiology Department personnel."

********

Reference # 9154
Subject: Dressing Change-Surgical
Effective: (blank)

Policy:

Equipment:
...Red biohazardous waste bag (small size for soiled dressings)
Disposable sterile pack containing scissors and forceps...

Assessment of the Incision:
Assess incision...surrounding skin...Erythema...Drainage, Color.
Pick up all soiled dressings...hold red plastic bag...open...and pull bag down over...soiled dressings..."

********

1. An observation was conducted in the Emergency Room (ER) on 1/22/18 at 11:10 AM to observe Employee Identifier (EI) # 6, Registered Nurse (RN), perform Finger Stick Blood Sugar (FSBS) in ER # 7. EI # 6 performed the FSBS, removed one (1) of his/her gloves and retrieved a bandaid from the clean supply drawer and a patient gown from the clean cabinet without performing hand hygiene.

EI # 7, RN, who was present in the room, asked EI # 6 to assist with getting the patient on the bedpan. EI # 6 assisted with getting the patient on the bedpan and then removed 1 glove and removed the blood pressure cuff on the patients arm without performing hand hygiene.

At 11:45 AM EI # 7 cleaned the FSBS machine and removed his/her gloves without performing hand hygiene.

An interview was conducted on 1/24/18 at 10:06 AM with EI # 2, Director of Nursing, who confirmed the staff failed to change gloves, perform hand hygiene and maintain supply clean items as directed per the facility policy.

2. A tour of the Magnetic Resonance Imaging (MRI) system was conducted in the Radiology Department on 1/22/18 at 2:15 PM with EI # 21, Director of Radiology. The surveyor observed that the right bottom rail (side) of the MRI table was broken and covered with tape. The tape was peeling off and revealed cloth like material underneath.

The surveyor asked EI # 22, Radiology Technician, how he/she cleaned the MRI table? EI # 22, stated, "With these wipes (disinfectant wipes)". The surveyor then asked EI # 21, if the table could be cleaned in the area where the tape was coming off. EI # 21 stated, "No".

An interview was conducted on 1/24/18 with EI # 2, Director of Nursing, who verified the aforementioned findings.


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3. During an observation with EI # #8, Registered Nurse (RN) conducted on 1/22/18 at 2:30 PM to observe EI # 8 administer Lasix 40 milligrams (mg) intravenous infusion (IV). EI # 4 performed hand hygiene prior to donning clean gloves, verified patient's name with the medication and proceeded to slowly perform IV push, discarded the medication. EI # 8 pick up the patient's cell phone, remote control and water jug and moved them to the other side of the bed. EI # 8, still wearing the same used gloves moved the side table closer to the patient. EI # 8 then removed used gloves then exited the patient's room. EI # 8 washed his/ her hand at the sink close to the nursing station.

In an interview with EI # 2, conducted on 1/24/18 at 11:00 AM, EI # 2 confirmed the staff failed to follow hospital's policy and procedures.


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4. During Geropsychiatric Unit medication pass observations on 1/22/18 from 12:00 PM to 1:00 PM and on 1/23/18 from 8:30 AM to 9:00 AM, EI # 25, Licensed Practical Nurse (LPN) completed hand hygiene and turned off the water faucet with bare hands on numerous occasions.

5. An observation of care on the medical floor on 1/23/18 at 10:55 AM was conducted with Patient Identifier (PI) # 13, who was placed on Contact Isolation (gown and gloves required) for draining wounds according the LPN, EI # 28. EI # 28 removed the old dressing which contained a large amount (grapefruit size) bloody drainage.

EI # 28 discarded the bloody dressing into the regular trash and not the red bag used for medical waste which would include the contaminated bloody dressing.

EI # 28 performed wound care to 8 individual open wounds which were recently I & D'd (surgically incised and drained) on 1/22/18. EI # 28 removed the dressing packing from the 8 wounds using tweezers, irrigated each wound with prefilled saline syringes, then with scissors/hemostats packed all 8 wounds. EI # 28 used the same scissors/hemostats to pack all 8 wounds.

EI # 28 failed to clean the scissors/hemostats between each wound.

After wound care was completed, EI # 28, removed his/her left glove, repositioned the overbed table, retrieved the television remote, patient cell phone and water pitcher using the gloved hand.

EI # 28 failed to remove both gloves and immediately perform hand hygiene.

In an interview on 1/24/18 at 11:00 AM, EI # 13, Infection Control Manager, confirmed staff failed to follow hospital infection control policy.



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6. An observation was conducted on 1/23/18 at 8:45 AM to observe EI # 9, RN administer Jevity 1.5 Calorie liquid, 237 ml (milliliters), via PEG (Percutaneous Endoscopic Gastrostomy) tube.

The surveyor observed EI # 9 use his/her stethoscope on the patient's bare abdomen to asses tube placement. EI # 9 then laid his/her stethoscope on the patient's bed during the tube feeding. After completing his/her tasks, EI # 9 failed to clean the stethoscope before placing around his/her neck and leaving the room.

During an interview on 1/24/18 at 10:30 AM, with EI # 13, Infection Control Manager, the above findings were confirmed.