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Based on interviews and document review, the facility failed to ensure the quality program evaluated preventative actions and the mechanisms implemented to prevent reoccurrence of patient safety events, specifically, one of one wrong drug events reviewed (Patient #39) and one of 12 emergency department patient occurrence reports reviewed (Patient #35).

Findings include:

Facility policy:

The Clinical Quality Assurance, Patient Safety and Performance Improvement Plan read, the Quality Department performs the following activities/functions: facilitates the patient safety event review process, including initial investigation of individual cases and analysis and reporting of safety event trends.

Department leaders are accountable for the quality of care within their respective departments including but not limited to: collection and analysis of data; evaluating service delivery and processes of care; developing and implementing action plans for improvement activities; and fostering a culture that supports high reliability, safety, and a just culture.

Patient Safety leaders report to the Quality Department and perform the following functions: proactively addresses patient safety concerns in addition to identifying through occurrence reports, information provided by associates, patients, or families, or director observations; and collaboratively develops action plans for identified patient safety issues and plans to eliminate preventable harm with Clinical directors and Managers.

1. The facility failed to evaluate the effectiveness of the preventative actions implemented after a patient safety event occurred.

a. Review of Patient #39's occurrence report revealed a medication error occurred on 9/13/18. According to the report, a code blue (cardiopulmonary arrest) was called for the patient who arrived at the emergency department (ED) via ambulance. During the code blue, the pharmacist was asked to make an epinephrine drip (a medication used for its potent vasoconstrictive effect and its ability to increase heart rate, muscle contractility and increase conductivity through the AV node, which controls the heart rate) but instead, mixed the drip with adenosine (a medication used to slow the conduction of the AV node).

b. On 9/24/18, the director of pharmacy (Director #16) documented a summary of events. According to the summary of events, Pharmacist #17 compounded the medication for the epinephrine drip and then gave the medication to the nurse to be administered to the patient. The medication error was discovered after the medication was administered. Pharmacist #17 showed Pharmacist #18 (Pharmacy Manager) the adenosine vial which was used to mix the intravenous (IV) infusion during a review of the code.

Additionally, Director #16 documented after the medication error was identified that pharmacy staff reviewed the workflow for compounding intravenous medications during a code blue situation and the practice was changed to require pharmacy staff to tape the vial of medication to the syringe or infusion in order for nursing to be able to verify the medication was correct.

c. Review of the Pharmacist Monthly Minutes, dated 9/18/18, showed the code cart medication trays and code back-up box were updated to include medical tape and all unmarked/unlabeled syringes and bags should have a taped bottle to the syringe/bag to help with a secondary double check of the medication by nursing staff.

d. Review of an email, dated 9/21/18, sent to ED staff from the Director of the ED (Director #19), revealed that as a safety guard and to serve as a double check in emergent situations, pharmacy would tape the vial of the medications to the outside of the bag and/or syringe only during emergency situations. The email further read Director #19 staff was required to look at the vials to ensure the correct medication was in the drip.

e. On 2/28/19 at 10:00 a.m., an interview was conducted with Director #19. He stated the pharmacy clinical manager (Manager #18) attended several code blues after Patient #39's safety event. He said the manager observed pharmacy staff to ensure they were compliant with taping the medication vials to the bags or syringes prior to the nurse administering the medication. Director #19 said Manager #18 did not document or track his observations to evaluate the effectiveness of the preventative actions implemented after the medication error.

f. On 2/28/19 at 11:04 a.m., an interview was conducted with the interim patient safety manager (Manager #20) and the director of quality and patient safety (Director #21). Manager #20 stated she was responsible for forwarding patient occurrences to the appropriate department. She said she also controlled the closing of the occurrences and ensured everyone involved reviewed the event.

When asked about the Patient #39 medication error which occurred on 9/13/18, she stated at the time of the event, she was not involved in the investigation. However, Manager #20 stated she reviewed the event when she gathered the information during survey. She stated she questioned how the facility was monitoring to ensure staff were still following the process change. Manager #20 stated follow up should have been done to make sure the new process was still in place.

Upon exit, the facility was not able to provide any evidence the action plan implemented to prevent a compounding medication error during a code blue was monitored and effective.

2. The facility failed to analyze potential causes of an occurrence identified during the facility's investigation of a patient event to determine if preventative actions were needed. .

a. Review of Patient #35's occurrence report revealed on 10/13/18, the patient was in the ED for nine hours. Neurosurgery assessed the patient and wanted to take him emergently to the operating room (OR). The OR notified the neurosurgeon it would take five to six hours to sterilize the equipment needed for the surgery. The patient then was transferred to another hospital due to the nature of the surgery and neurosurgery preference.

The internal report was closed on 12/11/18 with a status: no action required.

b. Review of the investigation attached to the report revealed emails between multiple staff involved in the investigation.

-On 10/14/18, an email was sent from House Supervisor (Supervisor #22) to the ED director (Director #19). The email read the patient was evaluated with multiple tests due to progressing symptoms, the neurosurgeon was consulted and he felt the patient had an acute spinal cord compression and rapidly progressive thoracic compression with weakness, sensory loss and bowel/bladder dysfunction. The neurosurgeon felt surgery was necessary and urgent.

The email further read the surgery department was notified and was in the process of setting up but there were no sterile instruments immediately available and a minimum of five hours would be needed to prepare the instruments for surgery. It was decided the patient be transferred to another hospital for urgent surgery to prevent loss of neurological function and paralysis.

Concerns summarized on the email were:

- Admission time to neurosurgeon evaluation was over nine hours.
- Neurosurgeon stating CT evaluation of the spinal cord and canal would be more appropriate in diagnostics.
- Availability of instrumentation for urgent cord decompression.

-On 10/15/18 at 9:33 a.m., Director #19 requested the ED medical director (Physician #23) review Patient #35's encounter in the ED. Director #19 wrote to the ED medical director that he would send the case to peer review for the reasons listed: length of stay and surgical equipment availability. Director #19 said he would review the case from the nursing perspective.

-On 10/15/18 at 5:50 p.m., Physician #23 responded via email to Director #19. He wrote that he had reviewed Patient #35's case. He questioned if a process needed to be in place for times when instruments were needed for an emergency. Physician #23 also wrote he would have to understand if the first ED physician was aware of the patient's progression of symptoms to understand if another test should have been ordered earlier.

-A third email was sent on 10/15/18 from Director of Surgical Services (Director #3) to Director #19 and the prior patient safety manager. The email read Director #3 had looked into the portion of Patient #35's case where the OR stated the trays were not ready. She wrote the OR staff mentioned it would take around five hours for a tray due to the vendor tray not being available but the facility's instruments were ready.

There was no documentation in Patient #35's occurrence report indicating the quality department had assessed the input from the various staff above, and how the quality department had determined no further action was required.

c. On 2/28/19 at 11:04 a.m., an interview was conducted with the interim patient safety manager (Manager #20) and the director of quality and patient safety (Director #21). Manager #20 stated she was responsible for forwarding patient occurrences to the appropriate department. She said she also controlled the closing of the occurrences and ensured everyone involved reviewed the event.

Manager #20 stated she was not involved in Patient #35's occurrence report investigation. However, she said she reviewed the report investigation when she provided it during survey. She said information was gathered, but she did not know by reading the report, if there was enough of an investigation. Manager #20 was unaware if any follow up occurred for resolution of the event.

d. On 2/28/19 at 7:35 a.m., an interview was conducted with Physician #23. He said he remembered reviewing Patient #35's transfer out to another hospital. He said he remembered people wanted the event to be reviewed to understand why it took so long to figure out the patient's issues and move forward with a plan to address the issues.

When asked if there were any process changes implemented after the investigation of the event, he said he talked with the chief medical officer regarding vendor trays and having the right equipment. He said he knew there was talk about it, but he did not know the specifics.

e. On 2/28/19 at 2:05 p.m., an interview was conducted with the chief medical officer (Physician #24). She reviewed Patient #35's medical record and the occurrence report. She stated that although she did not see a concern with care, there was no evidence the information provided from multiple staff was assessed for an action plan. She stated she believed everyone involved in the review of the event dropped it because of how the event was presented. She said because the focus was on the instruments, the occurrence assessment and follow up was not completed. She said the patient safety manager at the time closed it out, documenting no action was needed, but did not document why.

Based on observations, interviews and document reviews, the facility failed to ensure medical records were readily accessible when requested, as evidenced in review of one of one patient record requested by an outside provider. (Patient F).

Findings include:

Facility Policy:

The policy, Patient's Right to Request Access to Their Protected Health Information, stated requests for medical records must be acted upon within a specific timeframe. Copies of medical records requested would be fulfilled within 10 business days of receipt of written request. Furthermore, an additional 30 day extension was allowable if written notice of the delay was provided. Additionally, the policy stated the health information management department will file all forms and correspondences of denial in the patient's electronic health record.

1. The facility failed to ensure medical records were readily accessible when requested by an outside provider

a. On 2/27/19 at 9:05 a.m., a review of Patient F's record was conducted with Health Information Manager (Manager #15) and Release of Information Specialist (Specialist #14), to examine record requests from an outside physician's office.

Manager #15 identified a scanned fax of a request for Patient F's medical record dated 10/23/18. Specialist #14 pointed out the request for the record had been cancelled and a note entered stating no information found. There was no evidence that either the cancellation or the reason for the cancellation was communicated back to provider who requested the record.

Continued review of Patient F's record identified a second request, dated 11/14/18, from the same outside physician's office with a note on the cover page which stated "re-fax from 10/23, request is now STAT (now)." The second request was made 16 business days after the first request. Again, there was documentation of this request was cancelled due to no information found. As with the 10/23/18 request, there was no evidence either the cancellation or reason for the cancellation was communicated back to the provider who requested the record.

Manager #15 identified a document in Patient F's record from the Medical Records Office (MRO), a separate department that completed large volume requests and requests from private clinics and not considered a part of the hospital, which specified a conversation with the outside physician's office requesting the record. This document outlined the recommendations given to the outside physician's office in order to obtain the requested record, but this communication was not documented in the hospital's HIM record.

Further review revealed there was a document from Patient F's record released to the requesting outside physician's office on 12/17/18. The release of the request was 34 business days after the first request was received and contrary to facility policies above that outlined the timeline for requests to be filled and that specified the HIM department would file all forms and correspondences of denial in the patient's electronic health record.

c. On 2/27/19 at 9:05 a.m., an interview was conducted with Manager #15 and Specialist #14. Manager #15 stated when a record was requested, the HIM department tried to fulfill the request within 7-10 days.

In a subsequent interview at 2:09 p.m., Manager #15 stated timely release of medical records was not tracked within the HIM department. She further stated if there was an issue with timeliness, it was brought to her attention and managed by her.

Based on observations, interviews and record review, the facility failed to ensure confidentiality of patient records. Specifically, the facility released more than the minimum disclosure necessary to an outside facility in one of one medical record releases reviewed. (Patient E).

Findings include:

Facility Policy:

The policy, Limiting Use and Disclosure of Protected Health Information to Minimum Necessary, read, the facility will make reasonable efforts to use, disclose and request only the minimum amount of protected health information needed to accomplish the intended purpose of the use, disclosure or request. The policy also read, the facility will review information prior to it being disclosed to verify the minimum necessary standard was applied. In reference to handling requests for disclosure to an outside party, the policy stated the facility staff member receiving the request was responsible for evaluating the request and for releasing only the minimum amount of information to fulfill the request.

The policy, Release of Information, read requests from healthcare practitioners, healthcare practitioners may have access to the information needed to perform their jobs without patient authorization. Additionally, the policy read healthcare provider requests for psychological or psychiatric information may be denied if the record pertains to psychiatric or psychological problems or if the record would have a significant negative psychological impact on the patient. Furthermore, due to the sensitive nature of the medical condition, records which contain psychological/psychiatric information should not be faxed.

The policy, Patient Authorization for Use or Disclosure of Their Protected Health Information, read a valid authorization was necessary to disclose psychotherapy notes and substance abuse records to third parties.

1. The facility failed to ensure confidentiality of patient records by releasing more than the minimum disclosure necessary to fulfill a request.

a. On 2/27/19 at 10:02 a.m., Release of Information Specialist (Specialist) #14, in the presence of Health Information Management Manager (Manager) #15 demonstrated each of the steps taken in the electronic medical record to fulfill a request from an outside physician's office for the record of Patient E. Specialist #14 identified the details which should be on the request in order to verify the validity of the request. In the case of patient E, the request indicated the portion of the record needed was the Emergency Department (ED) visit.

Specialist #14 demonstrated each step of the process when a specific portion or the complete medical record could be selected for release. She explained she usually chose the complete record so the person or entity that made the request would not need to send another request for more information at a later time. Specialist #14 then explained her process for requests was to verify the fax number and destination before completing the request. She stated when the request was completed, the documents were sent to the automatic fax the facility used.

Specialist #14's demonstration and explanation of her process for fulfilling requests conflicted with expectations under regulation and facility policy to make reasonable efforts to use, disclose only the minimum amount of protected health information needed to accomplish the intended purpose of the request.

b. An interview was conducted with Manager #15 on 2/27/19 at 10:13 a.m., following the demonstration by Specialist #14. Manager #15 stated the only information that should have been sent to person or entity that made the request for Patient E was the ED report because it was the only record requested. Manager #15 further stated that from her review of Patient E's ED report, the reason for the patient's admission to the facility was psychiatric-related and therefore, the
minimum necessary information should be released. Moreover, the method of delivery (fax) of Patient E's record conflicted with facility policy regarding the release of psychological/psychiatric information.

c. A second interview with Manager #15 was conducted on 2/27/19 at 2:09 p.m. She explained the importance of differentiating records specific to psychiatric diagnoses. Manager #15 stated the release of psychiatric records was treated differently because the information released without valid authorization could result in a patient harming themselves or others.

Based on the onsite investigation, completed February 28, 2019, the facility failed to comply with the regulations set forth for Life Safety and, therefore, deficiencies were cited under Life Safety Code Tags K211, K291, K293, K321, K324, K353, K355, K363, K374, K511 and K918.

Based on the nature of standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.42, INFECTION CONTROL, was out of compliance.

A-0749 - Standard: The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. The facility failed to follow infection control standards in multiple areas throughout the hospital, including in the areas of hand hygiene at critical moments in 2 of 3 procedures observed (Patients #37 and #38), disinfection of patient care equipment after use for three of four patients (Patients A, B and C), safe use of personal protective equipment by staff, and correct labeling and storage of food prepared for patient use.

Based on observations, interviews and document review, the facility failed to follow infection control standards in multiple areas throughout the hospital, including in the areas of hand hygiene at critical moments in two of three procedures observed (Patients #37 and #38), disinfection of patient care equipment for three of four patients (Patients A, B, and C), safe use of personal protective equipment by staff, and correct labeling and storage of food prepared for patient use.

Findings include:

Facility policies:

The Hand Scrub, Surgical policy read, hand washing remains the most important measure in maintaining patient and health care personnel safety. The purpose of hand hygiene is to decrease the resident microorganism count to a minimum and inhibit the rapid rebound of microorganisms. The skin is a major potential source of microbial contamination of the surgical environment. Proper hand hygiene is imperative when providing direct care for patients.

Wearing gloves does not replace hand hygiene. A hand wash will be performed before and after every patient contact, before putting on gloves and after removing gloves or other PPE (personal protective equipment), and anytime there is a possibility that there has been contact with blood or other potentially infectious material. Hand washing may be performed using an alcohol-based antiseptic hand rub when soil is not present on hands. Use the manufacturers written directions for use and amount of the product.

The Hand Hygiene policy read, hand hygiene is the single most important process for interrupting the transmission of organisms from person to person and preventing health-care acquired infections. All healthcare personnel including associates, licensed independent practitioners (LIP), volunteers, students and contractors will perform hand hygiene as per this policy using approved products and techniques. Any healthcare personnel who experiences a reaction to hand hygiene or skin antisepsis agents will report to Occupational Health for evaluation. Only hospital approved hand sanitizing products are to be used including soap, waterless hand sanitizer and lotions.

The World Health Organization (WHO) outlines "Five Moments for Hand Hygiene:" before touching patients; before clean or aseptic procedures; after body fluid exposure risk; after touching a patients; and after touching patient surroundings.

Hands should be sanitized: before handling medications and clean equipment such as patient charts, computer monitors, keyboards, muse and intravenous (IV) supplies. Before putting on gloves and after removing your gloves.

The WHO Cleans What policy read, all equipment was cleaned if visibly soiled and/or after patient use. Nursing staff were responsible for cleaning glucometers after each patient use.

The POCT Glucometer policy read, for Maintenance, staff wiped down meter after every patient use with a 1:10 sodium hypochlorite (bleach) wipe. Meter must have remained wet with disinfectant for a minimum of 4 minutes. This was essential for the prevention of transmission of C-diff, MRSA, HIV, and several other organisms that may have survived on the crevices of the meters without proper cleaning techniques.

The Isolation: Standard and Transmission Based Precautions policy read, for Respiratory Hygiene with Standard Precautions, all used masks should have been discarded into the proper trash receptacle. For droplet precautions, staff were to refer to the isolation sign which stated healthcare workers should not wear contaminated PPE in corridors.

The Food Display and Storage policy read, all foods that were dated were monitored and removed per expiration date on a daily basis. Only food that has not expired was kept for use.

For food not in original containers, all leftover cold food to be stored in the refrigerator was clearly marked with the name of the item, the date made and the date of disposal. All leftover hot food for storage was clearly marked with the name of the item, the date it was made, and the date of disposal.

References:

The Oxivir 1 manufacturer's instructions read, this product cleans, disinfects and deodorizes hard, nonporous inanimate environmental surfaces and patient care equipment. For use on medical, hard, nonporous inanimate surfaces. It is a violation of Federal Law to use this product in a manner inconsistent with its labeling.

The Oxivir 1 Wipes Safety Data Sheet read to avoid contact with skin and eyes when handling.

According to Precision Xceed Pro Operator's Manual, it was recommended to clean the exterior surface of the monitor after each patient for infection control.

According to the Room Service Label Guide, any items that had a date on them and were unopened do not need a sticker. Once the package was opened, a sticker was placed starting the day it was opened.

1. The facility failed to ensure staff performed hand hygiene when preparing for a case in the gastrointestinal (GI) lab and during a procedure in the operating room (OR).

a. On 2/26/19 at 10:14 a.m., a patient tracer was performed . Patient #38 had his neck dissected to remove metastasis (cancer which had spread to a different part of the body from where it started). At 10:20 a.m., Anesthesiologist #1, who was not wearing gloves, was observed picking up a package which had been dropped on the floor during Patient #38's surgical procedure. Anesthesiologist #1 did not perform hand hygiene or don gloves before she proceeded to administer medication through Patient #38's intravenous (IV) port. At 10:30 a.m., Anesthesiologist #1 was observed again administering medication through the IV port without wearing gloves and without performing hand hygiene. At 10:37 a.m. and 10:45 a.m., Anesthesiologist #1 put gloves on without performing hand hygiene and administered medication through Patient #38's IV port. At 11:01 a.m., Anesthesiologist #1 was observed using her cell phone while wearing gloves. She then removed her gloves and proceeded to wipe her hands with Oxivir wipes.

On 2/26/19 at 11:45 a.m., Anesthesiologist #1 was interviewed. Anesthesiologist #1 stated she was allergic to facility provided hand foam because it was alcohol based. She stated she brought the Oximir wipes into the OR to use because they were hydrogen peroxide based. Anesthesiologist #1 stated if she picked up an item from the floor, she would take the dirty gloves off and put on clean gloves. She stated she was unable to use the Oximir wipes each time she should be performing hand hygiene because her skin would be too irritated.

b. On 2/26/19 at 11:48 a.m., OR Manager (Manager) #2 was interviewed during the patient tracer. Manager #2 stated everyone was expected to perform hand hygiene with hand foam per the policy. Manager #2 stated hand hygiene should be performed anytime staff picked up an item from the floor. Additionally, Manager #2 stated staff should be wearing gloves anytime they administered medication through the IV port. Manager #2 stated anesthesia should have hand sanitizer on their work stations in the OR. Furthermore, Manager #2 stated Oxiver wipes were not approved for hand hygiene. Manager #2 went on to state Anesthesiologist #1 should contact occupational health to find an appropriate replacement to the alcohol based foam due to her allergy. Manager #2 stated she was unaware prior to survey, that Anesthesiologist #1 was not performing hand hygiene with approved foam but rather with Oxiver wipes.

c. On 2/26/19 at 1:00 p.m., Registered Nurse (RN) #6 was observed in the GI lab, preparing a tray in the hallway outside of the procedure room for Patient #37's endoscopic retrograde cholangio-pancreatography (ERCP), a procedure which enables the provider to examine the pancreatic and bile ducts. RN #6 walked away from the tray he was preparing while wearing his gloves. He walked across the hall and used his gloved hands to open the staff lounge door. RN #6 went into the staff lounge and filled a plastic container with water. He then returned to the tray in the hallway and resumed preparation of the tray for Patient #37's procedure. While wearing the same contaminated gloves, RN #6 placed the guidewire into the water and pushed the wire through the balloon tubing (inserted into the scope during the procedure to remove stones). RN #6 then placed the balloon on the tray. The balloon was observed to be touching the wall. RN #6 then turned away from the tray and was walking toward the medication room when the charge nurse motioned for him to remove his gloves, which he did.

During the procedure, RN #6 tossed the prepared balloon onto the tray. The balloon came unraveled and wrapped around and under the tray. RN #6 then dropped the balloon when handing it to the provider. The contaminated balloon did not reach the patient.

During the procedure, the director of surgical services (Director) #3 stated the balloon should not touch the wall as she considered the wall contaminated.

d. On 2/26/19 at 3:21 p.m., RN #6 was interviewed. RN #6 stated hand hygiene was performed to protect patients and staff. RN #6 explained hand hygiene was to be performed before and after patient contact, after touching dirty fluid and after leaving the patient surroundings. RN #6 stated staff should not wear gloves after they left the patient area. He further stated he should not have gone into the lounge with gloves on. RN #6 stated he had received training within the last year on hand hygiene.

Review of RN #6's training record revealed he received the five moments of hand hygiene training on 7/17/18. The five moments of hand hygiene includes: before touching patients; before clean or aseptic procedures; after body fluid exposure risk; after touching a patients; and after touching patient surroundings. RN #6 additionally had a five moments of hand hygiene competency which was completed on 7/5/18.

e. On 2/26/19 at 2:21 p.m., Charge Nurse (RN) #7 was interviewed. RN #7 stated RN #6 should not have walked into the staff lounge with gloves on. She stated RN #6 should have removed his gloves and performed hand hygiene when he walked away from the tray. Additionally, RN #7 stated the balloon should not touch the wall and was contaminated since it did. RN #7 stated there was a risk of infection when the staff did not perform hand hygiene per policy. RN #7 stated hand hygiene was discussed in staff meetings.

On 2/27/19 at 4:28 director of quality and patient safety (Director) #8 stated there were no GI staff meeting minutes to verify hand hygiene was a discussed topic.

f. On 2/27/19 at 1:49 p.m., an interview with the director of anesthesia (Director) #5 was conducted. Director #5 stated the expectation was for all anesthesia contractors to follow the five moments of hand hygiene per facility policy which included hand hygiene after touching the patient's surroundings. Director #5 stated he sent out a mass email to the anesthesia group each quarter to reinforce policies, including those on hand hygiene and infection prevention. Director #5 stated anesthesia staff use a lot of gloves and hand sanitizers for each surgical case. Director #5 stated Oxivir wipes would kill bacteria, but would not be ideal for staff to use for hand hygiene due to the harshness of the product. Director #5 stated he was unaware staff used Oxivir wipes instead of the alcohol based foam for hand hygiene; he said had he known, he would have referred them to occupational health for alternatives to use.

g. On 2/27/19 at 2:46 p.m., an interview with the infection prevention manager (IP) #4 was conducted. IP #4 stated the reason for hand hygiene was for safe patient care and to prevent hospital acquired infections. IP #4 stated staff and anesthesia contractors were expected to perform the five moments of hand hygiene as described in the policy. IP #4 stated staff were trained in the five moments in May or June of 2018. IP #4 stated Director #5 had a newsletter that was sent out to the anesthesia staff which included the five moments of hand hygiene. IP #4 stated she performed hand hygiene auditing rounds which included verifying the presence of hand sanitizer on each anesthesia workstation. IP #4 stated staff should not wear gloves in the hallways. IP #4 stated RN #6 should have removed his gloves in the hallway and performed hand hygiene prior to touching equipment. Additionally, IP #4 stated instruments inserted into a patient should not touch walls as the walls are considered contaminated.

IP #4 stated the expectation when picking up trash from the floor in the OR was to throw the trash in a receptacle, remove gloves, and then perform hand hygiene. IP #4 further stated staff should not wear gloves when documenting or during cell phone use which she considered medical equipment. After use of equipment, IP #4 stated she expected hand hygiene to be performed. IP #4 stated staff were expected to use approved alcohol based foam for hand hygiene and she confirmed Oxivir wipes were not approved for hand hygiene. Additionally, IP #4 stated a staff member with an allergy to alcohol based hand hygiene foam should file a report with occupational health for an alternative means of approved hand sanitizer. IP #4 confirmed there had been no report of hand sanitizer allergy.

h. On 2/27/19 at 1:00 p.m., an interview with occupational health nurse coordinator (RN) #9 was conducted. RN #9 stated she had not been contacted by any personnel from anesthesia in regard to an allergy to hand sanitizer. RN #9 stated even though she did not provide services to contractors, she could provide assistance with alternative hand sanitizers for hand hygiene. RN #9 stated Oxivir wipes were not an approved product for hand hygiene.


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2. The facility failed to ensure staff disinfected the glucose meter (glucometer) after each patient use during 3 of 4 (Patients A, B, and C) patient blood glucose tests observed.

a. On 2/26/19, observations were conducted on the 4 east floor. Certified Nursing Assistant (CNA) #10 was observed preparing to check patients' blood glucose levels. CNA #10 took the glucometer off the docking station located at the nursing station and carried it with the glucometer case into room Patient A's room at 10:57 a.m. After checking Patient A's blood glucose level, CNA #10 placed the glucometer and case on the counter near the door while she completed hand hygiene.

CNA #10 then picked up the glucometer and the case and carried it into Patient B's room at 11:02 a.m. CNA #10 followed the same steps to check the blood glucose level of Patient B. When finished, CNA #10 placed the glucometer and case down on the counter near the door while she completed hand hygiene and then carried the glucometer and case into Patient C's room at 11:08 a.m. There, she followed the same steps to check the blood glucose level of Patient C. When done, CNA #10 again set the glucometer and case down on the counter in the patient's room while she completed hand hygiene. CNA #10 then exited the room and returned the glucometer to the docking station located at the nursing station and returned the case to an adjacent room. CNA #10 was not observed cleaning the glucometer or case at any time during the observations above.

b. An interview was conducted on 2/26/19 at 11:46 a.m. with CNA #10. CNA #10 stated she typically cleaned the glucometer after she checked all the patients who needed their blood glucose levels checked. CNA #10 stated when a patient was on isolation precautions, she cleaned the glucometer immediately after that patient. CNA #10 stated she thought she had cleaned the glucometer after she exited the last room at 11:08 a.m. before she returned to the glucometer to the docking station.

CNA #10 stated the last time she had training on the procedures for cleaning the glucometer was when she worked on the 3 east unit. CNA #10 stated when she worked on the 5 east unit, they disinfected the glucometer after each patient; however, she understood on the 4 east unit, it was okay to disinfect the glucometer once all the tests were completed unless one of the patients was on isolation precautions. CNA #10 stated she had not been told what the expectations were for cleaning the glucometer on the 4 east unit. CNA #10 stated she would have asked the clinical educator for clarification but the unit no longer had a clinical educator.

c. On 2/27/19 at 11:17 a.m., an interview was conducted with Assistant Nurse Manager (Manager) #11 who supervised CNA #10. Manager #11 stated her expectation was when the glucometer was in the docking station, it was considered clean. Manager #11 stated she expected staff to disinfect the glucometer after each patient use. She stated it was very important to disinfect the glucometer each time because it was used with patient blood and when the glucometer was set down or used on another patient, it could spread any type of infection. Manager #11 stated it was her understanding the procedure for disinfecting the glucometer was explained during orientation to the hospital. Manager #11 stated they did not audit staff to ensure the glucometer was disinfected on the unit.

d. An interview was conducted with IP #4 on 2/27/19 at 3:46 p.m. IP #4 stated patient care equipment needed to be disinfected when it was taken in and out of every room. IP #4 stated this was important to avoid transmission of infection.

3. The facility failed to ensure staff followed standard practice for use of personal protective equipment (PPE).

a. On 2/26/19 at 10:54 a.m., CNA #10 was observed at the nursing station wearing a respiratory mask fitted around her mouth but open around her nose. At 10:57 a.m., CNA #10 entered Patient A's room and performed a blood glucose check on Patient A while wearing the mask. CNA #10 then exited the room and did not dispose of the mask. At 11:02 a.m., CNA #10 entered Patient B's room wearing the same mask and performed a blood glucose check on Patient B while wearing the mask. CNA #10 then exited the room and did not dispose of the mask. At 11:08 a.m., CNA #10 entered Patient C's room wearing the same mask and performed a blood glucose check on Patient C. CNA #10 then exited the room at 11:11 a.m. and again did not dispose of the mask.

b. On 2/26/19 at 11:13 a.m., an interview was conducted with CNA #10 who was still wearing the mask observed above. CNA #10 stated she had placed the mask on before entering the Patient A's room where Patient D was on droplet precautions. (Review of the unit's daily census revealed Patient D was diagnosed with Influenza A and was on droplet precautions.) #10 stated she had also worn the mask in another patient room where the patient also was on droplet precautions.

CNA #10 stated she changed her mask whenever she remembered, and she wore the mask for good patient care. CNA #10 stated she did not recall any training she had received about when she should remove her mask.

c. On 2/27/19 at 11:17 a.m., an interview was conducted with Manager #11 who supervised CNA #10. Manager #11 stated her expectation for the unit was that staff did not go from room to room wearing a mask. She stated if a patient was on droplet precautions, the expectation was that staff removed the mask at the door when they exited the patient's room. Manager #11 stated she did not notice CNA #10 wearing the mask around the unit, but if she had noticed she would stop her and ask her to remove the mask. Manager #11 stated staff were not regularly monitored on the unit for correct practices around mask use and disposal.

d. An interview was conducted with IP #4 on 2/27/19 at 3:46 p.m. IP #4 stated masks were to be donned before staff entered patient rooms regardless of the type of isolation precautions. After providing patient care, staff were to remove the PPE upon exit from the room and then perform hand hygiene. Staff were to don a new mask every time they entered a new room.

IP #4 stated this practice was important to prevent the transmission of organisms. She stated her concern was the mask was contaminated. If staff touched the front of the mask and then cared for another patient, there was a risk staff transmitted organisms found on the mask and created contamination.

IP #4 stated staff needed hands on education to understand the correct process for use and disposal of PPE. IP #4 stated it was not okay if someone walked around a unit wearing a mask, regardless of the reason why the staff member was wearing the mask.

4. The facility failed to ensure food was identified, labeled, and dated with expiration or use by dates and labeled and dated food was discarded after the expiration date or use by date.

a. On 2/25/19 at 1:15 p.m., a tour of the kitchen was conducted with the Supervisor Chef (Chef) #12 who was responsible for supervising the preparation of patient food for the facility. Upon observation, multiple food items were observed improperly stored, including expired food and items without a label and date to determine the expiration date.

Examples of expired food observed in the kitchen:

- Tub of chopped red onions (labeled 2/10/19)
- Szechwan sauce (labeled 6/13)
- BBQ sauce (labeled 10/17)
- Tahini paste (labeled 10/1)
- Red pepper pesto (labeled 10/22)
- Enchilada sauce (labeled 10/28)
- Bin of bread crumbs last checked 7/13/18 (expired in 6 months)
- Bin of panko crumbs last checked 7/13/18 (expired in 6 months)
- Tray of frozen prime rib prepared in January, 2018

Examples of food with no label to indicate expiration:
- Tub of shelled eggs
- Tub of chopped green peppers
- Block of opened orange cheese
- Opened carton of egg whites, printed with use by date of 4/19/19 (no opened date)
- Opened carton of non-dairy creamer, printed with use by date of 3/31/19 (no opened date)
- Opened package gluten-free wraps (no opened date)
- Individual turkey pie
- 3 trays of pot roast
- Tub of frozen sliced olives
- 3 trays of macaroni and cheese
- 4 individual servings of lasagna
- Opened chicken stock
- Opened bag of chicken pieces (in freezer)
- Case of blueberry muffins (torn open in freezer)

Chef #12 was unable to ensure food items without a label were not expired and that food with expired labels had not been served to patients.

b. On 2/27/19 at 2:12 p.m., an interview was conducted with the Dietary Manager (Manager) #13 who stated all expired food should have been discarded and all food in the refrigerators should have had a label. She stated most food in the refrigerator had a three day shelf life. Manager #13 stated her rule was to throw the food away if there was no label or no date. Manager #13 stated it was everyone's responsibility to ensure the food was not expired and properly labeled. She stated she expected the food to be checked every day or expiration and use by dates. Manager #13 stated there was a possible risk to patients of food-borne illness if the food was expired.

c. An interview was conducted with IP #4 on 2/27/19 at 3:46 p.m. who stated all food was to be labeled and dated. IP #4 stated expired food was a known factor in the transmission of organisms and created a risk for gastrointestinal illness for patients. IP #4 stated if staff did not know the expiration date, they should not guess. IP #4 stated all food was to be labeled to ensure patient safety.