HospitalInspections.org

Based on observations. record reviews, and interview, the hospital failed to ensure that the Hemodialysis unit operated in a responsible manner to ensure the safety of those patients.

The findings include:

On 5/3/18 at 10:30 a.m., a request was made to the Chief Executive Officer (CEO) for the Medical Director appointment for the Hemodialysis unit. On 5/3/18 at 11:30 a.m., the Chief Operating Officer (COO), stated, "We do not have an appointment for a Medical Director over dialysis because in the contract it states it will be provided by the contracting agent." On 5/3/18 at 10:30 a.m., in an interview with the hospital's Quality Officer, he/she stated the contracting agent for the hospital's hemodialysis unit appointed the Medical Officer for the hemodialysis unit and that there were three Nephrology physicians who are "encouraged but not required to attend the hospital's staff meetings. On 5/3/2018 at 11:45 a.m., a review of the minutes for physicians showed three Nephrologist's names for the Medicine monthly meeting, but when the attendance rosters for the Medicine monthly meeting for January 2016 through April 2018 were reviewed, there was no documentation of attendance at the monthly Medicine meetings for the three Nephrologists. There was no documentation that the three Nephrologists were actively engaged with the hospital's leadership in the evaluation of the quality of care for the patients in the hospital's hemodialysis unit.

On 5/3/2018 at 12:20 p.m., review of the hospital's responsibilities recorded in the hospital's hemodialysis contract reads, "In-Hospital Dialysis and Aphaeresis Services Agreement", 2.05: Hospital has full medical responsibility for its Patients in general, and specifically, during the provision of the Services and agrees to supervise its Patients accordingly."

On 5/2/18 at 9:30 a.m., an interview was conducted with Director 2 who stated she receives a quarterly report from the contracted provider which reads, "Water Treatment and Water Quality'". On 5/2/18 from 5:10 p.m. to 5:20 p.m., Director 2 stated, ""I am just a liaison for them(dialysis contact agent). They were added to my service around March of 2017. I am the contact person between the contract agent and the hemodialysis staff. At one time when we were doing CRRT in the ICU, we were trained on that, but that's been many years ago, and we don't do it anymore. That was all I knew about dialysis. The only part I do is basically reconcile charges, order supplies like gloves, dressings, things like that. The dialysis nurse is basically supposed to be able to work on their own. We really don't have anything to do for them otherwise."

On 5/2/18 at 3:10 p.m., an interview was conducted with the Hospital Infection Control Officer (ICO) who stated, "I have never done any infection control audits in the dialysis unit or for their staff. They are not even on my surveillance. Everyone (Directors) drops their performance indicators into the folder with their quarterly data. I don't know who would be responsible for that area. I guess the ICU/Dialysis Director is."

Cross Reference to A 0144: The hospital's failed to ensure the Hemodialysis patient's right to receive care in a safe setting.

Based on record review and interview, the hospital governance failed to show the medical staff responsible for the quality of care for dialysis patients was proactive with the hospital's medical leadership in the evaluation of the care for its patients receiving Hemodialysis.

The findings are:

On 5/3/18 at 10:30 a.m., in an interview with the hospital's Quality Officer, he/she stated the contracting agent for the hospital's hemodialysis unit appointed the Medical Officer for the hemodialysis unit and that there were three Nephrology physicians who are "encouraged but not required to attend the hospital's staff meetings. In an interview with the Chief Operating Officer on 5/3/18 at 11:30 a.m., the Chief Operating Officer (COO) stated, "We do not have an appointment for a Medical Director over dialysis because in the contract, it states it will be provided by .....(contracting agent)." On 5/3/2018 at 11:45 a.m., a review of the minutes for physicians showed three Nephrologist's names for the Medicine monthly meeting, but when the attendance rosters for the Medicine monthly meeting for January 2016 through April 2018 were reviewed, there was no documentation of attendance at the monthly Medicine meetings for the three Nephrologists. There was no documentation that the three Nephrologists were actively engaged with the hospital's leadership in the evaluation of the quality of care for the patients in the hospital's hemodialysis unit.

In-Hospital Dialysis and Aphaeresis Services Agreement
1.09: Hospital shall perform all of their respective duties and obligations set forth herein in accordance with all applicable federal and state laws and regulations

2.03: Hospital shall ensure that an Approved Physician will be consulted to examine the Patient and determine if such Patient is a candidate for the Services and, if such Patient is a candidate, such Approved Physician will prescribe the appropriate treatment and procedural direction. Hospital shall provide or complete, or cause its Approved Physician to provide or complete, a written order for the Services to be available at the time when Services are scheduled, shall obtain proper Patient consents for such services.

2.05: Hospital has full medical responsibility for its Patients in general, and specifically, during the provision of the Services and agrees to supervise its Patients accordingly.

Based on record reviews and interviews, the governing body in accordance with hospital policy failed to ensure that specific care requirements of its contracted services for its Hemodialysis Unit were met.

The findings are:

Cross Reference to A 0392: The hospital failed to provide nursing care to its hemodialysis patients as needed.

Cross Reference to A 0749: The hospital's infection control leadership failed to provide monitoring and oversight of nursing as it relates to infection control principles, the hospital's policies and procedures, and review of hospital dialysis logs for its water quality system.

Based on record reviews and interview, the hospital's governance failed to ensure active valid contract agreements were secured for 2 of 3 contracts reviewed. (Hemodialysis and Refuse Contract)

The findings are:

On 5/2/18 at 10:00 a.m., review of the hospital's contract for its dialysis services revealed its "In-hospital Dialysis and Aphaeresis Services Agreement" for the Hemodialysis unit was authenticated by the Hospital Chief Executive Officer on 9/16/15, but the contacting agent had not authenticated the contract. The hospital's Dialysis service started on January 1, 2016. This finding was verified with the Chief Quality Officer on 5/2/18 at 12:50 p.m..

On 5/3/18 at 10:30 a.m., in an interview with the hospital's Quality Officer, he/she stated the contracting agent for the hospital's hemodialysis unit appointed the Medical Officer for the hemodialysis unit and that there were three Medical Directors who were "encouraged but not required to attend the hospital's staff meetings. In an interview with the Chief Operating Officer on 5/3/18 at 11:30 a.m., the Chief Operating Officer (COO) stated, "We do not have an appointment for a Medical Director over dialysis because in the contract, it states it will be provided by .....(contracting agent)." On 5/3/2018 at 11:45 a.m., a review of the minutes for physicians showed three Nephrologist's names for the Medicine monthly meeting, but when the attendance rosters for the Medicine monthly meeting for January 2016 through April 2018 were reviewed, there was no documentation of attendance at the monthly Medicine meetings for the three Nephrologists. There was no documentation that the three Nephrologists were actively engaged with the hospital's leadership in the evaluation of the quality of care for the patients in the hospital's hemodialysis unit.

In-Hospital Dialysis and Aphaeresis Services Agreement
1.09: Hospital shall perform all of their respective duties and obligations set forth herein in accordance with all applicable federal and state laws and regulations

2.03: Hospital shall ensure that an Approved Physician will be consulted to examine the Patient and determine if such Patient is a candidate for the Services and, if such Patient is a candidate, such Approved Physician will prescribe the appropriate treatment and procedural direction. Hospital shall provide or complete, or cause its Approved Physician to provide or complete, a written order for the Services to be available at the time when Services are scheduled, shall obtain proper Patient consents for such services.

2.05: Hospital has full medical responsibility for its Patients in general, and specifically, during the provision of the Services and agrees to supervise its Patients accordingly.



39208

On May 1, 2018 at 3:30 p.m., review of the hospital's contract for garbage removal revealed the hospital's 36 month contract expired 7/11/2014. The hospital's leadership authenticated the 36 month contract with the refuse disposal organization was dated 7/11/2011 and expired 7/11/2014. The hospital continues to use the services of the contracted entity without an active contract in place. The finding was verified with Director 5 on May 3, 2018 at 8:58 a.m. who stated, "We have been trying to get a current contract with them."

Based on observations, record reviews, review of the hospital's water quality logs, review of the hospital's Quality and Infection Control data, the hospital failed to ensure the oversight and monitoring of the care that patients received in its contracted hemodialysis unit for 1 of 1 Registered Nurses (RN 15) and 6 of 6 closed patient charts (Patient 28, 24, 20 21, 12, and 13)

The findings are:

On 5/2/18 at 5:50 p.m., observation in the acute dialysis unit revealed Registered Nurse (RN ) 15 incorrectly performed the total chlorine test. He/she obtained the water sample from the portable reverse osmosis (RO). Then swished the test strip for 60 seconds, visualizing the clock, then the strip was shaken, folded over and test results were read at 3 seconds. When asking RN 15 how long to wait to read the result of the strip, RN 15 whispered to the state surveyor, "Well I read it at about 3 seconds, but I look at it all the way to the trash can before I throw it away." At 6:25 p.m., further review of the Portable Water System Total Chlorine Log revealed No RO "on time" for RO # 73, and no Post Worker Carbon results had been charted yet, or signed by RN 1.

On 5/2/18 at 5:45 p.m., observations in the hospital's Acute Dialysis Unit revealed Registered Nurse (RN) 15 failed to don personal protective equipment (PPE) in the provision of care for 2 dialysis patients. On 5/2/18 at 5:49 p.m., observations in the Acute Dialysis Unit revealed RN 15 put hand sanitizer into his/her gloved hands, rubbed the hands together, wiped the wetted glove hand over the previously used stethoscope, and then threw the stethoscope across the room to the nurse's desk. Then, RN 15 continued the care for the dialysis patient wearing the same gloves. On 5/2/18 at 5:58 p.m., observations in the Acute Dialysis Unit revealed the dialysis patient located at dialysis station 1 removed a dirty soiled dressing from the left upper arm access site. RN 15 proceeded to cannulate the patient after gently wiping across the patient's left upper arm access site with one (1) alcohol wipe. RN 15 did not wash the patient's access site or clean the patient's access site with an antiseptic prior to placing the needle into the arterial portion of the arteriofistula (AVF). Using the same alcohol pad, RN 15 cannulated the second needle into the venous access. Then, RN 15 proceeded to the patient's dialysis chart, flipped through the dialysis orders, wrote on the patient's record, flushed the patient's access with saline, taped the lines to the patient gown, and then attempted to begin the dialysis treatment. RN 15 changed the soiled gloves, but did not perform hand hygiene before donning clean gloves. On 5/2/18 at 6:10 p.m., observations in the Acute Dialysis Unit revealed RN 15 wearing gloves soiled from the patient's access, changed only the glove on the left hand and proceeded to resume patient care. After a request change the other glove before resuming care, RN 15 removed the second soiled glove and donned a clean glove, but failed to perform hand hygiene between the gloving change. On 5/2/18 at 6:16 and 6:20 p.m., observations in the Acute Dialysis Unit revealed RN 15 removed the dirty gloves, donned clean gloves, but failed to perform hand hygiene. On 5/2/18 at 6:22 p.m., observations in the Acute Dialysis Unit revealed RN 15 reached into his/her right scrub pocket with gloved hands and removed an ink pen. On 5/2/18 at 6:24 p.m., observations in the Acute Dialysis Unit revealed RN 15 wearing blood soiled gloves reached into the clean supply cart wearing the blood contaminated gloves and removed a 10 cubic centimeter (cc) syringe to use on the patient located at dialysis station 1. Wearing the blood soiled gloves, RN 15 continued to provide care for the patient. Observations of RN 15 throughout the provision of care revealed RN 15 never performed hygiene before initiating care, throughout the provision of care, and at the cessation of care.

On 05/02/18 at 6:00 p.m., review of the hospital's crash cart logs for the dialysis unit revealed the staff on the dialysis unit which is a high risk problem prone dialysis unit failed to check the unit's emergency crash cart and document the data on the emergency crash cart flow sheet daily during the hours of operation for 7 of 13 months (January 2017 through January 2018). Review of the hospital's "Crash Cart Check Sheet" showed there was no documentation of the crash cart data on January 15, 2017, March 16, 2017, March 25, 2017, April 8, 2017, April 9, 2017, and April 18, 2017, August 5, 2017, August 6, 2017, December 3, 2017, December 16, 2017, December 17, 2017, December 22, 2017, December 23, 2017, December 24, 2017, January 7, 2018, January 16, 2018, January 20, 2018, and January 25, 2018. The last date recorded on the check sheet was February 1, 2018.

Hospital policy and procedure, titled, "Crash Cart Exchange and Defibrillator Maintenance" noted to have a "Reviewed" and "Last Revised" date of 03/2018-reads, " ...The crash cart ...will be checked ...by completing crash cart flow sheet located on the clipboard with crash cart. Exception to this policy is in ...Dialysis Services ... the cart will be checked once daily during hours of operation."

On 5/3/18 at 10:20 a.m., closed record review for Patient 28 revealed the patient was admitted on 2/5/17 with fluid overload and Dysnea. The patient was scheduled for a dialysis treatment on 2/6/17. On 2/6/17 at 1:30 p.m., the dialysis nurse entered physician orders for the dialysis treatment. The physician did not acknowledge or sign the physician orders until 2/10/17 at 9:18 a.m.. The duration was for three (3) hours, blood flow rate 350, dialysis flow rate 500, dialyzer 160, dialysate bath 2.0 Potassium (K+) 2.5 Calcium (Ca++), dialysis access via a new hemodialysis catheter placed on 2/6/17. The dialysis treatment began at 2:20 p.m. and the pre-treatment assessment was not completed until after the patient's treatment began at 2:45 p.m.. The treatment ended at 5:12 p.m. The findings were verified by RN 19 at the time of the review on 5/3/18 at 10:20 a.m..

On 5/2/2018 at 6:15 p.m., review of the closed chart for Patient 24 revealed the patient was admitted on 1/18/2017 at 5:33 p.m. for Chest Pain, End Stage Renal Disease, Hypertension, and Diabetes. Further review of the patient's record revealed a hemodialysis treatment was performed on 1/19/2017 at 6:32 a.m. without a physician order for the dialysis prescription. The findings were verified by RN 5 at 6:15 p.m. on 5/2/2018.

On 5/2/18 at 4:35 p.m., review of the closed chart for Patient 20's revealed the patient was admitted on 10/10/17 for a diagnosis of End Stage Renal Disease (ESRD). Review of the patient's chart revealed the patient received hemodialysis treatments on 10/11/17, 10/14/17 and 10/17/17, but there were no physician orders for the hemodialysis prescription for the treatments. On 5/2/2018 at 4:35 p.m., the findings were verified by Registered Nurse (RN) 1 at the time of the patient's chart review.

On 5/2/18 at 4:35 p.m., review of the closed chart for Patient 21 revealed the patient was admitted on 10/1/17 for a diagnosis of ESRD with ascites. Review of the patient's chart revealed the patient received a hemodialysis treatment on 10/4/17, but there was no physician orders for hemodialysis prescription for the hemodialysis treatment. On 5/2/2018 at 4:35 p.m., the findings were verified by Registered Nurse (RN) 1 at the time of the review of the patient's chart.

On 5/2/2018 at 6:00 p.m., review of the closed chart for Patient 12 revealed the 32 year old patient had been admitted on 1/4/16 with diagnoses including, but not limited to: Seizure, Essential Hypertension, and End Stage Renal Disease. Review of the patient's dialysis treatment sheet dated 1/4/16 revealed there were no authenticated physician orders in the patient chart for the patient's dialysis prescription, orders for Heparin, or parameters. During an interview on 5/2/18 at 6:20 p.m., Director 2, who verified the findings, and reported the physician would still write dialysis orders in the hospital for treatment even if the patient was on outpatient dialysis. Information included on the 1/4/16 dialysis treatment sheet indicated Patient 12 was to receive a Heparin bolus of 1000 units hourly as well as Heparin 1000 units hourly. The dialysis treatment sheet dated 1/4/16 revealed the Heparin bolus was not given until 5:30 p.m. which was delay of 30 minutes into the patient's dialysis treatment without documentation of the reason why. The total dose of Heparin administered should have been 4000 units Heparin, but the documentation on the patient's dialysis treatment sheet revealed the patient received a total of 3,500 units Heparin. Review of the dialysis treatment sheet dated 1/4/16 revealed the patient's blood pressures ranged from 226/138 to 252/168 during the dialysis treatment, but there was no documentation that a physician was notified or any medication was administered for the Hypertension. There was no physician signature on the dialysis treatment sheet. Review of the patient's dialysis treatment sheet dated 1/4/16 revealed the Registered Nurse (RN) failed to sign and date the post-treatment assessment of the patient. The findings were verified by Director 6 on 5/3/2018 at 9:30 a.m.. Review of the dialysis treatment sheet dated 1/6/16 revealed an ordered dialysis duration of 3 1/2 hours for the dialysis treatment, but documentation on the dialysis treatment sheet revealed the dialysis treatment on 1/6/16 ran from 1:05 p.m. to 4:06 p.m., a total of 3 hours and 1 minute. There was no documentation in the record as to the reason the treatment had ended early. The post weight of the patient had not been documented on the 1/6/16 dialysis treatment sheet. The findings were verified by Director #6 on 5/3/18 at 9:30 a.m..

On 5/3/2018 at 10:00 a.m., review of the closed record for Patient 13 revealed the patient had been admitted on 1/5/16 and discharged on 1/14/2018 with diagnoses including, but not limited to, Acute Renal Failure. Record review on 5/3/18 at 10:00 a.m. revealed the patient dialyzed once on 1/5/16. Dialysis ordered by the hospitalist dated 1/5/16 revealed "Dialysis Stat", but there were no other orders for the hemodialysis prescription that included any parameters for the dialysis treatment with regards to the dialysate prescription, treatment duration, dialyzer, blood flow rate, or dialyzer flow rate. Review of the 1/5/16 dialysis treatment sheet for the patient's stat dialysis revealed there was no documentation of the Bicarbonate or Sodium concentration. Review of the treatment sheet revealed the dialysis treatment ended at 4:40 p.m. and the patient's blood pressure was documented as 157/150, but there was no documentation that the physician was notified. The findings were verified by Director 6 on 5/3/2018 at 10:00 a.m. at the time of the review.

On 5/2/18 at 3:10 p.m., an interview was conducted with the Hospital Infection Control Officer (ICO) who stated,"I have never done any infection control audits in the dialysis unit or for their staff. They are not even on my surveillance. Everyone (Directors) drops their performance indicators into the folder with their quarterly data. I don't know who would be responsible for that area. I guess the Intensive Care Unit/Dialysis Director is."

On 5/2/18 at 9:30 a.m., an interview was conducted with Director 2 who reported that he/she receives a quarterly report from the contracted provider which reads, "Water Treatment and Water Quality: Water and dialysate tests were performed monthly and results were reviewed accordingly. Corrective and preventative action was taken to address any results outside the American Association of Medical Instrumentation (ANSI/AAMI) acceptable limits. The water quality test may be made available for your review with the Inpatient Services Program Manager. Please call if you have any questions or concerns, or wish to review the identified potential interventions from the QAI committee." On 5/2/18 from 5:10 p.m. to 5:20 p.m., Director 2 stated, ""I am just a liaison for the dialysis contact agent. They were added to my service around March of 2017. I am the contact person between the contract agent and the hemodialysis staff. At one time when we were doing CRRT in the ICU, we were trained on that, but that's been many years ago, and we don't do it anymore. That was all I knew about dialysis. The only part I do is basically reconcile charges, order supplies like gloves, dressings, things like that. The dialysis nurse is basically supposed to be able to work on their own. We really don't have anything to do for them otherwise."

Review of hospital policy,titled, "Transcription of Physician Orders", reads, "The nursing staff acknowledges, coordinates, and implements the diagnostic and therapeutic orders of medical staff members."

On 5/2/18 at 3:10 p.m., an interview was conducted with the Hospital Infection Control Officer (ICO) who stated," I have never done any infection control audits in the dialysis unit or for their staff. They are not even on my surveillance. Everyone (Directors) drops their performance indicators into the folder with their quarterly data. I don't know who would be responsible for that area. I guess the ICU/Dialysis Director is."

On 4/30/18 at 2:57 p.m., an observation in the Emergency Department (ED) triage revealed an open computer screen revealing 4 patient names with the chief complaints, vital signs, patient age, physician, and nurse name. RN 3 was assigned to triage at this time. He/she walked into triage while the state surveyor was present, looked at the computer, and then turned and walked out. Findings verified with RN 1 at the time of the observation. He/she stated, " I don't see the big issue, because we are in triage and there is no one else in here right now.


39208

Based on observations, interviews, and review of the hospital's policy, nursing failed to secure patient information on their computer screens when leaving the computers for 3 of 3 Registered Nurses(RN) observed in the work setting. (RN 8, RN 7, and RN 3)

The findings are:

On 5/1/18 at 9:25 a.m., observations of a Workstation on Wheels (WOW) in an unattended area revealed the patient's information was in view on the computer screen. When RN 8 returned to the computer, RN 8 verified the computer screen had been left unsecured with the patient's information visible. The finding was verified by RN 8 and the Infection Control Officer at 9:28 a.m. on May 1, 2018.

On 5/1/18 at 10:15 a.m., observations of RN 7 putting patient data into the computer revealed RN 7 left the computer with the screen with patient's information unsecured and in view. When RN 7 returned to the computer station, RN 7 verified the computer screen was unsecured and the patient's information was viewable. This finding was also verified by the Infection Control Officer on May 1, 2018 at 10:18 a.m. who was present.

Hospital Policy, titled, "1949841 Records Management, implemented 12/2015 and last reviewed and revised 12/2015, reads,"Scope: All company-affiliated facilities including, but not limited to, hospitals. ambulatory surgery centers, home health agencies, physician practices, service centers, and all Corporate Departments.: Purpose: To establish the policy and procedures for the creation, use, maintenance, retention, preservation, and disposal of Company records."
Policy:
4. All company employee and agents are responsible for ensuring that all records are created, used, maintained, preserved, and destroyed in accordance with this Records Management policy."
6. Records containing confidential and proprietary information will be securely maintained, controlled, and protected to prevent unauthorized access."

Review of the hospital's listing of Patient Rights revealed, "14. The patient has the right to confidentiality of his/her clinical records,except in such cases as suspected abuse or public health hazards and/or when reporting is permitted or required by law. The patient has the right to have his/her medical record read only by individuals directly involved in his/her treatment or in monitoring of quality. Other individuals may only read his/her medical record on the patient's written authorization or that of his/her legally authorized representative. The patient has the right to expect all communications and other records pertaining to his/her care, including the source of payment for treatment, to be treated as confidential."

Based on review of the hospital's quality program and interview, the hospital failed to ensure its problem prone high risk dialysis was included in it quality program to ensure the safety of its hemodialysis patients.

The findings are:

On 5/2/18 at 4:00 p.m., review of the hospital's Quality Monitoring Program revealed there was no scope, objectives, organization effectiveness, and appropriateness of the program for the dialysis unit. The hospital's 2018 Quality Improvement and Patient Safety Plan reads, " The assigned team/departments will establish priorities for improvement based on the guidelines established in this plan. When necessary, the Quality and Patient Safety Committee will assist the team or department/services in establishing priorities." On 5/2/18 at 4:35 p.m., Director 14 revealed , "We do not have any policies specific to dialysis. They use their own corporate policies." On 5/2/18 at 7:00 p.m., Director 14 stated , "Dialysis hasn't come up as one of our performance indicators. We don't include this in our quality program."

Based on observation, interview, record review, and facility log review, the hospital failed to ensure an ongoing program that shows measurable improvement in indicators, for hemodialysis, for which there is evidence that it will improve health outcomes in that there was no evidence that the hemodialysis unit was included in the hospital's quality program.

The findings include:

On 5/2/2018 at 4:00 p.m., review of the hospital's quality program revealed there was no documentationof the hemodialysis unit in the hospital's quality program. On 5/2/18 at 4:35 p.m., Director 14 revealed , "We do not have any policies specific to dialysis. They use their own corporate policies." On 5/2/18 at 7:00 p.m., Director 14 stated , "Dialysis hasn't come up as one of our performance indicators. We don't include this in our quality program."

Cross Reference to A 0392: The hospital failed to ensure the oversight and monitoring of the care that patients received in its contracted hemodialysis unit for 1 of 1 Registered Nurses (RN 15) and 6 of 6 closed patient charts (Patient 28, 24, 20 21, 12, and 13)

On 5/2/18 at 9:00 a.m., a review of the dialysis water and dialysate results and the Portable Water System Total Chlorine Log revealed there was no assessment of the quality of care and performance of monitoring of the water treatment system in the hospital's Quality program. The following was found on the Total Chlorine Logs:
4/3/17: No reverse osmosis (RO) "on time" for RO # 73, no Post Worker Carbon results charted, no RN signature of RN 15;
6/26/17: For RO # 74, no Post Worker Carbon results charted at 2345( time test taken), by RN 15
8/2/17: No RO "on time" for RO # 73 at test time for 1400 and 1600, by RN 15
10/19/17: No Post Worker Carbon results charted at 1834 for RO # 73, and no RN signature by RN 16
11/29/17: No Post Worker Carbon results charted at 1915 for RO # 73, and no RN signature by RN 15
1/9/18: No RO "on time" for RO # 74 at test time for 1245 and 1445 by RN 15
1/11/18: No RO "on time" for RO # 73 at test time for 1630 and 1830 by RN 15
3/1/18: No Post Worker Carbon results charted at 1930 for RO # 74, and no RN signature by RN 15
3/26/18: No Post Worker Carbon results charted at 1900 for RO # 74, and no RN signature by RN 15
4/2/18: No RO "on time" for RO # 73 at test time for 1415, by RN 15
4/10/18: No RO "on time" for RO # 74, no Post Worker Carbon results charted, no RN signature by RN 15.

Chemical Analysis date range 1/1/17 to 1/31/17 collected on 1/30/17- Equipment: Hd Machine 71, Hd Machine 72, Hd Machine 73, Hd Machine 82, Hd Machine 83, Portable RO 71, Portable RO 72- No date for the Medical Director Signature
Water Colony Count and Endotoxins date range 3/1/17 to 3/31/17- collected on 3/6/17 and 3/14/17- No Medical Director signature, including after an abnormal lab drawn on 3/14/17 of a water endotoxin of 0.209 was resulted and then redrawn on 3/16/17, resulting as <0.010
Chemical Analysis date range 4/1/17 to 4/30/17 collected on 4/4/17- Equipment: Hd Machine 71t, Hd Machine 72t, Hd Machine 73t, Portable RO 73 and Portable RO 74 colony count and endotoxins collected on 4/3/17- Signed by the Medical Director 9 months later on 1/24/18.
American Association of Medical Instrumentation (AAMI) Summary by Equipment- Portable RO 73 and 74- date range 6/1/17 to 8/31/17-signed by the Medical Director on 1/24/18
Chemical Analysis date range 6/1/17 to 6/30/17 collected on 6/5/17- Equipment Hd Machine 71t, Hd Machine 72t, Hd Machine 73t, Portable RO 73 and Portable RO 74
with Colony count and endotoxins- Signed by the Medical Director 7 months later on 1/24/18
Chemical Analysis date range 8/1/17 to 8/30/17 collected on 8/2/17- Equipment: Hd Machine 71t, Hd Machine 72t, Hd Machine 73t, Portable RO 73 and Portable RO 74 colony count and endotoxins collected on 8/17/17- signed by the Medical Director 5 months later on 1/24/18
Chemical Analysis date range 11/1/17 to 11/30/17 collected on 11/27/17- Equipment: Hd Machine 71t, Hd Machine 72t, Hd Machine 73t, Portable RO 73 and Portable RO 74 colony count and endotoxins collected on 11/16/17- signed by the Medical Director 2 months later on 1/24/18
Chemical Analysis date range 1/1/18 to 1/31/18 collected on 1/12/18- Equipment: Hd Machine 71t, Hd Machine 72t, Hd Machine 73t, Portable RO 73 and Portable RO 74 colony count and endotoxins collected on 1/17/18- signed by the Medical Director 2 months later on 3/8/18
AAMI Summary by Equipment- Portable RO 73 and 74- date range 2/1/18 to 2/28/18-have not been signed by the Medical Director
Chemical Analysis date range 3/1/18 to 3/31/18 collected on 3/15/18- Equipment: Hd Machine 71t, Hd Machine 72t, Hd Machine 73t, Portable RO 73 and Portable RO 74 colony count and endotoxins collected on 3/15/18- Have not been signed by the Medical Director

On 5/2/18 at 9:30 a.m., an interview was conducted with Director 2. He/she stated she receives a quarterly report from the contracted provider which reads, "Water Treatment and Water Quality: Water and dialysate tests were performed monthly and results were reviewed accordingly. Corrective and preventative action was taken to address any results outside the American Association of Medical Instrumentation (ANSI/AAMI) acceptable limits. The water quality test may be made available for your review with the Inpatient Services Program Manager. Please call if you have any questions or concerns, or wish to review the identified potential interventions from the QAI committee.

Based on observation, interview, hospital's quality program, and the hospital's dialysis log review, the hospital failed to ensure that clear expectations for safety were established for its contracted hemodialysis staff.

The findings include:

On 5/2/2018 at 4:00 p.m., review of the hospital's quality program revealed there was no documentation the hemodialysis unit in the hospital's quality program. On 5/2/18 at 4:35 p.m., Director 14 revealed , "We do not have any policies specific to dialysis. They use their own corporate policies." On 5/2/18 at 7:00 p.m., Director 14 stated , "Dialysis hasn't come up as one of our performance indicators. We don't include this in our quality program."

On 5/2/18 at 9:00 a.m., a review of the dialysis water and dialysate results and the Portable Water System Total Chlorine Log revealed there was no assessment of the quality of care and performance of monitoring of the water treatment system. The following was found on the Total Chlorine Logs:
4/3/17: No reverse osmosis (RO) "on time" for RO # 73, no Post Worker Carbon results charted, no RN signature of RN 15;
6/26/17: For RO # 74, no Post Worker Carbon results charted at 2345( time test taken), by RN 15
8/2/17: No RO "on time" for RO # 73 at test time for 1400 and 1600, by RN 15
10/19/17: No Post Worker Carbon results charted at 1834 for RO # 73 , and no RN signature by RN 16
11/29/17: No Post Worker Carbon results charted at 1915 for RO # 73 , and no RN signature by RN 15
1/9/18: No RO "on time" for RO # 74 at test time for 1245 and 1445 by RN 15
1/11/18: No RO "on time" for RO # 73 at test time for 1630 and 1830 by RN 15
3/1/18: No Post Worker Carbon results charted at 1930 for RO # 74, and no RN signature by RN 15
3/26/18: No Post Worker Carbon results charted at 1900 for RO # 74, and no RN signature by RN 15
4/2/18: No RO "on time" for RO # 73 at test time for 1415, by RN 15
4/10/18: No RO "on time" for RO # 74, no Post Worker Carbon results charted, no RN signature by RN 15.

On 5/2/18 at 4:00 p.m., review of the facility Quality Monitoring Program revealed no scope, objectives, organization effectiveness, and appropriateness of the program for the dialysis unit. The 2018 Quality Improvement and Patient Safety Plan reads, " The assigned team/departments will establish priorities for improvement based on the guidelines established in this plan. When necessary, the Quality and Patient Safety Committee will assist the team or department/services in establishing priorities." On 5/2/18 at 4:35 p.m., Director 14 revealed , "We do not have any policies specific to dialysis. They use their own corporate policies."

On 5/2/18 at 5: 50 p.m., observation in the acute dialysis unit revealed Registered Nurse (RN ) 15 incorrectly performed the total chlorine test. He/she obtained the water sample from the portable reverse osmosis (RO). Then swished the test strip for 60 seconds, visualizing the clock, then the strip was shaken, folded over and test results were read at 3 seconds. When asking RN 15 how long to wait to read the result of the strip, RN 15 whispered to the state surveyor, "Well I read it at about 3 seconds, but I look at it all the way to the trash can before I throw it away." At 6:25 p.m., further review of the Portable Water System Total Chlorine Log revealed No RO "on time" for RO # 73, and no Post Worker Carbon results had been charted yet, or signed by RN 1.

On 5/2/18 at 7:00 p.m., the state surveyor asked Director 14 what involvement there was with the dialysis unit in the hospital's quality program. Director 14 replied, "Dialysis hasn't come up as one of our performance indicators, so we don't include this in our quality program."

On 5/3/18 at 9:05 a.m., RN 4 was interviewed regarding adverse events in the dialysis unit. The state surveyor asked RN 4 if an incident report or adverse event was completed for a dialysis patient, would the hospital have a record of a similar report? RN 4 replied," Not necessarily." The dialysis contracting agent provided nine (9) incident reports from February 2017 through April 2018. When the incident reports were requested from the hospital, RN 4 stated there were none related to the dialysis unit.

Based on interview and review of the hospital's quality program, the hospital failed to ensure all services, including those services furnished under contract (hemodialysis), was monitored through the hospital's Quality Performance Improvement (QAPI) program.

The findings include:

On 5/2/18 at 4:00 p.m., review of the hospital's Quality Monitoring Program revealed there was no scope, objectives, organization effectiveness, and appropriateness of the program for the hemodialysis unit. The 2018 Quality Improvement and Patient Safety Plan, reads, " The assigned team/departments will establish priorities for improvement based on the guidelines established in this plan. When necessary, the Quality and Patient Safety Committee will assist the team or department/services in establishing priorities." On 5/2/18 at 4:35 p.m., Director 14 revealed , "We do not have any policies specific to dialysis. They use their own corporate policies." On 5/2/18 at 7:00 p.m., Director 14 replied, "Dialysis hasn't come up as one of our performance indicators. We don't include this in our quality program."

Based on review of the hospital's quality program and review, the hospital's governance failed to ensure it high risk problem prone hemodialysis unit was monitored through the hospital's quality program.

The findings are:

On 5/2/18 at 4:00 p.m., review of the hospital's Quality Monitoring Program revealed there was no scope, objectives, organization effectiveness, and appropriateness of the program for the dialysis unit. The hospital's 2018 Quality Improvement and Patient Safety Plan reads, " The assigned team/departments will establish priorities for improvement based on the guidelines established in this plan. When necessary, the Quality and Patient Safety Committee will assist the team or department/services in establishing priorities." On 5/2/18 at 4:35 p.m., Director 14 revealed , "We do not have any policies specific to dialysis. They use their own corporate policies." On 5/2/18 at 7:00 p.m., Director 14 stated , "Dialysis hasn't come up as one of our performance indicators. We don't include this in our quality program."

Based on observations, record reviews, review of the hospital's policies and procedures, the hospital's nursing service failed to provide nursing care to all patients per accepted principles for infection control, the hospital's policies and procedures, and review of South Carolina Code of Laws Chapter 33 Article 1 "Nurse Practice Act" for 3 of 19 concurrent medical records, and 5 of 28 closed medical records, and observations of 4 of 4 nurses in the provision of care. (Concurrent Patient Records: Patient 13, 17, and 6) ( Closed Patient Records: Patient 12, 13, 24, 20, 21) (Observations: Registered Nurse 3, 9, 13, and 15)

The findings are:

On 5/2/18 at 5: 50 p.m., observation in the acute dialysis unit revealed Registered Nurse (RN ) 15 incorrectly performed the total chlorine test. He/she obtained the water sample from the portable reverse osmosis (RO). Then swished the test strip for 60 seconds, visualizing the clock, then the strip was shaken, folded over and test results were read at 3 seconds. When asking RN 15 how long to wait to read the result of the strip, RN 15 whispered to the state surveyor, "Well I read it at about 3 seconds, but I look at it all the way to the trash can before I throw it away." At 6:25 p.m., further review of the Portable Water System Total Chlorine Log revealed No RO "on time" for RO # 73, and no Post Worker Carbon results had been charted yet, or signed by RN 1.

On 5/2/18 at 5:45 p.m., observations in the hospital's Acute Dialysis Unit revealed Registered Nurse (RN) 15 failed to don personal protective equipment (PPE) in the provision of care for 2 dialysis patients. On 5/2/18 at 5:49 p.m., observations in the Acute Dialysis Unit revealed RN 15 put hand sanitizer into his/her gloved hands, rubbed the hands together, wiped the wetted glove hand over the previously used stethoscope, and then threw the stethoscope across the room to the nurse's desk. Then, RN 15 continued the care for the dialysis patient wearing the same gloves. On 5/2/18 at 5:58 p.m., observations in the Acute Dialysis Unit revealed the dialysis patient located at dialysis station 1 removed a dirty soiled dressing from the left upper arm access site. RN 15 proceeded to cannulate the patient after gently wiping across the patient's left upper arm access site with one (1) alcohol wipe. RN 15 did not wash the patient's access site or clean the patient's access site with an antiseptic prior to placing the needle into the arterial portion of the arteriofistula (AVF). Using the same alcohol pad, RN 15 cannulated the second needle into the venous access. Then, RN 15 proceeded to the patient's dialysis chart, flipped through the dialysis orders, wrote on the patient's record, flushed the patient's access with saline, taped the lines to the patient gown, and then attempted to begin the dialysis treatment. RN 15 changed the soiled gloves, but did not perform hand hygiene before donning clean gloves. On 5/2/18 at 6:10 p.m., observations in the Acute Dialysis Unit revealed RN 15 wearing gloves soiled from the patient's access, changed only the glove on the left hand and proceeded to resume patient care. After a request change the other glove before resuming care, RN 15 removed the second soiled glove and donned a clean glove, but failed to perform hand hygiene between the gloving change. On 5/2/18 at 6:16 and 6:20 p.m., observations in the Acute Dialysis Unit revealed RN 15 removed the dirty gloves, donned clean gloves, but failed to perform hand hygiene. On 5/2/18 at 6:22 p.m., observations in the Acute Dialysis Unit revealed RN 15 reached into his/her right scrub pocket with gloved hands and removed an ink pen. On 5/2/18 at 6:24 p.m., observations in the Acute Dialysis Unit revealed RN 15 wearing blood soiled gloves reached into the clean supply cart wearing the blood contaminated gloves and removed a 10 cubic centimeter (cc) syringe to use on the patient located at dialysis station 1. Wearing the blood soiled gloves, RN 15 continued to provide care for the patient. Observations of RN 15 throughout the provision of care revealed RN 15 never performed hygiene before initiating care, throughout the provision of care, and at the cessation of care.

On 5/1/18 from 10:20 a.m. to 10:36 a.m., observations in the Emergency Department (ED) triage area revealed RN 3 triaged a patient, obtained vital signs, escorted the patient to ED Room 10, wiped down the stretcher, and returned to triage. RN 3 proceeded to wipe down the triage vital sign equipment with a disinfectant wipe with bare hands. A second patient was brought into the triage area, vital signs obtained, and then the patient was escorted to ED Room 2. RN 3 wiped down the equipment with the disinfectant wipes. RN 3 failed to perform hand hygiene throughout the observations. At 10:37 a.m., RN 3 stated, "Oh goodness, I sure didn't wash my hands. I am supposed to wash my hands before and after every patient." On 5/1/2018 at 10:40 a.m., the Chief Nursing Officer (CNO) and Director 1 verified the findings.

On 05/02/18 at 6:00 p.m., review of the hospital's crash cart logs for the dialysis unit revealed the staff on the dialysis unit which is a high risk problem prone dialysis unit failed to check the unit's emergency crash cart and document the data on the emergency crash cart flow sheet daily during the hours of operation for 7 of 13 months (January 2017 through January 2018). Review of the hospital's "Crash Cart Check Sheet" showed there was no documentation of the crash cart data on January 15, 2017, March 16, 2017, March 25, 2017, April 8, 2017, April 9, 2017, and April 18, 2017, August 5, 2017, August 6, 2017, December 3, 2017, December 16, 2017, December 17, 2017, December 22, 2017, December 23, 2017, December 24, 2017, January 7, 2018, January 16, 2018, January 20, 2018, and January 25, 2018. The last date recorded on the check sheet was February 1, 2018.

Hospital policy and procedure, titled, "Crash Cart Exchange and Defibrillator Maintenance" noted to have a "Reviewed" and "Last Revised" date of 03/2018-reads, " ...The crash cart ...will be checked ...by completing crash cart flow sheet located on the clipboard with crash cart. Exception to this policy is in ...Dialysis Services ... the cart will be checked once daily during hours of operation."

On 5/3/18 at 10:20 a.m., closed record review for Patient 28 revealed the patient was admitted on 2/5/17 with fluid overload and Dysnea. The patient was scheduled for a dialysis treatment on 2/6/17. On 2/6/17 at 1:30 p.m., the dialysis nurse entered physician orders for the dialysis treatment. The physician did not acknowledge or sign the physician orders until 2/10/17 at 9:18 a.m.. The duration was for three (3) hours, blood flow rate 350, dialysis flow rate 500, dialyzer 160, dialysate bath 2.0 Potassium (K+) 2.5 Calcium (Ca++), dialysis access via a new hemodialysis catheter placed on 2/6/17. The dialysis treatment began at 2:20 p.m. and the pre-treatment assessment was not completed until after the patient's treatment began at 2:45 p.m.. The treatment ended at 5:12 p.m. The findings were verified by RN 19 at the time of the review on 5/3/18 at 10:20 a.m..


39464

On 05/01/18 at 10:00 a.m., observations of Registered Nurse (RN) 13 in the provision of patient care in the patient's room for medication administration and wound care. Observations showed RN 13 performed hand hygiene, donned gloves, positioned the patient in the bed, obtained the patient's blood pressure, heart rate, and respirations using the medical monitor, positioned the WOW(work station on wheels) to the patient's bedside, entered data into the WOW, retrieved the medication administration screen (MAR) in the WOW, scanned each medication packet, opened each packet, and placed the medication in a medication cup, picked up the patient's drinking cup in one hand and the medication cup in the other and administered medication to the patient, discarded the empty medication packets in the trash can, removed the soiled gloves, and discarded the gloves in the trash can, donned a clean of gloves without performing hand hygiene.

RN 13 removed the soiled dressing from the patient's left wrist, and then pulled the trash can closer to the bedside wearing the same gloves, and then continued removing the soiled dressing from the patient's left wrist. RN 13 discarded the soiled dressing into the trash can, adjusted the trash can liner, opened a 4 x(by) 4 gauze pack, picked up wound cleanser bottle, sprayed and wiped the wounds to the patient's left elbow with the 4 x 4 gauze, discarded the soiled dressings into the trash can, applied the antibiotic ointment from the tube on the patient's bedside table, applied the ointment to a 4 x 4 gauze, dabbed the 4 x 4 gauze on the patient's left elbow wound, discarded the 4 x 4 gauze into the trash can, removed a strip of tape from a tape roll, wrapped the wound with a gauze bandage and secured the gauze bandage with tape.

RN 13 assessed the patient's hands, assisted the patient in lifting the right hand up, and removed two rings from the patient's fingers, placed the rings on the bedside table, applied antibiotic ointment to the wounds on the patient's left hand, wrapped the left hand with a gauze bandage and secured the bandage with tape. RN 13 repositioned the trash can, walked to the right side of the patient's bed, and cleansed the abrasions on the left hand knuckles, applied antibiotic ointment, applied a small gauze bandage, and secured the dressing to the patient's left thumb with tape.

RN 13 retrieved the wound cleanser bottle in one hand and a 4 x 4 gauze in the other, sprayed the cleanser on the gauze and wiped the wounds to the right side of the patient's face, applied antibiotic ointment, cleaned wounds to the patient's forehead and intact skin to the left side of face using the same 4 x 4 gauze. RN 13 walked to the trash can and discarded the old dressings, repositioned the trash can, and wearing the same pair of soiled gloves proceeded to remove the compression device from the patient's right foot, picked up the scissors from the bedside table, and cut the dressings from the patient's right foot. The findings were verified by RN 13 at 11:30 a.m. on 05/01/18.

RN 13 failed to use accepted principles of infection control for hand hygiene and gloving changes in the provision of wound care to prevent cross transmission of potential infectious agents in the hospital setting. RN 13 failed to change gloves and sanitize the hands after removing soiled, after contact with the patient's intact skin, after contact with the WOW, medical monitoring equipment, bedside table, and the trash can, and after contact with soiled wound dressings, and when moving from dirty to clean sites related to wound care.

Hospital's policy and procedure, titled, "Hand Hygiene", reads, ..."Indications for hand hygiene: contact with a patient's intact skin ..., contact with environmental surfaces in the immediate vicinity of patients, and after glove removal", "Indications for handwashing and hand antisepsis ...before having direct contact with patients, after contact with a patient's intact skin ..., after contact with body fluids or excretions ...wound dressings ..., if moving from a contaminated-body site to a clean-body site during patient care, after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient, after removing gloves".

Hospital policy and procedure, titled, "Non-Sterile Wound Dressing and Wound Cleansing", reads ...."Procedure ...6. Wash hands or use hand sanitizer per hospital policy and don clean gloves, 8. Carefully remove old dressing...8.3. Remove and discard gloves. Don another set of gloves ...12. Repeat for each wound using a new moistened gauze pad. Be care to prevent cross-contamination with multiple wounds...15. Remove and discard gloves, wash hands and don another set of clean gloves ...17. Apply...wound care product ...20. Remove and discard gloves. Wash hands".


39463

On 5/1/2018 at 10:30 a.m., review of the concurrent chart for Patient 17 revealed the patient was admitted on 4/27/2018 at 2:23 p.m. for a Urinary Tract Infection, Cellulitis of left foot, and Hypotension. Observations on 5/1/2018 at approximately 10:00 a.m. of Patient 17 revealed the patient received Rocephin 1 gram intravenous. Review of the patient's record revealed there was no physician order for the placement of an intravenous catheter. The findings were verified by Registered Nurse(RN) 1 at 2:23 p.m. on 4/27/2918.
Review of Patient 17's physician orders showed glucose testing before meals and bedtime, and physician orders for a blood glucose greater than 150 medicate with Regular Insulin sliding scale:
<150 BG(Blood Glucose) - mg/dl (milligrams/deciliter)
151 - 200 2 units , Sq(subcutaneous)
201 - 250 4 units Sq
251 - 300 6 units Sq
301 - 350 8 units Sq
351 - 400 10 units Sq
401 - 450 12 units Sq
>450 - Call
Review of the patient's glucose levels and the the patient's medication administration revealed the patient did not receive Regular Insulin for the glucose resulting greater than 150 per physician's orders on the following dates and times:
4/27/2018 at 04:41 p.m. - glucose 166
4/27/2018 at 07:47 p.m. - glucose 210
4/28/2018 at 05:04 a.m. - glucose 152
4/28/2018 at 05:18 p.m. - glucose 222
4/29/2018 at 05:00 a.m. - glucose 225
4/29/2018 at 9:44 a.m. - glucose 312
4/30/2018 at 05:48 a.m. - glucose 191
4/30/2018 at 10:40 a.m. - glucose 215
4/30/2018 at 04:13 p.m. - glucose 171
The findings were verified with RN 5 at 4:30 p.m. on 5/1/2018.

On 5/2/2018 at 6:15 p.m., review of the closed chart for Patient 24 revealed the patient was admitted on 1/18/2017 at 5:33 p.m. for Chest Pain, End Stage Renal Disease, Hypertension, and Diabetes. Further review of the patient's record revealed a hemodialysis treatment was performed on 1/19/2017 at 6:32 a.m. without a physician order for the dialysis prescription. The findings were verified by RN 5 at 6:15 p.m. on 5/2/2018.

Review of hospital policy,titled, "Transcription of Physician Orders", reads, "The nursing staff acknowledges, coordinates, and implements the diagnostic and therapeutic orders of medical staff members."

Review of South Carolina Code of Laws, Chapter 33, Article 1, titled, "Nurse Practice Act", reads, "The practice of registered nursing includes, but is not limited to administering and delivering medications and treatments prescribed by an authorized licensed provider."









29886

On 5/01/2018 at 10:00 a.m., Registered Nurse 9 entered Patient 6's room transporting the Workstation On Wheels(WOW) into the room with the patient's medication inside the cart. RN 9 assembled a syringe, needles, intravenous fluid, and a pill in a medicine cup without performing hand hygiene. Patient 6 was ordered Nexium 40 milligrams(mgs), Heparin 5,000 units subcutaneous, and Vancomycin 2 grams Intravenous every day. RN 9 drew up Heparin 5,000 units and changed the needle for injection, and then inserted the needle into the subcutaneous tissue of the patient's abdomen and injected the medication into the patient's abdomen without performing hand hygiene. RN 9 charted the medication administration in the WOW computer. RN 9 picked up the cup with the medication and administered the medication to Patient 6 without performing hand hygiene. RN 9 flushed the intravenous catheter, cleaned the intravenous septum with an alcohol swab, inserted the intravenous tubing into the intravenous catheter septum, and infused the medication. RN 9 returned to the WOW and charted the information into the computer. RN 9 transported the WOW out of the patient's room without performing hand hygiene. Observations throughout the provision of patient care revealed RN 0 failed to perform hand hygiene. On 5/01/2018 at 10:10 a.m., RN 4 and RN 9 verified the findings.


39310

On 5/2/18 at 4:35 p.m., review of the closed chart for Patient 20's revealed the patient was admitted on 10/10/17 for a diagnosis of End Stage Renal Disease (ESRD). Review of the patient's chart revealed the patient received hemodialysis treatments on 10/11/17, 10/14/17 and 10/17/17, but there were no physician orders for the hemodialysis prescription for the treatments. On 5/2/2018 at 4:35 p.m., the findings were verified by Registered Nurse (RN) 1 at the time of the patient's chart review.

On 5/2/18 at 4:35 p.m., review of the closed chart for Patient 21 revealed the patient was admitted on 10/1/17 for a diagnosis of ESRD with ascites. Review of the patient's chart revealed the patient received a hemodialysis treatment on 10/4/17, but there was no physician orders for hemodialysis prescription for the hemodialysis treatment. On 5/2/2018 at 4:35 p.m., the findings were verified by Registered Nurse (RN) 1 at the time of the review of the patient's chart.






28883

On 5/2/2018 at 6:00 p.m., review of the closed chart for Patient 12 revealed the 32 year old patient had been admitted on 1/4/16 with diagnoses including, but not limited to: Seizure, Essential Hypertension, and End Stage Renal Disease. Review of the patient's dialysis treatment sheet dated 1/4/16 revealed there were no authenticated physician orders in the patient chart for the patient's dialysis prescription, orders for Heparin, or parameters. During an interview on 5/2/18 at 6:20 p.m., Director 2, who verified the findings, and reported the physician would still write dialysis orders in the hospital for treatment even if the patient was on outpatient dialysis. Information included on the 1/4/16 dialysis treatment sheet indicated Patient 12 was to receive a Heparin bolus of 1000 units hourly as well as Heparin 1000 units hourly. The dialysis treatment sheet dated 1/4/16 revealed the Heparin bolus was not given until 5:30 p.m. which was delay of 30 minutes into the patient's dialysis treatment without documentation of the reason why. The total dose of Heparin administered should have been 4000 units Heparin, but the documentation on the patient's dialysis treatment sheet revealed the patient received a total of 3,500 units Heparin. Review of the dialysis treatment sheet dated 1/4/16 revealed the patient's blood pressures ranged from 226/138 to 252/168 during the dialysis treatment, but there was no documentation that a physician was notified or any medication was administered for the Hypertension. There was no physician signature on the dialysis treatment sheet. Review of the patient's dialysis treatment sheet dated 1/4/16 revealed the Registered Nurse (RN) failed to sign and date the post-treatment assessment of the patient. The findings were verified by Director 6 on 5/3/2018 at 9:30 a.m.. Review of the dialysis treatment sheet dated 1/6/16 revealed an ordered dialysis duration of 3 1/2 hours for the dialysis treatment, but documentation on the dialysis treatment sheet revealed the dialysis treatment on 1/6/16 ran from 1:05 p.m. to 4:06 p.m., a total of 3 hours and 1 minute. There was no documentation in the record as to the reason the treatment had ended early. The post weight of the patient had not been documented on the 1/6/16 dialysis treatment sheet. The findings were verified by Director #6 on 5/3/18 at 9:30 a.m..

On 5/3/2018 at 10:00 a.m., review of the closed record for Patient 13 revealed the patient had been admitted on 1/5/16 and discharged on 1/14/2018 with diagnoses including, but not limited to, Acute Renal Failure. Record review on 5/3/18 at 10:00 a.m. revealed the patient dialyzed once on 1/5/16. Dialysis ordered by the hospitalist dated 1/5/16 revealed "Dialysis Stat", but there were no other orders for the hemodialysis prescription that included any parameters for the dialysis treatment with regards to the dialysate prescription, treatment duration, dialyzer, blood flow rate, or dialyzer flow rate. Review of the 1/5/16 dialysis treatment sheet for the patient's stat dialysis revealed there was no documentation of the Bicarbonate or Sodium concentration. Review of the treatment sheet revealed the dialysis treatment ended at 4:40 p.m. and the patient's blood pressure was documented as 157/150, but there was no documentation that the physician was notified. The findings were verified by Director 6 on 5/3/2018 at 10:00 a.m. at the time of the review.

Based on direct observations, interview, and the review of the hospital's policy and procedure, Certified Registered Nurse Anesthetist (CRNA) 1 failed to clean the septum on three vials before with drawing medication from each vial, (Patient 11).

The findings are:

On 5/1/18 at 9:01 a.m., observations during Tracer Patient 11's surgical procedure, CRNA 1 opened 3 sterile syringes, opened 3 vials of medication, and withdrew the medication from each vial without cleaning the rubber septum on each vial. The findings were verified with Director 3 at 10:35 a.m. on 5/1/18.

Hospital policy and procedure, titled, "Administration of Medication in Adults: Intramuscular", reads, "...Cleanses the top of the vial with an alcohol swab and inserts the needle into the stopper of the medication vial....".

Based on observation, interview, and review of the Hospital policy and procedures, the facility failed to ensure 3 of 3 Registered Nurses (RN) observed, maintained confidentiality of patient electronic medical records. (RN 3, 7 ,and 8)

The findings include:

On 4/30/18 at 2:57 p.m., an observation in the Emergency Department (ED) triage revealed an open computer screen revealing 4 patient names with the chief complaints, vital signs, patient age, physician, and nurse name. RN 3 was assigned to triage at this time. He/she walked into triage while the state surveyor was present, looked at the computer, and then turned and walked out. Findings verified with RN 1 at the time of the observation. He/she stated, " I don't see the big issue, because we are in triage and there is no one else in here right now.
On 5/1/18 at 9:25 a.m., observations of a Workstation on Wheels (WOW) in an unattended area revealed the patient's information was in view on the computer screen. When RN 8 returned to the computer, RN 8 verified the computer screen had been left unsecured with the patient's information visible. The finding was verified by RN 8 and the Infection Control Officer at 9:28 a.m. on May 1, 2018.

On 5/1/18 at 10:15 a.m., observations of RN 7 putting patient data into the computer revealed RN 7 left the computer with the screen with patient's information unsecured and in view. When RN 7 returned to the computer station, RN 7 verified the computer screen was unsecured and the patient's information was viewable. This finding was also verified by the Infection Control Officer on May 1, 2018 at 10:18 a.m. who was present.

Hospital Policy, titled, "1949841 Records Management, implemented 12/2015 and last reviewed and revised 12/2015, reads,"Scope: All company-affiliated facilities including, but not limited to, hospitals. ambulatory surgery centers, home health agencies, physician practices, service centers, and all Corporate Departments.: Purpose: To establish the policy and procedures for the creation, use, maintenance, retention, preservation, and disposal of Company records."
Policy:
4. All company employee and agents are responsible for ensuring that all records are created, used, maintained, preserved, and destroyed in accordance with this Records Management policy."
6. Records containing confidential and proprietary information will be securely maintained, controlled, and protected to prevent unauthorized access."

Review of the hospital's listing of Patient Rights revealed, "14. The patient has the right to confidentiality of his/her clinical records,except in such cases as suspected abuse or public health hazards and/or when reporting is permitted or required by law. The patient has the right to have his/her medical record read only by individuals directly involved in his/her treatment or in monitoring of quality. Other individuals may only read his/her medical record on the patient's written authorization or that of his/her legally authorized representative. The patient has the right to expect all communications and other records pertaining to his/her care, including the source of payment for treatment, to be treated as confidential."

Based on record reviews, interviews, and review of the hospital's Medical Staff Rules and Regulations, the hospital failed to ensure that every medical doctor documented daily notes progress notes for 2 of 28 patients' closed medical records. (Patient 25 and 26)

The findings are:

On 5/3/2018 at 9:45 a.m., review of the closed record for Patient 25 revealed the patient was admitted on 1/8/2018 at 6:44 p.m. with Altered Mental Status and Renal Failure, and Nephrology was consulted on 1/9/2018. Review of Nephrology progress notes revealed there was no progress note documented for 1/13/2018.

On 5/3/2018 at 10:15 a.m., review of the closed record Patient 26 revealed the patient was admitted on 1/10/2018 at 1:39 p.m. with Acute on Chronic Kidney Disease and Suspected Pneumonia, and Nephrology was consulted on 1/11/2018. Review of the Nephrology progress notes revealed there was no Nephrology progress notes documented on 1/13/2018 and 1/16/2018. On 5/3/2018 at 9:46 a.m., the findings were verified by Registered Nurse 5.

Review of the hospital's Medical Staff Rules and Regulations revealed, "All Practitioners are required to visit each inpatient on their services at least daily...Documentation of the daily visit should exist in the form of Progress Notes."

Based on record reviews, interview, and review of the hospital's policy, entitled, "Consultation", the hospital failed to ensure an order had been written for a consult for Patient 12 (1 of 18 records reviewed for dialysis care), or that Patient #12 was seen by the consulting nephrologist (kidney specialist) within 24 hours.

The findings included:

On 5/3/18 at 9:45 a.m., review of the closed chart for Patient 12 revealed the patient had been admitted on 1/4/16 with diagnoses including, but not limited to, End Stage Renal Disease. Review of the patient's admission History & Physical, dictated on 1/4/16 at 5:50 p.m. revealed the admitting physician requested Physician 2, who is a nephrologist, to consult on the patient. There were no physician orders noted in the record for a nephrology consult for Patient #12. A review of physician notes revealed a nephrologist did not see Patient #12 until 1/6/16, more that 24 hours after the request for a consult had been dictated. These findings were verified by Director #6 at the time of the record review. When asked, Director #6 stated that when a consult is ordered, the consulting physician usually sees the patient within 24 hours. According to Director #6, the physician requesting a consult will usually write an order for the consult as well as call the consulting physician.

A review of the policy provided by the hospital, entitled, "Consultation", revealed "...3. Inhouse consults will be performed in the following manner: a. Attending will write order for consult, naming consulting physician. b. The clerk will transcribe, and enter data into the computer. Physicians should be notified via phone of consult as well. c. If consulting physician has not evaluated patient within 24 hours of consult order or is unavailable to see patient, the nurse will contact the primary physician and inform them. Complete documentation...".

Based on record reviews and interviews, the hospital failed to ensure consents for treatment were accurately and completely documented for 3 of 28 closed patient records reviewed for health consents. (Patient 12, 13, and 14)

The findings are:

On 5/3/2018 at 9:45 a.m., review of the closed record for Patient 12 revealed the patient had been admitted on 1/4/16 with diagnoses including but not limited to Seizures and End Stage Renal Disease. Review of the patient's hospital health treatment consent form revealed the patient's health consent form was signed by the patient's family member, but the date and time of the signature was not documented as well as the relationship to the patient, and the witness's signature/title. On 5/3/2018 at 9:45 a.m., the finding was verified with Director 6.

On 5/2/18 at 5:20 p.m., review of the closed record for Patient 13 revealed the patient was admitted on 1/5/16 with diagnoses including but not limited to Altered Mental Status and Acute Renal Failure. On 5/2/18 at 5:20 p.m., review of the patient's hospital health treatment consent form revealed the health consent form was signed, but there was no date and time documented. The finding was verified with Registered Nurse (RN) #13 on 5/2/18 at 5:20 p.m..

On 5/3/18 at 10:40 a.m., review of the closed record for Patient 14 revealed the patient had been admitted on 1/29/18 with diagnoses including but not limited to Acute Renal Failure. On 5/3/18 at 10:40 a.m., review of the patient's health consent form revealed the hospital health treatment consent was signed by the patient's spouse, but there was no date and time documented. The finding was verified with Director 6 on 5/3/18 at 10:40 a.m.

Based on observations, interviews, and review of the hospital's policy and procedure, the hospital failed to dispose of expired medications from the patient care areas.

The findings are:

On 4/30/18 at 3:57 p.m., random observations in the Operating Room holding area refrigerator revealed 1000 cubic centimeter (cc) bag of Normal Saline with an expiration date of 8/16. On 4/30/2018 at 3:57 p.m., the finding were verified by Director 3 at the time of the observation.

Hospital policy and procedure, titled, "Unusable Drugs and Devices", reads, "....Unusable drugs and devices include those that are expired....Unusable drugs and devices shall not be distributed or administered. Pharmacy, nursing, and other personnel who discover unusable drugs and devices shall return them to the pharmacy for proper disposition....".

Based on record reviews, observations, and interview, the hospital failed to meet individual patient nutritional needs in accordance with recognized dietary practices for 1 of 1 open record for Patient 17 with orders for a therapeutic diet. (Patient 17)

The findings are:

On 5/1/2018 at 10:30 a.m., review of the open chart for Patient 17 revealed the patient was admitted on 4/27/2018 at 2:23 p.m. for a Urinary Tract Infection, Cellulitis of left foot, and Hypotension with a physician dated 4/27/2018 at 3:36 a.m. for a consistent carbohydrate diet. On 5/1/2018 at 12:00 p.m., observations of the lunch service in the kitchen revealed the lunch tray prepared for Patient 17 contained a dinner roll, a hamburger bun, BBQ pork, BBQ sauce, California blend vegetables, small garden salad, and ranch dressing. Review of the hospital's patient menu dated 5/1/2018 revealed the Carbohydrate diet lunch did not include a hamburger bun. During an interview on 5/2/2018 at 12:04 p.m., in the kitchen, the Registered Dietician (RD) verified the prescribed diet and observation. The RD stated, "They should not have a hamburger bun on the tray."

Based on observations, interview, and review of the facility's policies and procedures, the hospital failed to ensure emergency equipment was present and in working condition in the hospital's Intensive Care Unit (ICU).


The findings are:

Observations in the hospital's ICU on 05/01/18 at 12:30 p.m. revealed the ICU had no flashlights to use in case of an electrical outage. On 05/01/2018 at 12:30 p.m., the Chief Nursing Officer (CNO) verified the finding.

Hospital policy and procedure, titled, "Safety Plan", reads, "Emergency power and equipment must be available and in working condition for the provision of care and safety ....ICU ...7. Flashlights are located in the drawer at the nurse's station."

Based on observations and interviews, the hospital failed to ensure expired supplies were removed and disposed of to provide an acceptable level of safety and quality for 1 of 1 laboratory setting.

The findings included:

Observations in the laboratory on 5/1/18 at 2:25 p.m. revealed the following expired blood collection tubes:
1 blue top tube had expired on 12/31/17.
2 blue top tubes expired on 2/28/18.
5 mint green tubes had expired on 3/31/18.
2 mint green tubes had expired on 2/28/18.
6 tiger topped tubes had expired on 2/28/18.
1 dark green tube had expired in 1/2018.
1 light green tube had expired on 3/31/18.
5 green tubes had expired on 3/31/18.
On 5/1/2018 at 2:25 p.m., Director 8 verified the findings.

Based on observations, interviews, and review of hospital policies and procedures, the Hospital Infection Control Leadership failed to maintain oversight of the Hemodialysis unit.

The findings include:

Cross Reference to A 0749: The hospital's leadership failed to provide monitoring and oversight of nursing as it relates to infection control principles and review of hospital dialysis logs for its water quality system through its infection control program.

On 5/2/18 at 9:30 a.m., an interview was conducted with Director 2. The state surveyor asked," When the monthly water cultures are sent to you every month, who is reviewing them?" Director 2 replied, "I do not review the cultures, but the Contract Agent sends me, through email, their quarterly meeting minutes. The Agent is required to sign these every month at their meeting, and there are three different doctors who are available to sign them. I am not notified if any labs are abnormal or otherwise when the follow-up is done after the abnormal lab. I have no idea what the labs or cultures are or what they are checking for. Our infection control officer use to be over that area, but it got added to my service probably around March of last year.'"

On 5/2/18 at 3:10 p.m., an interview was conducted with the Hospital Infection Control Officer (ICO). The ICO stated," I have never done any infection control audits in the dialysis unit or for their staff. They are not even on my surveillance. Everyone (Directors) drop their performance indicators into the folder with their quarterly data. I don't know who would be responsible for that area, I guess the ICU/Dialysis Director is."

On 5/2/18 at 3:20 p.m., Director 2 was asked about his/her infection control involvement, and Director 2 stated, "I have not done anything with infection control or any audits for dialysis."

Based on observations, record reviews, review of the hospital's policies and procedures, the hospital's infection control leadership failed to provide monitoring and oversight of nursing as it relates to infection control principles, the hospital's policies and procedures, and review of hospital dialysis logs for its water quality system. (Observations: Registered Nurse 3, 9, 13, and 15)


The findings are:

On 5/2/18 at 9:00 a.m., review of the hospital's dialysis water and dialysate results and the hospital's Portable Water System Total Chlorine Log revealed there was no evidence of oversight and monitoring the outcomes of the dialysis unit's water treatment system by the hospital's infection control program or the hospital's quality program.

Review of the Dialysis Unit's Total Chlorine Logs revealed:
4/3/2017: RO #73 - No documentation of the Reverse Osmosis (RO) "on time", the Post Worker Carbon results were not charted, and there was no Registered Nurse who authenticated the results;
6/26/2017: RO #74- No documentation of the Post Worker Carbon results at 2345(time test taken) by the Registered Nurse;
8/02/2017: RO #73- No documentation of the RO "on time" at test time for 1400 and 1600 by the Registered Nurse
10/19/2017: RO #73- No documentation of the Post Worker Carbon results at 1834, and no Registered Nurse authenticated the results
11/29/2017: RO #73- No documentation of the Post Worker Carbon results at 1915, and no Registered Nurse authenticated the results
1/09/2018: RO #74- No documentation of the RO "on time" at test time at 1245 and 1445 by the Registered Nurse
1/11/2018: RO #73- No documentation of the RO "on time" at test time at 1630 and 1830 by the Registered Nurse
3/01/2018: RO #74 - No documentation of the Post Worker Carbon results at 1930, and no Registered Nurse authenticated the results
3/26/2018: RO #74- No documentation of the Post Worker Carbon results 1900, and no Registered Nurse authenticated the results
4/02/2018: RO #73- No documentation of the RO "on time" at test time (1415) by the Registered Nurse
4/10/2018: RO #74- No documentation of the RO "on time", no documentation of the Post Worker Carbon results, and no Registered Nurse authenticated the results.

Monthly Chemical Analysis - Water Quality Results
3/1/2017 - 3/31/2017: Water Colony Count and Endotoxins - RO water specimen collected on 3/6/17 and 3/14/17- a water culture drawn on 3/14/17 of a water endotoxin of 0.209 was resulted and then redrawn on 3/16/17, resulting as <0.010. There was no documentation that the Medical Director was notified of the abnormal result and no documentation that the Medical Director reviewed the data.

Chemical Analysis date range 4/1/17 to 4/30/17 collected on 4/4/17- Equipment: Hd Machine 71t, Hd Machine 72t, Hd Machine 73t, Portable RO 73 and Portable RO 74 colony count and endotoxins collected on 4/3/17- No evidence that the Medical Director reviewed the reports until 1/24/18. (9 months later)

Date range 6/1/17 to 8/31/17: Quarterly American Association of Medical Instrumentation (AAMI) Summary by Equipment Report - Portable RO 73 and RO 74- No evidence that the Medical Director reviewed any of the reports until 1/24/18.

6/1/2017 to 6/30/2017: Chemical Analysis specimen collected on 6/5/17- Equipment Hd Machine 71t, Hd Machine 72t, Hd Machine 73t, Portable RO 73 and Portable RO 74 with Colony count and endotoxins - No evidence that the Medical Director reviewed the reports until 1/24/18. (Seven months later)

Date range -8/1/2017 to 8/30/2017:Chemical Analysis specimen collected on 8/2/17- Equipment: Hd Machine 71t, Hd Machine 72t, Hd Machine 73t, Portable RO 73 and Portable RO 74 colony count and endotoxins collected on 8/17/17- No evidence that the Medical Director reviewed the reports until 1/24/18. (5 months later)

Date range -11/1/17 to 11/30/17: Chemical Analysis specimen collected on 11/27/17- Equipment: Hd Machine 71t, Hd Machine 72t, Hd Machine 73t, Portable RO 73 and Portable RO 74 colony count and endotoxins collected on 11/16/17. No evidence that the Medical Director reviewed the reports until 1/24/18. ( 2 months later)

Date range 1/1/18 to 1/31/18: Chemical Analysis specimen collected on 1/12/18- Equipment: Hd Machine 71t, Hd Machine 72t, Hd Machine 73t, Portable RO 73 and Portable RO 74 colony count and endotoxins collected on 1/17/18- No evidence that the Medical Director reviewed the reports until 2 months later on 3/8/18.

Date range 2/1/18 to 2/28/18: Quarterly AAMI Summary Report by Equipment- Portable RO 73 and 74- No authentication of the report by the Medical Director.

Date range 3/1/2018 - 3/31/2018: Chemical Analysis specimen collected on 3/15/18 - Equipment: Hd Machine 71t, Hd Machine 72t, Hd Machine 73t, Portable RO 73 and Portable RO 74 colony count and endotoxins collected on 3/15/18. - No authentication of the report by the Medical Director.

On 5/2/18 at 9:30 a.m., during an interview conducted with Director 2, who is responsible for the hospital's dialysis unit, Director 2 stated that he/she received a quarterly report from the contracted hemodialysis agent which reads, "Water Treatment and Water Quality: Water and dialysate tests were performed monthly and results were reviewed accordingly. Corrective and preventative action was taken to address any results outside the American Association of Medical Instrumentation (ANSI/AAMI) acceptable limits. The water quality test may be made available for your review with the Inpatient Services Program Manager. Please call if you have any questions or concerns, or wish to review the identified potential interventions from the QAI committee." ." On 5/2/18 from 5:10 p.m. to 5:20 p.m., Director 2 stated, ""I am just a liaison for them(dialysis contact agent). They were added to my service around March of 2017. I am the contact person between the contract agent and the hemodialysis staff. At one time, when we were doing CRRT in the ICU, we were trained on that, but that's been many years ago, and we don't do it anymore. That was all I know about dialysis. The only part I do is basically reconcile charges, order supplies like gloves, dressings, things like that. The dialysis nurse is basically supposed to be able to work on their own. We really don't have anything to do for them otherwise."

On 5/2/18 at 3:10 p.m., an interview was conducted with the Hospital Infection Control Officer (ICO) who stated, "I have never done any infection control audits in the dialysis unit or for their staff. They are not even on my surveillance. Everyone (Directors) drops their performance indicators into the folder with their quarterly data. I don't know who would be responsible for that area. I guess the ICU/Dialysis Director is."

On 5/2/18 at 5:45 p.m., observations in the hospital's Acute Dialysis Unit revealed Registered Nurse (RN) 15 failed to don personal protective equipment (PPE) in the provision of care for 2 dialysis patients. On 5/2/18 at 5:49 p.m., observations in the Acute Dialysis Unit revealed RN 15 put hand sanitizer into his/her gloved hands, rubbed the hands together, wiped the wetted glove hand over the previously used stethoscope, and then threw the stethoscope across the room to the nurse's desk. Then, RN 15 continued the care for the dialysis patient wearing the same gloves. On 5/2/18 at 5:58 p.m., observations in the Acute Dialysis Unit revealed the dialysis patient located at dialysis station 1 removed a dirty soiled dressing from the left upper arm access site. RN 15 proceeded to cannulate the patient after gently wiping across the patient's left upper arm access site with one (1) alcohol wipe. RN 15 did not wash the patient's access site or clean the patient's access site with an antiseptic prior to placing the needle into the arterial portion of the arteriofistula (AVF). Using the same alcohol pad, RN 15 cannulated the second needle into the venous access. Then, RN 15 proceeded to the patient's dialysis chart, flipped through the dialysis orders, wrote on the patient's record, flushed the patient's access with saline, taped the lines to the patient gown, and then attempted to begin the dialysis treatment. RN 15 changed the soiled gloves, but did not perform hand hygiene before donning clean gloves. On 5/2/18 at 6:10 p.m., observations in the Acute Dialysis Unit revealed RN 15 wearing gloves soiled from the patient's access, changed only the glove on the left hand and proceeded to resume patient care. After a request change the other glove before resuming care, RN 15 removed the second soiled glove and donned a clean glove, but failed to perform hand hygiene between the gloving change. On 5/2/18 at 6:16 and 6:20 p.m., observations in the Acute Dialysis Unit revealed RN 15 removed the dirty gloves, donned clean gloves, but failed to perform hand hygiene. On 5/2/18 at 6:22 p.m., observations in the Acute Dialysis Unit revealed RN 15 reached into his/her right scrub pocket with gloved hands and removed an ink pen. On 5/2/18 at 6:24 p.m., observations in the Acute Dialysis Unit revealed RN 15 wearing blood soiled gloves reached into the clean supply cart wearing the blood contaminated gloves and removed a 10 cubic centimeter (cc) syringe to use on the patient located at dialysis station 1. Wearing the blood soiled gloves, RN 15 continued to provide care for the patient. Observations of RN 15 throughout the provision of care revealed RN 15 never performed hygiene before initiating care, throughout the provision of care, and at the cessation of care.

On 5/1/18 from 10:20 a.m. to 10:36 a.m., observations in the Emergency Department (ED) triage area revealed RN 3 triaged a patient, obtained vital signs, escorted the patient to ED Room 10, wiped down the stretcher, and returned to triage. RN 3 proceeded to wipe down the triage vital sign equipment with a disinfectant wipe with bare hands. A second patient was brought into the triage area, vital signs obtained, and then the patient was escorted to ED Room 2. RN 3 wiped down the equipment with the disinfectant wipes. RN 3 failed to perform hand hygiene throughout the observations. At 10:37 a.m., RN 3 stated, "Oh goodness, I sure didn't wash my hands. I am supposed to wash my hands before and after every patient." On 5/1/2018 at 10:40 a.m., the Chief Nursing Officer (CNO) and Director 1 verified the findings.







39464

On 05/01/18 at 10:00 a.m., observations of Registered Nurse (RN) 13 in the provision of patient care in the patient's room for medication administration and wound care. Observations showed RN 13 performed hand hygiene, donned gloves, positioned the patient in the bed, obtained the patient's blood pressure, heart rate, and respirations using the medical monitor, positioned the WOW(work station on wheels) to the patient's bedside, entered data into the WOW, retrieved the medication administration screen (MAR) in the WOW, scanned each medication packet, opened each packet, and placed the medication in a medication cup, picked up the patient's drinking cup in one hand and the medication cup in the other and administered medication to the patient, discarded the empty medication packets in the trash can, removed the soiled gloves, and discarded the gloves in the trash can, donned a clean of gloves without performing hand hygiene.

RN 13 removed the soiled dressing from the patient's left wrist, and then pulled the trash can closer to the bedside wearing the same gloves, and then continued removing the soiled dressing from the patient's left wrist. RN 13 discarded the soiled dressing into the trash can, adjusted the trash can liner, opened a 4 x(by) 4 gauze pack, picked up wound cleanser bottle, sprayed and wiped the wounds to the patient's left elbow with the 4 x 4 gauze, discarded the soiled dressings into the trash can, applied the antibiotic ointment from the tube on the patient's bedside table, applied the ointment to a 4 x 4 gauze, dabbed the 4 x 4 gauze on the patient's left elbow wound, discarded the 4 x 4 gauze into the trash can, removed a strip of tape from a tape roll, wrapped the wound with a gauze bandage and secured the gauze bandage with tape.

RN 13 assessed the patient's hands, assisted the patient in lifting the right hand up, and removed two rings from the patient's fingers, placed the rings on the bedside table, applied antibiotic ointment to the wounds on the patient's left hand, wrapped the left hand with a gauze bandage and secured the bandage with tape. RN 13 repositioned the trash can, walked to the right side of the patient's bed, and cleansed the abrasions on the left hand knuckles, applied antibiotic ointment, applied a small gauze bandage, and secured the dressing to the patient's left thumb with tape.

RN 13 retrieved the wound cleanser bottle in one hand and a 4 x 4 gauze in the other, sprayed the cleanser on the gauze and wiped the wounds to the right side of the patient's face, applied antibiotic ointment, cleaned wounds to the patient's forehead and intact skin to the left side of face using the same 4 x 4 gauze. RN 13 walked to the trash can and discarded the old dressings, repositioned the trash can, and wearing the same pair of soiled gloves proceeded to remove the compression device from the patient's right foot, picked up the scissors from the bedside table, and cut the dressings from the patient's right foot. The findings were verified by RN 13 at 11:30 a.m. on 05/01/18.

RN 13 failed to use accepted principles of infection control for hand hygiene and gloving changes in the provision of wound care to prevent cross transmission of potential infectious agents in the hospital setting. RN 13 failed to change gloves and sanitize the hands after removing soiled, after contact with the patient's intact skin, after contact with the WOW, medical monitoring equipment, bedside table, and the trash can, and after contact with soiled wound dressings, and when moving from dirty to clean sites related to wound care.

Hospital's policy and procedure, titled, "Hand Hygiene", reads, ..."Indications for hand hygiene: contact with a patient's intact skin ..., contact with environmental surfaces in the immediate vicinity of patients, and after glove removal", "Indications for handwashing and hand antisepsis ...before having direct contact with patients, after contact with a patient's intact skin ..., after contact with body fluids or excretions ...wound dressings ..., if moving from a contaminated-body site to a clean-body site during patient care, after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient, after removing gloves".

Hospital policy and procedure, titled, "Non-Sterile Wound Dressing and Wound Cleansing", reads ...."Procedure ...6. Wash hands or use hand sanitizer per hospital policy and don clean gloves, 8. Carefully remove old dressing...8.3. Remove and discard gloves. Don another set of gloves ...12. Repeat for each wound using a new moistened gauze pad. Be care to prevent cross-contamination with multiple wounds...15. Remove and discard gloves, wash hands and don another set of clean gloves ...17. Apply...wound care product ...20. Remove and discard gloves. Wash hands".



29886

On 5/01/2018 at 10:00 a.m., Registered Nurse 9 entered Patient 6's room transporting the Workstation On Wheels(WOW) into the room with the patient's medication inside the cart. RN 9 assembled a syringe, needles, intravenous fluid, and a pill in a medicine cup without performing hand hygiene. Patient 6 was ordered Nexium 40 milligrams(mgs), Heparin 5,000 units subcutaneous, and Vancomycin 2 grams Intravenous every day. RN 9 drew up Heparin 5,000 units and changed the needle for injection, and then inserted the needle into the subcutaneous tissue of the patient's abdomen and injected the medication into the patient's abdomen without performing hand hygiene. RN 9 charted the medication administration in the WOW computer. RN 9 picked up the cup with the medication and administered the medication to Patient 6 without performing hand hygiene. RN 9 flushed the intravenous catheter, cleaned the intravenous septum with an alcohol swab, inserted the intravenous tubing into the intravenous catheter septum, and infused the medication. RN 9 returned to the WOW and charted the information into the computer. RN 9 transported the WOW out of the patient's room without performing hand hygiene. On 5/01/2018 at 10:10 a.m., RN 4 and RN 9 verified the findings.


39310

On 4/30/18 at 3:03 p.m., random observations in Operating Room (OR) 3 revealed a dirty suction canister with tubing and an open Yankeur attached to the anesthesia cart with was visible blood inside the tubing. On 4/30/2018 at 3:03 a.m., the findings were verified by Director 3 at the time of observation who stated, "I'm not sure when this room was used last."

On 4/30/18 at 3:23 p.m., random observations in Post Anesthesia Care Unit (PACU) revealed wall suction canister with tubing and an opened Yankeur in Bay 5. On 4/30/18 at 3:23 p.m., direct observations in Post Anesthesia Care Unit (PACU) revealed wall suction canister with tubing and an opened Yankeur in Bay 6. On 4/30/2018 at 3:23 p.m., the findings were verified by Director 3 at the time of observations.

On 5/1/18 at 8:23, observations in the pre-operative holding area revealed Medical Doctor (MD) 1 entered and exited the room without performing hand hygiene after assessing Patient 11 prior to the procedure. Observations revealed MD 1 walked to the desk, signed the patient's chart, and walked into the next patient's room without performing hand hygiene. The findings were verified with Director 3 at 10:35 a.m. on 5/1/18.










28883

Observations and interview in the kitchen on 5/1/2018 at 11:12 a.m. prior to the lunch service revealed Dietary Aide 2 was not knowledgeable about how to check a thermometer to ensure it was accurate and working properly. Dietary Aide 2 was not knowledgeable of the proper cold food holding temperature. When asked if s/he could show the surveyor how the thermometer was checked to make sure it was working right, Dietary Aide 2 stated s/he checked to make sure the reading was on Fahrenheit and demonstrated by pushing the button on the digital thermometer. When asked if s/he were familiar with taking food temperatures and how to check to make sure the thermometer was working properly, Dietary Aide 2 reported s/he did this routinely as part of the job. Dietary Aide 2 wiped the thermometer with a sanitizing cloth and started taking the temperature of the cold deli meats. Dietary Aide 2 was asked to demonstrate how s/he would calibrate the thermometer if needed. Observations showed Dietary Aide 2 pushed the button on the digital thermometer, moving it from Celsius to Fahrenheit. Dietary Aide 2 did not answer the question or indicate by demonstration how this would be done.

When asked what a good reading would be that would indicate the thermometer was accurate for use, Dietary Aide 3 stated the reading in the ice bath should be 30 degrees Fahrenheit which was an incorrect answer. When the thermometer was retrieved from the ice bath, it read 31.6 degrees Fahrenheit. When asked if this was a good thermometer reading to indicate the thermometer was okay for use, Dietary Aide 3 stated, "Yes". Dietary Aide 3 obtained the temperature of the cold deli meats. A check of the cold deli meat revealed the temperature was appropriate at 36.5 degrees Fahrenheit. When asked what the correct cold food holding temperature was, Dietary Aide 3 stated the temperatures should be below 34 degrees Fahrenheit which was incorrect.

Observations of the kitchen on 5/1/18 at 11:30 a.m. revealed Dietary Aide 1 checked the hot food temperatures for the lunch service with gloved hands. Dietary Aide 1 placed the thermometer with the handle partially inserted into the food. The dietary aide cleaned the stem of the thermometer with a sanitizing wipe after each food item, but failed to clean the thermometer handle which had been contaminated. The finding was verified with the Chef at 11:30 a.m. on 5/1/2018.

Observations on 5/2/18 at 2:30 p.m. revealed Cook 2 washed pots and pans in the 3-compartment sink. After placing a pan in the sanitizing solution, s/he set the pan against the dirty stainless steel/tile backsplash to dry contaminating the pan. The finding was verified with Cook 2 who stated they used to place clean pots and pans on a rack to dry.

Observations on 5/2/18 at 2:32 p.m. revealed Dietary Aide 3 sweeping the kitchen floor. Dietary Aide 3 had a beard and mustache but was not wearing a facial hair restraint. When asked to test the red bucket for the appropriate amount of sanitizer solution, Dietary Aide 3 stated s/he was a porter and that s/he did not perform testing of the red sanitizer buckets. When asked, s/he stated that s/he normally did not wear a facial hair restraint. During an interview on 5/2/18 at 2:38 p.m., Director 12 stated that all staff with facial hair were supposed to wear a facial hair restraint in the kitchen even if they were not preparing food. During an interview on 5/3/18 at 9:00 a.m. in which dietary concerns were discussed with Registered Dietician(RD) 1 and Director 12, the RD 1 stated that Dietary Aide 3 tried to dodge the surveyor and get out of testing the red bucket by saying s/he was a porter. RD 1 verified that Dietary Aide 3 and all dietary staff should know how to check the red bucket for the appropriate amount of sanitizer.

During observations on 5/2/18 at 2:37 p.m., Dietary Aide 1 was asked to test the red bucket next to the dish machine for the appropriate amount of sanitizer solution. The dietary aide dipped the ph Hydrion strip into the solution in the red bucket for 60 seconds. When asked, s/he stated the strip is immersed for 60 seconds, and then checked to see if the color registers an adequate sanitizer amount. Review of the test strip instructions revealed the test strip was to be immersed for 10 seconds, and then read. Dietary Aide 1 was not knowledgeable about the timeframe the test strip was to be immersed in the sanitizer solution. After performing the test correctly, the solution was noted to have the appropriate amount of sanitizer solution.

Review of the hospital's policy, entitled, "Dress Guidelines for Food Service Management and Clinical Nutrition Staff" (Revised 1/17), revealed, "...Hair restraints are worn by all when in the kitchen...".



39208

On April 30, 2018 at 2:15 p.m., observations of Respiratory Therapist(RT) 1 revealed a lack of cleaning the rolling Workstation on Wheels (WOW) between patient room visits. RT 1 exited a patient room with the WOW and entered the nursing station. In a few minutes, RT 1 entered another patient's room without wiping down the WOW. The finding was verified by RT 1 on April 30, 2018 at 2:20 p.m. On May 1, 2018 at 8:55 a.m., the Infection Control Officer, stated, "There is no hospital policy on sanitizing the WOW."

On April 30, 2018 at 2:30 p.m., observations of RN 18 revealed a lack of cleaning the rolling WOW after a patient room visit. RN 18 exited a patient room, placed the WOW at the end of the hallway, plugged the WOW electrical cord to the electrical outlet to charge, and walked away. When RN 18 was asked if he/she was finished with the WOW, RN 18 responded, "Yes." RN 18 failed to wipe down the WOW after the patient visit. The finding was verified by RN 18 on April 30, 2018 at 2:30 p.m..

On May 2, 2018 at 10:26 a.m., observations during a patient receiving a cardiac stress test revealed RN 12 removed the soiled gloves and donned a clean pair of gloves without performing hand hygiene. The finding was verified by RN 12 on May 2, 2018 at 10:46 a.m..


39463

On 4/30/2018 at 2:45 p.m., observations of the walk in freezer revealed 3 boxes stored less than 18 inches from the ceiling in the walk in freezer preventing adequate ventilation space. At the time of the observation, the findings were verified by Director 12. Review of the hospital's policy, titled, "Food and Supply Storage", reads, "Frozen Storage. Store items 6 inches above the floor...and 18 inches from the ceiling, consistent with local food protection codes...Do not store within 18 inches of an overhead sprinkler head." On 4/30/2018 at 2:47 p.m., observations of the walk in freezer revealed debris on the floor under both sides of shelving. At the time of the observation the findings were verified by Director 12. On 4/30/2018 at 2:50 p.m., observations in the walk in refrigerator revealed a pan of frozen meat sauce that had been pulled from the freezer to thaw and had no label with the date the food was removed from the freezer, and the date by which it must be used. At the time of the observation, the findings were verified by the Chef. Review of hospital policy, titled, "Food Handling Guidelines (HACCP)", reads, "Thaw frozen meat/poultry/seafood under refrigeration at temperatures of 41 degrees Fahrenheit or less...Label with the date it was removed from the freezer, and the date by which it must be used."

On 4/30/2018 at 2:55 p.m., observations of the baker's freezer revealed a box of wheat rolls that were opened and not labeled with the date opened. At the time of the observation, the finding was verified by Director 12. Review of facility policy, titled, "Food and Supply Storage", reads, "Frozen Storage - Once the packaging around the food has been opened, food must be used within 3 months."

On 4/30/2018 at 3:00 p.m., observations in the kitchen of Oven 4 revealed the inside of the oven was covered in a brown black sticky substance. At the time of the observation, the finding was verified by Director 12 who reported the cleaning assignment for the ovens is that the exterior is cleaned daily, and the interior is cleaned on the weekends."

On 4/30/2018 at 3:05 p.m., observations in the kitchen revealed thick black and grease build up on 2 large sauce pans, 8 fry pans, 10 trays, 4 muffin pans, a meat press, and a large batch prep pan. At the time of the observations, the finding was verified by the Registered Dietician (RD) who stated, "We've tried everything to get it off. You would be amazed how expensive replacing them is."

On 4/30/2018 at 3:30 p.m., observations and interviews revealed dietary staff were not knowledgeable on the appropriate way to test for adequate sanitizer concentrations. When Cook 1 was asked to test the sanitizer concentration in the red sanitizer bucket, observations revealed Cook 1 dipped the Hydrion test strip for 40 seconds. When asked by the surveyor how long to dip the test strip in the water, Cook 1 stated, "40-60 seconds." Review of the Hydrion manufacturer instructions, reads, "Dip paper in quat solution for 10 seconds." At the time of the observation and interview, the findings were verified by Director 12. Review of the hospital's policy, titled, "Sanitizing Food Contact Surfaces", reads, "Sanitizer solution must be at 200 ppm(parts per minute) to 400 ppm for Oasis 146 Multi-Quat Sanitizer."

On 5/1/2018 at 11:35 a.m., observations and interviews prior to lunch service in the kitchen revealed knowledge deficit of proper cold holding temperatures of food for service. When asked by the surveyor to test the food temperature of the peaches, cream, and coleslaw prior to food service, the dietary supervisor tested and obtained a temperature of 44.9 degrees Fahrenheit for the peaches and cream, and a temperature of 44.2 degrees Fahrenheit for the coleslaw. When the dietary supervisor was asked by the surveyor if the temperatures were okay, he/she stated "It's okay." At the time of the observation, Chef verified the finding and instructed staff to not serve the peaches and cream and coleslaw. Review of the hospital's policy, titled, "Food Handling Guidelines (HACCP)", reads, "Cold Holding Temperatures. Foods should be held cold for service at a temperature of 41 degrees Fahrenheit or less."

On 5/2/2018 at 2:22 p.m., observations and interview of manual washing of pots and pans in the 3-compartment sink revealed staff knowledge deficit of proper wash procedure. When the surveyor asked Cook 2 to demonstrate proper wash procedure of pots and pans in the 3-compartment sink, observations revealed Cook 2 soaked the pan in the sanitizer for 15 - 25 seconds. When questioned by the surveyor of the length of time for pans to be sanitized, Cook 2 stated, "I soak (pots and pans) in sanitizer 15 seconds." Observations of manual pot and pan wash procedure posted on the wall above the 3-compartment sink, reads, "Submerge in sanitizer for one minute or as specified by product label and/or local guidelines." Review of manufacture guidelines of "Oasis 146-Multi-Quat Sanitizer", reads, " Expose all surfaces of equipment, ware or utensils to the sanitizing solution for not less than one minute." At the time of the observations, all of the findings were verified by Director 12 who was present during the observations.

Hospital policy, titled "Role and Scope of Participation of Each Department in Infection Prevention and Control and Employee Health", reads " ....Dialysis ....Important Aspects of Care ....Responsible for preventing occurrence of infection by practicing aseptic technique during dialysis ....Assures cleanliness of unit and all equipment used for dialysis ....Compliance with collection of recommended water cultures ....Implementation of transmission based precautions when required ....Measure to Reduce Risk Between/Among Staff/Patients ....Handwashing ....Universal /Standard Precautions ....Proper use of PPE ...Aseptic techniques (all aspects) ...Cleaning and disinfection of environmental surfaces ....Prompt handling/disposing of biohazard waste ....".

Based on observations, record reviews, review of the hospital's dialysis logs, interview, and review of the hospital policies and procedures, the hospital's leadership failed in its responsibilities to ensure its hospital-wide quality assurance program and tinfection control program addressed problems identified by the infection control officer and for the implementation of successful corrective action plans in affected problem areas for the Hemodialysis Unit.


The findings include:


On 5/2/18 at 9:30 a.m., during an interview conducted with Director 2, who is responsible for the hospital's dialysis unit, Director 2 stated that he/she received a quarterly report from the contracted hemodialysis agent which reads, "Water Treatment and Water Quality: Water and dialysate tests were performed monthly and results were reviewed accordingly. Corrective and preventative action was taken to address any results outside the American Association of Medical Instrumentation (ANSI/AAMI) acceptable limits. The water quality test may be made available for your review with the Inpatient Services Program Manager. Please call if you have any questions or concerns, or wish to review the identified potential interventions from the QAI committee." ." On 5/2/18 from 5:10 p.m. to 5:20 p.m., Director 2 stated, ""I am just a liaison for them(dialysis contact agent). They were added to my service around March of 2017. I am the contact person between the contract agent and the hemodialysis staff. At one time, when we were doing CRRT(Continuous Renal Replacement Therapy) in the ICU, we were trained on that, but that's been many years ago, and we don't do it anymore. That was all I know about dialysis. The only part I do is basically reconcile charges, order supplies like gloves, dressings, things like that. The dialysis nurse is basically supposed to be able to work on their own. We really don't have anything to do for them otherwise."

On 5/2/18 at 3:10 p.m., an interview was conducted with the Hospital Infection Control Officer (ICO) who stated, "I have never done any infection control audits in the dialysis unit or for their staff. They are not even on my surveillance. Everyone (Directors) drops their performance indicators into the folder with their quarterly data. I don't know who would be responsible for that area. I guess the ICU/Dialysis Director is."

Review of the Dialysis Unit's Total Chlorine Logs revealed:
4/3/2017: RO #73 - No documentation of the Reverse Osmosis (RO) "on time", the Post Worker Carbon results were not charted, and there was no Registered Nurse who authenticated the results;
6/26/2017: RO #74- No documentation of the Post Worker Carbon results at 2345(time test taken) by the Registered Nurse;
8/02/2017: RO #73- No documentation of the RO "on time" at test time for 1400 and 1600 by the Registered Nurse
10/19/2017: RO #73- No documentation of the Post Worker Carbon results at 1834, and no Registered Nurse authenticated the results
11/29/2017: RO #73- No documentation of the Post Worker Carbon results at 1915, and no Registered Nurse authenticated the results
1/09/2018: RO #74- No documentation of the RO "on time" at test time at 1245 and 1445 by the Rrgistered Nurse
1/11/2018: RO #73- No documetation of the RO "on time" at test time at 1630 and 1830 by the Registered Nurse
3/01/2018: RO #74 - No documentation of the Post Worker Carbon results at 1930, and no Registered Nurse authenticated the results
3/26/2018: RO #74- No documentation of the Post Worker Carbon results 1900, and no Registered Nurse authenticated the results
4/02/2018: RO #73- No documentation of the RO "on time" at test time (1415) by the Registered Nurse
4/10/2018: RO #74- No documentation of the RO "on time", no documentation of the Post Worker Carbon results, and no Registered Nurse authenticated the results.


Water/Chemical Analysis Results:
3/1/2017 - 3/31/2017: Water Colony Count and Endotoxins - RO water specimen collected on 3/6/17 and 3/14/17- a water culture drawn on 3/14/17 of a water endotoxin of 0.209 was resulted and then redrawn on 3/16/17, resulting as <0.010. There was no documentation that the Medical Director was notified of the abnormal result and no documentation that the Medical Director reviewed the data.

Chemical Analysis date range 4/1/17 to 4/30/17 collected on 4/4/17- Equipment: Hd Machine 71t, Hd Machine 72t, Hd Machine 73t, Portable RO 73 and Portable RO 74 colony count and endotoxins collected on 4/3/17- No evidence that the Medical Director reviewed the reports until 1/24/18. (9 months later)

Date range 6/1/17 to 8/31/17: Quarterly American Association of Medical Instrumentation (AAMI) Summary by Equipment Report - Portable RO 73 and RO 74- No evidence that the Medical Director reviewed any of the reports until 1/24/18.

6/1/2017 to 6/30/2017: Chemical Analysis specimen collected on 6/5/17- Equipment Hd Machine 71t, Hd Machine 72t, Hd Machine 73t, Portable RO 73 and Portable RO 74 with Colony count and endotoxins - No evidence that the Medical Director reviewed the reports until 1/24/18. (Seven months later)

Date range -8/1/2017 to 8/30/2017:Chemical Analysis specimen collected on 8/2/17- Equipment: Hd Machine 71t, Hd Machine 72t, Hd Machine 73t, Portable RO 73 and Portable RO 74 colony count and endotoxins collected on 8/17/17- No evidence that the Medical Director reviewed the reports until 1/24/18. (5 months later)

Date range -11/1/17 to 11/30/17: Chemical Analysis specimen collected on 11/27/17- Equipment: Hd Machine 71t, Hd Machine 72t, Hd Machine 73t, Portable RO 73 and Portable RO 74 colony count and endotoxins collected on 11/16/17. No evidence that the Medical Director reviewed the reports until 1/24/18. ( 2 months later)

Date range 1/1/18 to 1/31/18: Chemical Analysis specimen collected on 1/12/18- Equipment: Hd Machine 71t, Hd Machine 72t, Hd Machine 73t, Portable RO 73 and Portable RO 74 colony count and endotoxins collected on 1/17/18- No evidence that the Medical Director reviewed the reports until 2 months later on 3/8/18.

Date range 2/1/18 to 2/28/18: Quarterly AAMI Summary Report by Equipment- Portable RO 73 and 74- No authentication of the report by the Medical Director.

Date range 3/1/2018 - 3/31/2018: Chemical Analysis specimen collected on 3/15/18 - Equipment: Hd Machine 71t, Hd Machine 72t, Hd Machine 73t, Portable RO 73 and Portable RO 74 colony count and endotoxins collected on 3/15/18. - No authentication of the report by the Medical Director.

On 5/2/18 at 9:30 a.m., an interview was conducted with Director 2. He/she stated she receives a quarterly report from the contracted provider which reads, "Water Treatment and Water Quality: Water and dialysate tests were performed monthly and results were reviewed accordingly. Corrective and preventative action was taken to address any results outside the American Association of Medical Instrumentation (ANSI/AAMI) acceptable limits. The water quality test may be made available for your review with the Inpatient Services Program Manager. Please call if you have any questions or concerns, or wish to review the identified potential interventions from the QAI committee." On 5/2/18 from 5:10 p.m. to 5:20 p.m., Director 2 stated, ""I am just a liaison for them(dialysis contact agent). They were added to my service around March of 2017 and I became ICU(Intensive Care Unit) Director (the interim director in March), and then was appointed Director at the end of 2017. I am the contact person between the contract agent and the hemodialysis staff. At one time when we were doing CRRT in the ICU, we were trained on that, but that's been many years ago, and we don't do it anymore. That was all I knew about dialysis. The only part I do is basically reconcile charges, order supplies like gloves, dressings, things like that. The dialysis nurse is basically supposed to be able to work on their own. We really don't have anything to do for them otherwise."

On 5/2/18 at 3:10 p.m., an interview was conducted with the Hospital Infection Control Officer (ICO) who stated," I have never done any infection control audits in the dialysis unit or for their staff. They are not even on my surveillance. Everyone (Directors) drops their performance indicators into the folder with their quarterly data. I don't know who would be responsible for that area. I guess the ICU/Dialysis Director is."

Procedure titled, "Instructions for Completing Form TCL-1 Total Chlorine Log for Portable Water Systems", reads " ....Purpose: The purpose of this procedure is to provide instructions on the use of the Inpatient Portable Water System Total Chlorine Log 1 to properly document the performance of the first carbon filter prior to entering dialysis equipment ....1. Indicate Facility name. 2. Indicate the date. 3. a) Indicate (in military time/24 hour time) the time the RO machine was turned on. b). Indicate (in military/24 hour time) the time the test was performed. 4. Document the Total Chlorine reading as determined by the test method in use. 5. Place a check mark in either the "Yes" or "No" box depending on the Total Chlorine reading. If the test result is less than 0.10 ppm check the "Yes" box. If the Total Chlorine reading is 0.10 ppm or greater check the "No" box. 6. Signature of person who drew samples and performed testing. 7. Signature of Inpatient Clinical Manager. 8. Enter the date. 9. Enter the Portable Water System ID number ....".


Policy titled, " Microbiological Monitoring of Portable Water Systems", reads " ....Purpose: The purpose of this policy is to define the minimum monitoring requirements of microbiological contaminant levels in treated water ....Responsibility: Clinical Manager: Ensure samples are reviewed and correct individuals notified when results are at or above action level or exceeding allowable limit; Ensure microbiological monitoring data is presented and reviewed at the monthly QAI meeting; Ensure staff is trained in microbiological monitoring policies and procedures. Staff: Collect microbiological samples in accordance to this procedure. Medical Director: Review and sign microbiological summary reports in the monthly QAI meeting; Actively participate in the QAI process when microbiological results have initiated an action plan. Governing Body/and or Operational Review Committee: The Governing Body and/or Operational Review Committee are responsible for policy review and adoption to ensure quality patient care ....Documentation: Results at or above action level will be documented and reported to Medical Director and Technical management promptly and in accordance with action plans....At a minimum, Medical Directors must review and sign a summary report of all microbiological sample results obtained during the review period ....".

Hospital policy, titled "Role and Scope of Participation of Each Department in Infection Prevention and Control and Employee Health", reads " ....Dialysis ....Important Aspects of Care ....Responsible for preventing occurrence of infection by practicing aseptic technique during dialysis ....Assures cleanliness of unit and all equipment used for dialysis ....Compliance with collection of recommended water cultures ....Implementation of transmission based precautions when required ....Measure to Reduce Risk Between/Among Staff/Patients ....Handwashing ....Universal /Standard Precautions ....Proper use of PPE ...Aseptic techniques (all aspects) ...Cleaning and disinfection of environmental surfaces ....Prompt handling/disposing of biohazard waste ....".

Based on record reviews, interviews, and review the hospital policy, entitled, "Discharge Planning Policy", the hospital failed to ensure a system was in place to notify patients or a person acting on behalf of a patient that they can request a discharge planning evaluation.

The findings included:

Review of the hospital's "Discharge Planning Policy" on 5/2/18 at 10:00 a.m. revealed, "...It is the policy of ..... Regional Medical Center to complete a timely discharge assessment and evaluation of patients identified as high-risk, so that appropriate arrangements for post-hospital care are made prior to discharge to avoid unnecessary delays. Upon admission, patients or their representatives are informed of their right to request a discharge planning evaluation if the initial assessment does not indicate the need for evaluation...".

During an interview on 5/2/18 at 10:50 a.m., Director 11 stated that not all patients admitted to the hospital receive a discharge planning evaluation. When asked about how the hospital informs patients or their representatives that they can have a discharge planning evaluation upon request, the Director reported that he/she was not sure how this was done. Review of the hospital's "Notice of Privacy Practices" and the hospital's "Guide to Guest Services" with Director 11 revealed the data did not include statements or policies that addressed that a patient or representative could request a discharge planning evaluation. The "Guide to Guest Services" included information that "Case Managers are assigned to each patient care area and are trained to help patients and family members deal with financial, social, and emotional problems that relate to illness or hospitalization. Members of the department work with patients and families to help deal with long-term illnesses and rehabilitation and are involved in discharge planning." During interviews on 5/2/18 at 11:44 a.m. and 11:50 a.m., Director 6 and Registered Nurse 14 stated they were unaware of how patients are notified they can request a discharge planning evaluation.

Based on review of the hospital's emergency preparedness plan and interview, the hospital failed to ensure all staff received training on the hospital's Emergency Preparedness Plan and the Emergency Preparedness Plan's policies and Procedures in that 98 of 553 hospital employees had no documented annual training 2018 for the hospital's emergency preparedness plan.

The findings are:


On 5/03/2018 at 11:10 a.m., review of the hospital's emergency preparedness plan's documentation of the hospital's staff annual 2018 Safety training revealed Registered Nurse(RN) 13 had no date documented for the 2018 Safety training. In an interview with RN 13 on 05/03, RN 13 revealed that if there was no date documented for the individual listed on the training sheet, then the employee has not completed their annual emergency preparedness training for 2018 which was due by 4/30/2018. Review of the 2018 Safety training documentation revealed 98 of 553 hospital employees had not received the 2018 annual training. RN 13 verified the findings at 12:16 p.m. on 5/02/2018.