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Based on policy and medical record reviews and staff interviews, the hospital nursing staff failed to reassess a change in vital signs for 3 of 10 patients (#1, #2, #13) and failed to implement fall prevention tools in the Emergency Department (ED) per policy and to consistently and accurately assess patients for falls risk in 6 of 10 ED patients (#11, #13, #20, #14, #17, #12).

Findings included:

Review on 12/05/2017 of the "Patient Assessment / Reassessment" policy last revised 05/2017 revealed, "...A. ... 2. ...E. Time Frames: ... 2. ...Reassessment determines the patient's response to care and treatment... Patient reassessment is ongoing.... For all patients reassessment is at specified, regular intervals related to: ...c. significant change in the patient condition ..."

1. Medical record review on 12/05/2017 for Patient #1 revealed a 25 year-old female presented to the hospital on 11/05/2017 verbalizing complaints of increasing depression. Review of the History and Physical (H&P) revealed she also reported command auditory hallucinations, "telling her to jump off her porch or to slit her throat. She states that she has 'catatonic episodes' where she will fall asleep, become rigid, limp, and unresponsive. ..." Review revealed the patient's primary care provider (PCP) recommended electroconvulsive therapy (ECT) treatments. Review revealed diagnoses that were considered included bipolar affective disorder and acute psychotic episode. Review of the vital signs flow sheets revealed the patient's blood pressures (BP) were as follows (Normal range 90/60 to 120/80):
-11/05/2017 at 1800: 101/57
-11/06/2017 at 0600: 105/46
-11/07/2017 at 0600: 93/51
-11/07/2017 at 0930 (prior to discharge): 120/82 (3 hours, 30 minutes later)
Continued review failed to reveal documentation of reassessment or nursing interventions regarding the 0600 BP of 93/51.

Interview on 12/05/2017 with Administrative Staff #2 revealed frequency of vital signs vary within departments. Interview revealed vital signs for the Behavioral Health Unit (BHU) are obtained daily, unless otherwise specified. Interview revealed that although the BP was rechecked prior to the patient's discharge, the 0600 BP should have been rechecked "sooner" and if nursing interventions were implemented, they should have been documented in the medical record. Interview revealed the 7p-7a nurse and CNA (certified nursing assistant) assigned to the patient's care on 11/07/2017 were not available for further discussion. Interview confirmed the medical review findings.

2. Medical record review on 12/04/2017 for Patient #2 revealed an 81 year-old female who presented to the hospital with complaints of abdominal pain and vomiting on 10/06/2017. Review of the H&P revealed a CT (computed tomography) scan was performed which showed a "persistent left lower quadrant (LLQ) abscess". Review revealed diagnoses that were considered included hypertension and diverticulitis of large intestine with abscess without bleeding. Review of the vital signs flow sheet revealed the patient's BPs were as follows (Normal range 90/60 to 120/80):
- 10/06/2017 at 1545: 142/62
- 10/06/2017 at 1945: 112/69
- 10/07/2017 at 0000: 90/46
- 10/07/2017 at 0430: 92/40 (4 hours, 30 minutes later)
- 10/07/2017 at 0813: 86/30 (~3 hours, 43 minutes later)
- 10/07/2017 at 1211: 117/44 (~3 hours, 58 minutes later)
Continued review failed to reveal documentation of reassessment or nursing interventions following the noted change in BP on 10/07/2017.

Interview on 12/04/2017 at 1430 with Management Staff #1 revealed her expectation was that the CNA should recheck a vital sign if there was a noted change and notify the nurse. Interview revealed nursing staff were expected to notify the physician if the change in vital signs was unexpected and outside the norm for the patient.

Interview on 12/04/2017 at 1436 with RN #1 revealed she was the 7p-7a nurse assigned to the patient on 10/07/2017. Interview revealed, "Usually they (CNA staff) come tell us (referring to a noted change in vital signs) and we check it in the computer." Interview revealed previous results were reviewed to assess for trends. If a trend was noted, it did not cause as great a concern; however, if a trend was not identified, the nurse would reassess the patient and notify the physician. Interview revealed, "I am not concerned unless there are other issues going on such as pain or the heart rate is up." Interview revealed RN #1 could not recall whether CNA #1 reported concerns related to the BP but indicated vital signs were readily flagged and available for review in the EMR (electronic medical record).

Interview on 12/04/2017 at 1448 with CNA #1 revealed she obtained the patient's vital signs on 10/07/2017 at 0813. Interview revealed when there was a change in BP, CNA #1 was expected to recheck the BP and notify the nurse. Interview revealed a lower BP was expected when the patient is sleeping but at 0813 the patient would be up, moving around and the BP would be expected to be higher. Interview revealed the 0813 should have been rechecked but CNA #1 was not sure why it was not.

3. Medical record review on 12/06/2017 for Patient #13 revealed a 57 year-old male presented to the hospital on 10/14/2017 with complaints of depression and substance dependence. Review of the H&P revealed the patient was "judged to be at risk to himself" and was admitted to the Behavioral Health Unit Review revealed diagnoses that were considered included major depression, recurrent; cocaine, alcohol, and opiate use disorder and obstructive sleep apnea. Review of the vital signs flow sheet revealed the patient's BPs were as follows (Normal range 90/60 to 120/80):
- 10/19/2017 at 0600: 135/84
- 10/20/2017 at 0600 130/87
- 10/21/2017 at 0600: 135/81
- 10/22/2017 at 0600: 137/86
- 10/23/2017 at 0600: 137/77
- 10/24/2017 at 0600: 111/80
- 10/25/2017 No vital signs recorded or documentation of refusal available for review.
- 10/26/2017 at 0600: 142/102
Review of the nursing progress note by RN #5 revealed the patient was discharged 10/26/2017 at 1205 with "VS WNR" (vital signs within normal range). Continued review failed to reveal documentation of reassessment or nursing interventions following the noted change in BP on 10/26/2017 at 0600.

Interview on 12/05/2017 with Administrative Staff #2 revealed frequency of vital signs vary within departments. Interview revealed for vital signs for the Behavioral Health Unit (BHU) are obtained daily, unless otherwise specified. Interview revealed the patient's BP should have been rechecked prior to discharge and if nursing interventions were implemented, they should have been documented in the medical record. Interview revealed RN #5 was not available for further discussion. Interview confirmed the medical review findings.


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4. Review of hospital policy titled "Falls Prevention and Resources", revised 08/2017, revealed "...SCOPE:....This policy pertains to all patient care settings within the healthcare facility....Fall prevention procedures are based on the assessment of the patient, determination of the patient's risk for fall and implementation of interventions to reduce the risk....The Registered Nurse performs a FALL RISK ASSESSMENT during the initial assessment process and ongoing. To determine whether or not the patient is at risk for falls, the RN considers the following during the initial assessment or re-assessment. a. History of falling b. Secondary diagnosis c. Ambulatory aid d. IV (intravenous) or IV access e. Gait f. Mental status....Falls risk information is relayed to other departments involved in caring for the patient by means of the brightly colored yellow arm band....and a falls magnet on the patient's door. ..."

Review of a computerized Morse Fall Risk and Care Documentation Form, on 12/06/2017, revealed the following risk parameters to be assessed: History of Falling within the past 12 months, Presence of a Secondary Diagnosis, Use of Ambulatory Aids, IV or IV access, Gait Transfer, and Mental Status. Form review revealed a staff member responds either yes or no to the statements of History of falling within the past 12 months, IV or IV access, and Presence of Secondary Diagnosis. Review revealed the form provided additional direction for secondary diagnosis, stating "If the patient is on any of the following classes of medications, check "YES" for secondary diagnosis...Sedatives/Hypnotics (calming, sleep inducing drug), Benzodiazepines (medications that can help reduce anxiety), Narcotics (strong pain medicine)...Diuretics (causes increased urination)...Skeletal Muscle Relaxants... ." The form noted three choices in relation to the Gait Transfer assessment: 1) "Normal, bedrest, wheelchair", 2) "Weak" or 3) "Impaired". Further form review revealed that in response to the assessment of Use of Ambulatory Aids, the staff member would record one of following responses: 1) "None, bedrest, wheelchair", 2) "Crutches, cane, walker", or 3) "Furniture". In regards to the question of Mental Status, the form showed the employee would document either "Oriented to own ability" or "Overestimates, forgets limitations."

Observation of the ED (Emergency Department) on 12/04/2017 at 1600 and 12/06/2017 around 1015 did not reveal any falls magnets on ED patient room doors.

Interview with RN #8, an ED nurse, on 12/05/2017 at 0900, revealed RN #8 was not certain about all the details of the falls policy. Interview revealed the ED does not use the yellow bracelets or door magnets for falls risk.

Interview with Administrative Staff (AS) #3, on 12/06/2017 at 0850 revealed the ED was not using magnets on the doors or yellow fall bracelets. Interview revealed the ED was not following all of the falls policy.

4A. ED Record review, on 12/04/2017, revealed Patient #11 presented to the ED on 11/16/2017 at 0444, with a chief complaint of "pt (patient) states ....slipped and fell on left hip at 0330 this am. ..." Review revealed Patient #11 was evaluated in the ED and discharged home at 0631. Record review failed to reveal a Morse Fall Risk Assessment completed on Patient #11 while in the ED.

Interview with AS #3, on 12/06/2017 at 0850, revealed AS #3 saw the inconsistency in Falls Risk Assessments and the facility had opportunities to improve.

4B. ED record review of Patient # 13, on 12/05/2017, revealed the patient arrived to the ED by ambulance on 11/16/2017 at 1101. Review of a Provider Note, performed at 1159, revealed a chief complaint of "Syncope (fainting) episode Fall with hematoma rt (right) eye." Provider Note review revealed "...History of Present Illness The patient presents with Altered mental status. Family reports.... went to the house and found (Patient) lying on the ground....(Patient) has altered mental status with confusion to person and place....(Patient) has a history of lung cancer that is metastatic to liver and brain. (Patient) is undergoing chemotherapy and radiation therapy. Patient unable to provide any history....and answers 'I do not know' to every question posed... ." Review of "Documented Medications" revealed multiple medications, including narcotic pain medications. Review of Morse Risk Assessment, dated at 1207, revealed a Fall Risk Score of 20. Morse Fall Risk Review revealed "Fall Hx (History) Within Last 12 Months: No Morse Secondary Diagnosis Present: No....Morse Mental Status: Oriented to Own Ability." Review failed to reveal the risk assessment noted the fall prior to arrival, secondary diagnosis, or confusion/ altered mental status.

Staff interview with RN #10, on 12/06/2017 at 0900, revealed the RN did not know why there was a "no" answer to the question on history of falls. Interview revealed if a patient comes in with a fall, the answer should be yes. Further interview revealed Patient #13's mental status was acutely altered, it was not the patient's norm.

Interview with AS #3, on 12/06/2017 at 0850, revealed AS #3 saw inconsistency in Falls Risk Assessments and the facility had opportunities to improve.

4C. Review of Patient #20, on 12/06/2017, revealed the patient arrived to the ED from a Nursing Home on 12/05/2017 at 1202 with a chief complaint of "fall". Review revealed a CT of the Head and Spine were done and Patient #20 was discharged at 1509. Review of the Provider Note, time seen 1227, revealed "...The patient has severe dementia....Neurological....Patient is alert....has severe dementia....will not answer (Patient's) name....will not follow simple commands. ..." Review of Morse Falls Risk Assessment, timed at 1408, revealed "...Morse Mental Status: Oriented to own ability. ..."

Staff interview with AS #3, on 12/06/2017 at 0850, revealed AS #3 saw inconsistency in Falls Risk Assessments and the facility had opportunities to improve.

4D. ED record review of Patient #14, on 12/05/2017, revealed the Patient arrived to the ED at 0953 after a fall. Record review revealed "...Chief Complaint....fell at home....hx (history) of frequent episodes of vertigo (a sensation of feeling off balance). Provider Note review, performed at 1040, revealed "...States chronic history of acute loss of balance has been evaluated....diagnosed with vertigo....Condition: Unchanged .... Patient states has a walker and a wheelchair at home will use. Further Note review revealed a list of documented medications that included Hydrochlorothiazide (a diuretic) and Skelaxin (muscle relaxant) ..." Review of the Morse Fall Risk Assessment, documented at 1003, did not reveal notation of the patient's use of a walker/cane or a secondary diagnosis.

Staff interview with AS #3, on 12/06/2017 at 0850, revealed AS #3 saw inconsistency in Falls Risk Assessments and the facility had opportunities to improve.

4E. ED record review for Patient #17 on 12/05-06/2017, revealed the Patient arrived to the ED on 06/27/2017 at 2203 with a chief complaint of psychiatric disorder - intentional overdose. Record review revealed a Morse Fall Risk Assessment completed at 2257 and revealed a score of 35 related to impaired gait and mental status "Overestimates, forgets limitations." Review of a RN note, performed at 2253, revealed "...Pt walked, with family on both sides ....to the restroom ....Once (Patient) got out of the bathroom (Patient) reportedly fell to the floor in the presence of (Patient's family members). We assisted the pt back onto the bed and the ED MD came to the room to assess (Patient). ..."

Review of an "Event Report", dated 06/27/2017, revealed information related to Patient #17's fall. Event Report review revealed the time of the fall was 2230. Report review revealed a Morse Falls Risk Assessment, not timed, which stated a Morse Falls Risk Score of 15, with a yes given for secondary diagnosis but no concerns related to impaired gait or mental status. Review revealed inconsistency in the two risk assessments and did not reveal a risk assessment that noted the fall that occurred.

Staff interview with AS #3, on 12/06/2017 at 0850, revealed AS #3 saw inconsistency in Falls Risk Assessments and the facility had opportunities to improve.

Staff interview with AS #4, on 12/06/2017 at 1015, revealed the Falls policy was not clear in all the expectations and could be confusing. Interview revealed the facility had opportunities to improve.

4F. Medical record review of Patient #12 revealed the Patient arrived to the ED on 11/16/2017 at 1846 with a chief complaint of fall with chin laceration. Documentation showed the Patient #12 was fall risk assessed at 1947 with a Morse Falls Risk Score of 40. Review of the Morse Risk Assessment revealed "Fall Hx (history) within last 12 months: Yes Morse Secondary Diagnosis Present: Yes Morse Ambulatory Aid: None, bedrest, wheelchair, nurse assist Morse IV/IV Access: No Morse Gait/Transfer: Normal, bedrest, wheelchair Morse Mental Status: Oriented to own ability. ..." Review of a Nursing Note, performed at 1951, revealed "Pt alert, not answering all questions appropriately although (Patient #12) is oriented to person, DOB (date of birth), place and situation. Pt responding with intermittent inappropriate verbal responses and commands/actions." Review of a Provider Note, dated 11/16/2017 at 2003, revealed "....Condition: Stable Disposition: Discharged. Record review did not reveal the time the Patient left the facility. Review of a Nursing Note, dated 11/16/2017 at 2326 revealed "...Pt (Patient) d/c'ed (discharged) home via cab. Pt unable to get into (the) house due to door locked and no key, pt had informed us that someone was home prior to d/c but no one would answer door... ." On 11/17/2017 at 0225, review revealed "...RN in to check on pt at 0200, pt found laying in bed, blood in floor and on pt ....Pt alert to name and DOB (Date of Birth), not oriented to place or situation. ..." Review revealed Patient #12 was admitted with diagnoses of Acute UTI (Urinary Tract Infection), Multiple Falls, Altered Mental Status, Chin laceration, Fracture of left radius, Laceration of left hand. ..." Review of ED record did not reveal another Morse Falls Risk Assessment completed while in the ED.

Review of an Event Report revealed the fall in the ED occurred 11/17/2017 between 0130 and 0200. Review revealed documentation of a Morse Falls Risk Assessment but did not reveal timing of the assessment. Review revealed a total score of 40, 25 points for history of a previous fall and 15 points for "Morse Mental Status". Review revealed "Secondary Diagnosis Present" was not selected in this assessment.

Staff interview with RN #8 on 12/05/2017 at 0900, revealed the RN did not complete another risk assessment of Patient #12 and was not sure who had.

Staff interview with AS #3, on 12/06/2017 at 0850, revealed AS #3 saw inconsistency in Falls Risk Assessments and the facility had opportunities to improve.

Staff interview with AS #4, on 12/06/2017 at 1015, revealed the Falls policy was not clear in all the expectations and could be confusing. Interview revealed the facility had opportunities to improve.

Based on policy and medical record review and staff interview, the hospital nursing staff failed to follow physician orders for 2 of 3 patients (#5 and #14) with insulin orders and 1 of 2 patients who received blood transfusions (#4).

Findings included:

Review on 12/06/2017 of the hospital's policy titled, "Medication Administration" last reviewed 09/2017 revealed, "...POLICY: 1. Medication may be given to a patient only upon a prescriber's order....14. Medication Administration: 1. Before administering any medication, the nurse must check: ...b. The eMAR and the medication container for correct ...dose... 4. All PRN medication are to be recorded on the MAR/eMAR. a. The reason the patient is given a PRN medicaiton and the results of the effectiveness of the medication are to be charted...."

Review on 12/06/2017 of the hospital's policy titled, "Medication Safety: High Alert Medications" last reviewed 09/2017 revealed, "...POLICY...has agreed to designate the following medications as high alert medications...The following processes for managing high alert medications will include....*Verifying the 5 Rights all of [sic] high alert medications being ordered. ...Insulin...*Nursing will double check the order or MAR....dose required... This is documented with the names/initials of both nurses on the MAR. ..."

1. Medical record review on 12/06/2017 for Patient #5 revealed a 56 year-old male was admitted 12/01/2017 for depression and substance dependency. Review of the H&P revealed diagnoses included, but not limited to, major depression; alcohol use disorder; and non-insulin-dependent diabetes. Review of physician's orders dated 12/01/2017 at 1600 revealed a Regular Insulin Sliding Scale as follows:
61-150 = No Insulin
151-200 = 2 units
201-250 = 4 units
251-300 = 6 units
301-350 = 8 units
351-400 = 10 units
401-450 = 12 units

>450 = 12 units and recheck in 1 hour and call the results to the physician.

Review of FSBS results revealed:
- 12/02/2017 at 0541 = 216. Review revealed 2 units were administered (4 units ordered)
- 12/05/2017 at 0606 = 317. Review revealed 6 units were administered (8 units ordered)
- 12/05/2017 at 1940 = 368. Review revealed 6 units were administered (10 unit ordered)

Interview on 12/06/2017 at 1310 with Administrative Staff #1 and #2 revealed an identified trend noted during the medical record review. Interview revealed that both patients were on the same floor and incorrect insulin doses were administered by the same RN (RN #2). Interview revealed insulin is considered a high risk medication and requires a two-person verification prior to administration. Interview revealed both Administrative Staff members were concerned given that the two-person verification process is a safety check to ensure the correct type and dose of insulin is administered and failed. Interview revealed immediate action would be taken to ensure the safety of the patients. Interview revealed RN #2 and #3 (second nurse verifying dose) were unavailable for further discussion. Interview confirmed findings.

2. Medical record review on 12/06/2017 for Patient #14 revealed a 45 year-old male presented to the emergency department (ED) with suicidal ideation and depression on 11/05/2017. Review revealed he was found to be at risk to self and was admitted. Review of the History and Physical (H&P) revealed diagnoses included, but not limited to, schizoaffective disorder, bipolar type and non-insulin-dependent diabetes. Review of physician's orders dated 11/05/2017 at 1100 revealed a Regular Insulin Sliding Scale as follows:
61-150 = No Insulin
151-200 = 2 units
201-250 = 4 units
251-300 = 6 units
301-350 = 8 units
351-400 = 10 units
401-450 = 12 units

>450 = 12 units and recheck in 1 hour and call the results to the physician.

Review of finger stick blood sugar (FSBS) results revealed:
- 12/01/2017 at 1326 = 453. Review revealed a FSBS recheck at 1625 (2 hours, 55 minutes later)
- 12/02/2017 at 0603 = 231. Review revealed 8 units were administered (4 units ordered)
- 12/03/2017 at 0558 = 341. Review revealed 6 units were administered (8 units ordered)
- 12/05/2017 at 0707 = 284. Review revealed 8 units were administered (6 units ordered)

Interview on 12/06/2017 at 1310 with Administrative Staff #1 and #2 revealed an identified trend noted during the medical record review. Interview revealed that both patients were on the same floor and incorrect insulin doses were administered by the same RN (RN #1). Interview revealed insulin is considered a high risk medication and requires a two-person verification prior to administration. Interview revealed both Administrative Staff members were concerned given that the two-person verification process is a safety check to ensure the correct type and dose of insulin is administered and failed. Interview revealed immediate action would be taken to ensure the safety of the patients. Interview revealed RN #2 and #3 (second nurse verifying dose) were unavailable for further discussion. Interview confirmed findings.





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3. Closed medical record review on 12/05/2017 for Patient #4 admitted 10/25/2017 revealed a History and Physical (H&P) of "... 81 year- old with past medical history of coronary artery disease, mitral valve regurgitation, hyperlipidemia, benign hypertension, carotid artery disease, left subclavian stenosis." During medical record review, it showed on 11/02/2017, Patient #4 received 2 units of blood per physician orders. Review revealed a physician order on 10/25/2017 at 1156 for Hydralazine 10 mg IV push q 4 hrs prn for systolic blood pressure >140. Review of the vital signs during transfusion of both units revealed the patient's blood pressures (BP) were as follows:

- 11/02/2017 at 1200: 169/64 (Hydralazine not administered per MD orders for SBP >140)
- 11/02/2017 at 1215: 185/59 (Hydralazine not administered per MD orders for SBP >140)
- 11/02/2017 at 1230: 185/63 (Hydralazine not administered per MD orders for SBP >140)
- 11/02/2017 at 1300: 182/75 (Hydralazine not administered per MD orders for SBP >140)
- 11/02/2017 at 1400: 131/55 (Hydralazine not administered per MD orders for SBP >140)
- 11/02/2017 at 1523: 172/48 (Hydralazine not administered per MD orders for SBP >140)
- 11/02/2017 at 1745: 172/68 (Hydralazine not administered per MD orders for SBP >140)
- 11/02/2017 at 1800: 175/67 (Hydralazine not administered per MD orders for SBP >140)

Review of the medication administration record (MAR) failed to reveal documentation of administration of Hydralazine 10 mg IV push PRN for systolic blood pressure >140 as ordered .

Interview with Administrative Staff #3 on 12/06/2017 at 0915 revealed "It is an expectation that the ordered IV Hydralazine should have been given, the physician should have been called and it should have been documented in the medical record."

On 12/06/2017 at 1000 a telephone interview with RN #14 revealed she was the nurse administering both units of blood on 11/02/2017. Interview revealed, "I cannot recall administering IV Hydralazine" for a blood pressure >140 as ordered.

On 12/06/2017 at 1230 a telephone interview with MD # 5 revealed "If there are orders for PRN medication for blood pressure >140, then the expectation is that the medication should be given as the order states." Interview revealed nursing staff failed to follow physician orders.

Based on policy review, Environmental Services job description review, observations, and staff interviews, the hospital staff failed to maintain a sanitary environment for 1 of 2 units toured (Unit A) and to maintain sterile technique while performing 1 of 1 patients with a CVAD dressing change (Patient #6).

Findings included:

Review on 12/06/2017 of the "Hospital Infection Control and Prevention Plan" last revised 05/2017 revealed, "...PRIORITIES AND GOALS....2. (Hospital name) has identified the following priority areas for which we will limit exposure to infections by implementing specific prevention measures....a. Prevent and/or Reduce the Risk of Infections: The first goal is to provide an effective, ongoing program that prevents or reduces the risk of infection....through continuous improvement of the functions and processes involved in the prevention of infection that includes: *Identifying and preventing the occurrences of healthcare-associated infections by pursuing sound infection control practices such as....environmental sanitation...."

Review on 12/06/2017 of the "Environmental and Valet Services Job Description - Housekeeping" revealed, "...Housekeeping Position Goal: Our goal is to provide a superior level of cleaning quality in an assigned area to maintain a clean working environment. ...Cleaning Tasks: Restrooms Clean Daily ...*Tub/Shower (inside and outside)...*Mop floor...Clean Daily ...*Mop tile floors...."

Review on 12/06/2017 of the contracted Environmental Services policy titled, "Patient Room Cleaning-Daily Cleaning Service" last revised 05/2017 revealed, " ...PURPOSE: In our daily cleaning service for patient rooms, we've got three big goals. *First we want to create the safest possible healing environment by cleaning and disinfecting all contact surfaces in the room ...*We ALSO want to help provide the most pleasant healing environment possible as well. ...CONCLUSION: We want out patient's rooms to the [sic] safest possible healing environment for them. Our patients often have compromised immune systems when they're with us, so the work we do to keep their rooms clean is vital for their health and their healing process. ..."

Findings included:

1. Observation on 12/06/2017 at 1130 of Unit A revealed a 23-bed acute treatment area. Observation revealed a malodorous aroma noted immediately upon entering and throughout the unit. Observation revealed a microwave in the nursing station with food particles splattered on the inside top, sides, and door. Observation of the floor revealed areas of dried spilled coffee on the floor; debris; and a black, sticky substance throughout the unit. Observation of the dayroom revealed chipped and peeling paint around the door frame. Observation of the crash cart in the treatment room revealed a thick layer of dust on the bottom of the cart. Observation of room #714 bathroom shower head revealed a black substance covering the surface of the head easily wiped clean with a damp cloth. Continued observation of room #719 revealed the shower contained an approximate 4-5 inch chipped and cracking area noted along the lip of the shower base. Observation of the fixed shower head revealed a thick layer of a black substance covering the surface of the shower head that was easily wiped clean with a damp cloth.

Interview on 12/06/2017 at 1130 with Administrative Staff #2 revealed Environmental Services (EVS) was a contracted services. Interview revealed an EVS employee is assigned to each unit and is available 0700-1530 daily. Interview revealed the employee who routinely stripped, waxed, and buffed the floor quit recently and that the position had not been filled to date. Interview revealed nursing staff were expected to clean any spilled substances promptly and to maintain a clean, sanitary environment. Interview revealed the black substance on the shower heads was easily removed with a damp cloth and that the overall appearance of the unit was not acceptable. Interview confirmed observation findings.

Interview on 12/06/2017 at 1130 with Administrative Staff #1 revealed nursing staff were expected to clean spills promptly and to help maintain a clean, sanitary environment. Interview revealed the overall appearance of the unit was not acceptable. Interview confirmed observation findings.

Interview on 12/06/2017 at 1140 with EVS Staff #1 revealed an EVS employee was assigned to each unit 0700-1530 daily. Interview revealed there had been "No floor care" (i.e., stripping, waxing, buffing) for approximately one month. Interview revealed EVS staff are expected to mop the floor daily and clean the bathroom, in addition to other job duties. Interview revealed the black substance on the shower head was easily removed with a damp cloth and that shower heads should be cleaned as part of the daily routine. Interview revealed the overall appearance of the unit was not acceptable. Interview revealed the regularly assigned EVS employee was at lunch and was not available for discussion. Interview confirmed observation findings.

Interview on 12/06/2017 at 1520 with the Infection Control Preventionist revealed that maintaining a sanitary environment was a shared responsibility and that nursing staff is expected to clean spills promptly. Interview revealed further investigation and assessment of maintaining the shower heads in a clean condition would occur with input from an Infection Control staff. Interview revealed Infection Control rounds would increase in the identified areas


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2. Review of the policy on 12/06/2017 titled "Central Vascular Access Devices" (CVAD), last revised 08/2017 revealed, ">> Site Care and Dressing<< ... 2. Explain the patient's participation during the procedure and the importance of maintaining sterility....5. Don face mask. (Mask patient also, if tolerated). ... 8 Prepare sterile field by opening the dressing change kit ..."

Observation of CVAD insertion of a PICC (peripherally inserted intravenous catheter that ends just at the top of the heart area) line on 12/04/2017 at 1500 for Patient #6 revealed while Patient #6 was in the holding area after the completion of insertion of PICC, RN # 17 performed the dressing change due to excessive bleeding at the insertion site. The observation revealed the PICC dressing was changed as follows: RN #17 donned gloves and applied dry gauze to control the bleeding at the insertion site. RN #18 stood by to assist, without use of gloves, and placed packaged alcohol prep, Biopatch disc and transparent dressing onto a non sterile bedside table. RN #17 removed the soiled dressing, picked up the packaged alcohol prep off the bedside table and handed it to RN #18 to assist with opening. RN #17 reached for the alcohol pad to cleanse the excess blood, applied the biopatch disc, and transparent dressing. Observation revealed neither RN #17, RN #18, nor the patient had on a face mask during the dressing change Observation revealed nursing staff failed to follow policy for CVAD dressing change.

An interview on 12/04/2017 at 1615 with RN #17 revealed she was "not familiar with the policy of changing the dressing. The dressing changes usually occur on the unit floors, so this is something that I usually don't do." Interview revealed, "I should have placed a mask on the patient and myself and I should not have picked up the alcohol prep off of a non-sterile field."

An interview with the Administrative Staff #3 (present during interview of RN #17 and RN # 18) revealed, "The dressing change policy is to have the patient and those in room also wear a mask."

NC00132683; NC00133660; NC00133494