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Based on record review, policy and procedure review and interview the facility director of nurses failed to ensure the nursing staff was able to provide appropriate nursing care by failing to ensure the working operation of a cardiac defibrillator for 1 of 4 nursing units by failing to check the defibrillator's operation at start of each nursing shift.

The findings are:
On 2/7/17 beginning at approximately 3:22PM and inspection of the medical/ surgical unit crash cart was done with sampled staff F, the registered nurse (RN) and the unit manager (UM). Interview with sampled staff F at this time revealed the defibrillator should be checked every 24 hours. She stated they document the defibrillator test by running a test strip which automatically dates and times the strip when it is run. The nurse provided the surveyor with a book which she stated contained the documentation of the defibrillator tests. Review of this documentation with the nurse revealed the defibrillator had been checked on 2/7/17 at 10:48AM, 2/6/17 at 18:13PM, 2/4/17 at 3:05PM, 2/1/17 at 22:01PM, 1/30/17 17:43PM, 1/29/17 at 8:17AM, 1/27/17 time unknown, 1/22/17 at 1:12, 1/20/17 at 23:25. Interview with the Risk Manager (RM) on 2/8/17 at 4:08PM revealed the nursing staff should be checking the operation of the defibrillator every shift and we have two twelve hour shifts. Review of the facility's policy SC-08 with the RM revealed it states that the crash cart and its contents; which she stated the defibrillator is considered part of the crash cart; should be checked by the nursing staff at the start of each shift. Interview with the director of nurses (DON) on 2/10/17 at approximately 11:00AM confirmed the nursing staff should be checking the operation of the cardiac defibrillators at the beginning of each shift, which is two times a 24 hour period.

Based on observation, interviews and record review the facilty failed to ensure nursing care assignments were in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available.

Findings:

On 2/10/2017 at approxamitely 11:00am a tour was conducted of the facility's Intensive Care Unit (ICU). A Registered Nurse, Employee O, was observed seated at the nurse's station. There were two patients in the unit at the time of the observation. In interview with the employee, at the time of the observation, she was asked if she had a current Advanced Cardiac Life Support (ACLS). She stated "no, I had one but it has expired... I guess I should get it renewed."

Review of Employee O's personnel record was conducted revealing an active, current nursing license; and a current Basic Life Support certification. The record failed to document any Advanced Life Support certifications.
On 2/10/2017 at approximately 12:10pm an interview was conducted with the facility's Director of Nursing (DON). She confirmed Employee O to be currently assigned to the ICU patients, stated she was hired primarily as an ICU nurse, but assists in other departments as needed. She confirmed the employee is a full-time employee whose primary assigned unit is the Intensive Care Unit. She stated that the nurses in the Intensive Care Unit (ICU) have ACLS certification. When the DON was informed the nurse currently in ICU does not have a current ACLS certification, she stated she would never send a nurse to the ICU alone if they didn't have current ACLS certification. The DON confirmed Employee O was assigned to the ICU as the only nurse this morning, but will be sending another ACLS certified RN to the ICU to assist her today.

On 2/10/2017 the facility's policy titled "ACLS Card Requirements" was reviewed. The policy documented Registered Nurses (RNs) in the Emergency Department and Intensive Care Units will maintain a current Advance Cardiac Life Support certification.

Based on observations and interviews, the facility failed to ensure medications were stored in a secure manner for 2 of 4 nursing units.

Findings:

On 2/7/17 at approximately 11:00am, in the presence of the OR (operating room) supervisor, a surveyor observed a 5 drawer cart adjacent to one of the preoperative/postoperative bay area beds. The cart was observed not to be locked. The OR supervisor stated this cart housed the Preop/Post Anesthesia Care medications. Medications included protonix, zofran, nalosene, digoxin, nitrobid, antibiotics, 50% dextrose ampule and solumedrol, in addition to other medications. When the OR supervisor was questioned why the medications were not in a secured area, she replied "we have not been using that bay as it did not have a cardiac monitor." A cardiac monitor was observed to now be in place. The supervisor left the unsecured medications in place until once again this surveyor questioned the potential for medication accessibility to patients, family members and/or others who are not authorized to access.




20377

On 2/8/17 at approximately 11:15AM the surveyor and sampled staff X, a medication nurse, were in the locked medication storage room of the medical/surgical unit. The medication nurse was preparing the intravenous medication for sampled patient #11. The medication room can be entered through two different doors; each door has a window and has a key pad for entry. During this time sampled staff W, a certified nurses assistant (C.N.A.), entered the medication room using the key pad on 2/8/17 at approximately 11:15AM. He entered the medication room and placed a cart which contained personal hygiene products in the room and left. Interview with sampled staff X at this time revealed that the C.N.As on the medical/surgical unit have access to this room due to the personal hygiene and other supplies are stored in this area. On 2/9/17 at approximately 10:30AM the facility pharmacist was asked about the facility policy and procedure for appropriate staff with access to the medication room he referred the surveyor to the Risk Manager (RM). But he did state even his pharmacy staff do not enter the medication room without a nurse present. Interview with the RM on 2/9/17 at approximately 10:50AM revealed her statement the facility does not have a policy which addresses what staff are allowed in the medication room. When asked what is the facility's procedure for allowing staff in the area where medications are kept, the RM stated on the medical/surgical unit the C.N.A.s have access to the area where medications are stored due to that area also contains other supplies such as personal hygiene products the C.N.A. must have to provide patient personal care. Record review of the facilities policy PH-12 for pharmacy and medication storage revealed all medications at nursing stations shall be in lockable storage at all times. Authorized personnel included registered nurses (RN), licensed practical/vocational nurses (LPN/LVN), licensed psychiatric technician, respiratory therapist, pharmacist and pharmacy technicians. Interview with the RM on 2/10/17 at approximately 10:30AM confirmed these findings.

Based on observations, review of policy and procedures and staff interviews the facility failed to ensure only authorized personnel have access to locked and secured medications for 1 of 4 nursing units.


The findings are:

On 2/8/17 at approximately 11:15AM the surveyor and sampled staff X, a medication nurse, were in the locked medication storage room of the medical/surgical unit. The medication nurse was preparing the intravenous medication for sampled patient #11. The medication room can be entered through two different doors; each door has a window and has a key pad for entry. During this time sampled staff W, a certified nurses assistant (C.N.A.), entered the medication room using the key pad on 2/8/17 at approximately 11:15AM. He entered the medication room and placed a cart which contained personal hygiene products in the room and left. Interview with sampled staff X at this time revealed that the C.N.As on the medical/surgical unit have access to this room due to the personal hygiene and other supplies are stored in this area. On 2/9/17 at approximately 10:30AM the facility pharmacist was asked about the facility policy and procedure for appropriate staff with access to the medication room he referred the surveyor to the Risk Manager (RM). But he did state even his pharmacy staff do not enter the medication room without a nurse present. Interview with the RM on 2/9/17 at approximately 10:50AM revealed her statement the facility does not have a policy which address what staff are allowed in the medication room. When asked what is the facility's procedure for allowing staff in the area where medications are kept. The RM stated on the medical/surgical unit the C.N.A.s have access to the area where medications are stored due to that area also contains other supplies such as personal hygiene products the C.N.A. must have to provide patient personal care. Record review of the facilities policy PH-12 for pharmacy and medication storage revealed all medications at nursing stations shall be in lockable storage at all times. Authorized personnel included registered nurses (RN), licensed practical/vocational nurses (LPN/LVN), licensed psychiatric technician, respiratory therapist, pharmacist and pharmacy technicians. Interview with the RM on 2/10/17 at approximately 10:30AM confirmed these findings.

Based on observations and interviews, the facility failed to ensure expired medications and biologicals were removed from patient 3 of 4 patient care areas.

Findings:
On 2/7/17, commencing at approximately 10:30am, a tour of the facility's operating room (OR) suite was conducted in the presence of the OR supervisor. The medication cart in OR #2 contained three unopened 10 milliliter vial of 2% lidocaine with an expiration date of 2/1/17 and an unopened 500 milliliter bag of intravenous solution (Lactated Ringers) with an expiration date of 2/1/17.\

At approximatly 10:40 a tour of OR #1 was conducted. The medication cart in OR #1 contained two unopened 10 millerliter vial of 1% lidocaine with an expiration date of 2/1/17.

On 2/7/17 at approximately 11:00am, in the presence of the OR supervisor, observed a 5 drawer cart adjacent to one of the preoperative/postoperative bay area beds. The cart was observed not to be locked; and was informed by the OR supervisor this cart housed the Preop/Post Anesthesia Care medications. Medications included protonix, zofran, nalosene, digoxin, nitrobid, antibiotics, 50% dextrose ampule and solumedrol, in addition to other medications. When OR supervisor was questioned why the medications were not in a secured area, she replied "we have not been using that bay as it did not have a cardiac monitor." A cardiac monitor was observed to now be in place. The supervisor left the unsecured medications in place until once again this surveyor questioned the potential for medication accessibility to patients, family members and/or others who are not authorized to access.

On 2/7/17 commencing at approximately 3:00 pm, a tour of the Emergency Department (ED) was conducted
in the presence of Employee G. The surveyor observed the room designated as "trauma room" with 5 vacutainer tubes (blue top, yellow top, red top and orange top) wrapped with rubber band at bedside. The ED nurse stated each of the tubes would be drawn and sent to laboratory testing. The blue top, which contained a preservative, was noted to be expired with an expiration date of December 2016. The ED nurse was asked how the unit ensures expired supplies are removed from patient care areas. She examined the set of tubes and failed to identify the outdated blue top tube. She stated the nursing staff is responsible for ensuring no expired supplies are in care areas. THe nurse was informed of the expired laboratory tube and she removed it from the patient care area.





20377

An inspection of the medical/surgical nursing unit medication room was conducted on 2/7/17 beginning at approximately 3:00PM with sampled staff F, the registered nurse and unit manager for medical/surgical unit. At approximately 3:08PM the inspection revealed a box of 38 vacutainer tubes with 2 ml 9NC Coagulation Sodium Citrate 3.27 with expiration date of 12/2016. The nurse confirmed these vacutainer tubes were expired and she removed them from the medication room.

Based on observation, interview and policy review, the facility failed to ensure infection control practices related to hand hygiene were implemented in 1 of 4 hospital nursing units; failed to ensure isolation precautions were implemented for 1 of 1 patients sampled with isolation precautions in place; failed to maintain a clean and sanitary environment for 2 of 4 hospital nursing unit; and failed to report 14 of 24 infectious disease to the Department of Health in accordance with written requirements.

Findings:

On 2/7/17, commencing at approximately 10:30am, a tour of the preoperative/postoperative area of the facility was conducted. A thick layer of dust was observed on the wall mounted equipment that included cardiac monitors, wall suction regulators, wall suction canisters, located above each of the 4 recovery bay areas as confirmed by the Operating Room Supervisor at the time of the observations. She stated the nursing staff is responsible for ensuring the cleanliness of the equipment and housekeeping staff provides general housekeeping related to the floors and bathroom area.

On 2/7/17, commencing at approximately 10:50am, observation of patient care was conducted in the facility's designated preoperative/postoperative area. The handwash sink and a single bottle of hand sanitizer located in this area was in site of this surveyor during the observation period. A surveyor observed Employee S donn disposable gloves to prepare for an intravenous start without performing hand hygiene. The nurse then removed the gloves and proceeded to the handwash station to wash hands with soap and water following the procedure.

On 2/7/17, commencing at approximately 3:00pm, a tour of the facility's Emergency Department (ED) was conducted. A thick layer of visible dust observed on horizontal surfaces of cardiac monitors, wall suction regulators and suction canisters in each ED bay area. Interview with the ED charge nurse revealed that the ED staff is responsible for ensuring all patient care equipment is kept clean. The base of an intravenous pole in ED bay 2 was observed to have visible soiling. When wiped with a white tissue, a large amount of black substance adhered to the tissue. (Photo evidence obtained).

On 2/8/17, commencing at approximately 10:30am, observation of patient care was again observed in the preoperative/postoperative area of the facility. Observed EmployeeT insert an inravenous (IV) catheter for Patient # 14. Employee was observed not to perform handwashing and/or hand hygiene with hand sanitizer after removal of gloves following the IV insertion. A surveyor observed Employee T donn gloves and discontinue an intravenous catheter for Patient #15 without performing hand hygiene before or after glove removal. Interview with Employee T on 2/8/17 at approximately 11:40am revealed she has received infection control training that includes handwashing/hand hygiene. The employee was able to verbalize how hand hygiene is to be performed before and after glove use. When informed she was not observed performing hand hygiene following glove removal, she stated if unable to wash hands she uses hand sanitizer and pointed toward the preop bay area. When asked where the hand sanitizers were located within the preoperative/post operative areas, Employee S, stated "we have one bottle of hand sanitizer that is kept at the desk area." This was the only hand sanitizer observed in the preoperative/postoperative area as per Employee S's comments.

Review of the facility's Policy and Procedure titled "Handwashing" documents hands are to washed immediately before donning gloves and immediately after removing gloves. The policy, with original date of 1997 and cover sheet in the front of the policy indicating the policy was reviewed 12/21/16, failed to include use of hand sanitizers for performing hand hygiene. The policy documents alternative to handwashing when there is no running water is to apply alcohol-based rinse or foam, ... and documents as soon as running water is available, the hands must be washed.

Interview with the Infection Control designee on 2/10/17 at approximately 10:00am revealed she does not conduct any handwashing audits to ensure hand hygiene is being performed within the facility in accordance with their established policy and procedure.

Review of the facility's Infection Control Plan (ICP) documentation included the following: All Department Managers are responsible for maintaining their unit in a manner that promotes wellness, and for monitoring their staff to ensure compliance with infection control guidelines. The ICP documented "the Infection Control Nurse and the Director of Environmental Services collaborate in the evaluation of the hospital environmental conditions (utilizing inspection, quality surveys, etc).

On 2/8/17 at approximately 3:00pm, a surveyor observed an inpatient room (Room 108) have Personal Protective Equipment (PPE) on the door. There was no signage indicating type of isolation or any signage to direct visitors. Review of the medical record revealed the patient was admitted on 2/8/17 at 12:30pm with "diarrhea and feeling sick." Physician ordered contact isolation on 2/8/17 at 1:00pm. On 2/9/17 at approximately 3:00pm, the isolation room was again observed not to have any signage for the precautions in place; and no signage to direct and/or instruct family and visitors. On 2/9/17 at approximately 3:30pm, interview with Employee J revealed the "contact isolation" signage had been placed on the door yesterday, but must have been removed. She stated the signage to instruct visitors to the nurse's station prior to entering the room had just been added. The employee confirmed visitors would not know precautionary measures to take without any signage to direct them to the nurse's station prior to entering the room.

Review of facility's Policy and Procedure titled "Infectious Disease Precautions" documents the facility will utilize precautions as recommended by the Centers of Disease Control to contain and/or prevent the spread of infectious disease processes. The policy documents that when isolation is initiated the nurse will explain to the patient, and if appropriate, the patient's family the reason for the isolation and what they may expect in the way of staff attire. The procedure documents visitors will be educated about the isolation procedures and assisted when necessary to don the proper attire. The procedure failed to address signage to direct visitors to nursing for education prior to entering the room.

Interview with the Infection Control designee on 2/10/17 at approximately 10:00am revealed the contact isolation sign was placed, and had been removed by what she believes was a staff member thinking the signage was violation of patient privacy. She stated she has developed a memo to reeducate the staff. This statement could not be confirmed as observations made by the survey team failed to identify any signage until 26 hours following the patient being placed on isolation.

Review of the facility Infection Control Plan documents a goal of the plan to be "provide a safe environment for the staff, physicians, volunteers and visitors."

On 2/8/17 at approximately 2:00pm, a request was made to the facility's designated Infection Control Nurse (ICN) for the policy related to reporting infectious diseases to the County Health Department; and a list of those reported since last survey date of November 2015. The ICN stated the laboratory director is responsible for this reporting; and further stated she does not receive copies.

On 2/9/2017 at 11:30am a review of "Reportable Diseases/Conditions in Florida" was provided by the Clinical Laboratory Director. 14 of 24 files reviewed from November 2015 through the current date revealed they were not reported to the county health department in accordance with the Health Department Guidelines. The time line of reported diseases/conditions were obtained from the "Reportable Diseases/Conditions in Florida" which became effective June 4, 2014. (Photo Evidence) The below listed disease were required to be reported to the Health Department within 1 day of results, as stated in Florida Statue 281.0031:
Sample ID 720473 Hep C Resulted 1/16/2017 Reported 1/20/2017
Sample ID 720077 Hep B Resulted 1/12/2017 Reported 1/17/2017
Sample ID 633758 Hep C Resulted 7/13/16 Reported 7/16/2016
Sample ID 09114620 Chlamydia Resulted 11/09/2015 Reported 11/12/2015
Sample ID 719875 Hep A Resulted 1/13/2017 Reported 1/16/2017
Sample ID 720409 Gonorrhoeeae Resulted 1/15/2017 Reported 1/18/2017
Sample ID 693042 Hepatitis C Resulted 7/21/2016 Reported 7/25/2016
Sample ID 708151 Chlamydia Resulted 7/25/2016 Reported 7/31/2016
Sample ID 684432 Hep C Resulted 6/3/2016 Reported 6/7/2016
Sample ID 77783 Hep C Resulted 2/26/2016 Reported 2/29/2016
Sample ID 651597 Hep C Resulted 10/29/2015 Reported 11/21/2015
Sample ID 713824 Gonorrhoeae Resulted 12/6/2016 Reported 12/8/2016
Sample ID 711537 Hep B Resulted 11/18/2016 Reported 11/22/2017
Sample ID 718132 Chlamydia Resulted 1/4/2017 Reported 1/10/2017

On 2/9/17 at approximately 12:15pm, an interview was conducted with the facility's Clinical Laboratory Director and confirmed she is responsible for submitting the infection notification to the Health Department; and confirmed the 14 reports were not submitted in accordance with the guidelines. She stated that sometimes she does not have the time to submit the reportable diseases because sometimes she is the only person in the lab. She stated the laboratory gets busy and does not have time to submit the reports. She stated that if she is out of work or on vacation there is no one to cover for her.