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Based on observation, interview and record review, the facility's registered nurses failed to follow physicians' orders and accurately document the administration of packed red blood cells in 2 of 2 patients' records reviewed who had blood transfusions. Patient #s 11 and 16.
Findings:

Patient # 11
On 04/11/2016 at 10:45 a.m., Patient # 11 was observed in the main intensive care unit of the facility. The Patient was unresponsive and receiving hemodialysis treatment from a contracted service registered nurse.

Review of Patient #11's clinical record, revealed a physician's order dated March 29 2016 to " Transfuse PRBC- Numbers of Units 2 units., Frequency each over 2 Hours. Comment: Transfuse with HD. "

Review of Patient #11's clinical records (nurses' notes and acute hemodialysis treatment sheet), dated 03/30/2016, revealed documentation which indicated that Patient #11 was administered one unit packed red blood cells on 03/30/2016 at 11:00 a.m. - 12:00 noon. The unit of packed red blood cell was transfused during hemodialysis over a one hour period instead of two hours.

Review of the Patient's clinical record (nurses' notes and hemodialysis treatment sheet), revealed documentation which indicated that the patient was only administered one unit of packed red blood cells.

Subsequent review of Patient #11's clinical record, revealed an entry in a physician's progress notes dated March 30, 2016 which indicated the following: "Acute gastrointestinal bleeding. H and H decreases and we will transfuse I unit of red blood cells with dialysis. "

There was no indication in the patient's clinical record that registered nurses clarified the physician's order for the 2 units of packed red blood cell against what was written in the physician's progress notes.
Further review of Patient # 11's clinical record revealed a physician's order dated 04/04/2016 for
" Transfuse PRBC- Numbers of Units, 2 units, Frequency each over 2 Hours. Comment: Transfuse with HD. "

Review of Patient #11's clinical record (hemodialysis treatment sheet) revealed documentation which indicated that the patient was administered two units of packed red blood cells on 04/04/2016. Documentation indicated that the first unit of blood was transfused in hemo dialysis from 09:15 am - 9:45 a.m. and the second unit was transfused during treatment hemodialysis from 9:45 a.m. - 10:45 a.m.
The packed red blood cells were not transfused over 2 hours as ordered by the patient's physician.

Interview on 04/12/2016 at 2:22 p.m. with the Facility's Main Intensive Care Unit Registered Nurse Manager revealed, when an order is entered in the computer for packed red blood cell, the computer system automatically orders two units of red blood cells and orders for the blood to be transfused over 2 to 4 hours.


Patient #16
On 04/12/2016 Patient #16 was observed on the 6th floor medical surgical unit. The Patient was alert and oriented and was complaining of experiencing pain to his left hip.

Review of Patient #16's clinical record revealed a physician's order dated April 1st 2016 to " Transfuse PRBC- Numbers of Units 2 units., Frequency each over 2 Hours. Comment: Transfuse with HD. "

Review of the Patient's clinical record, revealed a blood transfusion record dated 04/02/2016, which was signed by the nurse administering the transfusion. The second signature validating information on the patient and the packed red blood cells were missing.

Review of Patient #16's clinical record (hemodialysis treatment sheet) revealed documentation which indicated that the two units of packed red blood cells were transfused on 04/02/2016 between the hours of 1530 and 1700.
The two units of packed red blood cells were not administered over two hours as ordered by the physician.

Based on observation, interview and record review, the facility failed to clean/ sanitize blood glucose monitoring machine after usage as evidenced by Patient Care Associate (PCA T) did not follow the facility's glucose monitoring protocol in 1 of 1 patient (Patient #39); failed to ensure the facility is free of dust; failed to ensure clean field used to catheterize patient is not cross contaminated during the procedure and failed to ensure operating room staff wear head gear and mask which totally covers the head, nostril and mouth during surgical procedures in 7 random observations.

Findings:


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Observation of Unit 5 PCA (T) on 04/12/2016 at 10:55 revealed she entered the room of Patient #39 (room 542) to perform blood glucose monitoring. PCA (T) removed the glucometer from its case, performed the blood glucose procedure, discarded the test strip and placed the glucometer on Patient #39's bed. She then returned the glucometer to its case and took it back to the nurse's station. She did not clean/ sanitize the glucometer after usage on Patient #39.


In an interview with PCA (T) on 04/12/2016 at 11:05, she stated the glucometer was " cleaned with Clorox in the morning " and that she does not clean it between patients.


In an interview with Unit 5 RN Manager ( W) on 04/12/2016 at 11:10, she stated: "The glucometer
(1) Is not to be placed on the patient's bed.
(2) Is to be cleaned between patients."


Record review of the facility's policy & procedure NU243, " Glucose Monitoring, " dated 09/15/2013 revealed th:e following " F. Cleaning: 1. Between each patient, use Clorox germicidal wipes to clean the exterior surfaces of the Inform II meter ... Wipe entire surface of meter, cover with wipe and let stand for one minute. Allow to air dry. "


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4 EAST MEDICAL SURGICAL:
Observation by Surveyor with Assistant Chief Nursing Officer #E, Stroke Quality Coordinator #AP, and Unit Director of Nursing #D on 04/11/2016 at 9:45 a.m., during the unit tour revealed 2 white hand sanitizers hanging on the wall outside of rooms 4049 and 4050 had dusts and dirt on top.

During an interview with Unit Director of Nursing #D on 04/11/2016 at 09:48 a.m., the Surveyor showed to her the hand sanitizers with dusts and dirt on top, she said "Okay we will send the housekeeping here now to clean all of those boxes."



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Indwelling catheter insertion :

Observation on 04-12-16 at 10:15 A.M. in operating room (OR) # 4 revealed Patient # 21 laying supine on the OR table being prepped for a "laparoscopic diverting colostomy."

Further observation revealed Registered Nurse (RN) Circulator # AH prepared to insert an indwelling urinary catheter into Patient # 21. The patient's legs were placed into metal table stirrups and a red biohazard bag was slipped under her buttocks at the end of the 'break-away" OR table.

RN Circulator # AH then opened the sterile indwelling catheter kit, and poured iodine antiseptic solution on several sponges contained in the kit. She then separated Patient # 21's labia and appropriately cleansed from top to bottom (over the urinary meatus) using an iodine soaked sponge.

RN Circulator # AH then disposed of the used iodine sponge by reaching around and across the catheter prep tray and discarding the sponge into a waste receptacle located behind her; thereby exposing the remaining iodine sponges to contamination. The remaining three (3) sponges were then used to continue cleansing the labia / urinary meatus area prior to catheter insertion.

Interview on 04-13-16 at 9:20 A.M. with Director of Surgical Services # AA she stated the contaminated iodine sponge should have been discarded into the biohazard bag at the end of the OR table.

Record review of Centers for Disease Control (CDC) Guidelines for "Prevention of Catheter-Associated Urinary Tract Infections," dated 2009, read: "...II. Proper Techniques for Urinary Catheter Insertion...3. In the acute care hospital setting, insert urinary catheters using aseptic technique and sterile equipment. ... a. Use sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for periurethral cleaning..."

Appropriate surgical attire:

Observation on 04-12-16 at 10:25 A.M. in operating room (OR) # 4 revealed Patient # 21 laying on the OR table undergoing a "laparoscopic diverting colostomy."

Further observation revealed Certified Registered Nurse Anesthetist (CRNA) # AJ prepared the anesthesia equipment and assisted with patient intubation by the anesthesiologist. CRNA # AJ failed to ensure her surgical mask was secured tightly over her mouth and nose. She was observed repositioning the mask several times during the procedure. The mask remained loosely tied with visible gaps between the mask and her face throughout the case.

Further observation revealed CRNA# AJ failed to have her hair completely covered. There was hair visible outside both sides of her surgical cap.

Observation at this same time revealed RN Circulator # AH failed to ensure her hair was properly covered. She was observed wearing two (2) two"bouffant-type" surgical caps." Hair was observed trailing outside the caps.

Further observation at this same time revealed the surgeon, Medical Doctor (MD) # AK and anesthesiologist MD # AI , both were wearing surgical "skull caps." Hair at the side burn and nape of neck areas was observed on both.


Interview on 04-13-16 at 9:20 A.M. with Director of Surgical Services # AA she said she was aware of the head covering and skull cap issue not being in compliance and this would be addressed.


Record review of Centers for Medicare & Medicaid Services (CMS) Region Vl, clarification of appropriate OR attire , dated April 2014, read: "...the regulations for surgical services require..services provided in accordance with acceptable standards of practice...The Association of periOperative Registered Nurses (AORN) require that all personnel should cover hair and facial hair, including sideburns and nape of the neck when in the semi- restricted and restricted areas of the surgical suite. The mask should cover the mouth and nose and be secured in a manner to prevent venting...Head covering should completely cover the hair...Skull caps are not permissible since it fails to contain the side hair above and in front the ears and at the nape of the neck..."


Record review of facility policy titled " Surgical Attire," dated January 2016, read: "...F. All head and facial hair, including sideburns and neckline, will be covered with a clean surgical hat when in the semi-restricted and restricted areas..G Masks will be worn by all personnel entering the restricted area when unwrapped sterile items are present.Vl. (policy) References..AORN Recommended Practice for Surgical Attire..."