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Based on medical record (MR) review and interview with facility staff, it was determined the facility failed to document an adverse event in 1 of 1 medical records reviewed for patients admitted to the detox unit. This did affect Patient Identifier (PI) # 3, and had the potential to affect all patients served by the facility.

Findings include:

1. PI # 3 was admitted to the facility's detox unit on 12/6/17 with diagnoses including Alcohol Abuse and Diabetes Mellitus.

Review of the Nurse's Note dated 12/9/17 at 8:00 AM revealed the following documentation: "Report from Housekeeping/(Staff) that 'There is a razor blade laying beside patient's head.' Counselor (first name only) indeed did come back to office with a 'razor blade' that appears to have been removed from our supplied shavers. She is to talk to patient."

The surveyor requested all documentation by counselor. Review of the documentation dated 12/7/17, 12/8/17, 12/9/17, and 12/11/17, revealed no documentation the counselor discussed the razor blade incidence with the patient.

The surveyor submitted the question to the facility on 12/13/17, was an incident report completed? The written response was, "no."

During an interview on 12/14/17 at 1:20 PM with Employee Identifier (EI) # 1, RN (Registered Nurse), Acting Director of Nursing, the surveyor was provided an Incident Report Form, dated 12/14/17 and completed by EI # 1.

The incident was not witnessed by EI # 1, and no other witness was listed on the form. Further review of the Incident Report Form revealed the following documentation by EI # 1 under the title 'Follow-up': "Will explain to staff incidence reports have to be filled out on day of occurrence." There was no documentation of follow up for the patient, or what was done to prevent another occurrence. EI # 1 confirmed the above findings.



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2. A review of substance abuse/ detox employees personnel files was conducted on 12/14/17 for 12 of 12 employees and revealed no documentation the employees completed hospital orientation including what to report as an adverse event.

In an interview conducted on 12/14/17 at 1:30 PM with EI # 1, the above findings were confirmed.

Based on review of the Anesthesia Policy and Procedures (P and P), Anesthesia Quality Assurance (QA)/ Quality Improvement (QI) and interview with the anesthesia staff, it was determined the department failed to accurately review, audit and report the appropriate criteria and audit tools to the Quality Coordinator.

Findings include:

Subject: Performance Improvement For Department of Anesthesia
Reviewed: December 2016 (online)

Policy:
It is the policy of Clay County Healthcare Authority to outline the method for performance improvement completion for the Anesthesia Department.

Responsibilities:
A. The Anesthesia Department Director shalt establish and/ or approve the pre-established criteria to be used to identify patients for review.
B. Post Acute Care Unit (PACU) and operating room personnel shall list the names and medical record numbers of all patients who meets the pre-established criteria.
C. The Anesthesia Department shall review each case and make appropriate recommendations.

Attachment:
1. Performance Improvement Indications and Notification Form
Surgery- Anesthesia- PACU (Surgery)
2. Surgical Services
Performance Improvement Log (Reference # 6010 Surgery)
3. Performance Improvement
Operative/ Invasive Procedure Review (Reference # 6011 Surgery)
4. Performance Improvement Quarterly Report (Reference # 6009 Surgery)
Confidential

During an interview conducted on 12/14/17 at 1:30 PM with the Employee Identifier (EI) # 8, Chief Nurse Anesthetist (CRNA), the surveyor requested to see the quality audits, summary and sample review that he/ she had done and submitted to the Quality Coordinator.

After the interview, EI # 8 came back and provided the surveyor with the following: Anesthesia QA/ QI for the month of November 2017 and an audit form labeled Anesthesia Quality Plus, Risk and Quality Management Collection Form. EI # 8 stated that these are the forms she/ he had been using to audit and was not aware the forms had been changed. The surveyor showed EI # 8 the forms found in the Anesthesia P and P, he/ she agreed the forms in the Anesthesia P and P should have been used.

Based on interview and review of the hospital's Quality Assessment Improvement (QAPI) program, the hospital failed to assure:

1. Information submitted by each department are collated and reported to the Governing Body.

2. Contracted services were included in QAPI.

This had the potential to affect all patients served.

Findings include:

Quality Assessment/ Assurance Performance Improvement Plan (QAPI): A Plan for Improving Organizational Performance.

I. Purpose Statement
Clay County Hospital's purpose is to provide excellent quality care and services as well as proactively maximizing quality improvement activities and programs in areas where no specific deficiencies are noted. Quality is defined as meeting and exceeding the needs, expectations and requirements of the patients cost-effectively while maintaining good patient outcomes and perceptions of care.

II. Scope

b. Clay County Hospital's full range of services included in our QAPI program are Emergency Room, Acute and Outpatient Care, Swing -bed and Outpatient Therapies as well as ancillary departments.

III. Goals Objectives

5. Integrating and coordinating all quality improvement activities throughout the hospital.

10. Informing clinical departments, physicians, and patients about outcomes of care.

IV. Authority and Responsibility for Quality Improvement

c. QAPI Committee

7. QAPI activities are reported to the governing body at Full Board meetings which is held quarterly.

IX. Documentation
1. Documentation of Quality Improvement activities is recorded in meeting minutes and in department quality reports.

3. The Director of Quality Management reports quality activities to the Medical Staff and the Board of Trustees.
4. Information is shared with employees through the Quality Improvement Committee, the Departmental Managers, memorandum and meetings.

During an interview conducted on 12/14/17 at 9:00 AM, Employee Identifier (EI) # 9, Emergency Room Director (ED) informed the surveyor that the Emergency Room (ER) department Continuous Quality Indicators (CQI) are those assigned by the Hospital Core Measures with 100 percent goal which was met for the months of January, February and March 2017. There were no further reports submitted by the ER department after March 2017 to November 2017.

During the interview with EI # 9, EI # 2, Director of Quality Management (DQM), was present. EI # 2 stated that she/ he collates all the reports and verbally presents the reports to the Governing Body and/ or the Full Board. The surveyor requested for a copy of what she/ he reports, EI # 2 was not able to provide the surveyor with the copy of the reports she/ he verbally reported to the Governing Body and/ or the Full Board.

Review of the Executive Committee Governing Body meeting minutes dated 1/31/17, 3/2/17, 3/28/17, 4/25/17, 5/30/17, 6/27/17, 7/25/17, 8/29/17, 9/25/17, 10/30/17, and 11/28/17 revealed no documented verbal QAPI reports were submitted.

Review of the Full Board meeting minutes dated 1/31/17, 3/2/17, 7/25/17 and 10/30/17 revealed no documented verbal QAPI reports were submitted.

Review of the above mentioned meeting minutes revealed no documentation of representation of the substance abuse/detox unit (Contracted).

In an interview conducted on 12/14/17 at 9:15 AM, EI # 2, confirmed the above mentioned findings.

Based on review of medical records (MR), policy and procedures, and interview it was determined the nursing staff failed to:

1. Document wound assessments to include appearance of the wound/ wound bed and surrounding tissue, exudates, drainage, odor, signs and symptoms of infection, measurements, and consistent site labeling and stages of wounds

2. Document specific wound care provided

3. Have orders for wound care provided.

4. Notify the physician of changes in the patient condition new wounds or bloody stools.

This affected 2 of 2 in-patient records reviewed of patients with wounds including Patient Identifier (PI)'s # 1, # 10 and had the potential to negatively affect all patients served by this facility.

Findings include:

Policy: Wound Care/ Decubitus Protocol Prevention, Care and Photographing
Revised Date: April 2017

Policy:
"It is the policy of Clay County Healthcare Authority that all patients admitted to Clay County Hospital shall receive a complete head-to-toe assessment, at which time a thorough examination of the skin will be done. If the patient has a decubitus ulcer(s) or if one develops during stay at this facility for medication treatment, a photograph may be taken. The assessment of the care or treatment needs of the patient will be ongoing throughout the patient's hospital stay...

General Assessment and Documentation of Wounds Assessment to include:
1. Type of wound
2. Location
3. Size in centimeters (cm) (length X (by) width X depth using cephalocaudal orientation)
4. Appearance of wound bed
5. Presence/ absence of tunneling...
6. Stage or category (as appropriate, NAME AFTER PHYSICIAN CONFIRMS STAGE)
7. Color, presence/ character of slough and/ or eschar
8. Presence/ character of exudate
9. Odor
10. Condition of surrounding skin
11. Absence/ presence of pain
12. Photo documentation on admission and as needed...
14. Date, time, MD (Medical Doctor) notified
15. Patient's response and compliance with interventions...

At the first sign of pressure sore/decubitus medical treatment:
1. A "Consent to photograph" form must be completed.
2. An initial photograph shall be taken of each decubitus stage and as needed...
4. Measure decubitus and document size.
5. Call physician to report and for treatment orders.
6. Begin treatment as ordered by MD.
7. Record the date and time of initial and subsequent treatment, per physician's orders."

1. PI # 1 was admitted to the facility in a swing bed on 11/15/17 with diagnoses including Hypovolemic Shock, Left Femoral Neck Fracture, Status Post Open Reduction Internal Fixation (ORIF), and Diabetes Mellitus Type 2.

Review of the initial assessment of patient completed on 11/15/17 at 12:07 PM by the Registered Nurse (RN) revealed the documentation, "Surgical incision, no dressing, and location of pressure ulcer open skin on buttock"

There was no documentation the RN notified the physician or obtained wound care orders for surgical wound or pressure ulcer.

Review of the Nurses Note (NN) dated 11/15/17 at 7:19 PM revealed the documentation, "Surgical incision, left hip, staples intact, no dressing, scant amount of serous, to upper part of incision".

Review of the NN dated 11/16/17 at 12:46 AM revealed the documentation of, "Redness noted to bottom with small open area with top of skin off to left coccyx..."

There was no documentation the nursing staff notified the physician and obtained orders for the care the patient's surgical wound or pressure ulcer.

Review of the physician orders and 31 progress notes for the dates of 11/15/17 to 12/6/17 revealed no physician orders for wound care.

Review of the NN's dated 11/16/17, 11/17/17, 11/18/17, 11/19/17, 11/20/17, 11/21/17, 11/22/17, 11/23/17, 11/24/17, 11/25/17, 11/26/17, 11/27/17, 11/28/17, 11/29/17, 11/30/17, 12/1/17, 12/2/17, 12/3/17, 12/4/17, 12/5/17, 12/6/17, 12/7/17, 12/8/17, 12/9/17, 12/10/17, 12/11/17, 12/12/17, and 12/13/17 revealed no documentation the nursing staff measured the pressure ulcers per policy.

Further review of the NN for 11/17/17 at 3:45 PM revealed documentation the patient had blood in stool and no documentation the staff notified the physician.

Further review of the NN for 11/20/17 at 7:00 AM revealed the patient now had 2 pressure ulcers.

There was no documentation the nurse notified the physician of the pressure ulcers, followed facility policy for pressure ulcer/ decubitus care, or obtained orders for care of the wounds.

In an interview conducted on 12/14/17 at 12:45 PM with Employee Identifier (EI) # 1, Acting Director of Nursing, the above findings were confirmed.

2. MR # 10 was admitted to the facility on 10/4/17 with diagnoses including Acute Gastroenteritis with Dehydration, Chronic Kidney Disease Stage 3.

Review of the physician H&P dated 10/5/17 revealed the patient had Stage 2 decubitus ulcers.

Review of the 10/5/17 physician's order at 9:31 AM for nursing to provide simple wound cleaning.

Review of the 10/5/17 physician's verbal order received at 2:56 PM revealed Carrington Wound Gel apply twice daily per decubitus treatment protocol.

Review of the NN dated 10/5/17 at 2:02 PM revealed the pressure ulcer documentation of, "right buttock cheek- 2 pressure sores noted, 1st one is 2 cm X 2 cm, irregular, and skin red but the epidermis is peeled off but the dermis is intact on the first one.

2nd sore is 1 cm X 1 cm, circular in shape, and skin red but the epidermis is peeled off but the dermis is intact on this sore. Also, the skin around the 2 pressure sores on the right and on the left has a large area of bluish- purple skin.

The 3rd pressure sore is on the upper part of the left buttock 1.5 cm X 0.75 and is irregular, skin red but the epidermis is gone but the dermis is intact, yellowish-white exudate noted to sore of left buttock...
Dressing: Cleansed wound using aseptic technique with wound cleaner, applied wound gel to sores, then placed an abd (abdominal) pad over pressure sores and secured with paper tape. Patient tolerated the wound cleansing well..."

Review of the physician's orders revealed no wound care orders for the above wound care provided.

Review of the 10/5/17 AM/ PM, 10/6/17 AM/ PM, 10/7/17 AM/ PM, 10/8/17 AM /PM, and 10/9/17 AM nursing notes revealed no documentation the staff performed a complete assessment of the wound that included the depth of the Stage 2 pressure ulcers/ decubitus or description of each wound identified.

Further review of the above mentioned nursing notes revealed no documentation of a complete wound assessment or care what was provided.

In an interview conducted on 12/14/17 at 1:10 PM with EI # 1, the above findings were confirmed.

Based on Medical Record (MR) review and interview, the hospital failed to assure all patient ordered medications were administered per physician orders and documented in the medical records for 1 of 6 inpatient medical records reviewed. This affected Patient Identifier (PI) # 21 and had the potential to affect all patients served by the hospital.

Findings include:

1. PI # 21 was admitted to the facility on 10/6/17 with diagnoses including Dehydration, Gastroenteritis, and Pneumonia Community Acquired.

Review of the Hospital Admission Orders dated 10/6/17, and included the following order: "Home Meds (Medications) per Medication Reconciliation."

Review of the MR revealed the physician failed to write complete admission orders that included all medications.

Review of the Nurse's Notes dated 10/10/17 at 9:09 AM revealed the following documentation: "Called (the doctor) office, spoke to Registered Nurse at physician's office. Reported BP (blood pressure) 158/102 manually. Patient has not been started on her home medication Losartan 100 mg (milligrams)/ (Hydrochlorothiazide) 25 mg PO (by mouth) daily. Received order to start medication back/ Read and verified."

Review of the medical record revealed an initial B/P of 139/80 on 10/6/17 at 3:34 PM.

During an interview on 12/14/17 at 12:30 PM with Employee Identifier # 1, RN, Acting Director of Nursing, confirmed the above findings.

Based on review of medical record (MR) and interview, it was determined the hospital staff failed to complete medical records within 30 days following discharge. This affected 1 of 6 discharged medical records reviewed. This did affect Patient Identifier (PI) # 21, and had the potential to negatively affect all patients served by this facility.

Findings include:

1. PI # 21 was admitted to the facility on 10/6/17 with diagnoses including Dehydration, Gastroenteritis, and Pneumonia Community Acquired.

The patient was discharged on 10/11/17.

The Discharge Summary dictated by Employee Identifier (EI) # 1, Registered Nurse, Acting Director of Nursing, dated 11/25/17 was reviewed. This was 45 days following discharge, and signed by the physician on 11/27/17, 47 days following discharge.

During an interview on 12/14/17 at 12:30 PM with EI # 1, confirmed the Discharge Summary was not completed within 30 days of discharge.

Based on a tour of the Dietary Department, interview, and facility policies, it was determined the facility failed to store food in a safe and sanitary manner. This had the potential to affect all persons served by the facility.

Findings include:

Policy: Food Storage
Policy # C001
Date revised: No date listed

"Expiration dates printed by the manufacturer apply until the product is opened. Once opened, use these time limits unless the manufacturer's date is earlier. The day of opening/preparation counts as Day 1.

Dry Storage:
...6 Months, or the manufacturer's expiration date, if sooner: Cereal, Sugar...
...1 Year, or the manufacturer's expiration date, if sooner: All unopened canned, carton boxed, or bottled goods, Spices...

Refrigerated Storage:
...4 Days: Unused portions of foods prepared on site that are reheated... Deli meats...
...7 Days: Cheese- all cheeses except hard cheese (14 days)
...30 Days: Salad dressings, mayonnaise...

Policy: Method for Disposal of Expired Food Items
Effective: March 2017

"Procedure: All food items will be labeled and dated. Expired food items that have expired dates will be thrown out.
1. Supervisor will inspect dry storage areas, refrigerators, and freezer once a week for expired food items.
2. All items with expired dates will be thrown out.

Policy: Infection Control
Department: Nutritional Services
Date revised: 3/2017

Policy: It is the policy of Clay County Healthcare Authority to prevent and control contamination and the spread of infection within the department and the Hospital.

...A ...1. To develop and maintain clean, sanitary work areas, storage areas and equipment for the handling of supplies in accordance with State and local health department standards.
*****

During a tour of the Dietary Department on 12/12/17 at 10:30 AM, the following opened, unlabeled, or expired items were observed:

Dry Food Storage:
1. 2- Ziploc bags of red crumbles (imitation bacon bits), opened, with no opened or expiration date.
2. 3- 12 oz (ounce) bags Low Sodium Chicken Flavored Gravy Mix, 2 labeled opened on 5/9, use by 5/16, 1 opened to air, no opened or expiration date.
3. 1- gallon container of Kikkoman Soy Sauce, labeled opened 4/27, manufacturer's expiration date is 9/1/16.
4. 1- pack of 10" (inch) flour tortillas, opened with no opened or expiration date.
5. 1- 18 oz bottle Ground Cumin, manufacturer's expiration date 10/13/16.
6. 1- 22 oz bottle of Cajun Seasoning, manufacturer's expiration date 9/3/15.
7. 2- 18 oz bottles of Spanish Paprika. 1 bottle with lid opened and product all over outside of container, manufacturer's expiration date 10/20/16. 1 bottle with expiration date 10/13/16.
8. 4- 23 oz bottles Montreal Chicken seasoning, opened, with no opened or use by date.
9. 1- 20 oz bottle of Lemon Pepper seasoning, opened, with no opened or use by date.
10. 1- 5 lb (pound) container of Pepper, opened, with no opened or use by date.
11. 1- 6 lb container of Garlic Powder, opened, with no opened or use by date.
12. 1- 28 oz bottle of Italian Seasoning, opened, with no opened or use by date.
13. 10- gallon plastic container labeled "Splenda," no opened or use by date. Container has crumbs all over the top.
14. 1- 15 oz box of raisins, opened to air, no opened or use by date.
15. 1- 24 oz bag vanilla pudding and pie filling mix, opened, with no opened or use by date.
16. 1- 5 lb container of Buttermilk Biscuit mix, opened date 12/12, no use by date.
17. 1 box of assorted Designer Dessert Sauce, 4 bottles opened and unlabeled. Brown substance on one bottle and in bottom of box.
18. 2- 16 oz bottles of White Chocolate Sauce, opened, with no opened or use by date.
19. 1- 16 oz bottle of Raspberry Sauce, opened, with no opened or use by date.
20. 4- 6 lb cans of Sliced Peaches, manufacturer's expiration date 7/6/17.
21. 9- 6 lb cans Pear Halves in light syrup, manufacturer's expiration date 11/10/16.
22. 5- 6 lb cans Mandarin Oranges, manufacturer's expiration date 10/31/16.
23. 1 case (100 containers) Smucker's 1.1 oz Sugar Free Syrup, manufacturer's expiration date 10/21/17. 16 containers in another box, manufacturer's expiration date 7/9/17.
24. 38 packets of Cocktail Sauce, manufacturer's expiration date May 2017, one packet opened in box.

The following opened and unlabeled items were observed in the outdoor cooler:

1. 1 bag of cooked chicken, opened 12/11, no use by date.
2. 1 gallon of Thousand Island dressing, labeled: opened 12/1, use by 12/8.
3. 1 bag shredded Cheddar Cheese, opened 12/12, no use by date.
4. 1 container Low Fat Cottage Cheese, opened 12/7, no use by date.

The following was observed in the outdoor freezer:

1. 1 box of frozen fish, opened on 12/6, no use by date.
2. 1 bag of smoked sausage, opened and no label.
3. 1 box of Beef Steak Fritters, opened and no label.

During a tour of the Dietary Department, Back Room, the surveyor found that a shelf with bags of bread had a large area of rat droppings on the floor below.

During an interview on 12/12/17 at 1:55 PM, with Employee Identifier # 7, Dietary Supervisor, the above findings were confirmed.

Based on review of facility policy, observation, and interview, it was determined the facility failed to ensure all medical supplies available for patient use in the facility were not expired. This had the potential to affect all patients served by the facility.

Findings include:

1. During a tour of the medication room conducted on 12/13/17 at 7:45 AM with Employee Identifier (EI) # 3, Registered Nurse, the surveyor observed the following supplies to be expired:

2- Spinal needles 25 gauge (gu) with the expiration date of 2/08.
2- Protonix Intravenous (IV) filter with the expiration dates of 12/05 and 2/06.
4- 23 gu 1 inch needles with the expiration date of 10/17.
3- purple top blood vials with expiration dates of 7/11, 9/11, and 10/12.
2- IV tubing open and not in packages in a drawer.
Skin staple extractor with the expiration date of 6/05.

In an interview conducted on 12/13/17 at 8:30 AM with EI # 1, Acting Director of Nursing, confirmed the above medical supplies were expired.

Based on review of facility policies and procedures, Centers for Disease Control (CDC) guidelines, observations and interview with the staff it was determined the facility failed to ensure the staff:

a) Followed the facility policy and procedure for proper hand washing and glove changes and disinfection of medical equipment used during patient care.

b) Monitored compliance of hand hygiene practices.

This affected 3 of 3 patient observation on hand hygiene including Patient Identifier (PI)'s # 2, # 4, # 1, and had the potential to negatively affect all patients served by the facility.

Findings include:

Subject: Infection Control Plan
Revised: Dec. 2016

"Policy: ...
B. Statement...

3. Each department, in partnership with the medical staff, will be responsible and held accountable for its role in the Infection Control Program. ... each department will be responsible for full and timely cooperation with the Infection Control Practitioner (ICP) and Infection Control Committee to develop and implement remedial/ corrective action.

5. The Infection Control Program at Clay County Hospital incorporates the following in a continuing cycle:
a. Surveillance, prevention and control of infections throughout the hospital
b. Develop alternative techniques to address the real and potential exposures.
c. Select and implement the best techniques to minimize adverse outcomes.
d. Evaluate and monitor the results and revise techniques as needed."

Subject: Hand Hygiene Monitoring
Reference # 3009
Effective: June 5, 2014

"Purpose: Effective hand hygiene practices reduce transmission of pathogenic microorganisms to patients and personnel.

Responsibility: Effective and hygiene is an institutional priority and is part of the hospital's overall Infection Control and Safety Plan. All hospital and nursing home personnel are responsible for adhering to the hand hygiene program.

Policy: ...
C. Use an alcohol- based hand sanitizer for routine decontamination of hands:

2. Before donning gloves, especially prior to insertion of invasive devices, e.g. intravenous catheters.
3. Before and After direct patient contact.
4. After contact with inanimate objects.
5. Before and After removing gloves.

Procedures:

B. Proper techniques for use of waterless alcohol-based hand sanitizer includes:
1. Apply product to palm of one hand hand and rub hands together, covering all surfaces of hands and fingers until hands are dry...

E. Education and Enforcement/ Monitoring

1. Infection Control will monitor compliance and designate departmental directors, managers, and supervisors to monitor their areas as well. Efforts to improve hand hygiene practice include education and feedback to staff on compliance and infection surveillance data...

3. Hand Hygiene detailed observation tool will be used to monitor compliance."

CDC Guideline for Hand Hygiene in Health-Care Settings
October 25, 2002 / 51(RR16);1-44

Gloving Policies

CDC has recommended that HCWs (Health Care Workers) wear gloves to 1) reduce the risk of personnel acquiring infections from patients, 2) prevent health-care worker flora from being transmitted to patients, and 3) reduce transient contamination of the hands of personnel by flora that can be transmitted from one patient to another... The Occupational Safety and Health Administration (OSHA) mandates that gloves be worn during all patient-care activities that may involve exposure to blood or body fluids that may be contaminated with blood.

1. An observation was conducted on 12/13/17 at 10:00 AM on the Medical Floor to observe Employee Identifier (EI) # 10, Registered Nurse (RN), administer Solu Medrol 125 milligrams (mgs) intravenously (IV) every 8 hours. Observed EI # 10 retrieve the medication from the Omnicell Medication Dispenser verified. EI # 10 failed to perform hand hygiene prior to and after accessing the medication from the Omnicell. With the surveyor and a stand-alone computer, EI # 10 entered PI # 2's room.

Without performing hand hygiene prior to and after scanning, EI # 10 scanned the patient's identification bracelet against the prepared medication.
Without performing hand hygiene and or/wearing gloves, EI # 10 cleanse the injection port and administered the medication. EI # 10 failed to perform hand hygiene after the medication was administered.

Without performing hand hygiene, EI # 10 keyed it the information about the medication administration into the stand- alone computer.

The surveyor observed EI # 10 fail to disinfect the stand- alone computer or perform hand hygiene after leaving the patient's room.

An interview was conducted on 12/14/17 at 12:05 PM with EI # 1, Acting Director of Nurses (ADON) who confirmed the above mentioned findings.

2. An observation was conducted on 12/13/17 at 2:00 PM on the Medical Floor to observe EI # 10 flush Patient Identifier (PI) # 4 Heparin Lock with 10 milliliters (ml) of Normal Saline (NS). EI # 1 entered the room wheeling in the stand- alone computer.
Without performing hand hygiene, EI # 10 proceeded to scan the patient's identification bracelet against the NS flush syringe.
Without performing hand hygiene or donning on gloves, EI # 10 cleanse the intravenous plug, wiped it with alcohol swab and infused the NS slowly.
After administering the NS flush and no hand hygiene performed, EI # 10 discarded the syringe then keyed in the information on the stand-alone computer and left the patient's room.
At the hallway, the surveyor asked EI # 10 who cleans/ disinfects the stand- alone computer, EI # 10 answered "no one". The surveyor asked EI # 10 how often do you clean the stand-alone computer? EI # 10 answered :" when it looks dusty". EI # 10 further stated, "I don't remember when we last cleaned this computer because we never had ".

An interview conducted on 12/14/17 at 12:10 PM with EI # 1, who confirmed the staff failed to follow the facility's policy and procedures.



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3. An observation of a medication pass was conducted on 12/13/17 at 9:05 AM with EI #'s 4 and 5, Licensed Practical Nurses (LPN).

The surveyor observed EI # 4 leave the nurses station and enter the medication (med) room. EI # 4 obtained the locked white rolling cart and entered PI # 1's room without performing hand hygiene.

The surveyor obtained permission to observe the medication administration from PI # 1, and family member at the bedside.

EI # 4 placed a clear plastic bag that contained Lantus SoloStar insulin pen and alcohol pads beside the mouse on the white medication cart with ungloved hands.

EI # 4 scanned the patient's bracelet and medications, opened the medication packaging, and administered the pills to the patient with ungloved hands.

Then EI # 4 applied gloves, then removed the insulin pen from the clear plastic bag, verified the dosage with EI # 5, and administered the insulin, removed gloves and reapplied gloves with no hand hygiene. Then EI # 4 applied cream to gloved hand and then applied the cream to patient's right shoulder removed gloves and left the patient's room. EI # 4 failed to perform hand hygiene after removing gloves and leaving the patient's room.

EI # 4 returned the med cart to the med room, replaced the clear plastic bag containing the insulin to PI # 1's med drawer and then went to the nurses station to speak with pharmacy.

EI # 4 returned to the med room to the locked white med card, obtained a cup labeled with an unsampled patient name medications and then washed hands.

EI # 4 failed to perform hand hygiene per policy.

In an interview conducted on 12/14/17 at 1:00 PM with EI # 1, confirmed the staff failed to follow facility policy for hand hygiene.

4. On 12/13/17 at 2:15 PM the surveyor requested from EI # 6, Infection Control/ Core Measure Abstractor, the hand hygiene monitoring tool documentation and none was provided.

At 2:40 PM EI # 6 stated to the surveyor there was no hand hygiene monitoring tool in place at this time.

In an interview conducted on 12/14/17 at 1:00 PM with EI # 1, confirmed the above findings.

Based on review of medical record (MR), facility policy, and interviews, it was determined the facility failed to demonstrate evidence of an ongoing activities program with scheduled activities to promote quality of life for patient's admitted to the swing-bed program. This affected 1 of 1 swing bed patient record reviewed, including Patient Identifier (PI) # 1 and has the potential to affect all patient's admitted to the facility's swing-bed program.

Findings include:

Facility Policy: Referral of Swing Bed Unit
Reviewed: July 2017

Policy:
"It is the policy of Clay County Healthcare Authority that Swing Bed unit is a short-term program...

C. The patient must have orders daily for skilled nursing to quality for this level of skilled care..."

1. Review of the facility policy for Referral to Swing Bed Unit on 11/14/17 revealed no documentation of how/ when the patient's activity assessment should be addressed by the staff.


2. PI # 1 was admitted to the facility in a swing bed on 11/15/17 with diagnoses including Hypovolemic Shock, Left Femoral Neck Fracture, Status Post Open Reduction Internal Fixation, and Diabetes Mellitus Type 2.

A review of the MR and Social Work documentation for the dates of 11/15/17 to 12/13/17 and revealed no Activities Assessment or Activities plan of care had been completed for the swing bed patient.

During the observation of a medication pass conducted on 12/13/17 at 9:20 AM the surveyor asked PI # 1 and the caregiver what activities was the hospital providing to the patient since admission. PI # 1 stated, "Therapy folks come and do therapy."

PI # 1's caregiver was not aware of any activities the staff had been providing other than therapy.

The surveyor submitted the question on 12/13/17 at 2:30 PM if the facility had documentation an activity assessment / activity plan of care for the swing bed patient.

The surveyor was provided on 12/18/17 at 9:30 AM via email a hand written Activity Interest Assessment completed on 11/22/17. This was 7 days after the patient was admitted to the swing bed and no plan how the activities would be provided to the patient.