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Based on observation, interview and document review the facility failed to ensure nursing staff followed their policy and procedure for labeling and dating Intravenous (IV) medication solutions and IV tubing that was in current use for 2 patients (#'s 13 and 14) of 3 patients observed during observations, resulting in the potential for less than optimal outcomes for patients (#'s 13 and 14). Findings include:

On 12/2/19 at 1030 while accompanied by Nurse Manager Staff J patient #13 was observed in bed. The patient did not respond to verbal command when prompted. An IV pump was observed with an IV solution labeled Heparin (medication used to reduce the risk of blood clots) that was infusing via pump via secondary IV tubing. Additionally, there was an IV solution of Sodium Chloride (NaCl) that was observed in current use. There were no dates on the IV solutions nor on the IV tubing's that documented when the bags were spiked, nor when the IV tubing's were hung. There was a Green sticker on the (NaCl) solution that was not dated but read: "Change Tuesday".

On 12/2/19 at 1045 while accompanied by Nurse Manager Staff J patient #14 was observed in bed. The patient was hard of hearing. An IV pump was observed with an IV solution labeled Zosyn (medication used to treat infections) that was infusing via pump via secondary IV tubing. Additionally, there was a primary IV solution bag of Sodium Chloride (NaCl) that was observed in current use. There were no dates on the IV solutions nor on the IV tubing's that documented when the bags were spiked, nor when the IV tubing's were hung.

On 12/2/19 at 1100 Staff J was queried regarding the facility's policy for labeling and dating IV solutions and IV tubing. At that time Staff J confirmed that her nursing staff should have labeled and dated the IV solutions and IV tubing when spiked for all patients.

A review of the facility's policy titled "Intravenous Therapy (IV)", last revised date 12/2018 documented:
Policy:
Solutions expire 24 hours after spiking. Document in the medical record when each IV fluid bag is spiked and/or hung.
IV tubing changes:
Label IV tubing with next date tubing is due to be changed (stickers may be obtained from Pharmacy), unless specified by unit policy...Replace primary IV tubing no more frequently than 96 hours and immediately upon suspected contamination or compromise...Tubing used for intermittent infusion through an injection/access port should be changed every 24 hours.

Based upon observation, interview and record review the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes for all patients up to and including death in the event of a fire. Findings include

See the individually and below cited K-tags dated December 5, 2019.
K-0223
K-0321
K-0353
K-0781
K-0914

This citation has multiple deficient practice statements

Deficient Practice Statement (DPS) 1

Based on observation, interview and record review the facility failed to 1) ensure 6 staff (MM, NN, OO, PP, QQ, and RR), of 8 staff observed in the cardio/vascular lab and the operating surgical areas, wore appropriate operating room personal protection equipment (caps, bouffant) according to nationally recognized guidelines and standards and 2) failed to ensure 2 staff (SS and YY) of 4 staff observed in the cardio/vascular lab area performed hand hygiene before and after glove changes according to facility policy, resulting in the potential for transmission of infectious agents for the 28 patients receiving surgical services at the time of the observations. Findings include:

During observations on 12/3/19 between 0900 and 1030 with the Surgical Director staff P and the cardio/vascular lab Manager staff O in the operating and cardio/vascular lab monitoring areas the following was observed:

At 0920 staff OO (registered nurse) was observed in the cardio/vascular lab monitoring area wearing a skull cap with short hair at the nape of the neck, and moderate length sideburns and beard exposed.

At 0930 staff PP (cardiologist) was observed in the cardio/vascular lab monitoring area wearing a skull cap that covered the short hair at the nape of the neck but exposed sideburns and beard.

At 0945 staff RR (certified registered nurse anesthetist) was observed in the cardio/vascular lab operating area while setting up for the next case wearing a skull cap with short hair at the nape of the neck, sideburns and beard exposed.

At 1010 staff QQ (registered nurse) was observed in the cardio/vascular lab operating area wearing a skull cap with short hair at the nape of the neck and sideburns exposed.

At 1010 staff OO (registered nurse) was observed in the cardio/vascular lab operating area wearing a skull cap with short hair at the nape of the neck and sideburns exposed.

At 0930 staff SS and YY (registered nurses) were observed in the cardio/vascular lab operating room during breakdown and cleaning of the operating suit to don and remove gloves multiple times without performing hand hygiene. Additionally, staff SS was observed to remove gloves exit the lab operating room, remove lead apron, and return to lab operating room, don new gloves and continue to clean the room.

During observations on 12/3/19 between 1030 and 1140 with the Surgical Director staff P in operating room #1 the following was observed:

At 1100 staff MM (certified registered nurse anesthetist) was observed in operating room #1 wearing a skull cap with short hair at the nape of the neck and sideburns exposed.

At 1110 staff NN (surgical scrub technician) was observed in operating room #1 wearing a bouffant cap over a cloth covering with the cloth covering exposed on the forehead.

On 12/3/19 at 1030 staff P (surgical director) stated "My understanding is skull caps can be worn as long as it is in my policy."

The CMS response letter dated 4/24/14 documented, . . ."Skull caps are not permissible since it fails to contain the side hair above and in front of the ears and hair at the nape of the neck."

The CMS (Center for Medicare and Medicaid Services) response to the American College of Surgeons OR Attire Statement dated 9/2016 documented: "The CMS Hospital Patient Safety Initiative drafted an Infection Control Worksheet (ICW) in order to determine compliance with Infection Control Conditions of Participation (CoP). The ICW (page 46), states, "Surgical attire (e.g. scrubs and surgical caps/hoods) covering all head and facial hair are worn by all personnel and visitors in the semi-restricted and restricted areas.' . .'The support for this item included on the Hospital ICW comes from the current 1999 CDC HICPAC SSI Guidelines, [Wear a cap or hood to fully cover hair on the head and face when entering the operating room]. . .'The following agencies/organizations have adopted the requirement of full head covering for surgical personnel: CDC-HICPAC Surgical Site Prevention guidelines (1999). OSHA-Prevention of Bloodborne Pathogens Final Rule (2001). WHO-Guidelines for Safe Surgery (2009). AST (Association of Surgical Technologists)- Standards of Practice (2007). AORN-2015 Guidelines for Peri-operative Practice.' . .'The surgical team members are responsible for preventing SSI by properly donning and wearing the appropriate head cover or hood. 1. The surgical head cover or hood should . . .cover all head and facial hair. . .3. Net caps, or skullcaps that do not offer complete hair cover should not be worn in the surgical suite.' . .'AORN has the following evidence supporting Recommendation IV that, [All personnel should cover head and facial hair, including sideburns and nape of the neck, when in the semi-restricted areas]."

Review of the facility policy G.3 titled "Attire in the Surgical Services Unit" dated revised 2/13/19 documented the following: "Skull caps maybe worn if the person wearing has limited hair on nape of neck and modest sideburns."

Review of the facility policy 1.4.4 titled "Hand Hygiene Policy" dated revised 1/19 documented the following: "Perform hand hygiene. . .D. Before donning sterile gloves. . .H. After removal of gloves."






32000

DPS 2

Based on observation, interview, and record review the facility failed to ensure sanitary conditions in the kitchen, resulting in the increased potential for cross contamination of food, foodborne illness and transmission of infectious agents potentially affecting 78 residents who receive meal services out of the facility's total census of 128 (50 nothing by mouth residents, or NPO). Findings include:

On 12/2/19 during a dietary tour of the kitchen 10:50 AM- 2:27 PM, the following observations, interviews, and record review took place:

1. On 12/2/19 at 10:55 AM, a single use item (cardboard) with visible staining and debris was observed being re-used as a sign underneath the beverage dispensing station near the retail service area of the kitchen. Upon observation the surveyor inquired with the Certified Dietary Manager, staff Q, on the purpose of the sign to which they replied, "it's for our flower deliveries in the cafeteria". On 12/2/19 at 11:25 AM, five cardboard containers with visible staining were observed being used for pop can recycling bins in the kitchen's dishwashing area. Upon observation the surveyor inquired with staff Q, on how the facility would clean a surface like cardboard to which they replied, "you really can't, we would have to just toss them and replace them".

2. On 12/2/19 soiled and debris covered non-food contact surfaces were observed at the following times and locations:

At 11:25 AM, on the flooring and on the exterior surface of a transport cooler in the meal cart storage/ pop can recycling area of the dish machine room.

At 11:25 AM, on the bottom seal of the supplement refrigerator.

At 12:36 PM, on the wall surround at the serving line's knife station.

At 12:55 PM, on the exterior of the fryer. At this time the surveyor requested the kitchen's daily cleaning logs for the last two weeks to review from the Certified Dietary Manager, staff Q,.

At 1:35 PM, on the exterior surface of the plastic wrap station in the retail prep area.

At 1:41 PM, on the floor in the walk-in freezer.

At 2:10 PM, on the basement dry storage room's flooring and on multiple exhaust and supply ventilation grates. On 12/2/19 at 2:12 PM, upon interview with staff Q and Executive Chef staff, R, on who is responsible for the cleaning of the exhaust and supply ventilation grates they stated, "Maintenance, and I'd have to talk to maintenance for information about the filters". Staff R then added, "after every delivery we are supposed to be cleaning the floors, but it's obviously not getting done".

On 12/2/19 at 2:26 PM, upon interview with staff Q on the status of the kitchen's daily cleaning logs for the last two weeks to review they stated, "they can't pull up anything recent. They check, but they don't write it down".

3. On 12/2/19 at 12:09 PM, record review of the facility's cooling logs revealed that on 10/28/19, chicken, on 11/4/19, brisket, and on 11/5/19, turkey, were all placed in cooling equipment, however no additional temperature verification with corresponding documentation was observed on the cooling logs. On 11/2/19, pork loin was documented at 71 degrees F two hours after placed in cooling equipment, and on 11/9/19, pork was documented at 80 degrees F two hours after placed in cooling equipment with no additional temperature verification or corrective actions documented. Further record review revealed categories stating "2 hours after placed in cooling equipment (must be 70 degrees F or less; if not, discard)" and, "6 hours after placed in cooling equipment (must be 41 degrees F or less; if not, discard)". At this time manager verification of the proper cooling of items taking place was found not being conducted as the lower left-hand corner of the logs stating, "Manager Review/ Date:" were found blank on each log reviewed. On 12/2/19 at 12:14 PM, during an interview with the Executive Chef, staff R, regarding the current state of the cooling logs they stated, "we missed some spots, I'll go over this with my staff today". At this time the surveyor requested a copy of these logs to be emailed to them for additional review.

4. On 12/2/19 at 1:26 PM, and at 1:33 PM Patient Dining Associate, staff DDD, was observed re-contaminating their hands after conducting handwashing due to the lack of a hand barrier being used to turn the faucet off. On 12/2/19 at 1:42 PM, the Administrative Bookkeeper, staff CCC, was observed re-contaminating their hands after conducting hand washing due to the lack of a hand barrier being used to turn the faucet off. Upon observation of this practice by staff BBB, the Certified Dietary Manager, staff Q, confirmed this was not correct procedure with the surveyor and was observed providing education to staff BBB. At this time the surveyor requested the facility's dietary handwashing policy for the facility to review. On 12/2/19 at 2:27 PM, upon interview with staff Q on the status of the facility's dietary handwashing policy to review they stated, "I know we have something, but I'm not sure if it's written. I'll get you something". At the time of the survey's exit no dietary handwashing policy was received by the surveyor.


26222

DPS 3

Based on observation, interview and record review, the facility failed to ensure proper storage of ice and single use items for patient use. This deficient practice has the potential to affect all patients in the Emergency Department Observation unit and two patient units.

On 12/2/2019 at approximately 12:50 PM, a red plastic cooler on wheels was observed sitting on the counter of the nourishment room in the Observation unit of the Emergency Department. The location on the counter had disconnected water supply and drain lines, indicating that the location was intended to house an installed ice machine. The plastic wheels on the cooler were observed to be etched and worn with the worn areas discolored with dirt, indicating that the wheels had been used on a floor or ground surface before the cooler being placed on the counter top. The interior of the cooler was observed to contain ice. A metal serving spoon was observed resting on a plate on the counter next to the cooler. Staff BBB was overheard asking unit staff where the permanently installed ice machine went, to which staff responded that it had been removed for repairs. At the time of the observation, when asked where the cooler came from, Staff BBB was not aware of the cooler's origin. On 12/2/2019 at approximately 2:30 PM, staff BBB informed the surveyor that the cooler had been brought to the unit from Dietary.

On 12/2/2019 at approximately 1:30 PM, a large gray plastic tote was observed on the floor of the nourishment room in the 3-South unit. Several plastic sleeves of Styrofoam cups were observed stored in the tote. Dust accumulation was visible inside the tote. When asked why the facility was using this storage method, Staff BBB stated that in an effort to eliminate cardboard storage on the units, the totes had been put into place.

On 12/2/19 at approximately 2:15 PM, a cardboard box containing several plastic sleeves of Styrofoam cups was observed stored on the floor of the combination clean workroom nourishment room in the Obstetrics unit, adjacent to the medication dispensing unit. The box was observed stored directly below the wall-mounted sharps disposal box. This observation was confirmed during interview with Staff BBB at the time of observation.

Record review of the 2013 Food and Drug Administration (FDA) Food Code, Section 4-903.11 revealed that " SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored:
(1)In a clean, dry location;
(2)Where they are not exposed to splash, dust, or other contamination; and
(3)At least 15 cm (6 inches) above the floor."