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Based on observation, staff interviews, and review of maintenance records on 2-13-17 through 2-15-17, the facility did not ensure that the building & building systems are constructed, installed, and maintained to ensure life safety to patients as revealed by the following deficiencies:

K-161 (Building Construction Type and Height),
K-225 (Stairways and Smokeproof Enclosures),
K-300 (Protection - Other),
K-321 (Hazardous Areas - Enclosure),
K-353 (Sprinkler System - Maintenance and Testing),
K-363 (Corridor - Doors),
K-372 (Subdivision of Building Spaces - Smoke Barrier Construction),
K-374 (Subdivision of Building Spaces - Smoke Barrier Doors),
K-712 (Fire Drills),
K-918 (Electrical Systems - Essential Electrical System Maintenance and Testing),

Please refer to the full description of the deficient practice at the individual K-tags. These observations are not compliant with 42 CFR 485.623. These deficiencies were confirmed at the time of discovery by a concurrent record review, observation, and interview with Staff VV.

Based on observation, staff interviews, and review of maintenance records on 2-13-17 through 2-15-17, the facility did not ensure that the building & building systems are constructed, installed, and maintained to ensure life safety to patients as revealed by the following deficiencies:

K-161 (Building Construction Type and Height),
K-225 (Stairways and Smokeproof Enclosures),
K-300 (Protection - Other),
K-321 (Hazardous Areas - Enclosure),
K-353 (Sprinkler System - Maintenance and Testing),
K-363 (Corridor - Doors),
K-372 (Subdivision of Building Spaces - Smoke Barrier Construction),
K-374 (Subdivision of Building Spaces - Smoke Barrier Doors),
K-712 (Fire Drills),
K-918 (Electrical Systems - Essential Electrical System Maintenance and Testing),

Please refer to the full description of the deficient practice at the individual K-tags. These observations are not compliant with 42 CFR 485.623. These deficiencies were confirmed at the time of discovery by a concurrent record review, observation, and interview with Staff VV.

Based on observation, interview, and record review this facility failed to ensure safe storage of medications and biologicals to ensure patient safety in 2 of 3 crash carts (Post Anesthesia Care Unit and Medical Surgical Unit).

Findings include:

During observation of the Medical Surgical Department crash cart on 2/13/2017 at 2:17 PM, review of the check logs was conducted . The logs were from December 1, 2016-February 13, 2017. December is missing check dates on 12/01/16 and 12/05/16, January is missing check dates on 1/13/17 and 1/17/17 and February is missing a check date on 02/06/2017.

Per interview with Director of Nursing AA on 2/13/17 at 2:17PM, AA stated that staff should be documenting every day, "they must have missed those days, I guess someone should be checking".




26711

A review of the Post Anesthesia Care Unit crash cart check logs was conducted on 2/14/2017 at 1:00 PM. The logs were from September 2016-February 14, 2017. November is missing a check date on 11/15/16. December is missing check dates on 12/12, 12/19, 12/23, and 12/29 2016. January is missing check dates on 1/6, 1/16, 1/26, and 1/31 2017. February is missing a check date on 2/10/2017.

Per interview with Surgical Services Director D on 2/14/2017 at 1:00 PM regarding these findings, Director D stated that the department is closed on the weekends but was not closed on any of those dates and stated that staff should be documenting every day the department is open that the cart check was completed.

Also discovered during review of the December log, on 12/10/2016 ( a Saturday) there is an entry stating, "Lock off." On Monday 12/12/2016, one of the days the cart was not marked as being checked, there is another entry stating, "Lock off." The next entry on 12/13/2016 has a lock code that differs from the lock code entered on 12/9/2016. When asked if this meant the crash cart went all weekend and that Monday without a lock on it, Director D stated, "I don't know."

The facility's policy titled, "Crash Cart Check," dated 8/2016, was reviewed on 2/14/2017 at 1:10 PM. The policy states in part, "Crash Cart and defibrillator checks are done daily. If a unit closes, the crash cart check is verified at the time of closure, and when unit opens (PACU) [post anesthesia care unit]...If locks are not intact, check crash cart inventory to see if every item is present and that the appropriate expiration dates are listed. When crash cart inventory is completed a break-away lock is placed on the drawer. Record lock number on Crash Cart Check Sheet."

Based on observation, interview and record documentation, the facility failed to provide and maintain a sanitary environment in 4 of 10 departments (Medical Surgical Unit, Environmental Services, Pharmacy, Respiratory).

Findings include:

Review of policy titled "Hand Hygiene" dated 7/2016 stated the recommendations for health care workers to perform hand hygiene are 1.) Before touching a patient 2.) Before clean/aseptic procedures 3.) After body fluid exposure/risk 4.) After touching a patient 5.) After touching patient surroundings. The policy did not address hand hygiene after glove removal.

On 2/14/17 at 3:15 PM went with Respiratory Therapist YY to observe 3 of 7 small volume nebulizer treatments ordered on Medical Surgical floor. Prior to pulling the medications from Pyxis, YY stated they usually pull out all the medications, place them in their jacket pocket prior to administering the treatments to save time, and asked writer if it was okay to do that. After several seconds YY stated, "I guess I should pull each one separately".

An interview was conducted with Director Respiratory Care S on 2/15/17 at 11:05 AM. S stated that the therapists should not be pulling medications for more than one patient at a time.


34337

Patient Care observations:

On 2/13/2017 at 2:00 PM, after an attempt to perform intravenous catheter insertion in Patient #28's left arm, Registered Nurse UU removed one glove and retrieved supplies from the clean supply tray without first performing hand hygiene. UU proceeded to don another glove and inserted the intravenous catheter in Patient #28's arm. Then, without removing the contaminated gloves or performing hand hygiene, UU withdrew a pen from UU's pocket, used the pen, and returned the pen to the pocket.




26711

An observation of a blood glucose check on Patient #7 with Certified Nursing Assistant P was conducted on 2/14/2017 at 11:40 AM. Upon entry to Patient #7's room, Assistant P did not perform hand hygiene.

An observation of intravenous medication administration for Patient #7 by Registered Nurse O was conducted on 2/14/2017 at 11:45 AM. Nurse O was noted to have several cellophane wrapped syringes in the pants pocket of O's scrubs, one of which Nurse O used for Patient #7. Per interview with Nurse O at the time of the observation regarding the syringes, Nurse O responded, "They are for anyone, I just carry them with me so I have them."

Per interview with Vice President of Patient's Care Services A on 2/14/2017 at 11:5 AM regarding these observations, Vice President A stated, "No, they are not supposed to do that." (Referring to carrying syringes in pockets.)

Environmental Services:
An interview with Director of Environmental Services C was conducted on 2/13/2017 at 1:40 PM. Director C stated that the facility uses an automated system (J-Fill Quattro) for filling mop buckets for cleaning floors etcetera, and the facility is currently not checking chemstrips to determine if the proper concentration of chemicals is being delivered when bottles are replaced.

The Manufacturer recommendations for testing for this product state, "Frequency: [Name of company] recommends facilities test dispensing systems whenever a concentrated bottle of disinfectant is changed."

During a tour of the facility, checking housekeeping closets, with Director C on 2/13/2017 at 2:10 PM, it was observed that a bottle of Vita Ice (a flavored drink) was on a shelf in the housekeeping closet on the medical/surgical floor. Per interview with Director C at the time of this observation regarding food/drink in the housekeeping closets, Director C stated, "I don't know what that is but it shouldn't be there."
Pharmacy:
During a tour of the Pharmacy on 2/14/2017 at 3:03 PM accompanied by Pharmacy Director R, a 250 cc (cubic centimeter) bottle of partially used sterile water was observed in the chemotherapy compounding room and the bottle was not dated. Per interview at the time of the observation, Director R stated that the sterile water is used as a cleaning agent but the policy is the same. It is still supposed to be dated for 28 days after being opened.

A review of the facility's policy titled, "Single-Dose and Multi-Dose Medications," dated 12/16, was reviewed on 2/14/2017 at 3:07 PM. The policy states in part, "All multi-dose containers will be labeled with date opened sticker and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial."


37421

Based on record review and interview, facility staff failed to provide patient education as indicated per the nursing plan of care for 2 of 3 discharged hospital inpatients reviewed (Patient #24, Patient #25).

Findings include:

Review of the policy "Patient/Family Education Policy" dated 6/2016 states: "Hospital Inpatient: The nursing process will serve as the basis from which a patient teaching plan will be developed, implemented and evaluated following physician diagnosis and based on current standards of practice."

Review of the policy "Plan of Care & Documentation, Interdisciplinary" dated 8/2016 states: "Patient progress will be documented with an entry (flow sheet, care plan note) every shift...Patient/family education will be provided by the Interdisciplinary Team and will be documented in the Education Record...Education Record: 1. The Interdisciplinary Teaching Record will be utilized on all inpatients to document patient/family teaching done by the Interdisciplinary team."

Review of the policy "Discharge of Patient/AVS [After Visit Summary]" dated 8/2016 states: "The RN is responsible for completing a discharge note, and resolving care plans and education upon discharge."

Per Patient #24's medical record, reviewed on 2/15/2017 at 9:45 AM, Patient #24 presented to the Emergency Department on 11/17/2016 for altered mental status. Patient #24 was subsequently admitted as an inpatient for "hallucinations secondary to accidental drug overdose." The admitting History and Physical documents a history of oropharyngeal carcinoma and gastric tube feeding status. The note states: "As per patient's wife who is primary caregiver, she put all patient's medication in a box, including oxycodone and citalopram. Patient took 40 mg citalopram and 20 mg oxycodone..." Patient #24's current medication list upon admission lists citalopram 10 mg/5 mL solution; citalopram 20 mg tablet; oxycodone 5 mg/5 mL solution; oxycodone 10 mg tablet; oxycodone 5 mg immediate release tablet. The Emergency Department note states "patient does have a G-tube in place and takes all fluid and food intake through G-tube."

The physician progress note, dated 11/18/2016 states: "...has G-tube placed there was some confusion about the nature of feedings and the amount of fluid...so we have arranged a nutrition consult." The nutrition evaluation, dated 11/18/2017, notes Patient #24's wife reporting administering tube feedings not as prescribed at home. The evaluation states: "Nutrition Diagnosis: ...Excessive enteral nutrition infusion related to misunderstanding of tube feeding instructions given to wife as evidenced by wife reporting."

Patient #24's care plan includes a problem for pain with an intervention of "educate and encourage patient to monitor pain and request assistance," a gastrointestinal problem with an intervention of "provide specific nutrition education as appropriate," and a fall safety problem with an intervention of "educate patient/family on patient safety including physical limitations." There is no documentation that Patient #24 or Patient #24's caregiver received education as identified in the care plan. Patient #24's medical record documents an admission partially contributed to medication error, and a caregiver's misunderstanding of tube feeding orders. There is no documentation in Patient #24's record that medication education or tube feeding education were addressed at any time during the inpatient hospitalization.

Patient #25 received inpatient services from 12/4/2016 through 12/12/2016 for shortness of breath. Patient #25's care plan includes a problem of anxiety with a goal of "will report anxiety at manageable levels." Interventions designed to facilitate the patient meeting the goal include "teach and rehearse alternative coping skills; assist patient & family to identify coping skills, available support systems and cultural and spiritual values; instruct patient/family in relaxation techniques, as appropriate." Review of Patient #25's care plan does not include evidence that the patient made progress toward the goal. There is no documentation in the medical record that the interventions detailed above were performed, no education related to anxiety is included in the care plan or education record.

During an interview on 2/15/2017 at 10:45 AM, Director of Nursing AA stated all patient education should be documented in the education tab of the electronic medical record.

Based on record review and interview, the facility failed to ensure physical restraints are used per order, and that verbal orders are signed per policy, in 1 of 1 restrained patient reviewed (Patient #27). This had the potential to affect all patients requiring restraints at this facility.

Findings include:

Facility policy "Restraints" dated 1/2013 states: "Time-limited orders: Restraint interventions require a physician's reorder prior to the following time limits: Acute medical/surgical patient--A face to face evaluation and reorder by the attending physician is required every 24 hours or once per calendar day."

Patient #27 received inpatient services from 10/15/2016 through 10/19/2016 for pneumonia. Per Patient #27's medical record, reviewed on 2/15/2017 at 11:45 AM, Patient #27 was in soft limb and secured mitt restraints daily during the inpatient stay. Orders for restraints are documented on 10/15/2016, 10/16/2016, 10/18/2016 and 10/19/2016. There are no orders for restraints on 10/17/2016. Patient #27's restraint flowsheet documents restraint use continuously from 10/17/2016 at 8:00 AM through the time of discharge on 10/19/2016.

During an interview on 2/15/2017 at 11:45 AM, Director of Nursing AA stated "I don't know why there's not an order [dated 10/17/2016], there should be an order for restraints daily."

The facility's Medical Staff Rules and Regulations, dated 1/2016, states in part: "All orders for treatment shall be entered into the EMR [Electronic Medical Record] and include date, time, and signature. Verbal/telephone orders shall be accepted...The hospitalist or attending practitioner shall authenticate the order as soon as possible after the fact. ...Restraints: Please refer to the Medical Center's restraint policy for details of the requirement."

Patient #27's record contains a verbal order for restraints, entered by the nurse, dated 10/16/2016 at 3:12 PM. The order is signed by the physician on 10/24/2016 at 5:06 PM. This finding was shared with Vice President A on 2/15/2017 at 12:15 PM. A stated the order should be signed "as soon as possible" or per the restraint policy, "within 24 hours."

Based on observation, interview, and record review, the facility failed to ensure that the medical records were protected from unauthorized use in1 of 1 medical record departments. This deficiency has the potential to affect all patients at this facility.

Findings include:

Review of policy "HIPAA [Health Insurance Portability and Accountability Act] Oversight" dated 8/2014 states "SCRMC (St. Croix Regional Medical Center) and its business affiliates create, store, maintain, use, transmit, collect and disseminate protected health information in an environment that promotes confidentiality and integrity."

On 2/14/2017 at 11:05 AM, during a department tour with Health Information Director II, it was observed that the back door to the department was propped open to a hallway. This open door could not be viewed by any of the staff and there were medical record charts laying on counters in the department. Health Information Director II stated that the door was open "for airflow". There was also a closed, unlocked door two feet from the open medical records door that opened to a public area with elevators.

An observation with Vice President of Patient Care Services A on 2/14/2017 at 12:50 PM was made that the Medical Records back door was propped open, and the door leading to the hallway from a public area with elevators had four visitors waiting for the elevator. A stated "they could walk in, unobserved, to the Medical Records Department and no one would see them. We have to make sure they close it and only open it with their badges." On interview with A on 2/14/2017 at 12:50 PM, A stated the back door to the Medical Records Department should be locked.

Based on observation, record review and interview, staff at this facility 1. Failed to complete an update to the history and physical immediately prior to surgery in 1 out of 3 surgical medical records reviewed out of a total of 25 medical records reviewed (Patient #2); 2. Failed to have properly executed informed consents for surgery in 2 of 3 surgical medical records reviewed out of a total of 25 medical records reviewed (Patient #2 and 3); and 3. Failed to follow proper aseptic technique in an effort to minimize risk to patients in 1 of 1 surgical departments and 3 of 3 Patients observed (Surgical Services, Patient #4, 5, and 6) .

Findings include:

Staff at this facility also failed to complete post-anesthesia evaluations in a time-frame for the patient to be sufficiently recovered from anesthesia in 1 out of 2 patients who received general anesthesia out of a total of 3 surgical medical records reviewed (Patient #1). (See C-0322)

This deficiency has the potential to affect all patients receiving surgical services at this facility including the 13 surgical patients on 2/13/2017.

Surgical Medical Records
Patient #2's closed same-day surgical medical record was reviewed on 2/13/2017 at 3:34 PM accompanied by Surgical Services Supervisor E and Surgical Services Director D who confirmed the following findings:

Patient #2 had a surgical repair of the right rotator cuff on 1/19/2017. The update to the History and Physical is dated 1/26/2017, 7 days after Patient #2's surgery. Per interview with Director D at the time of the record review, Director D stated that the update was not done before surgery.

The facility's Medical Staff Rules and Regulations dated January 2016, were reviewed on 2/13/2017 at 4:40 PM. The Rules and Regulations state in part, "An updated examination will be completed by the surgeon and documented, including any changes in the patient's condition within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services."

Patient #2's Operative Report indicates that the Surgeon had a Physician Assistant assist with the surgery. On page 2 of the informed consent for surgery, #7. states, "I also give permission to have ___(name of assistant) conduct significant surgical tasks, such as:..." This area on Patient #2's informed consent is blank and does not identify the Physician Assistant. Per interview with Director D on 2/14/2017 at 7:15 AM, Director D stated D discussed this with Vice President of Patient Care Services A and A stated that the Physician Assistant should have been identified on the consent form.


Patient #3's closed same-day surgical medical record was reviewed on 2/13/2017 at 3:55 PM accompanied by Surgical Services Supervisor E and Surgical Services Director D who confirmed the following findings:

Patient #3 had Cataract surgery on 1/30/2017. The informed consent for surgery does not include a time that the physician or patient signed it.

The facility's policy titled, "Consent for Treatment," dated 1/11/16, was reviewed on 2/14/2017 at 1:15 PM. The policy states in part, "Consents must be signed, dated, and timed in ink.


Aseptic Technique:
An interview was conducted with Director D on 2/14/17 at 8:10 AM. Director D stated the facility follows the recommendations of the Association of peri-Operative Registered Nurses (AORN).

Association of periOperative Registered Nurses, Perioperative Standards and Recommended Practices, 2013 Edition, "Masks should not be worn hanging down from the neck. The filter portion of a surgical mask harbors bacteria collected from the nasopharyngeal airway. A contaminated mask hanging from the neck may cross-contaminate the surgical attire top...Worn surgical masks should be discarded after each procedure and masks should be removed carefully by handling only the ties. After removal, hand hygiene should be performed."

Association of periOperative Registered Nurses Guidelines for Perioperative Practice Recommendation III Published online January 2017; "Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears, and facial hair.
Hair and skin can harbor bacteria that can be dispersed into the environment. The collective body of evidence supports covering the hair and ears while in the semi-restricted or restricted areas. The benefit of covering the head, ears, and hair is the reduction of the patient's exposure to potentially pathogenic microorganisms from the perioperative team member's head, hair, ears, and facial hair. 'III.a. A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn.'"

Review of the policy titled, "Surgical Attire," dated 9/2013 does not address covering ears or when to discard masks.

Review of the policy titled, "Surgical Hand Antisepsis," dated 12/2016 states "A handwash is performed: ...Before and after every patient contact; Before putting gloves on and after removing gloves, or other PPE [personal protective equipment]."

Review of the policy titled, "Infection Prevention Precautions," dated 10/2016 states "Personal Protective Equipment 1. Gloves: b. To be changed between tasks and procedures on the same patient and after contact with potentially infectious material. Hand hygiene must be performed every time gloves are removed."

Observation on admission:
An interview was conducted with Director of Surgical Services D on 2/14/2017 at 7:35 AM. Director D was informed that on 2/13/2017 around 1:00 PM, while waiting to enter for the survey, a hospital employee in steel blue scrubs was observed leaving the hospital through the front doors, cross the road, and smoke a cigarette. Director D stated that no steel blue scrubs (color of scrubs worn by surgical department staff) are allowed outside of the hospital. Director D responded, "Ok, good to know, thank you for telling me."

The following observations were made on 2/14/2017 in the Surgical Suite:
--At 7:30 AM, Registered Nurse Q was observed entering Patient #4's pre-operative room and failed to do hand hygiene on entry to the room. Per interview with Director of Surgical Services D at 10:07 AM on 2/14/22017, Director D stated that staff should be doing hand hygiene on entry to rooms.
--At 7:45 AM Registered Nurse H was observed attaching a piggy back tubing for antibiotics to Patient #5's intravenous line. Nurse H did not cleanse the luer lock connection with alcohol prior to attaching the tubing. Per interview with Director D regarding this finding at 10:07 AM on 2/14/2017, Director D stated that staff should be cleaning that connection.
--At 8:10 AM Surgical Technician I was observed leaving the Operating Room after a surgery ended. Surgical Technician I's ears were exposed, not covered by the surgical bonnet Technician I was wearing. Per interview with Director D right after this observation, Director D stated, "My perception is they only need to if wearing earrings."
--At 8:15 AM Certified Registered Nurse Anesthetist G was observed leaving the Operating Room with a patient to take that patient to the post-anesthesia care unit. Nurse G's mask was laying on G's chest. Per interview with Director D at 10:09 AM regarding this finding, Director D stated, "[G] should have removed the mask after leaving the OR [operating room]."
--At 9:01 AM Circulating Nurse J was observed to remove gloves then started typing on the keyboard of the computer in the operating room without performing hand hygiene. Per interview with Director D regarding this finding at 10:10 AM, Director D stated, "Yup, I saw that too."
--At 9:05 AM Surgical Services Supervisor E was observed assisting Doctor K with prepping Patient #5's left foot with local anesthetic, removed gloves, donned new gloves but did not perform hand hygiene.
--At 9:06 AM Supervisor E was observed to assist with positioning Patient #5 on the surgical table, removed gloves, donned new gloves, did not perform hand hygiene. Supervisor E then proceeded to do the surgical prep on Patient #5's foot with CholorPrep, removed gloves, handled the timer (to time for dry-time of the prep), put hands in pockets of scrubs, handled packaging for electrodes for cautery, applied the cautery electrode to Patient #5's leg, and then left the Operating Room without performing hand hygiene. Per interview with Director D regarding these observations, Director D stated, "Yup, I counted at least 3 [missed opportunities for hand hygiene]."
--Between 8:55 AM and 9:40 AM, during the time Patient #5 was receiving surgery, Certified Registered Nurse Anesthetist G, Doctor K, and Surgical Technician I were all observed to have ears exposed and not covered by their surgical bonnets. Per interview with Nurse G on 2/14/2017 at 12:45 PM regarding observations made in surgery, Nurse G responded, "Oh ya, my ears were showing."


Decontamination:
On 2/14/2017 at 10:25 AM, the decontamination room was observed with Surgical Technician L and Director D. The sink used to clean and soak surgical instruments was observed not to be marked for water capacity. When asked about the ratio of enzymatic cleaner to water for surgical instruments, Surgical Technician L stated, "I use one squirt." Technician L was unable to state how much "one squirt" of enzymatic cleaner amounted to, and stated, "I don't know," when asked how L would know if it was the proper ratio. The directions on the enzymatic cleaner bottle indicate 1/8-1/2 fluid ounce per gallon of water.


The following observations were conducted on 2/14/2017 in the Gastro Intestinal Procedure Area:
--At 10:42 AM, Surgical Technician N was observed preparing the room for Patient #6's Upper Endoscopy. Technician L was observed to remove gloves, not perform hand hygiene, and then put on a clean cover gown over scrubs.
--At 11:06 AM Technician N removed gloves after assisting with a biopsy through the endoscope, did not perform hand hygiene and donned new gloves, .
--At 11:10 AM Technician N removed one glove, handed an item to the Registered Nurse, did not perform hand hygiene and donned a new glove then continued to clean up supplies used during the procedure. Technician L then removed gloves, wheeled the cart containing the bin holding the used endoscope into the hall and donned new gloves without performing hand hygiene.
--At 11:14 AM, Technician N finished cleaning the endoscope, removed gloves, did not do hand hygiene, donned new gloves. Then Technician removed gloves again, left the "dirty" side of decontamination and went to the clean side, did not perform hand hygiene and donned new gloves. Technician N then removed gloves, left the "clean" side for supplies for the Medivator (automatic scope cleaner), returned to the "clean" side donned new gloves but did not perform hand hygiene.
Per interview with Director D at 11:20 AM regarding these observations and not observing hand hygiene practices between glove changes, Director D stated, "No, I did not either."

Based on record review and interview, staff at this facility failed to conduct a post-anesthesia evaluation in a time-frame that would allow the patient to be sufficiently recovered from anesthesia in 1 out of 2 patients receiving general anesthesia out of a total of 3 surgical records reviewed (Patient #1). Failure to complete post-anesthesia evaluations in a time-frame that patient's are sufficiently recovered from anesthesia has the potential to affect all surgical patients at this facility, including the 13 patients on the day of the survey.

Findings include:

Patient #1's closed same-day surgical record was reviewed on 2/13/2017 at 2:59 PM accompanied by Surgical Services Supervisor E and Surgical Services Director D who confirmed the following finding:

On 1/17/2017 Patient #1 had general anesthesia for a laparoscopic cholecystectomy (gallbladder removal). Patient #1 entered the post-anesthesia care unit at 8:25 AM and left phase I at 8:50 AM for phase II (movement from phase I to phase II is determined by the patient's condition/recovery from the anesthesia). The post-anesthesia evaluation was conducted at 8:28 AM, 3 minutes after Patient #1 arrived in phase I post-anesthesia care.

Per interview with Supervisor E at the time of the record review regarding the time of the post-anesthesia evaluation and if a patient would be sufficiently recovered from general anesthesia in 3 minutes, Supervisor E stated, "Post-anesthesia evals [evaluations] are usually done in short stay [phase II].

The facility's policy titled, "Pre & Post Anesthesia," dated 12/2008, was reviewed on 2/14/2017 at 7:10 AM. The policy states in part, "The patient's post-anesthesia status will be assessed by the anesthetist, who administered the anesthesia, and will be documented on the Pre-and Post-Anesthesia Record prior to discharge, not less than 30 minutes after case is completed (exception: patients that do not require Stage 1 recovery (PACU) [post-anesthesia care unit] may be seen sooner based on the level of anesthesia provided).

Per interview with Director of Anesthesia Services, Certified Registered Nurse Anesthetist G, on 2/14/2017 at 12:45 PM regarding when post-anesthesia evaluations are completed, Certified Registered Nurse Anesthetist G stated, "No sooner than 30 minutes used to be the policy but we kind of decided that if the patient is okay before that it's ok to do it sooner. That eval was probably a little fast though [referring to Patient #1's post-anesthesia evaluation completed 3 minutes after arriving in phase I]."

Based on observation, interview and record review, the facility failed to monitor and collect data on 1 of 1 of their hand hygiene programs and by failing to include 5 of 23 contracted services (Burnett Co ER Mental Health Crisis, Eye Tissue Donor, Pacemaker Interrogation Serv Medtronic, Mental Health Services Emergency Polk Co, and Organ Tissue Procurement) in their Performance Improvement Plan.

Findings include:

Review of policy "Hand Hygiene" dated 7/2016 revealed the hospital uses the World Health Organization as their hand hygiene standard of practice.

World Health Organization (WHO) states "survellance contributes to a 25-57% reduction in HAIs [healthcare acquired infections]. "WHO's 5 Moments for Hand Hygiene" encourages direct observation of hand hygiene compliance be performed.

During patient care observation on 2/14/17 between 7:30 AM and 11:14 AM 11 of 11 hand hygiene observations revealed missed hand hygiene opportunities (C0320).

During interview with Quality Director B on 2/14/2017 at 8:30 AM, Quality Director B stated, "We use World Health Organizations 5 Moments for Hand Hygiene." When asked if the facility did spot checks for hand hygiene on their clinical staff, Quality Director B said, "yes, but I don't have reports for those. It is not something that is in our quality data at this time."

An interview was conducted with Obstetrics Director WW on 2/14/2017 at 1:45 PM. WW states that staff observations for hand hygiene practices are not done, "I haven't done that for a while."

Review of "Performance Improvement Plan" (PIC) dated 2015-2016 stated "each department is expected to do at least two process improvements per year... "an annual report will be presented to the Performance Improvement Committee as described below: Department Annual Reporting Schedule to PIC". Contracted services are not included in this schedule.

During record review of departmental performance improvement plans on 2/15/17 at 1:35 PM with Director of Quality Services B, Director B stated that there is no set reporting schedule for contracted services but that most of the contracted services are included in the departmental annual review. When asked which contracted services were involved in their performance improvement plan, the list of their 23 contracted services was produced. B highlighted five services stating "these services are not included".

Based on record review and interview, facility staff failed to define and conduct timely referrals to the Organ Procurement Organization for 3 of 3 patient deaths reviewed (Patient #10, Patient #11, Patient #12).

Findings include:

Facility policy "Organ/Tissue/Eye Donations" dated 11/2016, states: "Contact [Organ Procurement Organization] to determine if patient is a potential organ or tissue donor."

Per medical record review on 2/14/2017 at 4:00 PM, Patient #10 was pronounced dead at the facility on 1/9/2017 at 9:50 AM. Patient #10's medical record contained a checklist for deceased patients documenting that the organ procurement organization was notified of the patient's death, along with a referral number. The time of the notification is not documented.

Per medical record review on 2/14/2017 at 4:10 PM, Patient #11 was pronounced dead at the facility on 9/9/2016 at 8:04 AM. Patient #11's medical record contained a checklist for deceased patients documenting that the organ procurement organization was notified of the patient's death, along with a referral number. The time of the notification is not documented.

Per medical record review on 2/14/2017 at 4:20 PM, Patient #12 was pronounced dead at the facility on 1/13/2017 at 10:30 AM. Patient #12's medical record contained a checklist for deceased patients documenting that the organ procurement organization was notified of the patient's death, along with a referral number. The time of the notification is not documented.

During an interview on 2/14/2017 at 3:30 PM, Emergency Department Director Z stated staff is expected to call the organ procurement organization "right away" for deaths that occur in the facility. Director of Nursing AA stated during interview on 2/14/2017 at 4:20 PM, "the time the OPO [Organ Procurement Organization] was called is not documented, we will have to change our form."

Based on record review and interview, facility staff failed to provide activities per policy for 1 of 2 swing bed patients reviewed (Patient #26).

Findings include:

Facility policy "Swing Bed Activity Program" dated 8/2016 states in part: "A. The Occupational Therapist (OTR) is responsible for evaluating and providing recommendations for activities suited to meet the needs of the patient. ...4. The RN or Certified Nursing Assistant will implement activities as recommended by the OTR...The RN or Nursing Assistant will refer to the activities eval for activities that are appropriate for the patient. The patients will be encouraged to participate, but not forced. Goals for each individual patient will be outlined on the daily activity records by the Swing Bed Activity Coordinator."

Patient #26 was admitted as a Swing Bed patient on 9/2/2016 for rehabilitation services. The OTR Wing Bed Activity Assessment, dated 9/2/2016, documents "Activities to offer the patient during their stay: Magazines, Movies, Music, Out of room activity, getting her hair done...Goals: 1) The patient will participate in 1-2 activities per day to decrease focus on symptoms and encourage increased strength, activity tolerance, and progress towards returning home."

Patient #26 was discharged from the facility on 9/7/2016. There is no documentation of activities offered, or activities in which Patient #26 participated or declined. Director of Nursing AA stated at the time of the medical record review on 2/15/2017 at 11:00 AM that staff are "supposed to be documenting the activities" in the medical record.