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Based on interview, personnel/education file review and policy review, the facility failed to thoroughly educate two (GGGG and HHHH) of two physicians' reviewed that would be required to assess, monitor, and order restraints (restricting movement of a limb or body) for patients. This had the potential to affect all patients that experience a restraint, possibly increasing the time in restraints, utilization of the wrong type of restraint for the assessed problem, or utilization of a restraint when lessor non-restrictive methods could be adequate. The facility census was 397.

Findings included:

1. Review of the facility's policy titled, "Patient Care-Violent Restraint and Seclusion," approved 05/15/17, showed the following:
- The policy did not address techniques to identify triggers.
- The policy did not address the least restrictive method of restraint based on assessment.
- The policy did not address safe application.
- The policy did not address the signs that restraint was no longer necessary.
- The policy did not address the monitoring (how and what should be included) of physical and psychosocial needs.
- The policy did not address first aid techniques.

2. Review of personnel/education files on 01/12/18, showed Staff GGGG's, Medical Doctor (MD), and Staff HHHH's, MD, Chief Medical Officer, files contained no evidence of restraint training.

3. During an interview on 01/12/18 at 2:04 PM, Staff YYY, Electronic Medical Record Coordinator, stated that since physicians don't actually apply restraints, or monitor, they were only required to read the policy and attest to its understanding with each restraint episode.

MLBased on observation, interview, record review and policy review, the facility failed to:
-Assess and document Vital Signs (body temperature, pulse rate, respiration rate [rate of breathing], blood pressure) and condition of one patient (#14) of one patient after complications from a sacral bone biopsy. (A-395)
- Realize that by removing two crash carts (a mobile cart with several drawers that includes supplies and medications utilized to revive a patient when their heartbeat and/or breathing stop) from two units, to subsidize a code blue (an emergency situation in which a patient is in cardiopulmonary arrest-heartbeat and breathing stopped) in the Interventional Radiology Department for Patient #14, they created a dangerous situation for all the patients left on those two units (with no crash cart to treat emergencies). (A395)
-Recognize Epinephrine in pharmacy prepared and labeled baggies in the crash code cart. (A-395)
VR-Assess one patient's skin, identify a skin issue, notify the physician and obtain possible treatment orders for one patient (#47) of three reviewed with skin issues. (A-0395)
-Address complaints of pain for one patient (#20) of three reviewed for pain. (A-395)
-Cleanse and apply skin protectant to two drainage sites for one (#33) of one patient reviewed with drains. (A-395)
-Develop individualized, pertinent interdisciplinary plans of care (IPOC), with updates specific to assessed care needs for eight patients (#19, #20, #22, #26, #27, #41, #45, and #46) of 13 care plans reviewed. (A-396)
These failures had the potential to affect all patients who were treated at the facility.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.23, Condition of Participation: Nursing Services, resulting in a condition of Immediate Jeopardy (IJ).

On 01/05/17, the facility provided an immediate action plan sufficient to remove the IJ by implementing the following:
- All clinical managers and staff in involved with the administration of moderate sedation were required to review of the policy related to moderate and deep sedation.
- Web based training related to sedation was modified to specify monitoring and documentation expectations during moderate sedation.
- All clinicians who administer or monitor sedation, were retrained to demonstrate recognition and management of clinical decline, to include assessment of specific skills as well as successful participation in a mock Code Blue experience until competency was demonstrated. The specific skills included recognizing dysrhythmias and decreased level of consciousness, and proper technique with the ambu bag (manually squeezed plastic bag, that forces air into the lungs), chest compressions, suction equipment, crash cart (which included locating supplies within the crash cart, location of crash cart, and back up crash carts), defibrillator (medical equipment which sends electrical impulses to shock a patient to change their heart rate of rhythm), crash cart medication administration (alternatives and substitution for medications and how to get additional medications), closed loop communication during the Code Blue, Code Blue roles and process for initiation of a Code Blue, Code Blue demonstration (initial response, basic life support guidelines, placing back board under patient, attaching defibrillator and providing shock if needed), Code Blue test and Code Blue debriefing.
- All education and re-training, along with evidence of competency, was mandatory for all staff who provided or monitored sedation, prior to administering or monitoring sedation on their next shift.
- Post education and re-training competency will be repeated quarterly, with immediate remediation plan for any area in which the staff member did not demonstrate competency.
- Communication from Pharmacy related to medication substitutions will continue through use of the Situation, Background, Assessment and Recommendation (SBAR) format. In addition to the current communication process, medications in the Code Blue boxes (containers which hold medications used in emergency), the SBAR communication will be laminated and placed with the substituted medication in the Code Blue box. Education related to this process was reinforced with the Code Blue training.



29047

Based on observation, interview, record review and policy review the facility failed to:
-Assess and document Vital Signs (body temperature, pulse rate, respiration rate [rate of breathing], blood pressure) and condition of Patient #14 after complications from a sacral bone biopsy.
- Realize that by removing two crash carts (a mobile cart with several drawers that includes supplies and medications utilized to revive a patient when their heartbeat and/or breathing stop) from two units, to subsidize a code blue (an emergency situation in which a patient is in cardiopulmonary arrest-heartbeat and breathing stopped) in the Interventional Radiology Department for Patient #14, they created a dangerous situation for all the patients left on those two units (with no crash cart to treat emergencies).
-Recognize Epinephrine (a medication used in life threatening emergencies) in pharmacy prepared and labeled baggies in the crash code cart.
-Assess one patient's skin, identify a skin issue, notify the physician and obtain possible treatment orders for one patient (#47) of three reviewed with skin issues.
-Address complaints of pain for one patient (#20) of three reviewed for pain.
-Cleanse and apply skin protectant to two drainage sites for one (#33) of one patient reviewed with drains.
These failures had the potential to affect all patients with the potential for code blues, skin issues, pain or drainage sites. The facility census was 397.

Findings included:

1. Review of the facility's policy titled, "Patient Care - Assessment of Patients - Policy," approved 12/19/16 showed the following:
-To recognize the significance of accurate, complete, and interdisciplinary assessment of patients that relies on gathering data, initially and continuously.
-Data is analyzed, and the information is used to make decisions about the course of treatment.
-Reassessment addresses the patient's response to care.
-It is completed and documented at a timeframe designated by each care setting or with any significant change in patient condition or diagnosis.

Observation on 01/02/18 at 3:00 PM in the Interventional Radiology Department showed multiple staff in a Computed Tomography (CT, an x ray which produces cross sectional images of the body using x rays and a computer) room where a code blue had been initiated. Also observed were three crash carts; one in the room and two at the entrance of the doorway.

During an interview on 01/02/18 at 3:25 PM, Staff E, Radiology Nurse Supervisor, stated that the two additional crash carts had been brought to the code blue because more drugs were needed. He stated that more epinephrine was needed during the code than was supplied in one crash cart. He stated that he was the medication nurse during the code and was administering the drugs to the patient.The RN did not recognize that four baggies with Epinephrine were also in the initial crash code cart along with the three boxed Epinephrine.

Staff failed to realize that by removing the two crash code carts from the other two units they created a dangerous situation for the patients left on those units (with no crash cart to treat an emergency).

During an interview on 01/03/18 at 9:00 AM, Staff P, Director of Pharmacy, stated that there had been a nation-wide shortage from suppliers of packaged epinephrine. He stated that in response to that, the pharmacy staff had prepared baggies of vials of epinephrine, syringes and filter needles. The bagged drug was labeled with the name of the drug and the dosage instructions and placed in the same section as the packaged drug. He stated that an e mail with an attached newsletter was sent on 06/30/17 to all Management and Supervisors in the hospital to inform them of the shortage. The IR supervisor would have been included in that e mail.

2. Review of the Interventional Radiology Operative Note dated 01/02/18 showed the following:
- Patient #14 presented for a Computed Tomography (CT, an x ray which produces cross sectional images of the body using x rays and a computer) guided Left Ischial (hip joint) Bone Biopsy (a sample of tissue taken).
- He had a history of Atelectasis (collapse or closure of the lung), Chronic osteomyelitis (infection of the bone), Diabetes Mellitus (chronic condition in which there are high blood sugars), and Hypertension (high blood pressure).
- Monitoring during procedure: Blood Pressure, Cardiac, Continuous Pulse Oximetry, Heart Rate and Respiratory Rate.
- Anesthesia: IV Sedation: 100 mcg ( is a unit of measurement) Fentanyl (a narcotic used in conjunction with other drugs for anesthesia and Local 1% Lidocaine (local anesthetic that causes numbness).
- Complications: Following biopsy, patient was repositioned supine (face up) and found unresponsive. Patient given Narcan (reverses narcotics) IV without improvement. (Ambu) bag ventilation (hand held device used to assist a patient to breath) performed, followed by calling code blue when pulse was lost. Patient coded for approximately 30 minutes before pulse returned. Transferred to ICU (Intensive Care Unit).

3. Review of Patient #14's "Sedation Analgesia Documentation Record" dated 01/02/18 at 1:40 PM showed the following:
- The patient arrival time in CT was 1:40 PM for a Sacral (triangular bone at the base of the spine) Bone Biopsy.
- His breath sounds were "Nonlabored breathing".
- At 2:00 PM: Blood pressure (BP) 137/66, Pulse (P) 72, Respirations (R) 16, no documented temperature (T), Pain score 0, Sedation Score 1 (awake & alert), Oxygen (O2) source 2 liters (l) per nasal cannula (nc), Oxygen saturation (amount of oxygen in the blood) 99%.
- At 2:18 PM: 100 mcg Fentanyl IV was given.
- At 2:20 PM: BP 100/84, P 74, R 16. T none documented, Pain Score 0, Sedation Score 1, O2 Source 2 l per nc, O2 saturation 97%.
- At 2:30 PM: BP 76/40, P 58, R 14, T none documented, Pain Score 0, Sedation Score 1, O2 Source 15 liters per mask. O2 saturation 91%,
- At 2:35 PM: BP 80/64, P 60, R 10, T none documented, O2 source 15 liters per mask, O2 saturation 92%.
- At 2:35 PM: 0.4 mg Naloxone (Narcan) IV was given.
- Complications - Yes, use of reversal agents.
- Discharge Criteria Not Met - Transfer to Medical Intensive Care Unit (MICU).

Review of the documentation Nurse's Note dated 01/02/18 at 3:43 PM by Staff VVVV, Registered Nurse (RN) showed the following:
- Patient to Intervention Radiology (IR) for sacral bone biopsy, consent signed.
- Patient placed on CT table in prone (face down) position, Patient secured, Vital Signs, Oxygen 90% on Room Air, BP 137/ 66, Heart Rate 72, Respirations 16.
- [Physician] informed of 02 saturation.
- Patient on 2 liters of oxygen per nasal cannula with Oxygen saturation at 99%.
- 100 mcg Fentanyl (a drug used for pain and in combination with other drugs as anesthesia) and Versed (a drug used for anesthesia) given and procedure started.
- 02 Saturation dropped to 85% and Oxygen increased to 6 liters per nc with oxygen saturation increased to 90%.
- Nasal cannula replaced with simple mask (a basic disposable mask, made of clear plastic to provide oxygen therapy for patients experiencing conditions such as chest pain, dizziness and minor hemorrhages) at 15 liters with a Blood Pressure of 76/40.
- Procedure completed.
- Patient moved to bed.
- Narcan given with Blood Pressure of 80/64 and Oxygen saturation of 92% at 15 liters.
- Patient unresponsive with minimal chest rise.
- Patient assisted breathing with ambu bag and full Oxygen.
- Normal saline (fluid and electrolyte replenished) bolus started.
- Code blue called.
- Code blue team arrived.

During an interview on 01/04/18 at 10:53 AM, Staff VVVV, RN, stated that the patient's oxygen saturation was 90% while supine and he informed the physician of the oxygen saturation and the patient was placed on oxygen per nasal cannula at 2 liters. The patient was then put in the prone position for the bone biopsy. The original plan was to give the patient Fentanyl but because of the oxygen saturation of 90%, the patient was not given the Versed because it can decrease respirations. He stated that he noticed the crown (top) of the patient's head was purple when they turned him over after the procedure was finished. He stated that he was maintaining the IV fluids that were given to the patient and although he glanced at the monitor which showed the patients vital signs, he did not record them.

No vital signs were recorded by the automatic monitor or documented by the staff for twenty minutes from 2:35 PM at the end of the procedure until the code began at 2:55 PM.

During an interview on 01/04/18 at 3:14 PM, Staff WWWW, Physician, stated that he intended to use conscious sedation for Patient #14 but did not because of his decreased oxygen saturation before the procedure started. He stated that he had no concerns related to the patient's condition until the patient was turned from the prone to supine position and he was purple from his chest up. He stated that the staff felt that this was a respiratory problem and the patient was not perfusing (blood was not being delivered throughout the body). He stated that he did not know when the patient lost his pulse.

During an interview on 01/04/18 at 2:45 PM, Staff Y, Stat Registered Nurse, stated that his role is to respond when a code blue was called. He stated that the patient did not have a palpable pulse until he used a doppler on the femoral artery at 3:05 PM, approximately eleven minutes after the code began. He stated that no blades (a metal device used to give a clear field (mouth and throat) in order to insert a tube to assist the patient to breath) for intubation could be found in the cart and another cart had to be brought to the code to obtain the blades.

The staff failed to fully assess the patient's respiratory status for twenty minutes Normal pulse oximeter readings usually range from 95 to 100 % on room air. Values under 90% are considered low. Normal blood pressures are 120/80, normal pulses are 60-100 beats a minute and normal respiratory rates are 12 -20 breaths per minute.
The patient was intubated (the placement of a flexible plastic tube into the windpipe to maintain an open airway) in CT and transferred to ICU where he again coded and died.

4. Review of the facility's policy titled, "Patient Care-Assessment of Patients," approved 12/19/16, showed nursing completes the admitting assessment within 24-hours of admission. The initial assessment includes signs of physical abuse or neglect.

Record review of Patient #47's Emergency Department (ED) record dated 01/08/18, showed the local police brought the patient to the ED because of threats to commit self-harm. The police placed the patient in handcuffs because she was uncooperative. The patient attempted to hit, bite and kick staff so hospital security staff placed the patient in four point restraints (straps that hold the arms/legs down so the patient can't hurt themselves or others).

Observation and concurrent interview on 01/11/18 at 1:48 PM, showed the following:
- Patient #47 had a small elongated scraped area measuring about 1/2-inch long, and multiple bruises to the inner aspect of her left wrist.
- Patient #47 stated that these injuries were sustained while being handcuffed and restrained.
- Patient #47 could not remember exactly who may have caused these injuries.

During an interview on 01/12/18 at 8:45 AM, Staff KKKK, Psychiatric Safety Director, stated that staff failed to assess Patient #47's skin upon admission.

During an interview on 01/12/18 at 12:20 PM, Staff UUU, Security Supervisor, stated that he was not aware of any injuries caused to Patient #47.

Review of Patient #47's Electronic Medical Record (EMR), on 01/12/18, showed no evidence of any skin injuries or treatment.

Review of the facility's policy titled, "Patient Care-Assessment of Patients," approved 12/19/16, showed reassessment addresses the patient's response to care and further assessment is based on each patient's diagnosis, and the patient's response to previous care. Patients will be assessed for pain with each vital sign assessment or with any new, or increase in pain.

5. Review of the facility's policy titled, "Patient Care-Pain-Standard of Care," approved 10/17/16, showed staff should notify the prescriber, and document any assessment changes, ineffective pain management and for a pain score of equal to or over "4."

Review of Patient #20's Admission Note, dated 01/03/18, showed the patient was admitted on that date with influenza type A. The patient was in enhanced body precautions isolation. The patient had been vomiting, had not eaten or drank for four days, ran a fever of 104 degrees, and had aches and pains.

Observation on 01/09/18 at 10:30 AM showed the patient told Staff Z, RN that she was in pain all over, especially her head. The patient rated the pain at a "9" on a scale of one to ten with ten being the worst.

Review of the patient's EMR, on 01/09/18 at 11:10 AM, showed the patient complained of pain the evening before at 4:00 PM, at a rating of "10." The only medication prescribed for pain, since admission, was Tylenol. There was no evidence the physician had been notified of the patient's pain complaints as of this review.

During an interview on 01/09/18 at 10:50 AM, Staff Z stated that she was planning to address the patient's pain as soon as she got time.

6. Review of an undated facility-provided guideline from their reference manual titled, "Jackson Pratt Drains," (a closed drainage system that utilizes a depressed bulb to suction drainage from a surgical site) showed staff were to change the dressing around the drain site if indicated, or ordered. Nurses were to assess the site for drainage and skin irritation, and if there was drainage, apply a skin protectant around the exit site.

Observation in Patient #33's room, on the Oncology (cancer) unit, on 01/10/18 at 9:57 AM, showed the following:
- Patient #33 had two Jackson Pratt drains.
- Staff OO, RN, removed the two drain site gauze pads and both had moderate drainage on them.
- Staff OO failed to cleanse the skin around the exit site, or put a skin protectant around the exit site.





27727

Based on observation, interview, record review and policy review the facility failed to develop individualized, pertinent interdisciplinary plans of care (IPOC), with updates specific to assessed care needs for eight patients (#19, #20, #22, #26, #27, #41, #45, and #46) of 13 care plans reviewed. This failure had the potential to affect all patients admitted as care was not planned. The facility census was 397.

Findings included:

1. Review of the facility's policy titled, "Patient Care-Interdisciplinary Plan of Care," approved 10/16/18, showed the following:
- The Registered Nurse (RN) completing the admission process will develop and initiate the IPOC within the admitting shift.
- The IPOC will be documented on every shift with goals and interventions added or discontinued based on changes in the patient.
- Goals will be based on the reason for admission. Orders and unit standards can be included in the IPOC.
- Goals and interventions will be focused on individual patient needs.
- The IPOC is individualized, with consideration of patient and family input, with changes made as the needs of the patient change.

2. Review of Patient #26's Electronic Medical Record (EMR) showed she was admitted to the facility on 01/08/18 with complaints of hemicranias continua (headache - that is continuous with fluctuating pain without shifting sides of the head).

Review of the patient's History and Physical (H&P) dated 01/08/18 showed the following information:
Chief Complaint: Headache, intractable (unmanageable) hemicranias continua.
Impression: The patient has a past medical history for hemicranias continua phenotype (characteristics). She has a prior lesion (a region in an organ or tissue that has suffered damage though injury or disease) in the anterior fossa (base of the skull) which may be related to it. Her headaches are beginning to flare up again, and I wish to try to stop them early, rather than waiting until they are fully developed, which takes up to a week to clear. I wish to admit her for 24-48 hour lidocaine (medication that can be used to treat pain) infusion (medication administered through a pump to deliver the desired rate and volume).
Plan:
- Admit to neurology service for intractable headache;
- Telemetry (monitor for arrhythmia-irregular heart pattern);
- Lidocaine infusion;
- Labs: CBC (complete blood count), BMP (Basic Metabolic Profile), daily lidocaine level, alpha-1acid glycoprotein level (transports protein in the blood); and
- EKG (Electrocardiogram - reads the electric al signals in the heart) at arrival and daily.

Review of the patient's Physician Orders (PO) dated 01/08/18 showed the following information:
- Saline Lock (a needle placed into a vein used to deliver fluids and medications as needed);
- EKG due to lidocaine infusion;
- Admit to Neuro Science group;
- Vital signs (blood pressure, temperature and heart rate) with neuro (check for consciousness, check pupils for equal size and reactive to light, hand grasp and facial symmetry - mirror image of each side) every four hours;
- Lidocaine Drip; and
- Labs: CBC, CMP, Alpha 1acid glycoprotein level, and lidocaine level.

Review of the patient's IPOC on 01/09/18 at 3: 20 PM showed staff had not initiated a IPOC for the patient to address her pain, need for daily EKG monitoring/telemetry, every four hour vital signs with neuro checks and daily lidocaine levels due to the effects of a lidocaine drip infusion.

During an interview on 01/09/18 at 3:20 PM, Staff FF, RN, Service Line Specialist (SLS), stated that staff are expected to initiate a IPOC for each patient within 24 hours of admission. Staff FF stated that she did not know what the facility's policy was for timeframes for IPOC to be initiated. Staff FF stated that Patient #26 did not have a IPOC to date to address her identified problems related to the lidocaine infusion to treat her headaches.

During an interview on 01/09/18 at 4:45 PM, Staff II, RN, Coordinator of Professional Services stated that the expectation of staff was to initiate a patient's IPOC before the end of their shift.

During an interview on 01/12/18 at 4:25 PM, Staff CCCC, RN, Chief Nuring Officer (CNO) stated that she expected nursing staff to at least initiate a IPOC before the end of their shift.

3. Review of Patient #41's consultation notes showed the patient was involved in a single vehicle crash. The patient received spinal injury that required stabilization and fusion (surgery to join two or more vertebrae into one single structure) of his spine by surgical intervention. He was admitted to the surgical intensive care unit.

Review of Patient #41's laboratory results, dated 01/08/18, showed elevated white blood count (WBC, normal range 3.50-10.50, high count indicates infection) of 12.69.

Review of Patient #41's patient care assessment, dated 01/10/18, showed wound type: surgical site.

Review of Patient #41's EMR, dated 01/10/18, showed no IPOC for wounds, impaired skin, or infection related problems.

During an interview on 01/10/18 at 1:10 PM, Staff WW, RN, stated that it was the nurse's responsibility to enter in the EMR an IPOC. Patient #41 did not have care plans related to wounds or infection, and the patient should have a care plan.

4. Review of Patient #45's admission note showed she was admitted with a splenic injury with diffused (spread, or cause to spread) free fluid requiring surgical intervention. She was admitted to the surgical intensive care unit.

Review of Patient #45's laboratory results, dated 01/08/18, showed elevated white blood count of 16.80.

Review of Patient #45's patient care assessment, dated 01/10/18, showed wound type: surgical site.

Review of Patient #45's EMR, dated 01/10/18, showed no IPOC for wounds, impaired skin, or infection related problems.

During an interview on 01/10/18 at 2:15 PM, Staff XX, RN, stated that it was the nurse's responsibility to enter in the EMR an IPOC. Patient #45 did not have care plans related to wounds or infection, and the patient should have a care plan.

During an interview on 01/10/18 at 2:20 PM, Staff VV, Surgical Services Manager, stated that the nurse's assessment and implementations did not populate an IPOC. It was the nurse's responsibility to enter an individualized care plan.

5. Review of Patient #46's consultation notes showed she was post tricuspid valve (valve in heart) replacement. She developed an infection and required intravenous (IV-a thin flexible tubing placed into the vein so fluids and medications can be administered) antibiotic therapy.

Review of Patient #46's patient care assessment, dated 01/09/18, showed wound type: incision vertical.

Review of Patient #46's EMR, dated 01/09/18, showed no IPOC for wounds, impaired skin, or infection related problems.

During an interview on 01/09/18 at 10:30 AM, Staff ZZ, Service Line Supervisor, stated that it was the nurses' responsibility to enter an IPOC. Patient #46 should have a care plan for wound problems.

6. Review of Patient #19's H&P, dated 01/04/18, showed the patient was admitted on that date with a history of dementia and a stroke. The patient had fallen two days prior to admission while trying to get out of bed.

Observation and concurrent interview in the patient's room on 5 West, 01/09/18 at 9:37 AM, showed the following:
- The patient had a large egg-shaped, and size, swollen bruised area on her right forehead near the brow, extending down to the right side of her neck.
- Staff GG, RN, stated that the patient had a bed alarm and it was set on the moderate sensitivity level.
- The bed alarm was currently turned off so Staff GG could do a dressing change.

During an interview on 01/09/18 at 10:02 AM, staff MMMM, Director of Nurses, stated that the IPOC should have individualized interventions based on assessment. Staff MMMM confirmed there was no intervention for the bed alarm. And, also stated that staff failed to turn the bed alarm back on after the dressing change (leaving the alarm off for approximately 25 minutes).

Review of the patient's fall risk scoring tools dated 01/09/18, showed the patient was a high risk for falls with a score of "90," (anything above 20 was considered high risk).

Review on 01/09/18, at 10:02 AM, of the patient's IPOC, dated 01/09/18, showed the problem of safety. Staff failed to enter interventions specific to this patient, such as the bed alarm, dementia and impulsivity.

7. Review of Patient #20's Admission Note, dated 01/03/18, showed the patient was admitted on that date with influenza type A. The patient was in enhanced body precautions isolation. The patient had aches and pains.

Observation on 01/09/18 at 10:30 AM, showed the patient told Staff Z, RN that she was in pain all over, especially her head. The patient rated the pain at a "9" on a scale of one to ten with ten being the worst.

Review of the patient's EMR, on 01/09/18 at 11:10 AM, showed the patient complained of pain the evening before at 4:00 PM, at a rating of "10." The patient was on two antibiotics, one called Ciprofloxacin and one called Vancomycin.

During an interview on 01/09/18 at 10:50 AM, Staff Z stated that the patient's physician thought the patient had an infection in her IV.

Review, on 01/09/17 at 10:50 AM, of the patient's IPOC, dated 01/03/18, showed staff failed to address the patient's infection or add interventions for the patient's pain.

During an interview on 01/09/10 at 11:10 AM, Staff AA, RN Clinical Manager, stated that Staff should have care planned the patient's problem of infection.

8. Review of Patient #22's H&P dated 12/05/17, showed the patient was admitted on that date with an infection in a post surgical right knee incision. The patient had an elevated white blood cell count of 71.25, indicative of an infection.

Review of the patient's EMR, dated 01/09/18, showed the patient was on three different antibiotics, Vancomycin, Ciprofloxacin, and Zosyn.

Review on 01/09/18, of the patient's IPOC, dated 01/09/18, showed staff failed to identify the patient's infection, with the problem, goals, and applicable interventions.

9. Review of Patient #27's H&P dated 12/15/17, showed the patient was admitted on 12/14/17 with a low white blood cell count of 3.75 (with 5-10 normal, neutropenia) related to his diagnosis of cancer.

Observation on 01/09/18 at 1:55 PM, showed the patient was in enhanced body precautions isolation.

Review of the patient's medications showed an order for Vancomycin and Meropenum (antibiotics).

Review on 01/09/18, of the patient's IPOC, dated 01/09/18, showed staff failed to identify the patient's infection, or potential for an infection with the problem, goals, and applicable interventions.
















18018




37921

Based on interview, record review and policy review, the facility failed to ensure restraint orders were complete by the ordering practitioner. The facility failed to ensure what needed to be restrained was included in the restraint order for five patients (#6, #7, #15, #17 #34) out of 10 current patients reviewed with restraint orders. This had the potential to affect all patients placed in restraints. The facility census was 397.

Findings included:

1. Review of the facility's policy titled, "Patient Care - Power Order Communication Types - Policy," dated 10/16/17 showed the directives for staff:
-All valid orders must contain, at a minimum:
- Patient name;
- Medical record number or encounter number;
- Test/Procedure/Action requested;
- Clinical indications/Presenting signs/symptoms/diagnosis; and
- Treating/ordering physician name.

2. Review of the facility's policy titled, "Patient Care - Restraint - Standard of Care," dated 06/30/15 showed the following directives for staff:
Least Restrictive Restraint:
- Type of restraint listed in order from least restrictive to most restrictive.
- Use the least restrictive method safe for the patient.
- Must document less restrictive restraints tried.

3. Review of Patient #6's Electronic Medical Record (EMR) showed he was admitted to the facility's Intensive Care Unit (ICU) on 12/01/17 due to chest trauma.

Review of the patient's Restraint Orders showed that from 12/01/17 through 12/28/17, 11 restraint orders were written for non-violent cloth restraints. The orders stated that the patient was tampering with medical care devices, soft (tied). The orders did not include the locations the restraints should be placed on the patient.

4. Review of Patient #7's EMR showed he was admitted to the facility's ICU on 12/09/17 with complaints of CHF (Congestive Heart Failure - a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues) exacerbation (an increase in the severity of a disease and/or signs and symptoms).

Review of the patient's Restraint Orders showed that from 12/20/17 through 01/03/18, seven restraint orders were written for non-violent cloth restraints. The orders stated that the patient was tampering with medical care devices, soft (tied). The orders did not include the locations the restraints should be placed on the patient.

During an interview on 01/03/18 at 9:10 AM, Staff ZZZ, RN (Registered Nurse), Service Line Specialist (SLS), Cardiovascular, stated that restraint orders do not direct staff what is to be restrained.

5. Review of Patient #34's EMR showed he was admitted to the facility's ICU on 01/06/18 with complaints of difficult breathing, had productive cough, subjective fever, and fast shallow breathing. Chest x-ray (pictures of inside of the body) showed concerns for pneumonia (infection of the lungs). The patient required Bilevel Positive Airway Pressure (BiPAP, non invasive support of the air way).

Review of the patient's restraint orders showed from 01/06/18 through 01/09/18, three restraint orders were written for non-violent cloth restraints. The orders stated that the patient was tampering with medical care devices, soft (tied). The orders did not give staff direction on what needed to be restrained.

During an interview on 01/09/18 at 11:15 AM, Staff RR, RN, stated that after review of the restraint order, the order did not direct staff what was to be restrained.

During an interview on 01/09/18 at 11:35 AM, Staff QQ, Clinical Manager, stated that restraint orders should have directions on what needed to be restrained. Patient #34's restraint orders did not direct the staff on what needed to be restrained, and should have given directions.

6. Review of Patient #15's EMR, showed a restraint order dated 01/02/18 at 12:01 AM, for cloth restraints. The order did not include the location the restraints should be placed on the patient.

7. Review of Patient #17's EMR, showed restraint orders dated 12/16/17 at 4:00 AM, and 12/25/17 at 1:32 AM, for cloth restraints. The orders did not include the locations the restraints should be placed on the patient.

During an interview on 01/03/18 at approximately 9:30 AM, Staff O, Surgical Intensive Care Unit (SICU), Seven West, Burn/Wound/Trauma Clinical Leader Manager, stated that she would have to clarify the restraint orders with the physician, in order to determine where the restraints were to be placed on the patient.

During an interview on 01/11/18 at 10:20 AM, Staff UUUU, Assistant Chief Medical Officer, stated that for a restraint order to be complete, the order should give staff directions to what should be restrained. The EMR used to have the directives in the order, but the EMR restraint orders had changed. The physicians now were required to open a drop down box to free text the data to give the directions of what should be restrained. The physicians were not entering the data into the restraint order, and should have entered what should be restrained.










29047

Based on interview, record review, and policy review, the facility failed to ensure informed consent was properly executed for patient procedures for four patients (#15, #16, #17 and #18) of 16 patients reviewed. This had the potential to affect all patients who underwent invasive procedures in the facility. The facility census was 397.

Findings included:

1. Review of the facility's policy titled, "Patient Rights & Responsibilities - Consent for Medical and Surgical Treatment," dated 06/15/15, showed Informed Consent:
- Is to protect the patient's right to make an informed decision about what procedures shall be performed and to educate patients on the risk, benefits or alternatives of those procedures;
- Is a legal and ethical precondition for medical treatment;
- Is required prior to treatment or the initiation of the procedure;
- Must be obtained from a competent adult or legal representative;
- Is the responsibility of the physician/practitioner performing the procedure to ensure the consent was properly obtained;
- Is required for invasive procedures, including internal endoscopic examinations; and
- Could include "serial consent (only one consent is required, when the same procedure must be repeated several times for diagnostic or treatment purposes)," which requires the consenting physician to write "serial consent" on the consent form, with the number of anticipated treatments in parentheses, and the patient shall initial (to indicate knowledge of) in the same area.

2. Review of Patient #15's medical record showed:
- An informed consent form dated 12/28/17 for "re-opening recent laparotomy (incision through the abdominal wall to gain access to the inside of the abdomen)" which documented that telephone consent for the procedure was provided by "6603885875", and did not contain the name of the person who provided consent for the procedure;
- Bronchoscopy (to view the airway and lungs through the use of a small, tube-like camera) Operative Procedure (Op/Procedure) Notes (documentation of the procedure that was performed) dated 12/24/17 and 12/29/17;
- Chest Tube (insertion of a flexible tube into the chest cavity, to drain fluid) Op/Procedure dated 12/25/17; and
- There were no informed consents signed for the Bronchoscopies or Chest Tube procedures.

3. Review of Patient #16's medical record showed there were no signed informed consent forms for the following procedures:
- Left radial art-line placement on 12/19/17;
- Central line placement on 12/19/17;
- Cerebral (brain) angiogram (x-ray dye inserted through a small catheter, into an artery, which when injected creates visibility of blood vessels on live X-ray video) with intracranial (within the brain) aneurysm (weakened blood vessel) using detachable coils (small coiled wires which are placed inside a vessel, used to block the flow of blood) dated 12/21/17; and
- Cerebral angiogram with angioplasty (small balloon inserted through a small catheter, into an artery, which is inserted into a desired blood vessel, and the balloon is inflated to open a blockage within the blood vessel).

4. Review of Patient #17's medical record showed:
- An informed consent form for a Central Line (catheter that is placed through the skin and into a vein, which is used to instill fluid or medication or to draw blood from an area near the heart)
and Arterial Line, which was undated.
- An informed consent form dated 11/14/17 for "Serial Consent" for "exploratory laparotomy, drainage of peripancreatic (around the pancreas, an organ that helps in digestion and regulates blood sugar) fluid collection, possible pancreatic debridement (removal of dead tissue), possible partial or complete pancreatectomy (removal of the pancreas), placement of abdominal drains.
- The informed consent form dated 11/14/17 did not include the number of anticipated treatments or the initials of the patient acknowledging the "Serial Consent".

5. Review of Patient #18's medical record showed:
- A bronchoscopy operative/procedure Note dated 12/25/17;
- An arterial line (art-line, plastic tube inserted into a large vessel to monitor pressures or to withdraw frequent blood samples) Op/Procedure note dated 12/28/17, which stated that informed consent was obtained by the family;
- There were no informed consents signed for the 12/25/17 bronchoscopy or the 12/28/17 art-line.

During an interview on 01/02/18 at approximately 3:30 PM, Staff N, Surgical Intensive Care Service Line Specialist (SLS), stated that all consents were considered serial. This meant that once a procedure was consented for, if the patient required additional procedures that were the same, an additional informed consent form did not need to be reviewed and signed with the patient or patient representative.

During an interview on 01/03/18 at approximately 9:30 AM, Staff O, Surgical Intensive Care Unit (SICU), Seven West, Burn/Wound/Trauma Clinical Leader Manager, stated that she was unsure what procedures required informed consent, and which ones did not. Staff O clarified that serial consents were only used if the exact same procedure would occur repeatedly, for example daily, and not intended to cover like or similar procedures.

During an interview on 01/03/18 at 10:18 AM, Staff I, RN Supervisor stated that consents were needed for each different procedure. The physician should explain risks versus benefits of each procedure with signatures of both the physician and patient.




29047

Based on observation, interview, record review, and policy review, the facility's staff failed to implement the accurate and timely interventions that corresponded to the documented fall risk interventions in the patient's medical record for one patient (#36) of one patient's medical record reviewed for fall risk. This had the potential to affect any patient on fall risk precautions. The facility census was 397.

Findings included:

1. Review of the facility's policy titled, "Record of Care, Treatment, and Services-Provider content of the Medical Record Policy," revised 08/24/17, showed that errors in documentation to be avoided included incorrect information.

2. Review of the facility's policy titled, "Patient Care- Assessment of Patients-Policy," revised 12/19/17, showed that reassessment addressed the patient's response to care. It is completed and documented at a timeframe designated by each care setting or with any significant change in the patient condition or diagnosis.

3. Review of the facility's policy titled, "Fall Prevention-Policy," revised 02/24/16, showed that patients/clients were assured of assessment of their risk for falls:
- Upon admission, a registered nurse (RN) will assess each patient/client for risk for falls using the fall risk assessment tools available in the Electronic Medical Record (EMR);
- If determined to be at risk for falls, the patient will be identified as at risk for falls; and
- Fall risk includes any patient with a fall risk score of 20 or greater.

4. Review of Patient #36's History and Physical (H&P), showed the patient had a pacemaker (artificial device for stimulating the heart muscle) for Sick Sinus Syndrome (abnormal heart beats), Chronic obstructive pulmonary disease (COPD, obstruction of lung airflow that interferes with normal breathing), use of 2 liters of oxygen, and anemia (decrease in red blood cells, or lowered ability of blood to carry oxygen). He required Bi-level Positive Airway Pressure (BiPAP, non-invasive ventilation to support airway), and chest x-ray consistent with fluid overload of the lungs. The patient's oxygen saturation decreased with performing task, such as eating breakfast.

Review of Coronary Care Unit (CCU) assignment sheet dated 01/09/18, showed Staff SS, RN, was assigned to Patient #36.

Review of Patient #36's Patient Care assessment on 01/09/18 at 8:00 AM, documented by Staff SS, RN, showed:
- Fall risk score was 60;
- Unstable gait/balance;
- Had a fall within a year;
- Yellow fall band on;
- Anti-slip footwear on; and
- Fall sign/Magnet on the door.

Observation on 01/09/18 at 2:00 PM, in Patient #36's room, showed no yellow fall band, anti-slip footwear, or fall sign/magnet on the door. There were no indicators the patient was a fall risk.

During an interview on 01/09/18 at 2:05 PM, Staff SS, RN, stated that:
- She documented in the EMR at 8:00 AM that Patient #36 had on yellow fall band, anti-slip footwear, and a fall sign/magnet on the door.
- After review of the room, the patient did not have any indicator that he was a fall risk;
- Other disciplinary teams would not of known he was a fall risk; and
- She did not implement what she documented because "she had not had time."

Staff SS, RN, documented at 8:00 AM that Patient #36 had on yellow fall band, anti-slip footwear, and fall sign/magnet on the door six hours before the patient was observed not having indicators implemented accurately. This failure to accurately and timely implement what she documented had the potential to cause injury and/or death to the patient.

During an interview on 01/09/18 at 2:10 PM, Staff TT, Clinical Manger, stated that:
- Nurse's documentation in the EMR should reflect accurate and timely interventions;
- Staff SS, RN, should not have "pre charted" that she implement fall risk interventions on the patient; and
- Patient #36 should have had the fall indicators as documented by Staff SS.

During an interview on 01/09/18 at 2:30 PM, Staff UU, Director of Nursing, stated that Staff SS should have implemented what she documented at that time.

Review of falls from 12/26/17 through 01/02/18 (seven day period) showed that the facility had 10 recorded falls. A fall ratio, greater than one fall per day.

Review of Staff SS RN's timecard showed she entered the facility at 6:52 AM and exited the facility at 7:56 PM.

During an interview on 01/12/18 at 9:30 AM, Staff III, Medical Record Manager, stated that:
- EMR documentation and interventions performed should be accurate and timely;
- The documentation was seen by multidisciplinary teams and should reflect accurate data; and
- It was not appropriate for staff to "pre chart" in the EMR.

Based on observation, interview, record review and policy review the facility failed to keep two of two patients' (#4 and #20) medications secure and out of visitors, and unqualified staff reach/use. This had the potential to allow any wandering patient, visitors and unqualified staff that entered a patient's room, to potentially ingest/administer an unprescribed, dangerous medication. The facility census was 397.

Findings included:

1. Review of the facility's policy titled, "Medication Management-Authorization of Access to Medication Storage Areas," approved 04/05/16, showed the following:
- Access to medication storage areas is limited to patient care staff, pharmacy and other disciplines who are authorized to administer medications.
- To ensure the security of medication, badge access procedures will be in effect.
- Medication storage areas will be locked.

2. Observation with concurrent interviews, in Patient #4's room on 5 East, on 01/03/18 at 9:30 AM, showed the following:
- The following medications were on the windowsill in the patient's room. And, there was no staff in the room to monitor the use of these medications- Clopidrogel (a blood thinner) 75 milligrams (mg), Humalog pen (insulin), Metoprolol (for blood pressure) 12.5 mg, Colchicine (used to treat gout-an inflammatory process in the feet) 0.6 mg, Lasix 40 mg (a diuretic), baby aspirin 81 mg, Lovenox (a blood thinner) 40 mg, and Lantus (insulin).
- The patient stated that the Registered Nurse (RN) brought the medications into the room and left them there approximately 30 minutes earlier.
- RN K, stated that he left the medications in the room to tend to another patient's needs. RN K was not sure what the facility policy was pertaining to unsecured medications.
- RN A, Clinical Manager for 5 East/West units, stated that the medications should not have been left in the patient's room unattended.

3. Observation and concurrent interview, in Patient #20's room, on 01/09/18 at 10:30 AM, showed the following:
- A Symbicort inhaler lying on the patient's overbed table.
- No staff in the patient's room to monitor the medication.
- RN, Staff Z, stated that she did not know if the patient had an order to self-administer this medication. This was Staff Z's first day caring for this patient and she had not noticed the Symbicort was in the patient's room.

During an interview on 01/09/18 at 11:10 AM, Staff AA, RN Clinical Manager for the family medicine unit, stated that medications should not be left in the patient's room.

Based on observation, interview, policy review and review of the United States Department of Health and Human Services Food Code (USDA Food Code), the facility's Director of Dietary failed to ensure that the dietary policies were followed by the dietary staff, for refrigerated, frozen food, dry storage, and failed to establish and maintain a sanitary environment in the kitchen. (Refer to A-620)

These failures had the potential for food borne illness for all patients, staff and visitors who ate foods prepared in the dietary kitchen. The facility census was 397.

The cumulative results of these findings resulted in the overall non-compliance with CFR 482.28, Condition of Participation: Food and Dietetic Services.

Based on observation, interview, policy review and review of the United States Department of Health and Human Services Food Code (USDA Food Code), the facility's Director of Dietary failed to ensure that the dietary policies were followed by the dietary staff, for refrigerated, frozen food, dry storage, and failed to establish and maintain a sanitary environment in the kitchen. These failures had the potential for food borne illness for all patients, staff and visitors who ate foods prepared in the dietary kitchen. The facility census was 397.

Findings included:

1. Review of the "USDA Food Code," updated on 09/09/16, stated that food shall be discarded if the food is not consumed before the expiration date and if it is in a container or package which does not bare a date.

2. Review of the facility's policy titled, "Dining and Nutrition Services-Food Receiving Storage and Labeling," dated 05/24/15, showed the directives for staff to ensure optimal food safety standards:
- That they follow the food safety program "US food code 2013" and "ServSafe essentials" (fifth edition), which showed that ready-to-eat foods that have been prepared onsite or commercially prepared and opened must be labeled with date to be consumed by;
- All food will be labeled with received by dates and best by date from manufacturer if in original container; and
- If foods were removed from original containers or open, the product will be appropriately labeled and dated.

3. Review of the facility's policy titled, "Dining and Nutrition Services-Monitoring of Food Quality and Safety-Guideline," dated 05/19/15, showed the directives for staff to ensure optimal food safety standards:
- Sanitizing of work surfaces between food products and at least every four hours;
- Prepared foods shall be transported to other areas in covered containers; and
- Proper equipment sanitation.

Observations on 01/11/18 at 8:25 AM through 11:15 AM, in the main facility's kitchen, showed the following:
-Scraps of paper, plastic lids, caps and unidentifiable trash debris accumulated on the floor in walk-in freezers, and the walk-in cooler.
- Accumulated blackened grease residue on one pan lid that was stored on a cart labeled "clean items only", ready for use in preparation of foods;
- Accumulated rust (breakdown of metal to powder form, which was known to harbor bacteria) and a bent support leg on one vegetable wash station;
- Mozzarella cheese particles, plastic lid, plastic straw, and unidentifiable accumulated debris in the bottom of the reach-in freezers;
- Unidentifiable red frozen sticky debris accumulated on the door edges, and six shelves with multiple breaks in the plastic covering exposing rust in the ice cream cooler; and
- Unidentifiable red sticky debris, unidentifiable hard white debris, unidentifiable yellow sticky debris, and multiple areas of rust on one large food mixer, that was in the evening preparatory area, ready for use in preparation of foods.

Observation on 01/11/18 at 9:50 AM, in the main facility's walk-in freezer one, showed food items uncovered (open to elements, not protected from cross contamination or freezer burn) and no label:
- Two large pans of French fries;
- Two large pans of frozen chicken strips; and
- Two large pans of frozen sweet potato fries.

Observation on 01/11/18 at 10:00 AM, in the main facility's walk-in freezer two, showed food items with no label:
- Six frozen pizza dough;
- One open container of tortilla shells;
- Two beef pastrami;
- Two containers of cheese;
- One large container of pepperoni; and
- One large container of cooked chicken.

Observation on 01/11/18 at 10:10 AM, in the main facility's walk-in cooler, showed food items with no label:
- One prepared pan of rice and beans;
- Three large containers of repackaged lettuce;
- One prepared container of feta noodles; and
- One prepared container of corn.

Observation on 01/11/18 10:50 AM, in the main facility's dry storage area, showed food containers removed from the original shipping containers with no label:
- One large prepared repackaged nuts;
- One large repackaged bag of chips; and
- Half bag of dry noodles.

During interview on 01/11/18 at 10:50 AM, in the main kitchen, Staff EEE, Dietary Store Clerk, stated that food items received in shipping boxes have the received date and beyond use date. If the food items were removed from the shipping boxes, the food items should be labeled with the received date and beyond use date.

During interview on 01/11/18 at 11:05 AM, in the main kitchen, Staff FFF, Culinary Associate, stated that prepared onsite or commercially prepared food items stored in the freezers and coolers should have been labeled with the prepared dated and beyond use date. Foods that were stored in the freezers and coolers that were not labeled should be discarded.

During interview on 01/11/18 at 11:25 AM, in the main kitchen, Staff DDD, Dietary Supervisor, stated that kitchen staff were to clean freezers and coolers every evening, and should not have accumulated debris within them. All foods stored should be labeled and covered.

During an interview 01/11/18 at 10:10 AM, in the main kitchen, Staff CCC, Interim Director of Dietary, acknowledged the accumulated debris and rust in the ice cream freezer, walk-in coolers, walk-in freezers, reach-in freezers, cooking equipment, and food preparation equipment. Staff CCC stated that kitchen staff was assigned to clean up their work areas, which included all food storage areas. Food preparation equipment should be clean and sanitized between uses, and any equipment that showed signs of heavy wear, rust, and/or accumulatation of black grease should have been removed from service. She also stated that foods that were in storage should have been covered at all times and labeled.

Observation on 01/12/18 at 11:15 AM, in the facility's off-site kitchen, showed two stacks of sheet trays with accumulated black grease, ready for preparation of foods.

Observation on 01/12/18 at 11:10 AM in the facility's off-site reach-in freezer, showed repackaged food items uncovered:
- One large bag of tater rounds;
- One large bag of chicken strips;
- One large bag of noodles;
- One large bag of meat balls;
- One large bag of sausage patties; and
- One large bag of black beans.

Observation on 01/12/18 11:30 AM, in the facility's off-site dry storage area, showed food containers removed from the original shipping containers with no label:
- Two half bags of dry noodles;
- Six bags of granola; and
- Four bags of peppers.

Observation on 01/12/18 at 11:45 AM, in the facility's off-site walk-in cooler, showed two large bags of peas on the floor (in the area where staff walked), and one bag of egg rolls that were removed from original container and not labeled.

During an interview 01/12/18 at 11:50 AM, in the facility's off-site kitchen, Staff NNN, Dietary Supervisor, acknowledged the accumulated grease on the sheet pans, uncovered foods, foods on the floor, and foods that were not labeled. Staff NNN stated that foods should be covered at all times, labeled, and not stored on the floor. She also stated that food preparatory equipment that had accumulated grease should have been removed from service.

During an interview on 01/11/18 at 11:05 AM, in the facility's off-site kitchen, Staff LLL, Culinary Associate, stated that prepared onsite or commercially prepared food items stored in the freezers and coolers should have been labeled with the prepared date and beyond use date. Foods that were stored in the freezers and coolers should have been covered at all times.

4. Review of the facility's kitchen checklist showed that the dietary staff was to perform daily cleaning and stocking of the kitchen including refrigerators, freezers, floors, and sign attesting that they completed the task. The facility could not provide signed checklists that the tasks were completed.

During an interview 01/11/18 at 12:10 PM, Staff BBB, Executive Director of Support Services, stated that the dietary staff have a daily checklist that directs them to perform cleaning and sanitizing of the kitchen with an area to sign attesting that the tasks were completed. The staff had not signed the checklist and the facility could not confirm that the tasks were performed. It was the facility's expectation that all staff adhere to all of the facility's policies.

Based on observation, interview, record review, and policy review, the facility failed to ensure that staff:
- Performed hand hygiene (either by washing with soap and water or using alcohol hand sanitizer) for eight (#2, #20, #24, # 25, #27, #30, #31, #46 and #52) current patients observed during care and treatment when hand hygiene was indicated. Refer to A-0749 for examples.
- Utilized and changed gloves as directed in their policy and after touching inanimate objects/equipment (computer keyboards, mouse, scanner, ASCOM phone - wireless phones used by staff) or when gloves were visibly dirty with blood/body fluids for five (#2, #20, #28, #30 and #31) current patients observed that received care, treatment and services by staff. Refer to A-0749 for examples.
- Clean and/or disinfect inanimate objects such as ASCOM phones, computer keyboards, computer mouse, scanner, IV pump (machine programmed to infuse fluids or medications into a vein) and other medical equipment as directed by facility policy. Refer to A-0749 for examples.
- Clean the stethoscope bell (equipment used to listen to heart, lungs and abdominal sounds during assessment) after being placed on a patient's bare chest. Refer to A-0749 for example.
- Performed hand hygiene before and after entry into patients' rooms as directed by the facility's policy. Refer to A-0749 for example.

The cumulative effects of these systemic failures resulted in the facility's non-compliance with 42 CFR 482.42 Condition of Participation (CoP): Infection Control and resulted in the facility's failure to ensure safe infection control practices to prevent infections and communicable diseases.

Based on observation, interview, record review, and policy review, the facility failed to ensure that staff:
- Performed hand hygiene (either by washing with soap and water or using alcohol hand sanitizer) for 10 (#2, #20, #24, #25, #27, #28, #30, #31, #46 and #52) current patients observed during care and treatment when hand hygiene was indicated. Refer to A-0749 for examples.
- Utilized and changed gloves as directed in their policy and after touching inanimate objects/equipment (computer keyboards, mouse, scanner, ASCOM phone - wireless phones used by staff), when gloves were or after removal of wound dressings for five (#2, #20, #28, #30 and #31) current patients observed that received care, treatment and services by staff. Refer to A-0749 for examples.
- Clean and/or disinfect inanimate objects such as ASCOM phones, computer keyboards, computer mouse, scanner, IV pump (machine programmed to infuse fluids or medications into a vein) and other medical equipment as directed by facility policy. Refer to A-0749 for examples.
- Cleane the stethoscope bell (equipment used to listen to heart, lungs and abdominal sounds during assessment) after being placed on a patient's bare chest. Refer to A-0749 for example.
- Performed hand hygiene before and after entry into patients' rooms as directed by the facility's policy. Refer to A-0749 for example.
These failed infection control practices by staff placed all patients, staff and visitors at increased risk for exposure to infections. The facility census was 397.

Findings included:

1. Review of the facility's policy titled, "Infection Control-2018 Exposure Control Plan Infection Prevention," approved 01/01/18, showed patients who pose a high risk of transmission to others will be placed in Enhanced Body Substance Precautions (EBSP).

2. Observation in Patient #20's room, on the 4 West unit, on 01/09/18 at 10:30 AM, showed the following:
- Patient #20 was in EBSP.
- Patient #20 had a central line (a thin, flexible tube placed in a large vein [usually in the upper arm or chest] so long-term medications and/or fluid can be administered).
- Staff Z, RN, put regular gloves on and touched the computer keyboard, scanner, multiple supplies, medications, the bed, sheets, the patient, intravenous (IV) pole, lines and administration pump. Staff Z then administered a flush and medications through a central line port with the same gloves on.

During an interview on 01/09/18 at 10:50 AM, Staff Z stated the following:
- The patient currently had the flu, type A, and Klebsiella (bacteria) in the blood stream.
- The patient's physician thought the patient may have a central line infection.
- She thought anything in the patient's room was considered touch acceptable with the same gloves on.

During an interview on 01/09/18 at 11:10 AM, Staff AA, RN Clinical Manger for 4 West, stated that Staff Z should have performed hand hygiene and changed her gloves before handling the central line.

Review of the patient's medications showed an order for Ciprofloxacin 400 milligrams (mg) IV daily, and an order for Vancomycin 2 grams IV every 96 hours (both antibiotics-used to treat infection).

3. Review of the facility's policy titled, "Infection - Control - 2018 Exposure Control Plan Infection Prevention," dated 01/01/18 showed directives for staff:
Gloves:
- Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, and/or moist body substances, (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these substances).
- If the patient is in Enhanced Body Substance Precautions then the patient's room is considered contaminated by the patient's body substances therefore gloves will be worn whenever a caregiver is touching the patient or the patient's environment.
- Gloves must be worn for all intravascular procedures.
- Change gloves between patient contact with different patients or different body sites of the same patient. Always use hand hygiene after removing gloves.
- Remove gloves when the task is finished or if touching public items or areas that others may contact.
Hand Hygiene:
Wash Hands Before:
- Patient contact;
- Putting on gloves;
- Performing invasive procedures;
- Changing dressings; and
- Moving from a contaminated to a clean site.
Do Hand Hygiene After:
- Patient contact;
- Contact with body substances or soiled surfaces;
- Touching beds or bedside objects; and
- Removing gloves.
Cleaning of Equipment: Computer keyboards, glucose meters, blood pressure cuffs, and other small equipment taken from patient to patient must be cleaned with a hospital approved antibacterial wipe or other quaternary ammonia spray prior to use on another patient.

4. Observation in Patient #27's room, on the Oncology (cancer) unit, on 01/09/18 at 1:55 PM, showed the following:
- Patient #27 was in isolation related to being neutropenic (a low white blood cell count which reduces the patient's ability to fight infection).
- Patient #27 had a peripherally inserted central catheter in the right inner arm (PICC-a tube placed into a vein so long-term medications and/or fluid can be administered).
- Staff HH, RN, put regular gloves on and touched the computer keyboard, scanner, a bag of blood product (platelets-the clotting factor in blood), the patient, IV pole, lines and administration pump, blood pressure cuff, thermometer, connected new IV tubing to a bag of normal saline, and platelets. Staff HH then administered the platelets via the PICC with the same gloves on.

Review of the patient's medications showed an order for Vancomycin 1000 mg IV every 12 hours, and an order for Meropenum (antibiotic) 500 mg IV every six hours.

Observation in Patient #27's room, on 01/10/18 at 9:15 AM, showed the following:
- Patient #27 remained in isolation.
- Staff HH put on regular gloves, touched the bed, and her contaminated ASCOM phone twice (brought in from outside the room, in Staff HH's uniform pocket, and was not cleansed before brought into Patient #27's room).
- Staff HH then removed the old PICC dressing and unlocked the anchor device, but left it in place, with the same gloves on.

During an interview on 01/11/18 at approximately 11:30 AM, Staff LLLL, Infection Preventionist, stated that the ASCOM phones had been identified as a problem related to infection prevention. Staff should clean the phones with disinfectant wipes if they are touched in a patient room.

5. Review of Patient #46's infection disease inpatient consult showed the patient developed Methicillin-Resistant Staphylococcus Aureus (MRSA, infection resistant to some antibiotics) in the surgical site. She received treatment with IV antibiotics. Aspiration from fluid collected at the surgical site was positive for gram positive staphylococcus (identifiable strand of bacteria). Her past history showed Hepatitis (infection of the liver) B, Hepatitis C, infectious endocarditis (infection around the heart), status post valve replacement.

Observations on 01/09/18, at 9:40 AM through 10:05 AM, showed Staff YY, RN, enter Patient #46's room, failed to perform hand hygiene, and/or use a waterless product. Staff YY touched the computer, scanner, and Patient #46, without putting on gloves. Staff YY administered six medications by mouth and administered IV medications. Staff YY performed no hand hygiene. Staff YY exited Patient #46's room, (no hand hygiene) walk down the hallway, touched the medication room door, entered the room (no hand hygiene) and used the computer. Staff YY exited the medication room, returned and entered Patient #46's room (no hand hygiene). Staff YY touched the computer, the patient, IV fluids and pump. Staff YY exited Patient #46's room (no hand hygiene).

During interview on 01/09/18, at 10:10 AM, Staff YY, RN, stated that staff should perform hand hygiene when entering and exiting a patient's room. She was unaware that she failed to perform hand hygiene. She also stated she missed some opportunities where hand hygiene needed to be performed.

During interview on 01/09/18, at 10:20 AM, Staff ZZ, Service Line Supervisor, stated that staff was to perform hand hygiene when entering and exiting the patient's room. Staff YY, RN should have performed hand hygiene when she enter and exited Patient #46's room.

6. Observation on 01/09/18 at 9:40 AM showed Staff CC, Registered Nurse, entered Patient #24's room to set-up and administer a PCA (Patient - Controlled Analgesia, a computerized machine/pump programmed by the prescriber that allows a patient to administer their own pain medication in a controlled environment with limits) pump with Hydromorphine (medication used to treat moderate to severe pain). Staff CC removed his gloves and did not perform hand hygiene and touched the following items after he removed the gloves:
- Pulse Oximetry machine (machine used to measure oxygen in the blood);
- Computer keyboard and computer mouse;
- IV pump (IV-intravenous, pump-machine programmed to administer medications/fluids at a prescribed rate);
- Typed on computer keyboard and used mouse;
- SCD (Sequential Compression Device - machine used to improve blood flow) cord;
- Blankets on the patient's bed;
- ASCOM phone (wireless phone used by staff to communicate) and keyboard; and
- SCD machine.

During an interview on 01/09/18 at 11:20 AM, Staff CC, RN, stated that hand hygiene should be performed:
- Before entry into a patient's room and upon leaving;
- Wash with soap and water if contact with body fluids;
- In-between clean and dirty;
- Before medication preparation and medication administration; and
- Before putting on gloves and after removal of gloves.
Staff CC, RN, stated that she should have done hand hygiene after she removed gloves and before touching things in the patient's room.

7. Observation on 01/09/18 at 2:00 PM showed Staff DD, RN, entered Patient #25's room to perform tracheostomy (Trach - a surgically created hole in the windpipe that provides an alternative airway for breathing) care. Staff DD with gloved hands that was worn during trach care reached into her pocket and pulled out her ASCOM phone and returned it to her pocket without cleaning it after being touched with the soiled gloves.

During an interview on 01/09/18 at 2:07 PM, Staff DD, RN stated that it was nursing's responsibility to clean the ASCOM phones and staff cleaned the phones at the end of the shift. Staff DD stated that the ASCOM phones are only cleaned by staff at the end of their shift. Staff DD stated that she should have cleaned the ASCOM phone after she touched it with her gloved hands.

8. Observation on 01/10/18 at 10:45 AM showed Staff MM, RN, prepped and administered nasal gastric (NG - tube placed into the nose used to administer fluids, nutrition and medications) tube medication to Patient #52. Staff MM removed her gloves but did not perform hand hygiene and touched the computer.

During an interview on 01/10/18 at 10:55 AM, Staff MM, RN, stated that hand hygiene should be done upon entry and exit of a patient's room and after removal of gloves. Staff MM stated she did not know when computer keyboards are cleaned but she thought housekeeping cleaned them in the morning.

9. Observation on 01/10/18 at 3:30 PM showed Staff BBBB, RN, Vascular Access Team and Staff CCCC, Licensed Practical Nurse (LPN), Vascular Access Team entered Patient #2's room to place a PICC (Peripherally inserted central catheter - a thin, soft long tube inserted into a vein used for prolonged administration of fluids, medications or nutrition) line. Staff CCCC touched the following items wearing the same pair of gloves:
- Placed blue pad under the patient's right arm.
- Cleaned the patient's right arm with cleanser, tied on a tourniquet (a device used to stop the flow of blood through a vein or artery) and scrubbed the area again with cleanser.
- Placed the ultra sound scanner onto the patient's right side of his neck.
- Wearing the same pair of gloves assisted Staff BBBB with putting a sterile drape over the patient's body from head to toe.
- Touched the ultra sound machine, computer screen, mouse and keyboard.
- Reached into his pocket and retrieved a beeper from his pocket, looked at the beeper and then placed it back into his pocket.
- Typed on the computer keyboard and used the mouse again.
- Touched the chair he was sitting in, got up, retrieved paper from the ultra sound machine and took out a pen and wrote on the retrieved paper from the ultra sound machine.
- Typed on the keyboard again, removed his ASCOM phone from his pocket, answered the phone and when finished returned the ASCOM phone back into his pocket.

Staff CCCC did not change his gloves after touching numerous inanimate objects in the room, wore the same pair of gloves when he assisted Staff BBBB with placing the sterile drape over the patient and did not cleanse his beeper or ASCOM phone after touching them with his gloved hands after he had touched several objects in the patient's room.

10. Review of the facility's policy titled, "Dialysis - Infection Control Precautions - Guideline," dated 07/06/15, showed the directive that staff should wear disposable gloves when caring for the patient or touching soiled patient equipment at the dialysis station. Gloves should be removed and hands washed between each patient station.

11. Observation on 01/10/18 from 9:00 AM to 9:45 AM of the Dialysis Care Unit showed Staff NN, RN, Dialysis Nurse touched the following items wearing the same pair of gloves:
- Computer keyboard, mouse, IV pump and dialysis machine for Patient #30.
- With the same pair of gloves, Staff NN touched the hard (paper) chart at the end of the bed, weight controls on the bed that Patient #31 rested in.
- With the same pair of gloves, Staff NN touched the computer keyboard and mouse again.
-Wearing the same pair of gloves, Staff NN wiped her nose with the back of her left gloved hand.
-Staff NN removed the gloves but did not perform hand hygiene and left the Dialysis Care Unit and went to a supply room across from the unit and handled a large bag of solution.

Staff NN did not remove her gloves, did not perform hand hygiene after she touched items from Patient #30's station or before going to Patient #31's station and touched items wearing the same pair of gloves or after she wiped her nose with the back of her left gloved hand. Staff NN removed the gloves but did not perform hand hygiene before she went into a supply room and handled a large bag of solution.

12. Observation on 01/09/18 from 9:00 AM to 9:45 AM on the Dialysis Care Unit showed Staff JJ, RN, Dialysis Nurse:
- Put on gloves and touched Patient #28's dialysis machine, blood pressure cuff, various pillows on the patient's bed, touched the patient's right arm, touched the left arm when she put on the blood pressure cuff, touched the hard chart at the end of the bed and the weight bed controls. Staff JJ removed her gloves but did not perform hand hygiene after removal.
- Without gloved hands, Staff JJ touched the patient's bedrails and placed a blue pad on top of a pillow. Staff JJ then put on a pair of gloves without any prior hand hygiene.
- With gloved hands Staff JJ picked up her stethoscope (medical equipment used to listen to a patient's heart, lung and abdominal sounds) and placed the bell on Patient #28's bare chest. Staff JJ did not clean the bell of the stethoscope before she placed it on the patient's chest or after she finished her assessment.
- Staff JJ put on gloves, programmed the patient's dialysis machine, removed the gloves but did not perform hand hygiene and put on another pair of gloves.

During an interview on 01/12/18 at 2:00 PM, Staff JJ, RN, Dialysis Nurse, stated that hand hygiene should be performed:
- Before and after touching a patient;
- Before and after touching medical equipment;
- Before putting on gloves and after glove removal;
Staff JJ stated that she should have cleaned the stethoscope bell after it came into contact with the patient's bare chest. Staff JJ stated that computer keyboards and mouse are cleaned daily.

During interview on 01/12/18 at 4:25 PM, Staff CCCC, RN, Chief Nursing Officer stated that she expected staff to remove gloves after wiping their nose with gloved hands and staff should perform hand hygiene before putting on gloves, after glove removal and before leaving patient care areas.






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