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Based on interview and review of hospital policies and procedures it was determined the hospital failed to follow its abuse policy for one (1) of thirty-seven (37) sampled patients. Patient #5 alleged a Certified Nurse Aide (CNA) verbally abused him/her on 02/16/10. However, staff failed to notify the patient's physician, the Quality Assurance Manager and the social worker per hospital policy. As a result, a thorough investigation was not conducted and Adult Protective Services was not notified of the allegations.

The findings include:

Record review revealed Patient #5 was admitted on 01/27/10 with the diagnoses of Chronic Obstructive Pulmonary Disease, chronic Tracheostomy, Sleep Apnea and Obesity.

Interview with alert and oriented Patient #5 on 02/22/10 at 12:40pm revealed the patient reported being verbally abused by a CNA on 02/16/10. According to the patient, he/she was attempting to use the bedpan and was experiencing some difficulty with breathing. The patient stated the CNA told him/her if the patient got his/her "fat ass" out of bed, it would be easier to go to the bathroom. The patient called his/her daughter and reported the incident. The daughter called the house supervisor and reported the verbal abuse.

Interview with the fourth floor Unit Manager on 02/22/10 at 2:30pm revealed she did the investigation of the allegation of verbal abuse concerning Patient #5. The Unit Manager stated she was notified by the house supervisor of the allegation. She interviewed the patient and was unable to get a description of the perpetrator. She "paraded" staff by the patient's door and asked him/her to identify the perpetrator. The patient was not able to identify the staff member. The unit manager concluded the investigation and stated that, without a perpetrator name, the allegation did not have to be reported. She was unsure if the house supervisor reported the allegation to administration and Adult Protective Services.

Interview with the Nursing House Supervisor on 02/24/10 at 3:25pm revealed she received a call from Patient #5's daughter on 02/16/10. According to the daughter, the patient alleged a CNA told him/her if the patient got his/her "fat ass" out of bed it would be easier for him/her to use the bathroom. The House Supervisor informed the unit manager. She did not report the allegation to administration, the social worker nor Adult Protective Services. It was acknowledged she was not aware of the hospital abuse policy for reporting.

Interview with the Quality Assurance Manager (QMA) on 02/24/10 at 1:00pm revealed she did not receive the allegation of verbal abuse concerning Patient #5. According to the QMA, there are two ways to inform administration of allegations/complaints: a dedicated telephone line and in writing. Social Services conducts the investigations and informs the appropriate agencies. The QMA acknowledged the allegation of verbal abuse concerning Patient #5 should have been investigated by Social Services and said their system failed with regard to following the hospital abuse policy.

The facility policy on abuse with a revision date of 01/2009, states the staff member who receives the allegation of abuse is to inform the immediate supervisor, the patient's physician and the social worker. The social worker gathers the information and notifies hospital administration and Adult Protective Services.

Based on observation, interviews and record review, the facility failed to follow their restraint policy for one (1) of thirty seven (37) sampled patients. Patient #4 was observed to be in bilateral soft wrist restraints without a current physician order in the medical record.

The findings include:

Observation of Patient #4 on 02/24/10 at 3:45pm and on 02/25/10 at 8:30am revealed the patient in bilateral soft wrist restraints. Patient #4 was admitted on 02/05/10 with a diagnosis of Respiratory Failure requiring the use of mechanical ventilation.

Record review revealed no physician order for restraints covering the dates 02/23/10 to 02/24/10 and 02/24/10 to 02/25/10.

Interview with Licensed Practical Nurse (LPN) #6 on 02/24/10 at 3:45pm revealed a physician order is required every twenty four hours to renew restraints.

Interview with LPN #7 on 02/25/10 at 8:30am revealed the policy of the facility requires the physician to reorder restraints every twenty four hours. She acknowledged Patient #4 was in bilateral soft wrist restraints without a current physician order. LPN #7 stated she would remove the restraints until an order was written in the medical record.

Review of the facility policy on restraints, revision date 11/2009, states the need for restraints must be continuously reevaluated and orders to renew the use of restraints must be entered at least once each calendar day.

Based on observation, record review, and staff interviews it was determined the facility failed to ensure implementation of infection control measures were consistently utilized by staff. Wound dressing changes were not performed with appropriate use of personal protective equipment (PPE) to control infections and communicable diseases for two (2) of twenty-nine (29) sampled patients. One therapy staff cross-contaminated the equipment utilized to administer medication to one (1) patient. One staff failed to appropriately disinfect equipment following use on a patient in a contact isolation room.

The findings include:

1. Observations on 02/22/10 at 11:45am revealed Staff #2, a nurse, failed to change her gloves and wash her hands between dressing changes for Patient #7. The nurse did not wash or disinfect her hands prior to putting on gloves to remove the patient's dressings on the patient's right heel and buttocks. The patient assisted in removing the old dressing with bare hands. Staff #2 sprayed the wound on the heal with a wound cleanser and wiped it with a 4x4 gauze. She then placed a 4x4 gauze over the wound and secured the edges with tape. Staff #2 proceeded to clean feces from the patient's buttocks but did not change her gloves nor wash her hands. She then folded the blue pad containing the feces-soiled brief beneath the patient's buttocks and left it rolled under the patient. The nurse removed an outer pair of gloves and tossed them across to the garbage container. The gloves missed the opening and landed on the floor. A second pair of gloves remained on the nurse's hands as she prepared to dress the stage IV pressure wound to the left ischium. The nurse sprayed the wound with the wound cleanser and wiped the wound several times with the same 4x4 gauze. Without changing gloves and sanitizing her hands, the nurse then poured Dakins solutions onto 4x4 gauze, compressed the wet gauze in her gloved hands and packed the gauze into the open wound. The wet gauze was covered by a couple of dry gauze pads. As the nurse picked up a roll of tape it fell to the floor which she retrieved and returned to the table with the clean supplies. She then obtained another roll of tape to secure the dressing to the patient's left ischium while wearing the same gloves. Staff #2 failed to remove the soiled pad beneath the patient and did not wash her hands or change her gloves as directed by the facility policy.

Medical record review on 02/22/10 for Patient #7 revealed diagnoses of MRSA of the wound, Paraphelegia, Hepatitis C, and Deep Vein Thrombosis. Physician orders were documented for dressing changes to the patient's right heel stage III decubitus and a stage IV left ischial tuberosity decubitus.

Interview on 02/22/10 at 11:50am with Staff #2 revealed she normally double-gloved just in case she had to clean up after a patient. She stated she thought she had changed her gloves.

Interview on 02/22/10 at 11:55am with Staff #1, a nurse manager, revealed the soiled pad should have been completely removed prior to initiating the dressing change. She stated staff were to change their gloves and wash their hands prior to changing the dressing. She further revealed staff were to change gloves/disinfect their hands once they removed the soiled dressings prior to cleaning and redressing the wound. In addition, she stated the tape should have been disposed of when it fell to the floor and should not have cross-contaminated the other clean supplies. She said the staff should have changed her gloves prior to completing the dressing change for Patient #7.

2. Observation on 02/23/10 at 10:50am revealed Staff #11, a wound care nurse, changed a wound dressing for Patient #24 but failed to change gloves and sanitize her hands properly while doing so. Following the removal of the old dressing, removing gloves, sanitizing her hands and applying clean gloves, the nurse was observed to clean the wound on the patient's coccyx with a piece of gauze sprayed with Sea Cleanser. The nurse wiped the area of the wound and margins of the wound with the damp gauze, disposed of the gauze, and moved immediately back to the area where supplies were set up for the dressing change. She did not change gloves or sanitize her hands. The nurse then opened a bottle of Dakins 1/8 strength solution, poured it onto gauze, packed the wound with the gauze, placed a gauze dressing over the wound and secured it with tape.

In an interview with Staff #11 immediately following the dressing change, the nurse revealed that she should have foamed her hands and changed her gloves when moving from a dirty area (cleaning of the wound) to a clean area (packing and dressing the wound). The nurse stated she thought she had done that.

Review of the facility policy dated 10/08 for "Applications of Dressings and Compresses; Function: Care of Patients (TX); Infection Control (IC);" revealed the purpose was to provide dry aseptic or sterile dressings for promotion of healing a wound in a non-contaminated environment and to prevent the development/spread of an infection from an infected site. The procedure identified the staff were to prepare a clean dry work area at the bedside, wash hands thoroughly, prepare the equipment, and assemble them on an aseptic or sterile field created from the dressing wraps. The staff were then to apply the gloves, remove old dressings and place the old dressing in a plastic bag with the now-dirty gloves. The next step identified was to apply a new set of gloves and clean the skin around the wound as necessary with aseptic solution as prescribed using sterile 4x4's (gauze). Staff were then to apply clean dressings and secure the dressings with tape if the patient was not allergic to the tape. Staff were to discard the plastic bag containing the old dressing into a red bag waste can and wash their hands thoroughly.

3. Observation on 02/23/10 at 9:10am of Staff #18, a Respiratory Therapist, revealed as she was preparing the nebulizer for Patient #25's breathing treatment, the staff opened the medication and the tip of the container fell to the floor. Staff #18 picked up the plastic tip with her gloved hand but failed to change her gloves and disinfect her hands prior to pouring the medication into the nebulizer cup. After contaminating the face mask the surveyor intervened. Staff #18 changed the glove on her right hand and continued to administer the breathing treatment via the nebulizer for Patient #25.

Medical record review for Patient #25 on 02/23/10 revealed the patient had a diagnoses of; Respiratory Insufficiency, Trache, and had history of Intraabdominal Sepsis, Asthma, and Obstructive Sleep Apnea.

Interview on 02/23/10 at 9:30am with the Respiratory Therapist revealed she had cross-contaminated the face mask and nebulizer. She stated she should not have picked up the plastic medication tip until she had completed the treatment.

Interview on 02/23/10 at 11:00am with the Chief Clinical Officer (CCO) revealed the Respiratory Therapist should have immediately changed her gloves and disinfected her hands prior to administering the breathing treatment for Patient #25.

Review of the Hand Hygiene policy revised 01/2007 revealed hand hygiene would be done after situations during which microbial contamination of the hands is likely to occur (ie.contact with potentially contaminated environmental surfaces).

4. Observation on 02/22/10 at 11:30am revealed RN #13 taking a glucometer (piece of medical equipment used to test a patient's blood sugar level) into a patient's isolation room, using it, and bringing it back out of the patient's room without using proper cleansing technique of the glucometer. RN #13 wiped the glucometer with a dry cloth after it was taken from the patient's room.

Interview with RN #13 on 02/22/10 at 11:35pm revealed the glucometer should have been wiped down with a Clorox wipe before removing it from the patient's room. She stated she had been in-serviced on proper infection control technique regarding cleansing of medical equipment taken into an isolation patient room, but failed to use proper technique.

Interview with the CCO on 02/22/10 at 11:40am revealed the Clorox wipe should have been used to cleanse the glucometer.

Interview with the Infection Preventionist on 02/25/10 at 2:10pm revealed the glucometer used by RN #13 on 02/22/10 should have been cleansed with a Clorox wipe and this is what the nursing staff was trained to do for infection control.

Based on observation and interview it was determined the hospital failed to ensure proper storage for the surgical care unit (SCU) bronchoscope.

The Findings include:

Observation of the storage area in the surgical care unit (SCU) on 02/24/10 at 2:45pm revealed no cabinet for storage of the bronchoscope. The bronchoscope was unavailable for observation.

Interview with the monitor technician on 02/24/10 at 2:45pm revealed the bronchoscope was kept in the storage room on top of a cart and covered with plastic.

Interview with the interim Director of Surgical Services on 02/24/10 at 2:15pm revealed she was unaware of the SCU bronchoscope. She stated all scopes should be kept in the endoscopy storage cabinets, hanging upright to promote proper drainage after cleaning. She stated the cabinet doors should be closed to prevent contamination from an outside source.

Interview with the Director of Surgical Services orientee on 02/25/10 at 9:00am revealed the bronchoscope for the SCU was located in the manager's office. He stated the scope was coiled in a towel. It was stated this was not the correct way to store a scope because it did not allow for proper drainage. He acknowledged improper storage of scopes can cause bacteria to grow inside the scope and become an infection control issue potentially causing harm to the patient.

The hospital policy with a revision date of 01/10 states, after scopes are terminally cleaned and disinfected using the Medivator, they are to be hung in the storage area.

Based on observation, interview, and record review it was determined the facility failed to ensure medications were administered for one (1) of thirty-seven (37) sampled patients in the accurate dosage as ordered by the physician.

The findings include:

Observation on 02/23/10 at 9:35am revealed Staff #14, a nurse, was preparing medications for Patient #27. The nurse removed a 20mg scored tablet of Citalopram from the packet and held the tablet between her thumb and forefinger of both hands as she applied pressure to snap the tablet into two pieces. Staff #14 placed one half of the tablet into a medication cup and disposed of the other half. The nurse obtained a round tablet identified as Reglan 10mg and placed it on the packet it was dispensed in and then placed it on the top of the cabinet. The nurse obtained a covered needle which she utilized to cut the scored pill into two unequal parts. The nurse took the needle when questioned of the accuracy of the dosage and began to pierce away parts of the thicker tablet. The nurse discarded the smaller of the tablet, dropped the tablet for patient administration onto the table, picked it up with her gloved hand and placed it into the medication cup. Staff #14 removed the tablets of Protonix, Vitamin C, Docusate, and Synthroid from the packets with her gloved hand and placed them in the medication cup prior to administering the medications to Patient #27.

Interview with Staff #14 revealed the physician had ordered 10mg of Citalopram and 5mg Reglan for Patient #27. However the tablets came to the unit as 20mg of Citalopram and 10mg of Reglan. She stated the tablets were scored and the usual way to break the pills were to snap them into two halves and discard one half. She stated staff normally used a needle to pierce round pills such as the Reglan and break them into two pieces. She stated they would discard the unused portion. Staff #14 stated they did not have pill splitters on the unit. The nurse stated she could not really be sure if the dosage was accurate without using a pill splitter.

Interview on 02/23/10 at 11:00am with Staff #15, the Chief Clinical Officer, and Staff #32, the Chief Clinical Officer, on 02/24/10 at 1:05pm, revealed the pharmacy should send the medication in the available doses. Although, the facility did not have a policy regarding splitting tablets, they stated the nurses should use a pill splitter for accuracy of the dosage. They said that medication dropped onto another surface should have been discarded. They stated medication was not to be handled as it was not good nursing practice.

Review of the facility policy # H-MM 50-001 for Administering Medications revealed "for tablets/capsules, open the unit dose medication package directly into the patient's hand or into a medication cup." The policy also required the staff administering medication to follow the seven (7) rights of medication administration including the "right dose".