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Based on observations, policy review, interviews, and record reviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:
1) failure of the RN to ensure each HD patient's vascular access site and bloodline connections were visible at all times for 2 (#17, #19 ) of 4 (#1, #17,# 18, #19) patients observed receiving hemodialysis treatments from a total patient sample of 30 (#1-#30);
2) failure of the RN to ensure physician's orders for blood flow rate and dialysate flow rate were implemented for 2 (#1, #17) of 3 (#1, #2, #17) sampled inpatient hemodialysis recipient records reviewed from a total patient sample of 30 (#1-#30); and
3) failure of the RN to ensure a new bottle of conductivity solution was labeled with the date it was opened in order to ensure the solution was discarded within 90 days of opening per manufacturer's labeling instruction for expiration dates.

Findings:

1) Failure of the RN to ensure each patient's vascular access sites and bloodline connections were visible at all times.

Review of the hospital policy titled, "Intradialytic Treatment Monitoring", Policy Number: 7-05-03, revealed in part: 5.The patient's vascular access site and blood line connections need to be continuously visible throughout the dialysis treatment. Allowing patients to cover access sites and line connections provides an opportunity for accidental needle dislodgement or a line disconnection to go undetected.

Patient #17
On 3/12/19 from 9:00 a.m. - 9:40 a.m. an observation was made of Patient #17 while the patient was receiving hemodialysis treatment. Patient #17's CVC site and bloodlines were completely covered and unable to be observed at all times by staff during the observation. HD nursing staff was observed at the patient's bedside during the observation and the patient was not instructed to uncover their access and bloodlines.

Patient #19
On 3/12/19 from 9:00 a.m. - 9:40 a.m. an observation was made of Patient #19 while the patient was receiving hemodialysis treatment. Patient #19's CVC site and bloodlines were completely covered and unable to be observed at all times by staff during the observation. HD nursing staff was observed at the patient's bedside during the observation and the patient was not instructed to uncover their access and bloodlines.

In an interview on 3/12/19 at 9:45 a.m. with S2DialysisMgr, he confirmed the patient's accesses and bloodlines should have been visible at all times during the patients' HD treatments.

2) Failure of the RN to ensure physician's orders for blood flow rate and dialysate flow rate were implemented.

Review of the hospital policy titled," Prescription Verification and safety Checks", Policy Number: 7-05-01, revealed in part: Purpose: To establish appropriate pre-treatment checks, intradialytic monitoring and documentation for every patient in conjunction with his/her individual plan of care. Policy: 1. Trained dialysis teammates will verify the dialysis prescription and perform safety checks prior to initiation of treatment.

Patient #1
Review of the hemodialysis treatment orders for Patient #1 revealed the physician ordered a BFR as tolerated to a maximum of 400 mL/min and a DFR of 800 mL/min. .

Review of Patient #1's treatment record for 3/9/19 revealed the physician's DFR order was not followed. The DFR was run at 600 mL/min instead of the ordered 800 mL/min from 10:15 a.m. - 11:20 a.m. with no documented reason for decreasing the DFR.

Patient #17
Review of the hemodialysis treatment orders for Patient #17 revealed the physician ordered a BFR as tolerated to a maximum of 300 mL/min and a DFR of 600 mL/min. .

Review of Patient #17's treatment records for 3/4/19, 3/7/19, and 3/9/19, revealed on 3/4/19 and 3/7/19 the physician's BFR order was not followed. The BFR was run at 350 mL/min which exceeded the ordered maximum of 300 mL/min. Further review revealed no documented reason for exceeding the maximum ordered BFR of 300 mL/min.

In an interview on 3/13/19 at 8:31 a.m. with S2DialysisMgr, he confirmed HD patients' physician's orders for BFR and DFR should have been followed by staff members. He verified there should have been a documented reason in the patients' treatment records indicating why the DFR and BFR were not implemented as ordered.


3) Failure of the RN to ensure a new bottle of conductivity solution was labeled with the date it was opened.

Review of the hospital policy titled,"Calibration Check and Calibration of Dual Range Conductivity Meter (2D)", Procedure Number: 7-11-04K, revealed in part: Notes: When a new bottle of conductivity solution is opened, label with date opened. Follow manufacturer's labeling of the solution for expiration dates.

On 3/12/19 at 9:15 a.m. an observation was made of a bottle of CalRite Conductivity Solution. Review of the manufacturer's label revealed the solution would expire in 90 days after being opened. Additional observation revealed the bottle had been opened and had no label indicating the date it had been opened.

In an interview on 3/12/19 at 9:45 a.m. with S2DialysisMgr, he confirmed the conductivity solution should have been dated when it was opened.

30984

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current individualized and comprehensive care plans for 2 (#2, #17) of 2 sampled HD patients' records reviewed for care plans from a total patient sample of 30 (#1-#30).

Findings:

Patient #2
Review of Patient #2's electronic medical record revealed an admission date of 2/17/19 with diagnoses including Diabetes and ESRD requiring hemodialysis treatment 3 times a week. Further review revealed the patient had an AVF (arteriovenous fistula) right arm access for HD treatment.

Review of Patient #2's care plan revealed monitoring of/care of the patient's AVF right arm access and Diabetes were not addressed as identified problems on the patient's plan of care.

In an interview on 3/11/19 at 3:00 p.m. with S5RN, chart navigator, he confirmed dialysis related monitoring of/care of the patient's right arm AVF access and Diabetes were not addressed as identified problems on the patient's plan of care, during review of the patient's electronic medical record.


Patient #17
Review of Patient #17's electronic medical record revealed an admission date of 3/2/19 with diagnoses including Diabetes Mellitus Type II and ESRD requiring hemodialysis treatment 3 times a week. Further review revealed the patient had a CVC (central venous catheter) access for HD treatment.

Review of Patient #17's care plan revealed monitoring of/care of the patient's CVC access was not addressed as identified problems on the patient's plan of care.

In an interview on 3/12/19 at 3:00 p.m. with S5RN, chart navigator, he confirmed dialysis related monitoring of/care of the patient's CVC access was not addressed as an identified problem on the patient's plan of care, during review of the patient's electronic medical record.

Based on observation, interview, and record review, the hospital failed to ensure the infection control officer developed and implemented a system for controlling infections and communicable diseases of patients and personnel. This deficient practice was evidenced by:
1) failure to ensure staff performed hand hygiene between patients, after contacting potentially contaminated patient care surfaces, and after glove removal; and
2) failure to ensure supplies taken to the patient HD station during treatment were not returned to the supply cart (clean area).

Findings:

1)Failure to ensure staff performed hand hygiene between patients, after contacting potentially contaminated patient care surfaces, and after glove removal.

Review of the hospital policy titled, "Hand Hygiene", Policy Number: 7-03-02, revealed in part: Purpose: To prevent the spread of microorganisms and cross contamination between teammates, patients, and equipment. Policy: 1. Hands will be washed upon entering the hospital/facility, prior to gloving, after removal of gloves, between patients, after contamination with blood or other infectious material, after patient and contaminated machine contact, between patients, before touching clean areas such as counter tops, supply carts or medication carts, and at the close of the business day prior to going home.

On 3/12/19 at 9:00 a.m. S2DialysisMgr was observed removing his gloves. S2DialysisMgr failed to sanitize his hands after glove removal.

On 3/12/19 at 9:15 a.m. an observation was made of S3RN moving between Patient #17 and Patient #18's machines, touching the screens to get readings off of the machines, with the same gloves on. S3RN failed to change her gloves and sanitize her hands after touching Patient #17's machine and prior to moving to Patient #18's machine.

On 3/12/19 at 9:25 a.m. S4RN was observed to go from Patient #17 to Patient #18 to Patient #19, documenting at the bedside. S4RN failed to sanitize her hands between the patients.

On 3/12/19 at 9:34 a.m. an observation was made of S3RN providing care to Patient #1 at the patient's bedside. After providing care she removed her gloves and failed to sanitize her hands after glove removal. S3RN was then observed going to the nurses' station.

In an interview on 3/12/19 at 9:45 a.m. with S2DialysisMgr, he confirmed hand hygiene should have been performed with glove changes and between patients.

2)Failure to ensure supplies taken to the patient HD station during treatment were not returned to the supply cart (clean area).

Review of the hospital policy titled," Infection Control in the Hospital Dialysis Setting", Policy Number: 7-03-01, revealed in part: Purpose: To promote a safe, clean environment for all patients and teammates of the dialysis unit and to reduce the risk of spreading infections or blood borne pathogens in a hospital dialysis setting.
Policy: 3. Medication vials, syringes, tape, alcohol swabs, dressings, gloves or other supplies will not be carried in pockets or placed on the patient's bed.
24 ... ... Items taken to the patient station during the treatment will not be returned to the supply cart.

On 3/12/19 at 9:12 a.m. an observation was made of S3RN taking a roll of tape to Patient #1's bedside in the treatment area. She was then observed taking the tape back to the clean area.

In an interview on 3/12/19 at 9:45 a.m. with S2DialysisMgr, he confirmed supplies taken to the patient bedside/care area should not be returned to the clean supply area.

Based on observations, interviews, and record reviews the hospital failed to ensure the Surgical Services Department followed acceptable professional standards of practice, acceptable infection control practices, and hospital policy. This deficient practice was evidenced by:
1) failure to ensure all head and facial hair and ears were covered completely as evidenced by multiple observations of hospital staff and Vendors in the ORs and/or Cardiac Cath Lab with head and facial hair exposed in the operative rooms while invasive procedures were being performed,; and
2) allowing staff to home launder surgical/procedural scrub wear and wear them in from outside the hospital into the Cardiac Cath Lab.
Findings:


1) Failure to ensure all head and facial hair and ears were covered completely.

Review of "AORN 2018 Edition Guidelines for Perioperative Practice" revealed in part: Surgical Attire, Recommendation III: Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears and facial hair. III.a. A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn.

Review of the hospital's policy # OR.905 titled, Surgical Attire/Dress Code, provided by S21DirPS as current, revealed in part personnel were required to wear surgical attire and cover all head and facial hair in the semi-restricted and restricted areas of the surgical environment. Further review revealed all personnel entering the semi-restricted and restricted areas of the surgical suites were required to wear clean Touro operating room scrub suits(pant/shirts), and should not be worn from home, even if covered by a lab coat. Further review revealed, "Hair shall be covered at al times while in the semi-restricted and restricted areas. Caps are to be worn to cover all hair...Cloth hats must be covered by a paper hat when in a semi-restricted and restricted area. Facial hair must be covered in the semi-restricted areas. Beard covers, hoods, and masks are provided to assure all hair is covered..."

The following observations related to breeches in surgical attire were made 3/12/19 from 1:05 p.m. to 2:20 a.m. during a tour of the Surgical Department's OR environment :
-OR "a": S18CRNA was observed to have her ears completely uncovered, S19ST's ears were completely uncovered, S20Vendor had hair exposed from the bottom of her bouffant cap at the nape of her neck;
-OR "b": S17CST was observed to have hair exposed from under her bouffant cap at the sides including her sideburns, and at the nape of her neck;
-OR "c": personnel, identified by S22DirOR as a resident (physician), with hair exposed from under his hair cover, and S14CRNA with part of his beard exposed at the side of his face, between his mask and head cover;
-OR "d": S11RN circulating the surgery with a paper skull cap that left his hair exposed at the sides of his head and the back of his head;
-OR "e": S15PCT with his hair exposed at the sides, and the lower part of the back of his head from under a paper skull cap, and S16CRNA with his beard/facial hair exposed at the side of his face between his mask and head cover. S21DirPS, present for the observation confirmed the observation and reported, "I put the beard cover on him just this morning" When asked to clarify her statement, she reported she had obtained a beard cover that morning and told him his beard must be covered.
-OR "f": S13Vendor with hair exposed protruding from under his head cover.

S21DirPS and S22DirOR were present throughout the tour and confirmed the observations. S21DirPS confirmed that all hair (head, face, nape of the neck) was supposed to be covered while within the semi-restricted and restricted areas as per their policy and procedure. S21DirPS reported the hospital's perioperative services followed AORN guidelines.

An observation conducted 3/12/19 from 2:25 p.m. to 2:50 p.m.,. of the surgical placement of an internal pacemaker, in Cath Lab "A" revealed the following breaches in surgical attire in the Cath lab:
-S8Vendor was noted to have his facial hair/beard exposed between a regular face mask and his head covering;
-S9Vendor was observed to have her ears completely uncovered, and hair exposed from under her head covering at the side of her head and from below her head covering at the nape of her neck.
-S10RN, providing and monitoring conscious sedation was observed to have facial hair exposed between his mask and his head covering.
S6DirCL, present in the control room with the surveyor, verified the observations.

In an interview 3/12/19 at 2:50 p.m. S7DirCVS reported the Cath Lab followed AORN as closely as possible, and would provide surveyor with policy and procedure for surgical attire for the Cath Lab.

In an interview 3/12/19 at 4:55 p.m. S7DirCVS, reported the hospital did not have a policy specific to surgical attire in the Cath Lab. She reported the Cath Lab followed the OR policies and procedures related to surgical attire. She provided an attestation form given to employees of the Cath Lab and reported everyone was required to sign one. Review of the attestation revealed hats and mask were to be worn any time the sterile /surgical field was open in the procedure room. Further review revealed Scrubs may be laundered at home and worn into the facility.

2) Allowing staff to home launder surgical/procedural scrub wear and wear them in from outside the hospital into the Cardiac Cath Lab.

Review of "AORN 2018 Edition Guidelines for Perioperative Practice" revealed in part: "Surgical Attire, Recommendation I, Clean surgical attire should be worn in the semi-restricted and restricted areas of the perioperative setting... I.b.1 Scrub attire should be donned in a designated dressing area before entry from the outdoors into the semi-restricted and restricted areas...Recommendation II- All individuals who enter the semi-restricted and restricted areas should wear scrub attire that has been laundered at a health care-accredited laundry facility or disposable scrub attire provided by the facility and intended for use within the perioperative setting..."

Review of a documented titled "Expectations for Surgical Attire in the Cath Lab", provided by S7DirCVS as what was used by the Cath Lab for guidance on surgical attire in the Cath Lab, revealed, in part, "...scrubs may be laundered at home and worn into the facility..." Further review revealed the form was to be signed by the employee as an attestation of their understanding of and responsibility to adhere to the requirements and practices regarding surgical attire in the Cath Lab.

In an interview 3/12/19 at 4:55 p.m. S7DirCVS, reported the hospital did not have a policy specific to surgical attire in the Cath Lab. She reported the Cath Lab followed the OR policies and procedures related to surgical attire.

Review of a list of personnel and the scrubs in which they were dressed (hospital laundered scrubs vs home laundered scrubs),provided by S7DirCVS, revealed 2 of the 10 persons in the Cath lab during the placement of Patient #25's internal pacemaker 3/12/19 were wearing surgical scrubs that had been laundered at home and worn into the hospital from outside.