HospitalInspections.org

Based on observation and staff interviews, the facility failed to ensure their staff were implementing infection control techniques to prevent the spread of infection as evidenced by the lack of handwashing/sanitizing and lack of knowledge related to proper disinfection of patient care equipment.

Findings include:

1. Cross-reference to C 279.

2. During a tour of the specialized rehabilitation services department on 8/5/14 at 10:15 A.M., it was found that staff used the ProSpray wipes to clean and disinfect the patient care equipment such as the sliding boards, exercise bands, wheelchairs, etc. However, the staff could not state the contact time to assure its effectiveness.

During a tour of the radiology department on 8/5/14 at 1:30 P.M., staff stated the ProSpray wipes were also used to clean the table where patients laid on. The staff also did not know the contact time but stated, "I think it's a minute or two--then I wipe it down with dry cloths."

On 8/5/14 at 2:25 P.M. during an interview with LN #1 in the emergency department, she stated, "ProSpray--contact time is 10 minutes." This was also verified by the housekeeper as the correct contact time for the ProSpray to be effective and written on the label (manufacturer's directions for use).

Based on observation, staff interviews and a review of the facility's policy and procedure, the facility failed to ensure the administration of medication was in accordance with accepted standards of practice, including the use of clean technique for the preparation of medications for 2 of 20 patients in the case sample.

Findings include:

On 8/5/14 at 8:50 A.M., Licensed Nurse #2 (LN #2) was observed passing medications to Patient
#2. At the start when LN #2 began pouring each medication, she did so without cleaning the top of the medication cart. There was a single brownish strand of hair on top the medication cart. LN #2 also placed the heparin syringe right on top of the hair strand. LN #2 was also noted to don clean gloves after pouring the medications, but did not sanitize her hands prior to doing this.

At approximately 9:20 A.M., during another medication administration observation for Patient #1, LN #2 had to return to the Pyxis machine to retrieve an additional dose of Lisinopril 5 mg. In doing so, she left the Levemir pen on top of the cart and although LN #2 locked the other medications, she did not secure the Levemir pen. In addition, LN #2 failed to sanitize her hands upon her return nor before she poured water into a cup for the Miralax mixture.

Then, for the Vancomycin preparation, LN #2 was observed to inject normal saline into the 1 gram vial, withdraw the syringe and needle, recap the needle atop the medication cart, pick up and roll the vial to mix it and re-enter/puncture the vial with the same needle/syringe to withdraw the medication. LN #2 did not reswab the vial top with alcohol before re-entering it with the same needle/syringe.

Once in Patient #1's room, LN #2 also placed four prefilled normal saline syringes on top of a wet spot on the patient's overbed table. LN #2, with her right gloved hand, then picked rubbish off the floor, removed the glove and then put on a new glove. She did not sanitize her right hand prior to donning the new glove. LN #2 proceeded to prime the intravenous (IV) line for the Vancomycin administration. However, since she primed it before flushing the patient's PICC line, she handed the tubing/line to the patient to hold and said to the patient, "don't touch the end" and walked around to the left side of the bed to flush the patient's PICC line.

LN #2 realized she had extra prefilled normal saline syringes which she placed into the patient's cubicle area above the dresser. LN #2 started the Vancomycin administration and started to walk out of the room at 10:10 A.M. LN #2 was then asked about the five prefilled syringes which she left at the patient's bedside. She initially said she was going to return for it, but then stated she would have to "waste all five," because she could not return it to the cart since it was left in the patient's room.

Review of the facility's policy, "Infection Control - Handwashing & Handcare" (Policy No. ICON 0024) found, "Handwashing shall be regarded by this organization as the single most important means of preventing the spread of infections. Policy Interpretation 1. All personnel shall follow our established handwashing procedures...2. All personnel shall wash and care for their hands appropriately. Appropriate ten (10) to fifteen (15) second handwashing must be performed under the following conditions:...2.B Before applying and after removing gloves...H Before preparing or handling medications."

On 8/6/14 at 1:25 P.M., during a concurrent interview with the Administrator and Director of Nursing, they stated that LN #2 received training for patients with PICC lines and infection control (handwashing protocol). They acknowledged LN #2 should not have the patient hold the primed IV tubing as part of the medication administration. The DON also said there should be use of a different needle/syringe or that LN #2 should have kept it in the Vancomycin vial after the first entry and drawn the medication out after mixing it. They also verified that each time staff removed gloves, they were to wash or sanitize their hands.

Based on record review, staff interview and a review of the facility's policy and procedure, the facility failed to ensure the medical records contained a discharge summary which discussed the outcome of the CAH stay, the disposition of the patient, and provisions for follow-up care for 2 of 18 closed record reviews conducted of the 20 sampled records. In addition, 4 of the 18 medical records contained patient discharge summaries completed/signed by the attending physician(s) that were beyond 30 days after the patients' discharges.

Findings include:

A review of the facility's policy and procedure, "CAH Discharge of Patients" (Policy No. MRE00; Rev 8/2013) stated the purpose was, "To outline procedure and medical staff responsibility for appropriate discharge of patients." The policy included, "7) At the time of an inpatient discharge, the practitioner discharging the patient must complete the discharge instructions documenting his or her final diagnosis. The final diagnosis (es) shall contain no abbreviations and/or symbols. The discharge summary should be completed within 72 hours of patient's discharge, and must be done no later than 30 days after the patient's discharge."

A review of the clinical records revealed non-compliance with the facility's own policy and procedure on the discharge process. This was confirmed by LN #1 during a concurrent record review on 8/6/14 and which the following was found:

1. Patient #6's clinical record revealed the patient was admitted on 5/29/14 and discharged on 6/12/14. There was no discharge summary found in the patient's record. On the morning of 8/6/14, Licensed Nurse #1 (LN #1) verified it was not done by the attending physician (Physician #1) and thus the record was incomplete.

2. Patient #3 was admitted on 3/21/14 and discharged on 3/28/14. However, Physician #1 completed/signed the discharge summary on 5/15/14, approximately 7 weeks after the patient was discharged.

3. Patient #4 was admitted on 4/4/14 and discharged on 4/11/14. However, Physician #2 completed/signed the discharge summary on 5/26/14, approximately 6 weeks after the patient was discharged home.

4. Patient #5 was admitted on 4/11/14 and discharged home on 5/1/14. However, Physician #1 completed/signed the discharge summary on 8/6/14, approximately 3 months after the patient was discharged.



31436

5. Patient #7 was admitted on 5/1/14 and discharged home 5/16/14. There was no documentation of discharge summary found in the medical record. According to LN #1, Physican #1 was informed of this.

6. Patient #8 was admitted on 4/10/14 and discharged home on 4/13/14. Physician #2 completed/signed the discharge summary on 5/26/14, which was about a month and 13 days after the patient was discharged.

On 8/6/14 at 1:25 P.M., concurrent interviews with the Administrator and Director of Nursing revealed the discharge summaries were checked by the regional medical records staff. However, per the facility's policy, the discharge summary was to be completed no later than 30 days after a patient's discharge.