HospitalInspections.org

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Based on observations, document review, and interview, in six (6) of twelve (12) observations of patients identified at risk for falls, the facility did not ensure that the Nursing Staff fully implemented the Care Plan Interventions as per facility Policy.

This lapse in Fall Prevention Measures placed patients at an increased risk for injury.

Findings:

The facility's Policy and Procedure titled "Fall Prevention Patient / Resident" last revised 08/10/13, directs Nursing Staff under Fall Risk Interventions and Fall with Harm Risk Interventions, to "check all interventions implemented as deemed appropriate...provide visual cues: yellow wrist band, red socks and room signage and do hourly rounding."

During observations of the facility's 5 South Nursing Unit on 12/13/16 at 10:35AM, Patient #8 was observed without a yellow wrist band, red socks and checked signage indicating the appropriate safety alarm.

This was observed in the presence of Staff L, who confirmed the findings.

During an interview with Staff M, when asked if she was aware that Patient #8 was a fall risk and did not have a yellow wrist band, red socks or signage checked, stated "I was aware the patient was a fall risk, but I didn't check to see if he had a yellow wrist band, red socks on or signage checked".

During observations of the facility's 5 North Nursing Unit on 12/13/16 at 9:15AM, Patient #7, identified as a fall risk, was observed laying across her bed with her legs over the side rails. There was no Fall Risk Sign posted above the patient's bed.

This observation was made in the presence of Staff Members J and K who confirmed there should have been a Fall Risk Sign above the patient's bed.

Similar findings of patients without signage indicating the type of Alarm Interventions was observed for Patients #9, #10, #11 and #12.
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Based on observations, document review, and interview, the facility did not ensure that the Nursing Staff identified patients in accordance with safe practices and facility Policy.

These practices placed patients at risk for receiving the wrong treatments.

Findings:

The facility's Policy and Procedure titled "Patient Identification" last revised 01/15/15 directs staff in "the process and procedure to correctly match a patient to the correct intervention (service, test, treatment, and or procedure) at every encounter...use two (2) patient identifiers - full name and Date of Birth (DOB)...include the active patient participation... Compare patient statement to identification (ID) band and source document(s), bar-code technology."

During observations of the Six South Nursing Unit on 12/12/16 at 11:15AM, Staff F was observed performing glucose testing on a patient. Staff F stated the patient's last name, informed her that she was going to test her blood sugar then scanned the patient's identification band without asking the patient's full name and Date of Birth (DOB).

During an interview with Staff G at the time of the observation, when questioned about the facility's Policy regarding patient identification, stated "the patient should have been identified using the patient's first and last names and date of birth".

During observations of the Five North Nursing Unit on 12/13/16 at 11:10AM, Staff H was observed administering medications to patients. Staff H stated the patient's last name, informed her that she was going to administer her medications then scanned the patient's identification band without asking the patient's full name and DOB.

This was observed in the presence of Staff I, who intercepted the medication administration and instructed Staff H to identify the patient as per facility Policy.
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Based on observation, document review, and interview, the facility did not ensure the safe storage of supplies and equipment as required by facility Policy.

These practices have the potential for contamination of supplies and equipment.

Findings:

The facility's Policy and Procedure titled "Materials Operations" last revised 09/02/16, stated the following: "Materials should be stored six (6) inches above the floor and eighteen (18) inches from the ceiling when applicable according to safety code. No items should be stored under traps or sinks."

During a tour of the 4 North Nursing Unit on 12/12/16 at 1:20PM, two (2) boxes of purple pads used for patient care was observed on the floor under the sink in the Medication Room.

During this same tour of the Unit's Clean Supply Room, packets of purple pads used for patient care were observed stored on a shelf less than eighteen (18) inches from the ceiling.

These observations were made in the presence of Staff D who confirmed the findings.

During observations of the facility's 5 North Nursing Unit on 12/13/16 at 9:15AM, a patient scale was observed on the floor under the sink in the Medication Room.

This was observed in the presence of Staff E, who confirmed that the scale should not be stored under the sink.
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Based on observation, document review, and interview, the facility did not ensure that staff provided care in accordance with acceptable standards of Infection Control Practices when performing (A) hand hygiene, and (B) blood glucose testing.

These lapses in Infection Control Practices may have placed patients at increased risk for infections.

Findings pertaining to A include:

The facility's Policy and Procedure titled "Hand Hygiene" last revised 10/23/14, directs staff to do the following: "Alcohol hand sanitizer procedure: Apply an adequate amount of sanitizer to cover all surfaces...the procedure should take about thirty (30) to sixty (60) seconds...rub hands together...until hands are dry...before donning gloves and after removing them and before administering medication."

During observations of the facility's 6 South Nursing Unit on 12/12/16 at 11:15AM, Staff F was observed removing dirty gloves, applying alcohol hand sanitizer, then without allowing hands to dry, donning clean gloves.

This was observed in the presence of Staff G, who acknowledged the findings.

During observations of medication administration on the 5 North Nursing Unit at 11:10AM on 12/13/16, Staff H was observed removing dirty gloves then, without performing hand hygiene, removed clean gloves from a box and attempted to put them on.

This was observed in the presence of Staff I who confirmed the findings.

Additionally, the facility's Policy titled "Hand Hygiene" instructed staff to do the following: "Hand Hygiene with soap and water: Dry hands thoroughly with paper towel(s)."

During observation of hand washing on the 5 North Nursing Unit on 12/12/16 at 11:25AM, Staff F was observed washing hands in the patient's bathroom. Staff F washed their hands, retrieved a paper towel from the dispenser then without drying their hands closed the faucet.

This was observed in the presence of Staff G who confirmed the findings.

Findings pertinent to B include:

During observations on the 5 North Unit on 12/13/16 at 11:10AM, Staff N was observed entering Patient #14's room with an Accu-Chek machine. Staff N took two (2) pieces of paper towel and placed them under the glucometer on the patient's tray table. Staff N then performed glucose testing on the patient and placed the bloody alcohol pad on the unprotected table top. Staff N then exited the room with dirty gloves on, opened the Sani-Wipes, removed a wipe with the contaminated gloves then proceeded to reenter to the room.

During an interview with Staff I on 12/13/16 at 11:15AM, Staff I indicated that Staff N should have removed the dirty gloves and performed hand hygiene prior to exiting the room to retrieve the Sani-Wipes.

The facility's Policy and Procedure titled "Use of the Roche Accu-Chek Inform II Meter System for Blood Glucose Monitoring" last revised 07/15, directed Nursing Staff to: "remove and dispose of gloves and sanitize hands..., then don clean gloves to disinfect meter after blood glucose testing."

During observations of the 6 South Unit on 12/12/16 at 11:15AM, Staff F was observed entering a patient's room with a clean Accu-Chek machine. Staff F placed the clean machine on the windowsill, then placed the testing supplies on the patient's tray table without cleaning the table or placing a barrier.

This was observed in the presence of Staff G, who confirmed the findings.

The facility's Policy and Procedure titled "Use of the Roche Accu-Chek Inform II Meter System for Blood Glucose Monitoring" last revised 07/15, lacked guidance directing the Nursing Staff to clean the surface or place a barrier prior to performing glucose testing.