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24 HOSPITAL AVE

DANBURY, CT 06810

PATIENT RIGHTS

Tag No.: A0115

The Condition of Participation of Patient Rights has not been met.

Based on tour of the facility and observations with staff, the facility failed to ensure that the physical environment was maintained in a safe manner when ligature points and other hazards were identified on the psychiatric units and/or failed to follow the facility grievance process and/or failed to ensure restraints were used in accordance with hospital policy.


Please see A118, A144, A165, A168, A169, A172, A174, and A188

PATIENT RIGHTS: GRIEVANCES

Tag No.: A0118

Based on medical record reviews, review of facility documentation, review of facility policies and interviews for one of three patients reviewed for grievances, (P #18), the facility failed to follow the facility grievance process. The finding includes:

Patient #18 was admitted to the hospital on 5/23/18 for GYN (gynecology) surgery. PACU (post anesthesia care unit) nursing notes dated 5/23/18 at 5:01 PM identified a pain level of "5" (scale of 1-10), with occasional tearing/frowning and was surgically related. Documentation by RN #8 dated 5/23/18 at 5:23 PM indicated that a bladder scan was performed because P #18 felt that the urinary catheter was not draining and the result was "0" urine in bladder. The GYN progress note dated 5/23/18 at 8:26 AM (on in-patient unit) noted that P #18 thought his/her bladder was bruised, was having intense burning and the catheter was adjusted in PACU without relief.

The GYN progress note dated 5/24/18 at 5:20 PM identified that P #18 was upset that her bed was hit in PACU and Urology had not seen him/her for a questionable bladder rupture since there was blood in the urinary bag in PACU and complained of sharp pains in the mons pubis. The GYN progress note dated 5/25/18 at 7:02 AM indicated that P #18 "brought up" that while in PACU, his/her bed was bumped into which caused his/her eye to hit the railing, bruising and swelling were not noted and given the multiple complaints, concerns would be discussed with Risk Management.

The Urology Consult dated 5/25/18 at 2:35 PM noted that P#18 stated that he/she was trying to turn in the bed in PACU, the bed was bumped and the urinary catheter was stretched and cause bladder pain since that time. The consult note further indicated that it was highly unlikely that P #18 had a bladder injury and could follow up with his/her urologist as an outpatient. Facility documentation dated 5/24/18 identified that P #18 complained about the treatment received in PACU and alleged that a male staff member purposely hit his/her bed with his hip after he/she asked him to please stop using the side rail of the bed to assist himself from a bending position as it caused him/her pain causing him/her to cry and have a bruised bladder. Although P #18's medical record and/or emails from/to Risk Management noted that P #18's complaint regarding a possible bladder injury was investigated and addressed with P #18 "in real time", the alleged mistreatment by a staff member in PACU was not documented as part of the investigation. Further, the hospital failed to send the patient written notice of the outcome of the grievance in accordance with facility policy.

Interview with the PACU RN (RN #8) on 3/19/19 at 9:45 AM noted that she did not recall P #18 and/or complaints regarding mistreatment. Interview with Manager #13 on 3/19/19 at 11:15 AM identified that she did not recall P #18 or complaints regarding mistreatment. Interview with the Administrative Director of Perioperative Services on 3/19/19 at 10:19 AM indicated that Manager #13 spoke with P #18 while P #18 was on the in-patient unit, investigated the alleged mistreatment of P #18 by a male staff member and could not substantiate the allegation. Further interview with the Director of Perioperative Services on 3/19/19 at 10:19 AM noted that documentation of the alleged mistreatment investigation could not be provided.

The facility grievance policy identified, in part, that a grievance is a formal or informal written or verbal complaint by a patient when the complainant feels their initial complaint was not adequately resolved by staff present. The policy further identified that all grievances will result in a written response to the patient and/or designee.

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on tour of the facility and observations with staff, the facility failed to ensure that the physical environment was maintained in a safe and comfortable atmosphere. The findings include:

a. The surveyor, accompanied by facility staff in the 6 West Behavioral Health unit observed that the following hazardous conditions were present in this type of environment:

i. The waiting area room had removable ceiling tiles in suspended grid ceiling allowing for a ligature risk within this area that is not monitored;
ii. The door to the Janitors Closet lacked an automatic closing device;
iii. The stair tower door at the end of the corridor was not secured by an alarming notification device failing to safe guard the patients from entering other floors or exiting the facility;


b. The surveyor, accompanied by facility staff in the 7 West Behavioral Health unit observed that the following hazardous conditions were present in this type of environment:

i. The light fixture in the sitting room was not of safe/ institutional type as required and the long television wires not concealed or securely fastened to the wall;
ii. The unit had multiple breakable plastic clocks not securely fastened to the wall;
iii. The unit had observation mirrors within each patient room mounted on the corner of the walls which were plastic and cracked when minimal force was applied;
iv. The patient rooms throughout the unit had ceiling light fixtures that were not sealed with pick proof caulk.


c. Observations on 3/13/19 at 10:10 AM identified on unit 6 (common area for behavioral health) door handles to rooms were not ligature resistant. The sink in the dining room on unit 6 had wrist blade type hot and cold levers that were not ligature resistant. In rooms 1, 5, 7 and 9 there were over the bed tables that could pose a ligature hazard. Interview with RN # 8 on 3/13/19 at 10:10 AM stated that staff conduct shift change environmental rounds but did not have a mechanism for more frequent environmental rounds. RN # 8 further stated that patients are monitored every fifteen minutes and although the policy states to visually scan the environment for potentially harmful items, there is no documentation to identify what staff were to look for.

Subsequent to surveyor inquiry a 15 minute check list was developed to include potential environmental hazards and all staff were being educated regarding what they needed to look for.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0165

Based on clinical record review and review of facility policy for 1 of 5 patients with restraints (Patient #25) the facility failed to ensure that the least restrictive restraints were utilized in accordance with facility policy. The finding includes:

Patient #25 was evaluated in the Emergency Department on 2/24/19 after calling EMS for feeling scared and not being able to manage on his/her own.

Review of a nurses note dated 2/24/19 at 10:50 PM identified that the patient was wandering the halls, gait unsteady, several attempts to redirect unsuccessful, and the patient was combative. At 11:20 PM the physician was notified of the patient's unsteady gait and combativeness and gave an order for Benadryl 50 milligrams (mg) and enclosure bed. Review of an order dated 2/24/19 at 11:38 PM identified risk of injury due to impulsiveness and directed an enclosure bed until the patient was able to follow directions. At 11:50 PM a note identified that an enclosed bed was not available.

On 2/25/19 at 12:21 AM a note identified that the patient was redirectable and calm and was placed in a reclining bed. On 2/25/19 at 1:51 AM the patient received a dose of Benadryl 50 mg IM.

A note dated 2/25/19 at 1:54 AM identified that the patient awakened and started walking in room with an unsteady gait. Staff attempted to redirect and toileting the patient were ineffective. The patient became extremely agitated, combative and yelling. The note identified that it took 6 staff members to restrain for safety.

Review of a physician's order dated 2/25/19 at 1:57 AM directed soft limb restraints for risk of injury due to impulsiveness, maximum 24 hours, when patient able to follow directions.

Review of the record on 2/25/19 for the period of 1:57 AM to 4:58 AM identified that the patient was restrained with a vest restraint and had all four extremities restrained with soft limb restraints. The record failed to identify a physician's order for a vest restraint and/or failed to identify that the least restrictive device was applied as a vest and 4 point soft limb restraints were applied initially and throughout the specified timeframe.

Review of the hourly monitoring notes identified that at 2:10 AM the patient was yelling and highly agitated, at 3:10 AM the patient was yelling, agitated, restless and uncooperative, at 4:10 AM the patient's behavior was described as yelling and a trial release was unsuccessful, the patient had an unsteady gait, was unable to be redirected, and was combative. At 4:18 AM care was provided. At 4:35 AM Ativan 1 mg IM was administered and at 5:34 AM the patient was no longer exhibiting behavior threatening to harm self and the restraints were removed.

Review of the restraint policy identified, in part, that when a restraint is necessary, the type used must be the least restrictive intervention necessary. The policy identified that the following categories of devices are approved and should be tried in order of least to most restrictive. Side rails, enclosure bed, mittens, Vest, then 1, 2, 3, 4 point soft limb restraints.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0168

Based on clinical record review, interview and policy review for 2 of 5 patients in restraints (Patients #13 and 25) the facility failed to ensure that an order for the use of restraints was obtained/renewed. The findings include:


a. Patient #13 was admitted to the facility on 3/3/19 with headache, rash and nausea. The patient was identified to have disseminated shingles with encephalopathy. A physician's order dated 3/6/19 at 11:17 PM directed to apply bilateral wrist restraints due to interference with medical devices. Patient #13 remained in bilateral wrist restraints from 3/6/19 through 3/11/19. Review of the clinical record with the Manager on 3/11/19 at 10:00 AM indicated that on 3/7/19 at approximately 12:00 AM identified that a renewal order was documented on 3/8/19 at 9:51 AM approximately 34 hours after the initial order. The restraint policy identified that restraint order renewals are to be completed every 24 hours. The facility failed to ensure that a renewal order was timely.


b. Patient #25 was evaluated in the Emergency Department on 2/24/19 after calling EMS for feeling scared and not being able to manage on his/her own.

Review of a nurses note dated 2/24/19 at 10:50 PM identified that the patient was wandering the halls, gait unsteady, several attempts to redirect unsuccessful, and the patient was combative. At 11:20 PM the physician was notified of the patient's unsteady gait and combativeness and gave an order for Benadryl 50 milligrams (mg) and enclosure bed. Review of an order dated 2/24/19 at 11:38 PM identified risk of injury due to impulsiveness and directed an enclosure bed until the patient was able to follow directions. At 11:50 PM a note identified that an enclosed bed was not available. On 2/25/19 at 12:21 AM a note identified that the patient was redirectable and calm and was placed in a reclining bed.

A nurses note dated 2/25/19 at 1:54 AM identified that Patient #25 awakened and started walking in room with an unsteady gait. Staff attempts to redirect and toilet the patient were ineffective and the patient became extremely agitated, combative, and was yelling. The note identified that it took 6 staff members to restrain the patient for safety. Review of a physician's order dated 2/25/19 at 1:57 AM directed soft limb restraints for risk of injury due to impulsiveness, maximum 24 hours, when patient able to follow directions.

Review of the clinical record identified that on 2/25/19 between 2:10 AM and 5:50 AM Patient #25 remained in 4-point soft limb restraints as well as a vest restraint. The record was reviewed with RN #5 on 3/13/19 at 11:20 AM and failed to identify an order for a vest restraint.

Review of the policy identified that a physician's order is required for the use of restraints and only physician or licensed practitioners (LIP) may order restraints. The policy further identified that all physician's orders for restraints must include the date and time of the order, type of restraint uses, reason/indication for restraint and duration of restrain (time limit). The restraint policy identified that restraint order renewals are to be completed every 24 hours.



25210

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0169

Based on clinical record review, interview and policy review the facilty failed to ensure that a new restraint order was obtained each time a patient was placed in restraints for 1 of 5 patients (Patient #33) who was placed in restraints. The findings include the following

Review of the clinical record for Patient #33 indicated that on 2/23/19 at 12:00 AM the physician's orders directed the use of an enclosure bed for risk of injury related to impulsiveness. The record indicated that the patient remained in the enclosure bed for the period of 2/23/19 through 2/26/19.

The flow sheet dated 2/25/19 indicated that at 10:00 AM and 12:00 PM the patient was out of the enclosure bed sitting in a recliner chair. The flow sheet indicated that at 2:00 PM the patient was placed back in the enclosure bed.

The policy indicated the patient should be monitored at a minimum of every two hours and documented on the non-violent flow sheet. The policy indicated that temporary, directly supervised releases that occur for the purpose of caring for the patient's need, such as feeding, toileting, and range of motion. If the patient is left unattended and unrestrained the restraint is considered discontinued and a new order is required.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0172

Based on clinical record review, interview and policy review the facility failed to ensure that 1 of 5 patients (Patient #13) were evaluated by the physician and/or LIP within 24 hours of restraint application. The findings include the following:

a. Patient #13 was admitted to the facility on 3/3/19 with headache, rash and nausea. The patient was identified to have disseminated shingles with encephalopathy. The physician's order dated dated 3/6/19 at 11:17 PM directed the use bilateral wrist restraints for interference with medical devices. Review of the record with the Manager on 3/11/19 at 10:00 AM indicated that the patient remained in bilateral wrist restraints for the period of 3/7/19 through 3/11/19. Review of the record with the Assistant Manager on 3/11/19 at 10:00 AM indicated that although there were daily physician notes the physician failed to address an assessment of the patient in relation to the usage and ongoing need for restraints.

The policy indicated that a renewal order must be obtained once each day and the LIP must do a face to exam of the patient while the restraints are in place.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0174

Based on clinical record review, interview and policy review the facility failed to ensure that for 3 of 5 patients (Patients #13, 31 and 33) that restraints were discontinued at the earliest time. The findings include the following:


a. Patient #13 was admitted to the facility on 3/3/19 with headache, rash and nausea. The patient was identified to have disseminated shingles with encephalopathy. The physician's order dated dated 3/6/19 at 11:17 PM directed the use bilateral wrist restraints for interference with medical devices. Review of the record with the Manager on 3/11/19 at 10:00 AM indicated that the patient remained in bilateral wrist restraints for the period of 3/7/19 through 3/11/19. Review of the restraint monitoring indicated that for the period of 3/8/19 at 3:00 PM through 3/11/19 the patient was appropriate and calm. The documentation indicated that the patient can be impulsive.

Interview with the Nurse Manager on 3/11/19 at 10:15 AM indicated that the patient is on isolation and is very impulsive and if he/she gets out of bed staff can't get into the room quickly, to prevent him/her from pulling at the medical devices. The Nurse Manager indicated that the patient has a PICC line with nothing infusing and a Foley catheter.


b. Patient #31 presented to the ED on 2/28/19 at 12:36 AM after a motor vehicle accident. Review of the record indicated a physician's order dated 2/28/19 at 12:56 AM that directed the use of four point locked restraints for imminent risk for harm to others. Review of the restraint monitoring indicated that on 2/28/19 at 1:22 AM the patient was sleeping and at the next check at 2:30 AM the patient remained sleeping. The documentation indicated that at 2:49 AM on 2/28/19 restraints on the left arm and right leg were removed and the patient continued to sleep. The documentation dated 2/28/19 at 3:00 AM, and 3:15 AM indicated that the patient was calm. Documentation dated 2/28/19 at 3:33 PM indicated that the restraints on the right leg and left arm were removed. The facility failed to ensure that restraints were discontinued at the earliest possible time.


c. Review of the clinical record for Patient #33 indicated that on 2/23/19 at 12:00 AM the physician's orders directed the use of an enclosure bed for risk of injury related to impulsiveness. The record indicated that the patient remained in the enclosure bed for the period of 2/23/19 through 2/26/19.

The flow sheet dated 2/25/19 indicated that for the 5:13 AM and 8:00 AM check the patient was calm and cooperative and remained in the enclosure bed. The 10:00 AM check indicated that the patient was out of bed to the chair at the 12:00 PM check. The flow sheet indicated that at 2:00 PM the patient was back in bed, restraint use continued for the identified behavior, while in restraints was calm and cooperative. For the period of 2:00 PM through 8:05 PM the patient was identified as being calm and cooperative however remained in the enclosure bed. The facility failed to ensure that restraints were discontinued at the earliest possible time.

Review of the policy indicated that termination of the restraint should occur as soon as the safety of the patent and others can be assures or maintained with less restrictive interventions regardless of the expiration date/time.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0188

Based on clinical record review, interview and policy review the facilty failed to ensure that 1 of 5 patients (Patient #32) was monitored while in restraints. The findings include the following:

Patient #32 presented to the ED on 2/10/19 at approximately 1:00 AM intoxicated. The clinical record indicated that on 2/10/19 at approximately 1:00 AM the patient was placed briefly in restraints for control of behavior escalation. The record indicated that at 1:30 AM the restraints were removed and although patient remained restless and uncooperative he/she is now re-directable. The nursing note dated 2/10/19 at 2:12 AM indicated in part that the patient was walking with the RN, grabbed the RN at which time security restrained the patient to the stretcher and patient ended up in four point for safety. Patient remained in restraints until the doctor came to evaluate the patient. Review of the record with RN # 5 failed to reflect restraint monitoring/documentation that identified the exact time of restraint application, monitoring and/or the time of restraint removal.

Review of the policy indicated that the violent /self destructive restraint documentation should be completed every hour at a minimum. Documentation should include in part, the patients response to the intervention, individual assessments and reassessments.

PHYSICAL ENVIRONMENT

Tag No.: A0700

The Condition of Participation of Physical Environment has not been met.

Based on tour of the facility and observations with staff, the facility failed to ensure that the physical environment was maintained in a safe and sanitary manner when ligature points and other hazards were identified on the psychiatric units, and/or when unsanitary conditions were identified in the Central Sterile Department and in the hospital's main kitchen.


Please see A701

MAINTENANCE OF PHYSICAL PLANT

Tag No.: A0701

1. Based on tour of the facility and observations with staff, the facility failed to ensure that the physical environment was maintained in a safe and comfortable atmosphere. The findings include:

a. The surveyor, accompanied by facility staff in the 6 West Behavioral Health unit observed that the following hazardous conditions were present in this type of environment:

i. The waiting area room had removable ceiling tiles in suspended grid ceiling allowing for a ligature risk within this area that is not monitored;
ii. The door to the Janitors Closet lacked an automatic closing device;
iii. The stair tower door at the end of the corridor was not secured by an alarming notification device failing to safe guard the patients from entering other floors or exiting the facility;

b. The surveyor, accompanied by facility staff in the 7 West Behavioral Health unit observed that the following hazardous conditions were present in this type of environment:

i. The light fixture in the sitting room was not of safe/ institutional type as required and the long television wires not concealed or securely fastened to the wall;
ii. The unit had multiple breakable plastic clocks not securely fastened to the wall;
iii. The unit had observation mirrors within each patient room mounted on the corner of the walls which were plastic and cracked when minimal force was applied;
iv. The patient rooms throughout the unit had ceiling light fixtures that were not sealed with pick proof caulk.

Following these observations, the facility immediately removed the glass mirrors and wall clocks.


c. Observations on 3/13/19 at 10:10 AM identified on unit 6 (common area for behavioral health) door handles to rooms were not ligature resistant. The sink in the dining room on unit 6 had wrist blade type hot and cold levers that were not ligature resistant. In rooms 1, 5, 7 and 9 there were over the bed tables that could pose a ligature hazard. Interview with RN # 8 on 3/13/19 at 10:10 AM stated that staff conduct shift change environmental rounds but did not have a mechanism for more frequent environmental rounds. RN # 8 further stated that patients are monitored every fifteen minutes and although the policy states to visually scan the environment for potentially harmful items, there is no documentation to identify what staff were to look for.

Subsequent to surveyor inquiry a 15 minute check list was developed to include potential environmental hazards and all staff were being educated regarding what they needed to look for.



2. Based on tour of the facility and observations with staff, the facility failed to ensure that the physical environment was maintained in a clean and sanitary condition. The findings include:

a. The surveyor, accompanied by facility staff, observed that the area behind the sterilizing units within the Central Sterile Department had a significant accumulation of dirt, dust, debris, office supplies, tools, used oil containers, standing water in drip pans under appliances, open wall separation penetrations, missing pieces of drywall, and missing ceiling tiles, not being able to maintain a sanitary condition in a sterile environment.

b. The surveyor, accompanied by facility staff, observed the followings conditions within the Main Kitchen area;

i. A very heavy accumulation of dirt, grease, and debris behind, under, and around the main cook line appliances.
ii. Multiple trash containers overflowing with trash on floor surfaces around same.
iii. Hand wash sinks that lacked faucets with wrist blade devices to ensure a "hands free" operation.
iv. A heavy accumulation of dirt and debris throughout the entire Department space, especially on horizontal surfaces.
v. Standing water that was leaking from appliances on floor surfaces was being "diked" by used mop heads.
vi. Dirty, burned, and stained ceiling tiles throughout the entire Department.

INFECTION PREVENTION CONTROL ABX STEWARDSHIP

Tag No.: A0747

The Condition of Participation for Infection Control has not been met.

Based on tour of the facility and observations with staff, the facility failed to ensure that the physical environment was maintained in a clean and sanitary condition to avoid sources and transmission of infectious and communicable diseases when unsanitary conditions were identified in the central sterile department, main kitchen, and in operating and/or endoscopy suites, failed to ensure that sterilizer cycles/loads were properly monitored, failed to ensure that dialysis equipment was properly cleaned and/or that dialysis equipment cultures were signed off by the Medical Director, and failed to ensure that IV (intravenous) fluids had not expired.


Please see A749

INFECTION CONTROL PROGRAM

Tag No.: A0749

1. Based on observations during tour of the surgical department to include the CSD (Central Sterile Department/SPD- Sterile Processing Department), interview, and policy review, the facility failed to ensure proper hair covering and/or sanitization. The finding includes:

a. A tour of the surgical suites in the main OR (operating room) and the ASU (ambulatory surgical unit) was conducted on 3/11/19. Observation of OR #5 on 3/11/19 at 10:36 AM, OR #2 at 11:02 AM, OR #9 at 11:05 AM and OR "F" at 11:12 AM identified the Circulator Nurse and/or Anesthesia Staff and/or ST (scrub tech) and/or Resident and/or Vendor in the operative suite with head and/or facial hair that was not contained within the head covering and/or mask. Interview with the OR Manager at 10:56 AM on 3/11/19 noted that all hair must be contained within the head covering and the facility had beard covers to be used to cover facial hair. The facility policy for surgical attire identified that all head and facial hair, including sideburns and hair at the nape of the neck will be covered when in the restricted and semi- restricted areas.


b. A tour of the surgical suites in the main OR (operating room) and the ASU (ambulatory surgical unit) was conducted on 3/11/19. Observation of OR #5 on 3/11/19 at 10:36 AM, OR "G" at 11:17 AM identified rusted equipment (OR table base, weights, stands, tables) rendering the equipment unable to be properly sanitized. In addition, an accumulation of dust and debris on OR monitors and/or phone and/or window shade was also observed in these two ORs. Interview with the OR Manager on 3/11/19 at 10:48 AM noted that sanitizing wipes are used to clean OR equipment between cases. The facility policy for environmental/terminal cleaning of the OR identified that all horizontal surfaces of the OR will be damp dusted before the first scheduled surgical procedure of the day. The policy further directed that terminal cleaning and disinfection will be performed in each OR suite after the last procedure of the day to include, in part, the OR bed and computers.


c. A tour of the Central Sterile Department (CSD) was conducted on 3/12/19. Observations on 3/12/19 at 11:15 AM identified a room that was located behind the 5 steam sterilizers with the access door and vent located adjacent to the sterilized instrument tray assembly area. Observation of this room noted excessive, caked dust/debris build-up on ceiling vents, the vent adjacent to the assembly area, piping and floor and standing water with black floating debris in three of three functioning sterilizer drip pans. In addition, the surveyor, accompanied by facility staff also observed office supplies, tools, used oil containers, open wall separation penetrations, missing pieces of drywall, and missing ceiling tiles, not being able to maintain a sanitary condition in a sterile environment.


Review of environmental/infection control rounds and interview with the IP (Infection Preventionist) on 3/12/19 at 11:45 AM and at 1:20 PM identified that an Environmental Services Staff member cleaned the main SPD daily, major dust build-up was observed in the SPD back room in August of 2018 which was cleaned and the room behind the sterilizers was cleaned of only dust in December and no water was noted in the drip pans. Further interview with the IP on 3/14/19 at 10:57 AM indicated that he/she was just informed that there was a miscommunication issue between the Manager of CSD and the Environmental Services Staff Member as the Environmental Services Member believed he only needed to clean the room behind the sterilizers when he was notified to do so and not on a routine basis. The facility policy for clinical requirements, infection control identified that the entire CSD will be cleaned by Environmental Services personnel daily following strict guidelines.


In addition, interview with the SPD Manager on 3/14/19 at 10:40 AM indicated that increased steam sampling was conducted by the Contracted Company beginning December of 2018 and the last testing was performed on 3/8/19. Further interview with the Manager of SPD at this time indicated that although she ensured proper attire was utilized by the Contracted staff who performed the steam sampling, she did not check the room behind the sterilizers after the testing was performed. Interview with the Manager of Plant Services on 3/14/19 at 10:52 AM identified that he accompanied the Contracted staff into the room behind the sterilizers on March 8, 2019 and observed the water and black floating material in the drip pans beneath sterilizers. Interview with the Chairman of Infectious Disease on 3/14/19 at 2:37 PM indicated that given the positive pressure in the Main SPD and the non-aerosolized black debris in the stagnant water of the drip pans, the health impact on patient's and/or employees would be negligible. The Safety Management Plan for the facility identified that the facility will provide the safest possible environment and to reduce hazards for patients, personnel, physicians and others, through the identification, and minimization of risk and adherence to applicable regulatory requirements. The job description for the Director of Infection Control/prevention identified an accountability to direct infection control and prevention network activities. The job description for Assistant Chief of facilities/Environmental included a responsibility to maintain a safe environment for patients, staff and visitors by managing Building Services work teams.

The facility subsequently developed a new log to monitor rounds in the SPD area to include actions taken to address identified issues. Interview with the IP on 3/14/19 at 11:06 AM indicated that a cleaning schedule will be developed in the SPD based on data from the newly developed log.





2. Based on a tour of the dental clinic, review of facility logs, review of facility policies, observations and interviews, the facility failed to ensure that sterilizer cycles/loads were properly monitored. The finding includes:

a. A tour of the satellite dental clinic was conducted on 3/12/19. Observation of the clean room on 3/12/19 at 9:30 AM identified that the facility utilized three autoclaves for instrumentation sterilization. Review of multiple load strips from each machine indicated that the initials of the staff who ran each load was not documented as to ensure that the physical parameters (time, temperature and pressure) of each sterilized load were met. Interview with the Dental Assistant on 3/12/19 at 9:38 AM noted that she removed the strip of sterilized loads from each sterilizer at the end of the day, did not check the physical parameter of each load and did not know what the required sterilizer pressure should reach for each load. The facility policy for sterilizer monitoring maintenance identified that graph recording charts record time, temperature, pressure and are to be changed daily and are evaluated before and after each sterilized load. The policy further directed that the personnel evaluating sterilization criteria are to initial graph cycle.




3. Based on observation during tour of the endoscopy suite, review of facility policy, and interview, the facility failed to ensure that IV (intravenous) fluids had not expired. The finding includes:

a. A tour of the endoscopy suite was conducted on 3/11/19. Observations in the endoscopy suite at 11:45 AM identified five spiked IV bags filled with IV fluid, hanging on a single IV pole and each IV tubing label noted 10:40 AM as the time in which the IVs were spiked. Interview with the Assistant Manager of Endoscopy on 3/11/19 at 11:45 AM noted that she spiked the IV's at 10:40 AM and the fluids would expire in 1 hour after spiking if administration of the fluid was not initiated. The facility policy (per Lippincott) identified that if a solution is prepared outside the pharmacy, the administration should begin within 1 hour after the start of the preparation.


15482

4. Based on observation during tour and interview the facility failed to ensure that the dialysis equipment was properly cleaned and/or that equipment cultures were signed off by the Medical Director in accordance with facility policy. The findings include the following:

a. During a tour of the inpatient dialysis unit on 3/13/19, the primer container located on a dialysis machine in use (room #25) was observed with dry brown build up in the hollow handle as well as brown spots on the outside of the bucket. Tour of room 28 which was not in use further identified brown build up in the hollow handle of the prime bucket.

b. Tour of the inpatient dialysis unit on 3/13/19 identified that the unit utilizes an Accucheck blood glucose meter (Inform II System). Interview with RN#3 on 3/13/19 at 11:20 AM identified that blood is drawn from the patient's dialysis line then a syringe is used to extract a sample for the blood glucose monitoring. RN #3 stated at no time does a patient's finger come in contact with the glucometer. RN #3 stated that she wiped the front panel and the indicator with alcohol wipes and cleaned the back and sides with bleach wipes (1:10 ). Review of the hospital policy and procedure for disinfecting the accucheck meter directed to use the germicidal wipe ( 1:10) to disinfect by gently wiping the surfaces to the meter three times vertically and three times horizontally. Allow the meter to stay damp for one minute.

In a subsequent interview on 3/14/19 at 1:00 PM, RN #3 indicated that he/she was under the impression that bleach could damage the sensor, therefore, alcohol was used on that part of the machine but he/she always used bleach on the outside of the meter. RN #3 stated that he/she was made aware that no alcohol is to be used so going forward he/she would only use the bleach wipes.

c. Review of the monthly dialysate and water cultures for the period of 1/1/18 through 3/14/19 failed to reflect acknowledgement of the results by the Medical Director. Review of the water and dialysis cultures dated 9/20/18 indicated that RO #8 had a culture result of 500 CFU's (normal <10 CFU's). The lab result failed to be acknowledged by the Medical Director in accordance with facility policy. Review of the documentation failed to identify a redraw was completed, however, subsequent to inquiry, additional testing was located in the computer.

Review of the Davita policy indicated that in part the Program Manager or designee are responsible for ensuring dialysis quality water testing results are obtained, reviewed approved and signed off by the Medical Director and necessary actions taken.





27249

5. Based on tour of the facility and observations with staff, the facility failed to ensure that the physical environment was maintained in a clean and sanitary condition. The findings include:

a. The surveyor, accompanied by facility staff, observed the followings conditions within the Main Kitchen area;

i. A very heavy accumulation of dirt, grease, and debris behind, under, and around the main cook line appliances.
ii. Multiple trash containers overflowing with trash on floor surfaces around same.
iii. Hand wash sinks that lacked faucets with wrist blade devices to ensure a "hands free" operation.
iv. A heavy accumulation of dirt and debris throughout the entire Department space, especially on horizontal surfaces.
v. Standing water that was leaking from appliances on floor surfaces was being "diked" by used mop heads.
vi. Dirty, burned, and stained ceiling tiles throughout the entire Department.