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Based on interview and record review, the facility failed to circulate the learning concepts from two patient adverse events to similar locations within the facility.

This deficient practice had the potential for similar adverse patient events to occur in other locations of the hospital.

Findings:

During an interview and concurrent document review with the Quality Team, including the Chair of Surgery (ChS), the Director of Patient Safety (DPS), and Vice President of Quality (VPQ) on 10/24/19 at 10:35 a.m., the Quality Team presented the root cause analysis (RCA, a systematic process for identifying the underlying causes of problems or events and developing an approach for future response to a similar problem.) for an August 2019 wrong-site surgery at the trauma hospital operating room. The ChS stated there were issues with team communication and clear surgical site marking. The VPQ and DPS stated the corrective action plan included staff education that: no incisions were to be made unless site marking was clearly visible; all team members must actively participate in the time-out process (a surgical team protocol performed before the initiation of surgery to verify patient identity and intended surgical site and procedure); the attending physician must write the procedure and specific site for the surgery on the operating room white board. The DPS stated the random audits for compliance with the correction action plan began in the trauma hospital operating rooms in September 2019.

The Quality Team provided an undated document, authored by the ChS, titled, "Time-out Improvement Project." The ChS stated the document resulted from the root cause analysis of the wrong-site surgery. In the document, the ChS wrote he had observed time-outs in the trauma hospital operating rooms on 8/26/19. The document included the following errors in procedures, "3) The pre-anesthesia worksheet had the incorrect side for the operation listed...6) Anesthesia often pre-occupied during the Time-out...7) A surgeon was seen manipulating the wound during Time-out...."

During a concurrent interview with the DPS, the DPS stated the RCA corrective action plan, staff education, and learning concepts were not extended to any other procedural or surgical areas of the hospital system, including the community hospital operating rooms.

During an interview and concurrent document review with the Quality Team on 10/24/19 at 9:34 a.m., the Director of Patient Safety (DPS) presented the RCA for an August 2019 wrong-site procedure at the hospital dental clinic. The DPS stated the investigation revealed problems with clear surgical site marking, adhering to the time-out protocol team communication, and ensuring all team members were present for the time-out. The DPS stated the corrective action plan for the dental clinic began 10/1/19, and included random audits of surgical site marking and team member presence during the time-out.

During a concurrent interview DPS stated that preliminary data from the dental clinic audits still indicated that not all team members were present during the time-out. The Chair of Surgery (ChS) stated the department leadership team held a meeting at the dental clinic on 10/22/19, to educate staff members to halt the procedure until all team members were present. The Vice President of Quality (VPQ) stated the corrective action plan, staff education, and learning concepts for the dental clinic were not extended to other procedural or surgical areas of the hospital system.

During the interview with the Quality Team on 10/24/19 at 10:35 a.m., the VPQ stated the trauma center surgery occurred before the dental clinic surgery, and both had problems with compliance with the time-out protocol, and surgery site.

Based on observation, interview, and record review, the hospital failed to ensure a non-employee licensed nurse knew how to withdraw blood from one (Patient 24) of one patient's port-a-catheter (a thin, flexible tube threaded into a large vein in the heart to administer medications and obtain blood samples) in accordance with hospital policy and procedures.

This failure had the potential to result in injury to Patient 24 due to catheter complications.

Findings:

During an observation in Patient 24's room on 10/23/19 at 9:00 a.m., Registered Nurse 4 (RN 4) collected blood from Patient 24's right chest port-a-catheter for laboratory (lab) tests ordered by the physician. RN 4 withdrew and discarded 10 milliliters (mLs) of blood to clear the catheter, and drew the sample blood. RN 4 was unable to transfer the sample blood to the lab specimen tube with the transfer device, so RN 4 obtained a second set of blood sampling supplies. RN 4 repeated the sampling process and withdrew and discarded 10 mLs of blood to clear the catheter, withdrew the sample blood, and placed the sample blood in the lab specimen tube.

During an interview with RN 4 on 10/23/19 at 9:28 a.m., RN 4 stated he was a temporary employee from a traveler nurse staffing registry. RN 4 stated he had difficulty with the collection of Patient 24's blood as he was not familiar with the hospital policy and procedure for blood sampling from a patient's port-a-catheter. RN 4 stated, "They collect it [blood] differently here, [I am] not used to it."

During an interview with the Charge Nurse (CN) on 10/23/19 at 9:36 a.m., CN stated RN 4 was an agency traveling nurse assigned to the nursing unit. The CN stated she was responsible for supervising RN 4's clinical activities, but she had not known RN 4 was unfamiliar with the hospital policy for blood sampling from a port-a-catheter.

During a concurrent interview and record review of RN 4's personnel file with the Regulatory Director (REGD) on 10/24/19 at 1:31 p.m., REGD confirmed RN 4 was hired on 2/18/19. The record indicated RN 4 was hired on 2/18/19. REGD stated the hospital required the traveler nurses to be oriented to hospital policies and procedures.

The hospital policy and procedure titled, "Central Line Catheters/Picc Lines/ Port-A-Caths," (long-term indwelling tubes placed in large blood vessels in the body core to obtain blood samples, and deliver medications/fluids), dated 1/2015, indicated the purpose of the policy and procedure was to ensure nurses followed proper infection control measures to prevent infection, and followed measures designed to prevent occlusion or other complications associated with the catheter use. The policy indicated blood sampling from a port-a-cath must be,"performed by an RN with documented competency."

Based on observation, interview, and record review, the facility failed to ensure that policies and procedures for safe and effective administration and use of medications were developed and implemented when:

1) Two of two emergency department (ED) nurses who were interviewed, were not aware of malignant hyperthermia (MH, is an inherited muscle disorder triggered by certain drugs including succinylcholine, which is a paralytic agent used in anesthesia, and volatile anesthetics that may cause a fast-acting life-threatening crisis) supply locations and procedures. These failures had the potential for serious injury or death of a patient, as a result of untimely management of MH.

2) Emergency Department Registered Nurse 2 (RN 2) incorrectly used Broselow tape ((a measuring tape used in emergency situation to determine an estimated weight of a pediatric patient for more accurate dosing of pediatric medications) to determine the weight of a mock pediatric patient. This failure resulted in an inaccurate dose calculation of the medication adenosine (used for management of irregular heart rhythm in emergency situations), which had the potential to result in ineffective management of patients during emergency treatment.

3)Multi-dose vials (MDV) of insulin (medication for regulating blood sugar) were accessed in patient care areas in the emergency department (ED) and used for multiple patients not in accordance with facility followed CDC (Centers for Disease Control and Prevention) standards. This failure had the potential of exposing patients to infections due to cross contamination.

Findings:

1) During an interview with Registered Nurse (RN 1) while on a tour of the ED on 10/21/19 at 11:42 a.m., RN 1 was unable to state the location of the malignant hyperthermia (MH) supplies. RN 1 stated she had administered succinylcholine (a trigger for MH) for traumas and intubations. RN 1 said she did not know the processes for treatment of MH, and would have to check the policies and procedures.

During an interview with Registered Nurse 2 (RN 2) while on a tour in the ED on 10/21/19 at 11:46 a.m., RN 2 stated she did not know the procedures for MH.

During an interview with the assistant ED Manager (AEM) on 10/21/19 at 11:54 a.m., AEM stated the MH supplies were located in the surgery department and the process was to call surgery, who would bring the supplies to the ED. AEM stated there had been no MH drills with staff in the ED.

Review of facility policy, "Malignant Hyperthermia," dated 7/2019, indicated, "Anesthetizing departments, ED...To increase a positive patient outcome by providing guidance to personnel in departments that ...utilize Succinylcholine (routinely or emergently only); which are known triggers for inducing a Malignant Hyperthermia episode...At the onset of a Malignant Hyperthermia (MH) episode, the MH Crisis Hotline will be called for consultation...Departments that provide general Anesthesia or Succinylcholine for patient care will:...Provide staff education related to MH, with documented verified staff competencies which:...includes location and contents of nearest MH cart..."

Review of MHAUS (Malignant Hyperthermia Association of the United States, referenced in the facility policy) website www.mhaus.org indicated, "The general signs of the MH crisis include increased heart rate, greatly increased body metabolism, muscle rigidity and/or fever that may exceed 110 degrees F along with muscle breakdown, derangements of body chemicals and increased acid content in the blood. Severe complications include: cardiac arrest, brain damage, internal bleeding or failure of other body systems. Thus, death, primarily due to a secondary cardiovascular collapse, can result."

2) During an observation in the ED on 10/21/19 at 11:48 a.m., Registered Nurse 2 (RN 2) demonstrated how to calculate the dose of adenosine for a mock pediatric patient during a cardiopulmonary arrest (an emergent life threatening situation of no breathing and/or no heart beat). A designated length on a counter surface was used to indicate the size of the hypothetical pediatric patient. RN 2 measured the length with a Broselow tape. RN 2 placed the grey section of the tape at the "head" of the hypothetical patient and measured the length, which showed the estimated weight to be 12-14 kilograms (26 pounds to 30 pounds). RN 2 calculated the dose of adenosine to be 1.3 milligrams for a pediatric patient weighing 12-14 kilograms.

A review of the written instructions on the Broselow tape showed an arrow and the words, "Measure from This End" at the red end of the tape. A repeated measurement using the red end of the tape at the "head" of the mock patient showed an estimated weight of 3-5 kilograms (six to 11 pounds), with the correct calculated dose of adenosine equal to 0.3 milligrams.

During an interview with AEM on 10/21/19 at 11:54 a.m., AEM stated ED nurses were expected to know how to use Broselow tape during emergency situations.

3) During an observation in the ED medication room on 10/21/19 at 12:15 p.m., an opened, previously used, multi-dose vial of insulin (a medication for controlling elevated blood sugar) was in the ED medication room; the vial had no patient-specific label.

During a concurrent interview AEM stated the multi-dose vials of insulin were used for ED patients. AEM stated nurses could draw up the medication from the vial in the medication room, or at a patient's bedside, to facilitate bedside scanning of the vial.

During an interview on 10/21/19 at 11:25 a.m., the Quality Director (DQ) stated the facility followed Center for Disease Control (CDC) standards for infection control practices for medication.

Review of CDC website (www.cdc.gov) indicated, "Safe Practices for Medical Injections...If multi-dose vials must be used for more than one patient, they should only be kept and accessed in a dedicated clean medication preparation area (e.g., nurses station), away from immediate patient treatment areas. This is to prevent inadvertent contamination of the vial through direct or indirect contact with potentially contaminated surfaces or equipment that could then lead to infections in subsequent patients. If a multi-dose vial enters an immediate patient treatment area, it should be dedicated for single-patient use only."

Based on observation, interview, and document review, the facility failed to ensure that compounding (mixing) was performed in a safe manner when:

1) In the sterile (germ free) IV (intravenous, injected through the vein) compounding room, the cleaning agents dwell time (the amount of time that a surface must remain wet to allow the chemical to be in contact with the organism in order to kill it) was not ensured per manufacturer specifications by pharmacy and EVS (environmental services) staff.

2) Pipes under the sink in the IV room were not clean and were covered with greenish material that came off on wiping.

These failures had the potential of exposing patients to contaminated compounded sterile products.

Findings:

1) During an interview in the inpatient IV room on 10/21/19 at 11 a.m., Pharmacy technician (PT) was asked how the hoods (equipment for compounding) were cleaned. PT stated the cleaning agent was wiped on, and left to dry for one minute for daily cleaning with [antibacterial agent], and three minutes for monthly cleaning with [anti-fungal/sporicidal agent]. PT stated that the cleaning agent was not reapplied as the process was to leave it to air dry.

During an interview with inpatient pharmacy manager (IPM) on 10/21/19 at 11:08 a.m., IPM stated that she was not aware the surfaces had to be observed and rewetted if dried within the dwell time. IPM acknowledged that the laminar flow hood had a very high air exchange rate and areas where sporicidal cleaner Peridox was applied first could dry out within the 3 minutes if they were not rewetted. IPM stated the IV room was cleaned by EVS and was not sure if dwell times were followed by EVS staff.

Review of facility document "Standard Operation Procedure-Cleaning Sterile Compounding Area for Pharmacy & Supporting Personnel," dated 9/15/17, indicated, "Use [antibacterial agent] wipes...set timer for 1 minute and let it dry...Allow [anti-fungal/sporicidal] to dry out for three (3) minutes." The procedure did not address dwell time and observation to ensure the surface being cleaned remained wet during the dwell time.

2) During an observation on 10/21/19 at 2 p.m., the infusion center sterile IV room revealed a sink in the ante room (area used to prepare for compounding). The sink had exposed pipes underneath. The pipes were wiped with a dry wipe and greenish material was observed on the wipe.

In a concurrent interview IPM acknowledged that the pipes were not clean.

Review of facility document "Standard Operation Procedure-Sterile Hazardous and Non-Hazardous Compounding Preparations," dated 9/15/17, indicated, "All equipment used in the areas designated for compounding will be made of a material that can be easily cleaned and disinfected."

Based on observation, interview, and document review, the facility failed to ensure nursing staff secured medications from unauthorized access when:

1. Two of three medication carts were unlocked in a shared-use storage room of the community hospital medical/surgical floor.

2. Insulin (an injectable medication used to lower blood sugar) was left unattended at the bedside of one of 40 sampled patients (Patient 20). Patient 20 shared a room with another patient, and another visitor, and a laboratory staff member, were present during the observation.

These failures had the potential for unauthorized medication access by patients, visitors, and hospital staff, and may have resulted in serious harm from use of the medication.

Findings:

1. During an observation and concurrent interview in the community hospital medical/surgical floor storage room, with the Nurse Manager (NM), and Charge Nurse 2 (CN 2) on 10/21/19 at 11:30 a.m., non-nursing staff entered the supply room, gathered supplies, and left the room. The room contained physical therapy supplies, medical supplies, a refrigerator for patient food, and three medication carts; NM confirmed two of the three medication carts (Cart 1 and 3) were unlocked. NM stated Cart 3 should be locked, but Cart 1 had a broken lock, and could not be locked. NM confirmed Cart 1 contained medications and was in current use. CN 2 stated the medication carts should be locked to avoid theft or unauthorized use of the medications.

2. During an observation of medication administration on 10/23/19 at 10:23 a.m., Patient 20, another patient, a visitor, a laboratory technician, and Registered Nurse 6 (RN 6) were in Patient 20's room. RN 6 exited Patient 20's room to collect medical supplies; an insulin vial was on top of a wheeled cart (Workstation on Wheels) stationed at Patient 20's bedside. The laboratory technician left the room after RN 6 left, and during continual observation, RN 6 returned one minute and 22 seconds later.

During an interview with RN 6 on 10/23/19 at 11:09, RN 6 stated he had not realized the insulin vial was on top of the workstation when he left the room. RN 6 stated unsecured medications were a potential hazard, as they could be accessed and used by unauthorized people.

A review of the hospital policy, "Medication: Security," effective date 2/18, indicated medications are never to be left unsecured in locations where unauthorized persons could have access to them.

Based on observation, interview and document review facility failed to ensure that medications were stored in accordance with manufacturer instructions when vials of Lidocaine and Epinephrine (for anesthesia) were not protected from light. This failure had the potential of exposing patients to ineffective or contaminated medications.

Findings:

During an observation in the inpatient pharmacy on 10/21/19 at 10:45 a.m., multiple 20 and 30 milliliter (mL) vials of the combination medication lidocaine/epinephrine 1% and 2% were outside their original packaging carton. The manufacturer label on the vials indicated, "Protect from light."

During a concurrent interview the inpatient pharmacy manager (IPM) confirmed that the vials were not stored in accordance with manufacturer instructions.

Review of facility policy, "Medications: Storage," dated 3/2018, indicated, "medications are labeled and stored safely
and securely under the proper and necessary conditions according to manufacturer's recommendations."

Based on observation, interview, and record review, the facility failed to ensure the food and nutrition services staff disposed of trash from the main hospital kitchen in a sanitary manner, and in accordance with standards of practice.

This deficient practice had the potential to expose patient food and food-contact surfaces to contaminated waste and lead to foodborne illness.

Findings:
During an observation of the main hospital lunch tray line with the Food and Nutrition Services Systems Director (FNSSD) on 10/21/19 at 11:15 AM, Foodservice Worker (FSW 1) pushed an uncovered, trash-filled, wheeled garbage bin through the kitchen; the wheeled bin did not have an attached or unattached lid present. FSW 1 stopped at the cold food preparation station on the tray line, and emptied trash from a small trash bin at the preparation station into the wheeled garbage bin. In a concurrent interview, FSW 1 stated this was the normal process for combining all of the kitchen trash into the wheeled garbage bin before taking it to the facility dumpster. FSW 1 stated she did not know the wheeled garbage bin should be covered. The FNSSD confirmed the wheeled garbage can should be covered at all times when not in active use, as the uncovered trash was an infection control risk.

A review of the facility procedure, "Sanitation and Infection Prevention/Control," revised 1/2017, "Food waste...in the Food and Nutrition Services Department/Dining Services will be disposed of in an approved manner to prevent contamination of food, dishes, or clean working areas ...Garbage containers are clean, lined, and covered at all times ...When transporting trash bin to dumpster area ...Keep trash bin covered during transportation."

Based on observation, interview, and record review, the hospital system failed to ensure kitchen equipment was maintained in the rehabilitation hospital Food and Nutrition Services Department in a safe, operating, and fully functioning manner, when:

1. A walk-in freezer in the rehabilitation hospital had ice and condensation build-up on the back wall, the ceiling, and on cases of food inside the freezer;

2. Three reach-in refrigerators had door gaskets with holes and visible signs of wear and tear.

These failures had the potential to impact the ability to safely store and serve food in a sanitary manner to prevent foodborne illness.

Findings:

During an observation with the Food and Nutrition Services System Director (FNSD) and Food and Nutrition Service Director 2 (FND 2) at the rehabilitation hospital Food and Nutrition Department kitchen on 10/22/19 at 12:55 p.m.:

1. A walk-in freezer that stored frozen meat and vegetables had ice build-up on the ceiling, vent fans, and five cases of food in the right corner. In a concurrent interview FND 2 stated the freezer needed repair, as there should not be ice build-up inside the freezer.

2. Three reach-in refrigerators had door gaskets with tears and rips in them. One refrigerator stored patient nourishments including pudding, yogurts, fruit cups, and other foods dependent on controlled temperature for food safety. The other two refrigerators stored milk cartons and yogurt for tray line. FND 2 confirmed the door gaskets had tears and rips.

According to the 2017 FDA Federal Food Code, section 4-204.18 titled Condenser Unit, Separation., "A dust-proof barrier between a condenser and food storage areas of equipment protects food and food-contact areas from contamination by dust that is accumulated and blown about as a result of the condenser's operation ..."

Based on observation, interview, and record review, the hospital failed to implement a system for controlling sources of infection in accordance with internal policies and procedures, and nationally recognized infection control guidelines and regulations when:

1. A walk-in freezer floor in the main hospital patient food kitchen was dirty floor with crumbs, trash, and food stains;

2. Air gaps were not correctly placed in two kitchen floor drains at the main hospital, and one kitchen floor drain at the rehabilitation hospital in accordance with regulations and standards of practice;

3. Registered Nurse 6 did not disinfect the blood glucose monitor (a device for measuring the concentration of sugar in the bloodstream) and the carrying case after a patient blood glucose check.

4. Corrugated (cardboard) boxes were stacked near clean and sterile (free from bacteria) supplies in the Emergency Department (ED) Clean Utility/Nutrition room.

5. Plastic water pitchers for patient use were stored on a cabinet shelf covered with a brown/ gray particulate matter in the Intensive Care Unit (ICU, a critical care unit) Clean Utility/Nutrition room.

6. The Registered Nurse (RN) left a ten milliliter (ml) syringe (a plastic tube with a nozzle and piston) filled with blood, uncapped, unlabeled, and unattended on Patient 24's window sill.

7. The physician did not discard personal protective equipment (PPE) after use, in accordance with hospital policy and procedure for droplet precautions (germs spread through close respiratory or mucous membrane contact) and infection control.

8. Three of three nurses (Registered Nurses 7, 8, and 9) observed during a medication pass failed to perform hand sanitation before entering or exiting a patient room and providing care.

These deficient practices had the potential to result in spread of infection and/or foodborne illness.

Findings:

1. During an observation of the main hospital kitchen with Executive Chef (EC), Food and Nutrition Services System Director (FNSD), and Food and Nutrition Service Director 1 (FND 1) on 10/21/19 at 10:30 a.m., the walk-in freezer had several pieces of trash and debris on the floor, including crumbled food wrappers, large brown food crumbs, a smashed vanilla ice cream cup, and a dark brown sticky substance in the right corner. During concurrent interviews, EC, FNSD, and FND 1 confirmed the freezer needed cleaning. FND 1 stated the evening supervisor was supposed to complete a checklist to ensure the cleanliness of the walk-in freezers and refrigerators on a daily basis when the kitchen closed.

A review of facility policy titled, "Retail Food Services, Department Daily Closing Procedures," dated 7/10, indicated, "Action ...Floor clean of debris ..."

2. During an observation of the main hospital kitchen with FNSD and FND 1 on 10/21/19 at 10:50 a.m., two floor drains had air gaps that were not in compliance with regulations and standards of practice. One drain underneath the Cook's prep sink had a pipe going directly into the drain, and the other pipe, located underneath a three-compartment sink, was ½ inch above the floor drain. FNSD acknowledged the two floor drains did not have appropriate air gap spacing.

During an observation at the rehabilitation hospital kitchen with FNSD, and Food and Nutrition Service Director 2 (FND 2) on 10/22/19 at 12:50 p.m., the floor drain underneath the dishwashing machine had dirt, brown stains, black sticky substance, and debris inside the drain. Directly inside the drain and touching the inner filter was a drain pipe; there was no air space between the pipe and the floor drain. In a concurrent interview, both the FNSD and FSD 2 confirmed the floor drain was dirty and did not have an appropriate air gap space between the drain and the pipe.

A review of the Food and Drug Administration Federal Food Code 2017, Section 5-202.13 titled, "Backflow Prevention, Air Gap," showed, "An air gap between the water supply inlet and the flood level rim of the plumbing fixture equipment ... shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (one inch) ..."


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3. During an observation on 10/23/19 at 10:23 a.m., Registered Nurse 6 (RN 6) took a blood glucose case from the nursing station and brought it to Patient 20's bedside to check a blood sugar. RN 6 removed the monitor from inside its carrying case and took a blood sample from Patient 20. Without disinfecting the blood glucose monitor, RN 6 returned the blood glucose monitor to its carrying case, shut the case, and returned to the nursing station with the carrying case. At the nursing station, RN 6 removed the blood glucose monitor from its carrying case, mounted the blood glucose monitor on a charging unit, and stored the carrying case on a shelf.

During an interview with RN 6 on 10/23/19 at 11:09 a.m., RN 6 stated he forgot to clean the blood glucose monitor and the carrying case. RN 6 stated they should be disinfected after use, to "avoid spread of germs."

A review of the hospital policy and procedure, "Point of Care Blood Glucose Testing-[monitor trade name]," revised 4/20/17, indicated the glucose monitor must be cleaned after every patient test and the carrying case cleaned with [disinfecting] wipes after removal from a patient's room.


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4. During an observation and concurrent interview, in the emergency department (ED) clean utility/nutrition storage room, with the Infection Control Preventionist (ICP) on 10/22/19 at 9:09 a.m., two corrugated boxes sat on the storage room floor next to a clean supplies rack. The ICP examined the boxes and stated the boxes had attached shipping labels which indicated they were used as external shipping cartons. The ICP stated shipping boxes should not be stored in the storage room. The ICP stated hospital supplies should be removed from the corrugated boxes prior to entering the ED clean utility room to prevent cross contamination. The ICP stated the ED clean utility room stored clean and sterile patient supplies which required a clean storage environment. The ICP stated corrugated boxes had the potential to introduce dirt and bacteria (germs) in to the clean utility room, which could adversely impact the health of patients.

The hospital policy and procedure titled, "Corrugated Boxes (Shipping Containers)," dated 6/20/2018, indicated, "...This is an infection control prevention measure...Mice, insects, vermin, dirt with pathogenic organisms can be carried into a hospital within the cardboard boxes used as external shipping cartons ...Shipping boxes are not to be stored or used as containers for stock supplies in patient care areas...The stock supplies will be removed from the shipping box and placed in a clean container..."

5. During an observation and concurrent interview in the intensive care unit (ICU) Clean Utility/Nutrition room, with the Environmental Services Supervisor (EVS) on 10/21/19 at 11:50 a.m., a floor cabinet contained plastic water pitchers. The floor cabinet shelf and doors were covered with a brown/gray particulate substance. EVS wiped the shelf with her right hand and the brown/gray substance lifted off the surface. The EVS stated the cabinet was not clean nor sanitary. The EVS stated housekeeping was responsible for maintaining the cleanliness of the utility/nutrition room clean. The EVS stated, "It's obvious it [cabinet] wasn't cleaned for a while."

During an interview with the intensive care unit (ICU) Administrator (IA) on 10/21/19 at 11:58 a.m., IA stated ICU patients were susceptible to hospital acquired infections. The IA stated the unclean storage room cabinet increased the risk of contaminating the water pitchers and had the potential to cause patient illness.

The hospital policy and procedure titled, "Food Supply and Storage," dated 7/2014, indicated, "All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination..."

6. During an observation in Patient 24's room, on 10/23/19 at 9:16 a.m., Registered Nurse 4 (RN 4) used a 10 milliliter (mL) syringe to collect a blood sample from Patient 24's right chest port-a-catheter (a thin, flexible tube threaded into a large vein in the central body core to administer medications and sample blood), but was unable to transfer the blood into the laboratory specimen tube. RN 4 placed the blood-filled syringe on Patient 24's window sill and left the patient's room to procure additional blood transfer supplies. The blood filled syringe was left uncapped, unlabeled, and unattended for six minutes until RN 4 returned to room. After RN 4 returned to Patient 24's room, he removed and discarded the blood-filled syringe from the window sill, but did not clean the window sill.

During an interview with RN 4 on 10/23/19 at 9:28 a.m., RN 4 confirmed he left the blood filled syringe uncapped and unattended on the patient's window sill.

During an interview with the Charge Nurse (CN) on 10/23/19 at 9:36 a.m., CN stated blood left uncapped and unattended placed patients, staff, and visitors at risk for injury and infection. The CN stated the uncapped syringe had the potential to contaminate the surface it was placed on, which increased the risk for patients to acquire infections.

A review of the hospital policy and procedure, "Central Line Catheters/PICC Lines/Port-A-Caths," dated 1/2015, indicated the blood sampling process for port-a-caths included, "Using a 10 mL syringe ...withdraw 2 mL of blood. Remove syringe and discard in bio-hazardous waste container."

7. During an interview with the ICP on 10/23/19 at 3:10 p.m., ICP stated the hospital followed the Centers for Disease Control and Prevention (CDC, a federal agency that conducts and supports health promotion, prevention and preparedness activities with the goal of improving overall public health) guidelines and recommendations for infection control.

During a concurrent observation and interview with the ICP, on 10/24/19 at 10:55 a.m., Patient 28's door had a sign indicating Patient 28 was on droplet precaution isolation. During a continual observation, a physician exited Patient 28's room wearing a surgical mask, and walked through the hallway in the patient care area on the second floor. ICP validated the signage, and stated the physician had not followed hospital protocol for patients on droplet precautions. The ICP stated all clinical staff, including physicians, were expected to follow isolation precautions of removing all PPE prior to leaving the patient's room, to prevent the spread of germs throughout the hospital.

A review of Patient 28's medical record document titled, "[Hospital name] Infection," dated 10/24/19, indicated, "[Patient 28] ...Primary Problem...Right lower lobe pneumonia...Isolation...Droplet...."

A review of the hospital policy and procedure titled, "Transmission Based Precautions," dated 1/2012, indicated, "Use Droplet Precautions as recommend in Attachment A [of 2007 CDC Transmission Based Precautions] ...Personal Protective Equipment (PPE) ...Follow procedure for Standard Precautions and IN ADDITION wear a surgical mask."


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8. During an observation of medication administration on 10/22/19 at 9 am, Registered Nurse 7 (RN 7) removed medication from the Pyxis (automated medication dispensing system) in the medication room without sanitizing or washing her hands (hand hygiene). RN 7 left the medication room, entered Patient 44's room, administered medication to Patient 44, and left Patient 44's room without any hand hygiene.

During an observation of medication administration on 10/22/19 at 9:15 a.m., Registered Nurse 8 (RN 8) failed to use hand hygiene prior to removing medication from the Pyxis in the medication storage room. RN 8 went to Patient 45's room, administered medication to Patient 45, and exited the patient's room, without any performance of hand hygiene.

During an observation of medication administration on 10/23/19 at 9 am, Registered Nurse 9 (RN 9) left the nurse station with medication for Patient 46. RN 9 entered Patient 46's room, administered medication to Patient 46, and left the room without any performance of hand hygiene.

In an interview on 10/23/19 at 9:10 a.m., the Assistant Nurse Administrator (ANM) stated nurses should perform hand hygiene before giving medications, and between providing care to different patients.

A review of the hospital policy and procedure titled, "Hand Hygiene," dated 12/2016, showed hand hygiene should be performed upon entering and exiting a patient's room.