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.

ST CHARLES HOSPITAL 200 BELLE TERRE ROAD PORT JEFFERSON, NY 11777 June 14, 2017
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
.
Based on observation, document review, and staff interview, the facility did not maintain the conditions of the physical plant in such a manner that the well being of the patients was assured.

Findings:

During a tour of the facility on 06/12/17 at 11:25AM, the perforated ceiling air return was observed to be hanging down from the ceiling frame in Clean Utility Storage Room E3CU in the 3 East Unit of the facility. This presents a risk of dusting which may lead to contamination of the clean supplies.

During the tour of the facility on 06/12/17 approximately around 11:30AM, it was observed that the anterooms of the Isolation Rooms were used as Storage Rooms. The anteroom of Isolation Room EG 86 was used for storing one (1) portable climbing stairs and two (2) IV poles. The anteroom of Isolation Room EG 91 was with four (4) IV poles, supply cart, and a thirty-two (32) gallon biohazard waste can.

During interview, staff were not aware if the above items were cleaned.

The above findings were identified in the presence of the Life Safety Manager (Staff DD) and was brought to the attention of the facility's leaders during the Exit Conference.
.
VIOLATION: INFECTION CONTROL Tag No: A0747
.
Based on observation, document review, MR (Medical Record) review, and interview, the facility failed to maintain an active, hospital-wide program for the prevention, control, and investigation of infections and communicable diseases.

This failure may place patients and staff at increased risk for the transmission of infections and communicable diseases.

Findings:

See Tag A 749
.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
.
Based on observation, document review, and interview, the facility failed to ensure that staff followed acceptable standards of Infection Control Practices in the: A) OR (Operating Room) and B) Nursing Care Units.

These Infection Control breaches place all patients at risk for exposure to infectious diseases.

Findings for (A) Operating Room discovered between 06/12/17 and 06/13/17:

In OR #4 a large clear plastic bag filled with garbage was hanging down from a linen hamper with the bottom of the bag lying on the floor.

Staff GG (Circulating Nurse) placed a camera, light cord, and heat cord in the garbage bag with both hands making contact with the refuse and the sides of the bag. After removing her gloves, washing her hands and donning gloves, she returned to the garbage bag. She placed both hands in the bag, making contact with the refuse and the sides of the bag, and removed the camera. She placed the camera on the second shelf of the instrument table. She repeated the process two (2) additional times removing the light cord and the heat cord.

During an interview with Staff EE (Nurse Manager OR) at the time of the observation, the staff member stated "she (the Nurse) should have never put them (camera, light cord, and heat cord) in the garbage. She could have placed them on a stand or directly on the second shelf (of the instrument table.)" She also stated "it is common practice for the garbage bag to hang down from the linen hamper, sitting on the floor. You will find this in all the ORs. We need (garbage) containers."

In OR #6 a large clear plastic bag filled with refuse was hanging down from a linen hamper with the bottom of the bag lying on the floor.

Staff HH (Registered Nurse) placed her hand in the garbage bag to push the refuse down. Without removing her gloves, washing her hands and donning clean gloves, she opened the sterile drape for the Surgical Technician who placed the drape over the instrument table. Staff HH placed the cover of the drape in the garbage bag with her hand making contact with the refuse and the side of the bag. Without removing her gloves, performing hand hygiene and donning gloves, she opened an instrument tray for the Surgical Technician. Then Staff HH placed the cover of the instrument tray in the garbage bag with her hand making contact with the refuse and the side of the bag.

Staff EE (Nurse Manger OR) instructed the Nurse not to put her hands in the garbage bag. The Nurse replied "how am I going to get the garbage in the bag?". Staff EE adjusted the mouth of the bag making it larger and instructed the Nurse to "drop it in". However, once again while Staff HH was putting refuse in the bag, she placed her hand in the garbage bag and pushed the refuse down.

In OR #7 the staff were cleaning the OR between surgeries.

On three (3) separate occasions Staff II (Housekeeping Aide) placed his hand in the garbage bag and pushed the refuse down as he discarded refuse. Without removing his gloves, performing hand hygiene and donning gloves, he disinfected the spot light.

Staff JJ (Housekeeping Aide) with his right hand picked up a bag full of garbage and moved it. Without removing his gloves, performing hand hygiene and donning gloves, he took wipes from a container and disinfected a table. Then he disinfected the cement pedal and wire. He placed the disinfected wire on the (dirty) floor.

While holding disinfecting wipes in his hand, Staff JJ touched the garbage bags with both hands. Without removing his gloves, performing hand hygiene and donning gloves, he disinfected the double ring stand with the wipes that had contact with the garbage bag.

Staff II had a bottle of cleaning fluid hanging from his back pocket until Staff KK instructed him to remove the bottle.

When Staff II cleaned the Bair Hugger he did not completely disinfect all the sides of the machine and the hose.

Staff II disinfected the OR table and the Flowtron Machine. He placed the Flowtron on the OR table. Then, with the bags of refuse having contact with his gown, he moved the three (3) bags to the entrance of the OR. Without removing his gloves, performing hand hygiene and donning gloves and changing his apron, he used a mop to wipe the ceiling above the OR table. With one (1) hand he picked up the Flowtron Machine and with his other hand he wiped the OR table where the machine once sat. Then, he placed the Flowtron Machine back on the table. He never disinfected the Flowtron Machine and the whole OR table after he contaminated the equipment when he mopped the ceiling.

After touching the "dirty" anesthesia cart and anesthesia supply cart and the IV pole, Staff LL (Housekeeping Aide), without removing her gloves, performing hand hygiene and donning gloves, disinfected a monitor, the top of the anesthesia cart and anesthesia supply cart, and the blood pressure cuff. She did not disinfect the blood pressure cord. She rolled the cord and placed the cuff and cord on the "dirty" anesthesia cart. Then, she discarded a piece of paper and tongue depressor and without removing her gloves, performing hand hygiene and donning gloves, she disinfected a laryngoscope. She placed the laryngoscope in a plastic bag filled with equipment and then placed the bag in the top drawer of the anesthesia cart.

The anesthesia cart and anesthesia supply cart were not completely disinfected. The IV pole and pump were not disinfected. Staff MM (CRNA) entered the Anesthesia Area and her hands had contact with the "dirty" anesthesia supply cart, monitor and keyboard. Without performing hand hygiene, she walked across the OR and opened the door to the Sterile Supply Cabinet. She removed three (3) sterile cloths and closed the door. She opened the drapes and placed one on the top of each cart.

At the time of the observation the surveyor asked Staff MM "How do you know the Anesthesia Area has been disinfected?" She stated "I asked Staff II". The surveyor stated "Staff II is not in the OR". She stated "I asked him in the hallway". Staff II entered the OR. The surveyor asked Staff II "How do you know the Anesthesia Area was disinfected?" Staff II stated "I saw her clean it". This surveyor observed that Staff II had been in and out of the room while disinfecting it. When this was brought to his attention, Staff II stated, "I monitor the room".

These findings were confirmed with Staff EE (OR Nurse Manager). She agreed the OR needed to be correctly disinfected and stated "I won't let them do surgery".

After Staff OO (Surgeon) completed a surgical scrub he entered the OR Suite with wet scrubs.

After Staff NN (Surgeon) completed a surgical scrub/rub he entered the OR Suite with wet scrubs.

These findings were confirmed with Staff PP (Infection Control) during the observation.

In OR #1 two (2) Surgeons at the sterile field had uncovered hair on the top and the sides of their heads. The Scrub Technician also at the sterile field had the sides of his beard uncovered.

In OR #6 the sterile supplies and instruments were opened and an Anesthesiologist did not have the lower two (2) strings of his mask tied.

In the Semi-Restricted Hallway Staff FF (Central Sterile Aide) was observed without his mustache and side burns covered.

During an interview with Staff FF at the time of the observation, he stated "I cover my facial hair before I walk in" the Unit. He did not offer a reason why his mustache and side burns were not covered.

The facility Policy and Procedure (P&P) titled, "Surgical Attire: Operating Room, PACU, ASU and Central Sterile" last revised 03/13/17, indicated the following: "Restricted Area: It includes rooms where surgical or other invasive procedures are performed. Personnel are required to wear surgical attire and cover head and facial hair. Masks must be worn in the restricted areas where sterile supplies are open. Semi-Restricted Area: Personnel in the semi-restricted area must wear surgical attire and cover head and facial hear. Surgical Attire: Scrub Clothes 2. Scrub clothes will be donned daily prior to entering the semi-restricted area, and will be changed whenever they become soiled or wet. Masks 2. The masks must cover the mouth and nose entirely and be tied securely to prevent venting. Personal Protective Equipment (PPE): 3. Gloves should be changed and hand hygiene performed between patient contact or after contact with contaminated items."

The facility P&P titled "Environmental Sanitation" last revised 01/13/17, stated the following: "A safe, clean environment should be reestablished after each surgical procedure. This is accomplished by always cleaning from Top to Bottom and Clean to Dirty. C: After Surgical Procedure: perform hand hygiene immediately after removing gloves and/or when hands become visibly soiled when cleaning any OR Suite. Clean with a hospital approved wipes all horizontal surfaces including, but not limited to: a. furniture, d. equipment, nonporous surfaces, and Anesthesia Equipment high-touch surfaces. 7. Reusable noncritical items are cleaned and disinfected, including but not limited to: a. Blood Pressure cuffs, and d. convection warming units and hose.'

The facility P&P titled "Hand Hygiene" last revised 01/12/17, stated the following: "Decontaminate hands with antibacterial soap and water, or an alcohol-based waterless hand cleaner: after contact with contaminated inanimate objects (including medical equipment) in the immediate vicinity of the patient. After removing gloves to maintain low levels of bacteria on the hands."

Findings for (B) Nursing Care Units:

The facility P&P titled "Hand Hygiene" last revised 01/12/17 stated "...Hands must be cleaned before and after every patient encounter ... Decontaminate hands with antimicrobial soap and water, or an alcohol-based waterless hand cleaner: Prior to donning gloves. Ensure hands are completely dry before donning gloves. After contact with patient's intact skin ... After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient ... When decontaminating hands with alcohol-based waterless hand cleaner, apply a "dime" size amount of product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until the hands are dry (for approximately five [5] seconds) ... When washing hands with a non-antimicrobial or antimicrobial soap, wet hands first with warm water; apply 3-5 ml of detergent to hands and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with warm water and dry thoroughly with a disposable towel. Use towel to turn off faucet."

During a tour of 3 North on 06/07/17 at 10:05AM, Staff I (Registered Nurse) was observed dispensing sanitizer into hands, but failed to rub hands together and cleanse hands after patient contact and before opening the medication cart

This observation was acknowledged by Staff A (Nurse Executive) and B (Director).

During observation of blood administration on 3 East on 06/07/17 at 12:15PM, Staff J (Registered Nurse) did not wash or cleanse hands after doffing dirty gloves and before donning clean gloves.

At 12:16PM, Staff H (Assistant Nurse Manager) did not wash or cleanse hands before donning clean gloves during during blood administration.

These observations were acknowledged by Staff Members A and B.

During a tour of the ICU (Intensive Care Unit) on 06/08/17 at 10:30AM, Staff K (Registered Nurse) was observed, during blood glucose testing, retrieving blood glucose testing supplies from his pockets with dirty gloves donned. Staff K was then observed performing inadequate hand hygiene, by not allowing sanitizer to dry thoroughly, in between glove changes.

This was acknowledged by Staff A at the time of observation.


The facility P&P titled "Isolation Precautions" last revised 01/12/17 stated "...for patients with iagnosed or suspected C-Difficile, soap and water is to be used for hand hygiene ..."

During a tour of 4E on 06/07/17 at 2:40PM, Staff Q (Housekeeper) was observed emptying garbage in Room E413 for Patient #32 who was on Contact Precautions for C-Diff (Clostridium difficile, a bacteria). Upon exiting the room, Staff Q removed PPE (Personal Protective Equipment), failed to wash hands with soap and water, and walked across the hall to the cleaning cart. This room had no anteroom (a space between the isolation room and the hallway where staff can wash hands and don and doff PPE upon entering or exiting the isolation room).

Staff Q was interviewed on 06/07/17 at 2:47PM. Staff Q stated he was going to wash his hands, but the only sink to wash was in the patient's bathroom. When asked where he would go to wash his hands, Staff Q replied "I don't really know". At the time of observation, Staff Q was directed by Staff F (Director) to walk across the hall into an empty patient room to wash hands. When asked where could Staff F go if that room was occupied by another patient, Staff F directed Staff Q to re-don PPE and re-enter the isolation room to wash hands. When asked how would Staff Q remove their dirty PPE after they had washed hands before exiting the isolation room, Staff F revealed that not all isolation rooms have anterooms making this a continuing challenge for the facility.

Staff Y (Director) agreed this was a challenge for the staff and explained staff are instructed to walk to the Soiled Utility Room to wash their hands.

Observation of the Soiled Utility Room revealed it was approximately fifteen to twenty (15-20) feet away from Room E413. In addition, staff were required to use their hands or elbows to push down on the door handle to open it.

This was confirmed with Staff A (Nurse Executive) and Staff B (Director) at the time of observation.


The facility P&P titled "Blood Glucose Monitoring" last revised 10/25/16 stated "All meters are cleaned after each patient use ... [after test result is accepted] Remove test strip and properly dispose of all supplies used. Disinfect the exterior surface of the meter according to policy. Remove gloves and perform hand hygiene. Dock glucometer ..."

During blood glucose monitoring of Patient #6 on 06/07/17 at 11:25AM at the nursing station, Staff T (Registered Nurse) was observed: failing to clean the glucometer before patient use, and wiping Patient #6's finger with an alcohol swab, then reusing the same alcohol swab to wipe a different finger for testing. After performing patient test, Staff T placed the glucometer with the bloody test strip directly onto the Nursing Station desk (without a barrier); failed to clean the glucometer after patient use; and redocked the glucometer with dirty gloves still donned.

Staff T was interviewed on 06/07/17 at 11:30AM and stated that glucometers are cleaned when the controls are run every twelve (12) hours. When asked if there are other times the glucometer should be cleaned, Staff T replied "I should have cleaned it after I used it".

This observation was confirmed with Staff F (Director). As per Staff F, glucometers are to be cleaned after each patient use as per facility Policy.



The facility P&P titled "Care of the Patient with a Central Line Catheter" last revised 12/05/16 stated "Dressing is changed every 7 (seven) days with the use of the Biopatch® and changed as needed to maintain a sterile dressing ... Date and initial dressing using the label attached to the dressing ... Document site assessment and dressing change in EHR (Electronic Health Record) ..."

Observation of the ICU (Intensive Care Unit) on 06/09/17 at 2:30PM identified Patient #31's central line dressing was not labeled with the date and initials of the last dressing change. This was confirmed with Staff M (RN).

Review of Patient #31's MR (Medical Record) identified the following: On 06/02/17 patient was admitted with a central line in place. As per the patient information provided on admission, the central line was inserted on 05/26/17 at another facility.

Seven days later, during the 06/02/17 admission, a Nursing Note stated "[Central line] Dressing reinforced." A second Nursing Note dated
06/02/17 at 4:16PM stated "Dressing due to change 06/06/17." On 06/04/17, Nursing Note stated "Dressing reinforced". On 06/09/17 Nursing Note stated "Dressing due to be changed".

There was no documented evidence that the central line dressing had been changed since its initial insertion at the previous facility on 05/26/17.

These findings were confirmed with Staff F (Director) and Staff R (Electronic Medical Record Trainer) on 6/9/17 at 3:45pm.

Interview with Staff Y (Director) on 06/09/17 at 4:00PM revealed that for patients with central lines present on admission "the practice is to get the Chest X-Ray, assess the site and to change the dressing. This is documented on the flowsheet [to obtain a baseline timeframe in which to perform central line dressing changes].

This was acknowledged by Staff B (Director). When asked if this practice was reflected in the current Policy, Staff B stated "No, it is not in the Policy."



During a tour of 3 North on 06/07/17 at 9:50AM, Patient #15's indwelling urinary catheter bag was found touching the floor. Patient #15 had a UTI (Urinary Tract Infection) and was on his second day of IV (Intravenous) Rocephin Antibiotic treatment for the UTI.

This was observed and acknowledged by Staff A (Nurse Executive) and Staff B (Director), who both stated the [indwelling urinary catheter) bag should not be touching the floor.

During a tour of 3 East on 06/07/17 at 10:55AM, Patient #34's indwelling urinary catheter was found touching the floor.

This was observed and acknowledged by Staff A (Nurse Executive) and Staff H (Assistant Nurse Manager).

Policy titled "Urethral Catheterization Indwelling (Insertion, Maintenance and Removal)" dated 04/2015 stated "...maintain drainage bag below the level of the bladder at all times (but not on the floor, even when emptying)."



The facility policy and procedure (P&P) titled "IV: Intravenous Policy" last revised 10/13/16 stated "...Primary and Secondary [IVPB - Intravenous Piggy Back] sets used for continuous administration are changed every 96 hours using aseptic technique ... Any IV (Intravenous) tubing (primary or secondary) used for intermittent therapy is changed every 24 hours ..."

A tour of 3 East on 06/07/17 at 11:00AM revealed that Patient #25 had Vancomycin for intermittent therapy. IVPB (Intravenous Piggy Back) tubing was dated 06/04/17 with an expiration date of 06/08/17. As per Policy, IVPB tubing was to be changed after 24 hours, on 06/05/17. The IVPB tubing was 2 days expired.

As per interview at the time of observation, Staff D (Registered Nurse) stated "IV tubing should be changed every 4 days [96 hours]. This information did not coincide with the Policy. This was acknowledged by Staff A (Nurse Executive).

A tour of ICU on 06/08/17 at 10:30AM revealed that Patient #31 had a primary line of IVF
(Intravenous Fluid) infusing with a label dated 06/03/17 and an expiration date of 06/08/17. As per Policy, continuous primary IV tubing was to be changed after 96 hours, on 06/07/17. The IV tubing was 1 day expired.

This was confirmed with Staff M (Registered Nnurse) and acknowledged by Staff A.

A tour of 4 East on 06/09/17 at 2:25PM revealed that Patient #49 had an IVPB for intermittent therapy. IVPB was dated 06/08/17 with an expiration date of 06/12/17. As per Policy, IVPB tubing was to be changed after twenty-four (24) hours, on 06/09/17. Tubing was expired that day, and was labeled with the incorrect expiration date by three (3) days.

As per interview at the time of observation Staff P (Registered Nurse) stated, "Change the IVPB every 4 days [96 hours]. This information did not coincide with the Policy. This was acknowledged by Staff A.


The facility P&P titled "IV: Intravenous Policy" last revised 10/13/16 stated "...Label pink IV tubing sticker / label with Nurse's initials, date and time indicating scheduled change. Wrap onto all IV tubing ..."

A tour of 3N on 06/07/17 at 9:50AM revealed that Patient #15 had an empty Rocephin IVPB connected to his IV with an undated / unlabeled secondary tubing.

A tour of the ICU on 06/08/17 between 10:30AM and 10:35AM revealed Patient #26 had an undated / unlabeled primary IV tubing and Patient #27 had both undated / unlabeled primary and secondary tubing.

Similar findings were found for Patients #9, #28, #29 and #30.

All findings were acknowledged by Staff A.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
.
Based on observation, document review, and interview, the Nursing Staff failed to: (A) ensure that Fall Risk signage was appropriately posted for ten (10) of fifteen (15) high risk fall patients, and (B) secure sharps in a patient care area.

These lapses in safety may place patients at increased risk for injury.

Findings for (A) include:

The facility policy and procedure (P&P) titled "Falls Prevention Policy" dated 10/19/15 stated "The Morse (Fall Risk Scale) score of 45 or higher categorizes the patient at High Risk for falls ... High Risk Interventions (scores of 45 or greater) for fall prevention [include] ... Fall prevention sign posted outside the patient room and above the patient's bed ..."

A tour of 3 North on 06/07/17 between 10:30AM and 11:00AM revealed that Patient #15 had a Morse score of 85; no fall prevention sign was posted outside of Patient #15's room or above the bed. No fall prevention signage was posted above the beds of Patient #16 (Morse score 80), Patient #17 (score 45) or Patient #18 (score 45).

A tour of 3 East on 06/07/17 at 11:05AM revealed that Patients #19 (score 60), #20 (score 60) and #21 (score 70) did not have fall prevention signage posted above their beds. Patients #22 (score 60), #23 (score 70) and #24 (score 60) did not have fall prevention signage outside the rooms or above the beds.

These findings were confirmed by Staff Members A (Nurse Executive) and B (Director).

Findings for (B) include:

Observations in the facility's (Emergency Department) during a tour on 06/08/17 at
11:12AM, revealed an unsecured and unlocked phlebotomy/IV (Intravenous) cart in the hallway of a patient care area. This cart did not have a door or lock, and contained unsecured Angiocaths
(intravenous drip needles for giving blood, medicine or other fluids to a patient intravenously) and Phlebotomy needles (needles for drawing blood) that were in plain sight of patient or visitor passersby.

This was confirmed by Staff A and G (Assistant Nurse Manager).

The facility P&P titled "Medication and Sharps Security" last revised 12/15/16 stated "All medication / sharps shall be in lockable storage at all times. Medications / sharps and floor stock are stored either in lockable automated dispensing unit medication carts or the medication room on selected units ..."
.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

.
Based on document review, MR (Medical Record) review and interview, the Nursing Staff did not ensure that Nursing Care Plans were reviewed daily by a Registered Nurse (RN) in 3 (three) of 3 (three) MRs.

This failure to consistently review Nursing Care Plans may lead to delays or a lack of treatment and care.

Findings:

Policy titled "Plan of Care" last revised 05/16/17 stated "Care Plan needs to be reviewed, updated, modified and/or documented on at least daily by the Registered Nurse (RN) and any member of the healthcare team ..."

MR review of the documented Care Plan activity for Patient #2, admitted [DATE], revealed that an RN had not reviewed the Care Plan for 7 of 27 admission days.

MR review of the documented Care Plan activity for Patient #3, admitted [DATE], revealed that an RN had not reviewed the Care Plan for 8 of 23 admission days.

Similar findings were found with Patients #4 and #5. These findings were confirmed with Staff R (Electronic Medical Record Trainer) on 06/07/17 at 11:30AM.

Per interview with Staff F (Director of Risk Management) on 06/07/17 at 11:30AM, "Care Plans are to be reviewed daily by the RN".
.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

.
Based on MR (Medical Record) review, document review and interview, the RN (Registered Nurse) staff did not: (A) ensure that Skin Risk Assessments were performed every shift in 5
(five) of 5 (five) MRs, and (B) ensure that Fall Risk Assessments were performed every shift in 4 (four) of 4 (four) MRs, in accordance with facility Policy.

These failures place patients at increased risk for adverse outcomes.

Findings for (A) include:

The facility policy and procedure (P&P) titled,
"Assessment and Reassessment: Nursing" last revised 05/26/16 stated "...[All] Patients are reassessed every shift and more frequently as necessary ... this includes the assessment of, but is not limited to ... Skin Assessment: include color/condition, incisions and pressure ulcer, Braden scale ..."

MR review for Patient #1 revealed missing Skin Assessment documentation for 8 of the 12 days reviewed. No Skin Assessment by the RN
(Registered Nurse) was performed for the 4 consecutive days prior to Patient #1's development of a non-pressure related ulcer [unknown etiology].

MR review for Patient #42 revealed his skin was not assessed for 17 of 17 day shifts and 7 of 17 night shifts. No RN Skin Assessment documentation was found for 10 of 17 days.

MR review for Patient #43 revealed skin was not assessed for 13 of 17 day shifts and 1 of 17 night shifts. No RN Skin Assessment documentation was found for 3 of 17 days.

Similar findings were found for Patients #44 and #45.

As per interview on 06/07/17 at 10:30AM, Staff S (Assistant Nurse Care Coordinator) stated "Skin Assessments are not performed every day on this Unit. We [RNs] perform a comprehensive skin assessment on admission, and then assess the skin as needed or if there is a problem."

This information did not coincide with the current facility Policy. This discrepancy between facility Policy and Unit practice was acknowledged and confirmed by Staff U (Performance Improvement Nurse) and Staff F (Director of Risk Management), who stated, "This policy is for all patients hospitalwide."

Findings for (B) include:

he facility P&P titled "Falls Prevention Policy" dated 10/19/15 stated "All ADULT patients will be assessed for fall and risk injury ... on admission, every shift, upon transfer, change in condition, change in level of care [and] post fall ..."

MR review for Patient #2, admitted [DATE], revealed fall risk was not assessed by the RN for 27 of 27 day shifts, and 3 of 27 night shifts.

MR review for Patient #3 admitted [DATE] revealed fall risk was not assessed by the RN for 20 of 23 day shifts and 1 of 23 night shifts.

Similar findings were found for Patients #4 and #5. These findings were confirmed with Staff R (Electronic Medical Record Trainer) on 06/07/17 at 11:30AM.

Per interview with Staff S on 06/07/17 at 12:00PM "Fall risk is assessed daily ... The districts are divided up between the shifts, so on 5 North, the day shift [RN] will assess fall risk on [the patients in] Rooms 501 to 505, and night shift [RN] will assess Rooms 506 to 510. On 5 South, the day shift [RNs] will assess Rooms 511 to 515 and the night shift [RNs] will assess Rooms 523 to 527."

During interview of Staff F (Director) on 6/7/17 at 12:30PM, when asked if a separate Fall Risk Assessment policy existed for the patients on these units, Staff F stated, "this is the only policy for the hospital. The hospital policy says falls are to be assessed on all patients every shift."
.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

.
Based on MR (Medical Record) review, document review, and interview, the CDU (Chemical Dependency Unit) Staff did not have a formal Policy and Procedure (P&P) that assured a patient's right to request treatment.

This may place patients at risk for delayed treatment and care.

Findings:

Review of Patient #1's MR identified the following: This [AGE]-year-old was admitted on [DATE] for rehabilitation from alcohol dependency. On 02/27/17, patient developed an open sore with purulent drainage to his right ankle. On 03/01/17 the patient underwent an IED (Irrigation and Excisional Debridement) of Right Ankle Abscess Down to Fascia with Placement of VAC (Vacuum Assisted Closure) Dressing.

The Incident Report dated 03/06/17 (for Incident Date: 02/25/17) stated "Was on Alcohol and Drug Rehab Floor 5 North. Noticed a lump on my foot. Asked to see the doctor. No doctor. Asked again twice on 2/26/17. No doctor. Asked again on 2/27/17 in the morning. By this point lump had turned into a sore that had opened with no skin over it and pus oozing out of it. Finally doctor came in at 7:45pm on 2/27/17 ... [Doctor] came in to see me after my significant lodged a complaint on 3/2/17. He was supposed to look into why I was not allowed to see a doctor when I asked for one 3 days in a row ..."

Discharge Summary dated 02/27/17 indicated "On 2/25/17, [Patient #1] developed an ulcer on the anterior aspect of ankle area with surrounding [DIAGNOSES REDACTED]." Discharge Summary dated 2/28/17 indicated "... [Patient #1] stated Friday [2/24/17] started with a bug bite like wound on the right anterior foot and blossomed into a cellulitis ..."

During an interview on 06/07/17 at 10:30AM, Staff S (Assistant Nurse Care Coordinator) stated "When patients request to see a physician, their names are added to a list; we won't call a doctor immediately if it isn't an emergency. When the doctor makes rounds, we verbally communicate to the doctor that the patient wants to be seen."

When asked to show that day's list, Staff S presented an 8.5 x 11in. white-lined paper, dated 06/07/17 with 2 patient names listed (see attachments). When asked for the previous days' lists, Staff S stated "We do not keep them. They are shredded every day." When asked how are patients' Physician requests tracked, Staff S stated "the Nurse should write a note in the Medical Record".

No documented evidence was found in the MR from 02/25/17 to 02/27/17 indicating the patient had requested a Physician Evaluation. No documented evidence of Skin or Site Assessments were found from 02/23/17 to 02/26/17, 4 days prior to Patient #1's foot wound opening on 02/27/17. No documented evidence indicating what date(s) Patient #1 had requested to see a Physician was found. No formal process was in place to identify if patients' requests for Physician Evaluations are recorded.

These findings were confirmed with Staff F (Director of Risk Management) who indicated that the physician request list was not a part of the MR or a formal way to track patient requests "staff should write a note to memorialize the requests in the MR".

Policy titled "Assessment and Reassessment: Nursing" last reviewed 05/26/16 stated "The RN (Registered Nurse) is responsible for performing accurate and timely assessments, in collaboration with the health care team. The RN, Physicians ... and other members of the health care team appropriately collaborate and coordinate their findings as they perform assessments and reassessments ... Assessments and ongoing reassessment by the RN in collaboration with the health care team / other disciplines is documented in the (EHR) Electronic Health Record. The data collected and the patient's response to care, interventions or treatments are documented in notes and document flow records in EHR ..."
.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation, document review, and interview, Nursing Staff did not ensure the confidentiality of patient records 4 (four) observations.

This may lead to the unauthorized disclosure of patients' health information.

Findings:

Observations in the facility's ED (Emergency Department) during a tour on 06/08/17 at
11:10AM identified an unsecured Specimen Log Book, found near a sink outside of Room 8. The open Specimen Log Book was opened to a page containing patient labels for Patients #10, #11, #12, #13 and #14. Labels contained full patient names, dates of birth, Medical Record numbers, account numbers and the ages and sex of patients, as well as tests performed for each patient.

This was confirmed by with Staff G (Assistant Nurse Manager).

Policy titled "Patient Health Information Privacy Policy" dated 11/14/11 stated "Every inpatient and outpatient of the facility is guaranteed by law to the right of privacy. All facility staff must respect this right and treat all PHI (Protected Health Information) properly and in the most confidential manner possible ..."

Observations on 3 North on 06/07/17 at 10:20AM identified an unsecured computer workstation in Patient #7's doorway. The computer screen was on and visible with legible patient information facing towards the hallway.

This was confirmed by Staff A (Nurse Executive) and Staff B (Director) at the time of observation.

Observations on 2 East on 06/07/17 at 2:40PM identified an unsecured computer workstation in front of the Nursing Station with visible and legible information for Patient #8 exposed.

Tour of the ED (Emergency Department) on
06/08/17 at 11:00AM revealed an unsecured computer workstation with Patient #4's visible and legible patient information. This workstation was located in the hallway between bed bays #4 and #6.

These findings were confirmed by Staff A at the time of the observations.

Policy titled "Workstation Use Policy" dated
01/14/09 stated "Active workstations shall not be left logged on to systems and/or applications while unattended for extended periods of time ..."
.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
.
Based on document review and interview, the facility did not ensure that the Perioperative Quality Assurance Program: a) analyzed, tracked, trended and implemented appropriate corrective actions to prevent reoccurrence for breaches in infection control, and b) implemented a corrective action plan to address a significant drop in compliance regarding OR (Operating Room) cleaning between patients.

This places patients at risk for exposure to infectious diseases.

Findings:

a) The facility's 01/17-05/17 Interprocedure Cleaning Inspection Sheets revealed the following:

On 03/13/17 the telephone was not thoroughly disinfected and "had to reclean few spots"

On 03/27/17 the telephone and OR door handle were not thoroughly disinfected and they "had to (be) reclean(ed)".

On 05/10/17 the prep stand was not thoroughly disinfected and it "had to (be) reclean(ed)".

On 05/09/17 (three {3} observations) documented "spray not available as per Carmella".

There was no documented evidence of the staff that participated in the cleaning of the OR and that corrective actions were taken with the staff that breached infection control practices.

There was no documented evidence that inspections were analyzed, tracked, trended and that corrective actions were implemented to prevent a reoccurrence.

During an interview with Staff AA (Director of Perioperative Services) on 06/14/17 at 2:20PM, the staff member confirmed these findings.

b) A review of the facility's "Perioperative Dashboard" dated 10/16-01/17 documented that OR cleaning inspections were at 100% compliance. Between 02/17-05/17 there was a drop in compliance regarding OR cleaning, 02/17 83.34%, 03/17 82.35%, 04/17 76.50% and 05/17 50.0%.

A review of the Operating Room Committee Meeting Minutes dated 04/17/17, revealed there was no documented evidence of a corrective action plan to address the decrease in compliance.

During an interview with Staff AA (Director of Perioperative Services) on 06/14/17 at 2:20PM, the staff member stated "there was no discussion during the April (2017) Perioperative Meeting regarding the decrease in compliance in February and March" (regarding the Interprocedure Cleaning). "It should have been discussed because of the downward trending. During the month of May we only did two OR inspections instead of eight. We ran out of the spray to do the testing. That is why compliance dropped to 50%. One of the two observations" fell out."

A review of the facility's Performance Improvement Program 2017/2018 documented "In coordination with the HPIC (Hospital Performance Improvement Committee), the Department of Nursing Performance Improvement Program is designed to objectively and systematically monitor and evaluate the performance of patient care, pursue opportunities to improve care and resolve identified problems".
.