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Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23 Nursing Services, was out of compliance.

A- 0395 A registered nurse must supervise and evaluate the nursing care for each patient. The facility failed to consistently provide patients with a nurse call light and failed to ensure the patient could activate the call light in 5 of 10 patients observed (Patients #1, #2, #7, #8 and #10). Further, the facility staff failed to perform hand hygiene when providing patient care in 3 of 4 observations (Patients #3, #8 and A). Additionally, the facility failed to ensure patient weights were obtained in accordance with physician orders in 2 of 10 charts reviewed (Patients #4 and #9). These failures created the potential for patient's medical and personal needs to not be met. Further, the failure of not performing hand hygiene put patients and staff at risk for transmission of an infectious microorganism.

A - 0398 Non-employee licensed nurses who are working in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of the clinical activities of non-employee nursing personnel which occur within the responsibility of the nursing services. The facility failed to ensure contracted nursing staff were oriented to the nursing unit and failed to evaluate contracted staff's competency to provide safe patient care in 8 of 8 contracted Registered Nurses. This failure created the potential for patients' medical and personal needs not being addressed per facility standards by contracted staff.

Based on observations, interviews, and document review the facility failed to consistently provide patients with a nurse call light and failed to ensure the patient could activate the call light in 5 of 10 patients observed (Patients #1, #2, #7, #8 and #10). Further, the facility staff failed to perform hand hygiene when providing patient care in 3 of 4 observations (Patients #3, #8 and A). Additionally, the facility failed to ensure patient weights were obtained in accordance with physician orders in 2 of 10 charts reviewed (Patients #4 and #9).

These failures created the potential for patient's medical and personal needs to not be met. Further, the failure of not performing hand hygiene put patients and staff at risk for transmission of an infectious microorganism.

POLICY

According to Nursing - Scope of Services, recognition of the needs of the medically complex patient and the patient's family will be a constant factor in the approach to care provided. Nursing encompasses the recognition of priority health care needs, health care teaching, and patient advocacy.

According to Hand Hygiene, decontaminate hands before having direct contact with patients. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. Decontaminate hands after removing gloves.

According to Patient Rights and Responsibilities, patients have the right to receive care in a safe setting.

REFERENCE

According to the Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health Care Settings, October 25, 2002, indications for hand hygiene include after glove removal (p. 27). Failure to remove gloves after patient contact or between "dirty" and "clean" body-site care on the same patient must be regarded as non-adherence to hand hygiene recommendations (p. 24).

1. Observations revealed call lights were not accessible for patients' use.

a) On 07/06/17 at 9:22 a.m., Respiratory Therapist (RT) #12 was observed providing oral care to Patient #8. At this time, Patient #8's call light was hanging on medical equipment behind his/her bed, out of reach. Patient #8 was at the facility due to respiratory failure, was able to move all extremities and use a regular call light when it could be reached. Patient #8 required mechanical ventilation to breathe and was currently in the process of weaning off ventilator (breathing machine) support to breathe on his/her own.

At 9:22 a.m. Patient #8, who was non-verbal due to a tracheostomy (an incision of the windpipe to assist in mechanical ventilation), nodded yes confirming s/he used the call light to call for assistance. Three minutes later, RT #12 exited the room leaving Patient #8's call light still hanging behind the bed, out of the reach. At 9:49 a.m., Patient #8 still did not have access to his/her call light and had been without a way to call for help for 27 minutes.

At 9:52 a.m. Director of Respiratory Therapy (Director) #3 entered Patient #8's room upon report the patient was desaturating (diminished supply of oxygen). Patient #8's ventilator was alarming at this time. Two minutes later, Registered Nurse (RN) #17 entered Patient #8's room, noticed Director #3 at the bedside and left the room. RN #17 was interviewed upon exiting the patient's room. RN #17 confirmed Patient #8 made his/her needs know via the call light. S/he stated before a RN left the room they should ensure the patient had everything s/he needed. RN #17 confirmed every staff member that entered and left a patients room was responsible to ensure the patient had a means to contact staff.

At 9:58 a.m. Director #3 exited Patient #8's room and was asked if the patient was able to use the call light to call for assistance. Director #3 replied s/he did not know. At 10:01 a.m. Director #3 stood at the doorway of Patient #8's room and asked the patient to press the call light. Patient #8 tossed pillows around searching for the call light. Director #3 entered the room and was able to locate the call light still hanging behind the patient's bed. Director #3 confirmed Patient #8 was unable to reach his/her call light. S/he stated it was all staffs' responsibility to make sure patients had their call light before leaving a room.

During the 39 minutes Patient #8 was without a call light 3 staff members entered and left the room without ensuring s/he had a call light within reach.

b) During an interview with RT #12 on 07/06/17 at 2:39 p.m., s/he stated Patient #8's ventilator had been alarming due to a disconnection between the ventilator and the patient. S/he stated this was a high priority alarm and should be answered immediately. RT #12 confirmed prior to the alarm sounding, s/he had left Patient #8 without his/her call light. Patient #8 had no way of calling for assistance when the alarm sounded. RT #12 reported so many things going on in his/her head that s/he forgot to make sure the patient had his/her call light before s/he had left the room.

c) On 07/05/17 at 5:14 p.m. an interview was conducted with Patient #7. Patient #7 was a quadriplegic and had a special call light referred to as the "tent." The tent call light could be easily activated by patients lacking extremity dexterity and control, such as Patient #7. Patient #7 reported that when the call light was placed and secured appropriately it could be used; however, Patient #7 reported the light was rarely secured correctly. Patient #7 attempted to activate the call light during the interview. The call light fell over and was no longer accessible to Patient #7, the call light had not been activated. Patient #7 reported s/he would try to holler out when this happened, but was unsure in staff heard. Patient #7's spouse reported s/he always wanted to stay in room to ensure the patient's needs were met.

d) On 07/06/17 at 9:02 a.m., Patient #10 was interviewed. Patient #10 had limited movement of his/her arms. Patient #10's call light was placed on top of his/her blankets and his/her arms had been placed underneath the blanket. Patient #10 was asked to activate the nurse call light. Patient #10 attempted to move his/her arms and was unable to get them above the blankets to activate the call light. Patient #10 had been left without a means of contacting staff for assistance due to his/her inability to move arms out from under blankets.

e) While RN #9 was observed providing care to Patient A on 07/05/17 at 10:45 a.m., there was an audible whistling sound. RN #9 initially stated this sound was the floor cleaner and continued care for Patient A. The floor cleaner was turned off; however, the whistling continued. RN #9 then stated this could have been his/her other patient, Patient #1 in a different room.

Patient #1 was a quadriplegic that had been instructed to activate the "tent" call light via his/her chin. During an interview at 11:10 a.m. Patient #1 demonstrated that s/he was unable to use the call light due to the way the call light was placed under his/her chin. Therefore, s/he whistled to get staff members' attention. RN #9 was in charge of Patient #1's care and did not respond to or know what the whistling sound was when asked about it earlier.

RN #9 entered Patient #1's room 25 minutes after Patient #1 had signaled for help via whistling. RN #9 assessed Patient #1, placed the call light under the patient's chin and left the room without assessing if patient could use the call light or if it was secured in place. Patient #1 demonstrated three times that s/he was unable to signal for a staff members' assistance with how the call light was left by RN #9.

During a subsequent interview with RN #9 s/he stated s/he was a new contracted RN. S/he was unaware how to secure the call light into place. Facility staff had not shown RN #9 the different call light options and had not shown him/her how to use the different call lights.

f) During an interview with Patient #2's family member on 07/05/17 at 10:05 a.m., s/he stated that s/he could not leave the facility. S/he went on to explain Patient #2 was a quadriplegic and could not use the call light to signal when s/he needed help. The family member felt it was not safe to leave Patient #2 alone in the facility. Patient #2 did not have a call light that they would be able to use and it was not within reach. Patient #2 stated s/he discussed this with staff and reported nothing had changed since the conversation.

During an interview with Certified Nursing Assistant (CNA) #6, on 07/06/17 at 2:51 p.m. s/he stated Patient #2 should have access to a call light even when family was present in the room. CNA #6 stated quadriplegic patients, such as Patient #2, should have access to a soft touch (a call light for patients with limited or no hand dexterity). CNA #6 confirmed any staff member could provide this for Patient #2 and this had not been done for this patient.

An interview with RN #7 was done at 07/06/17 at 3:24 p.m. S/he explained Patient #2 should have access to a soft touch call light even when family was at the bedside. Currently, Patient #2 did not have an accessible call light. RN #7 stated without an accessible call light, patients could not make their needs known to facility staff, such as when they were in pain or had bathroom needs. RN #7 stated s/he was unsure why Patient #2 had not been provided with a call light and report s/he would make sure the patient had one after the interview.

g) During an interview with Director of Quality & Risk (Director) #2 on 07/07/17 at 1:34 p.m. s/he stated that patients should have a proper call light in order to make their needs known. A RN assessment should have identified a proper call light was in place and patients could use it.

h) During an interview with Chief Nursing Officer (CNO) #1 on 07/06/17 at 11:34 p.m., s/he confirmed staff should ensure all patients had a call light they could activate before leaving the room. The call lights should have been secured via attached clip to ensure it would not slip away from the patient. CNO #1 stated the RNs and CNAs were expected to ensure patient's had a call light they could use.

2. Call light response time was identified by nursing leadership and patients as a concern; however, front line staff were not educated regarding how to improve the response time to call lights.

a) During the survey, seventeen patients were interviewed regarding their care. Nine of seventeen patients reported staff taking longer than 20 minutes to answer call lights once activated. As example,

Patient #7 stated on 7/5/17 at 3:11 p.m. the staff would answer the call light at the nurses station and stated they would be right there. Patient #7 reported it took staff an average 45 minutes after this exchange to assess the patient's needs.

On 7/5/17 Patient B stated it took over an hour to receive care from the RN on night shift.

The same day, Patient C stated it took a couple hours of waiting to get his/her pain needs addressed.

Patient D reported staff taking 10-30 minutes to answer call lights during an interview on 7/5/17.

b) Review of the facility's complaints revealed four patient complaints regarding staff response time to call light since March 2017. Review of Nurse Staff Meeting minutes revealed this was a topic on the agenda and was discussed at multiple meetings since 2/2017. The staff was instructed that any staff member should have answered call lights. Call light response time was discussed three times at daily staff huddles in May; no other mention of call light response time to staff was noted. No further education or plan for front line staff to improve call light response time was noted.

c) During an interview with Director #2 on 07/07/17 at 1:34 p.m., s/he stated the call light response time had been a continuous issue leadership worked on. The call light response time was measured based on the facility's customer service survey sent to patients which included a question regarding call light response time. Director #2 confirmed that this was a project leadership had been working on; however, front line staff had not been educated on methods to improve response time.

d) During an interview with CNO #1 on 07/07/17 at 1:03 p.m., s/he stated call light response time had been identified as a concern via patient satisfaction surveys. CNO #1 stated their goal for a response time was 5 minutes. However, CNO #1 stated leadership had no way of monitoring call light response times. S/he confirmed this was a topic at nurse meetings since 02/2017; but leadership had yet to determine a solution to improve the patient care concern. Nursing leadership had proposed a nurse locator system 8 months prior in 11/2016. This system was on track to be done in 12/2017. CNO #1 confirmed staff that performed patient care had not received additional training regarding call light response times since it had been identified as a patient and leadership concern.

3. Nursing staff failed to perform hand hygiene according to identified national guidelines.

a) On 07/05/17 at 10:20 a.m. RN #16 was observed giving Patient #3 medication per his/her percutaneous endoscopic gastrostomy (PEG) tube (a tube placed into the patient's stomach through the abdominal wall as a means of feeding when oral intake was not possible). Patient #3 was in contact isolation. RN #16 entered the room and placed the bedside chart on the nurse server. S/he then gowned, performed hand hygiene and put on gloves. S/he assessed Patient #3's PEG tube entrance at the abdominal wall, obtained a new syringe and bottle and checked stomach content residual with the syringe attached to the tube and placed the syringe in the bottle. RN #16 then administered Patient #3 medications using the syringe and flushing the tube with water from the bottle. S/he then returned to the nurse server and flipped through pages of the binder with contaminated gloved hands. Next, RN #16 removed his/her gloves, wrote a label for the syringe and bottle used during patient care to indicate s/he had opened it that day. RN #16 put the label on the contaminated bottle with ungloved hands while in the contact isolation room. S/he then performed hand hygiene. RN #16 then took the contaminated bedside chart back to the nurses' station.

b) On 07/05/17 at 10:45 a.m., RN #9 was observed providing care for Patient A. RN #9 was observed passing Patient A's medications with clean gloved hands. After the medication was given, RN #9 removed his/her gloves and asked if Patient A needed assistance to the bathroom. RN #9 put new gloves on without performing hand hygiene. S/he then bent over to look on the floor and placed a gloved hand onto the floor for support. RN #9 then assisted Patient A to the bathroom with the contaminated gloved hand. RN #9 continued to assist Patient A with hygiene with the contaminated glove by handing wipes and toilet paper that Patient A used to clean him/herself.

c) On 07/06/17 at 8:56 a.m. RN #13 was observed providing care to Patient #8 after performing hand hygiene and putting on clean gloves. RN #13 administered medications via injection and through a nasal gastric tube (tube placed into nose and passed into stomach). At 9:07 a.m. RN #13 cleaned Patient #8's bowel movement and applied cream to Patient #8's bottom. Next, RN #13 suctioned Patient #8's tracheotomy with the same contaminated gloved hands used to clean the bowel movement. S/he then removed gloves and performed hand hygiene.

d) On 07/07/17 at 7:53 a.m. an interview with RN #14 was done. RN #14 stated a change of gloves and hand hygiene should have been completed after cleaning the patient's bowel movement and before suctioning a tracheostomy. RN #14 explained bacteria could be introduced into the patient's lungs via the tracheostomy. S/he stated this could lead to sepsis (a life-threatening infection).

e) During an interview with Director of Risk Management #2 on 07/07/17 at 1:34 p.m., the above mentioned hand hygiene observations were discussed. Director #2 explained she functioned as the Infection Control RN. Director #2 stated hand hygiene and glove change should have been performed after touching a contact isolation patient and before returning to the patient bedside chart, after touching the floor, and after cleaning the patient's bowel movement. S/he explained these incidents could spread bugs between staff and patients. Director #2 stated staff should follow facility policy and CDC guidelines regarding hand hygiene.

f) During an interview with CNO #1 on 07/07/17 at 1:03 p.m. s/he confirmed the staff was expected to follow facility policy and CDC guidelines. Observations were reviewed with CNO #1. CNO #1 confirmed hand hygiene should have been done after touching the patient; before a clean procedure, such as suctioning a tracheostomy; and after touching patient surroundings, specifically the floor. CNO #1 stated the purpose of wearing gloves was to prevent contamination between staff and patients.

4. The facility failed to ensure weights were obtained in accordance with physician order.

a) A review of Patient #4's medical record revealed s/he was admitted to the facility for wound care after a post operative infection of an aortic aneurysm graft. Patient #4 had a history of Stage III renal disease. S/he was ordered total parenteral nutrition (TPN) with daily weights on 05/09/17. Patient #4's medical record revealed no weights noted from 05/13/17 - 05/19/17, one week of Patient #4's stay at the facility.

b) A review of Patient #9's medical record revealed s/he was admitted to the facility for acute respiratory failure requiring mechanical ventilation and was diagnosed with acute renal insufficiency and pleural effusion (buildup of fluid between the tissues that line the lungs and the chest). On 04/24/17 daily weights were ordered. Weights for Patient #9 were absent 14 days of his/her stay and included 5/28/17 - 6/1/17; 6/5/17; 6/7/17 - 6/11/17; and 6/14/17 - 6/16/17.

c) Interviews were conducted with CNO #1 and Director #2 on 07/07/17 at 1:00 p.m. and 1:34 p.m. respectively. Both CNO #1 and Director #2 stated physician orders should be followed by RNs unless the RN had questions regarding what was ordered. CNO #1 explained any clarification of orders should have been documented.

Clarifications of daily weight orders were not found in Patients #4 or #9's medical record.

d) Document review showed there had been 20 reported incidents where weights were not obtained as ordered in the previous 10 weeks. Patient #4 and Patient #9 were patients during those 10 weeks and were not among the 20 incidents reported.

Based on observations, interviews, and document review the facility failed to ensure contracted nursing staff were oriented to the nursing unit and failed to evaluate contracted staff's competency to provide safe patient care in 8 of 8 contracted nurses.

This failure created the potential for patients' medical and/or personal needs not being addressed per facility standards by contracted staff.

POLICY

According to Agency/Contract Labor Staff and Clinical Purchased Services Use, contract staff files are maintained and updated by the Scheduler or individual designated by the department leader. It will be the responsibility of the department supervisor to assure personnel files are maintained and to provide orientation to contracted personnel. All contract Staff will be required to complete General Hospital Orientation self-study and test. Department Orientation will be provided on the assigned unit by designated team members by using the "Contract Staff Orientation and Evaluation" form. Contract Staff will be evaluated by the department supervisor or designee after the first shift worked by using the "Contract Staff Orientation and Evaluation" form.

According to Nursing Orientation Program all newly hired nurses will complete an orientation specific to the Nursing Department. The goals of Nursing Orientation are to enhance the nursing skills and knowledge base of the nurse and to familiarize the nurse with policies and procedures of the hospital.

1. Contracted nurses did not follow facility policy and were not oriented to nursing units or evaluated by facility staff.

a) On 07/05/17 at 10:45 a.m., Registered Nurse (RN) #9 was observed providing patient care for Patient A. RN #9 was observed passing Patient A's medications with clean gloved hands. After the medication was given, RN #9 removed his/her gloves and asked if Patient A needed assistance to the bathroom. RN #9 put new gloves on without performing hand hygiene. S/he then bent over to look on the floor and placed a gloved hand onto the floor for support. RN #9 then assisted Patient A to the bathroom with the contaminated gloved hand. RN #9 continued to assist Patient A with hygiene with the contaminated glove by handing wipes and toilet paper that Patient A used to clean him/herself.

An interview with RN #9 was conducted after Patient A's care on 07/05/17. S/he stated s/he was a contracted agency nurse and was not an employee of the facility. RN #9 stated his/her orientation did not include a discussion regarding hand hygiene.

On 07/07/17 a review of RN #9's Human Resources (HR) file did not contain orientation to the facility or the unit s/he was assigned to work. In addition, there was no evaluation of RN #9 by the facility.

b) On 07/07/17 at 7:42 a.m. it was observed that Patient #1, a functional quadriplegic (the complete inability to move without brain or spinal cord damage), did not have access to his/her call light. An interview was conducted with Patient #1's nurse, RN #10, at 7:52 a.m. RN #10 was shown the position of the call light and recognized this was inaccessible to Patient #1. RN #10 stated this was a problem because Patient #1 could not make his/her needs, such as pain or bathroom needs, known without access to the call light. RN #10 was unaware of the Soft Touch option for patients with limited movement, which included Patient #1.

RN #10 went on to say s/he had worked at the facility for 1.5 months and was a contracted employee. Review of RN #10's HR file revealed s/he had completed the General Employee Orientation. This included a Nursing/CNA Orientation and a General Clinical Orientation. However, there was no Contract Staff Orientation and Evaluation form that oriented staff to the facility patient care units and evaluated contracted staff on care provided for RN #10.

c) On 07/07/17 at 11:38 a.m. an interview with HR Director #8 confirmed all contracted staff should have a completed RN Contract Staff Orientation and Evaluation form. The Orientation Form should have been completed during the first shift worked in facility and included a hospital tour, general hospital and personal safety, the hospital routine, the nurse's station, and documentation. Job duties were also listed. The Evaluation Form should have been completed by the Charge Nurse, Department Manager, or their Designee for first shift worked and included an evaluation of patient care and infection control standards by the contracted employees.

d) On 07/07/17 at 12:15 p.m. six additional contracted staffs' HR files were requested. Review of files revealed 3 of 8 contracted RNs attended General Employee Orientation. None of the 8 contracted RNs had completed the RN Contract Staff Orientation and Evaluation.

e) On 07/07/17 at 12:28 p.m. Chief Nursing Officer (CNO) #1 confirmed no contracted RNs had a completed orientation or had an evaluation of the patient care provided.