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Based on observation and interview the Hospital failed to ensure that clean linen was stored by methods that will ensure its cleanliness in the clean linen storage room, the whirlpool room and the linen storage area on the nursing unit in room 105.

Findings include:

Observation 7/1/13 at 10:30 a.m. during initial tour of the hospital the following was observed:

-The clean linen storage room revealed three carts of linen. The linen was not covered. The bottom metal rack did not have a plastic liner to prevent splashes on the linen during mopping of the floors. The ceiling vent was observed covered in dust / lint. A portable fan was observed sitting on the counter with dust on the blades and the face of the fan.

-The whirlpool tub room had towels and sheets on a shelf. The linen was not covered.

-The linen stored on the nursing unit in room 105 revealed a linen cart. The linen cart did not have a plastic liner on the bottom shelf.

The Director of Nursing acknowledged 7/1/13 at 10:45 a.m. that linen should be kept covered.



17028

Based on observation, record review and interview, the facility failed to follow physician's order to hold medication on patients in 1 of 1 in patient observed during drug pass. Patient #1
Findings:
Observation on 07/02/2013 at 9:18 a.m. during drug pass revealed, Licensed Vocational Nurse (J) was observed administering morning medication to patient #1. During the drug pass, Licensed Vocational Nurse (J) administered Norvasc 5 mg one tablet and Lisinopril 20 mgs / Hydrochlorothiazide 12.5 mg to patient #1.
Review on 07/02/2013 of the patient's clinical record located in the computer revealed a physician's order dated 06/29/13 to " Hold blood pressure and diabetic medication. "
Review on 07/02/2013 of the Patient's Medication Administration Record located in the computer, revealed documentation by Licensed Vocational Nurse (J) that she had held blood pressure medication on the patient on 07/02/2012.
The Surveyor informed the Facility's Chief Nursing Officer that she the Surveyor had observed that Licensed Vocational Nurse (J) had administered blood pressure medication on 07/02/2013 during the drug pass.
Interview on 07/02/2013 at 11:05 a.m. with Licensed Vocational Nurse (J) revealed she could not recall if she had administered blood pressure medication to Patient #1.
A review of the discarded medication packet revealed evidence that the patient was administered Norvasc.
Review of the Facility's current Policy and procedure on Medication Administration located in Licensed Vocational Nurse (J) Personnel file directed staff as follows: " When nursing shift change verify the accuracy of medication prior to administering drugs. The medication administration record is a legal record of all drugs administered to the patient. "

Based on observation, interview and record review, the facility failed to operationalize it's policy and procedure to ensure nursing staff wash hands in between removal of contaminated gloves and handling clean supplies; failed to ensure clean supplies were not stored adjacent to sharp containers with contaminated needles and syringes; failed to ensure staff handle trash appropriately and adequately sanitize beds after patient use in 3 of 3 direct care staff observed providing care to patients. Licensed Vocational Nurse (A , J and K)
Findings:
On 07/01/2013 at 11:15 a.m. Licensed Vocational Nurse (A) was observed in room 103, of the medical surgical nursing unit providing care to patient #1. Patient #1 was observed with a dressing in place to her right hip and a Foley catheter in place to bedside drain. Observation at this time revealed Licensed Vocational Nurse (A) removed her contaminated gloves which she used to provide care to Patient #1, held the contaminated gloves in her hand and left the patient's room. She then discarded the contaminated gloves in the garbage can located in the hallway. She then proceeded to open the clean supply cart with her contaminated hands and touched clean items in the cart. Licensed Vocational Nurse (A) then walked over to the emergency room and picked up patient's charts. She did not wash or clean her contaminated hands after removal of the contaminated gloves.
During an Interview with Licensed Vocational Nurse (A) on 07/01/2013 at 11:17 a.m., the Surveyor informed Licensed Vocational Nurse (A) that she did not wash / clean her contaminated hands after removal of her contaminated gloves. Licensed Vocational Nurse (A ) stated. " You are correct. "
Licensed Vocational Nurse (J)
On 07/02/2013 at 9:18 a.m. Licensed Vocational Nurse (J) was observed on the medical surgical unit of the facility administering medication and providing wound care to patient #1. Observation revealed Licensed Vocational Nurse (J) washed her hands and donned a pair of gloves. She then prepared the patient's medication, scanned the patient's arm with the medication scanner then administered oral medication to the patient.
After administering the medication to the patient, Licensed Vocational Nurse (J) removed her contaminated gloves and donned a pair of clean gloves. Licensed Vocational Nurse (J) then set up supplies on the bedside table for wound care. The supplies (4 X 4 gauze dressings and Mepilex dressings) were brought to the patient's room in the nurse's scrub pocket. Licensed Vocational Nurse (J) removed the supply from her pocket and placed it on the bedside table. She removed the Mepilex dressing from its wrapper. The Mepilex dressing fell to the floor. Licensed Vocational Nurse (J) picked up the dressing and placed it on the bedside table. Licensed Vocational Nurse cleaned the patient's wound with Sterile Water obtained from a bottle of 1000 mls sterile water. Licensed Vocational Nurse (J) then applied the contaminated Mepilex dressing that had fallen to the floor unto the patient's sacral wound.
After completing the dressing to the patient's wound, Licensed Vocational Nurse removed her contaminated gloved, picked up the bag containing the patient's medication and wound ointment and left the room. She did not wash or clean her hand after administering medication and providing wound care to the patient. She then entered the clean supply cart which contained syringe needles with her contaminated hands.
During an interview on 07/02/2013 at 9:30 a.m. with Licensed Vocational Nurse (J), the Surveyor informed her that she did not wash/ clean her contaminated hands after removing her contaminated gloves and that she had used the dressing that had fallen to the floor to dress patient #1's wound. She stated " OK "
Review on 07/02/2013 of the facility's Policy and Procedure on Hand washing / Decontamination revised 01/25 13 directed staff as follows " Personnel are expected to wash hands at the following times: " Before and after direct contact with patient's blood, body fluid, mucus membranes, non- intact skin, glove use and objects which are likely to be contaminated."
Clean and dirty
Review of the facility's current Policy and Procedure on Standard Precautions and Transmission Based Precaution. ( The policy was not dated ) directed staff as follows: " Handle used patient care equipment soiled with blood, body fluids secretions, excretions, in a manner that prevents skin and mucus membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments. "
On 07/1/2013 at 10:10 a.m. during initial tour of the Facility's Blood Draw Room, revealed a red sharp container with used syringes and needles was observed stored on a shelf. The outside of the sharp container had droplet of dried blood. Stored immediately beside the sharp container were the following items: Clean / sterile 2 x 2 gauze, needles and syringes. The Facility's Chief Nursing Officer was present during the observation. The Surveyor informed the Chief Nursing Officer of her observation.
On 07/1/2013 at 10:30 a.m. during initial tour of the Facility's CAT scan room, revealed a red sharp container with used syringes and needles was observed stored on a shelf. Stored immediately beside the sharp container were the following items: Clean/ sterile 2 x 2 gauze, needles, and syringes and with Normal Saline. The Facility's Chief Nursing Officer was present during the observation. The Surveyor informed the Chief Nursing Officer of her observation.



17028


Staff K

Observation on 7/2//2013 at 2:10 pm in the Emergency Room (ER) revealed Staff (K)housekeeping staff was emptying garbage bins in the ER without wearing gloves. The Staff put on gloves after the surveyor talked to her, after collecting the trash Staff (K) went into the clean linen cupboard retrieved a wash cloth, wet the cloth with disinfectant and used the wash cloth to clean the surface of the mattress on the treatment bed. She changed gloves did not wash her hands before going to the clean linen supply cupboard and removed clean linen.
During an interview on 7/2/2013 at 2:32 pm with Staff (K) she stated she was aware gloves should be worn but she was rushing.

Review of policy for Cleaning of patient room after discharge dated 5/14/2012 documented the following information :

"Strip the patient bed and remove soiled linen. Disconnect bed from wall receptacle. Wash the top of the mattress then the bottom of the mattress. Clean the sides frame and spring. Wash side rails headboard and foot board. Make bed.
Review of the housekeeping manual revealed gloves was only mentioned for the cleaning up of blood and body fluid spills".

Review of the facility ' s infection Control policy/procedure manual dated 2012 under Standard Precautions (# 2) documented staff should:
"Wear gloves (clean non-sterile gloves are adequate) when touching blood, body fluids, secretions and contaminated items. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient".

During an interview on 7/3/2013 at 8:45 am with the Chief Nursing Officer/Infection Control Director she stated the used ER beds should be cleaned as for any used bed in the facility. The CNO stated she had not reviewed the housekeeping manual so she was not sure there was a requirement for staff to wear gloves.

Based on record review and interview the facility failed to develop policy/procedure to ensure the quality of food service in the facility.

Findings:

Review of the facility ' s food service agreement with a Nursing Home dated December 2010 revealed documentation that "food service shall consist of breakfast, lunch, and dinner as well as drinks and snacks".

Review of dietary policy dated 6/6/2013 revealed the policy did not include the following information:

System for ordering meals from the contract provider and for providing late trays, frequency of food service and inspection to ensure the quality of food received from the provider. There was no documentation of the required training for staff handling food in the facility.

Review of personnel record revealed no evidence of training for the food service manager and other food service staff at the facility.

The Diet Manual provided by the facility was not reviewed since September 2006.

During an interview on 7/2/2013 at 10:15 am with the Chief Nursing Officer (CNO) she stated she was the Director of Food Service in the facility, but she did not have any food service training or experience. She stated the facility did not liaison with dietary staff at the providing facility as often as they should and there was no documentation that quality monitoring was done for food service.

Based on interview and record review the Hospital failed to ensure that the contracted Dietary department was evaluated as part of their Quality Assurance program in 2012 and 2013.

Findings include:

Record review of Quality Assurance meeting minutes for 2012 and 2013 revealed no discussion or quality indicators established for the Dietary department.

The Director of Nursing (D.O.N.) acknowledged 7/2/13 at 8:30 a.m. the Dietary department is a contracted service from the neighboring nursing home. The DON stated that the quality of food was monitored about 1 1/2 years ago due to food complaints but the data was not documented in the quality assurance meeting minutes. The DON stated that food is brought over in a container from a nursing home next door. The hospital could not demonstrate that food temperatures were monitored or quality indicators were established for the dietary department.

Record review of a policy titled "Process Improvement Plan" dated 4/2012 stated "Quality Indicators: B.) Maintain appropriate quality control programs including, but not limited to, the following:
1. Laboratory
2. Dietary (not operating at this date 5/10)
3. Radiology
Etc..."