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Based on interviews and document review the facility failed to obtain restraint orders immediately after the restraint was applied in 1 of 3 restraint medical records reviewed (Patient #1).

This failure created the potential for an unsafe patient care environment in which the responsible attending physician or LIP was not aware of the patient's medical needs and current health status.

FINDINGS

POLICY

According to Restraint/Seclusion an order for restraint or seclusion must be obtained from a Licensed Independent Practitioner (LIP) /physician who is responsible for the care of the patient prior to the application of restraint or seclusion. When an LIP/physician is not available to issue a restraint or seclusion order, an RN with demonstrated competence may initiate restraint or seclusion use based upon face-to-face assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint or seclusion is initiated.

1. The facility did not obtain a restraint order immediately after the restraint was initiated for Patient #1.

a) On 01/31/17, a review of Patient #1's medical record was completed. Documentation revealed restraints were applied to Patient #1 on 11/2/16 at midnight. Further review revealed a physician's order for restraints was obtained on 11/2/16 at 8:41 a.m. Patient #1 was restrained for 8 hours and 41 minutes before an order for restraints was obtained.

b) During an interview on 02/01/17 at 2:49 p.m., Registered Nurse (RN) #2 stated if a restraint order had not been obtained before restraint application an order should have been obtained immediately after a patient was restrained. RN #2 stated s/he thought an order needed to be obtained within one hour of restraint application during these emergency situations.

c) During an interview on 02/02/17 at 8:38 a.m., Director of Patient Care (Director) #6 stated restraint orders needed to be obtained immediately after application of restraints. S/he stated Patient #1's restraint order was not obtained quick enough. Director #6 stated Patient #1's restraint documentation did not follow facility policy.

d) During an interview on 02/02/17 at 10:00 a.m. a review of Patient #1's medical record was done with Director of Clinical Education (Director) #4. Director #4 stated Patient #1's restraint documentation was not ok. S/he further stated restraint orders needed to be obtained within minutes of restraint application.

e) During an interview on 02/02/17 at 11:15 a.m. Chief Nursing Officer (CNO) #7 stated staff was expected to follow facility policy. CNO #7 stated the restraint order for Patient #1 was obtained too late.

Based on observations and interviews, the facility failed to provide a sanitary environment with a lack of adherence to professionally acceptable standards of practice for infection control during medication administration. Additionally, the facility failed to follow approved policies and professionally acceptable standards during blood transfusions and intravenous (IV) medication administration.

This failure created a potential for the transmission of infectious organisms and negative patient outcomes.

FINDINGS:

POLICY

According to the Hand Hygiene policy, if hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described below. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient as well as a patient chart that has been taken to the bedside and handled during the assessment. Decontaminate hands after removing gloves. Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure.

According to Blood/Blood Component Transfusion, the blood infusion rate will be no greater than 120 milliliters (ml)/hour for the first 15 minutes unless indicated by age of clinical condition. The blood infusion rate will be increased to infuse the unit as fast as tolerated or per physician order if no adverse reaction occurred within the first 15 minutes of blood transfusion. Vital signs will be checked and documented: prior to transfusion (within 30 minutes).

REFERENCE

According to Peripheral IV and Central Line Maintenance Review, flush before and after each use using vigorous pulsatile technique, wiping with Chlorhexidine Gluconate (CHG)/Alcohol antiseptic wipe for 10 seconds between every flush.

According to the Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health-Care Settings, hand contamination may occur as a result of small, undetected holes in examination gloves, contamination may occur during glove removal, and wearing gloves does not replace the need for hand hygiene. Indications for hand hygiene were: contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed), contact with environmental surfaces in the immediate vicinity of patients, and after glove removal.

According to the CDC, Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it.

According to the World Health Organization (WHO) Guideline for Hand Hygiene in Health - Care Settings wash hands with soap and water when visibly dirty or visibly soiled with blood or other body fluids or after using the toilet. If exposure to potential spore-forming pathogens is strongly suspected or proven, including outbreaks of C. Difficile, hand washing with soap and water is the preferred means. Use an alcohol-based handrub as the preferred means for routine hand antisepsis in all other clinical situations if hands are not visibly soiled. If alcohol-based handrub is not obtainable, wash hands with soap and water. Perform hand hygiene: a) before and after touching the patient, b) before handling an invasive device for patient care, regardless of whether or not gloves are used, c) after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings, d) if moving from a contaminated body site to another body site during care of the same patient, e) after contact with inanimate surfaces and objects (including medical equipment) in the immediate vicinity of the patient, f) after removing sterile or non-sterile gloves Before handling medication or preparing food perform hand hygiene using an alcohol-based handrub or wash hands with either plain or antimicrobial soap and water. Soap and alcohol-based handrub should not be used concomitantly.

1. The facility failed to ensure patient care staff administered medication according to established guidelines and approved medical staff practices regarding hand hygiene and IV medication administration.

a) On 01/30/17 at 1:50 p.m., Registered Nurse (RN) #1 was observed administering medication to Patient #6. RN #1 accessed the Pyxis medication system and obtained Patient #6's medication. S/he then entered Patient #6's room without performing hand hygiene. RN #1 documented the medication administration via the computer keyboard in Patient #6's medical record. S/he then opened the medication, put the pills into a medication cup, and administered them to Patient #6. RN #1 did not perform hand hygiene after documenting on the keyboard or before handling the medication and administering it to Patient #6. RN #1 did not perform hand hygiene when exiting Patient #6's room. These observations were in contrast to facility policy.

b) On 02/01/17 at 8:35 a.m., RN #11 prepared an injection for Patient B. RN #11 removed the IV medication from the Pyxis medication system, checked to ensure the correct medication was removed, and obtained a needle to instill sterile saline into the medication vial. RN #11 did not scrub the hub of the medication vial before inserting the needle into the medication vial. This was in contrast to CDC standards of care.

c) On 02/01/17 at 10:22 a.m., RN #2 was observed administering medication to Patient C. RN #2 touched Patient C's arm with clean gloved hands, s/he then touched the computer keyboard to document into Patient C's electronic medical record. RN #2 touched Patient C with the same-gloved hands and scanned Patient C's wristband, s/he then documented on the computer keyboard with the same contaminated gloves. RN #2 then changed gloves without performing hand hygiene. Next, RN #2 drew up the IV medication to administer. Before administering the medication to Patient C, RN #2 leaned over, picked trash up off the floor,and discarded it. RN #2 then touched the Patient C's IV tubing and administered the IV medication with the same contaminated gloved hands. RN #2 washed hands with soap and water for approximately 2-3 seconds. These observations were in contrast to facility policy.

During the same observation, RN #2 prepared the IV medication for administration via a peripheral line in Patient C's left hand. RN #2 removed the plastic cap off the medication vial; s/he did not scrub the rubber hub on the medication vial before drawing up the medication. It was noted that RN #2 retrieved a sterile saline syringe to flush Patient C's IV before administering the medication. RN #2 scrubbed the end of the saline flush syringe, but did not scrub the hub of the IV before administering the flush.

During the same observation, RN #2 noticed Patient C's left hand peripheral IV was leaking when the IV flush was administered. Patient C stated s/he felt fluid running between his/her fingers when RN #2 flushed the IV. RN #2 wiped the extra fluid coming from the IV and continued to administer IV medication into the leaking IV. After administering the IV medication, RN #2 wiped the extra fluid leaking around Patient C's IV.

d) On 02/01/17 at 2:50 p.m. an interview was conducted with RN #2. S/he stated hand hygiene was to have been performed when entering and exiting a patient's room. RN #2 further stated if patient's surroundings were touched, hands had to be cleaned before you touched the patient. RN #2 reported hand hygiene was to help prevent an infection and so patient's surroundings were not contaminated. RN #2 stated s/he could not be certain Patient C was given the full dose of their IV medication due to the IV leaking when the medication was administered.

e) During an interview on 02/02/17 at 10:56 a.m., Infection Preventionist (RN) #3 stated hand hygiene should be done when gloves were changed. S/he also stated hand hygiene needed to be performed after touching the computer keyboard and before touching a patient. RN #3 stated hand hygiene also must be performed again after touching the patient and before touching the computer. RN #3 stated if a nurse removed trash from the floor s/he should have removed their gloves after picking up the trash, perform hand hygiene and then put on a clean pair of gloves before performing patient care. RN #3 reported that the required time to effectively perform hand hygiene with soap and water was 15 to 20 seconds. S/he stated the reason for hand hygiene was to stop infections and make sure one did not cause transmission of an infection. RN #3 stated hand hygiene was known to protect the patients and was the number one way to stop the spread of infection. S/he further stated the cultural expectation for all staff regarding hand hygiene was based on the World Health Organization (WHO) five moments in hand hygiene.

f) During an interview on 02/02/17 at 10:00 a.m., Director of Education #4 (Director) stated staff were educated and expected to follow policy regarding hand hygiene during medication and blood product administration.

g) During an interview on 02/02/17 at 10:00 a.m., RN #5 stated s/he also assisted in staff education. S/he stated staff were educated and expected to follow policy regarding hand hygiene during medication administration.

h) On 02/02/17 at 8:38 a.m., the Director of Patient Care (Director #6) was interviewed regarding hand hygiene. Director #6 stated staff were expected to follow the policy regarding hand hygiene, as it was the number one action to prevent infection between patients and staff. S/he also stated the length of time required for safe hand hygiene when soap and water were used was to sing the ABC song and use friction, 2-3 seconds of friction was not sufficient. Director #6 stated hand hygiene should always be performed after touching the computer and before touching the patient. S/he also stated hand hygiene should have been performed after picking trash up from floor and before contact with the patient.

i) During an interview on 02/02/17 at 11:15 a.m., Chief Nursing Officer (CNO #7) stated s/he expected all staff to follow the facility's policies. CNO #7 stated their cultural expectation with regard to hand hygiene was based on the WHO five moments in hand hygiene and should have always been done before patient care. CNO #7 further stated IV medication administration could not be guaranteed if the the medication was administered through an IV which was leaking.

2. The facility failed to ensure patient care staff administered blood products according to established guidelines and approved medical staff practices regarding the rate of administration.

a) During an observation on 01/30/17 at 3:34 p.m., RN #9 administered a blood product to Patient A. RN #9 scrubbed the central line hub with alcohol and flushed the line with a saline syringe. RN #9 then attached the IV tubing for blood product administration to the central line without scrubbing the hub of the central line catheter with alcohol. RN #9 then started the infusion rate at 125 ml per hour. This was a faster rate than the facility policy stated for blood product administration.

b) During an observation on 02/01/17 at 11:45 a.m., RN #12 administered a blood product to Patient D. RN #12 explained s/he would start the infusion at 120 ml per hour. RN #12 stated all blood products were started at this rate to monitor the patient for a transfusion reaction. RN #9 then set the blood product to infuse at a rate of 125 ml per hour. This was in contrast to his/her explanation and facility policy.

c) During an interview on 02/02/17 at 10:56 a.m., RN #3 (Infection Preventionist) stated it was important not to introduce microorganisms into central lines due to the risk of infection. RN #3 stated staff was provided education on peripheral IV and central line maintenance. As referenced above and stated by RN #3 the education stated to wipe the central line access with CHG/Alcohol wipe between every flush and for each access. RN #3 stated RN #9 should have scrubbed the hub of the central line after the saline flush and before the blood product was attached.

d) During an interview on 02/02/17 at 8:38 a.m., Director #6 stated the policy did not state to start the blood product administration at 120 ml per hour. However, review of the policy confirmed the blood infusion rate will be no greater than 120 ml per hour for the first 15 minutes.

e) During an interview on 02/02/17 at 11:15 a.m., CNO #7 stated RNs should have followed the blood product administration policy regarding the rate to start blood product infusion.