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Based on observation, interview and record review; the facility failed to ensure for one of one patient, #63, that restraints were implementation with safe techniques.

Findings:

During the observation on 09/08/2015 at 3:50 PM; I observed patient # 63 lying in bed with the head of the bed to be raised at ~ 45 degrees but the patients ' body had slid down with his head elevated at ~ 25 degrees. The patient had a Dobhoff tube placed in his right nares from which he was receiving nutrition. I observed the patient with 3 restraints; two soft wrist restraints on each wrist and on his right ankle; one soft ankle restraint. During observation; I observed his left hand to be bound tightly to the bed. I inspected the restraints application and found the restraints were applied to the non-moveable part of the bed frame and the restraint did now allow for room for the patient to be moved higher in the bed, this position placed the patient at risk for aspiration. I asked his nurse, employee (V) if she could place her fingers underneath the left wrist restraint; she walked around the bed and untied the left wrist restraint and placed her fingers under the restraint. I asked her if she thought the restraint was attached properly and she responded; yes, I tied it to the frame so it does not move.
Beginning on 09/08/2015; I conducted a chart review for patient # (63) and reviewed the physician orders. The order read to apply bilateral soft wrist restraints and to release every two hours and PRN for range of motion and care. The reason documented show the reason to prevent the patient from pulling out the tubes necessary for treatment; during the record review; an order written on 09/06/2015 at 12 PM show an order for the right ankle restraint to be discontinued. On 09/08/2015 at 4:04 PM I conducted an interview with employee (V). During the interview she confirmed receiving report from the prior shift and knew the patient did not have an order for the ankle restraint. During the interview; she stated he needs it though because he moves his foot around and it hits the side rails. During the interview; she confirmed she should have contacted the doctor for an order and stated she was going to do that immediately. During the interview she confirmed she had received training on how to properly apply restraints.

Based on observation interview and record review, the facility failed for one of one patient, #63 to use restraints in accordance with physicians orders.

Findings:

During the observation on 09/08/2015 at 3:50 PM; I observed patient # 63 lying in bed with the head of the bed to be raised at ~ 45 degrees but the patients ' body had slid down with his head elevated at ~ 25 degrees. The patient had a Dobhoff tube placed in his right nares from which he was receiving nutrition. I observed the patient with 3 restraints; two soft wrist restraints on each wrist and on his right ankle; one soft ankle restraint. During observation; I observed his left hand to be bound tightly to the bed. I inspected the restraints application and found the restraints were
applied to the non-moveable part of the bed frame and the restraint did now allow for room for the patient to be moved higher in the bed, this position placed the patient at risk for aspiration. I asked his nurse, employee (V) if she could place her fingers underneath the left wrist restraint; she walked around the bed and untied the left wrist restraint and placed her fingers under the restraint. I asked her if she thought the restraint was attached properly and she responded; yes, I tied it to the frame so it does not move.
Beginning on 09/08/2015; I conducted a chart review for patient # (63) and reviewed the physician orders. The order read to apply bilateral soft wrist restraints and to release every two hours and PRN for range of motion and care. The reason documented show the reason to prevent the patient from pulling out the tubes necessary for treatment; during the record review; an order written on 09/06/2015 at 12 PM show an order for the right ankle restraint to be discontinued. On 09/08/2015 at 4:04 PM I conducted an interview with employee (V). During the interview she confirmed receiving report from the prior shift and knew the patient did not have an order for the ankle restraint. During the interview; she stated he needs it though because he moves his foot around and it hits the side rails. During the interview; she confirmed she should have contacted the doctor for an order and stated she was going to do that immediately. During the interview she confirmed she had received training on how to properly apply restraints.

Based on observation and record review the facility failed to ensure that for 1 of 2 endoscopic procedures observed the facility failed to appropriately maintain controlled medications.

Findings:

Observation on 09/09/2015 at 11:06 AM during a endoscopy performed on patient #64 at Shands Endoscopy Center revealed the Certified Registered Nurse Anesthetist, (CRNA), hold up two syringes and state to the nurse on the other side of the room "I'm wasting Propofol and Fentanyl". The CRNA the reached into a large needle container located on the floor away for view of any one in the room and injected the medications in the container. Review of the Omnicell records following the procedure revealed that the medication wasting was documented by both the CRNA and Circulating Registered Nurse but record failed to document the amounts of the medications wasted for either of the two medications..

Based on observation, interview and facility policy review, the facility failed to secure and lock 1 of 2 medication carts containing drugs and biologicals in the Rehab Hospital, and failed to lock and secure 2 of 4 medication carts containing drugs and biologicals on 10 - 4 PICU step down unit. .

Findings:

Observation on 9/9/2015 at 9:42 AM in the Rehab Hospital revealed a medication cart that was unlocked and parked outside the nurses ' station. There are several unit dose medications in every patient ' s drawers including antibiotics, Lasix and ointments noted. The medication cart is parked in the hallway where visitors, other patients have access to. Observed a nurse standing at the nurses ' station with his back facing the unlocked medication cart. The Director of Nursing confirmed that the medication cart was unlocked on 9/9/2015 at 9:43 AM and she immediately pressed the button to lock the medication cart.
Interview with the Rehab unit charge nurse, (Staff D) on 9/9/2015 at 2:05 PM stated that there are individual medication cart in the rehab unit and one cart in Zone 1 that is being accessed by multiple nurses. Staff D stated that the cart is always parked outside the nurses ' station in the hallway because the medications are given to patients when they come to eat in the main dining room. Charge Nurse stated that the nurse who last used the medication cart is responsible to secure and lock the cart back in.
Charge nurse and surveyor tested the locking mechanism of the cart on 9/9/2015 at 2:03 PM. Charge Nurse unlocked the cart and timed at 4 minutes 20 seconds for the cart to secure itself.

Observation on 9/11/2015 at 2:30 PM on 10-4 PICU step down unit revealed a medication cart that was unlocked and unsupervised in the hallway. The Clinical Leader and Unit Assistant of 10-4 PICU confirmed that the medication cart was unlocked at 2:31 PM. Surveyor was able to pull out all 6 drawers containing drugs and biologicals. The medication cart was observed with numerous needles, syringes, pre-filled heparin syringes in 3 different dosages, prefilled normal saline syringes, normal saline unit dose, several bottles of blood culture solutions, and other laboratory tubes with different solutions. Interview with the Clinical Leader and Unit Assistant on 9/11/2015 at 2:32 PM stated that the medication cart has a locking mechanism.

At 2:32 PM, observed a flashing red light on the cart and Unit Assistant stated that the battery needs replacement and summoned someone to replace the batteries. Clinical leader stated that there are 4 medication carts on the unit. Unit Assistant stated that nurses, doctors, support technicians, critical care team has access to the medication carts.
Further observation of medication cart # 4 at the opposite end of the hallway on 10-4 PICU at 2:35 PM revealed the cart is parked in the hallway, unlocked and unsupervised. Surveyor was able to pull out all 6 drawers containing drugs and biologicals. There are visitors and other ancillary personnel walking in the hallway. Observed the contents of the medication cart and is identical to all the medications / supplies observed in the first medication cart.

Review of the UF health Shands Core Policy and Procedure titled Medication Storage provided by the Rehab Hospital Director of Nursing on 9/9/2015 at 2:00 PM has a Policy # CP02.064 approved by the Chief Medical Officer and digitally signed on 3/26/2015. digitally signed and approved by the Chief Executive Officer on 4/14/2015.
Page 2 of 2 of the policy reads: item # 4 - Mobile nursing carts, anesthesia carts, epidural carts, and other medication carts containing drugs or biologicals must be locked when not in use. Under B - Secure Area -reads an area where drugs and biologicals are stored in a manner to prevent unmonitored access by unauthorized individuals.

Based on observation, staff interviews and record review the facility failed to ensure that consistently implement infection control measures.

Based on observations, interviews and facility policy review, the facility failed to maintain a sanitary hospital environment; facility staff failed to exhibit hand washing hygiene; failed to monitor compliance with infection control program requirements; failed to monitor compliance with policies, procedures, protocols and other infection control program requirements.


Findings:

1. Observation on 09/09/2015 at 9:10 AM at Children's Surgical in the pre-operative area of patient #62 revealed an Anestheologist performing an assessment of the patient. The Anestheologist was observed with a stethoscope around his neck. Attached to the stethoscope was a cloth stuffed bear that was approximately 4 inches long. The Anestheologist was observed using the stethoscope to listen to the patient's heart and lung sounds.

2. Observation on 09/11/2105 at approximately 10:35 AM in the GI endoscopy suite located in the South Tower revealed that patient #73 was position and ready to undergo a colonoscopy. The physician was note to have gowned and gloved for the procedure when he observed the foot pedal located next to the cart to be upside down and somewhat tangled with other wires/cables. He was observed to reach down with his right gloved hand, untangle the the food pedal and place the foot pedal upright. He was then observed to contaminate the endoscope by grasping the endoscope with his right hand about half way between the tip of scope and the handle. The scope was then inserted in the patient and the colonoscopy was completed.

3. Observation on 09/11/2105 at 10:50 AM and again at 11:00 AM in the GI endoscopy suite located in the South Tower revealed the Anestheologist to remove his gloves and replace them with clean gloves without sanitizing between glove changes.

4. During an observation surgical procedure on patient # (64) on 09/08/2015 at 12:58 at Shands surgical center (endo) the surgical tech (X) was observed walking away from the sterile field and picked up a package that fell on the floor then she placed it on the shelf with all the other packages and returned to her area without washing her hands or donning new gloves. She proceeded back over to the sterile area and held the endoscope for the surgeon using the hand she picked up the dirty package off the floor with. During the procedure the surgeon obtained three specimens for biopsy. .

5. On 09/08/2015 at 1:40 PM; I arrived at Shands orthopedic surgical center. During the observation the anesthesiologist was observed touching equipment; the patient and the computer screen. At 2:45 PM; I observed him walking over to the medication cart and changing his gloves prior to retrieving medication from the medication cart located on the right side of the room, he failed to sanitize his hands prior to donning new sterile gloves. After preparing the medication; he walked over the IV port and administered the medication without " scrubbing the hub " with alcohol.

6. Beginning on 09/10/2015 at 9:40 AM; Employee (S) obtained permission for me to observe a dressing change and medication administration. I conducted an observation of patient # (69) receiving a PICC dressing change. The dressing was visibly intact with blood drainage observed under the transparent part of the dressing. Employee (S), proceeded to wash her hands and don clean gloves and mask; she handed a clean mask to the patient to put on, she opened her sterile dressing change kit placing it within her site and placed a clean towel towards the foot of the bed. She removed the soiled dressing and removed the soiled gloves. Without sanitizing or washing her hands she donned the sterile gloves and proceeded to clean the area with chlora prep pre filled sponges from the kit and allowed the area to air dry. During an interview with employee (S); she stated " I know I am supposed to wash my hands before donning sterile gloves " but we do not have any since they took the pump bottles off the floor. During an interview with the unit manager at 10:00 AM; she confirmed there are no there sanitizing measures except the dispensers on the walls and sinks. She stated she would approach the Infection control team regarding this matter and stated they could customize the kits to contain hand sanitizer in them.

7. Beginning on 09/11/2015 at 9:00 AM I returned to 8 East the inpatient chemo unit where the nurse had stated she had no means to sanitize her hands prior to donning sterile gloves. Upon arrival to the unit; I observed no additional sanitizers. The unit manager (T), joined me and stated she was going to get with the infection control team and come up with a solution. I informed her that the outpatient unit ha bottles of Purell at each patient station. She immediately requested someone from the floor to retrieve some for temporary use. During the interview she confirmed there was a total of 7 patients who received PICC line dressing changes yesterday on 09/10/2015; during the interview she state some of the nurses were removing the dressing and washing their hands prior to opening their sterile field, her concerns were voiced as she confirmed her fear that the PICCs would become dislodged unattended. An interview was conducted with the infection control manager (L) at 9:30 AM during the interview she was able to explain the processes in place to ensure safety and infection control and stated the unit holds weekly meetings and concerns are brought to the monthly meetings which then goes to the medical board for approval. She did confirm concerns regarding the removal of the pump bottles from the bedsides have not been discussed.



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16. Observation on 09/10/15 at 10:40 AM showed patient # 99 , on Pediatric medical/Surgical unit (45) that door to room 4413, had two signs on the door that stated patient had enhanced contact precautions and droplet precautions. The sign that had droplet precautions was placed on the door, near the bottom of the door. Both signs were easy to read and had large print on them. Two staff members, identified as part of the Stat team, who were at this patient ' s room, to put IV (intravenous) line in the patient. Both Staff members put gowns on and gloves, but not masks. Primary RN (registered nurse) and clinical leader, were at the door to the patient ' s room, and allowed both staff members to enter the room without masks.

During an interview on 09/10/15 at 11:03 AM, Staff P ( RN ) , states that with this patient, gown, gloves and mask is needed to be put on before entering the room. Staff P, states that droplet precautions are done on all patients, to rule out a virus and are waiting at this time for those results.

During an interview on 09/10/15 at 11:14 AM, Staff 0, Clinical leader, states that her expectation is that any child on droplet precautions, all staff should be putting a mask on, when enter the room. All nurses on the pediatric floor and in the hospital have training in isolation procedures.

During an interview on 09/10/15 at 11:37 AM, Staff Q and R, both staff members who are RN ' s, did not see the sign on the door to room, because not at eye level, when went into the room.

Review of patient # 99, medical record showed, that on the banner (Top Area of the Chart which has name of the patient, and in red precautions). There was a lab note that showed patient did have an infection and that droplet precautions should be maintained.

Record review of the facility ' s policy titled " Mandatory education for all Shands personnel policy number CPO1.031, General Administrative " . All personnel shall receive education and training in the following areas as part of their initial orientation, which includes infection control.

17. Observation on 09/11/15 at 10:41 AM, showed patient # 94, on 5W Trauma and general surgery Unit (51). Patient # 94, IV (Intravenous) site on left arm, had dressing on, but no initials or date and time on the site.

During an interview on 09/11/15 at 10:45 AM, Staff X, clinical leader of unit 5W, states that there should be date, time and initials of the person, who put the IV in.

Review of patient # 94, medical record on 09/11/15 at 10:55 AM, shows that on 09/10/15, the IV was started.

Record review of the facility ' s policy titled " IV therapy: Peripheral Access Policy " , dated 07/05/15, showed that all IV dressings are to be labeled with date, time and initials of the person performing the procedure.




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15. On 09/10/2015 at 11:15 AM Staff I was observed performing glucose monitoring for patient #39. During the procedure Staff I touched the table with the equipment, touched the patient with her gloved hands and picked up the glucose meter with her gloved hands. After performing the procedure Staff I removed her gloves, used hand sanitizer,and left the room. She went to the nurse's station and returned the glucose monitor into the docking station without cleaning it.
An interview with Staff I on 09/10/2015 at 11:17 AM revealed she cleans the Accucheck after going into isolation rooms.
Review of the policy/procedure Number: BT-004 dated March 2015 Titled Bedside Blood Glucose Monitoring with the Acc-cheek Inform II Glucose Meter revealed:
The glucose meters should be cleaned, then disinfected after use on each patient with a Sani-Cloth Plus Germicidal Disposal Cloth. All surfaces should be thoroughly wiped with the disinfecting wipe, avoiding the strip port area and the connector. Allow the meter to air dry between each use. The meter should be placed on a flat surface while wiping over the strip port area, making sure that no liquid enters the strip port. Before downloading on the base unit, ensure that the meter (including connectors) is thoroughly dry after disinfecting.
Review of the Point of Care policy/procedure Number: POC-01-021 Dated Jan 2014 revealed:
The Accu-Check Inform II meter is used for monitoring blood glucose levels in hospitals and ambulatory practices.
21. Clean and disinfect after each use. Remove gloves and return meter to its docking station. XIII. Maintenance Policy and Procedure
At a minimum, clean and disinfect the meter after each new patient use and when soiled with Sani-Cloth.

16. On 09/08/2015 at 12:00 PM Patient #32 was observed with an IV (intravenous) of 0.09 % normal saline with approximately 700 left in the bag. She had a catheter on the right dorsal hand with no labeling to indicate when it was put in. An interview on 09/08/2015 patient #32 revealed she came in Sunday through the emergency department about 3 AM. The IV was started in the emergency department. .
On 09/08/2015 at 12:05 PM an interview with Staff J, charge nurse revealed a saline lock is changed after 72 hours. It should be labeled with a date and time. If it becomes soiled it would be changed and an occlusive dressing put on and a label. He confirmed there was no date or time or label on the catheter. He further stated the IV tubing should be labeled when hung. He confirmed there was no label.
On 09/10/2015 at 11:15 patient #39 was observed with an IV access on the left forearm and another IV access on the right forearm with no label indicating the date they were put in.
On 09/10/2015 at 11:24 AM an interview with patient #39 revealed the IV access on the right forearm was put in at another hospital before being transferred to this location. The IV access on the left forearm was put in the emergency room here 09/08/2015.
An interview on 09/10/2015 at 11:27 AM with Staff L revealed the IV sites should be changed if not dated when patient comes with it.
Review of patient #39's record showed: 09/08/2015 showed a 20 gauge IV access in the left forearm and on 09/08/2015 a 20 gauge right forearm.
On 09/08/2015 at 11:58 AM Employee K, charge nurse, confirmed there was label indicating the date the IV's were started.
On 09/10/2015 at 10:30 AM patient 3100 was observed with an IV access was observed with an IV access to the right forearm with no label.
On 09/10/2015 at 10:33 AM, Staff M stated she put IV in yesterday. No label on IV site.
On 09/10/2015 at 10:34 AM Employee N revealed nurse should have labeled IV when started.
Review of patient #39's chart showed a 22 gauge saline lock was placed on the right forearm on 9/9/15 at 2:05 PM.
Review of the Policy Number: IV-VA-003. Category: IV access dated July, 2014
Titled: IV Therapy: Peripheral Access Policy
XX: Label all IV dressings with date, time and initials of person performing the procedure.
XXII. Peripheral IV's placed in the field should be labeled " Field " on the IV dressing, " EMS " in the electronic medical record (EMR) or " PTA " (Prior to Arrival) on the Trauma Flowsheet. These IV's should be changed within 24 hours of arrival to the hospital. An IV should be considered " field " placed when it is placed in an out of hospital setting where sterility cannot be confirmed.


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8. Tour of the 64 Medicine floor with Staff B, Clinical Leader on 9/8/2015 at 12:13 PM revealed the soiled utility room floor is sticky, with dark brown discolored spots / stains noted all over the floor. There are dirty food trays on a rack. Clinical Leader confirmed that the floor is dirty on 9/8/2015 at 12:14 PM and stated that the room is cleaned daily.

9. Observation on 9/9/2015 at 8:00 AM revealed the bathroom in the main lobby of the Rehab Hospital has numerous debris cluttered on the floor, papers on top and around the toilet bowl and on top of the sink. The toilet was not flushed with feces on it. Administrator was notified and stated it will be cleaned immediately.

10. Observation on 9/9/2015 at 9:41 AM at the Rehab Hospital revealed Staff E, Patient Care Assistant (PCA) was passing water in the rehab unit hallway beginning from room 1908 to room 1921. The PCA has a portable cart with 11 pitcher liners filled with water and ice that has no protective covers.
Interview with Staff E, Patient Care Assistant (PCA) on 9/9/2015 at 1:55 PM stated that she worked here for three years on the day and evening shift. PCA stated that she passes fresh water at the beginning of her shift using a clean liner. She goes to the ice machine, takes a new pitcher liner and fills it up with water and ice then rolls the cart to the rehab unit without a cover. She goes room to room, removes the old liner from the pitcher in the patients ' room and replaces it with the new liner.

11. Observation on 9/9/2015 at 2:49 PM revealed Staff A, Phlebotomist attempted x 3 to obtain a venipuncture on Patient # 30 ' s left antecubital arm but was unsuccessful. Phlebotomist used a butterfly needle to access the vein on the patients left arm for the third attempt but was unsuccessful. Phlebotomist placed all three (3) used butterfly needles on top of the lab cart, placed all used alcohol swabs, used gauze, and used butterfly needles on top of the lab cart that has no barrier. Phlebotomist failed to change her gloves or perform hand hygiene in between procedures with the same patient during these three venipuncture attempts.

Review of the facility hand hygiene policy provided by the Rehab Hospital Director of Nursing on 9/9/2015 at 4:12 PM digitally approved by the Chief Executive Officer on 5/15/2015 reads on page 2 of 3 reads: Hand Hygiene is required between procedures on the same patient. Interview with the DON on 9/9/2015 at 4:20 PM stated that hand hygiene is specific to the use of Purell hand sanitizer. DON confirmed that Phlebotomist failed to place the sharps directly to the sharp container located on the side of the lab cart. Interview with the Phlebotomist on 9/9/2015 at 4:32 PM stated and confirmed that she did not place a barrier on top of the lab cart, confirmed that she failed to perform hand hygiene in between 3 intravenous attempts with the same patient. Phlebotomist was unaware to place a barrier and to perform hand hygiene in between procedures with the same patient.

12. Observation on 9/10/2015 at 9:15 AM on 65 medicine floor revealed the soiled utility room with paper debris on floor, observed a large area of red colored stain on floor and dark brown discoloration stains on floor. Staff C confirmed the observation at 9:15 AM and stated will have it cleaned immediately.
At 9:21 AM room 6520 , observed with over flowing trash cans over the rim of the trash can.
At 9:23 AM room 6526 2 trash cans overflowing with trash and used personal protective equipment i.e. yellow gown. Observed pieces of debris of a disposable yellow gown are scattered on the floor. The Clinical leader, Staff G on 9/10/2015 at 9:25 AM confirmed the overflowing trash cans and stated; " we will get it emptied right away " .

Unit Manager of 65 Medicine stated on 9/10/2015 at 9:33 AM that there is a designated housekeeping staff responsible for cleaning the floor, the soiled utility room and there is a different group of staff responsible for pulling trash from all the rooms.

Interview on 9/10/2015 at 9:40 AM with Staff H, Environmental services aide stated she worked here for 4 years. When asked how often does she cleans or mops the soiled utility room, she replied, " whenever I can, most times I cannot get to it " The last time I checked and cleaned the room was last Tuesday (9 days ago). Sometimes I get pulled off the floor to a different floor to do something else. When there is a discharge, I clean that room first. Staff H stated that she is responsible for the entire floor (24 rooms) and she also pulls all the trash from the rooms.

13. On 9/10/2015 at 10:14 AM in 55- Vascular / EENT floor revealed in room 5508 an overflow of personal protective equipment (PPE) of a red isolation barrel with yellow gowns hanging off the barrel, paper debris on the floor around the patients bed and three soiled anti-skid socks on the floor near the trash can. Nurse Manager confirmed the condition of the room at 10:15 AM.

14. Observation on 9/10/2015 at 10:18 AM revealed 4 open and unused needles and 3 opened syringes, alcohol preps and other intravenous supplies were observed on top of the computer on wheels (COW) that was unattended in the hallway near room 5508. Nurse Manager of 55 Vascular/EENT floor confirmed these observations on 9/10/2015 at 10:18 AM and stated; " these should not be there " . Nurse Manager moved the COW to a different location.