HospitalInspections.org

Based on hospital policies and procedures (p/p), medical record (MR) review and staff interview it was determined the hospital failed to ensure ED (Emergency Department) staff followed hospital p/p's and provided a safe environment of care in 1 of 3 suicidal patient record reviews. This did affect MR # 11 and had the potential to affect all at risk behavioral health patients who present to the hospital ED.

Findings include:

Hospital Policy and Procedure
Scope: Emergency Room
Title: Protocol-Ingestion Error, Possible Overdose (OD), Possible Attempted Suicide
Reviewed/Revision Date: 2/2021

Protocol Procedure:

The patient will be triaged; orders will be implemented according to the protocol...below.
...Complaints...Possible OD
Procedures
Suicidal Precautions, if indicated.
Place in Room ASAP (as soon as possible); Room 3 if available, remove any potential harmful devices/furniture.
Notify Poison Control and document...
...Keep door open for eyesight monitoring, or place sitter if available...

Hospital Policy & Procedure Number: 02.33.04
Scope: Senior Care Center
Title: Suicide Precautions
Reviewed/Revision Date: 01/2020

...The purpose of this policy is to provide guidelines for placing a patient on suicide precautions.

Policy

...If a patient is deemed a risk for suicide, they will be placed on suicide precautions

I. Screening:
II. Suicide Precaution Level:
Level I-Low risk
1. Assess and monitor for changes in mental status and behavior
2. Supportive interventions...
3. Place on Level I patient observations
4. The Special Precautions Patient Observation Record should...indicate...patient is on suicide precautions
...
Level II-Moderate Risk
1. Level 1 precautions and:
2. Place on Level II patient observation (line of sight-LOS)
...4. Patient will be assigned to a room closer to the nursing station...

1. MR # 11 presented to the ED 8/16/21 at 12:33 PM with diagnoses of Acute Psychotic Break, Depression, and Psychosis.

MR review revealed MR #11 was delusional and hallucinating, symptoms in the ED were of moderate severity with a suicidal plan for drinking bleach and cutting self per the ED physician documentation.

Record review revealed MR # 11 was admitted to ED Room 3. There was no documentation potential harmful devices/furniture was removed from the ED treatment room, no documentation the door was open for eyesight monitoring and no documentation the patient was on continuous observation/monitoring.

MR review revealed the patient was observed in the treatment room awake/alert/cooperative at 1:07 PM, 1:22 PM, 1:37 PM, 1:52 PM, 2:07 PM, 2:22 PM, 2:37 PM, and 2:52 PM.

Further record review revealed at 3:40 PM, which was 48 minutes after the last observation was documented, MR # 11 was transferred via emergency medical transport to a specialty hospital.

On 11/16/21 at 3:10 PM, the surveyor requested the ED p/p's for care of an at-risk behavioral health patient. The Protocol-Ingestion Error, Possible Overdose (OD), Possible Attempted Suicide and Senior Care Center Suicide Precautions policy were provided.

In an interview on 11/18/21 at 11:30 AM Employee Identifier (EI) # 1, Chief Nursing Officer verified expectations were that staff monitor the suicidal patient every 15 minutes and document the observation. EI # 1 confirmed staff failed to document all supportive interventions including removal of any potential harmful devices/furniture, patient monitoring every 15 minutes and there was no documentation MR # 11 was placed on LOS.

Based on review of the hospital Quality Assurance and Performance Improvement (QAPI) Program and Plan, hospital policy and procedure (p/p) and interviews, it was determined the hospital failed to assure all hospital services participated in hospital QAPI program. This affected hospital services and contracted services and had the potential to affect all patients served.

Findings include:

Hospital Policy and Procedure
Scope: Medical Center Barbour Housewide
Title: QAPI
Reviewed/Revision Date: 4/21

Purpose...to provide a systematic...organized mechanism to promote safe and quality care and services...Recommendations to resolve problems and opportunities to improve the quality and safety of patient care and services. Assessment of effectiveness of actions taken by initiation or ongoing monitoring. Emphasis on education...

Scope of Activities and Services:

The scope of the Quality Improvement Program (QIP) covers measurement and assessment of activities of the Medical Staff, Nursing and ancillary or support services. All clinical and non-clinical departments are included...

Improve:

Opportunities for improvement are identified by continuously assessing and measuring the services and processes provided...actions may include...adjusting staffing...Adding...revising p/p...Modifying orientation procedures.

On 11/18/21 at 11:40 AM an interview with Employee Identifier (EI) # 3 Quality Director /Risk Manager was conducted and the hospital QAPI data was reviewed. There was no information/data related to contracted services for outpatient infusion services and inpatient dialysis services included in the hospital QAPI program.

Further review of the hospital QAPI program revealed no data for rehabilitation services which included inpatient physical therapy services. There was no quality data for physical environment services which included contracted services for preventative maintenance of patient medical equipment.

EI # 3 reported the rehabilitation unit was not considered a department and was "under nursing services". EI # 3 confirmed no quality data had been collected for rehabilitation services.

In an interview on 11/18/21 at 4:30 PM, EI # 3 confirmed all hospital services had not collected and reported quality data for the 2021 QAPI plan.

Based on staff interviews, care observations, the Alabama Board of Nursing Chapter 610-X-6 Standards of Nursing Practice, the hospital and Sanderling Renal Services (contracted services) policies and procedures (p/p), medical record (MR) reviews, the CCHT (Certified Clinical Hemodialysis Technician) job description and clinical competency checklist documentation, it was determined the hospital failed to ensure:

1. Only licensed, trained RN's (Registered Nurse) provided care to the CVC (central venous catheter) according to hospital policy which included CVC exit care, preparation of the external access and initiation of dialysis treatment using a CVC.

2. Staff obtained physician orders and provided wound care according to physician orders.

3. Staff performed and documented wound assessments including wound measurements per hospital p/p

4. Staff performed and documented foley catheter care daily per hospital policy.

This affected MR # 1, 1 of 1 record review with a CVC, MR # 4, 1 of 3 records reviewed with wounds and 1 of 1 record review with a foley catheter. This had the potential to negatively affect all patient served by this hospital.

Findings include:

Alabama Board of Nursing Chapter 610-X-6 Standards of Nursing Practice

...610-X-6-.11 Assignment, Delegation and Supervision

(1) The RN shall be accountable and responsible for the assignment of nursing activities and tasks to other health care workers based on, but not limited to:
(a) Knowledge, skills, and experience.
(b) Complexity of assigned tasks.
(c) Health status of the patient.
(2) Assignments may not exceed the scope of an individual licensed nurse's scope of practice, including, but
not limited to:
(a) Educational preparation, initial and continued.
(b) License status.
(c) State and federal statutes and regulations.
(d) State and national standards appropriate to the type of practice.
(e) Nursing experience.
(f) Demonstrated competence.
(g) Consideration for patient safety.
(h) Knowledge, skills, and ability to manage risks and potential complications.
(3) The licensed nurse shall delegate only after considering various factors, including but not limited to:
(a) Knowledge, skills, and experience of the person receiving the delegation.
(b) Complexity of the delegated tasks.
(c) Health status of the patient.
(4) Tasks delegated to unlicensed assistive personnel may not include tasks that require:
(a) The exercise of independent nursing judgment or intervention.
(b) Invasive or sterile procedures...
(5) Supervision shall be provided to individuals to whom nursing functions or responsibilities are delegated or functions or responsibilities are delegated or assigned.

Sanderling Renal Services Policy/Procedure
Date: 03-21-12
Preparation of the External Access for Treatment Initiation
Scope: All licensed personnel. Licensed personnel to delegate duties as allowed by state law.

Supplies:
PPE (personnel protective equipment)
Clean barrier ...
Two empty 20 cc (cubic centimeter) or 12 cc syringes
Two 10 cc or 12 cc syringes filled with a minimum of 10 cc saline
One syringe filled with prescribed heparin bolus ...
Two facemasks-one for patient, one for staff member
Two hemosafe connectors

Note:
1. The catheter exit site should be examined prior to preparation of the access for treatment initiation ...
2. Do not inject anything into the catheter if you have...doubts about its patency...
3. The clamps on the catheter must be clamped shut when disconnecting or connecting anything to them...

Procedure:
Don PPE, including facemask
4. Have patient wear facemask ...Wearing a mask prevents the spread of bacteria, which can harbor in the nares...
7. Remove tape from caps and catheter clamps.
8. Aseptically attach an empty 10 cc or 12 cc syringes to the first catheter lumen end.
9. Unclamp the catheter lumen and withdraw 3-5 cc heparinized blood, re-clamp and remove syringe
10. Aseptically attach a 10 cc...syringe
11. Unclamp the catheter lumen; flush the lumen, re-clamp, leave syringe attached.
12. Repeat steps...with second lumen
13. If prescribed, aseptically attach heparin bolus....
16. Initiate dialysis

Sanderling Renal Services Policy/Procedure
3-12-12: CVC Dressing Change
Scope: Licensed Staff or Dialysis Technicians as allowed by State regulations.

Purpose: To provide proper instructions for catheter dressing change...to prevent infection at the insertion site of catheters.

Policy:
1. The patient and staff must wear a mask for catheter dressing changes.
2. The dressing will be changed each treatment and the assessment of the exit site will be documented regardless if the catheter is actively used.
4. Chloraprep is...preferred cleaning agent for catheter site care. If patient is allergic to Chloraprep, obtain an order from the nephrologist for alternate cleaning agent...

Sanderling Renal Services Job Description
Job Title: Patient Care Technician-Certified
Reports To: Tele-Nurse

Summary
To initiate, monitor and discontinue hemodialysis treatments as assigned by the RN...and practice...p/p as set forth...

Monitor patient/equipment parameters during dialysis...

Hospital Policy and Procedure
Scope: Nursing Services
Title: Pressure Ulcer (PU) Treatment/Alteration of Skin integrity
Reviewed/Revision Date: 5/17

Purpose ...establish guidelines for the assessment and treatment of pressure related wounds ...

Policy

Patients will be assessed on admission ...and daily by licensed nurse, for wounds...and document in the patient's MR at a minimum...
The stage of the wound following the National Pressure Ulcers Advisory Panel Staging System; Location; Describe tissue type and/or wound bed ...Size including length, width, and depth ...Describe...exudate/drainage (odor, color, type and/or character); Describe...surrounding tissue (intact, erythema, warmth...)

Procedure:
An RN will perform assessment of the patient on admission to inspect for breaks in the integrity of the skin. A licensed nurse will reassess daily. Upon discovering a pressure related wound, the anatomical man will be used to document any alteration of skin integrity. Any intervention will be implemented...
Care guidelines:
The nurse may treat...without a physician's order: Skin Tears, Stage 1...Stage 2 PU...
The nurse must obtain a physician's order to treat...Stage II..IV, Abrasions with cellulitis...

Documentation: All assessments and intervention will be documented in the patient's MR...

Hospital Policy Number: 2.102
Scope: Housewide
Title: Urinary Catherization
Reviewed/Revision Date: 5/17

Procedure:

Catheter Care and Maintenance

B. Meatal Care
The meatal area should be cleansed with soap and water at least once daily, and as needed if area becomes soiled with fecal matter, or other contaminants...

1. On 11/17/21 from 9:30 AM to 11:55 AM, observations of care for MR # 1 for dialysis treatment and staff interviews with EI (Employee Identifier) # 6, CCHT and EI # 4, ICU (intensive care unit) RN were conducted.

During preparation of the NxStage dialysis machine, the surveyor asked EI # 6 what type dialysis access the patient had? EI # 6 reported MR # 1 has a CVC. The surveyor asked EI # 6 what staff perform CVC care for MR # 1? EI # 6 reported "the nurses do."

At 10:20 AM in ICU 5, the surveyor observed EI # 6, CCHT disinfect the CVC hub with alcohol, unclamp the catheter lumens, and attach a 10 cc syringe, aspirate blood and discard, then attach a 10 cc prefilled NS syringe and flush the CVC ports with NS, leaving the syringe attached to the CVC ports and repeated those steps a second time. MR # 1 was not wearing a facemask during preparation of the external access per Sanderling policy.

EI # 4, RN, then administered IV heparin into a dialyzer port, then removed the 2 syringes from the CVC and attached the dialysis lines to the CVC. Next, EI # 6, CCHT started the dialysis treatment using a NxStage hemodialysis machine.

In an interview on 11/17/21 at 11:06 AM, the surveyor asked EI # 4 who performs CVC site care for MR # 1? EI # 4 responded "most of the time EI # 6 (the CCHT) does." The surveyor questioned EI # 6 once again in the presence of EI # 4 about CVC care performance? This time EI # 6 responded, "I was doing it (CVC care/dressing changes) at first, then they changed that". EI # 6 was asked to clarify what that meant and when he/she stopped performing CVC care? EI # 6 reported last night the nurse did it (CVC care) that was when I was told by EI # 1, the CNO (Chief Nursing (Chief Nursing Officer), not to perform CVC care anymore.

The surveyor asked EI # 6 to explain how he/she performed CVC care and where this was documented? EI # 6 reported he/she removes the old dressing, cleans the CVC site with an alcohol swab stick (from the ICU supply room) and placed a tegraderm dressing over the exit site each treatment. EI # 6 reported he/she did not document in the MR the CVC care.

Review of the Sanderling Renal Services Clinical Competency Checklist-Dialysis Staff Job Description dated 2/12/21 CCHT for EI # 6 revealed the following:
Clinical Assessment
...Fistula...needle placement, and prevention of complications=Competency Met
Graft...needle placement, and prevention of complications=Competency Met
Initiation and Termination of Dialysis
...Inspecting Access for patency and, after cannulation is performed and heparin administered, initiating treatment...= Competency Met
...Inspecting, Cleaning and Dressing Access according to facility=Competency Met
Access Cannulation
Inspecting the access for patency...Preparing the Skin...Placing Needles Correctly...Replacing Needles...Knowing when to call for Assistance...=Competency Met...

EI # 6's job description and competency failed to include CVC care, preparation of an external access for treatment initiation via a CVC including blood aspiration and NS flush.

In an interview on 11/17/21 at 3:40 PM, EI # 1 and EI # 2, Infection Preventionist/Assistant CNO confirmed hospital policy allowed only RN to perform CVC care. EI # 1 was asked if the state of Alabama allowed non licensed personnel to perform external access preparation and CVC care? EI # 1 reported the dialysis contract service group verified EI # 6's competency. The hospital failed to ensure only licensed trained nurse staff provided CVC site care, CVC dressing change and preparation of the external access for treatment initiation.

2. MR # 1 was admitted to the hospital on 10/27/21 with diagnosis including Pneumonia.

Record review revealed an ICU Shift Assessment dated 10/27/21 at 7:25 PM which revealed the presence of a left chest permcath.

Record review for MR # 1's dialysis treatment dated 11/15/21 failed to reveal documentation that CVC care every dialysis treatment was completed by licensed staff per the hospital and Sanderling Renal Service p/p.

Review of the Nursing Note dated 11/17/21 at 6:00 AM completed by the RN revealed "Dressing to L chest dialysis catheter changed at this time. Bio patch applied to site and area cleansed with sterile technique." There was no site observation (s), and the type cleansing solution used to clean the CVC site and the type dressing applied by the RN were not documented.

In an interview conducted on 11/18/21 at 11:13 AM, EI # 1, CNO confirmed the RN failed to perform and document CVC care per hospital policy and procedure.

3. MR # 4 was admitted to the hospital ICU unit on 10/1/21 at 5:00 PM with diagnosis including Unspecified Combined Systolic (congestive) and diastolic failure and expired at the hospital on 10/5/21 at 3:27 AM.

Review of the 10/1/21 4:37 PM Admission History and Physical revealed the presence of a right (R) breast wound and a foley catheter with Zosyn (antibiotic) ordered for treatment for a urinary tract infection.

Review of the 10/1/21 5:00 PM ICU Nurse Admission Assessment revealed the presence of a coccyx pressure ulcer (PU) (not staged) open, red serous drainage (no amount, no odor), undefined wound edges, and covered with Duoderm (hydrocolloid dressing). There was a R breast abscess, scab hard to touch, red 2/3 breast involvement, eschar, wound edges edematous, firm, reddened with no drainage. Also, there was an US (unstageable) R foot PU, red tissue, no exudate, defined edges.

There were no wound measurements documented on 10/1/21 for the coccyx PU, R breast wound and R foot US PU.

Review of nursing orders dated 10/1/21 at 5:44 PM revealed the following: cleanse R breast with ns (normal saline) apply Santyl and 4x4 (gauze) daily. There were no wound care orders for the unstaged coccyx PU and no physician order for the Duoderm dressing applied to the coccyx PU at 5:00 PM.

Further record revealed no documentation daily Santyl dressing changes were performed the R breast wound on 10/1/21.

Review of the 10/2/21 nurse documentation revealed no wound assessments were documented and there were no wound measurements documented for the coccyx and R foot PU's and the R breast wound on 10/2/21.

Further record review revealed no documentation foley catheter care was performed on 10/2/21.

Review of the 10/3/21 nurse documentation failed to include R breast and coccyx wound measurements. Also, there was no wound assessment and no wound measurements documented for R Foot PU on 10/3/21.

MR review revealed no documentation the nurse assessed the wounds and obtained wound measurements for the R foot PU, coccyx PU and R breast wound on 10/4/21. There was no documentation daily Santyl dressing changes were performed to the R breast wound on 10/4/21.

There was no documentation foley catheter care was performed on 10/4/21.

In an interview on 11/18/21 at 2:11 PM, EI # 2, Infection Preventionist/Assistant Chief Nursing Officer confirmed nursing staff failed to follow physician wound care orders for daily Santyl dressings, obtain an order for the Duoderm dressing, perform and document wound assessments including wound measurements. In addition, staff failed to perform and document daily foley catheter care.

Based on review of facility policy and procedures, personnel files, and interview with human resource staff it was determined the facility failed to ensure their staff were deemed competent as evidence by:

1. Completion of Orientation Skills Checklist for Licensed Practical Nurse (LPN) and Mental Health Technician (MHT) hired in 2021.

2. Completed annual Competency Skills Checklist for 2 critical care Registered Nurse (RN)'s hired longer than 5 years.

3. Completed annual Competency Skills Checklist for MHT hired longer than 3 years.

This affected 1 Intensive Care Unit RN and 1 Emergency Department RN, 2 of 2 MHT's and 1 of 1 LPN personnel file reviewed. This deficient practice had the ability to affect all patients served by this facility.

Findings include:

Hospital Policy: Competency
Policy Number: 01.01.28
Reviewed/Revision Date: 6/13

Purpose: It is necessary to identify specific tasks needed to perform job functions and the required qualifications expected of the staff performing those job functions... Competency is defined as the demonstration of knowledge, interpersonal relationship and technical and critical thinking skills in the delivery of patient care.

Competency requirements must be updated on an on-going basis since work processes may change a result of quality assessment and improvement; new developments in health care management....and changing patient care needs...

Policy: It is the policy of Medical Center Barbour to provide a realistic assessment of staff members to be competent, as appropriate to his/her responsibilities...

Procedure:...

5. All clinical staff members must demonstrate competency prior to independently performing a skill/task/function. Competency requirements shall be completed prior to the end of orientation period and annually thereafter...

11. Documentation of all annual requirements, the Department Head should retain a copy of the completed Verification of Completion of Annual Requirements...

1. On 11/17/21 at 11:14 AM the surveyor observed Employee Identifier (EI) # 25, LPN draw up and administer insulin to a patient on the Senior Care Unit.

On 11/18/21, a review of EI # 25's personnel file was conducted which revealed the date of hire (DOH) was 10/7/21 and a signed job description for a MHT.

Further review of EI # 25's personnel file revealed no Initial LPN Orientation/ Competency Checklist had been completed.

In an interview conducted on 11/18/21 at 3:30 PM, EI # 46, Human Resource Manager, stated, "She was a MHT and then became a LPN, I can't find the Initial LPN Orientation/ Competency Checklist."

2. Review of EI # 4, RN, ICU (Intensive Care Unit), DOH 3/8/11 personnel filed revealed the signed job description dated 3/8/2011. The last completed Annual Competency Checklist documentation was dated 11/5/16.

In an interview conducted on 11/18/21 at 3:30 PM, EI # 46, confirmed the facility failed to provide documentation of annual competency since 2016 per policy.

3. Review of EI # 5, an Emergency Department (ED) RN, personnel file revealed the date of hire was 1/11/16 and the last Annual Competency Checklist documentation was dated 5/13/16.

In an interview conducted on 11/18/21 at 3:30 PM, EI # 46 confirmed the facility failed to provide documentation of annual competency since 2016 per hospital policy.

4. A review of EI # 24, MHT, personnel file revealed the DOH was 10/28/21.

Further review of personnel file revealed the General Orientation Competency and Equipment Checklist for the Mental Health Technician revealed the Director's Initials and a line was drawn from top to bottom of page 1. The space for the date the Director deemed the employee competent for the skill(s) was left blank. On page 2 of the Competency and Equipment Checklist, the Director failed document his/her initials or date the employee was deemed competent.

In an interview conducted on 11/18/21 at 3:30 PM, EI # 46 confirmed the Director failed to complete General Orientation Competency and follow policy.

5. A review of the EI # 23, MHT, personnel file revealed the DOH was 8/12/19 and there was no documentation an annual Competency Checklist had been completed for 2020 or 2021.

In an interview conducted on 11/18/21 at 3:30 PM, EI # 46 confirmed the facility failed to provide documentation of annual employee competencies.

Based on review of hospital policy and procedure, medication pass observations in the Senior Care Unit (SCU) and interviews with hospital staff, it was determined the nurse failed to prepare and administer medications according to the hospital policies.

This affected Medical Record (MR) # 19 and an unsampled patient during 2 of 2 medication pass observations in the SCU. These deficient practices also have the potential to negatively affect all patients admitted to the SCU.

Findings include:

Hospital Policy: Medication Administration and Waste.
Reviewed/Revision Dates: 9/20

Purpose:
Safely and accurately administer medications for treating injuries and disease as prescribed by the physician...
Procedure:
Electronic Medication Administration Record (eMAR)
- Check the eMAR for medication due; read complete order carefully.
- Compare eMAR to the patient's profile in Pyxis to dispense appropriate medications...
- Determine the amount and route to be given from eMAR (read three (3) times)...
- Prepare medication as indicated on the eMAR in the prescribed amount and route.
- Follow the seven "R's" of medication administration:
Right patient
Right medication
Right dose
Right route
Right time
Right reason
Right documentation

- Greet and identify the patient by asking the patient to tell you his/her name/date of birth and compare the response to the identification bracelet...
- The medication should be scanned for accuracy to confirm the right drug and dose is being administered to the patient. Explain and administer the medication...

Documentation
- Electronic documentation of medication administration through Patient Care eMAR in the HMS charting system.

1. During SCU medicaton pass observations on 11/17/21 from 11:14 AM to 2:00 PM the surveyor observed the following:

At 11:14 AM, Employee Identifier (EI) # 25, Licensed Practical Nurse (LPN) entered the medication room to prepare medication for PI # 19. EI # 25 signed onto the computer checked the eMAR. EI # 25 selected a cup from a stack of cups on medication preparation counter for MR # 19. (Each of the plastic cups had a patient label on it.)

EI # 25 then obtained a bottle of Humalog insulin from the medication refrigerator, cleaned the septum with alcohol and removed 2 units of insulin using an insulin syringe. EI # 25 scanned the insulin bottle and the patient label on the plastic cup for PI # 19. Then EI # 25 went to the computer and documented on the eMAR the insulin was administered in upper right arm, applied gloves, and exited the medication room.

EI # 25 proceeded to the dining room and asked PI # 19 if his/her name was XXXX and administered the 2 units of insulin in the upper right arm. EI # 25 returned to medication room discarded the dirty insulin syringe in sharps container, removed gloves and exited the medication room.

EI # 25 failed to follow hospital policy and procedure for medication administration by not scanning MR # 19's arm band identification before administering insulin. EI # 25 also documented the medication was given before actually administering the insulin.

At 1:35 PM the surveyor observed the medication administration for an unsampled patient in the SCU. EI # 25 entered the medication room, signed onto the computer, found plastic cup that contained patient label for unsampled patient. EI # 25 then removed 2 Hydralazine 50 mg tablets from the Pyxis machine, scanned the patient label on the plastic cup, went to eMAR and documented medication was given to patient.

EI # 25 exited the medication room and went to locate patient. After administering the medication, EI # 25 returned to the medication room and the surveyor asked EI # 25, "Why do you scan the patient label on the plastic cups?" EI # 25 replied, "Sometimes they lose their arm bands."

In an interview conducted on 11/17/21 at 2:00 PM, EI # 22, RN confirmed the staff failed identify patient and administer medications to patients per hospital policy.

Based on review of the MHT (Mental Health Technician) documentation, hospital policy and procedure and staff interviews, it was determined the hospital failed to ensure staff performed and documented patient observations and monitoring every 15 minutes. This affected 9 of 9 current Senior Care Units (SCU) patients and had the potential to negatively affect all patients admitted to the SCU.

Findings include:

Facility Policy: Patient 15 Minute Observation
Policy Number: 02.33.02
Reviewed/Revision Date: 2/21

Purpose:
To provide behavioral health patients with quality care, treatment and services by ensuring they are monitored regularly.

Policy
Patients will be monitored and observed on a regular timeframe to ensure they are medically stable, safe and receiving appropriate treatment.

Procedure
I. Patients will be monitored and observed Face to Face on 15 minute timeframe...

A. Face to Face:
1. Staff will make random rounds starting and stopping in different areas each time...

3. Staff will make face to face contact on each encounter-observing patient's:
a. Location,
b. Behavior,
c. Level of alertness....

5. All documentation will be completed as the procedure/rounding is being performed.

Advanced documentation is falsification of records and is illegal. Retroactive documentation is also not allowed.

1. On 11/16/21 at 1:20 PM the surveyor reviewed the Special Observation List (Patient 15 minute observation) documentation.

Review of the Special Observation List dated 11/16/21 revealed no time entry documentation from 12:00 PM to 1:15 PM for 5 of 5 patients completed by Employee Identifier (EI) # 23, MHT.

Review of the Special Observation List documentation dated 11/16/21 revealed no time entry documentation from 11:45 AM to 1:15 PM for 4 of 4 patients completed by EI # 45, MHT.

In an interview conducted on 11/16/21 at 1:20 PM, EI # 22, Registered Nurse, confirmed the staff failed to complete and document every 15 minute observations per hospital policy.

Based on observations, hospital policy and procedure, and staff interviews the hospital failed to assure all expired medications and supplies were not available for patient use. In addition, the hospital failed to assure multi-use medication containers were dated by staff when opened for use. This had the potential to affect all patients served by the hospital.

Findings include:

Hospital Policy and Procedure
Title: Expiration Dates
Reviewed/Revised: 9/2020

Policy: Expired drugs and devices shall not be made available for patient care...

Procedure:

Expiration dates for prepackaged products:
Expiration dates shall be assigned to all prepackaged products.
Expiration dates shall be assigned in accordance with...laws and regulations of this state and/or national standards...
Expiration of multi-dose vials:
Multi-dose vials will be labeled when opened-after 28 days the multi-dose discarded ...

1. During the initial tour and care observations in the ED (Emergency Department) on 11/16/21 at 11:10 AM, the ED Director, Employee Identifier (EI) # 39 was present. The surveyor observed in the hallway an emergency cart with two 25 % Dextrose pediatric injectables with an expiration date of 10/21. There were 8 laboratory (lab) specimen tubes and all specimen tubes in the emergency cart which included blue top tubes expired 5/16/2020, purple top tubes expired 6/15/21, red top tubes expired 5/15/2020, and green top tubes expired 6/13/2020.

The surveyor observed in ED Room 6 in the emergency cart all 8 lab specimen tubes had expired which included blue top tubes expired 11/13/19, purple top tubes expired 6/15/21, red top tubes expired 5/16/21 and green top tubes expired 6/13/2020.

In an interview on 11/16/21 at 11:15 AM, EI # 39 reported Pharmacy was responsible for replacing expired/outdated medications and ED nurse staff are responsible for monitoring the emergency carts and ensuring all patient supplies for use were not expired. EI # 39 confirmed the lab tubes and pediatric Dextrose injectables had expired. EI # 39 removed the expired medications and supplies from the emergency carts.



32470

2. An observation was conducted on 11/16/21 at 9:30 AM in the Intensive Care Unit (ICU) to observe care and review of medications and supplies.

The ICU emergency cart was opened and medications and supplies were checked. The following medications and supplies were found to be expired:

1- D 50 (Dextrose) prefilled syringe 50 ml (milliliters) expired October 21/2021.
2- packages of Curity cotton tipped swabs expired August 2021
2- Midline cotton tipped swabs expired February 8, 2020
1- 5.0 mm (millimeter) ET (Endotracheal Tube) expired November 15/2021
2- 6.0 mm ET tube expired January 2021

An interview was conducted on 11/16/21 at 10:15 AM with EI # 12, ICU Registered Nurse (RN), who agreed the cotton tipped swabs, the D 50 and ET tubes had expired and were available for patient use. EI #12 removed the expired medication from the emergency cart.



41623

6. A tour of the surgical services area was conducted 11/16/21 at 10:45 AM with EI # 16, RN, Director of Surgery. The emergency cart was unlocked by the surveyor and EI # 16 and the following outdated supplies were observed:

1. Select Silicone Foley Catheter, expired 10/31/21.
2. Central Venous Catheter, expired 7/31/21.

In an interview on 11/16/21 at 11:45 AM, EI # 16 confirmed the supplies in the cart were beyond the expiration date and were available for patient use.

7. A tour of the Laboratory Department was conducted on 11/17/21 at 3:15 PM with EI # 42, Medical Technologist. The following outdated supplies were observed:

1. Assayed Chemical Control vials x 2, opened, no label indicating the date the vials were opened.
2. Immunoassay Control vials x 2, opened, no label indicating the date the vials were opened.
3. Urinalysis Control vial, opened, no label indicating the date the vial was opened.
4. Protocol Deionized Water with a label indicating the container was opened on 9/2/21.

In an interview conducted on 11/17/21 at 3:30 PM, EI # 43, Laboratory Director, confirmed the supplies had not been labeled with an expiration date after opening and had not been discarded per policy.




34107

3. During a tour of the Senior Care Unit (SCU) conducted on 11/16/21 from 9:20 AM to 12:30 PM the surveyor observed the following:

At 10:40 AM in the medication room in a plastic basket labeled "Wound Care", the following observations were made:

Open packages of sterile gauze and 3 rolls of used (dirty) tape.
1 75% full box of skin prep packages, expiration date 7/2020.
2 packages of Aquacell wound dressings, expiration date 1/1/2020.
8 packages of hydrolloid dressings expiration date 6/21.
4 Acticoat wound dressings expiration date 6/21.
1 biohazard bag with a patient label on it. The surveyor asked EI # 22, RN, "Is this patient currently a patient?" EI # 22 replied, "No, I'm not sure when they were discharged. This should have already been disposed of"

Found in the SCU medication room:
3 boxes of Accucheck Strips, expiration date 8/21/21.
1 unpackaged bag of Normal Saline (NS) 1000 ml.

At 11:45 AM the surveyor inspected the SCU emergency cart and found the following expired items:
1 Central Venous Line (CVL) kit expiration date 10/31/21.
1 Suction tubing expiration date 6/21.

Found in the SCU was an orange plastic box labeled 'Resp' with the following expired items:
4 Clear transparent dressings expiration date 12/18.
1 blood gas kit expiration date 2/19.
6 packages of tincture of Benzoin expiration date 11/19.

In an interview conducted on 11/16/21 at 12:30 PM, EI # 21, SCU Manager, confirmed the staff failed to ensure all patient care supplies available for use were not expired.

4. A tour of the medical /surgical floor was conducted on 11/16/21 from 2:40 PM to 3:35 PM with EI # 32, RN and the surveyor observed the following unlabeled medications and expired patient care supplies:

At 2:45 PM in the medication refrigerator the surveyor observed 10 of 10 multi-dose vials open and the date of first use was not documented on the bottles:

Humulin R (regular) insulin.
Lantus 100 insulin.
Ademlog (regular insulin).
Humulin N (human insulin).
Humalog 75/25 insulin.
Novolog 70/30 insulin.
Levemir 100 insulin.
Humulin 70/30 insulin.
Flu vaccine
Humulin N insulin expiration 8/21.

The surveyor asked EI # 32, How long should multi-use vials of medication be used after opening?" EI # 32 replied, "Usually we wouldn't keep them more than 3 days, I really don't know."

The following expired patient care items were found at the medication preparation area:

3 pink and blue 'para pak' vials expiration date 10/2020.
4 sterile cotton tip applicators expiration date 8/1/21.
1 IV (intravenous) extension set expiration date 6/21.
6 betadine packages expiration date 5/21.

At 3:15 PM the surveyor observed the following open/ expired patient care supplies were observed in the clean storage room:

3 BARD (tm) TriCath dialysis tubing packages expiration date 10/31/21.
1 CVL kit expiration date 6/21/21.
1 tray of open 3 ml syringes labeled "Pharmacy use only".

The surveyor confirmed with EI # 32 at 3:30 PM, the staff failed to label multi-dose vials of medication with open date, open and expired medications and supplies were not available for patient use.

5. A tour of the pharmacy was conducted on 11/17/21 at 2:45 PM with EI # 31, Pharmacy Technician, the surveyor observed the following expired medications available for patient use in:

Pharmacy refrigerator:

2 bags of Vancomycin 250 mixed for discharged patient to be administered 9/20/21 and 9/21/21. EI # 31 stated, "These should have been thrown away."

Scheduled drug storage (locked closet):

6 Fentanyl 100 microgram (mcg)/2 ml syringes expiration date 6/21.
3 Fentanyl 250 mcg/5 ml vial expiration date 3/21.
1 Demerol 10 mg/ ml syringe expiration date 2/21.
25 Demerol 50 mg/ml vials expiration date of 11/1/21.

The surveyor observed 6 large boxes of medications in the pharmacy floor and multiple stacks of medications on the counters. EI # 30, Pharmacist, stated, "This is all of the expired medicines we are sending back. We send return medication every quarter."

Review of the pharmacy expired medication return log revealed the expired medications had been returned 1/22/19, 7/24/2020 and 5/20/21.

In an interview conducted on 11/18/21 at 3:55 PM, EI # 30 confirmed medications were available for patient use which had expired.

Based on observations and interviews it was determined the facility failed to provide a process for receiving and reporting of tissue specimens. This deficient practice affected Unsampled Patient (UP) # 1, UP # 2, and had the potential to affect all patients having tissue samples collected.

Findings include:

A tour of the Laboratory was conducted on 11/17/21 at 3:15 PM with Employee Identifier (EI) # 42, Medical Technologist.

During the tour, EI # 42 was asked what the process was for receiving tissue specimens. EI # 42 stated when the specimens are brought in they are placed on the counter.

EI # 42 was then asked how the specimens were logged and tracked. EI # 42 responded, "we don't have a log, the lab technician takes a copy of the lab request and places it in the folder", EI # 42 pointed to a collapsible folder at the end of the counter. "When we get the result back we pull the copy of the request and report the results to the physician."

During the review of the folder, the surveyor observed a pathology lab request for UP # 1 for Cecal Polyp specimen dated 10/27/21, which was 21 days after the pathology request. EI # 42 was unable to determine at that time if the results had been received and reported.

Also observed in the folder was a pathology lab request for UP # 2 for a Hernia Sac specimen dated 11/5/21. EI # 42 stated that the specimen had been received on 11/17/21 and had the incorrect date on the request.

No policy was provided for the receipt of specimens.

In an interview conducted on 11/17/21 at 3:45 PM, EI # 43, Laboratory Director, confirmed the proper provisions for the receipt and reporting of tissue specimens had not been followed.

Based on United States Health Public Food Code 2017 regulations, observations and interview, it was determined the hospital failed to ensure food was stored in a safe and sanitary manner. This had the potential to negatively affect all patients served by the facility.

Findings include:

United States Health Public Food Code 2017

3-302.12 Food Storage Containers, Identified with
Common Name of Food.
Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD...

3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.
...commercially processed food open and hold cold
(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in
(A) of this section and: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date based on FOOD safety. Pf
(C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest- prepared or first prepared ingredient.
(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include:...
(2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (A) of this section;
(3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (B) of this section...

Hospital Policy: Proper Labeling and Storage of Food Items
Effective Date: 7/2014

Purpose:

To ensure standardization if food storage and ensure that certain safety and food quality standards are met by properly labeling opened items.

Policy:

All food items received in the dietary department shall be received and placed in the designated storage area...

Perishable items will be placed in the cooler or freezer, which ever applies as quickly as possible...

The following labels will be used in the Dietary Department to ensure the quality and safety of the food item:
Date Opened
Use First
Expiration Dates
Item Date Prepared

All items when opened, prepared, or made in house shall have a label placed on the package or box as follows using the above labels:

Date Opened: This date will be placed on any and all items when an item is opened to be used for the first time. The label will be applied and the date the item was opened will be written on the label the day it is opened. This applies to all items used in the kitchen and Cafeteria area.

Use First: This label will be placed on all packages that have been opened and all the product was not used. This is to signify that this item should be used completely before opening another bag, box or container of like item.

Expiration Date: All opened items or in house made items will have an expiration dated label placed on the item if the original package does not have a printed expiration date on the package...

Item Date Prepared: This label will be placed on all items prepared in the Dietary Department that are made or placed in a container from the original container. An expiration date label will also be placed on these items.

Storing opened containers: All containers that have a plastic snap lid or zip lock closer will be completely sealed and labeled using the method above. All bags or loose items will be securely wrapped in clear wrap and labeled according to method above.

A daily inspection will be performed checking for expiration dates and spoiled items, any items found will be thrown out and never used.

A tour of the Dietary Department was conducted on 11/16/21 at 12:15 PM.
During the tour on the shelves by the triple sinks were a several bottles of seasoning. Each bottle was inspected and the following was found:

1 large container of black pepper open and no label for open date.
1 Blackened Seasoning container 24 ounce (oz) open and no open date label.
1 Granulated garlic seasoning 24 oz open and no open date label
1 Jamaican Jerk seasoning 25 oz open and no open date label
1 Spanish Paprika seasoning 18 oz open and no open date label
1 Mild Chili Powder seasoning 18 oz open and no open date label
1 Crushed Red Pepper seasoning 12 oz open and no open date label
1 Parmesan Cheese Grated 16 oz open and no open date label and expired July 22, 2021

In the kitchen area were shelves which contained large bins of food supplies which were not labeled to identify the items and there were no expiration labels on the bins.

1 large bin with numerous individual sugar packets and individual Splenda packets no label with expiration date, no identifying label
1 large bin with numerous individual salt packets and individual pepper packets no label with expiration date and no identifying label
1 large bin with numerous individual Thick and Easy packets no label with expiration date and no identifying label
1 large bin with numerous individual Mrs. Dash seasoning packets no label with expiration date and no identifying label
1 large bin with numerous individual packs of crackers no label with expiration date and no identifying label
All of the above bins failed to have lids covering the food products.

In the cooler area was a cart with 9 containers of food and covered with plastic wrap. No labels were identified. A dietary employee entered the cooler and asked the surveyor if he/she should dispose of the items. The surveyor responded by saying what do you usually do with the food? The employee took the cart out of the cooler and disposed of the food products in each unlabeled container.

1 unlabeled container of strawberries with a lid and lid was loose on the container was on the shelf with an open date of 9/28/21. The lid was lifted and the strawberries were moldy.

In the freezer area on the third shelf was an open bag of what appeared to be omelets. There was no identifying label, expiration label and no open date label.

An interview was conducted on 11/16/21 at 12:40 PM with Employee Identifier # 8, Dietary Manager, who stated the products should be labeled with open dates, removed if expired and labels to identify each product.

Based on review of the employee file for the hospital RD (Registered Dietician) and interviews with the staff interviews it was determined the hospital failed to ensure the facility staff explained and completed the dietitian job description and obtained signatures including the RD. This had the potential to negatively affect all patients served by the hospital.

Findings include:

Hospital Position Description/Evaluation
Position Job Title: Dietary

1. Position Purpose:

The Dietitian is a R.D. who is directly responsible to the Dietary Manager...

The R.D. serves as a member of the multidisciplinary team to provide nutritional care and patient education as appropriate for the patients in the hospital...for assessment and/or diet teaching...

3. General Responsibilities:

1. The R.D. exercises his/her expertise and professionalism in both administrative and clinical dietetic practice.

2. The R.D. functions in an advisory capacity to administration, the dietary department, physicians and other members of the health care team.

3. Communicates effectively with the health care team, patients, and families of patients to promote optimum nutritional care throughout the facility.

1. Review of the employee file for Employee Identifier (EI) # 7, Dietitian, revealed EI # 7 was hired on 12/14/2020. The job description in EI # 7's employee file was blank, the evaluation section was blank and there were no signatures by EI # 7 nor were there signatures of the Director of Dietary or Human Resources.

An interview was conducted on 11/17/21 at 10:40 AM with EI # 7 by phone. EI # 7 was asked what his/her responsibilities were to the hospital. EI # 7 stated he/she was hired to remotely do consults and to assess nutritional status, complete evaluations and assessments and document in the computer system. EI # 7 also stated he/she was hired to be available for consults remotely. He/she explained to the surveyor he/she was hired to work remotely only and to complete nutritional assessments and any consults and document in the medical record under nutrition.

EI # 7 was asked if he/she over sees the menus for the dietary department. EI # 7 stated the menus are done and approved by a dietitian who works for US (United States) Foods. EI # 7 stated he/she was not included in that and was only hired to do assessments and enter into the computer system.

EI # 7 was asked what type of system is in place to ensure patients receive their diet as ordered. EI # 7 responded by stating he/she did not understand what the surveyor meant. The surveyor explained and EI # 7 responded by stating he/she was not hired for that task but would think orders get from the floor to dietary by the computer system.

EI # 7 was asked if the Dietary Department has a Therapeutic Diet Manual and who reviews it. EI # 7 stated he/she did not understand what a Therapeutic Diet Manual was but there was a diet manual online and everyone may access it. EI # 7 stated the diet manual has all the diets in it including specialty diets. EI # 7 was unsure of who reviews the manual.

EI # 7 was asked what his/her responsibilities were to the hospital. EI # 7 replied by stating he/she was hired to do evaluations and to complete assessments remotely on patients and to be available for any consults. EI # 7 was asked if he/she speaks to the patients or the patients family for the assessments. EI # 7 replied by stating no he/she looks at the medical record, the height, weight, body mass index (BMI) and the nursing assessment and documents his/her recommendations from those. EI # 7 was asked if he/she oversees the dietary department and EI # 7 stated no the dietary manager oversees the dietary department.

An interview was conducted on 11/17/21 at 11:00 AM with EI # 2, Assistant Chief Nursing Officer, who also sat in on the phone interview. EI # 2 stated the job description should have been completed and the dietitian should have known about the Therapeutic Diet Manual.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations for findings.

Based on observations, review of hospital policies and procedures (p/p), and interview it was determined the hospital failed to ensure:
1. Preventive maintenance (PM) was performed on all hospital equipment.

2. Safety Surveillance Rounds for the facility were completed per p/p.

3. Patient care supplies not previously used were not stored in biohazard/ trash bags.

4. Unit Safety Rounds were conducted on the Senior Care Unit (SCU) per p/p.

This had the potential to negatively affect all patients, staff and visitors.

Findings include:

Hospital Policy
Title: Department of Safety Surveillance Rounds
Reviewed/Revised Date: 2/2020

Purpose
To inform the Safety Committee of unsafe conditions that may be present within the facility.

Procedure
1. Safety Surveys will be conducted once a year in non-clinical areas and twice a year in clinical areas and will not exceed 6 months.

2. The Survey Team will consist of the Safety Officer, Infection Control Officer, a member of Plant Operations, and the Department Manager. A member for the Administrative team may also be asked to join.
3. Work orders will be filled out to correct any deficiencies found by the Safety Office...
4. A follow up visit will be made to the inspected department within 30 days to ensure deficiencies have been corrected ...

Hospital Policy:
Title: General Hospital Safety and Patient Management
Reviewed/Revised Date: 2/2020

Policy
The Medical Center Barbour environment is maintained in a safe, clean and orderly manner at all times. Medical Center Barbour is routinely checked to protect patients, visitors, and personnel from potential safety hazards...

Procedure: MINIMAL STANDARD OF CARE SHALL INCLUDE THE FOLLOWING:

There are effective safety committees maintained to evaluate the safety... procedures and environment. These committees will make recommendations as to modifications and initiations of safety policies and procedures...

Personnel are to report all potential safety hazards to their supervisor immediately.

All hospital equipment is to routinely checked for safety through the Engineering Department...All equipment needing repairs must be removed from service and reported to the appropriate department for repair...

Hospital Policy
Title: Unit Safety Guidelines
Policy Number: 07.02.01
Reviewed/Revision Date: 2/21

Purpose:
The Organization and SCU will have established guidelines for patient, staff and visitor safety...

Ongoing monitor of the unit ensures the safety of patients and staff...

A ligature risk assessment of the unit will be conducted annually...

All medications, drugs, disinfectants, and cleaning fluids and insecticides are to be kept in a locked cabinet/closet until needed.

1. Tours and observations of care in the Emergency Department (ED) were conducted on 11/16/21 at 9:20 AM to 11:45 AM and from 2:20 PM to 3:30 PM.

Observed in ED Treatment Room 5 was one Plum 360 Infusion pump, labeled Intermed 301526 with PM documentation, due 4/21 (April 2021). In ED Treatment Room 1, was one Plum 360 Infusion pump, labeled Intermed 163806, with PM documentation, due 4/21.

In an interview at 3:20 PM on 11/16/21, EI (Employee Identifier) # 33, the ED Director confirmed PM was not current for all ED patient equipment.



34107

2. During a tour of the SCU on 11/16/21 at 10:10 AM, the surveyor observed an oxygen concentrator labeled with a green label which revealed PM due 7/21. There were 2 oxygen tanks and no date the oxygen tanks were last inspected.

EI # 21, SCU Manager, confirmed at the time of the tour the facility failed to ensure all patient care equipment was inspected annually.

3. During a tour of the Medical-Surgical unit conducted on 11/16/21 at 3:15 PM the surveyor observed in the clean utility room:

1 - Bi-pap machine with no PM inspection sticker on it.
1 - Infusion Pump with a note taped on it, "Fix me, I'm broke."

The surveyor asked EI # 32, RN, "How long has that infusion pump been in here?" EI # 32 confirmed there was no PM inspection sticker and stated "The infusion pump has been in here so long, I don't even remember."

The surveyor observed 3 bags hanging on the right side of shelves (1 red biohazard bag and 2 white trash bags). The 3 bags contained multiple packages of unopened and NOT expired patient care supplies ex: IV tubing, syringes, needles, oxygen tubing, tube feeding tubing, multiple types of wound care products, etc.

The surveyor asked EI # 32, "Where the unopened patient care supplies came from?Why is a biohazard bag in the clean utility storage room?" EI # 32 replied, "I have no idea where they came from or why they are in here."

On 11/18/21 at 8:50 AM the surveyor asked EI # 8, Materials Management Manager, "Should patient equipment have a PM sticker and why would an infusion pump be in clean utility storage with a sign that says 'Fix me. I'm broke' longer than 1 month?" EI # 8 replied, "Yes everything is inspected and no the pump shouldn't be there for more than a month."

The surveyor then asked EI # 8 about the biohazard bag and trash bags filled with unopened, not expired patient care supplies found in the clean utility room. EI # 8 replied, "I have no idea why the supplies are in there. Housekeeping is supposed to dispose of them."

EI # 8 referred the surveyor to talk with the Plant Operations Manager about the equipment.

In an interview conducted on 11/18/21 at 8:50 AM with EI # 8, Materials Management Manager, confirmed all patient care equipment should be inspected annually and patient care supplies should not be stored in trash bags or biohazard bags.

3. On 11/18/21 at 8:20 AM the surveyor requested the Unit Safety Rounds documentation conducted for the SCU for the past 12 months.

EI # 21 stated, "I've made rounds on the unit, but I don't have any documentation."

4. On 11/18/21 at 8:50 AM the surveyor requested from EI # 8, Materials Management Manager, the hospital Safety Surveillance Rounds documentation and the PM logs conducted for the past 12 months. EI # 8 stated, "I don't have documentation of any patient safety rounds. You need to see EI # 20, Plant Operations Supervisor."

On 11/18/21 at 12:20 PM the surveyor requested from EI # 20 PM logs and patient safety rounds for the past 12 months. EI # 20 replied, "I don't have any documentation for patient safety rounds and a we contract a company called "Intermed". They conduct all the biomedical PM's for the patient equipment."

EI # 20 stated, "He's not here today. I don't have access to the PM logs. I can call him/her to come in, but it takes about 2 hours to get here."

The surveyors were not provided PM logs or completed patient safety round documentation for the past 12 months.

Based on observations, review of the hospital's Infection Control (IC) plan policy and procedure (p/p) and the hospital 2021 hand hygiene compliance surveillance data, hospital p/p, the Centers for Disease Control hand hygiene guidelines for healthcare settings, the facility failed to ensure an effective IC program was established and identified facility wide IC noncompliance and implemented appropriate actions to address IC nonadherence.

Refer to A 0749 and A 0750 for findings.

Based on observations, recommendations of Centers for Disease Control (CDC) hand hygiene guidelines for healthcare settings and Injection Safety Information for Providers, Sani-Wipes directions for use, hospital policies and procedures, and interviews, it was determined the hospital failed to ensure:

1. Staff performed hand hygiene and wore gloves per CDC recommendations and hospital policy.

2. Staff stored disinfectants properly.

3. Staff cleansed/disinfected re-usuable equipment after patient use.

4. A sanitary environment was maintained and staff cleaned patient rooms according to hospital policy and disinfectant product recommendations for 3 of 3 observations.

5. Labeled all patient personal belongings and items.

6. Staff followed CDC recommendations for Safe Practices for Medical Injections and always enter a medication vial with a sterile needle and sterile syringe.

7. Staff stored all patient supplies in a clean environment and not in staff uniform pockets.

This affected MR # 2, MR # 18, MR # 19, MR # 21, MR # 1 and MR # 24 and had the potential to negatively affect all patients served by this facility.

Findings Include:

Hospital Policy and Procedure
Scope: Housewide
Title: Hand Hygiene
Reviewed/Revision Date: 7/19

Policy:

...Medical Center Barbour personnel will follow hand hygiene practices in accordance with ...current CDC guidelines.

Procedure:
Hand Hygiene is considered the single most important procedure for preventing healthcare acquired infections. Bacteria are easily spread in the hospital environment ...via hands of healthcare workers. Any contact within the patient or patient's environment could conceivably result in microorganisms to the hands...
Type
Hand wash ...Method ...Soap for 20 seconds ...Hand antisepsis ...Method ...Antimicrobial soap or alcohol based handrub for at least 15 seconds...
Hands should be rubbed together vigorously, covering all skin surfaces...for at least 20 seconds...with soap and water...rinsed thoroughly...dried with paper towel...used to turn off faucet.

...Employee should wash hands... Before and after direct patient care
Before gloving...After removing gloves
Moving from contaminated patient body site to clean site during patient care
After contact with inanimate objects or medical equipment close to patient
...Before handling food ...

CDC and Prevention Guidelines for Hand Hygiene in Health-Care Setting
Last Updated June 25, 2018

When to Perform Hand Hygiene:

Before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed)

After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings.

After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

After glove removal.

CDC "Clean Hands Count for Patients"

How should your healthcare providers clean their hands?

Using soap and water:
1. Wet their hands with water.
2. Apply an amount of soap recommended by the manufacturer to their hands.
3. Rub their hands together for at least 15 seconds, covering all surfaces of the hands and fingers.
4. Rinse their hands with water and dry with a disposable towel.
5. Use the towel to turn off the faucet.

Sani-Cloth Bleach Germicidal Disposable Wipe
GENERAL GUIDELINES FOR USE
1. Always dispense wipe through lid ...Pull through about one inch. Replace lid...2 ....When not in use, keep lid closed to prevent moisture loss ...4. Treated surface must remain visibly wet for a full four (4) minutes. Use additional wipe(s) if needed to assure continuous 4-minute wet contact time.

CDC Centers for Disease Control and Prevention
FAQs (frequently asked questions) regarding Safe Practices for Medical Injections

Medication Preparation Questions
...How should I draw up medications? Parenteral medications should be accessed in an aseptic manner ...This includes using a new sterile syringe and sterile needle to draw up medications while preventing contact between the injection materials and the non-sterile environment ...
Medication Administration Questions
4. Is it acceptable to re-use a syringe and/or needle to enter a medication vial for the same patient if the medication vial and syringe will be discarded at the end of the procedure and not used for subsequent patients?
The safest practice is to always enter a medication vial with a sterile needle and sterile syringe, even obtaining additional doses of medication for the same patient ...

Hospital Policy: Environmental Cleaning and Infection Prevention
Policy Number: 4.100
Reviewed/Revision Date: 2/19

Purpose:
To maintain a healthy, hygienic environment for patients staff, and to prevent the environment from becoming a reservoir of unwanted, harmful microorganisms.

Policy:
The use of established guidelines will be adhered to by the cleaning of equipment utilized by all departments...

Procedure:
1. Workstations and floors in patient care areas should be disinfected daily with an organization approved disinfectant...
5. Walls, shelves and storage areas should be disinfected regularly.
6. ... If common use equipment for multiple patients is unavoidable, clean and disinfect shared equipment before use on another patient...
8. Equipment utilized in patient care is to be cleaned by Environmental Services...
If it is unclear whether patient care equipment has been cleaned, it must be cleaned before patient use...

Hospital Policy
Title: Terminal/ Discharge Cleaning
Reviewed Date: 3/21

Procedure:...

Cleaning of Patient Rooms

1. Wash hands and put on personal protective equipment.
2. Properly dispense the appropriate cleaning solution into the hand pail and mop bucket.
3. Remove any nursing equipment from the room except the IV (intravenous) pole...pumps.
4. Empty the trash receptacle, damp wipe and reline trash receptacles. Remove soiled line and trash from room.
5. Start from far corner of room and work your way out; dust all ledges, tops of light fixtures, picture frames...
6. Dry mop the floor or area using a chemically treated mop head attached to a handle. Start from the farthermost corner of the room and work your way out of the room...
8. Clean the bathroom. First, spray germicide on the shower tile and toilet. Clean the walls (starting with the shower). Clean shower curtain, sink, and the outside of toilet...

Hospital Policy and Procedure
Title: Storage-General
Effective Date: 1/1/2008

Purpose
To provide directions for safe storage of drugs and devices

Food Storage and Consumption
Food shall be stored only in designated areas...

Clean Storage
Storage areas shall be kept clean, uncluttered...

Emergency Department (ED) Observations

1. During observations of care in the ED on 11/16/21 from 9:45 AM to 12:00 PM the surveyor observed EI (Employee Identifier) # 5, ED RN (Registered Nurse), attempted to start a peripheral IV (intravenous) on an unsampled patient in ED Treatment Room 5. EI # 5 dropped the syringe on the floor, removed gloves but failed to immediately perform hand hygiene before opening the ED door and exiting the Treatment Room for additional supplies.

EI # 36, Radiologist Technician entered ED Treatment Room 5. Without first performing hand hygiene, retrieved patient supplies (Coban) from the ED cabinet.

EI # 37, Laboratory Aide/Phlebotomist, entered ED Treatment Room 5, donned gloves without first performing hand hygiene, then attempted to obtain blood for laboratory analysis.

At 10:30 AM, EI # 5 performed an external jugular IV insertion procedure and removed gloves but EI # 5 failed to immediately perform hand hygiene. Then, without performing hand hygiene, EI # 5 adjusted the vital sign monitor above the patient bed.

EI # 5 sanitized hands but failed to don gloves before disinfection of the IV hub site and initiation of an IV Cardizem infusion.

Staff failed to perform hand hygiene upon entering the treatment room, before touching patient supplies and immediately before and after glove removal. Staff failed to don gloves during IV medication administration.

During the ED tour and observations of care the surveyor observed Sani Wipe disinfectant canisters with open lids stored on countertops in Triage Exam, and ED Treatment Rooms 3, 5 and 6. There was an accumulation/build-up of dust observed in ED Treatment Room 7 on the infant/neonatal warmer unit and in ED Treatment Room 6 on the countertop where 6 battery packs and 5 battery charging stations were stored.

At 2:30 PM, EI # 38, ED RN disinfected Treatment Room 2 using Sani-Wipes bleach cloth which included the ED bed. EI # 36 placed a clean sheet over the ED bed before the 4-minute contact time completion and when the bed was still shiny wet. EI # 36 also failed to disinfect the countertop.

Dietary Observations

1. An observation was conducted on 11/16/21 at 11:30 AM in the Dietary Department to observe the preparation of patient's lunch meal. During the observation EI # 9, Cook, was at the counter in Dietary and was placing individual rolls in a bag to place on the trays. EI # 9 removed gloves and donned clean gloves and failed to wash or sanitize hands prior to donning clean gloves.

At 11:50 AM EI # 9 removed gloves did not sanitize hands, obtained to go boxes, donned clean gloves and failed to sanitize hands prior to donning gloves. Once completed the filling of the to go boxes EI # 9 removed gloves and was going to don clean gloves when EI # 2, Assistant Chief Nursing Officer (ACNO) motioned for EI # 9 to wash hands. EI # 9 preceded to the back of dietary to the large sinks at the dishwasher and rinsed hands under water briefly and dried hands on a towel. EI # 9 then donned 1 glove and began to place individual rolls in bags for the patient trays. EI # 9 then removed the 1 glove and after being instructed by EI # 2 went to the back sink, rinsed hands for 4 seconds and dried on a towel.

While plating the to go boxes, EI # 9 was placing food in a to go box for the Psychiatric Unit and rice had gotten in the side with the meat. EI # 9 used his/her gloved hand and removed the rice and placed it back into the large pan of rice.

At 12:00 PM EI # 10, Cook, placed the trays into the cart and left the dietary area with his/her apron on and delivered the food to the designated area, returned to dietary and continued to assist with plating with the same apron on which was worn to a hospital floor to deliver plates.

EI # 9 continued with plating of food when complete EI # 9 removed gloves, failed to sanitize hands and donned clean gloves.

An interview was conducted on 11/16/21 at 12:30 PM with EI # 8, Dietary Manager, who confirmed the staff is to wash their hands each time they remove gloves and before placing new gloves on. EI # 8 also stated the employees are to remove their aprons before leaving the dietary department and donning the apron once back in the dietary department.

Surgery/Procedure Room Observations

1. On 11/16/21 from 11:45 AM to 1:00 PM an observation of a Colonoscopy procedure was observed in surgery on MR # 2.

After the procedure was completed, EI # 18, Surgical Technician, was observed removing gloves then donning new gloves and placing colonoscope equipment in transport container. EI # 18 failed to perform hand hygiene after removing gloves.

EI # 18 then removed the gloves, donned new gloves, and transported the colonoscope equipment container from the surgery room to be cleaned. EI # 18 failed to perform hand hygiene after removing gloves.

EI # 19, RN, was observed donning new gloves after the procedure and placing the specimen containers in a bag. EI # 19 then removed the gloves and donned new gloves without performing hand hygiene.

EI # 19 then removed soiled towels from the bed, removed gloves, donned new gloves, then transported MR # 2 to the recovery room. EI # 19 failed to perform hand hygiene after removing gloves.

In an interview conducted on 11/18/21 at 9:15 AM, EI # 19 and EI # 17, Director of Surgery, confirmed hand hygiene was not performed after gloves were removed.

SCU (Senior Care Unit) observations

1. A tour of the SCU was conducted on 11/16/21 from 9:15 AM to 1:30 PM the following observations were made by the surveyor:

At 9:20 AM while inspecting the patient showers the surveyor observed an unsampled patient open a closed door in the shower area. The patient placed his/her shampoo and soap in a bin labeled with patient room numbers. EI # 23, Mental Health Technician (MHT), said, "That's where the patient's store their personal care supplies, we don't keep them in the patient rooms." The surveyor observed an unlabeled 16 oz spray bottle containing a clear liquid. The surveyor asked, EI # 23, "What's in this bottle?" EI # 23 replied, "Bleach to clean the showers." EI # 23 confirmed there was no label.

The surveyor also observed in the patient personal supply closet an open container of hair gel with tiny black particles in the gel. EI # 23 said, "When we have time we try to fix up our patient's hair." The surveyor asked, "Which patient does the hair gel belong to?" EI # 23 replied, "It doesn't belong to one patient, we use it for everyone."

The floor of the patient care supply closet was covered in dirt and dust. Also on the floor were partially used supplies and used wash cloths.

At 9:45 AM the surveyor observed the patient rooms did not contain any clothes, and asked EI # 23, "Where do patient's keep their extra clothes?" EI # 23 replied, "We have a closet for their clothes. Plus, we have a closet with donated clothes" The surveyor observed a closet with several plastic bins/drawers labeled with patient room numbers. There were several items of clothing laying on top of the drawers, on the floor and not in a bin. EI # 23 stated, "It's a challenge to get everyone to keep this closet straight."

The floor of the patient clothes closet covered in dust and dirt. The surveyor asked EI # 21, SCU Manager, "How often are the closet floors inspected and cleaned? Which patient do those items on the floor belong to?" EI # 21 called EI # 23 to put socks in appropriate bin and stated, "I'm not sure how often the floors are cleaned. I'll speak to housekeeping about cleaning the closets." EI # 23 picked up the socks from the dirty floor and placed in bin labeled 101.

At 9:50 AM the surveyor observed the donated clothes closet which contained several baskets of used clothing along with used foam heel protectors.

The floor of the donated patient clothes closet was covered in dust and dirt. The surveyor asked, "EI # 21, "How can the foam heel protectors be cleaned for another patient, and how often are floors cleaned?" EI # 21 instructed EI # 23 to dispose of the used foam heel protectors.

At 10:00 AM in patient room 101 A, the surveyor observed a dirty urinal. EI # 21 picked up the urinal with ungloved hands and placed inside the paper trash bag. EI # 21 failed to clean hands after handling the dirty urinal.

At 10:30 AM the surveyor observed EI # 41, Nurse Practitioner (NP), conduct a physical assessment on MR # 19. EI # 41 used a stethoscope to listen to lungs and heart and then touched top of his/her foot with ungloved hands. After completing the physical assessment on MR # 19, EI # 41 went to the other 5 patients in the dining room and performed their physical assessment. EI # 41 failed to clean ungloved hands or the stethoscope between patients.

At 10:45 AM the surveyor observed 2 spray bottles that containing clear liquid. The surveyor asked EI # 22, RN, "What's in these containers?" EI # 22 replied, "I guess it's some kind of cleaner." The staff failed to label containers per policy.

At 11:00 AM, EI # 22 entered the medication room and obtained a blue and white plastic box with glucometer supplies. EI # 22 applied gloves and took the blue and white box and the glucometer to the dining room table where 2 patients were coloring. After performing the glucose testing on an unsampled patient, EI # 22 removed gloves and placed the blue and white box on the medication room counter. EI # 22 failed to perform hand hygiene before applying gloves and clean the blue and white box with glucometer supplies before returning to the clean medication room counter.

At 12:00 PM the surveyor observed MR # 18, MR # 19 and MR # 21 and 5 unsampled patients for a total of 8 patients in the dining room when dietary staff delivered patient lunch trays. The staff delivered the trays to the patients at the tables and the patients began to eat. The staff failed to remind /offer patients the opportunity to clean hands before eating their meals.

In an interview conducted on 11/16/21 at 12:20 PM, EI # 21 confirmed staff failed to ensure chemical containers were labeled and stored per policy, hair care supplies and disposable heel protectors were used by only one patient, the unit closet floors were clean, the staff cleaned re-usable equipment after patient use, staff washed hands before donning and after doffing gloves, and patients were offered the opportunity to clean hands before meals.

2. A medication pass observation on the SCU was conducted on 11/17/21 at 11:14 AM with EI # 25, Licensed Practical Nurse (LPN). EI # 25 entered the medication room to prepare medication for MR # 19. EI # 25 signed onto the computer checked the eMAR (electronic medication administration record). EI # 25 selected a cup from stack of cups on medication preparation counter. The surveyor noted the plastic cup had a patient label for MR # 19.

EI # 25 then obtained Humalog insulin from the medication refrigerator and prepared the insulin for injection, applied gloves and then exited the medication room.

EI # 25 went to the dining room and the 2 units of insulin in the upper right arm. EI # 25 returned to medication room discarded the dirty insulin syringe in sharps container, removed gloves and exited the medication room.

EI # 25 failed to follow facility policy and procedure for hand hygiene per hospital policy and procedure upon entry to the medication room, before applying gloves and after administering the insulin when gloves were removed.

At 1:35 PM the surveyor observed the medication administration for an unsampled patient in the SCU. EI # 25 entered the medication room, signed onto the computer, found plastic cup that contained patient label for unsampled patient. EI # 25 then removed medication from the Pyxis machine, documented on the eMAR, and exited the medication room to locate patient. After administering the medication, EI # 25 returned to the medication room,

EI # 25 failed to perform hand hygiene when entering the medication room, before obtaining medications from the Pyxis machine, and after administering the medications.

In an interview conducted on 11/17/21 at 2:00 PM, EI # 22, RN confirmed the staff failed perform hand hygiene per facility policy and procedure.

3. During observations of care conducted on 11/18/21 at 11:26 AM in the SCU the surveyor observed EI # 41, NP, conduct a physical assessment on multiple patients in the dining room. EI # 41 used a stethoscope to listen to lungs and heart and with ungloved hands. After completing the physical assessment one patient went to another patient in the dining room and performed their physical assessment. EI # 41 failed to clean ungloved hands or stethoscope between patients.

In an interview conducted on 11/18/21 at 2:00 PM, EI # 21 confirmed the NP failed follow hand hygiene policy.

MSU (Medical Surgical Unit) Observations

1. On 11/16/21 at 1:35 PM the surveyor observed the terminal cleaning of a discharged patients room and tour of the MSU.

From 1:35 PM to 2:15 PM the surveyor observed EI # 27, Housekeeper, perform a terminal cleaning on room 314. EI # 27 obtained and moistened a microfiber cloth from utility cart, cleaned the inside of trash can and then cleaned the patient tray/ overbed table. While cleaning the bottom of the table the microfiber cloth swiped the floor, EI # 27 then cleaned the patient remote control with the same microfiber cloth used to clean inside of trash can.

While cleaning the wall, EI # 27, removed laminated pages from the wall, wiped the wall down then replaced the laminated pages to the wall. EI # 27 failed to clean the laminated pages.

EI # 27 proceeded to clean the rest of the room and bathroom and when completed removed gloves and but failed to perform hand hygiene.

The surveyor asked EI # 27, "Did you clean the lamented pages from wall, blue air circulator, bathroom light switch, bathroom inner door, inner door handle, or shower curtain?" EI # 27 confirmed the above areas were not cleaned.

2. On 11/16/21 at 2:40 PM the during a tour of the 3rd MSU with EI # 32, RN, and the surveyor observed:

In the unoccupied patient room 315 the surveyor noted a SCD (Sequential Compression Device) pump on a shelf, the power cord was hanging down to the floor. The surveyor asked, "Has this equipment been cleaned?" EI # 32 replied, "I don't know."

At 3:15 PM the surveyor inspected the clean utility room and found the following:

3 (three) IV poles with IV pumps connected to them with partially used alcohol connector strips hanging from the poles.
2 (two) SCD pumps, bear hugger pump, 3 - feeding pumps, and walkers covered in dust.

The surveyor asked EI # 32, "How do you ensure these items are clean before using on a new patient." EI # 32 stated, "They should be cleaned when they are put in here."

1 IV pump sitting on a bedside commode top and labeled, "Fix me, I'm broke." The surveyor asked EI # 32, "How long has this IV pump been in here?" EI # 32 replied, "It's been so long, I can't even remember."

3. On 11/16/21 at 3:35 PM the surveyor observed EI # 28, Housekeeper, perform a terminal cleaning patient room # 318. EI # 28 used a pump mister and sprayed QUAT 356 (hospital disinfectant) all over the room including the furniture, walls, unemptied trash cans, patient bed while linens were on the bed. EI # 28 started cleaning the walls with a mop.

EI # 28 failed to remove linens from bed and room before beginning to clean.

EI # 28 obtained a green microfiber cloth from the utility cart, cleaned the inside, then outside of the bathroom trash can. EI # 28 then placed the green microfiber cloth on the computer table, cleaned the computer table, monitor and keyboard with the same cloth used to clean the inside of the bathroom trash can.

EI # 28 removed several packages of unopened patient care supplies from a drawer of the bedside table and disposed of items in the patient trash can. EI # 28 then removed the trash and liner from the patient room and cleaned the trash can inside and outside with the green microfiber cloth.

EI # 28 failed to remove trash from the room before beginning to clean the room per policy.

Then EI # 28 cleaned the drawers, oxygen regulator, removed the packaged Yankeur suction catheter from the top of the plastic suction canister, wiped the package and canister and replaced the unopened Yankeur suction package to the top of the disposable plastic suction canister.

With the same gloves EI # 28 removed the clean gloves from an almost empty box of clean gloves and placed the clean gloves in another box of medium gloves. EI # 28 failed to remove dirty gloves before touching clean gloves.

EI # 28 then went to the patient bathroom and sprayed the QUAT 356 to the shower walls and failed to clean the shower curtain. EI # 28 removed gloves and replaced gloves without performing hand hygiene.

In an interview conducted on 11/18/21 at 8:50 AM, EI # 8, Environmental Services Manager, confirmed the staff failed ensure containers were labeled, floors were clean, staff used good infection control practices, hand hygiene, terminal cleanings were conducted per policy and patient care equipment was clean and available for use.

4. An observation was conducted on 11/17/21 at 9:20 AM with EI # 33, RN, to observe the administration of medication. EI # 33 entered room # 304 with a rolling computer. EI # 33 failed to sanitize hands and logged into computer system. EI # 33 scanned the patient's bracelet and scanned each medication. EI # 33 then donned clean gloves and failed to sanitize hands prior to donning gloves. EI # 33 administered oral medications. EI # 33 then removed 1 glove and donned a clean glove without sanitizing hands. EI # 33 administered IV medication and subcutaneous medications to the patient. EI # 33 removed gloves and failed to sanitize hands. EI # 33 then left the room. EI # 33 went into kitchen area for juice for medication administration did not sanitize hands. EI # 33 re-entered the patient's room, donned clean gloves and did not sanitize hands. EI # 33 then removed gloves prior to leaving room and sanitized hands for 10 seconds which was not the required time the policy requires.

An interview was conducted on 11/17/21 at 10:00 AM with EI # 2, Assistant Chief Nursing Officer (ACON) and all information was explained on the observation. EI # 2 stated each employee should wash or sanitize their hands before donning clean gloves and after removing the gloves.

ICU (Intensive Care Unit) Observations

1. An observation was conducted on 11/17/21 at 8:45 AM to observe medication administration in the ICU 5. EI # 4, RN, performed hand hygiene and scanned the patient's bracelet and each medication and administered to the patient. EI # 4 removed gloves and failed to sanitize hands. EI # 4 then went back to the Pyxis to obtain a newly ordered medication and failed to sanitize hands after using the Pyxis. EI # 4 then scanned the patient's bracelet. EI # 4 donned clean gloves and failed to sanitize hands prior to donning the gloves. EI # 4 then administered the medication to the patient, removed gloves and EI # 2, ACON, motioned for EI # 4 to wash hands.

An interview was conducted on 11/17/21 at 9:00 AM with EI # 2, who verified EI # 4 failed to wash or sanitize hands each time gloves were removed and prior to donning clean gloves.

2. Observations of care were performed on 11/17/21 from 9:30 AM to 11:45 AM in ICU with EI # 6, CCHT (Certified Clinical Hemodialysis Technician) and EI # 4, ICU RN provided care to MR # 1.

Upon entry into ICU 5, EI # 6 removed gloves and gown then performed hand hygiene at the sink and turned off the faucet with bare hands. EI #6 failed to removed gloves, perform hand hygiene then remove gown and repeat hand hygiene per CDC guidelines.

During initiation of dialysis with a CVC EI # 6 aspirated blood from the CVC (central venous catheter) lumens, placed the blood filled syringes in the sharps container, removed gloves and opened ICU room 5 and retrieved the telehealth cart. Then EI # 6 sanitized hands and donned clean gloves. EI # 6 failed to perform hand hygiene immediately after glove removal.

During IV heparin administration, EI # 4 requested EI # 6 obtain an alcohol pad from his/her uniform pocket. EI # 5 removed gloves but failed to perform hand hygiene after glove removal.

EI # 7 then removed the alcohol pad (a patient care supply) from EI # 4's uniform pocket. EI # 4 disinfected the CVC port with the alcohol pad stored in his/her pocket and administered IV Heparin. Staff failed to ensure patient supplies were stored in a clean environment and not in staff uniform pockets.

During dialysis treatment initiation using a CVC, the staff failed to provide the patient with a mask as per the dialysis initiation policy.

EI # 4 prepared from two single use 10,000 Unit Procrit vials using the same needle and syringe to draw up the parental medications from 2 separate medication vials then administered 20,000 Units Procrit. EI # 4 failed to follow CDC Injection Safety Recommendations and always enter a medication vial with a sterile needle and sterile syringe.

Following medication administration, EI # 4 removed gloves, gown and then performed hand hygiene at the sink. EI # 4 failed to perform hand hygiene immediately after glove removal.

In an interview conducted on 11/18//21 at 9:30 AM, EI # 2, Assistant Chief Nursing Officer/Infectionist Preventionist confirmed the staff failed to follow the facility hand hygiene and infection control policies.

3. An observation was conducted on 11/17/21 at 11:20 AM in the ICU to observe EI # 40, ICU RN, obtain a blood sugar. EI # 40 entered patient's room # 2, placed the glucometer on the counter, turned on glucometer and controls were due on the machine. EI # 40 exited room after removing gloves and not sanitizing hands, went out to the medical/surgical floor to obtain the control solution bottles. EI # 40 entered the patient's room and performed the controls on the glucometer and then placed both bottles in his/her scrub pocket. EI # 40 sanitized hands approximately 10 seconds, donned clean gloves and took glucometer and supplies to the bedside and laid the supplies on the patient's bed. EI # 40 performed the blood sugar, removed gloves and sanitized hands approximately 10 seconds. Exited the patient's room, placed glucometer on nursing station counter, donned clean gloves, did not sanitize hands prior to donning gloves, cleaned glucometer with bleach wipes and let dry and did not clean the counter after laying the glucometer on the counter.

An interview was conducted on 11/17/21 at 11:55 AM with EI # 2, ACNO who confirmed the control bottles should not have been placed in the scrub pocket and EI # 40 did not sanitize his/her hands prior to donning clean gloves at the nurses station.

Outpatient Wound Clinic Observations

1. An observation of wound care provided by EI # 16, RN, was conducted on 11/18/21 at 2:55 PM in the Wound Care Outpatient Department.

After performing wound care to right great toe of MR # 24, EI # 16 discarded soiled supplies, removed gloves, then donned new gloves. EI # 16 then performed wound care to left great toe, discarded soiled supplies and removed gloves. EI # 16 failed to perform hand hygiene each time gloves were removed.

In an interview conducted on 11/18/21 at 3:25 PM, EI # 16 confirmed hand hygiene was not performed after removing gloves.



32470





34107





41623

Based on observations of care from 11/16/21 to 11/18/21, review of the hospital's Infection Control (IC) plan policy and procedure (p/p) and the hospital 2021 hand hygiene compliance surveillance data the hospital failed to identify opportunities for improvement in staff hand hygiene adherence/performance and initiate improvement actions when goal(s) were not met.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

Hospital Policy and Procedure, Number 1.000
Scope: Housewide
Title: Infection Control Plan
Reviewed/Revision Date: 11/19

Purpose:
The goals of an infection control program are to improve patient care practices...by preventing acquisition of healthcare associated infections. Control of healthcare associated infections depends on a surveillance program capable of identifying the number and characteristics of such infections...implementing appropriate measures to prevent...spread and identify....causative factors.

Objectives
...To conduct activities to prevent and control infections for patient and personnel.
...To assure compliance with all federal, state, and local regulations in regard to infection control...

Surveillance Policies

...Use of surveillance data is to:
Protect patients, employees and the community.
Ensure compliance with IC policies...
Provide information for inservice training...

Review of the hospital IC program was conducted on 11/18/21 at 10:00 AM with Employee Identifier (EI) # 2, Infection Preventionist, (IP) Assistant Chief Nursing Officer, and EI # 1, Chief Nursing Officer. The surveyor reviewed the following hospital hand hygiene surveillance compliance documentation from January 2021 through October 2021: Goal 100%

January-2021; 100 % compliance- 7 employees observed performing appropriate hand hygiene
February-2021; 75% compliance- 6 employees observed performing appropriate hand hygiene
March-2021; 93% compliance- 13 employees observed performing appropriate hand hygiene

Summary of Findings-Analysis of Data 1Q21 (first quarter 2021) 89% average interviews/observations; Actions to be taken, continue to monitor; By Whom, IP, Education, Quality, Directors, Secret Shoppers; By When Monthly; Follow-up-Monthly.

The analysis of quarter one data failed to include proposed actions to address the surveillance findings and ensure compliance with IC policies. There was no documentation of Q121 actions taken to reach the compliance goal of 100%.

April-2021; 62 % compliance- 8 employees observed performing appropriate hand hygiene
May-2021; 96% compliance- 22 employees observed performing appropriate hand hygiene
June-2021; 100% compliance- 17 employees observed performing appropriate hand hygiene

Summary of Findings-Analysis of Data 2Q21 (second quarter 2021) 86% average interviews/observations; Interviews and observation; Actions to be taken, continue to monitor; increased monitoring; By Whom, IP, Education, Quality, Directors, Secret Shoppers; By When Monthly; Follow-up-Monthly.

The analysis of the second quarter data failed to include proposed actions to address the surveillance findings and ensure compliance with IC policies. There was no documentation staff education/re-education was performed with 62% compliance in April. There was no documentation of 2Q21 actions taken to reach the compliance goal of 100%, other than "continue to monitor, increased monitoring".

July-2021; 100 % compliance- 14 employees observed performing appropriate hand hygiene
August-2021; 93% compliance- 8 employees observed performing appropriate hand hygiene
September-2021; 91.7 % compliance- 11 employees observed performing appropriate hand hygiene

Summary of Findings-Analysis of Data 3Q21 (third quarter 2021) 97.5% average interviews/observations; Interviews and observation; Actions to be taken, continue to monitor; increased monitoring; By Whom, IP, Education, Quality, Directors, Secret Shoppers; By When Monthly; Follow-up-Monthly.

The analysis of quarter 3 data failed to include proposed actions to reach the compliance goal of 100%, other than "continue to monitor".

October-21, 100% compliance-10 employees observed performing hand hygiene.

During the interview with EI # 1 and EI # 2, the surveyor summarized the surveyor's observations which included IC breaches in hand hygiene, injection practices, open, not dated multi-does vials, glucometer use, and terminal cleaning in which employees were nonadherent with hospital p/p and Centers for Disease Control IC recommendations. The surveyor asked how the observers were educated and instructed on monitoring? EI # 2 reported routine annual IC education was provided to all observers. EI # 2 reported the hospital was considering use of a more directive surveillance tool with specific tasks for observations. EI # 2 confirmed there was no documentation of any hospital efforts/actions to improve IC compliance. EI # 2 was unable to identify the reason(s) as to why the survey IC observations and hospital surveillance were so different.

Based on observations, medical record (MR) review, and interviews, it was determined the Outpatient (OP) Hospital Department failed to ensure a physician was notified of changes in patient condition.

This deficient practice affected 1 of 2 OP records reviewed including MR # 23 and had the potential to affect all outpatients.

Findings include:

1. An observation of Outpatient Intravenous (IV) administration to MR # 23 was conducted on 11/17/21 at 9:00 AM.

Review of the Physician Orders dated 10/27/21 revealed an order for Vancomycin 1 gram IV every 24 hours and signed by Employee Identifier (EI) # 44, FNP-BC (Family Nurse Practitioner-Board Certified).

EI # 15, Registered Nurse (RN) obtained the patient's vital signs prior to the procedure including a Blood Pressure (BP) of 179/97. EI # 15 communicated to the patient that he/she would try to contact his/her physician again about the high BP.

The surveyor asked EI # 15 who was he/she discussing the high BP with. EI # 15 responded, I have been trying to get (him/her) an appointment with (his/her) family doctor." The surveyor then asked EI # 15 if there was anyone local he/she could contact if needed. EI # 15 responded, "the one who wrote the orders for the IV are not going to treat his BP."

Review of the Patient Assessment Report dated 11/16/21 revealed the nurse documented "Left message on voicemail at (Family Physician) office in regards to pt's (patient's) elevated BP and requesting appointment for patient. Instructed patient to call 911/go to ER (Emergency Room) for headache, dizziness, blurred vision, weakness, chest pain. (He/She) verbalized understanding."

Policies and Procedures were requested for Outpatient IV therapy and Medication Profile, no policies were provided.

In an interview conducted on 11/17/21 at 10:00 AM, EI # 15 confirmed the elevated BP had not been discussed the family physician or local staff practitioner and there was no documentation of a medication profile.

Based on ED (Emergency Department) policy and procedure, medical record (MR) reviews and staff interviews, it was determined ED staff failed to provide examination and treatment documentation to the receiving facility at the time of transfer. This affected 2 of 3 ED transfer record reviews which included MR # 5 and MR # 11 and had the potential to negatively affect all ED transfers.

Findings include:

Hospital Policy and Procedure
Scope: Emergency Room Department
Title: Medical Screening, Stabilization, and Emergency Transfers
Reviewed/Revision Date: 2/21

Purpose: To provide procedure for an external transfer of patient.

...Procedure:
Any patient requiring emergency transfer to another medical facility will have the Medical Center Barbour (MCB) Emergency Transfer Form completed and signed by a Registered Nurse (RN) and the referring physician.

...h. Copies of all available MR's relating to the emergency condition are forwarded to the receiving facility (laboratory test results, radiological findings, electrocardiogram) and a copy of the completed MCB Emergency Transfer form...

1. MR # 5 presented to the ED on 7/2/21 at 9:34 AM with diagnosis of Cerebellar Stroke Syndrome.

Record review revealed MR # 5 was transferred to a facility for higher level of care via emergency transport on 7/2/21 at 11:45 AM.

Review of the Patient Transfer Form and Nurse Notes failed to reveal documentation that MR # 5's ED examination and treatment records were provided to the receiving facility at the time of transfer.

In an interview on 11/18/21 at 1:29 PM, EI (Employee Identifier) # 1, Chief Nursing Officer confirmed there was no documentation staff provided the receiving facility with patient MR documentation at time of transfer.

2. MR # 11 presented to the ED on 8/16/21 at 12:33 PM with diagnoses of Suicidal and Homicidal Ideation.

Record review revealed MR # 11 was transferred to a specialty facility via emergency transport on 8/16/21 at 3:04 PM.

Review of the Patient Transfer Form and Nurse Notes failed to reveal documentation that MR # 11's ED examination and treatment records were provided to the receiving facility at the time of transfer.

In an interview on 11/18/21 at 1:34 PM, EI # 1 confirmed there was no documentation ED staff provided the receiving facility with patient ED records at time of transfer.

Based on review of employee files and interviews with the staff it was determined the hospital failed to ensure employee files were current for annual competency completion. This affected 1 of 2 Physical Therapists (PT) files reviewed and had the potential to negatively affect all patients served by the hospital.

Findings include:

On 11/16/21 at 3:15 PM employee files for the Rehabilitation Department were reviewed. During the review it was found Employee Identifier (EI) # 34, Physical Therapist (PT) was hired on 4/6/2020 and an initial competency skills list was complete. Further review revealed there was no documentation an annual competency skills list was completed.

An interview was conducted on 11/17/21 at 3:55 PM with EI # 2, Assistant Chief Nursing Officer, who confirmed the annual competency skills list was not completed annually.