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 JOSEPH MEDICAL CENTER 1401 ST. JOSEPH PARKWAY HOUSTON, TX 77002 Oct. 15, 2015
VIOLATION: GOVERNING BODY Tag No: A0043
The Governing Body of the facility failed to ensure that the facility's policies and procedures were enforced; failed to oversee the operations of their contracted services, specfically hemodialysis services being provided to its patients; failed to ensure that clients rights were encouraged and supported, specifically in the area of behavioral health; and failed to proactively maintain a strong infection control program. Please cross refer to the tags that follow in this Statement of Deficiencies for additional and more specific information and examples.

The Governing Body failed to ensure that the policy entitled Interdisciplinay Assessment and Treatment Plan was followed, especially those areas in the policy that refer to what the Treatment Plan will include (Section #4 of the policy), and when the treatment plan is to be revised (Section #8 of the policy). Cross refer to tag A-0130.

The Governing Body failed to ensure that the hospital staff was appropriately trained in escort procedures on Behavioral Health units, in that an escort was demostrated as a CPI Transport Position, which was a restraint. Cross refer to tag A-0154.

The Governing Body failed to ensure that dialysis services provided under contract utilized safe procedures, placing patients receiving dialysis services through this contracted services at a potential for harm. Cross refer to tags A-0618 and A-0619.
VIOLATION: CONTRACTED SERVICES Tag No: A0083
Based on observation, interview and record review, the Facility failed to ensure contracted Registered Nurses who provide care and services to hemodialysis patients in the facility implemented Facility's Policies and Procedures to provide pre - hemodialysis treatment assessment and weight evaluation to patients in 4 of 7 sampled hemodialysis patients #s 28, 49 , 61 and 63.

Findings:

Review of the facility's current policy and procedure on Pre Dialysis Patient - Assessment, directs staff as follows: "Obtain pre - dialysis weight. Compare with target weight and previous takeoff weight to determine the amount of fluid to be removed"

Failure to weigh patients pre-hemodialysis affects the ability to determine the amount of fluid to be removed from patients during hemodialysis treatment. Failure to weigh patients post hemodialysis treatment affects the ability to determine the amount of fluid removed during hemodialysis treatment which may result in the removal of too much or too little fluids during hemodialysis of patients.

Review of the facility's current policy and procedure on physician's order sheets, directs staff as follows: "Before a patient is to be treated, written routine dialysis standing physician's orders must be completed by the patient's attending physician. This covers the routine procedures encountered in the course of a normal dialysis treatment."

"Non- routine orders may be written on supplemental physician's orders sheets. The acute nurse is responsible for ensuring that these orders have been carried out. The acute nurse must sign and date the right hand column of the sheet to indicate the orders have been noted."

"It is understood that in emergency situations , it may be necessary for the acute nurse to take an order over the telephone. To prevent error, the order should be repeated back to the physician. The order should be written as follows "Epinephrine 1:1000, 5 cc SQ stat. Telephone order per Dr Jones/Mary Smith , RN "

On 10/13/2015, at 10:10 a.m., Patient (#28) was observed in the facility's acute care hemodialysis unit. The patient was receiving hemodialysis treatment using a Fresenius 2008 K hemodialysis machine.

Review of the patient's treatment sheet dated 10/13/2015, located at the chairside, revealed no documented evidence that a pre-treatment dialysis weight was obtained prior to initiation of hemodialysis treatment on the patient.

Interview on 10/13/2015, at 10:15 a.m., with Registered Nurse KK revealed the bed that the patient was in, is capable of weighing the patient but most of the time the bed is not zeroed so no weight is done on the patient.

Patient #61
On 10/14/2015, at 10:25 a.m., Patient # 61 was observed in the acute hemodialysis unit of the facility. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/minute and dialysate flow rate of 600 mls/minute. The patient was using a Fresenius 180 non reuse dialyzer.

Review on 10/14/2015, at 10:25 a.m., of the patient's treatment sheet dated 10/14/2015, located at the nurses's station, revealed documentation which indicated that the Patient's hemodialysis treatment was initiated at 7:30 a.m. Review the treatment sheets revealed no documented pre-treatment weight on the patient.

Review of the treatment sheets revealed documentation which indicated that the patient's last recorded blood pressure was timed at 8:15 a.m. The blood pressure sensor on the hemodialysis machine was inoperable so a portable blood pressure was observed beside the patient's bed.

Sections on the treatment sheet for the patient's prescription and pre-treatment assessment were blank. The section for venous pressure monitoring was blank, trans membrane pressure documentation was blank and fluids administered during hemodialysis were blank.

During an interview on 10/14/2015, at 10:45 a.m., with Registered Nurse AM, the Surveyor notified the Registered Nurse AM that the last documented blood pressure on the patient was timed 8:15 a.m. and that the patient's weight, pre-treatment assessment, prescription, trans membrane pressure, and venous pressure were not documented.

The Surveyor also informed the Registered Nurse AM that the most current physician's order dated 10/12/2015 had dialysate orders for Fresenius 160 dialyzer and a dialysate flow rate of 800 mls/ minute; but, the patient was using a Fresenius 180 dialyzer and the dialysate flow rate was 600 mls /minute.

Registered Nurse AM said she was busy with the patient because the dialyzer clotted. She said the bed that the patient is transferred to the unit in, was not accurate and so she did not do a weight on the patient. Registered Nurse (AM) said she had received a verbal order from the physician to change the dialyzer and dialysate flow rate but she did not write the order down.

Subsequent observation on 10/14/2015, at 10:50 a.m., revealed Registered Nurse AM took the patient's treatment sheet dated 10/14/2015, and filled in all blank areas on the sheet from memory. She did not obtain the information from any recorded source.

The Surveyor asked the Registered Nurse AM how is she able to recall all the missing information on the patient's treatment sheet, since she did not document the various readings for blood pressure, venous pressure, trans membrane pressure, and blood flow rate change over time. The Registered Nurse stated "Because I was watching."




Observation on the Surgical Intensive Care Unit (ICU) on 10/13/2015, between the hours of 9:30 a.m and 10:40 a.m revealed the following information:


Patient(# 63).
Patient (#63) was observed in bed receiving hemodialysis treatment via a temporary intravenous catheter.

He was receiving his hemodialysis with a Fresenius 160 dialyzer, dialysate flow rate (DFR) at 800 and blood flow rate (BFR) at 350.

Review of the physician's orders dated 10/13/2015, revealed no orders for a dialyzer. Further review of physician orders, progress notes and dialysis treatment flow sheets revealed Patient # 63 started hemodialysis treatment on 10/10/2015.

Review of Physician orders dated 10/10/2015, and 10/14/2015, revealed the orders did not include a dialyzer. The use of a dialyzer for hemodialysis treatment require a physician's order.

Review of the treatment records for 10/10/2015, revealed dialyzer Fresenius 160 was used to dialyze the patient without a physician's order.

On 10/11/2015, and 10/12/2015, the orders did not include blood flow rate or dialysate flow rate. Blood Flow Rate (BFR) and Dialysate Flow Rate (DFR) are a component of the patient's hemodialysis prescription and requires a physician's order.

Review of the treatment records for 10/11/2015, revealed the patient was dialyzed at a dialysate flow rate of 300 mls/hr without an order, there was no documentation of what the DFR was .

During an interview on 10/13/2015, at 10:15 a.m., with Staff II who was providing the hemodialysis treatment for the patient he stated the hemodialysis orders are standing orders.

Review of hemodialysis treatment record dated 10/10/2015 through 10/13/2015, revealed no documentation that the patient had a pre or post dialysis weight necessary to determine the amount of fluid to be removed during the treatment and determine the effectiveness of the hemodialysis treatment post dialysis.

During an interview on 10/13/2015, at 10:25 a.m., with the Nurse Manager for the unit regarding weights and physician orders for hemodialysis patients. She stated staffs are required to weigh the patients pre-dialysis. She stated the orders were incomplete.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on observation, interview, and record review, the facility failed to ensure contracted services staff who provide dialysis treatment to facility's patients followed manufacturer's recommendations and facility's policy for checking conductivity of dialysate solutions prior to initiating hemodialysis treatment on patients; failed to ensure contracted services calibrate the Myron - L D-1 Meter used for checking conductivity on dialysate solutions used for patient's hemodialysis treatment.

Over mixing bicarbonate, particularly, will decrease carbon dioxide in the concentrate. Failure to validate the conductivity of the dialysate solution with an independent calibrated meter can result in the use of improperly mixed dialysate concentrate, thus causing harm to the patient utilizing the concentrate.

The facility failed to ensure that the contracted services staff that provided hemodialysis treatment to facility's patients followed manufacturer's recommendations for validating the composition of the concentrate of the dialysate solution with a laboratory, following installation of 3 of 4 Fresenius 2008 T hemodialysis machines. Machine #s 41, 42, 43.

Hemodialysis machines utilize one specialized family of concentrate for hemodialysis treatment. Verifying the composition of the dialysate concentrate ensures the proper mixture of the concentration by the hemodialysis machine.

The facility failed to ensure physician's orders were obtained to dialyze patients in the facility.

Findings:

Review of manufacturer's recommendations for Fresenius 2008 hemodialysis machines Hemodialysis machine operators manual, direct users as follows: "The operator should always check conductivity and approximate PH of the dialysate with an independent device prior to initiating treatment and whenever concentrates are changed during the operation."

Review on 10/13/2015, of the facility's policy and procedure on Testing Dialysate Conductivity, directs staff as follows: "Dialysate conductivity will be tested before each treatment via the Myron - L D-1 Meter."

On 10/13/2015, at 10:10 a.m., Patient #28 was observed in the facility's acute care hemodialysis unit receiving hemodialysis treatment using a Fresenius 2008 K hemodialysis machine.

Review of the Patient's treatment sheet dated 10/13/2015, revealed no indication that the conductivity of the dialysate solution was validated with an independent meter Myron -L D-1 Meter

Interview on 10/13/2015, at 10:12 a.m., with Registered Nurse KK revealed she did not check the conductivity on the dialysate solution prior to initiation of hemodialysis treatment on patients because there was no solution available in house for calibrating the Myron - L D-1 Meter used for checking conductivity. Further interview with Registered Nurse KK revealed she worked with a company that is contracted with the hospital.

Review of the facility's Myron - L D-1 Meter Log revealed the last date calibration was done on the Myron - L D-1 Meter was dated January 11, 2015. Review of the facility's Myron - L D-1 Meter Log revealed documentation which indicated the facility's dialysis unit has three Myron - L D-1 Meters, serial numbers 2, 4 and 5 for checking of dialysate conductivity. Review of the log revealed documentation which indicated that all three meters were last calibrated on 01/11/2015.

Review of the Manufacturer's Instructions for Myron - L D-1 Meter direct users as follows: "The Conductivity Standard Solutions and PH Buffers below are used for factory calibration. Regular use of these solutions is recommended to ensure specified instrument accuracy. Frequency of conductivity recalibration depends upon use, but once every month should be sufficient for an instrument used daily."

Review of the facility's current policy and procedure on Calibrating the Myron- L D-1 Meter directed users as follows: "This procedure should be performed once every month for an instrument that is used daily (as per manufacturer's requirement)".

During an interview on 10/13/2015, at 10:41 a.m., with the Facility's Chief Biomedical Technician for dialysis , he said it was the responsibility of the nurses who provide dialysis to patients to calibrate the Myron - L D-1 Meter.

Verification of dialysate composition

Interview on 10/13/2015, at 10:30 a.m, with the facility's Chief Biomedical Technician for dialysis revealed the facility had 4 new Fresenius 2008T hemodialysis machines in use in the facility for hemodialysis treatment of patients.

Review of manufacturer's recommendations for Fresenius 2008T hemodialysis machines direct users as follows:

"The Machine must be labeled to indicate the type of concentrate for which it is configured. Check the composition (i.e., Na, Cl , K, Ca, Mg, HCo3 and pH) of the dialysate solution after the machine is installed or after the machine is modified for different concentrate type."

"Check the conductivity and appropriate pH of the dialysate solution with an independent device before initiating dialysis."

Observation on 10/13/2015, at 2:40 p.m., revealed hemodialysis machine #s 41, 42 and 43 were observed in the dialysis equipment room of the facility. Tags on the machines indicated they were ready for usage. One machine was tagged as out of service.

Interview on 10/13/2015, at 2:40 p.m., with the facility's Chief Biomedical Technician for dialysis revealed four Fresenius 2008 T hemodialysis machines were put into service in January 2015, and were being used for hemodialysis treatment of patients. He said he did not validate the dialysate composition with a laboratory after the machines were installed.

Interview with the facility's Chief Biomedical Technician for dialysis revealed he works with a company that is contracted to the facility.













Patient (#48) named in a complaint conducted during the survey.

Review of Patient # (48) Hemodialysis Orders dated 07/28/2015, revealed the Physician wrote "Hemodialysis x 2 hrs today, hemodialysis x 3 hrs WED".

Review on 10/13/2015, of the Patient# (48)'s treatment sheets revealed he did not receive hemodialysis treatment on Wednesday, 07/29/2015, but instead it was done on Thursday, 07/30/2015, with no hemodialysis treatment orders.

Review of Patient # (48)'s Hemodialysis Orders dated 08/03/2015 revealed the Physician wrote "HD for 3 hours today and on Wednesday."

Review of the Patient# (48)'s treatment sheets revealed that he received hemodialysis treatment on 08/03/2015, but did not have it on Wednesday, 08/05/2015. Another hemodialysis treatment was done on Friday, 08/07/2015, with no hemodialysis treatment orders.

An interview with Quality Consultant FFFF on 10/13/2015, at 03:05 p.m., the Surveyor notified her of the missing hemodialysis orders for services rendered on 07/30/2015, and 08/07/2015, she said "That was from the previous contract we had; and usually once we have the orders we think that the contracted service for dialysis or their nurses would call for the orders from the doctors if they need to clarify something."
VIOLATION: PATIENT RIGHTS Tag No: A0115
The Condition of Participation for Patient's Rights is not met, as the hospital failed to provide services to patients in a safe manner, specifically in the areas of the provision of dialysis services, individualized treatment planning, and staff education and use of appropriate escort versus restraint techniques.


The facility failed to provide safe dialysis services by not insuring that pre and post hemodialysis treatment weights were obtained, and that the accurate and immediate recording of changes in the patient's condition were completed. Cross refer to tags A0083, A0084.


The facility failed to ensure active patient involvement in the development and updating of individualized treatment plans on the behavioral health unit; and the facility also failed to ensure that their own policy regarding individualized treatment planning was followed. Cross refer to tag A 0130.


The facility failed to adequately train staff in the use of the least restrictive method for patient escort on the behavioral health units, in that training staff demonstrated a method of restricting patient movement as a method of escort. Cross refer to tags A 0154 and A 0201.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

This standard is not met. Interview and record review indicated that patients were presented with the staff's plan of care for them, and then the patients signed off on the plan of care upon presentation and discussion. This does not indicate that the patient's right to participate in the development and implementation of the plan of care was maintained. This issue was found in 13 of the 13 records reviewed for plan of care, citing patient #s 1, 2, 3, 4, 10, 11, 12, 13, 14, 15, 17, 18, 19, 52, and 53.


In addition, in particular citation of patient #2's treatment planning, the fact that there was no mention of the patient's alleged diabetic condition and non-inclusion of the patient's own beliefs of this medical condition on the treatment plan had the potential for placing the patient at harm.


Findings included:


On behavioral health unit:


Patient (#2)

In review of the medical record of patient #2, hypertension was noted as a problem for this patient. However, there was no mention of hypertension in the patient's individualized treatment plan, nor were there any modalities described for interventions for this medical issue.


Further, in review of this patient's record, Insulin- sliding scale- was ordered by the physician. Insulin is usually prescribed for the treatment of diabetes and the sliding scale provides guidance to nursing staff on the dosage of insulin to be given to the patient depending on the blood sugar level.


There was no mention of diabetes in the patient's individualized treatment plan. Interview with the nurse on the unit indicated that the insulin was not being administered to this patient secondary to the fact that the patient was refusing "finger sticks" to test his blood sugar levels, and that the patient himself was denying that he had a diabetic condition. Again, there was no mention of diabetes, nor the modalities of blood sugar measurements or administration of insulin mentioned in the patient's individualized treatment plan. There was no indication that the patient participated in the development and implementation of his own treatment plan.


Patient (# 1)

In review of the medical record of patient #1, the initial physician's assessment and admitting orders were accomplished via the use of telemedicine. There was no indication that the patient was involved in the development and implementation of his treatment plan.


Patient #3

Review of Patient #3's medical history and physical record revealed a 61 year old, female, admitted on [DATE]. Reason for admission: The patient was found with her bra wrapped around her neck in the bathroom and a bottle of pills by her hand. She was unconscious.

Review of Patient #3's Physician Orders - Behavioral Medicine General Admission form dated 10/2/15, timed at 10:00 a.m., revealed there were no precautions ordered. The Physician Orders were not signed by a physician.

Review of Patient#3's Interdisciplinary Adult Plan of Care (undated) reflected an admission date of [DATE]. The Plan of Care reflected fall Risk and interventions per fall Risk Assessment tool was checked. There were no desired outcome/goals written or checked for the Safety Fall Risk.

Further review revealed patient # 3's treatment plan Suicide risk was not a part of the treatment plan; her admitting reason for admission indicated a suicide risk.

During an interview on 10/12/15, on the 8th floor Medical/Psych unit, Staff W, Registered Nurse (RN), when asked how the fall interventions are determined she stated the Fall Risk Assessment tool is completed on admission. Staff W stated, "The facility uses a Fall Risk Assessment Form." She was unable to provide the form or evidence that the form had been completed on Patients #3, 4, or 5.

During an interview on 10/12/15, on the 8th floor Medical/ Psych unit Staff , RN stated, "The unit is new and the fall form has not been implemented yet. She stated,"The staffs check on the patients frequently.

Patient #4

Review of Patient #4's medical history and physical record revealed a 63 year old, female, admitted on [DATE]. Reason for admission: The patient was delusional, threatening to kill her brother and herself with a knife and apparently, she was running down the street naked.

Review of Patient #4's Physician Orders - Behavior Medicine General Admission form dated 10/11/15 at 12:30 a.m. revealed Precautions: Fall was checked. Suicide Precautions was not checked; her admitting reason for admission indicated a suicide risk.

Review of patient#4's Interdisciplinary Adult Plan of Care (undated) reflected an admission date of [DATE]. The Plan of Care reflected fall Risk and interventions per fall Risk Assessment tool was checked. There was no desired outcome/goals written or checked for the Safety Fall Risk. Risk of injury to self/others was checked as a problem, therapeutic communication was an intervention, there were no further interventions and there were no desired Outcomes/Goals recorded.



Patient (#10)

In review of the medical record of patient #10, it was noted that the patient required an extensive seclusion episode on 9/7/15, requiring seclusion for 3 hours and 15 minutes. There was no notation that there were any changes made in the patient's plan of care following the seclusion episode.


The patient refused to sign his treatment plan, and there was no indication that the patient was involved in the development of his individualized treatment plan. The patient was subsequently transferred to a State Hospital facility after an inpatient psychiatric hospitalization of more than three weeks.


Patients #11, #12, #14, #15, #17, #18, #19, and #53


Review of medical records #11, #12, #14, #15, #17, #18, #19, and #53, the individualized treatment plan for all eight patients showed the reason for psychiatric hospitalization as "potential for danger to self or others", and also the statement "alteration in mood" or "alteration in thought" as the presenting problems requiring inpatient psychiatric treatment. There was no description of how the "alterations" manifested themselves in any of the above mentioned patients, or how the patients were a danger to themselves of others.


Patients #12, #13, #14, and #52


Review of the medical records of patients #12, #13, #14, and #52, there were no dates in the space provided for the dates (with the word "date" under the line or space provided) after the staff signatures, so it could not be ascertained if the staff members signed the treatment plan prior to or after the patient.


Patients #19, and #53


Review of the medical record of patient #19, and #53, there was no patient signatures and no dates by the staff signatures even though a space was provided for the date with the word "date" under the line of space provided.


In interview with a social worker, and registered nurse, on the behavioral health unit on 10/13/2015, in the afternoon, it was reported that the staff designs the treatment plan after completing required assessments, and then the treatment plan is presented to the patient for his or her signature. There was no evidence offered to indicate patient involvement in the development of the plan.


The facility has a policy entitled "Interdisciplinary Assessments and Treatment Plan, policy # CBH.30," with an origination date of October 2004 and a final approval date of 9/10/2013.


The policy states that the treatment plan "utilizes information from" various assessments, and that the treatment plan "will include:


a. A list of all diagnosis for the patient with notation as to which diagnosis will be treated at the hospital. The list of diagnosis must include:

i. At least one mental illness

ii. Any substance abuse diagnosis

iii. Any non-psychiatric condition


b. A list of problems and needs that are to be addressed during the patient's hospitalization .


c. A description of all treatment interventions including:

i. Each psychotropic medication prescribed along with the symptoms it targets

ii. Identification of the level of monitoring the patient is assigned to

iii. A description of the short and long term goals

iv. The specific modalities for each treatment intervention including type and frequency

v. The staff member responsible for ensuring treatment

vi. A description of the rationale for the treatment interventions

vii. The time frames and measures to evaluate progress toward goals

viii. Documentation to justify diagnosis, treatment, and appropriate timely discharge

ix. A description of the recommended services and supports needed by the patient after discharge".


The policy further stipulates: "The treatment plan is revised when:

a. There is a change in the patient's condition or diagnosis

b. Clinically indicated".
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interview and record review, the facility failed to ensure contracted Registered Nurses who provide care and services to hemodialysis patients in the facility implemented facility's policies and procedures to provide pre-hemodialysis treatment assessment and weight evaluation to patients in 4 of 6 sampled hemodialysis patients. #s 28, 49, 61 and 63.

The facility failed to ensure contracted services staff who provide hemodialysis treatment to facility's patients follows manufacturer's recommendations and the facility's policy for checking conductivity of dialysate solutions prior to initiating hemodialysis treatment on patients; failed to ensure contracted services staff calibrated devices used for checking conductivity on dialysate solution used for patients' hemodialysis treatment.

The facility failed to ensure contracted services staff who provide hemodialysis treatment to facility's patients follow manufacturer's recommendations for validating the composition of the concentrate of the dialysate solution with a laboratory, following installation of 3 of 4 Fresenius 2008 T hemodialysis machines. Machine #s 41, 42, 43.

The Facility failed to ensure contracted Registered Nurses who provide care and services to hemodialysis patients in the facility met the qualification outlined in their job description in 8 of 8 sampled contracted nurses observed and reviewed.

The failure to have contracted staff complete a Color Vision Test prevents the employee from effectively monitoring the water quality used to dialyze the facility's patients therefore putting the patients at risk for harm and not practicing according to acceptable standards of practice. Citing Registered Nurses #s KK, II, AM, TTT, UUU, VVV, WWW and XXX.


The facility failed to ensure that a suicidal patient was placed on suicide precautions as outlined in the policy and procedure in one of one patient named in the complaint (Patient #3)


Findings:

Review on 10/13/2015, of the facility's current policy and procedure on Pre Dialysis Patient -Assessment, direct staff as follows: "Obtain pre-dialysis weight. Compare with target weight and previous takeoff weight to determine the amount of fluid to be removed"

Review of the Facility's current policy and procedure on physician's order sheets, directs staff as follows: "Before a patient is to be treated, written routine dialysis standing physician's orders must be completed by the patient's attending physician . This covers the routine procedures encountered in the course of a normal dialysis treatment."

"Non- routine orders may be written on supplemental physician's orders sheets. The acute nurse is responsible for ensuring that these orders have been carried out. The acute nurse must sign and date the right hand column of the sheet to indicate the orders have been noted."

"It is understood that in emergency situations, it may be necessary for the acute nurse to take an order over the telephone. To prevent error, the order should be repeated back to the physician. The order should be written as follows: "Epinephrine 1:000, .5 cc SQ, STAT. Telephone order per Dr Jones/Mary Smith, RN." Transcribed as written in policy.

On 10/13/2015, at 10:10 a.m., Patient (#28) was observed in the facility's acute care dialysis unit receiving hemodialysis treatment using a Fresenius 2008 K hemodialysis machine.

Review of the Patient's treatment sheet dated 10/13/2015, located at the chairside revealed no documented evidence that a pre-treatment dialysis weight was obtained prior to initiation of hemodialysis treatment on the patient.

Interview on 10/13/2015, at 10:15 a.m., with Registered Nurse KK revealed the bed that the patient was in, is capable of weighing the patient but most of the time the bed is not zeroed so no weight is done on the patient.

Patient #61
On 10/14/2015, at 10:25 a.m., Patient # 61 was observed in the acute dialysis unit of the facility. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/minute and dialysate flow rate of 600 mls/minute. The patient was using a Fresenius 180 non reuse dialyzer.

Review on 10/14/2015, at 10:25 a.m., of the patient's treatment sheet dated 10/14/2015, located at the nurses's station, revealed documentation which indicated that the patient's hemodialysis treatment was initiated at 7:30 a.m. Review the treatment sheets revealed no documented pre/hemodialysis treatment weight on the patient.

Review of the patient's treatment sheets revealed documentation which indicated that the patient's last recorded blood pressure was timed at 8:15 a.m. The blood pressure sensor on the hemodialysis machine was inoperable so a portable blood pressure was observed beside the patient's bed.

Sections on the patient's treatment sheet for patient's prescription and pre-treatment assessment were blank. The sections for venous pressure monitoring was blank, Trans membrane pressure documentation was blank and fluids administered during hemodialysis was blank.

During an interview on 10/14/2015, at 10:45 a.m., with Registered Nurse AM, the Surveyor notified the Registered Nurse AM that the last documented blood pressure on the patient was timed 8:15 a.m., and that the patient's weight, pre- treatment assessment, prescription, Trans membrane pressure, and venous pressure were not documented.

The Surveyor also informed the Registered Nurse AM that the most current physician's order dated 10/12/2015, had dialysate orders for Fresenius 160 dialyzer and a dialysate flow rate of 800 mls/ minute, but the Patient was utilizing a Fresenius 180 dialyzer and the dialysate flow rate was 600/mls/ minute.

Registered Nurse AM said she was busy with the patient because the dialyzer clotted. She said the bed that the patient is transferred to the unit in, is not accurate and so she did not do a weight on the patient. Registered Nurse AM said she had received a verbal order from the physician to change the dialyzer and dialysate flow rate but she did not write down the order.

Subsequent observation on 10/14/2015, at 10:50 a.m., revealed Registered Nurse AM took the patient's treatment sheet dated 10/14/2015 and filled in all blank area on the sheet from memory. She did not obtain the information from any recorded source.

The Surveyor asked the Registered Nurse AM how she was able to recall all missing information on the patient's treatment sheet since she did not document the various readings for blood pressure, venous pressure, Trans membrane pressure, and blood flow rate changes over time.
The Registered Nurse stated "Because I was watching."

Conductivity of dialysate solution
Review of manufacturer's recommendations for Fresenius 2008 hemodialysis machines Hemodialysis machine operators manual, direct users as follows: "The operator should always check conductivity and approximate pH of the dialysate with an independent device prior to initiating treatment and whenever concentrates are changed during the operation."

Review on 10/13/2015, of the facility's policy and procedure on Testing Dialysate Conductivity, directs staff as follows: "Dialysate conductivity will be tested before each treatment via the Myron - L D-1 Meter."

On 10/13/2015, at 10:10 a.m., Patient #28 was observed in the facility's acute care hemodialysis unit receiving hemodialysis treatment using a Fresenius 2008 K hemodialysis machine.

Review of the Patient's treatment sheet dated 10/13/2015, revealed no indication that the conductivity of the dialysate solution was validated with an independent meter Myron -L D-1 Meter

Interview on 10/13/2015, at 10:12 a.m., with Registered Nurse (KK) revealed she did not check the conductivity on the dialysate solution prior to initiation of hemodialysis treatment on patients because there was no solution available in house for calibrating the Myron - L D-1 Meter used for checking conductivity. Further interview with Registered Nurse (KK) revealed she worked with a company that is contracted with the hospital.

Review of the facility's Myron - L D-1 Meter Log revealed the last date calibration was done on the Myron - L D-1 Meter was dated January 11, 2015. Review of the facility's Myron - L D-1 Meter Log revealed documentation which indicated the facility's dialysis unit has three Myron - L D-1 Meters, serial numbers 2, 4 and 5 for checking of dialysate conductivity. Review of the log revealed documentation which indicated that all three meters were last calibrated on 01/11/2015.

Review of the Manufacturer's Instructions for Myron - L D-1 Meter directed users as follows: "The Conductivity Standard Solutions and pH Buffers below are used for factory calibration. Regular use of these solutions is recommended to ensure specified instrument accuracy. Frequency of conductivity recalibration depends upon use, but once every month should be sufficient for an instrument used daily."

Review of the facility's current policy and procedure on Calibrating the Myron- L D-1 Meter directs users as follows: "This procedure should be performed before once every month for an instrument that is used daily (as per manufacturer's requirement.)"

During an interview on 10/13/2015, at 10:41 a.m., with the Facility's Chief Biomedical Technician for dialysis, he said it was the responsibility of the nurses who provide dialysis to patients to calibrate the Myron - L D-1 Meter.

Verification of dialysate composition

Interview on 10/13/2015, at 10:30 a.m, with the facility's Chief Biomedical Technician for dialysis revealed the facility has 4 new 2008T hemodialysis machines in use in the facility for hemodialysis treatment of patients.

Review of manufacturer's recommendations for Fresenius 2008T hemodialysis machines direct users as follows:
"The Machine must be labeled to indicate the type of concentrate for which it is configured. Check the composition (i.e. Na, Cl , K, Ca, Mg, HCo3 and pH) of the dialysate solution after the machine is installed or after the machine is modified for different concentrate type."

"Check the conductivity and appropriate pH of the dialysate solution with an independent device before initiating dialysis."

Observation on 10/13/2015, at 2:40 p.m., revealed hemodialysis machine #s 41, 42 and 43 were observed in the dialysis equipment room of the facility. Tags on the machines indicated they were ready for usage. One machine was tagged as out of service.

Interview on 10/13/2015, at 2:40 p.m., with the facility's Chief Biomedical Technician for dialysis revealed four Fresenius 2008 T hemodialysis machines were put into service in January 2015 and were being used for hemodialysis treatment of patients. He said he did not validate the dialysate composition with a laboratory after the machines were installed.

Interview with the facility's Chief Biomedical Technician for dialysis revealed he works with a company that is contracted to the facility.


Registered Nurses Qualifications
Registered Nurse KK

On 10/13/2015, at 10:10 a.m., Registered Nurse KK was observed in the dialysis unit of the facility providing care and services to Patient #28 who was receiving hemodialysis treatment.


Review of Registered Nurse KK's Job description titled: "St Joseph Contract Employee Addendum - Dialysis RN." Revised 10/02/2015, and signed on 10/07/2015, by Registered Nurse (KK) revealed the following : "This job has special vision requirement check all that apply. Color vision ( ability to identify and distinguish colors.)" The requirement to identify and distinguish colors was checked.


Review on 10/14/2015, of Registered Nurse KK's personnel and health records revealed no indication that a test was performed to determine the Registered Nurse's ability to detect and distinguish colors.


Registered Nurse II
On 10/13/2015, at 2:40 p.m., Registered Nurse II was observed in the dialysis unit of the facility providing care and services to Patient #72 who was receiving hemodialysis treatment.


Review of Registered Nurse II's Job description titled "St Joseph Contract Employee Addendum - Dialysis RN." Revised 10/02/2015, and signed on 10/08/2015, by Registered Nurse (II) revealed the following : "This job has special vision requirement check all that apply. Color vision ( ability to identify and distinguish colors.) " The requirement to identify and distinguish colors was checked.


Review of Registered Nurse II's personnel and health records revealed no indication that a test was perform to determine the Registered Nurse's ability to detect and distinguish colors.



Registered Nurse A.M

On 10/14/2015, at 10:25 a.m., Registered Nurse AM was observed in the dialysis unit of the facility providing care and services to Patient #28 who was receiving hemodialysis treatment.


Review of Registered Nurse AM's Job description titled "St Joseph Contract Employee Addendum - Dialysis RN." Revised 10/02/2015, and signed on 10/07/2015, by Registered Nurse AM revealed the following: "This job has special vision requirement check all that apply. Color vision ( ability to identify and distinguish colors.") The requirement to identify and distinguish colors was checked.


Review of Registered Nurse AM's personnel and health records revealed no indication that a test was perform to determine the Registered Nurse's ability to detect and distinguish colors.


Interview on 10/14/2015, at 1:10 p.m., with the Registered Nurse in charge of the dialysis unit, the Surveyors requested documentation that tests were conducted to determine the nurse's ability to to detect and distinguish colors. The Registered Nurse in charge of the dialysis unit said these tests were not performed on the nurses.



Review of personnel files for Staff #s TTT, UUU, VVV, WWW, and XXX, revealed the staff did not have documentation that a color blind test was conducted on these staff.)

Review on 10/13/2015 of St Joseph Medical Center Job Description, titled "St. Joseph Contract Employee Addendum-Dialysis RN", states the following information:

"This job has special vision requirements. Color Vision (ability to identify and distinguish colors)".








Patient #3

In an interview with RN Employee W on the Medi-Psych Unit, on 10/12/15, at 1100, she stated that Patient #3 was placed on suicide precautions at the time of admission. RN Employee W stated she could not provide documentation of suicide precautions, adding, "Patient #3 was on automatic suicide precautions." Suicide precautions included visual checks every 15 minutes, CareView, and placement near the nurse's station. RN Employee W also stated that there was no system in place to determine if suicide precautions needed to be continued or discontinued every 24 hours. She did not write a nursing order for suicide precautions. She did not know that the doctor needed to co-sign a nursing order for suicide precautions.


Record review of Physician Orders - Behavioral Medicine General Admission by MD Employee OO dated 10/01/15, at 01:30 p.m., and 10/02/15, at 10:30 a.m., revealed no suicide precautions. However, suicide precautions were discontinued on 10/03/15, at 09:48 a.m., by MD Employee OO.


Record review of the Close Observation Monitoring Form of Patient #3 for 10/01/15, 10/02/15, and 10/03/15, revealed no documentation by staff that patient rooms were "checked for hazardous items once per shift."


Record review of "Special Precautions Monitoring Policy," approved 06/09/15, revealed: "An order for suicide precautions is written by a physician, or by a registered nurse as an independent nursing intervention. A physician's order must be obtained within 1 hour of the nursing order. The order must include reason ... The order for suicide precautions is reviewed daily, and it will be renewed, as indicated, by the physician (with input from the treatment team) ... The patient and room are checked once per shift for hazardous items ... and this is documented on the Close Observation Monitoring Form. "
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation, interview, and record review, the facility's direct care staff failed to remove gloves and wash/sanitize hands after direct contact with contaminated items and patients in 9 random observations in the facility's intensive care unit, hemodialysis unit, new born nursery; II, RR, AM , HH and five random physicians.

Failed to ensure physicians' orders were obtained for insertion of Foley catheters and monitored for appropriateness of continued use of Foley catheters in 2 of 6 Patients monitored with Foley catheters Patient #s 63 and 65

Failed to maintain a clean and sanitary environment in the facility's community kitchen, psychiatric units, and surgical suites . Cross refer to A 0620, 0749, and A 0951.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility's direct care staff failed to remove gloves and wash/sanitize hands after direct contact with contaminated items and patients in 9 random observations in the facility's intensive care unit, hemodialysis unit, new born nursery; II, RR, AM , HH and five random physicians.

Failed to ensure physicians' orders were obtained for insertion of Foley catheters and monitored for appropriateness of continued use of Foley catheters in 2 of 6 Patients monitored with Foley catheters Patient #s 63 and 65

Failed to maintain a clean and sanitary environment in the facility's community kitchen psychiatric units and surgical suites .

Findings:

Review of the Facility's Policy and Procedure on Universal Blood and Body Fluid Precautions obtained from the hemodialysis Policy Manual,section VIII, direct staff as follows: "Hand and other skin surface must be washed immediately (or as soon as possible) with soap and water if contaminated with blood or any other body fluid. Hands will be washed immediately after gloves are removed and upon leaving the work area."

"Gloves must be worn during all venous and arterial punctures. Sterile gloves will be worn when necessary."

Patient #s 26 and 27. Registered Nurse HH

On 10/13/2015, at 1:55 p.m., Registered Nurse HH was observed wearing a pair of gloves while pushing patient # 26's bed into the dialysis unit from the outside of the unit.

On entering the unit, Registered Nurse HH repositioned the patient in bed, and handed over the patient to the dialysis nurse. After handing the patient over, Registered Nurse HH continued to wear the contaminated gloves that she had used to transfer the patient. Registered Nurse HH placed her contaminated gloved hands in her pocket and retrieved two syringes and ampoules with medication from her pocket. The Registered Nurse then walked over to the computer terminal, verified the physician's order and pulled up medication from the ampoules containing medication. She continued wearing the contaminated gloves she had used to transport the patient.

Registered Nurse #HH walked over to Patient #27, who was in an adjacent bed receiving hemodialysis treatment. She administered intravenous medication to Patient #27 using the contaminated gloves she had used to transfer Patient (#26).

Registered Nurse HH did not remove her gloves and wash/ sanitize her hands after transferring the patient from the unit.

Interview on 10/13/2015, at 2:15 p.m., with Registered Nurse HH, the Surveyor notified the Registered Nurse that she had used the same gloves that she used to transfer Patient # 26 with to administer Patient #27's intravenous medication.

Registered Nurse HH stated : "Shuck, Just now I thought about it."

PATIENT #72 Registered Nurse II

On 10/13/2015, at 2:30 p.m., Registered Nurse II was observed on the hemodialysis unit, at the bedside of Patient # 72. Observation revealed Registered Nurse II donned a pair of gloves, pulled up the side rails on the patient's bed , reset the settings on the patient's hemodialysis machine, removed his gloves. The Registered Nurse did not wash or sanitize his contaminated hands. Registered Nurse II walked over to the clean glove box located at the nurses station and picked up clean gloves with his contaminated hands.

Observation on 10/13/2015, at 2:40 p.m., revealed Registered Nurse II was observed at the bedside of Patient #72. The Registered Nurse was observed initiating hemodialysis treatment on Patient #72. Registered Nurse II applied a gown and a mask to his face. While securing the disposable mask around his neck , the Registered Nurse directly touched the back of his neck and head. The Registered Nurse did not wash/sanitize his hands. He then picked up clean gloves from the box of gloves, with his contaminated hands he had used to touch his neck and head.

He then donned the glove and proceeded to clean Patient #72's vascular access. After cleaning the patient's vascular access located on the patient's left lower arm, Registered Nurse II retrieved the stethoscope from his neck and examined the patient's chest and back, touching the Patient's chest and back with his gloved hands. Registered Nurse II then cannulated the patient's vascular access wearing the same gloves he used to examine the patients chest and back.

During an interview on 10/13/2015, at 2:45 p.m., the Surveyor informed registered Nurse II that he did not wash/sanitize his hands after touching his neck and head and that he used the same gloves that he had used to examine the patient's neck and chest to cannulate the Patient's vascular access. Registered Nurse (II) stated "I agree."

Patient # 28 Registered Nurse AM

On 10/14/2015, at 10.50 a.m., Registered Nurse AM was observed in the dialysis unit at the chair-side of Patient #28. Registered Nurse AM reset the patient's hemodialysis machine wearing one hand of a glove to her right hand. After resetting the patient's contaminated hemodialysis machine, Registered Nurse AM entered information on the patient's treatment sheet while wearing her contaminated glove. She then walked over to the nurse' station with her contaminated gloved hand picked up the clean glove box from the nurses' station with her contaminated gloved hands. Registered Nurse AM did not remove her contaminated glove and wash/sanitize her hands after touching patient #s 28 contaminated hemodialysis machine.

During an interview on 10/14/2015, at 10:55 a.m., the Surveyor notified Registered Nurse AM that she had reset the panel on the patient's hemodialysis machine with her gloves, that she had contaminated everything at the nurses station by wearing her contaminated glove to the station and touched items at the nurses' station.
Registered Nurse AM responded "yes"

On 10/14/2015, at 11:05 a.m., Registered Nurse AM donned a pair of gloves and pulled the contaminated biohazard box from across the room to the bedside of Patient #28. She touched the inside of the opened lined carton with her gloves. Wearing the same pair of gloves Registered Nurse AM walked to the hemodialysis machine of Patient (#28) and reset the hemodialysis machine of the patient.

The Facility's Director of Critical Care who was present notified Registered Nurse AM that she needed to change her gloves before touching the Patient's hemodialysis machine.
Registered Nurse AM stated " I only used one hand of gloves "

Patient #28, Registered Nurse AM

On 10/14/2015, at 11:15 a.m., was Registered Nurse AM observed on the bedside of Patient ( #28 ). Observation revealed the Registered Nurse donned a pair of gloves, disconnected the patient's central venous catheter from the external blood line. After disconnecting the patient's external blood lines, the Registered Nurse removed her contaminated gloves, walked over to the clean box of gloves located at the nurses station and picked up clean gloves with her contaminated previously gloved hands.

The Surveyor immediately notified Registered Nurse AM that she did not wash/sanitize her hands. Registered Nurse AM said "Oh!"






Observation on the Surgical Intensive Care Unit (ICU) on 10/13/2015, between the hours of 9:30 a.m. and 10:40 a.m. revealed the following information:

Staff # II
Patient (#63) was observed in bed receiving hemodialysis treatment via a temporary intravenous catheter.

Staff II Registered Nurse (RN) caring for the patient was observed wearing gloves, and was documenting on a paper record attached to a clip board.

The staff went to the patient's bedside touch the patient's dialysis machine and supplies located on top of the dialysis machine. The Staff did not remove the gloves and sanitize his hands after touching the dialysis machine and supplies. He continued his documentation wearing the dirty gloves.

Staff II went back to the dialysis machine touched the machine , removed the gloves he was wearing and did not wash/ sanitize his hands. He continued documenting on the paper record with his unwashed hands.

Further observation on 10/13/2015, on the ICU revealed five (5) Physicians went into a patient's room(#4) and did not sanitize their hands prior to entering the patient's room.

The physicians spent approximately 10-15 minutes in the patient's room then left. Three (3) of the five (5) physicians did not wash/sanitize their hands after leaving the patient's room.

Hand sanitizer was located at the entry to each room and hand washing sink with soap and water was available in the patient's room.

Staff RR
Observation on 10/13/2015, at 11:45 a.m., in the new born nursery revealed Staff RR Registered Nurse providing care to an infant in his cot.

After completing her care the nurse removed her gloves, did not wash her hands, she picked up the patient's paper record, went to the desk at the nurse's station and began documenting at the computer.

Hand sanitizer and hand washing sinks were readily available in the nursery.

During an interview on 10/13/2015, at 11:05 a.m., with the RN Manager on the unit she stated she saw the physicians go into the room without hand sanitization and addressed the issue with them.

The RN Manager further stated the paper record used by Staff II goes into the patient's paper chart at the end of the treatment. The Paper chart is kept at the Nurse ' s station and is handled by all staff.

The observation revealed not all the physicians complied with the instructions when they left the patient's room.

Patient #63
Patient #63 was observed on 10/13/2015, at 9:30 a.m., in bed. He had a Foley catheter to drain.

Review of physician's orders progress and nurses notes dated 10/9/2015 through 10/13/2015, revealed the patient was admitted to the unit on was admitted to the facility 10/8/2015, and had a left Carotid Endarterectomy(surgical procedure of the artery) done.

He was transferred to the Intensive Care Unit ( ICU) on 10/9/2015, with a Foley Catheter in place. There was no orders or indication for Foley Catheter use documented on the patient's medical record.

Patient # 65
Observation on 10/14/2015, at 10:05 a.m., on the ICU revealed Patient (#65) in bed with a Foley catheter to drain.

Review of the patient's Interdisciplinary notes dated 10/9/2015 through 10/14/2015, revealed the patient was diagnosed with Dysphasia and was intubated.

She was admitted on [DATE], with the Foley Catheter in-place.

Review of Physician's orders revealed there was an order for Foley Catheter but no indication for use was documented.

During an interview on 10/15/2015, at 10:05 a.m. ,with the Infection Control Manager he stated there is a Foley Catheter protocol that should be used on all units.

According to Manager there should be a written order with indication for use, for the Foley catheters.






Psychiatric Intake

Observation on 10/15/15, at 9:30 a.m., of the Psychiatric intake unit revealed an Environmental Services staff cleaning a large room. The room contained (4) pull out vinyl covered beds and the floor was smeared with copious amounts of what appeared to be brown fecal matter. The fecal matter was observed to trail out of the room into the carpeted entry. There was a white towel placed over one large brown spot. There was no other barrier to prevent the three patients sitting in the outer room from accessing the area.


Further observation revealed an unidentified nurse dragging a soiled linen bag across the carpeted entry and out into the tiled hall by the elevators; she placed the bag in an open laundry hamper. When the surveyor asked what was in the bag, she stated it was the patient's fecal soiled clothes.


Staff EEEE was observed walking in and out of the unit wearing tan pants that were spotted with fecal matter. Staff EEEE stated he was waiting for a clean uniform to be delivered to the unit. When the clean uniform was delivered, he changed. He was observed taking the soiled uniform into the nursing station and placing the soiled uniform on the carpeted floor. There was no barrier to protect the floor from contamination.


During an interview on 10/15/15, at 9:45 a.m., Staff EEEE stated, "I was going to place the dirty uniform in a plastic bag."


During the observation period, the white towel was removed over the large brown spot on the carpeted entry, it had not been cleaned. Two (2) patients on two separate occasions were observed being escorted, by staff, through the fecal covered carpet. The patients were only wearing socks, and their feet could have come in contact with the fecal matter. Staff T, the Infection Control Director was informed, he stated he would ensure the carpet was cleaned immediately and would re-educate the staff.


KITCHEN

Observation on 10/12/15, at 2:00 p.m., in the facility's kitchen revealed:

- A 55 gallon white plastic trash bag filled with food and garbage and liquid refuse sitting on the kitchen floor. The plastic bag was leaking onto the kitchen floor.

- Five staff handwashing sinks did not have trash receptacles to dispose of used hand towels

- The dry storage room had shelves with shipping boxes stored over open disposable food supplies.

- The dietary floors were dirty and sticky throughout the department, creating an environment for pests and bacterial growth.

- There were multiple cracked and chipped baseboards and tiles making the area not cleanable; there was built-up dirt and debris in the cracks.

- There were (4) boxes of Chocolate Pretzels and (1) box of Cheddar crackers stored on the floor of an office, making them accessible to pests and other contaminants.

- There was a smoke alarm, several ceiling and air vents with dust and dirt residue over food items and in the food preparation areas.

- A metal can of Sesame Seed oil with (2) puncture holes was sitting on the spice rack and was accessible for use.

- There was food debris on the Buffalo Chopper, electric food slicer, large floor mixer, and on various walls throughout the department.

- The facility's (2) deep fat fryers had spilled oil on the bottom shelves, and old food debris in the fryer baskets.

- Four (4) plastic food cutting boards had multiple deep gouges, making them difficult to clean. The cutting boards had a dark residue in the gouges and were accessible for use.

- Staff S, the Dietary Manager was chewing gum in the kitchen creating possible saliva transfer to prepared foods.


Further observation of the facility kitchen on 10/12/15, at 3:00 p.m., revealed the facility's large dishwashing machine had food debris floating in the wash tanks and the water was dirty. There was a built-up lime deposit on the inner doors. The lunch dishes had been completed and the dish machine had not been drained and cleaned.


During an interview on 10/12/15, at 2:40 p.m., Staff S, the Dietary Manager when asked by the surveyor how often does the dish machine get cleaned and the water get changed, he stated the dish machine is drained and cleaned at the end of the night.


During an interview on 10/12/15, at 3:00 p.m., Staff V, a Dietary Aide, stated he does not empty and clean the dish machine after each meal, it is emptied at the end of the night. Staff V stated that sometimes if the water gets too bad, then he will change the water out.


Observation on 10/13/15, at 11:40 a.m., in the facility's kitchen revealed two (2) large 55 gallon white plastic trash bags filled with food and garbage and liquid refuse sitting on the kitchen floor. There was a large pool of pink milky substance on the kitchen floor under the leaking plastic bags.


Review of the facility provided DISH MACHINE CLEAN UP PROCEDURE (undated) reflected: How often: End of shift and/ or end of day.


Review of the facility provided Hobart FT900 Series Dishwasher Manufacturer's Operation manual (dated Oct. 2007) reflected,

CLEANING
The dishwasher MUST be thoroughly cleaned at the end of each working shift or after each meal.


Open all front access doors. Drain the machine ...Remove and clean the curtains ...clean the interior and all tanks shelves using a good hose ...Flush all debris toward the strainers ... Remove end caps. Clean wash arms. Remove, clean and replace the strainers.


During the tour of the Facility's kitchen Staff T, the facility's Infection Control Director, confirmed the above findings. Staff T stated he depends on the Department director to oversee the sanitation of the kitchen. Staff T stated he did not perform routine inspections of the facility kitchen as part of the facility's Quality Program.


An interview was conducted with the Infection Control officer for the facility (Staff T) on 10/13/15, in the Conference Room of the QA Department. Staff T was asked how often he insepcted the kitchen of the facility. Staff T reported that the kitchen is visited monthly; but that the inspection by the Infection Control officer is not as complete or thorough as the one conducted by the DSHS Survey staff. Staff T reported that the facility depends on the Directors of the various departments to report any issues with infection control to Staff T.


The Chairman of the Governing Body, a physician, was interviewed on 10/13/2015, at noon in the Conference Room of the QA Department of the facility. The Board Chairman was asked how frequently he visited the kitchen of the facility, and he reported that he had been in the kitchen two times during his tenure as a physician at the facility. He stated that he depends on what is reported to the Board by the staff in terms of making decision or recommendations regarding the overall operation of the facility and any expenditures required.



SURGICAL SERVICES

On 10/13/15, at 9:15 a.m., during a tour of the facility's Surgical Services revealed:

- Pre-operative unit revealed (2) chairs in the waiting room with torn vinyl, making them difficult to clean.

- (16) of (16) medical records charts had old adhesive tape stuck to the outsides of the charts.

The charts were being transported back and forth into the operating rooms and were not able to be cleaned.

- The Endoscopy room doors had numerous old adhesive tape residues left on the doors.

-Operating Room # 17, which was in use, had (2) wheeled carts, and (1) table with rust on all the casters. There was a 12 inch hole in the wall, revealing the plaster. The instrument foot switch had debris on it. There was rust along the base of the operating table.

- Operating Room #2, the orthopedic room where they perform had an air vent and grate above the surgical table with (2) approximately 4 inch by 5 inch stains with rust, and the air vent was damaged from a possible leak. There were several pieces of equipment with rust on the casters and surgical adhesive tape and residue in the room.

- Operating Room #16, the heart room where cardiac bypasses are performed was set up and ready for emergency surgery. There was blood residue on the Rapid Infuser and the Transesophageal echo scanner. There were several pieces of equipment with rust on the casters and surgical adhesive tape and residue in the room.

- The ear, nose and throat operating room had a large microscope with adhesive tape on it and there were pieces of equipment with rust on the casters and surgical adhesive tape and residue in the room.

- The Andrias table, used for laminectomy surgery, knee pad had multiple holes in it, making it not able to clean.

- Operating Room #5 on the Woman's Unit revealed a Valley Lab cart with chipped paint and a large rusted area. There were several pieces of equipment with rust on the casters and surgical adhesive tape and residue in the room. Ther was a hole in the baseboard and a large chip in the door. The arm board had (3) cracks in the vinyl, making it not able to clean.


During an interview on 10/13/15, in the afternoon in the Infection Control Office with Staff T, the facility Infection Control Director and Staff EEE, the Corporate Director of Risk and Infection Control, Staff T stated the facility had discussed the rust on the Operating Room equipment in a Spick and Span committee meeting. Staff EEE stated, "We are aware of the rust on the Operating Room equipment. Staff T had discussed it at a special Spick and Span meeting and then had brought it to the Quality Committee, then to the Medical Executive Committee but it stopped at the Governing Body."


POLICIES

Review of the facility provided SANITATION OF OPERATING ROOM SUITES AND EQUIPMENT SS.26 (dated 9/17/13) revealed:

POLICY:
To keep the number of bacteria to the lowest possible level so that the Operating Room Suite will have a minimal amount of bio-load.

PROCEDURE:
1. Between Cases:

a. All horizontal surfaces including O.R. table, will be cleaned and disinfected.

b. Floors will be mopped with disinfectant.

c. Lights, walls, footstools, kick buckets, I.V. poles, and any other equipment used will be spot cleaned as necessary.


Review of the facility provided CLEANING AND STORAGE OF NON-CRITICAL REUSABLE PATIENT EQUIPMENT IC.10a (dated10/9/2015) reflected:

DEFINITIONS:
Cleaning: The physical removal of foreign material (e.g. dust, oil, organic material such as blood, secretions, excretions, and micro-organism). Cleaning reduces or eliminates the reservoirs of potential pathogenic organisms.

Non-Critical Equipment: Those items that either touch only intact skin but not mucous membranes or do not directly touch the patient/ resident/ client.

PROCEDURE A
Equipment made of metal, plastic, vinyl, wood, leather or rubber (i.e. IV poles, infusion pumps, diagnostic imaging equipment, monitoring equipment, wheelchairs)

2. Remove all tape and tape residue. (Equipment is not considered clean unless all tape residues is removed.)


Review of the facility provided INFECTION AND CONTROL PROGRAM PLAN 2015 (revised February 9, 2015) revealed:

IV. RESPONSIBILITIES AND PROGRAM FRAMEWORD

A. Governing Board

The Governing Board has ultimate responsibility for ensuring the quality of patient care services and operational performance of the hospital..


V. INFECTION CONTROL DEPARTMENT SERVICES

Daily activities
Infection control staff members provide ongoing review and daily analysis activities necessary for reducing infection risks and achieving the goals of the program.


2. Observation and Evaluation
Observation and Evaluation includes:

Monitoring and surveillance:

-Establishing and maintaining routine activities that address patients and personnel, including licensed independent practitioners, allied health, staff, volunteer, students/trainees, contract workers and visitors and families, as warranted, in each area of the organization to ensure compliance with current infection control standards.

Evaluating environmental issues:

- Inspecting the environment, including patient care areas and rooms and observing personnel activities for the purpose of detecting possible infection hazards and evaluating compliance with current healthcare and regulator standards.

- Conducting routine environmental evaluations and workplace analyses, integrating evaluation criteria and partnering with other programs such as Safety, Environmental Services, and Risk Management.

4. Education

The Infection Control Department is responsible for:

-Specific practices established by the hospital to prevent disease transmission are identified and practiced.

-Regulatory mandates associated with infection control are discussed and followed.

7. Occupational Health Support

The Infection Control Department is responsible for:

-Assisting in educating personnel in using personal protective equipment.

8. Supply and Equipment Evaluation

The Infection Control Department is responsible for:

-Monitoring products and equipment in use to ensure they are safe (for example, biologically and chemically) for patient and employees.
VIOLATION: OPERATING ROOM POLICIES Tag No: A0951
Based on observation, interview, and record review, the facility failed to develop and implement disinfection procedures for the Surgery waiting room, Pre-Operative area and operating rooms, thus not assuring the achievement and maintenance of high standards of practice and patient care.


Findings included:

On 10/13/15, at 9:15 a.m., during a tour of the facility's Surgical Services revealed:

- Pre-operative unit revealed (2) chairs in the waiting room with torn vinyl, making them difficult to clean.

- (16) Of (16) medical records charts had old adhesive tape stuck to the outsides of the charts. The charts were being transported back and forth into the operating rooms and were not able to be cleaned.

- The Endoscopy room doors had numerous old adhesive tape residues left on the doors.

-Operating Room # 17, which was in use, had (2) wheeled carts, and (1) table with rust on all the casters. There was a 12 inch hole in the wall, revealing the plaster. The instrument foot switch had debris on it. There was rust along the base of the operating table.

- Operating Room #2, the orthopedic room where they perform had an air vent and grate above the surgical table with (2) approximately 4 inch by 5 inch stains with rust, and the air vent was damaged from a possible leak. There were several pieces of equipment with rust on the casters and surgical adhesive tape and residue in the room.

- Operating Room #16, the room where cardiac bypasses are performed, was set up and ready for emergency surgery. There was blood residue on the Rapid Infuser and the Transesophageal echo scanner. There were several pieces of equipment with rust on the casters and surgical adhesive tape and residue in the room.

- The ear, nose and throat operating room had a large microscope with adhesive tape on it and there were pieces of equipment with rust on the casters and surgical adhesive tape and residue in the room.

- The Andrias table's, used for laminectomy surgery, knee pad had multiple holes in it, making it not able to clean.

- Operating Room #5 on the Woman's Unit revealed a Valley Lab cart with chipped paint and a large rusted area. There were several pieces of equipment with rust on the casters and surgical adhesive tape and residue in the room. There was a hole in the baseboard and a large chip in the door. The arm board had (3) cracks in the vinyl, making it not able to clean.


During an interview on 10/13/15, in the afternoon in the Infection Control Office with Staff T, the facility Infection Control Director and Staff EEE, the Corporate Director of Risk and Infection Control, Staff T stated the facility had discussed the rust on the Operating Room equipment in a Spick and Span committee meeting. Staff EEE stated, "We are aware of the rust on the Operating Room equipment. Staff T had discussed it at a special Spick and Span meeting and then had brought it to the Quality Committee, then to the Medical Executive Committee but it stopped at the Governing Body."


Review of the facility provided SANITATION OF OPERATING ROOM SUITES AND EQUIPMENT SS.26 (dated 9/17/13) revealed:

POLICY:

To keep the number of bacteria to the lowest possible level so that the Operating Room Suite will have a minimal amount of bio-load.


PROCEDURE:

1. Between Cases:

a. All horizontal surfaces including O.R. table, will be cleaned and disinfected.

b. Floors will be mopped with disinfectant.

c. Lights, walls, footstools, kick buckets, I.V. poles, and any other equipment used will be spot cleaned as necessary.


Review of the facility provided CLEANING AND STORAGE OF NON-CRITICAL REUSABLE PATIENT EQUIPMENT IC.10a (dated10/9/2015) reflected:

DEFINITIONS:

Cleaning: The physical removal of foreign material (e.g. dust, oil, organic material such as blood, secretions, excretions, and micro-organism). Cleaning reduces or eliminates the reservoirs of potential pathogenic organisms.

Non-Critical Equipment: Those items that either touch only intact skin but not mucous membranes or do not directly touch the patient/ resident/ client.

PROCEDURE A

Equipment made of metal, plastic, vinyl, wood, leather or rubber (i.e. IV poles, infusion pumps, diagnostic imaging equipment, monitoring equipment, wheelchairs)

2. Remove all tape and tape residue. (Equipment is not considered clean unless all tape residues is removed.)
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
This standard is not met. The facility failed to train staff appropriately in escort technique as staff have been trained to utilize a movement-restricting hold for the purposes of "escort" as demonstration to the suurveyors. An escort does not prohibit a patient's freedom of movement whereas a restraint does prohibit a patient's movement.


Findings included:


On 10/14/2015, at 3:20 p.m., in the Conference Room of the QA Department of the facility, a Nurse Educator (Employee AAA) was asked to demonstrate an appropriate method of escorting a patient to the unit's quiet room. A Quiet Room is utilized voluntarily by a patient for temporary removal from the milieu and an escort is used to gently guide the patient to the quiet room via such methods as an offered hand, a gentle hand of the patient's shoulder to reinforce directional movement.


On demonstration of the allegedly approved escort procedure, the nurse educator immediately approached one of the surveyors, wrapping her right hand around the surveyor,s left upper arm, and then grabbing the surveyor's left wrist with her left hand, and pushing her right hip into the surveyor's left hip.


As the surveyor offered some resistance, the educator stated that this would be a "two person escort". Another surveyor then proceeded to do the same physical holds on the writer, mirroring the nurse educator's movements and holds on the right side of the other surveyor's body.


When the surveyor being escorted asked if this was an approved escort procedure, the nurse educator related that this was an approved CPI manner of escort. When the surveyor remarked that this was a restraint, the nurse educator again said that this was an escort and not a restraint.


Review of the CPI Nonviolent Crisis Intervention Training Program described this action as the "CPI Transport Position," which is meant to "assist you in safely moving an individual who is beginning to regain control", and "The cross-grain grip better secures the individual between staff during transport".


The facility has a policy on restraint and seclusion, and this policy states that an escort is utilized "using appropriate CPI techniques". A review of both the CPI participant workbook and the CPI key point refresher workbook (copywrite 2005, with a reprint date of 2014) shows no technique for an escort, there is no definition in the workbooks glossary of escort; ergo, there is no "approved CPI technique for escort" as stipulated in facility policy.


On 10/15/2015, at approximately 8:45 a.m., in a walkway, while walking with the CEO and the director of clinical services for behavioral health, as we were discussing the citation, the surveyors demonstrated the "escort" procedure, as demontrated by the Nurse Educator, on the director of clinical services, who immediately remarked that this was a restraint.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview, and record review, the Facility failed to ensure contracted Registered Nurses who provide care and services to hemodialysis patients in the facility implemented facility's policies and procedures to provide pre-hemodialysis treatment assessment and weight evaluation to patients in 4 of 6 sampled hemodialysis patients # 28, 49, 61 and 63.

The facility failed to ensure contracted services staff who provide hemodialysis treatment to facility's patients followed manufacturer's recommendations and the facility's policy for checking conductivity of dialysate solutions prior to initiating hemodialysis treatment on patients; failed to ensure contracted services calibrate devices used for checking conductivity on dialysate solution used for patients' hemodialysis treatment.

The facility failed to ensure contracted services staff who provide hemodialysis treatment to facility's patients followed manufacturer's recommendations for validating the composition of the concentrate of the dialysate solution with a laboratory, following installation of 3 of 4 Fresenius 2008 T hemodialysis machines. Machine #s 41, 42, 43.

The facility failed to ensure contracted Registered Nurses who provide care and services to hemodialysis patients in the facility meet the qualification outlined in their job description in 8 of 8 sampled contracted nurses observed and reviewed.Citing Staff #s KK, II, AM, TTT, UUU, VVV, WWW, and XXX.

Cross reference A 398.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
Based on observation, interview, and record review, the facility failed to ensure contracted Registered Nurses who provide care and services to hemodialysis patients in the facility implemented facility's policies and procedures to provide pre-hemodialysis treatment assessment and weight evaluation to patients in 4 of 6 sampled hemodialysis patients. #s 28, 49, 61 and 63.

The facility failed to ensure contracted services staff who provided hemodialysis treatment to facility's patients followed manufacturer's recommendations and the facility's policy for checking conductivity of dialysate solutions prior to initiating hemodialysis treatment on patients; failed to ensure contracted services calibrate devices used for checking conductivity on dialysate solution used for patients' hemodialysis treatment. .

The facility failed to ensure contracted services staff who provided hemodialysis treatment to facility's patients followed manufacturer's recommendations for validating the composition of the concentrate of the dialysate solution with a laboratory, following installation of 3 of 4 Fresenius 2008 T hemodialysis machines. Machine #s 41, 42, 43.

The facility failed to ensure contracted Registered Nurses who provided care and services to hemodialysis patients in the facility met the qualification outlined in their job description in 8 of 8 sampled contracted nurses observed and reviewed. Citing Registered Nurses #s KK, II, AM, TTT, UUU, VVV, WWW and XXX.

The failure to have contracted staff complete a Color Vision Test prevents the employee from effectively monitoring the water quality used to dialyze the facility's patients therefore putting the patients at risk for harm and not practicing according to acceptable standards of practice.

Findings:

Review of the facility's current policy and procedure on Pre Dialysis Patient -Assessment, direct staff as follows: "Obtain pre-dialysis weight. Compare with target weight and previous take off weight to determine the amount of fluid to be removed"

Review of the Facility's current policy and procedure on physician's order sheets, directed staff as follows: "Before a patient is to be treated, written routine dialysis standing physician's orders must be completed by the patient's attending physician. This covers the routine procedures encountered in the course of a normal dialysis treatment."

"Non- routine orders may be written on supplemental physician's orders sheets. The acute nurse is responsible for ensuring that these orders have been carried out. The acute nurse must sign and date the right hand column of the sheet to indicate the orders have been noted."

"It is understood that in emergency situations, it may be necessary for the acute nurse to take an order over the telephone. To prevent error, the order should be repeated back to the physician. The order should be written as follows: "Epinephrine 1:000, .5 cc SQ, STAT. Telephone order per Dr Jones/Mary Smith, RN." Transcribed as written in policy.

On 10/13/2015, at 10:10 a.m., Patient #28 was observed in the facility's acute care dialysis unit receiving hemodialysis treatment using a Fresenius 2008 K hemodialysis machine.

Review of the Patient's treatment sheet dated 10/13/2015, located at the chairside revealed no documented evidence that a pre-treatment dialysis weight was obtained prior to initiation of hemodialysis treatment on the patient..

Interview on 10/13/2015, at 10:15 a.m., with Registered Nurse KK revealed the bed that the patient was in, is capable of weighing the patient but most of the time the bed is not zeroed so no weight is done on the patient.

Patient #61
On 10/14/2015, at 10:25 a.m., Patient # 61 was observed in the acute dialysis unit of the facility. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/minute and dialysate flow rate of 600 mls/minute. The patient was using a Fresenius 180 non reuse dialyzer.

Review on 10/14/2015, at 10:25 a.m., of the patient's treatment sheet dated 10/14/2015, located at the nurses's station, revealed documentation which indicated that the patient's hemodialysis treatment was initiated at 7:30 a.m. Review the treatment sheets reveled no documented pre- hemodialysis treatment weight on the patient.

Review of the patient's treatment sheets revealed documentation which indicated that the patient's last recorded blood pressure was timed at 8:15 a.m. The blood pressure sensor on the hemodialysis machine was inoperable so a portable blood pressure was observed beside the patient's bed.

Sections on the patient's treatment sheet for patient's prescription and pre-treatment assessment were blank. The sections for venous pressure monitoring was blank, Trans membrane pressure documentation was blank and fluids administered during hemodialysis was blank.

During an interview on 10/14/2015, at 10:45 a.m., with Registered Nurse AM, the Surveyor notified the Registered Nurse AM that the last documented blood pressure on the patient was timed 8:15 a.m. and that the patient's weight, pre- treatment assessment, prescription, trans membrane pressure, and venous pressure were not documented.

The Surveyor also informed her that the most current physician's order dated 10/12/2015, had dialysate orders for Fresenius 160 dialyzer and a dialysate flow rate of 800 mls/minute, but the Patient was utilizing a Fresenius 180 dialyzer and the dialysate flow rate was 600/mls/minute.

Registered Nurse AM said she was busy with the patient because the dialyzer clotted. She said the bed that the patient is transferred to the unit in, is not accurate and so she did not do a weight on the patient. Registered Nurse AM said she had received a verbal order from the physician to change the dialyzer and dialysate flow rate but she did not write down the order.

Subsequent observation on 10/14/2015, at 10:50 a.m. revealed Registered Nurse AM took the patient's treatment sheet dated 10/14/2015, and filled in all blank area on the sheet from memory. She did not obtain the information from any recorded source.

The Surveyor asked the Registered Nurse AM how she was able to recall all mising information on the patient's treatment sheet, since she did not document the various readings for blood pressure, venous pressure, Trans membrane pressure, and blood flow rate changes over time. The Registered Nurse stated "Because I was watching."

Conductivity of dialysate solution
Review of manufacturer's recommendations for Fresenius 2008 hemodialysis machines Hemodialysis machine operators manual, direct users as follows: "The operator should always check conductivity and approximate pH of the dialysate with an independent device prior to initiating treatment and whenever concentrates are changed during the operation."

Review on 10/13/2015, of the facility's policy and procedure on Testing Dialysate Conductivity, directs staff as follows: "Dialysate conductivity will be tested before each treatment via the Myron - L D-1 Meter."

On 10/13/2015, at 10:10 a.m., Patient #28 was observed in the facility's acute care hemodialysis unit receiving hemodialysis treatment using a Fresenius 2008 K hemodialysis machine.

Review of the Patient's treatment sheet dated 10/13/2015, revealed no indication that the conductivity of the dialysate solution was validated with an independent meter Myron -L D-1 Meter

Interview on 10/13/2015, at 10:12 a.m., with Registered Nurse KK revealed she did not check the conductivity on the dialysate solution prior to initiation of hemodialysis treatment on patients because there was no solution available in house for calibrating the Myron - L D-1 Meter used for checking conductivity. Further interview with Registered Nurse KK revealed she works with a company that in contracted with the hospital.

Review of the facility's Myron - L D-1 Meter Log revealed the last date calibration was done on the Myron - L D-1 Meter was dated January 11, 2015. Review of the facility's Myron - L D-1 Meter Log revealed documentation which indicated the facility's dialysis unit has three Myron - L D-1 Meters, serial numbers 2, 4 and 5 for checking of dialysate conductivity. Review of the log revealed documentation which indicated that all three meters were last calibrated on 01/11/2015.

Review of the Manufacturer's Instructions for Myron - L D-1 Meter direct users as follows: "The Conductivity Standard Solutions and pH Buffers below are used for factory calibration. Regular use of these solutions is recommended to ensure specified instrument accuracy. Frequency of conductivity recalibration depends upon use, but once every month should be sufficient for an instrument used daily."

Review of the facility's current policy and procedure on Calibrating the Myron- L D-1 Meter directs users as follows: "This procedure should be performed before once every month for an instrument that is used daily (as per manufacturer's requirement.)"

During an interview on 10/13/2015, at 10:41 a.m., with the Facility's Chief Biomedical Technician for dialysis, he said it was the responsibility of the nurses who provide dialysis to patients to calibrate the Myron - L D-1 Meter.

Verification of dialysate composition
Interview on 10/13/2015, at 10:30 a.m., with the facility's Chief Biomedical Technician for dialysis revealed the facility had 4 new Fresenius 2008T hemodialysis machines in use in the facility for hemodialysis treatment of patients.

Review of manufacturer's recommendations for Fresenius 2008T hemodialysis machines direct users as follows:
"The Machine must be labeled to indicate the type of concentrate for which it is configured. Check the composition (i.e. Na, Cl , K, Ca, Mg, HCo3 and pH) of the dialysate solution after the machine is installed or after the machine is modified for different concentrate type."

"Check the conductivity and appropriate pH of the dialysate solution with an independent device before initiating dialysis."

Observation on 10/13/2015, at 2:40 p.m., revealed hemodialysis machine #s 41, 42 and 43 were observed in the dialysis equipment room of the facility. Tags on the machines indicated they were ready for usage. One machine was tagged as out of service.

Interview on 10/13/2015, at 2:40 p.m., with the facility's Chief Biomedical Technician for dialysis revealed four Fresenius 2008 T hemodialysis machines were put into service in January 2015 and were being used for hemodialysis treatment of patients. He said he did not validate the dialysate composition with a laboratory after the machines were installed.

Interview with the facility's Chief Biomedical Technician for dialysis revealed he works with a company that is contracted to the facility.


Registered Nurses Qualifications
Registered Nurse KK

On 10/13/2015, at 10:10 a.m., Registered Nurse KK was observed in the dialysis unit of the facility providing care and services to Patient #28 who was receiving hemodialysis treatment.


Review of Registered Nurse KK's Job description titled: "St Joseph Contract Employee Addendum - Dialysis RN." Revised 10/02/2015, and signed on 10/07/2015, by Registered Nurse (KK) revealed the following : "This job has special vision requirement check all that apply. Color vision ( ability to identify and distinguish colors.)" The requirement to identify and distinguish colors was checked.


Review of Registered Nurse KK's personnel and health records revealed no indication that a test was perform to determine the Registered Nurse's ability to detect and distinguish colors.


Registered Nurse II
On 10/13/2015, at 2:40 p.m., Registered Nurse II was observed in the dialysis unit of the facility providing care and services to Patient #72 who was receiving hemodialysis treatment.


Review of Registered Nurse II's Job description titled "St Joseph Contract Employee Addendum - Dialysis RN." Revised 10/02/2015, and signed on 10/08/2015, by Registered Nurse II revealed the following "This job has special vision requirement check all that apply. Color vision ( ability to identify and distinguish colors.)" The requirement to identify and distinguish colors was checked.


Review of Registered Nurse II's personnel and health records revealed no indication that a test was perform to determine the Registered Nurse's ability to detect and distinguish colors.



Registered Nurse AM

On 10/14/2015, at 10:25 a.m., Registered Nurse AM was observed in the dialysis unit of the facility providing care and services to Patient #28 who was receiving hemodialysis treatment.



Review of Registered Nurse AM's Job description titled "St Joseph Contract Employee Addendum - Dialysis RN." Revised 10/02/2015, and signed on 10/07/2015, by Registered Nurse AM revealed the following: "This job has special vision requirement check all that apply. Color vision ( ability to identify and distinguish colors.") The requirement to identify and distinguish colors was checked.


Review of Registered Nurse AM's personnel and health records revealed no indication that a test was perform to determine the Registered Nurse's ability to detect and distinguish colors.


Interview on 10/14/2015, at 1:10 p.m., with the Registered Nurse in charge of the dialysis unit, the Surveyors requested documentation that tests were conducted to determine the nurse's ability to to detect and distinguish colors. He said they were not performed on the nurses.







Observation on the Surgical Intensive Care Unit (ICU) on 10/13/2015, between the hours of 9:30 a.m and 10:40 a.m., revealed the following information:


Patient(# 63).
Patient (#63) was observed in bed receiving hemodialysis treatment via a temporary intravenous catheter.

He was receiving his hemodialysis with a Fresenius 160 dialyzer, dialysate flow rate (DFR) at 800 and blood flow rate (BFR) at 350.

Review of the physician's orders dated 10/13/2015, revealed no orders for a dialyzer. Further review of physician orders, progress notes and dialysis treatment flow sheets revealed Patient # 63 started hemodialysis treatment on 10/10/2015.

Review of Physician orders dated 10/10/2015, and 10/14/2015, revealed the orders did not include a dialyzer. The use of a dialyzer for hemodialysis treatment require a physician's order.

Review of the treatment records for 10/10/2015, revealed dialyzer Fresenius 160 was used to dialyze the patient without a physician's order.

On 10/11/2015, and 10/12/2015, the orders did not include blood flow rate or dialysate flow rate. Blood Flow Rate (BFR) and Dialysate Flow Rate (DFR) are a component of the patient's hemodialysis prescription and requires a physician's order.

Review of the treatment records for 10/11/2015, revealed the patient was dialyzed at a dialysate flow rate of 300 mls/hr without an order, there was no documentation of what the DFR was.

During an interview on 10/13/2015, at 10:15 a.m., with Staff II, who was providing the hemodialysis treatment for the patient, he stated the hemodialysis orders are standing orders.

Review of hemodialysis treatment record dated 10/10/2015 through 10/13/2015, revealed no documentation that the patient had a pre or post dialysis weight necessary to determine the amount of fluid to be removed during the treatment and determine the effectiveness of the hemodialysis treatment post dialysis.

During an interview on 10/13/2015, at 10:25 a.m., with the Nurse Manager for the unit regarding weights and physician orders for hemodialysis patients. She stated, staffs are required to weigh the patients pre-dialysis. She stated the orders were incomplete.





Review of personnel files for Staff #s TTT, UUU, VVV, WWW, and XXX, revealed the staff did not have documentation that a color blind test was conducted on these staff.

Review of St Joseph Medical Center Job Description titled "St. Joseph Contract Employee Addendum-Dialysis RN", states the following information:
"This job has special vision requirements. Color Vision (ability to identify and distinguish colors)".




























Patient # 49
Review of the Patient# 49's treatment sheets revealed no documented evidence that a pre-treatment dialysis weight was obtained prior to initiation of hemodialysis treatment on the patient.

1. 10/08/2015
2. 10/09/2015
3. 10/10/2015
4. 10/12/2015

Interview on 10/14/2015, at 08:45 a.m., with Registered Nurse VVV revealed that she is one of the dialysis nurses from the Contracted Services. The Surveyor notified her of the missing weight prior to treatment of Patient #49 and said "Yes, we are supposed to weigh them before each treatment, I do not know why the other nurses don't do that."
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and review of medical records of patients, it was determined that entries in the medical records were not complete, lacked dating when required, and were not consistent with hospital policies and procedures. Further, the facility failed to ensure complete medical records when physician orders were not signed, Special Precautions, although being done, were not ordered, and treatment plans on the behavioral health units were not individualized, did not include individualized goals or outcomes in 10 of 10 records reviewed on two units. Patient #s 1, 2 , 3, 4, 12, 13, 14, 19, 52, and 53.


Findings were:

Patient #3

Review of Patient #3's medical history and physical record revealed a 61 year old, female, admitted on [DATE]. Reason for admission: The patient was found with her bra wrapped around her neck in the bathroom and a bottle of pills by her hand. She was unconscious.

Review of Patient #3's Physician Orders - Behavioral Medicine General Admission form dated 10/2/15, timed at 10:00 a.m., revealed there were no precautions ordered. The Physician Orders were not signed by a physician.

Review of Patient#3's Interdisciplinary Adult Plan of Care (undated) reflected an admission date of [DATE]. The Plan of Care reflected fall Risk and interventions per fall Risk Assessment tool was checked. There were no desired outcome/goals written or checked for the Safety Fall Risk.

Further review revealed patient # 3's treatment plan Suicide risk was not a part of the treatment plan; her admitting reason for admission indicated a suicide risk.

During an interview on 10/12/15, on the 8th floor Medical/Psych unit, Staff W, Registered Nurse (RN), when asked how the fall interventions are determined she stated the Fall Risk Assessment tool is completed on admission. Staff W stated, "The facility uses a Fall Risk Assessment Form." She was unable to provide the form or evidence that the form had been completed on Patients #3, 4, or 5.

During an interview on 10/12/15, on the 8th floor Medical/ Psych unit Staff , RN stated, "The unit is new and the fall form has not been implemented yet. She stated,"The staffs check on the patients frequently.

Patient #4
Review of Patient #4's medical history and physical record revealed a 63 year old, female, admitted on [DATE]. Reason for admission: The patient was delusional, threatening to kill her brother and herself with a knife and apparently, she was running down the street naked.

Review of Patient #4's Physician Orders - Behavior Medicine General Admission form dated 10/11/15 at 12:30 a.m. revealed Precautions: Fall was checked. Suicide Precautions was not checked; her admitting reason for admission indicated a suicide risk.

Review of patient#4's Interdisciplinary Adult Plan of Care (undated) reflected an admission date of [DATE]. The Plan of Care reflected fall Risk and interventions per fall Risk Assessment tool was checked. There was no desired outcome/goals written or checked for the Safety Fall Risk. Risk of injury to self/others was checked as a problem, therapeutic communication was an intervention, there were no further interventions and there were no desired Outcomes/Goals recorded.

Patient #5
Review of Patient #5's medical history and physical record revealed a 63 year old, female, admitted on [DATE]. Reason for admission: acting abnormal, having hallucinations, and supposedly a seizure disorder.

Review of Patient #5's Physician Orders - Behavior Medicine General Admission form dated 10/9/15, at 12:30 a.m., revealed Precautions: Elopement and Fall were checked off.

Further review revealed patient # 5's treatment plan Seizure risk was not a part of the treatment plan; her admitting reason for admission indicated a Seizure precaution.

During an interview on 10/12/15, at 4:00 p.m., on the Medical/ Psych unit, Staff W, RN stated, "If orders are missing for suicide precautions the nurse should call the physician to obtain the order."

POLICY:
Review of the facility provided Special Precautions Monitoring Policy CBH. 32 (dated 6/9/2015) revealed:

The purpose of the assessment for suicide, homicide and self-harm is to provide guidelines for the safe management of patients with suicidal ideations and to minimized self-harming acts by all patient admitted to the facility's Center for Behavioral Health.

DEFINITIONS:
A. "Suicidal Patient" is one who has recently made an attempt in the last 12 months ...
B. "Risk Factors" for suicide or psychological or environmental factors ...

PROCEDURE:
An order for suicide precautions is written by a physician, or by a registered nurse as an independent nursing intervention. A physician's order must be obtained within 1 hour of the nursing order. The order must include reason.

Review of the facility provided policy for MEDICAL RECORDS (undated) revealed:

E. Physician Orders

1. All orders for treatment shall be in writing, dated, and timed.

2. Persons receiving dictated orders will sign the order, read back, verify, and confirm with the practitioner's name/ ("per") the transcriber's name. Following dictated order, the responsible practitioner must authenticate such order by signature as soon as possible.

On behavioral health:

Review of the medical record of patient #2, hypertension was noted as a problem for this patient. However, there was no mention of hypertension in the patient's individualized treatment plan, nor were there any modalities described for interventions for this medical issue. Further review of this patient's record revealed, Insulin-sliding scale - was ordered by the physician. Insulin is usually prescribed for the treatment of diabetes and the dosage is dependent on the blood sugar level result per the sliding scale order. There was no mention of diabetes in the patient's individualized treatment plan. Interview with the nurse on the unit indicated that the insulin was not being administered to this patient secondary to the fact that the patient was refusing "finger sticks" to test his blood sugar levels, and that the patient himself was denying that he had a diabetic condition. Again, there was no mention of diabetes, nor the modalities of blood sugar measurements or administration of insulin mentioned in the patient's individualized treatment plan. There was no indication that the patient participated in the development and implementation of his own treatment plan.


In review of the medical record of patient #1, the initial physician's assessment and admitting orders were accomplished via the use of telemedicine. There was no indication that the patient was involved in the development and implementation of his treatment plan.


In review of the medical records of patients #12, #13, #14, and #52, there were no dates in the space provided for the dates (with the word "date" under the line or space provided) after the staff signatures, so that it could not be ascertained if the staff members signed the treatment plan prior to or after the patient.


In review of the medical record of patient #19 and #53 there was no patient signature and no dates by the staff signatures even though a space was provided for the date with the word "date" under the line of space provided.
VIOLATION: DIRECTOR OF DIETARY SERVICES Tag No: A0620
Based on observation, interview and record review the facility's Dietary Director failed to maintain an organized and sanitary kitchen and show evidence for the daily management of dietary services.

Findings included:

Observation on 10/12/15, at 2:00 p.m., in the facility's kitchen revealed:

- A 55 gallon white plastic trash bag filled with food and garbage and liquid refuse sitting on the kitchen floor. The plastic bag was leaking onto the kitchen floor.

- Five staff handwashing sinks did not have trash receptacles to dispose of used hand towels

- The dry storage room had shelves with shipping boxes stored over open disposable food supplies.

- The dietary floors were dirty and sticky throughout the department, creating an environment for pests and bacterial growth.

- There were multiple cracked and chipped baseboards and tiles making the area not cleanable; there was built-up dirt and debris in the cracks.

- There were (4) boxes of Chocolate Pretzels and (1) box of Cheddar crackers stored on the floor of an office, making them accessible to pests and other contaminants.

- There was a can of W-D40, chemical to oil mechanical objects, stored with food items, creating a possible chemical ingestion.

- There was a smoke alarm, several ceiling and air vents with dust and dirt residue over food items and in the food preparation areas.

- A metal can of Sesame Seed oil with (2) puncture holes was sitting on the spice rack and was accessible for use.

- There was food debris on the Buffalo Chopper, electric food slicer, large floor mixer, and on various walls throughout the department.

- The facility's (2) deep fat fryers had spilled oil on the bottom shelves, and old food debris in the fryer baskets.

- Four (4) plastic food cutting boards had multiple deep gouges, making them difficult to clean. The cutting boards had a dark residue in the gouges and were accessible for use.

- Staff S, the Dietary Manager was chewing gum in the kitchen creating possible saliva transfer to prepared foods.


Further observation of the facility kitchen on 10/12/15, at 3:00 p.m., revealed the facility's large dishwashing machine had food debris floating in the wash tanks and the water was dirty. There was a built-up lime deposit on the inner doors. The lunch dishes had been completed and the dish machine had not been drained and cleaned.


During an interview on 10/12/15, at 2:40 p.m., Staff S, the Dietary Manager when asked by the surveyor how often does the dish machine get cleaned and the water get changed, he stated the dish machine is drained and cleaned at the end of the night.


During an interview on 10/12/15, at 3:00 p.m., Staff V, a Dietary Aide, stated he does not empty and clean the dish machine after each meal, it is emptied at the end of the night. Staff V stated that sometimes if the water gets too bad, then he will change the water out.


Observation on 10/13/15, at 11:40 a.m., in the facility's kitchen revealed two (2) large 55 gallon white plastic trash bags filled with food and garbage and liquid refuse sitting on the kitchen floor. There was a large pool of pink milky substance on the kitchen floor under the leaking plastic bags.


Review of the facility provided DISH MACHINE CLEAN UP PROCEDURE (undated) reflected: How often: End of shift and/ or end of day.


Review of the facility provided Hobart FT900 Series Dishwasher Manufacturer's Operation manual (dated Oct. 2007) reflected,

CLEANING
The dishwasher MUST be thoroughly cleaned at the end of each working shift or after each meal.

Open all front access doors. Drain the machine ...Remove and clean the curtains ...clean the interior and all tanks shelves using a good hose ...Flush all debris toward the strainers ... Remove end caps. Clean wash arms. Remove, clean and replace the strainers.

During the tour of the Facility's kitchen Staff T, the facility's Infection Control Director, confirmed the above findings.