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Based on observation, interview and record review, the facility's contracted staff failed secure physician's order to use sodium variation on a patient during hemodialysis treatment, failed to follow manufacturer's instructions when checking the water used for a patient's hemodialysis treatment for total chlorine; failed to follow manufacturer's instruction when testing facility's dialysate solution used to treat patients on hemodialysis for pH ; failed to wash hands, changed contaminated gloves during central venous catheter care in 5 of 53 sampled patients. #s 16, 20, 22, 25, 30

Findings:
Patient #20
On 02/25/2014 at 11:00 a.m. patient # 20 was observed in her room on unit 600 receiving hemodialysis treatment. Observation of the hemodialysis machine revealed the staff was using sodium profile variation Linier mode on the patient.
Review of the patient's treatment sheet dated 02/25/2014, revealed no documentation that the patient was receiving sodium variation during her hemodialysis treatment. Review of the patient's medical record revealed no physician's order for sodium variation.

During an interview on 02/25/2014 at 11:05 a.m. with Contract Nurse # #37, the Surveyor asked the Contract Registered Nurse why was the patient receiving sodium variation during his hemodialysis treatment. Contract registered Nurse # 37 said he had started sodium variation on the patient because the patient's blood pressure had dropped but he did not secure a physician's order.

Observation on 02/26/2014 at 11:15 a.m. of Contract Registered Nurse (# 31) revealed he was observed in the room of Patient #22. The Contract Registered Nurse was observed checking the water used for hemodialysis treatment for a patient for Total Chlorine. Observation revealed Contract Registered Nurse # 31 ran a steam of water unto the Hisense Strip and read the strip to the Surveyor. The Contract Registered Nurse did not have a watch/ timer when checking for the Total Chlorine in the water and he did not swish the test strip in the water for 30 seconds.
Observation revealed the patient's hemodialysis machine external blood lines and dialyzer were primed with normal saline and the acid and sodium bicarbonate solution were set up for the treatment prior to checking the water for total chlorine.

The Surveyor immediately notified him that he did not the follow the manufacturer's instruction to collect 20 mls of water and swish for 30 seconds. The Surveyor then pointed out to the Contract Registered Nurse that there was a clock on the wall in the patient's room with a second hand. He responded " Thank you."

Review on 02/26/2014 of the Manufacturer's instruction located on the label of the container, instructs user as follows: "Fill sample cup with water to be tested. discard contents and refill 20 mls. Start timer and immerse indicator pad into water. Vigorously swish strip for 30 seconds."
Infection control:
Patient #22
On 02/26/2014 at 11:17 a.m. Contract Registered Nurse (#31) was observed in the patient ' s room providing care to Patient # (22) who had a central venous catheter in place to his right thigh. Contract Registered Nurse (#31) was observed cleaning the patient's central venous catheter. Prior to starting the central venous catheter care, the Contract Registered Nurse primed the external blood lines on the hemodialysis machine, spiked the acid solution and connected the bicarbonate solution in the jug and the portable Reverse Osmosis machine. During the procedure Contract Registered Nurse (#31) donned his gloves, set up the machine for hemodialysis, spiked the acid bottle, checked the water for total chlorine, applied a mask to the patient's face, then cleaned the hub of the patient's central venous catheter with alcohol swab, then accessed the patient's central venous catheter and flushed the catheter. The Contract Registered Nurse then returned to the patient's hemodialysis machine wearing his contaminated gloves and proceeded to check the external blood lines, but the arterial and venous chambers remained empty and the Trans-membrane Pressure of the machine remained high. Contract registered Nurse ( #31) then removed the right hand of his contaminated glove and retrieved his cell phone from his pocket with his contaminated hand
Registered Nurse (#31) did not remove his contaminated gloves and wash his hands before accessing the patient's central venous catheter.

During an interview on 02/26/2014 at 11:35 a.m. outside the patient's door, the Surveyor informed Contract Registered Nurse (# 31) that he used the same contaminated gloves to set up the patient 's hemodialysis machine, spiked the acid solution and accessed the patient central venous catheter. He stated " You are correct"

Review of the facility's contracted Policy and Procedure # 7 -03- 02 adopted by the facility directed staff as follows : " Hands will be washed upon entering the hospital/ facility, prior to gloving, after removal of gloves, between patients, after contamination with blood and other infectious material, after patient and contaminated machine contact, between patients, before touching clean areas such as counter tops, supply carts and at the close of the business day prior to going home."



33438

On 02/27/2014 at 11:22 a.m. Contract Registered Nurse (#30) was observed in Surgical ICU room # 10 room of patient #16, testing the dialysate solution for pH. During the observation, Registered Nurse (#30) collected 20 mls of dialysate in the cup. She then dipped the strip into the solution using the RPC E-Z Check.

Review on 02/27/2014 of the Manufacturer's instruction located on the bottle insert, instructs user as follows: "Fill sample cup with water to be tested. Dip into test solution and shake off excess liquid. Compare color scale after 10 seconds on strip to color chart on bottle to determine closest match. Read pH value for the closest match."

During an interview on 02/27/2014 at 11:23 a.m. with Registered Nurse (#30) inside Surgical ICU room #10, the Surveyor asked her how many seconds does she need to wait before comparing the strip to the color scale. She stated " I do it right away, and that is what we are supposed to do".
The Surveyor then showed the instruction on the bottle to her "Compare color scale after 10 seconds on strip to color chart on bottle to determine closest match".
















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Patient #25

Observation on 2/26/14 at 9:37 a.m. in Operating Room #4 revealed Patient #25 was being prepared for a tunnel dialysis catheter removal. RN (Registered Nurse) #28 was scrubbing the area with a chlorohexadine scrub brush. She washed the insertion site, then cleaned the multilumen catheter. She then scrubbed the skin from the insertion site outward in a circular motion. RN #28 then went back to the insertion site and the catheter and washed them again with the same brush.

Interview with RN #28 at this time, she said she was a Contract nurse with a 12 week contract to work at the hospital. She said she had worked at the hospital before and was given a one week orientation. She said that since she came back within 3 months, she did not get an orientation.

Interview on 2/26/14 at 10:10 a.m. with Interim Director of Surgery, RN #12, she said the skin should be prepped from the center out and the nurse should not have gone back to the center again with the same brush.

During an interview on 2/26/14 at 10:15 a.m. with RN #28 after the surgery, she was asked why she went back to the center once she had scrubbed the area outward. She said she felt the first scrub was just a before prep. She said a lot of nurses only used the ChloraPrep, but she liked to scrub the area first with a brush. She said she did not consider it a real prep, but just a before prep.

Interview on 2/26/14 at 10:25 a.m. with Surgery Manager, RN #11, she said when the hospital had contract nurses, she was not always sure of how they will do with the skin prep. She said sometime they did it correctly and sometimes not. When she was asked if it was her responsibility to make sure the prep was done correctly, she said it was. She said because the wound for Patient #25 was not openly infected, the skin prep should have started at the insertion site, the catheter and then outward from the insertion site. She said if the nurse felt there needed to be more prep time, then a new scrub brush should be used to go back to the center.

Record review of the facility's Policy and Procedure for Surgical Preps dated 10/2000 and reviewed/revised on 1/2011 revealed the following:
"...VII. Prep the area using aseptic technique and incorporating the following principles.
A. Use a vigorous mechanical action to remove bacteria.
B. Use a circular motion beginning at the incision site and progressing to the periphery.
C. Scrub from the incision site out and never return to the incision site with the sponges previously used in that area.
D. Prepping time should be five (5) minutes to ten (10) minutes, depending on the chosen solution, procedure, and surgeon preference....
X..
A. Paint progressing from the incision site to the periphery...never returning to the incision site..

Based on observation, record review, and interview, the facility failed to inform 9 of 11 patients on Medicare (#'s 6, 35, 17, 18, 19, 38, 39, 40, and 41) from a sample of 53 sampled patients, or the patient's representative of the patient's right to receive a CMS (Centers for Medicare/Medicaid Services) Important Message (IM) form 2 days after admission and 2 days before discharge.

Findings include:

Patient #6
Observation on 2/25/14 at 1:30 p.m. of Patient #6 in his room on the 5th floor with Charge Nurse RN #15 revealed he was asleep and had a certified nurse technician in the room with him. Charge nurse #15 said the patient was disoriented and tried to crawl out of his bed.

Record review on 2/27/14 of Patient #6's current medical record revealed he was 70 years old, on medicare and admitted on 2/18/14 with diagnosis of subdural hematoma.

Further review of the record revealed there was no IM (Important Message) letter in the patient's record.

Interview on 2/27/14 at 9:40 a.m. with Case Manager #59, she checked the chart and was not able to find an IM letter. She said the admission nurse gave the letter to the patients, because the letter was part of the admission packet. She said the letter was also given at discharge.

Interview on 2/27/14 at 10:10 a.m. with Patient Registration Staff #51, she said she was responsible for delivering the IM letter to the patient within 2 days of admission and getting it signed. She said she had tried to get a signature from the patient, but he was not able to sign. She said she tried several times to get a responsible party to sign the letter, but no one was present when she visited the patient. She said she did not know what she was supposed to do when no one was available to sign for the patient. She had not documented her efforts to get the letter signed.

Patient #35
Record review on 2/27/14 of Patient #35's current medical record revealed he was 66 years old, on medicare and admitted on 2/18/14. There was no IM letter in the chart.

Interview on 2/27/14 at 10:20 a.m. with Patient Access Director #52, she said that Patient Registration Staff #51 had come to her and said that she had not gotten the IM letter to Patient #35. Staff #51 had told her she got " bogged " down in her work and had not been able to get the letter to the patient. Director #52 said that she had counseled her that she should have come to her to let her know she was not able to complete her work. Director #52 said they take getting the letters to the patients very seriously. She said the facility mailed out the second letter to the responsible party if they were not able to get it signed by the patient.

Patient #17
Record review on 2/27/14 of Patient #17's medical record revealed she was 67 years old, on medicare and admitted on 2/18/14. There was an IM letter in the chart signed by the patient, but it was not dated.

Patient #18
Record review on 2/27/14 of Patient #18's medical record revealed she was 82 years old, on medicare and admitted on 2/24/14. There was no IM letter in the chart.

Patient #19
Record review on 2/27/14 of Patient #19's medical record revealed she was 86 years old, on medicare and admitted on 2/18/14. There was no IM letter in the chart.

RN #58 looked through the medical records for Patients #18 and #19, but she was not able to find an IM letter.

On 2/27/14 at 1:00 p.m., the facility was given a list of closed records for the following medicare patients to review:

Patient #38 - admitted 11/26/13 and discharged on 2/1014
Patient #39 - admitted on 1/3/14 and discharged on 1/14/14
Patient #40 - admitted on 2/6/14 and discharged on 2/26/14
Patient #41 - admitted on 12/31/13 and discharged on 1/8/14

Interview on 2/27/14 at 1:40 p.m. with Quality Manager RN #13, she said she had looked at the electronic closed records for the above patients and none of them had an IM letter for 2 days after admission or for 2 days before discharge.

Interview at this time with Case Manager Director #65, she said that patients not having IM letters was not the hospital's standard. She said delivering the letters to the patients and getting them signed was the responsibility of the Case Managers and no one else. Case Manager Director #65 was informed that the nurses gave the IM letters to the patients on discharge. She said that the Case Managers should be responsible and not the nurses. She said that she understood the importance of getting the letters to the patients 2 days after admission and 2 days before admission so the patient could report concerns and have time to appeal a discharge date.

Record review on 2/27/14 of An Important Message From Medicare About Your Rights, CMS form 193 dated 7/10, revealed as a hospital inpatient the following rights:
-to know about any medically necessary hospital services at the hospital and after discharge, who would pay for them and where to get the services
-to be involved in any decisions about the hospital stay and who would pay for it.
-to be able to report any concerns about the quality of care received to the Quality Improvement Organization (QIO) listed on the sheet.
-to know discharge rights - discharge planning and what to do if the patient felt he/she was being discharged too soon. " If you want to appeal, you must contact the QIO no later than your planned discharge date and before you leave the hospital ....Please sign and date here to show you received this notice and understand your rights. "

Record review of the facility's Policy and Procedure dated 12/1/2008 revealed an algorithm for Process for Important Message from Medicare. The IM form was to be given to the patient at the point of admission. If the registrar could not answer the questions, then the patient would be referred to Case Management. The patient was to be given the original, a copy was to be put in the patient's medical record and a copy to the patient ' s financial folder. There was nothing in the document about giving the IM form 2 days before discharge.

Record review of the facility's Policy and Procedure for Process for Important Message from Medicare dated 01/01/14 revealed that patients admitted to inpatient status under Medicare were to be given the Important Message form. The patient " must acknowledge the receipt of the document and the timing of the presentation to the patient must comply with CMS guidelines ....In the event that the Important Message from medicare cannot be presented to the patient at the time of admission to inpatient status, appropriate follow-up must occur. Follow-up may include subsequent visits to the patient's room and/or mailed copies of the Message to the patient's home address in the event that the patient cannot sign and no family members or representatives are available.. " Further review of the document revealed there was nothing about what the CMS guidelines were.

Based on record review and interview, the facility's Quality Assessment Performance Improvement Program failed to analyze data collected and conduct root cause analysis to determine the reason the facility was not meeting goal for hypotensive episodes in patients during contracted hemodialysis treatment in the facility.

Findings:

Review on 02/28/2014 of the facility's Quality Assessment Performance Improvement Program data revealed the following findings for patients experiencing hypotensive episode during contracted hemodialysis treatment in the facility : Facility's set goal 90%
August 2013: 82.82 % of patient's did not experience hypotensive episode during hemodialysis treatment

September 2013 : 87.6 % of patient's did not experience hypotensive episode during hemodialysis treatment

October 2013: 82.43% of patient's did not experience hypotensive episode during hemodialysis treatment

November 2013: 85.56% of patient's did not experience hypotensive episode during hemodialysis treatment

December 2013: 84.8% of patient's did not experience hypotensive episode during hemodialysis treatment

January 2014 80:.86% of patient's did not experience hypotensive episode during hemodialysis treatment

Review of the data revealed the facility had not met its set goal of 90% of its patients not experiencing hypotensive episode since August 2013 to January 2014. Review of the record revealed no evidence of analysis of the data collected and root cause analysis conducted as to the reason patients were becoming hypotensive during hemodialysis treatment
For each month the documented action plan were as follows: " Primary Nurse notified. Fluid administered as ordered."


On 02/28/2014 at 10:290 a.m. the Surveyor reviewed the data with the facility's Associate Chief Nursing Officer and the Facility's Director of Quality . They agreed that the data was not analyzed and a root cause analysis conducted to determine the reason the facility was not meeting goal for hypotensive episodes in hemodialysis patients.


Review of the facility's current Policy and Procedure on Plan Performance Improvement and Patient Safety # 965.4431 direct staff as follows: "Framework for Performance Improvement. Overall concept, Appropriate statistical methods are used. Data compared over time with other organizations with up to date resources. Intensive assessment is initiated when statistical analysis detects significant undesirable variation."

Based on observation, interview and record review, the facility's registered nurse failed to follow standard of practice adopted into facility's policy and procedure when administering medication via PEG (Percutaneous endoscopic gastronomy tube); failed to administer medication as prescribed by the patient's physician; failed to collect samples of patient's stool and test for occult blood in 3 of 53 sampled patients Patient #s 15, 24, 53
Findings:

Patient #15
On 02/27/2014 at 10:13 a.m. Registered Nurse # 23 was observed in patient # 15's room on unit 600, administering medication to the patient who had a PEG tube in place to her abdomen. The medications were crushed and mixed in a slurry to be administered to the patient.

Interview with Registered Nurse ( #23) at that time revealed the following medication were crushed by her in a slurry and placed in the medication cup for administration to the patient.: Iron, Norvasc and Prinivil

Observation of the medication administration via the patient's PEG tube revealed, Registered Nurse # 23 disconnected the patient's PEG from the feed she was receiving, checked for residual feed, returned the residual feed aspirated from the patient's stomach to the patient then administered the medication to patient #15 with the plunger of the syringe. The nurse did not flush the tube prior to administering the medication to the patient. The nurse did not administer the medication by gravity into the patient's stomach.

During an interview on 02/27/2013 at 10:25 a.m. with Registered Nurse # 23, the Surveyor notified her that she the Surveyor had observed that she the Registered Nurse did not flush the residual feed from the PEG tube prior to administering the medication and that she had forced the medication into the patient's stomach with the plunger of the syringe instead of allowing the medication to flow by gravity into the patients stomach. Registered nurse # 23 agreed with the Surveyors observation.

Review of Lippincott Procedures on Gastrostomy Tube Drug Instillation, page 2 of 5. Adopted into facility's policy and provided to the Surveyor by facility's staff, directs staff as follows: " Request liquid forms of medication if available. If a liquid form of medication is not available and the medication is an immediate - release tablet, crush the prescribed dose of each medication separately into a fine powder, in a cup or plastic bag designed for this purpose using a mortar and pestle or other pill crushing device. if you're administering more than one medication, administer each medication separately and flush the tube with sterile water after administering each medication.
Flush the tube with 30 mls of sterile water to clear any enteral feeding from the tube and prevent mixing with medications. Clamp the tube and remove the syringe.
Reattach the syringe, without the piston to the end of the tube. Begin to pour the medication into the syringe and unclamp the tube. If medication flows smoothly, slowly add more until the entire dose has been given. If the medication doesn't properly don't force it, instead , raise the syringe slightly. If too thick, dilute with additional sterile water."

Physician's order.
On 02/27/2014 at 10:13 a.m. Registered Nurse #23 was observed on unit #600 administering medication to patient # 15 who had a PEG tube in place to her stomach. The Registered Nurse did not administer Colace to the patient.

Review on 02/27/2014 of the patient's medical record, revealed a physician's order dated 02/21/2014 for Colace 100 mg tablet by mouth daily. Review of the patient's Medication Administration Record revealed no documentation that the patient had received Colace as prescribed by the patient's physician.

Review of the patient's clinical record, (Demographic Data) revealed the patient was admitted to the facility with physician's order for oral medication but a PEG tube was inserted in the facility. The patient's prescription continued to indicate medication by mouth although the patient had a PEG tube in place and was unable to take medication by her mouth.

On 02/27/2014 at 10:40 a.m., the unit's Charge Nurse and the Surveyor reviewed the patient's clinical record in the computer and the hard copy of the record. The Charge Nurse said she could not locate any documentation that the patient was administered Colace prescribed by the patient's Attending Physician.

Patient #24
Review of patient #24's medical record revealed a physician's order dated 02/24/2014 for "Stool for occult blood X 3."
Review of the patient's medical record (staff documentation) dated 02/26/2014 and 02/27/2014 revealed documentation which indicated that the patient had two bowel movements on 02/26/2014 and one bowel movement on 02/27/2014.
Review of the patient's medical record revealed no documentation that the patient's stool was collected and tested for occult blood as ordered by the patient's attending physician.
On 02/27/2014 at 11:00 a.m. the Surveyor reviewed the hard copy and the electronic copy of the patient's record with the Unit Director and the Charge Nurse. They stated that they could not locate evidence that the patient's stool was collected for occult blood as ordered by the physician.


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Patient #53

Observation on 2/27/14 at 8:45 a.m. revealed Patient #53 was in ICU on a ventilator.

Record review at this time revealed ICU and SICU Initial Ventilator Orders dated 2/27/14 at 11:00 p.m. The orders were misdated because the patient was admitted to the unit on 2/26/14 at 11:00 p.m. per ICU (Intensive Care Unit) Director, RN #53. There was an order for Albuterol 2.5 mg in 3 ml. of normal saline. The frequency was not written in the blank.

Interview with ICU Director, RN #53 at this time, she said the ER note had every 4 hours. She was asked to show when the patient received the Albuterol. She called the Respiratory Therapy (RT) Department Manager to come to the unit.

Interview on 2/27/14 at 9:10 a.m. with RT Department Manager #54, he said Patient #53 got his first dose of Albuterol on 2/27/14 at 8:04 a.m. RT #54 said the patient should have gotten the medication around 4:00 a.m. or within one hour of getting the order. He said he would have to see when the order came in. At 9:30 a.m. RT #54 said the order came into the RT department at 12:00 a.m. He said it must have been overlooked.

Further interview on 2/27/14 at 10:00 a.m. with RT #54, he said the order for other RT services for Patient #53 came to the RT computer at 12:00 a.m. He said the order for the Albuterol did not come to the computer. He said the morning RT did not see the order until he printed it out the next morning and that was when the first dose was given.

Interview on 2/28/14 at 11:45 a.m. with Quality Manager, RN #13, she said there was a problem with orders being sent appropriately to the RT department. She presented an e-mail dated 2/27/14 at 6:25 p.m. that showed "When ordering a Neb (nebulizer) Medication, there should be a reflex consult to the Respiratory Department to inform them this patient needs their attention to administer medication. This issue should be corrected now..."

Based on observation, interview and record review, the facility failed to ensure that medical records were complete per facility policy for 3 of 53 sampled inpatients (Patient ID# 1, # 10, # 52). The facility failed to ensure:
*Physician orders were obtained and proper documentation completed related to tracheotomy care and suctioning for Patient ID # 1.
*Timely completion of a History and Physical exam for Patient # 10.
*Properly completed consent for blood transfusion for Patient # 52.
Findings include:
Patient ID# 1
Observation 2/25/14 at 10:45 a.m. in the emergency room revealed patient ID# 1 with a tracheotomy.
Medical record review ( Medical Screen) revealed patient ID# 1 presented to the emergency room 2/20/14 at 10:44 a.m. with a chief complaint of suicidal ideation. The medical screen examination listed additional surgical history " tracheotomy. "

Record review of physician orders from 2/20/14 to 2/25/14 revealed no orders for the care of a tracheotomy. Nursing notes revealed the following:
2/20/14 at 19:22 - " Patient alert and oriented. Has trach in place .....Patient suctions his trach about 3 times a day. Trach has been in a while. "
2/20/13 at 22:00 - " Patient's trach suctioned for thick yellowish secretions. "
2/21/14 at 08:45 - " Eats and used the restroom. He does all this by himself including cleaning his trach. "
2/21/14 at 18:06 - " Respiratory therapy brought trach kit. Kit at bed side. Patient is able to clean trach by himself. "
2/22/14 at 15:07 - " Patient is still suicidal; we cleaned and changed his tracheal inner cannula. "

A respiratory therapist (ID# 56 ) acknowledged 2/25/14 at 11:20 a.m. that respiratory cleans the patient's trach every shift and suctions the patient.

Record review of respiratory therapy notes from 2/20/14 to 2/25/14 revealed no documentation of suctioning or cleaning of the patient ' s tracheotomy.
Record review of a policy titled " Care of Tracheotomy " dated 4/09 stated " Purpose: To maintain an open airway and to keep area around the tube clean. To be done every eight house and recorded ... "


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Patient ID # 10 :

H & P issue

Record review on 02-25-14 of Patient ID# 10's clinical record ( History and Physical) revealed he was admitted to the facility on 02-18-14 for abdominal pain, nausea, and vomiting. Further record review revealed the History & Physical (H & P) examination for Patient # 10 was dictated and typed on 02-20-14, two days after admission.

Interview on 02-25-14 at 11:00 a.m. with RN # 17 she stated the timeframe for completion of H & P exam was within 24 hours of patient admission.

Record review of the facility Medical Staff Rules & Regulations, revised date 12-06-13, read: " ...9. A complete admission history and physical examination shall be recorded within twenty-four (24) hours of a patient's admission ... "


Patient ID # 52:

Consent issue

Record review on 02-25-14 of Patient ID # 52's clinical record ( History and Physical) revealed she was admitted to the facility on 02-22-14 and had Coronary Artery Bypass Graft (CABG) surgery on 02-25-14.

Further review of Patient ID # 52's clinical record revealed a surgical consent form, dated 02-25-14 that included a consent for blood transfusion. Under the section for " transfusion of blood & blood components, " Patient ID # 52 had checked both " I do " and " I do not ' consent to blood /blood product administration.


Interview on 02-25-14 at 10:45 a.m. with ICU Director / RN # 53 she stated that having both " I do " and " I do not " checked for blood administration was not acceptable. RN ID # 53 said it should have been clarified and a line, ' error, ' and staff initials through the portion not applicable.

Record review of the facility policy titled " Consent-Informed Consent and Disclosure For Adults & Minors," revised 08/12, read: " ...B. Hospital Responsibility ...the nurse or other licensed hospital employee who is requested by the physician to participate in the informed consent process shall limit the participation to the following: to screen the completed consent form for accuracy ... "

Based on record review and interview the facility failed to enforce their medical record policy to ensure verbal orders were authenticated by a physician within 48 hours of the order. Citing 3 of 3 medical records reviewed on the Rehabilitation Unit from a sample of 53 patients. #s 45, 46, and 47.

Findings:

Review on 2/26/2014 of clinical record for the three Patients revealed verbal orders for medication, therapy services, and laboratory(Lab) tests were not authenticated by a physician.

Patient (#47)

was admitted to the Unit on 2/20/2014 at 22:30. Verbal orders for Milk of Magnesia 30 milliliters( mls) orally (P.O.) daily as needed for constipation , Colace 100 mg, one P.O., twice a day as needed for constipation. Nicotine patch 14 mcg apply every 24 hours.
Physical Therapy Monday - Sunday BID(twice a day) until discharge.
Verbal orders dated 2/22/2014 at 10:00 am for Zofran 4 mg tablet P.O. every 6 hours as necessary and verbal orders dated 2/24/2014 for Basic Metabolic Panel(BMP) Lab test .

Patient (#45)

was admitted to the Unit on 2/21/2014 at 22:45 there were verbal orders for MOM 30 ml P.O., daily as necessary for constipation.
Fleets enema, daily as needed for constipation, Colace 100 mg, one P.O., twice a day as needed for constipation.
Bisacodyl suppository, 10 mg per rectum, daily for constipation. 2 gram sodium renal diet.
Therapy Monday- Sunday BID until discharge for Physical Therapy, Occupational Therapy and Speech / Language Pathology . There was also orders dated 2/21/2014 for Social Work and Dietary Consult.
Verbal orders dated 2/22/2014 for Accu checks mornings and nights, oxygen 2 liters via nasal cannula as needed and Zofran 4 mg as needed every 6 hours for vomiting/nausea.

Patient (#46)
was admitted to the Unit on 2/10/2014 at 22:03 here were verbal orders for MOM 30 ml P.O., daily as necessary for constipation.
Fleets enema, daily as needed for constipation, Colace 100 mg, one P.O., twice a day as needed for constipation.
Bisacodyl suppository, 10 mg per rectum, daily for constipation. 1800 Renal ADA diet.

Therapy Monday- Sunday BID until discharge for Physical Therapy, Occupational Therapy and Speech / Language Pathology. There was also orders dated 2/21/2014 for Social Work and Dietary Consult. The orders for Patient (# 46) were signed and dated on 2/26/2014 at 11:30 am 16 days after the verbal orders were made.

Review of the facility's verbal order policy # 712.4077 dated 5, 2013 revealed the following information:

"Verbal orders must be countersigned by the physician within 48 hours( or 24 hours when the order is for restraints or DNR)".

Based on observation, interview and record review, The facility's registered nurses failed to wash hands, changed contaminated gloves during wound care, central venous catheter care and contact with patient's on contact isolation in 5 of 53 sampled patients. #s 15, 22, 25, 50, 51.

Findings:

Infection control:
Patient #22
On 02/26/2014 at 11:17 a.m.Contract Registered Nurse (#31) was observed in the patient ' s room providing care to Patient # (22) who had a central venous catheter in place to his right thigh. Contract Registered Nurse (#31) was observed cleaning the patient's central venous catheter. Prior to starting the central venous catheter care, the Contract Registered Nurse primed the external blood lines on the hemodialysis machine, spiked the acid solution and connected the bicarbonate solution in the jug and the portable Reverse Osmosis machine. During the procedure Contract Registered Nurse (#31) donned his gloves, set up the machine for hemodialysis, spiked the acid bottle, checked the water for total chlorine, applied a mask to the patient's face, then cleaned the hub of the patient's central venous catheter with alcohol swab, then accessed the patient's central venous catheter and flushed the catheter. The Contract Registered Nurse then returned to the patient's hemodialysis machine wearing his contaminated gloves and proceeded to check the external blood lines, but the arterial and venous chambers remained empty and the Trans-membrane Pressure of the machine remained high. Contract registered Nurse ( #31) then removed the right hand of his contaminated glove and retrieved his cell phone from his pocket with his contaminated hand
Registered Nurse (#31) did not remove his contaminated gloves and wash his hands before accessing the patient's central venous catheter.

During an interview on 02/26/2014 at 11:35 a.m. outside the patient's door, the Surveyor informed Contract Registered Nurse (# 31) that he used the same contaminated gloves to set up the patient 's hemodialysis machine, spiked the acid solution and accessed the patient central venous catheter. He stated " You are correct"

Review of the facility's contracted Policy and Procedure # 7 -03- 02 adopted by the facility directed contract staff as follows : " Hands will be washed upon entering the hospital/ facility, prior to gloving, after removal of gloves, between patients, after contamination with blood and other infectious material, after patient and contaminated machine contact, between patients, before touching clean areas such as counter tops, supply carts and at the close of the business day prior to going home."



Patient #15
On 02/27/2014 at 11:40 a.m. Physical Therapist # 30 was was observed in Patient #15's room located on the unit 600. The Physical Therapist was lavaging a wound to the patient's sacral area.
Observation revealed the Physical Therapist donned a pair of gloves, lavaged the patient's wound, removed his gloves and then secured clean gloves from a packet of gloves stored in the patient' room. He then swabbed the solution from the bed of the wound using a 4 X 4 swab with his gloved hand. After completing the procedure the Physical Therapist removed his contaminated gloves and then reset the patient's feeding pump. The Physical Therapist did not wash/ clean his contaminated hands after removing the contaminated gloves.

During an interview on 02/27/2014 at 11:55 a.m. with Physical Therapist #30 , the Surveyor notified him that she the Surveyor had observed that he the Physical Therapist did not wash/ clean his hands after removing his contaminated gloves used in the patient's wound.. The Physical Therapist agreed with the Surveyor's observation.

Review of the facility's current Policy and Procedure on Infection Control ( Hand Hygiene) # 966.4228, revised on 12/13 directed staff as follows: " Healthcare Workers must wash hands with soap and water when hands are visibly dirty, contaminated or soiled and use alcohol - based hand rub when hands are not visibly soiled to reduce bacterial counts. Hand washing is indicated : before and after each patient contact
Before donning gloves
Before preparing or administering medication
When inserting a central venous catheter (CVC)
When inserting urinary catheters
When inserting peripheral vascular catheters
Before performing other invasive devices that don't require surgery
After contact with a patient's intact skin
After contact with non- intact skin or wound dressings
After contact with patient gown or linens
After contact with inanimate objects in patients room
After removing gloves
After using the rest room. "



16838


Patient #25

Observation on 2/26/14 at 9:37 a.m. in Operating Room #4 revealed Patient #25 was being prepared for a tunnel dialysis catheter removal. RN (Registered Nurse) #28 was scrubbing the area with a chlorohexadine scrub brush. She washed the insertion site, then cleaned the multilumen catheter. She then scrubbed the skin from the insertion site outward in a circular motion. RN #28 then went back to the insertion site and the catheter and washed them again with the same brush.

Interview with RN #28 at this time, she said she was a Contract nurse with a 12 week contract to work at the hospital. She said she had worked at the hospital before and was given a one week orientation. She said that since she came back within 3 months, she did not get an orientation.

Interview on 2/26/14 at 10:10 a.m. with Interim Director of Surgery, RN #12, she said the skin should be prepped from the center out and the nurse should not have gone back to the center again with the same brush.

During an interview on 2/26/14 at 10:15 a.m. with RN #28 after the surgery, she was asked why she went back to the center once she had scrubbed the area outward. She said she felt the first scrub was just a before prep. She said a lot of nurses only used the ChloraPrep, but she liked to scrub the area first with a brush. She said she did not consider it a real prep, but just a before prep.

Interview on 2/26/14 at 10:25 a.m. with Surgery Manager, RN #11, she said when the hospital had contract nurses, she was not always sure of how they will do with the skin prep. She said sometime they did it correctly and sometimes not. When she was asked if it was her responsibility to make sure the prep was done correctly, she said it was. She said because the wound for Patient #25 was not openly infected, the skin prep should have started at the insertion site, the catheter and then outward from the insertion site. She said if the nurse felt there needed to be more prep time, then a new scrub brush should be used to go back to the center.

Record review of the facility's Policy and Procedure for Surgical Preps dated 10/2000 and reviewed/revised on 1/2011 revealed the following:
"...VII. Prep the area using aseptic technique and incorporating the following principles.
A. Use a vigorous mechanical action to remove bacteria.
B. Use a circular motion beginning at the incision site and progressing to the periphery.
C. Scrub from the incision site out and never return to the incision site with the sponges previously used in that area.
D. Prepping time should be five (5) minutes to ten (10) minutes, depending on the chosen solution, procedure, and surgeon preference....
X..
A. Paint progressing from the incision site to the periphery...never returning to the incision site...



17028

Observation on 2/25/2014 at 11:10 am on the Intensive Care Unit (ICU) revealed a sign on the entry to room (#2) indicating Patient (#50) was on contact isolation .

Observation at that time revealed Staff (#62) Registered Nurse and Staff( # 63)Radiology technologist were in the room preparing the patient for radiology procedure. Both staff were touching the patient and handling his bed linen. After positioning the patient both staff stepped out in the hallway in their gloves and gowns.

Staff (#63) Radiology Technician removed her gloves, but did not wash/sanitize her hands and used her ungloved hands to break down the X-ray equipment.

Staff (#53) RN, Director on the Unit was observed at 11:15 outside the door of room (# 2) with the patient on contact solation , reached into the room and pulled the privacy curtain accross the entrance to the patient's room with her un-gloved hands.

After completing his care of Patient (#50,on contact isolation) Staff (# 62) RN, removed his gloves and gown, left the room without cleaning his hands at the hand wash sink in the room . He used sanitizer located in the hallway outside the isolation room.


Observation on 2/25/2014 at 11:40 am in the ICU revealed Patient (# 51) in room 5 was on contact isolation. Staff (#60) Registered Nurse was observed providing care to the patient including administering Intra Venous (IV) medication, handling the patient's bed linen and administering oral medication.


The Registered Nurse took a medication cup with pills from the work table in the patient's room and went into the clean dedicated medication room on the unit to crush pills. The Registered Nurse went back to the patient's room with the medication.


During an interview on 2/25/2014 at 11:56 am with Staff (#60) RN regarding taking a contaminated item to the clean medication room she stated there was no capability in the patient's room to crush medication, so she had to take it to the mredication room.

During an interview on 2/25/2014 at 12:10 pm with the Unit Director who was present during the observation she stated pill crushers would be provided for the isolation rooms.


On 2/25/2014 at 1:30 pm in the blood bank at facility's laboratory revealed Staff (#64) Registered Nurse came to the department to collect blood. The Laboratory Staff who was handling blood specimen with gloves on retreived a unit of blood from the refridgerator. During the verification process Staff (#64) RN handled the unit of blood without wearing gloves. She left the room with the blood and did not wash her hands.


During an interview on 2/25/2014 at 2: 15 pm with the Nurse Educator she stated the protocol is for the laboratory staff to place the blood into the plastic bag without touching the bag to ensure the Nurse did not contaminate her hands. She stated if the nurse had to handle the blood she should put on gloves.

Review of the facility's Infection Control Precautions # 966.4267 dated December, 2013 documented the following information:

"Contact Precautions will be used as recommended for patients with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission.
Personal Protective Equipment (PPE):

Gloves will be worn whenever touching the patient's intact skin or surfaces and articles in close proximity to the patient.

Gowns will be worn whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient.
Additional PPE will be used in accordance to Standard precautions.
Standard precautions:
Disposable gloves will be worn when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) could occur."

Based on record review and interview, the facility failed to ensure 6 of 6 patients' records reviewed indicated patients received post - anesthesia evaluation after endoscopy procedure from a sample of 53 patients. #s 26, 27, 28, 29, 30, and 31
Findings :

Patient's # 26, # 27, & # 28

Record review revealed the Post - Anesthesia / Sedation Evaluation forms were incomplete. The post-anesthesia evaluation include assessing for respiratory function (airway patent, and oxygenation within expected parameters), cardiovascular function (pulse and blood pressure within expected parameters) mental status (arousal and able to follow simple commands, or returned to pre-status), and pain within expected parameters.
The Anesthesiologist's signature, was missing on the all three forms. The date and time were missing on all three forms.

Patient 's # 29, # 30, & # 31

Record review revealed on the Post - Anesthesia / Sedation Evaluation forms the date and time were missing on all three forms.


Interview with staff member (# 25) on 02/25/14 @ 1:35 PM acknowledged that Post-op Anesthesia Evaluations should be done. Staff member (#25) stated"he was not aware that the post-op evaluations were not being done until this interview occurred".


Record review of the policy titled " Post Anesthesia Patient Evaluation" Revision Date 04/13 notes :
Any post-anesthetic note should include the time and / or date of the visit and the visiting anesthesiologist' s signature. A post-anesthesia evaluation will be performed by anesthesia prior to discharge of the patient.