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Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) supervised the care of one (1) of 4 sampled patients on the Intermediate Care Unit (East Houston Regional) on an on-going basis (Patient # 61).

RN failed to ensure Patient #61 was weighed daily per physician's order.

Findings include:

Record review of the clinical record of Patient #61 revealed he was a 59-year-old male admitted the the facility on 09/14/2016 with a diagnosis of acute bronchitis and a history of congestive heart failure and atrial fibrillation.

Further review revealed a physician order, dated 09/14/2016, that read: "weigh patient daily."

Record review on 09/22/2016 of the recorded weights for Patient #61 showed daily weights had been missed for four (4) of the last seven (7) days. RN #198 was unable to locate documented weights for Patient #61 for September 16, 19, 20 and 21, 2016.

Interview at this same time, RN #198 stated nursing was responsible for ensuring physician's orders were implemented.

Based on observation, interview and record review the facility failed to ensure that nurses maintained current nursing care plans for 2 of 5 patients on the Medical/Surgical Units at East Houston Regional.

Findings include:

-- Patient #80 on the north medical/surgical unit.

Observation of Patient #80's food tray on 09/22/16 at 1000 revealed a clear liquid diet.

In an interview with RN #201 on 9/22/16 at 1000 on north medical/surgical unit, she stated that nursing care plans are to be maintained on a "daily basis" as the status of the patient changes.

Record review of Physician Order dated 09/21/16 revealed an order for Patient #80 to have a clear liquid diet.

Record review of Nursing Care Plan for Patient #80 dated 9/22/16 [no time] revealed nothing by mouth status.


-- Patient #82 on the south medical/surgical unit.

Observation of Patient #82 on 9/22/16 at 01100 revealed a cachetic elderly female with a nasogastric tube in left nare.

Record review of Nursing Care Plan for Patient #82 dated 9/21/16 [no time] revealed that malnutrition had not been identified as a problem by nursing.

In an interview with RN Manager #182 on 9/22/16 at 1045 she stated that the nursing care plan should have identified malnutrition as a problem.

In an interview with Dietician #197 on 9/22/16 at 1300 she stated:
-She was very familiar with this patient's physician's protocol for TPN (Total Parenteral Nutrition);
-She shared with the nursing staff her diagnosis of malnutrition;
-She confirmed with the physician her recommendation for TPN at a rate of 40cc/hour; and
-She wrote an order for TPN and sent it to pharmacy.

Based on interview and record review, the facility failed to ensure that verbal orders were authenticated per facility policy for one (1) of two sampled patients in the Intensive Care Unit (ICU) - [ East Houston Regional] - Patient #60.

Two (2) physician orders (verbal) that required signatures within 48 hours remained unsigned after 2 weeks.

Findings include:

Record review on 09/22/2016 of Patient #60's clinical record revealed he was a 71-year -old male admitted to the facility on 09/08/2016 with a diagnosis of Systemic Inflammatory Response, End Stage Renal Disease, and Pulmonary Edema.

Further review of Patient #60's clinical record revealed the following documented "VERBAL" orders by Physician #206:

1. "09/08/2016, time 2200: NS (normal saline) - bolus 500 ml (milliliter) x 1, repeat another after 1 hour. 500 ml continue NS at 60 ml/hr. ("read back & verified")

2. "09-08-16 , time 2200: continue NS, 1 liter @ 60 ml hour. ("read back & verified")

Interview on 09/22/2016 at 10:45 A.M., at the time of review with ICU Registered Nurse (RN) #203, she stated the verbal orders should have been signed by the physician within 48 hours.

Review of facility "Medical Staff Rules & Regulations," dated 08/02/2016, read: "...Read back and clarification of verbal and telephone orders shall be accomplished. The responsible practitioner shall authenticate (date,time, sign, and print name, stamp name or mnemonic entered) such orders within 48 hours..."

Based on record review and interview the facility failed to implement its infection control policies to ensure staff handle, store and use linen in a safe manner to prevent the spread of infection.

The facility failed to ensure staff:
--Clean used equipment and floors;
--Change gloves and wash hands after patient contact to prevent cross contamination and the spread of infection; and
--Wear personal protective equipment (PPE) when entering rooms of patients on isolation precautions.

This failed practice had the potential for the spread of infection to staff and patients.

Citing random observations on two (2) of four (4) medical/surgical units; two (2) of two(2) operating Room suites.

Findings included:
Observation on 9/20/2016 on Medical/Telemetry Unit (Unit 4) at 10:45am revealed Patient #30 was lying in bed with a Foley Catheter attached to a urine drain bag. The bag was on the floor atop a patient bath towel.

Observation at 11:25am on (Unit 4) revealed Staff #131, a Licensed Vocational Nurse, was providing care that included suctioning for Patient #32 who was on contact isolation for MRSA (Methicillin-resistant Staphylococcus Aureus) of the nares.

Staff #131 rolled her work station on wheels (WOW) containing paper work, a phone, computer and other supplies into the patient's room.

After completing Patient #32's care, Staff #131 left the patient's room with the WOW and failed to clean all the attachments on the cart, including the scanner, post and base of the cart.

During an interview on 9/20/2016 at 11:30am with Staff #132 (the RN Manager), she stated staff should not use patient towels on the floor and that the urine bags should be placed in a container. Staff #132 further stated the WOWs were used in all patient rooms and should be cleaned from top to bottom after each use.

Review of the facility's infection control infection control policy and procedure dated July 2016, revealed the following information: "Reusable equipment will be cleaned and reprocessed appropriately before use in the care of another patient. Do not place soiled linen on the floor"



37266


Clean utility room.
Observation of the north medical/surgical unit at East Houston Regional on 9/22/2016 at 0945 revealed a dust ball on the floor in the clean utility room.

In an interview with RN #201 on 9/22/2016 at 0945, she stated that the dust ball should not be there.

Record review of the facility's policy, "Cleaning Procedure-Utility Rooms" dated 8/2008 stated: "#11 ... Dust mop floor, starting in the far corner of the room and working back toward entrance ... #17 ... Inspect the room."


Cross contamination.
Observation on south medical/surgical unit on 9/22/2016 at 1045 revealed RN #166 performing pericare on Patient #82. After removing the patient's diaper, the nurse went to the patient's storage area without removing her gloves. She then changed gloves without sanitizing her hands. She provided the pericare and retaped the diaper. She then picked up the periwipe container with contaminated gloves and replaced the container in the storage area. She removed her gloves and, only with the prompting by RN Manager #182, washed her hands.

In an interview with RN #182 on 9/22/2016 at 1045, she stated that RN #166 contaminated the peri-wipes container when she did not wash her hands.

Record review of the facility's policy, "Isolation, Standard Precautions/Transmission Based Precautions" dated 01/2015 stated: "All healthcare workers will practice proper hand hygiene and adhere to the 'Hand Hygiene and Artificial Nails' policy [and] wear disposable medical examination gloves for providing direct patient care ... remove gloves after contact with a patient and/or surrounding environment (including medical equipment), using proper technique to prevent hand contamination ... Change gloves during patient care if the hands will move from contaminated body site to a clean body site."



37322


Soiled linen supply room.
Observation on south medical/surgical unit on 9/22/16 at 1100 revealed a bag of soiled linens on the floor.

In an interview with RN #182 on 9/22/16 at 1100, she stated that the bag of soiled linens should not have been on the floor.

Record review of facility's policy, "Isolation Standard Precautions/Transmission Based Precautions" dated 01/2015 stated: "Soiled linen including towels, wash cloths, and patient clothing may be contaminated with pathogenic organisms ... Do not place soiled linen on the floor."



37490


Bayshore Medical Center.
Observation one (1) of one (1) surgical skin preparation for surgery at Bayshore Medical Center on 9/20/2016 at 11:45am revealed the following:

Registered Nurse circulator #137 performed skin asepsis for patient #13 while wearing a short-sleeved scrub top.

Interview with Perioperative Services Educator #199 on 9/21/2016 at 9:27am revealed that facility policies are based on recommended practices of the Association of Perioperative Registered Nurses (AORN). Facility policies are updated every three (3) years. When new recommendations are presented by AORN policies are looked at and are updated if needed. Educator #199 acknowledge having knowledge of recommendation by AORN for nurses performing skin asepsis is to wear a long-sleeved jacket to avoid skin squames from the nurses bare arm to drop onto the the area being prepped, increasing the risk of surgical site infection.

Record review of the facility policy titled, "Attire for Restricted and Semi-Restricted Areas," dated 8/2016, revealed the following: "Non scrubbed personnel are encouraged to wear long-sleeve jackets in the operating room during the procedure."


East Houston Regional Hospial.
Observation at East Houston Regional Hospital in the Surgical Services department on 9/22/2016 at 10:32am revealed the following:

Physician #179 entered the Surgical Services area wearing his white lab coat. He proceeded to the operating room where surgery was in progress for patient #74. Physician #179 did not have a surgical mask on. He stuck his head and shoulder into the room to speak to surgeon #193 and then left the Surgical Services area.

Interview with Director of Perioperative Services #171 on 9/22/2016 at 10:32am revealed that physicians were not allowed to wear lab coats into the restricted area and that there was a designated area for lab coats to be placed.

Interview with Physician #179 revealed that he was aware of the proper attire required in the restricted area and acknowledge that he broke protocol.

Record review of facility policy titled, "Attire for Restricted and Semi-restricted Areas," dated 8/2016 revealed the following: "Appropriate surgical attire will be worn to promote high-level cleanliness and hygiene and to reduce microbial contamination in the environments where sterile procedures are performed."



23032


Bayshore Medical Center.
Observation on 09/20/2016 at 11:40am outside Patient #23's room on the Intermediate Care Unit (IMCU) at Bayshore Medical Center revealed lab technician #157 donned a gown, gloves and mask. Further observation revealed a sign on the patient's door that read: "STRICT CONTACT Precautions."

In an interview at the time of observation with lab technician #157, she said the difference between "strict contact" and "contact" isolation was that "strict contact meant more PPE (personal protective equipment) was worn; a mask was needed because of airborne issues."

Further observation revealed lab technician #157 entered Patient #23's room and performed venipuncture to obtain blood samples for lab tests. Prior to exiting the room, she removed the PPE and sanitized her hands with hand gel. She failed to wash her hands with soap and water.

In an interview with IMCU Manager #119 at the time of observation, she stated, "STRICT contact precautions meant the patient had a C. Diff (Clostridium difficile) infection. Staff were required to wear gown and gloves and wash their hands prior to entering and prior exiting the room with soap and water. In addition, all hard surfaces and equipment within the patient's room must be cleaned with bleach wipes."

Record review of lab results for Patient #23, dated 09/16/2016 read: "...positive antigen and toxin: indicates POSITIVE for presence of C. Difficle."


East Houston Regional.
Observation on 09/22/2016 at 11:10am outside room #2907 revealed a sign on the door that read "STRICT Contact Isolation." Room #2909 (adjacent to #2907) had a sign that read "CONTACT Isolation."

In an interview at the time of observation with Housekeeper #164, she stated the difference between strict contact and contact precautions was "for STRICT we are more careful, more strict. We cover up more because it is airborne." When asked if the patient room was cleaned differently for strict contact precautions, Housekeeper #164 stated, "No, we clean the same for all rooms."

Record review of facility policy titled, "Isolation, Standard Precautions/Transmission Based Precautions," dated 07/2016, read: "Strict Isolation - use Strict Contact Precautions for specified patient known or suspected to be infected or colonized ... with important organisms that require the use of hand hygiene and/or the use of bleach products as a disinfectant, such as Clostridium difficle and Norovirus ... 1. Gowns, gloves and Handwashing. A. Perform hand hygiene before entering room. B. Wear gown and gloves when entering room ... E. wash hands with soap and water before leaving room ... 1. Environmental Disinfection: a. All common equipment and environmental surfaces should be disinfected with a bleach product. b. EVS (Environmental Services) to clean room daily with bleach."


Bayshore Emergency Room (ER).
Observation on 09/20/2016 at 10:30am revealed a locked room with a sign, "Soiled Utility" on the door. Further observation revealed several areas of dark red "smears" on the floor.

In an interview with Charge nurse / Registered Nurse #116, she stated, "That looks like blood; it should have been cleaned up." Another staff member provided RN #116 with gloves and bleach wipes. She cleaned the floor and the bottom of her shoes before exiting the room.


East Houston Regional ER.
Observation on 09/22/2016 at 9:30am in Exam Room #5 revealed an open alcove-type storage area. The floor inside this alcove had a thick layer of dirt and grime. In an interview at the time of observation with ER Director #181, she stated this was the space in which the industrial blood alcohol level screening machine was stored. She went on to say someone had removed the machine to use it and the floor should be cleaned.

Further observation in Exam Room #5 revealed a crumpled absorbent pad and a stained adult brief in a storage cabinet. ER Director #181 confirmed the contaminated pad and brief should have been properly discarded and not returned to the cabinet.

Continued observation revealed multiple (5 +) wall-mounted hand sanitizers in the ER had a thick layer of dust on the top of them and also on the "drip tray" at the bottom of the dispenser.

Review of facility policy titled, "Cleaning of Utility Rooms," dated 01/2012, read: "...11. Dust mop floor ... 13. Place a Wet Floor sign at door ... 14. Wring out mop in a bucket of germicidal solution. 15. Damp mop the room, starting at the far corner of the room."


East Houston Regional ER.
Sterile Patient Supplies.
Observation on 09/22/2016 between 0900 and 1000am in the ER revealed the following unwrapped, single-use sterile patient supplies:
--Exam Room # 5: oxygen mask (non-rebreather) and tubing; and
--Respiratory therapy supply area: BiPAP (bi-level positive airway pressure) mask and tubing.

In an interview with ER Director #181 at the time of observation, she stated that, once opened, single use patient supplies should be discarded if not used.


Bayshore Cardiovascular Intensive Care Unit (CVICU).
Linen Transport.
Observation on 09/20/2016 at 11:15am in the CVICU revealed Housekeeper #158 entered the unit through double doors from an outside corridor. She obtained several clean bedsheets and a blanket from the linen cart. Further observation revealed Housekeeper #158 exited the CVICU through the double doors holding the clean linen immediately next to, and touching, her uniform. She continued walking down the hallway.

In an interview with Housekeeper #158 at the time of observation, she started she was taking the linen to a room being prepared for a new patient. CVICU Manager #205 explained to Housekeeper #158 that she had contaminated the linen by holding it next to her dirty uniform. The CVICU Manager also informed the housekeeper that "clean linen should be transported by a linen cart or held away from your body." Housekeeper #158 said, "No one has ever told me this before. "

Review of facility policy titled, "Guidelines for Handling of Linen," dated 01/2012, revealed details for the process for staff handling of soiled linen only; not clean.

Based on observation and interview , the facility failed to have policies and procedure in place to address patient safety concerns in reference to the use of electrocautery grounding pad and placement of patient safety strap.


Findings include:

Observation one (1) of one (1)surgical procedure at Bayshore regional Hospital on 9/20/2016 at 11:30 AM in operating room #7 revealed the following:

Patient #13 had electrocautery grounding pad placed on her left lower extremity. The grounding pad was removed by staff member #137 and repositioned on the same extremity. Patient #13 had the safety strap removed and was placed in lithotomy position, with arms extended slightly less than ninety (90) degrees on arm boards. There was no safety strap replaced on the patient. When surgeon #202 entered the operating room, he questioned the surgical team if the bed was functioning properly. Anesthesiologist #143 proceeded to tilt the table from side to side without any mention of the fact that the patient had no safety strap in place.

In an interview with perioperative services educator #199 on 9/21/2016 at 9:27am, she stated that there were no official policies on grounding pad or safety strap placement. She also stated the Association of Perioperative Registered Nurses (AORN) recommended practices are used to guide nursing practice in the operating room and that nurses at the facility were taught to get a new grounding pad if needed, not to reposition the same one.

In an interview with the Director of perioperative services #200 on 9/21/2016 at 9:30am, she stated that the facility promotes a culture of patient safety by encouraging the staff to speak up when issues of safety arise.

Both the Educator #199 and Director of Perioperative Services #200 acknowledged that none of the surgical team spoke out in regards to patient #13.

Based on record review and interview the facility failed to implement its infection control policies to ensure staff handle, store and use linen in a safe manner to prevent the spread of infection.

The facility failed to ensure staff:
--Clean used equipment and floors;
--Change gloves and wash hands after patient contact to prevent cross contamination and the spread of infection; and
--Wear personal protective equipment (PPE) when entering rooms of patients on isolation precautions.

This failed practice had the potential for the spread of infection to staff and patients.

Citing random observations on two (2) of four (4) medical/surgical units; two (2) of two(2) operating Room suites.

Findings included:
Observation on 9/20/2016 on Medical/Telemetry Unit (Unit 4) at 10:45am revealed Patient #30 was lying in bed with a Foley Catheter attached to a urine drain bag. The bag was on the floor atop a patient bath towel.

Observation at 11:25am on (Unit 4) revealed Staff #131, a Licensed Vocational Nurse, was providing care that included suctioning for Patient #32 who was on contact isolation for MRSA (Methicillin-resistant Staphylococcus Aureus) of the nares.

Staff #131 rolled her work station on wheels (WOW) containing paper work, a phone, computer and other supplies into the patient's room.

After completing Patient #32's care, Staff #131 left the patient's room with the WOW and failed to clean all the attachments on the cart, including the scanner, post and base of the cart.

During an interview on 9/20/2016 at 11:30am with Staff #132 (the RN Manager), she stated staff should not use patient towels on the floor and that the urine bags should be placed in a container. Staff #132 further stated the WOWs were used in all patient rooms and should be cleaned from top to bottom after each use.

Review of the facility's infection control infection control policy and procedure dated July 2016, revealed the following information: "Reusable equipment will be cleaned and reprocessed appropriately before use in the care of another patient. Do not place soiled linen on the floor"



37266


Clean utility room.
Observation of the north medical/surgical unit at East Houston Regional on 9/22/2016 at 0945 revealed a dust ball on the floor in the clean utility room.

In an interview with RN #201 on 9/22/2016 at 0945, she stated that the dust ball should not be there.

Record review of the facility's policy, "Cleaning Procedure-Utility Rooms" dated 8/2008 stated: "#11 ... Dust mop floor, starting in the far corner of the room and working back toward entrance ... #17 ... Inspect the room."


Cross contamination.
Observation on south medical/surgical unit on 9/22/2016 at 1045 revealed RN #166 performing pericare on Patient #82. After removing the patient's diaper, the nurse went to the patient's storage area without removing her gloves. She then changed gloves without sanitizing her hands. She provided the pericare and retaped the diaper. She then picked up the periwipe container with contaminated gloves and replaced the container in the storage area. She removed her gloves and, only with the prompting by RN Manager #182, washed her hands.

In an interview with RN #182 on 9/22/2016 at 1045, she stated that RN #166 contaminated the peri-wipes container when she did not wash her hands.

Record review of the facility's policy, "Isolation, Standard Precautions/Transmission Based Precautions" dated 01/2015 stated: "All healthcare workers will practice proper hand hygiene and adhere to the 'Hand Hygiene and Artificial Nails' policy [and] wear disposable medical examination gloves for providing direct patient care ... remove gloves after contact with a patient and/or surrounding environment (including medical equipment), using proper technique to prevent hand contamination ... Change gloves during patient care if the hands will move from contaminated body site to a clean body site."



37322


Soiled linen supply room.
Observation on south medical/surgical unit on 9/22/16 at 1100 revealed a bag of soiled linens on the floor.

In an interview with RN #182 on 9/22/16 at 1100, she stated that the bag of soiled linens should not have been on the floor.

Record review of facility's policy, "Isolation Standard Precautions/Transmission Based Precautions" dated 01/2015 stated: "Soiled linen including towels, wash cloths, and patient clothing may be contaminated with pathogenic organisms ... Do not place soiled linen on the floor."



37490


Bayshore Medical Center.
Observation one (1) of one (1) surgical skin preparation for surgery at Bayshore Medical Center on 9/20/2016 at 11:45am revealed the following:

Registered Nurse circulator #137 performed skin asepsis for patient #13 while wearing a short-sleeved scrub top.

Interview with Perioperative Services Educator #199 on 9/21/2016 at 9:27am revealed that facility policies are based on recommended practices of the Association of Perioperative Registered Nurses (AORN). Facility policies are updated every three (3) years. When new recommendations are presented by AORN policies are looked at and are updated if needed. Educator #199 acknowledge having knowledge of recommendation by AORN for nurses performing skin asepsis is to wear a long-sleeved jacket to avoid skin squames from the nurses bare arm to drop onto the the area being prepped, increasing the risk of surgical site infection.

Record review of the facility policy titled, "Attire for Restricted and Semi-Restricted Areas," dated 8/2016, revealed the following: "Non scrubbed personnel are encouraged to wear long-sleeve jackets in the operating room during the procedure."


East Houston Regional Hospial.
Observation at East Houston Regional Hospital in the Surgical Services department on 9/22/2016 at 10:32am revealed the following:

Physician #179 entered the Surgical Services area wearing his white lab coat. He proceeded to the operating room where surgery was in progress for patient #74. Physician #179 did not have a surgical mask on. He stuck his head and shoulder into the room to speak to surgeon #193 and then left the Surgical Services area.

Interview with Director of Perioperative Services #171 on 9/22/2016 at 10:32am revealed that physicians were not allowed to wear lab coats into the restricted area and that there was a designated area for lab coats to be placed.

Interview with Physician #179 revealed that he was aware of the proper attire required in the restricted area and acknowledge that he broke protocol.

Record review of facility policy titled, "Attire for Restricted and Semi-restricted Areas," dated 8/2016 revealed the following: "Appropriate surgical attire will be worn to promote high-level cleanliness and hygiene and to reduce microbial contamination in the environments where sterile procedures are performed."



23032


Bayshore Medical Center.
Observation on 09/20/2016 at 11:40am outside Patient #23's room on the Intermediate Care Unit (IMCU) at Bayshore Medical Center revealed lab technician #157 donned a gown, gloves and mask. Further observation revealed a sign on the patient's door that read: "STRICT CONTACT Precautions."

In an interview at the time of observation with lab technician #157, she said the difference between "strict contact" and "contact" isolation was that "strict contact meant more PPE (personal protective equipment) was worn; a mask was needed because of airborne issues."

Further observation revealed lab technician #157 entered Patient #23's room and performed venipuncture to obtain blood samples for lab tests. Prior to exiting the room, she removed the PPE and sanitized her hands with hand gel. She failed to wash her hands with soap and water.

In an interview with IMCU Manager #119 at the time of observation, she stated, "STRICT contact precautions meant the patient had a C. Diff (Clostridium difficile) infection. Staff were required to wear gown and gloves and wash their hands prior to entering and prior exiting the room with soap and water. In addition, all hard surfaces and equipment within the patient's room must be cleaned with bleach wipes."

Record review of lab resu