The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

KINDRED HOSPITAL-ST LOUIS AT MERCY 615 S NEW BALLAS ROAD 7TH FLOOR SAINT LOUIS, MO Feb. 5, 2015
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, and policy review, the facility failed to ensure that Medicare patients were informed of their discharge rights as described in The Important Message From Medicare (IM) for one current patient (#2) of 10 current patients reviewed and eight discharged patients (#11, #12, #16, #35, #36, #37, #38, and #39) of eight discharged Medicare patient records reviewed.
This had the potential to affect all Medicare patients for failure to be informed of their discharge options and/or exercise their patient rights.
The facility had 179 documented Medicare inpatients during the last 12 months. The facility census was 30.

Findings included:

1. Record review of the undated facility document titled, "Hospital Discharge Appeal Rights," showed the following directives:
- Hospitals must issue the IM within two calendar days of admission and must obtain the signature of the beneficiary of his/her representative. The hospital must provide a signed copy of the IM to the patient/his or her representative at that time.
- Hospitals must notify Medicare beneficiaries who are hospital inpatients about their hospital discharge appeal rights.
- The Case manager will deliver a copy of the signed notice at the time of discharge, not more than two calendar days before discharge, and not less than four hours before actual discharge for all Medicare beneficiaries.
- These requirements apply if a beneficiary is eligible for original Medicare and Medicaid (dual eligibility) is eligible for original Medicare and another insurance program or has Medicare as a secondary payor. No matter where Medicare falls in the sequence of payers, these requirements still apply.
- Case Manager must document the timely delivery of the IM in the medical records, either by notation or copy of IM in record.
- The beneficiary (or representative) should initial the signed IM copy and it should be dated and timed.

2. During an interview on 02/02/15 at 3:30 PM, Patient #2 stated that he didn't receive a copy of the IM upon admission. He stated he had never heard of an IM and did not have one in his paperwork. He stated that he was a Medicare beneficiary.

Record review of Patient #2's Face Sheet showed the patient was admitted on [DATE] and insurance section showed he was a beneficiary of Medicare Part A and B.

3. Record review of discharged Patient #11's medical record showed the Medicare patient was admitted on [DATE] and discharged on [DATE]. The medical record contained no signed, dated, and timed IM completed on admission or discharge.

4. Record review of discharged Patient #12's medical record showed the Medicare patient was admitted on [DATE] and discharged on [DATE]. The medical record contained a signed and dated admission IM but no evidence could be provided for an IM upon discharge.

5. Record review of discharged Patient #16's medical record showed the Medicare patient was admitted on [DATE] and discharged on [DATE]. The medical record contained a signed and dated admission IM but no evidence could be provided for an IM upon discharge.

6. Record review of discharged Patient #35's medical record showed the Medicare patient was admitted on [DATE] and discharged on [DATE]. The medical record contained a signed and dated admission IM but no evidence could be provided for an IM upon discharge.

7. Record review of discharged Patient #36's medical record showed the Medicare patient was admitted on [DATE] and discharged on [DATE]. The medical record contained a signed and dated admission IM but no evidence could be provided for an IM upon discharge.

8. Record review of discharged Patient #37's medical record showed the Medicare patient was admitted on [DATE] and discharged on [DATE]. The medical record contained a signed and dated admission IM but no evidence could be provided for an IM upon discharge.

9. Record review of discharged Patient #38's medical record showed the Medicare patient was admitted on [DATE] and discharged on [DATE]. The medical record contained a signed and dated admission IM but no evidence could be provided for an IM upon discharge.

10. Record review of discharged Medicare Patient #39's medical record showed the patient was admitted on [DATE] and discharged on [DATE]. The medical record contained a signed and dated admission IM but no evidence could be provided for an IM upon discharge.

11. During an interview on 02/04/15 at 12:47 PM, Staff J, Case Manager, stated that Medicare patients were given the IM the day before or the day of discharge. She stated that if the patients transfer to the same level of care that the IM is not required at discharge. She stated that they did not give the patients a new IM at discharge but that they have them sign and date the admission IM. She stated, "That's how we've always done it."

During an interview on 02/04/15 at 1:10 PM, Staff Y, Director of Case Management, stated that patient's #11, #12 and #16 were not Medicare beneficiaries. She stated, "Just because a patient is [AGE] years old doesn't mean they're on Medicare, maybe they didn't sign up for it". She stated that commercial Medicare recipients did not require the IM.

12. During an interview on 02/05/15 at 9:20 AM, Staff EE, Market Accounting Specialist, stated that Armed Forces Veteran's and Commercial Medicare beneficiaries would not appear on the list of the 179 inpatient Medicare beneficiaries that had been treated at the facility in the last 12 months, which she provided for review. She stated that patients that were Veteran's and Commercial Medicare recipients were Medicare beneficiaries and should have received the IM at admission and discharge.

The number of inpatients with the designation of Veteran or Commercial Medicare recipient for the last 12 months could not be determined or was not disclosed.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on observation, interview, record review, and policy review, the facility failed to ensure that patients with actual or potential skin breakdown were turned and/or repositioned according to the physician's order for one current patient (#2) of one current patient reviewed and four discharged patients (#11, #12, #14 and #15) of four discharged patients reviewed. This practice had the potential to affect all patients with an increased risk of skin breakdown and/or failure to promote current wound healing. The facility census was 30.

Findings included:

1. Although requested, the facility could not provide a policy or procedure for patients to be turned or repositioned when they were at risk for skin breakdown.

2. Record review of current Patient #2's History and Physical (H&P) showed the patient had decreased mobility due to a right above the knee amputation and transmetatarsal amputation (a surgical procedure to remove the forefoot or toes) on the left foot.

Record review of the physician's order gave direction to turn and reposition the patient every two hours.

Record review of the nurses' notes that documented patient repositioning showed that in the three days reviewed (02/02/15, 02/03/15 and 02/04/15) the patient was not turned or repositioned in a timely manner on nine separate occasions ranging from two hours 30 minutes to five hours 23 minutes.

3. Record review of discharged Patient #11's care plan showed that she had the potential for impaired skin integrity related to skin assessment and limited mobility.

Record review of the physician's order gave direction to turn and reposition the patient every two hours.

Record review of the nurses' notes that documented patient repositioning showed that in the three days reviewed (12/23/14, 12/24/14 and 12/25/14) the patient was not turned or repositioned in a timely manner on eight separate occasions ranging from two hours 15 minutes to five hours 23 minutes.

4. Record review of discharged Patient #12's care plan showed that he had impaired skin integrity related to skin assessment and limited mobility.

Record review of the physician's order gave direction to turn and reposition the patient every two hours.

Record review of the nurses' notes that documented patient repositioning showed that in the three days reviewed (01/24/15, 01/25/15 and 01/26/15) the patient was not turned or repositioned in a timely manner on 11 separate occasions ranging from two hours 15 minutes to five hours five minutes.

5. Record review of discharged Patient #14's care plan showed that he had impaired skin integrity related to an infected stage four (full thickness skin loss with extensive destruction, tissue death) pressure wound and limited mobility.

Record review of the physician's order gave direction to turn and reposition the patient every two hours.

Record review of the nurses' notes that documented patient repositioning showed that in the three days reviewed (01/03/15, 01/04/15 and 01/05/15) the patient was not turned or repositioned in a timely manner on six separate occasions ranging from two hours eight minutes to two hours fifty minutes.

6. Record review of discharged Patient #15's care plan showed that she had impaired skin integrity related to an open infected abdominal wound after surgery and limited mobility.

Record review of the physician's order gave direction to turn and reposition the patient every two hours.

Record review of the nurses' notes that documented patient repositioning showed that in the three days reviewed (10/14/14, 10/15/14 and 10/16/14) the patient was not turned or repositioned in a timely manner on nine separate occasions ranging from two hours fifteen minutes to seven hours 30 minutes.

During an interview on 02/04/15 at 12:20 PM, Staff AA, Education Manager, confirmed that the records showed that the patients were not being turned or repositioned timely according to the physician's orders.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on observation, interview, record review and policy review the facility failed to ensure staff developed care plans for three patients (#7, #8, #10) of thirteen patients care plans reviewed. These failures had the potential to prevent patients from meeting their nursing and medical needs. The facility census was 30.

Findings included:

1. Review of the facility's policy, "Assessment/Reassessment-Interdisciplinary Patient", dated 02/2014, showed staff the following direction:
- Based on the initial and ongoing assessment of the patient, the Registered Nurse (RN) would develop a patient Plan of Care (individualized plan that identifies the patient's problems, appropriate planned nursing interventions that follows the nursing process and measurable goals for care) based on patient specific identified problems/unmet needs.
- The Plan of Care contained specialized interventions, nursing care and treatments specific to the patient based on but not limited to the assessment findings and response to treatment.
- All patient assessments and reassessments were documented in the medical record every twelve hours.

2. Observation on 02/02/15 at 3:15 PM of Patient #7 showed the following:
- The right foot and toes had a large wound that was a dark red and black color;
- Tracheotomy (tube surgically inserted in the neck/below the chin to provide an airway) and a tracheotomy bandage;
- The patient received continuous tube feeding through a gastrostomy tube (GT, a surgically inserted tube in the stomach); and
- A urinary catheter tube (tube inserted into the urinary bladder to drain urine) attached to a collection bag hanging on the side of the bed.

Record review of Patient #7's nursing care plan showed no development of care plans for the following identified problems:
- Wounds;
- Altered respiratory status;
- Altered nutritional status (including tube feedings); and
- Altered urinary status.

3. Observation on 02/02/15 at approximately 3:45 PM showed Patient #10 with the following:
- A rectal tube (tube inserted into the rectum to drain stool) hanging from the side of the bed attached to a collection bag;
- A urinary catheter tube hanging from the side of the bed attached to a collection bag;
- A sign posted above the patient's bed that read, "don't turn/position on the left side"; and
- A wedge placed at the patient's right shoulder, which placed the patient in a left side lying position.

During an interview on 02/02/15 at approximately 3:45 PM Staff K, Registered Nurse (RN), stated that Patient #10 had severe liquid stools, had a very big pressure ulcer on her buttocks, had renal failure (function of the kidneys to cleanse the blood and make urine) and was sedated due to respiratory failure. She further stated that the patient was positioned on the left side to prevent pressure ulcers.

Record review of Patient #10's nursing care plan showed no development of care plans for the following identified problems:
- Wounds;
- Sedation;
- Altered respiratory status;
- Altered elimination needs (rectal and urinary catheter); and
- Positioning requirements related to a problem.

4. Observation on 02/03/15 at 10:20 AM of Patient #8 showed the following:
- The patient was very thin, appeared malnourished and had a frown and grimacing facial expressions that appeared to be caused by pain.
- The patient held her abdomen and rubbed her leg and appeared to have pain in the area.
- Multiple opened boxes of food were located close to her on a tray table.
- A tube feeding pump (a machine used to deliever liquid nutrition with a tube at a controlled rate) infused liquid nutrition through a gastrostomy tube.

During an interview on 02/03/15 at 10:20 AM Patient #8 stated that:
- Everything she ate "ran out of her" but she was always hungry and kept trying to eat little bits of anything (she pointed to opened boxes of food in the room).
- She had two infected wounds, one wound was into the bone and caused terrible pain.
- She (at the time of interview) had severe pain and had not been given pain medication when she requested, and the pain had been severe for more than nine hours.
- Nurses refused to administer pain medication due to her "low vital signs".
- Nurses stated to her that they did not know what to do for her other than give her pain medicine and she would have to "tough" it out until her doctor came that day.
- She expected that the nurses or doctor would have had something more to offer her if they couldn't raise her vital signs or give her pain medication.

Review of Patient #8's nursing care plan showed no nursing care plan developed for the following problems:
- Nutrition;
- Pain;
- Altered elimination;
- Wounds; and
- Altered cardiac status (related to low blood pressure [vital signs]).

During an interview on 02/04/15 at 3:30 PM, Staff Q, RN, Director of Quality, stated that nurses use doctor orders in place of care plans in many instances. She further stated that after review of care plans for Patients #7, #8 and #10, patient specific problems with planned nursing interventions and goals were not present in the care plans and nursing care plans, when developed, improved patient outcomes.

During an interview on 02/05/15 at 10:15 AM, Staff AA, Education Nurse, stated that nurses use doctors' orders instead of care plans routinely. She stated that nursing interventions are "just done" when needed and charted when needed if not included in a physician order or the nurse task list. During concurrent review of Patient #7's nursing care plan, she stated that she agreed specific nursing interventions could improve patient care outcomes.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation, interview, record review, and policy review, the facility failed to ensure that staff:
- Followed facility Policy and required a second nurse verification with documentation in the patient's record when High-Alert Medications were administered for 17 current patients (#2, #6, #7, #9, #10, #17, #18, #20, 21, #22, #23, #24, #26, #27, #28, #30, and #42) of 17 current patients prescribed these medications. These failures placed all patients prescribed High-Alert Medications to be at an increased risk for harm/injury or death.
- Followed the medication administration policy when staff crushed a medication listed on the Do Not Crush list and failed to administer the medication per mouth as ordered but administered the medication by nasal gastric (NG-tube placed into the nose used to administer fluids/medications) tube for one current patient (#32) of one patient observed with an NG tube. This failed practice placed patients at increased risk during medication administration.
- Followed the facility's policy for hazardous drugs when staff failed to wear Nitrile (gloves made of synthetic rubber and offer excellent resistance to wear, tears and are more puncture resistant) gloves when handling hazardous medications for one current patient (#32) of one patient observed who received a hazardous medication. This failed practice placed both patients and staff at increased risk related to unsafe practice during hazardous medication administration.
- Followed the facility's policy that required a physician order for patient self-administration (not administered by facility staff) of medication for one patient (#8) of one patient reviewed for self medication administration. This failed practice had the potential to cause increased risks of medication administration errors for all patients who did not have a physician order to self administer their medications. The facility census was 30.

Findings included:

1. Record review of the facility's policy titled, "High-Alert Medications," dated 08/2014, showed the following:
- The purpose of this policy is to identify High-Alert Medications. The goal is to assure appropriate medication usage while minimizing or alleviating the potential patient risk of harm/injury of these medications.
- High-Alert Medications are those drugs involved in a high percentage of medication errors and/or sentinel (a serious adverse event that requires immediate attention) events and medications that carry a higher risk for abuse, errors or other adverse outcomes.
- At a minimum the following medications are required to be on the High Alert Medication List: Insulin's, Heparin drips (as well as the medications named Warfarin and Lovenox are anticoagulant medications used to treat or prevent blood clotting), Therapeutic doses of Low-Molecular Weight heparin (LMWH), Direct thrombin inhibitors (Lovenox, a medication to treat or prevent blood clots), and all oral anticoagulants (medications to treat or prevent blood clots); as well as Warfarin.
- Insulin must require a second nurse verification.
- Heparin drips and direct thrombin inhibitor drips will require second nurse verification of pump settings and ideally a pharmacy double check of dosing parameters/calculations.
- All High Alert Medication are labeled with an auxiliary label marked "HIGH ALERT MEDICATION" or similar wording.
- If a High-Alert Medication requires a second nurse verification, that verification must be documented in the patient's medical record.
- Double check system is in place for High Alert Medication infusions that includes verification of: Drug, concentration, pump rate setting and line attachments against the order with a second nurse.
- The facility specific approved High Alert Medication list will be placed in all medication storage areas and pharmacy to ensure staff awareness.

Record review of the facility's documents titled, "High Alert Medication List," dated 08/2014, showed the following:
- Insulin, verify dose with second nurse prior to administration. Verify pump rate with second nurse prior to starting pump.
- Heparin Drip, Verify pump rate with second nurse prior to starting pump. Warfarin specific requirement includes INR (international normalized ratio) stands for a way of standardizing the results of prothrombin time (PT, at test that measures how long it takes for blood to clot) tests verification and patient assessment.
- Total Parenteral Nutrition (TPN, a method of supplying all the nutritional needs of the body by infusing a nutritional solution intravenously), before administering any of these agents a second nurse must independently check PATIENT NAME, formula and pump settings.
- Metoprolol (affects blood pressure and blood flow through the veins/arteries) ,before administered pharmacy and nursing were to verify IV access type, a second nurse independently checked the drug, dose and pump setting.
- Amiodarone (affects blood pressure and heart muscle to control the rhythm and rate of contractions [beats]), before administered pharmacy and nursing were to verify IV access type, a second nurse independently checked the drug, dose and pump setting.
- Fentanyl (strong sedative used with anesthesia), before administered a second nurse independently checked the drug, dose and pump setting.
- Dopamine and Dobutamine (affects blood pressure and improves the pumping action of the heart and blood flow to kidneys), before administered a second nurse must independently check drug, dose and pump settings.

Record review of the facility's document titled, "Management of Patient Receiving Subcutaneous Insulin (medications that regulate sugars in the blood)," dated 08/2014, showed the following: Two nurses will verify all insulin orders and doses prior to medication administration. One of the two verifying nurses must be the nurse who will administer the insulin to the patient. This double-check process will be documented on the MAR (Medication Administration Record). Insulin will be labeled as a "high-alert" medication.

Record review of the facility's policy titled, "Medication Management" dated 08/2014, showed the following direction for staff:
- Administer medications to patients safely, accurately and efficiently.
- Document medication administration in the electronic medical record MAR immediately after administration.
- Clinical assessment was necessary before administering specific types or doses of medications and the clinical assessment must be documented.

2. Record review of the following patient's MARs showed that they were administered insulin without verification from a second nurse:
- Patient #2 was administered two types (fast acting and slow acting) insulin on 46 separate occasions.
- Patient #6 was administered insulin on 28 separate occasions.
- Patient #17 was administered insulin on seven separate occasions.
- Patient #20 was administered two types (fast acting and slow acting) insulin on nine separate occasions.
- Patient #21 was administered two types (fast acting and slow acting) insulin on 81 separate occasions.
- Patient #23 was administered insulin on one occasion.
- Patient #24 was administered insulin on two separate occasions.
- Patient #42 was administered insulin on one occasion.

3. Record review of the following patient's MAR showed that they were administered Warfarin without verification from a second nurse. Each patient's physician order read: "HIGH ALERT MEDICATION ! ! !:
- Patient #18 was administered Warfarin on one occasion.
- Patient #22 was administered Warfarin on four separate occasions.
- Patient #26 was administered Warfarin on four separate occasions.
- Patient #27 was administered Warfarin on five separate occasions.
- Patient #28 was administered Warfarin on 13 separate occasions.

4. Record review of Patient #7s MAR showed that she was administered Lovenox without verification from a second nurse on four separate occasions. Her physician's order read: "HIGH ALERT MEDICATION ! ! !

5. Record review of the following patient's MAR showed that they were administered TPN without verification from a second nurse: Patient #24 was administered TPN on 14 separate occasions. Patient #30 was administered TPN on five separate occasions.

6. Record review of Patient #7's MAR for the dates 01/30/15 through 02/04/15 showed;
- Staff administered eight doses of Warfarin 5 mg.
- No documented review of the patient's required INR.
- No documented patient assessment for risk factors associated with Warfarin therapy.

7. Record review of Patient #9's MAR for dates 01/28/15 through 02/04/15 showed the following:
- No documented verification by a second nurse prior to the administration of 38 doses of insulin.
- No documented verification of the INR results or patient risk assessments prior to the administration of five doses of Warfarin 5 mg.
- No documented verification by a second nurse prior to the administration of 21 doses and infusion pump changes of Dopamine.
- No documented verification by a second nurse prior to the administration of 14 doses and/ or infusion pump changes of Dobutamine.
- No documented assessments of the heart rate and/or blood pressure prior to the administration of 39 doses of Dopamine, Dobutamine, and Amiodarone (medications that require patient assessment prior to administration related to the potential effects on blood pressure, heart rhythm and rate).

8. Observation on 02/02/15 at approximately 3:45 PM of Patient #10 showed an unlabeled (no high-alert medication label) Fentanyl Citrate IV bag/tubing connected to a programmed continuous infusion pump and then connected to an IV inserted into the patients right chest.

Record review of Patient #10's MAR for dates 02/02/15 through 02/04/15 showed no documented verification by a pharmacist of the IV access at the time the initial dose was administered or verification by a second nurse of the first or ongoing infusion of Fentanyl citrate.

9. Record review of Patient #30's MAR for the dates 01/27/15 through 02/03/15 showed no documented verification by a second nurse of 18 Dopamine and 22 Dobutamine doses administered by staff.

During an interview on 02/03/14 at 2:00 PM, Staff S, Registered Pharmacist, Director of Pharmacy, stated that he did not track the High-Alert Medications and the software system did not alert pharmacy or generate a report if a second nurse did not document the MAR for a second verification on medication administration.

During an interview on 02/03/14 at 3:35 PM, Staff G, Registered Nurse (RN), stated that she did not request that a second nurse verify her Insulin administration to patients. She stated that she knew the medication was a High-Risk Medication and gave no explanation for her actions.

During an interview on 02/03/14 at 4:03 PM, Staff P, Chief Clinical Officer, stated that he was unaware that the High-Alert Medications were not being given per policy.

10. Record review of the facility's policy titled, "Medication Administration" release date 08/2014, showed the following direction for staff:
- Refer to ISMP (Institute for Safe Medication Practices) Oral Dosage Forms That Should Not Be Crushed.
- Valcyte (valGANCiclovir-anitviral medication used to treat herpes viruses) is listed on the ISMP do not crush list.
- The Seven "R's" (rights) of administering medications will be followed with each medication administration: "Right" route.

Record review of the facility's policy titled, "Hazardous Drugs: Safe Handling and Waste Disposal," release date 08/2014 showed the following direction for staff: Oral Administration: Nitrile gloves are required.

11. Observation on 02/03/15 at 9:00 AM showed Staff T, RN, entered Patient #32's room to administer medications. A sign was posted on the patient's door that read: CAUTION: Hazardous medications are being administered to patient in this area. Implement Hazardous medication process and contact pharmacy if you have questions. Staff T entered the patient's room with personal protective equipment on and non-sterile gloves. Staff T removed the medications from the medication bin in the patient's room that included valGANciclovir 450 mg (milligrams) tablet. Staff T crushed the tablet and administered the medication per the patient's NG tube.

Record review of the patient's Electronic Medication Administration Record (e-MAR) showed valGANciclovir, PO (oral) tab (tablet) 450 mg. INSTRUCTION: Hazardous Medication: Do Not Crush-Double Glove.

Staff T did not wear Nitrile gloves when she administered valGANciclovir. Staff T crushed the medication tablet and administered it per NG tube when it was ordered to be given by mouth and not to crush the tablet.

During an interview on 02/03/15 at 9:55 AM, Staff U, Pharmacy Technician, and Staff V, Pharmacist, stated that:
- The e-MAR would instruct staff when not to crush medications and when staff should double glove.
- She (Staff U) checked with Patient #32's physician and speech therapy and they both cleared the patient to take her medications orally.
- She (Staff V) expected staff to follow the the facility's pharmacy policies/procedures and to follow instructions on the e-MAR.

During an interview on 02/04/15 at 1:35 PM, Staff S, Director of Pharmacy, stated that he expected staff to follow the facility's policy and procedures. Staff S stated that staff should wear Nitrile gloves when handling hazardous medications.

During an interview on 02/04/15 at 3:15 PM, Staff S, stated that he expected staff to administer medications per physician's orders. Staff S stated that if a patient changed the way they wanted a medication to be administered, for example, from oral to NG tube he expected staff to notify the physician, have the route changed, have the order clarified and verified.

During an interview on 02/03/15 at 10:01 AM, Staff T stated that patients' with a Hazardous Medication sign posted on the door meant the patient has medications that require double gloving and the medication should not be crushed. Staff T stated that she did crush the medication tablet and should not have crushed it. Staff T stated that she double gloved when administering the hazardous medication.

During an interview on 02/04/15 at 1:40 PM, Staff T, RN, stated that she double gloved to administer the patient's hazardous medications because the facility did not provide Nitrile gloves. Staff T stated that she had been instructed to double glove when Nitrile gloves are not available.

12. Observations throughout the survey from 02/02/15 to 02/05/15 showed no Nitrile gloves were seen in Patient #32's room for staff to wear during hazardous medication administration.

13. Record review of facility policy titled, " Medication Management" dated 08/2014, showed Medications for self-administration must have a physician order.
Medications stored in the patient's room for self administration will be kept in the patients secure medication cabinet and labeled with patient specific information including patient name, location, date dispensed and directions for use.

14. Observation on 02/03/15 at 10:40 AM in Patient #8's room showed:
- One opened tube of Pliocene gel (medication used to numb skin);
- One opened tube of centrifugal cream 2% (medication applied to skin to treat fungal infections);
- One opened tube of Prepayment ALF (medication applied to skin to treat fungal infections); and
- Two opened tubes of 17 percent zinc oxide cream (medication applied to skin for wound healing).
- No labeled medication with patient specific information.

During an interview on 02/03/15 at 10:40 AM, Patient #8 stated that she used the medications at the bedside when staff were too busy to change her abdominal bandage. Otherwise, staff placed the medications at the bedside for their use.

Review of Patient #8's MAR showed no physician order's for self administration of medication or medications left at the patient's bedside.

During an interview on 02/02/15 at 3:35 PM with Staff N, RN, stated that medications applied to the patients' skin were kept at the patient's bedside for convenience of all staff and a physician's order was not required. Staff N provided direct patient care; acted as a Nurse Supervisor when needed; and provided nurse orientation and education.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview, record review and policy review, the facility failed to ensure that:
- Staff followed their policy for hand hygiene (to cleanse hands with hand sanitizer or soap and water) and glove use for six patients (#1, #2, #5, #7 #32, #33) out of six patients observed.
- Staff followed their policy for employee health for one staff (Staff A), observed wearing a yellow surgical mask (worn to cover mouth and nose to protect from influenza-flu, bacteria and germs).
- Staff followed their policy for keeping medical equipment clean for four patients (#7, #8, #10, #33) of four patients with medical equipment.
- Staff maintained clean air mattresses for four patients (#1, #7, #32, #33) of four patients with air mattresses.
- Staff maintained and stored wound care supplies in areas that controlled and reduced the spread of infection and/or contamination from non clean items for two of two patients (#7 and #8).
- Staff maintained a clean lift pad (large fabric pad placed under patients and attached to a mechanical lift) for one of one patient (#10).
- There was a mechanism in place to clean refrigerators that stored inpatient snacks and food.
These failed practices increased the risk of infections and cross contamination and placed all patients, visitors, and personnel at increased risk for hospital acquired infections (HAI) and communicable diseases.
The facility census was 30.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene," dated 08/2012, directed facility staff: Hand Hygiene Will Be Performed As Follows:
- Before and after patient contact;
- Between patients;
- After situations during which microbial (a microscopic living organism) contamination of the hands is likely to occur (i.e. contact with potentially contaminated environmental surfaces); and
- Before donning (putting on) and after removal of gloves.

2. Observation on 02/02/15 at 3:30 PM showed:
- Staff A, RN, wore a yellow surgical mask down under her nose and entered Patient #1's room to administer prn (as needed) pain medication. On the patient's door was posted a Contact Isolation notice that indicated the patient was on contact isolation precautions (measures taken to prevent contagious diseases from being spread from one person to another).
- Staff A put on Personal Protective Equipment (PPE, gown and gloves to protect from contaminated surfaces and environment) and gloves.
- Staff A with gloved hands touched the patient's right arm and identification (ID) band to verify the patient prior to medication administration.
- Staff A went to the computer and with the same gloved hands touched the computer screen to verify the medication order.
- Staff A removed the PPE and gloves and performed hand hygiene and exited the room to retrieve the medication. Staff A did not remove the yellow surgical mask when she exited the patient's room.
- Staff A returned to the patient's room and had on the same yellow surgical mask.
- Staff A put on PPE and gloves and assisted the patient care technician (PCT) to reposition the patient but did not remove her gloves or perform hand hygiene after she assisted with repositioning the patient.
- Staff A with the same gloves, removed medication from the package, touched it with gloved hands and placed it into a plastic sleeve to crush.

During an interview on 02/03/15 at 3:40 PM, Staff A, RN, stated that she did not change her gloves or perform hand hygiene yesterday after she touched Patient #1 and the environment prior to preparing the medication.

3. Observation on 02/02/15 at 3:30 PM showed Staff C, Wound Care Nurse, entered Patient #2's room to perform wound care. The patient was in contact isolation. Staff C gowned and gloved but failed to perform hand hygiene. Staff C:
- Typed on the computer keyboard and used the touch screen before removing the dirty dressing from the patient's left leg and foot;
- Changed gloves but did not perform hand hygiene;
- Used clean gauze and a medicated solution to wipe the patient's skin;
- Did not change gloves after cleansing the patient's leg and wore the contaminated gloves to apply clean gauze dressings to the patient's leg and foot;
- Then removed her right glove only and discarded it in the trash and put a clean glove only over her index finger to touch the computer screen and keyboard;
- Then put on the right glove and with contaminated gloves touched the patient's bed sheets touched a clean bandage, which was on an above the knee amputation on the patient's right leg; and
- With the same contaminated gloves she picked up the unused dressing supplies and put them in the patient's cabinet for later use.

4. Observation on 02/02/15 at 4:20 showed Staff K, RN, entered Patient #7's room. The patient was in contact isolation. She performed care in the following sequence:
- Put on gown and gloves;
- Touched the patient's soiled gown and sheet;
- Touched the patient's urinary catheter (tube inserted into the bladder to drain urine) tubing and urine collection container;
- Repositioned his right foot (with wound);
- Touched the IV pole and infusion pump; and
- Touched the computer keyboard.
Staff K did not perform hand hygiene after she touched the patient and/or environmental surfaces and thereby increased the risk for spreading germs to and/or from the patient and environmental surfaces.

5. Observation on 02/03/15 at 9:00 AM showed:
- Staff T, RN, entered Patient #32's room to administer medications. On the patient's door was posted a Contact Isolation notice.
- Staff T put on PPE and gloves and administered intravenous (IV-a needle placed into a vein) antibiotic (medication used to treat infections) medication.
- Staff T wore the same gloves and touched the computer screen to verify the patient's medications.
- Staff T did not remove her gloves or perform hand hygiene after touching the computer screen.
- Staff T wore the same gloves and removed the patient's medications from a bin and opened various pills/tablets/capsules and touched them with her gloved hand and placed them into a plastic medication cup.

During an interview on 02/03/15 at 10:01 AM, Staff T, RN, stated that she should have changed her gloves after she touched the computer screen and before she opened the medication packages.

6. Observation on 02/03/15 at 9:00 AM showed Staff G, RN, entered Patient #5's room for medication administration. She performed hand hygiene and put on gloves then typed on the computer keyboard. With the same gloves she opened all the medications and put them in a paper cup and gave them to the patient. She picked up a piece of paper off the floor and threw it in the trash then typed on the computer keyboard.

During an interview on 02/03/15 at 3:35 PM, Staff G responded to her lack of changing gloves and hand hygiene and stated, "Oh, I did do that and I know better."

7. Observation on 02/03/15 at 2:05 PM, showed Staff X, Respiratory Therapist (RT), entered Patient #33's room to administer aerosol (the delivery of medication during the inhalation phase of respiration) therapy and suction (to remove oral/mouth secretions that a person is unable to remove by coughing) his tracheostomy (an opening surgically created through the neck into the trachea-windpipe).
- Staff X put on PPE and gloves and checked the patient's ID band to verify the patient.
- Staff X wore the same gloves and touched the computer screen and keyboard to verify the aerosol treatment.
- Staff X did not remove her gloves or perform hand hygiene after she touched the patient's ID band, computer screen and keyboard.
- Staff X wore the same gloves and administered the aerosol treatment per the patient's tracheostomy.
- Staff X wore the same gloves and removed the patient's tracheostomy cap (placed into the opening of the tracheostomy tube) to allow the patient to speak and to suction his tracheostomy.
- Staff X did not remove her gloves or perform hand hygiene after she removed the tracheostomy cap or before she suctioned the patient.
- Staff X wore the same gloves and suctioned the patient's tracheostomy, replaced the tracheostomy cap and listened to the patient's lungs with a stethoscope (acoustic medical device used to listen to the internal sounds of the body).
- Staff X did not remove her gloves or perform hand hygiene after she provided care and treatment to the patient.
- Staff X wore the same gloves and went back to the computer and touched the computer screen to document the care and treatment she provided.
- Staff X wore the same gloves when she touched the bed controls and elevated the patient's head of bed.
- Staff X removed her gown and gloves but did not perform hand hygiene before leaving the patient's room.

During an interview on 02/03/15 at 3:15 PM, Staff X, RT, stated that she should have changed her gloves after she touched the computer screen and keyboard.

8. Record review of the facility's policy titled, "Infection Control-Employee Health," dated 08/31/14, showed the following direction for staff:
Influenza (flu):
- Annual immunization is recommended for any individual six (6) months of age or older.
- Annual immunization documentation is required for all employees,
physicians, LIPs (licensed independent practitioners) or contractors.
Exceptions:
- Employees granted a medical exemption MUST wear a surgical mask during the influenza season. The mask MUST BE WORN AT ALL TIMES WHILE ON THE FACILITY CAMPUS.

9. Record review of the facility's policy titled, "Personal Protective Equipment (PPE)," dated 08/2013, showed the following direction for
staff:
Mask:
- Secure ties or elastic bands at middle of head and secondarily at the neck.
- Fit flexible band to bridge of nose.
- Fit mask snug to face and below chin.

10. Observation on 02/02/15 at 3:45 PM showed Staff A, RN, wore the same yellow surgical mask down under her nose when she entered/exited patient rooms that included patients' on Contact Isolation precaution and as she walked throughout the unit.

Observations made on 02/03/15 from 1:30 PM to 3:36 PM showed:
- At 1:30 PM Staff A, RN, wore a yellow surgical mask down under her nose, entered a patient's room who was on Contact Isolation precaution.
-At 3:00 PM Staff A continued to wear the same yellow surgical mask and walked down the hall and entered another patient's room.
-At 3:30 PM, Staff A came out of the patient's room wearing the same yellow surgical mask and walked down the hall.
-At 3:36 PM, Staff A came out of a patient's room wearing the same yellow surgical mask.

During an interview on 02/03/15 at 3:32 PM, Staff M, RN, Infection Preventionist, stated that:
- She expected staff to change the yellow surgical mask when they enter or exit patient rooms.
- She expected staff to follow the facility's Infection Control policy and procedures and the facility's PPE policy when they have to wear a surgical mask because they are not able to take the flu vaccine.
- Staff are expected to wear the yellow surgical mask up over their nose.

During an interview on 02/03/15 at 3:40 PM, Staff A, RN, stated that:
- She wears the yellow surgical mask because she is unable to take the flu vaccine.
- She puts on the yellow surgical mask when she comes onto the unit and removes it when she leaves.
- She did not remove the yellow surgical mask between patient rooms today or yesterday.
- She should have changed the yellow surgical mask after she exited a patient's room and that she had several masks in her pants pocket.

During an interview on 02/03/15 at approximately 4:00 PM, Staff AA, RN, Nurse Educator, stated that it is expected that even if a mask is worn because staff are unable to receive the flu vaccine, the mask is to be changed just like all other PPE. Staff AA stated that Staff A had received education related to PPE in September 2014 before the flu season.

11. Record review of the facility's policy titled, "Cleaning of Shared Patient Medical Equipment," dated 08/2013, showed:
- Shared patient medical equipment has been cleaned and disinfected prior to use on other patients so that transmission of infections is minimized.
- All shared patient care equipment is cleaned after each patient use according to manufacturer's instructions for use.
- An Environmental Protection Agency (EPA) registered disinfectant that has been approved by the Infection Prevention and Control Committee shall be used for this purpose.

12. Observation on 02/02/15 at 3:15 PM of Patient #7's room showed the following:
- A Contact Isolation sign.
- The patient rested in bed, his right foot and toes were uncovered. Dark red to black skin wounds covered a large area of the foot and toes.
- A mattress covering with more than twenty areas of dried tan, white and translucent colored liquid stains throughout multiple surfaces were visible on areas directly below and surrounding the patient.
- An IV pole (vertical pole on a base with wheels) had multiple dried liquid stains visible throughout the pole and base.
- The vertical and lateral surfaces of two infusion pumps (patient care equipment programmed to deliver liquid nutrition, medication and fluids at a programmed rate) attached to the IV pole had multiple tan and translucent dried liquid stains too numerous to count.
- Opened wound care supplies, used personal care items that included a hair comb on the patient's tray table, multiple opened containers of sterile gauze pads, various types of opened unlabeled wound cleansers, rolls of bandage tape with areas of discoloration, opened packages of cotton swab applicators and many scattered single cotton swabs , skin/wound medications and one pair of scissors (typically used for wound care).
- One opened package of nine oral suction catheter tubes (used for clearing the patient's mouth of secretions) was available for staff use on top of the lid of the soiled laundry bin (no patient care items in use, especially items placed in the mouth should be stored on highly contaminated surfaces such as a soiled laundry bin).

Patient #7 had an infection that required special precautions for isolation. His uncovered wound and body was exposed (while he laid in the bed) to the soiled mattress. Wound care supplies were stored in a unsanitary condition. The patient's equipment had an accumulation of dried liquid debris.

13. Observation on 02/03/15 at 2:20 PM showed Patient #33's air mattress had approximately a three inch light tan streak on it. The patient's IV pole (pole with rollers that holds IV pumps-machine that administers IV solutions per programmed rate and Tube Feeding pumps-machine that administers tube feeding per programmed rate) had three light tan/yellow spots and three short strands of dark hair on the base of the stand. The top of the IV pump had several dark and light tan colored streaks across the top of the pump and dark spots resembling dirt/dust. The Tube Feeding pump had a light tan smudge on the program buttons that appeared like dried tube feeding.

14. Observation and concurrent interview on 02/05/15 at approximately 9:30 AM Staff M, RN, Infection Preventionist confirmed/stated that:
- The air mattress in Patient #33's room had a visible approximate three inch light tan streak on it.
- The patient's IV pole base had three light tan dried irregular shaped areas and three short black strands of hair on it.
- The IV pump and Tube Feeding pump had visible dirt and debris on them.
- The air mattress in Patient #32's room had visible several irregular light tan splotches at the head of the bed and a large area in the middle of the bed with a white substance on it.
- She expected all staff to clean patients' environment when it becomes visibly soiled. For example, air mattresses, IV poles and equipment (IV pumps and Tube Feeding pumps).
- There is no established scheduled or formal assignment in detail to clean patients' environment and equipment.

15. Observation on 02/02/15 at 3:45 PM showed Patient #1's air mattress had several irregular white splotches on it located where the patient's buttocks rested. The white substance looked like skin barrier cream that had been applied to the patient's buttocks.

16. Observation on 02/03/15 at 9:00 AM showed Patient #32's air mattress had several irregular light tan dried splotches at the head of the bed and a large white substance where the patient's buttocks rested. The light tan areas resembled dried tube feeding (the patient had a nasal gastric tube-a tube placed into the nose to administer fluids/medications) and the large white substance resembled skin barrier cream.

17. Observation on 02/03/15 at 10:15 AM of Patient #8's room showed the following:
- A bedside table drawer opened with multiple wound care supplies (too numerous to count) protruding out the drawer sides that prevented closure.
- Among the supplies were opened packages of sterile gauze pads, rolls of tape with tan stains, three opened tubes of wound care medication and two bottles of wound cleansers.
- Three large areas of tan colored dried liquid stains were located on the handle of the drawer.
- Opened food items, multiple personal personal care items and toilet tissue was located above the opened drawer of sterile dressing supplies.
- Dried liquid tan and translucent colored stains too numerous to count were scattered on the floor surrounding the patient's bed.

During an interview on 02/03/15 at 10:20 AM, Patient #8 stated that staff had used the wound care supplies and medications when they cleaned and changed her two wound bandages. She stated that her wounds were infected and that the abdominal wound had a lot of wound drainage and soaked the bandages often. The wound on her buttocks was deep and went into her bone, and because she had very frequent loose stools, was hard to keep clean. She stated that the floor was "sticky" because nurses spilled liquid tube feeding and medication fluids when they changed the IV bags on the pumps.

18. Observation on 02/03/15 at 10:40 AM of Patient #10's room showed the following:
- Multiple areas (too numerous to count) of dried amber colored liquid stains on the floor in the area under and surrounding a urine collection bag;
- An IV pole with two infusion pumps attached with multiple areas (too numerous to count) of dried liquid debris on lateral and vertical surfaces of the pole, pumps and base; and
- A lift pad draped on a chair with brown dried stained matter (appeared to be dried semi-liquid stool) on an area approximately three inches by four inches located in the area where the patients buttocks would be positioned.

19. During an interview and concurrent observation of the High Acuity Unit (HAU) on 02/02/15 at 4:30 PM, Staff M, RN, stated that the following observations had the potential to cause harm through increased risk of infection to patients:
- Soiled mattress coverings;
- Staffs' failed hand hygiene;
- Inappropriate storage of patient wound care supplies; and
- Soiled environmental surfaces and patient care equipment.
Staff M stated that dirty mattress coverings "had been a problem". She further stated that the facility did not have a policy for cleaning or changing the mattress covering, or equipment during patients' admission and mattress covers were only changed at discharge. However, all staff were expected to clean anything they saw soiled. She stated that staff did not have a mattress disinfectant.

20. Observation on 02/03/15 at 10:55 AM showed a refrigerator in the nurses' station next to room numbered 7538 labeled, "Patient's only". The refrigerator had visible dark marks and smudges on the handle and surfaces. Inside the refrigerator the shelves and doors had spots of red and white substances.

During an interview on 02/03/15 at 4:03 PM, Staff P, CCO, stated that he didn't know who was responsible for cleaning the refrigerator in the nurses' station, whether it was their facility or the host hospital (the facility is located on the 7th floor of a host hospital).

During an interview on 02/04/15 at 3:00 PM, Staff P acknowledged that the refrigerator needed cleaned and stated that there was no policy or procedure for cleaning the patient refrigerators.