HospitalInspections.org

Based on observation, interview, and record review, the facility's governing body failed to implement its policy and procedure on employee orientation, to ensure contract staff received facility based orientation in 3 of 4 contract staff observed in the facility. Contract staff E, U and CC

Findings:

Observation, interview, and record review revealed, three contract registered nurses were not provided with general orientation to the facility and orientation on Facility's Policies and Procedures.
Cross Reference A 0083

The facility's contract Registered Nurses failed to follow manufacturer's direction for use when testing water use for hemodialysis treatment of patients for total chlorine in two of two staff observed.
Cross reference A 0084

Based on observation, interview and record review, the facility's staff failed to prepare medication in a clean / sanitary environment; failed to clean septum of medication vials; failed to wash/ sanitize hands after direct contact with patients and contaminated equipment; failed to wash/ sanitize hands after removal of contaminated gloves , failed to wear personal protective equipment when having direct contact with patients on isolation, failed to discard contaminated supplies, and failed to clean equipment after use for patients on contact isolation and prior to using for another patient. Citing 18 of 26 sampled, monitored facility's staff ( B, D, E, F, G, S, O, DD, Q, R, V,W,L,HH JJ,X,K and Z).


Findings:

Observation on 03/15/2016 during tour of the facility's intensive care unit revealed, a census of seven patients were observed on the unit receiving care and services.

Interview on 03/15/2016 at 10:35 a.m. with Registered Nurse (A) revealed 5 of 7 patients were positive for MRSA, VRE, C Diff and MDRO.

Observation on the IMU unit revealed 5 of 15 patients were on contact isolation, for VRE, C Diff and MRSA.



On 03/16/2016 at 8:50 a.m. and 8:55 a.m. revealed Registered Nurses ( S) and (O) were observed preparing oral medications, intravenous medications and medications to be administered via a patients' PEG tube. The medications were prepared at the nurses' station. The medication pill crusher used to crush the medications was stored directly adjacent to the Accucheck machine used to test patients' blood during blood glucose testing.



Handwashing

(a) On 03/15/2016 revealed Contract Registered Nurse (E) did not wash or sanitize his contaminated hands after touching the contaminated drain bucket of Patient #1 and after leaving the isolation room of the patient who was positive for MRSA. He left the room and used his contaminated hands to answer the telephone at the nurses' station.

(b) On 03/15/2016, Registered Nurse (S) entered the room of Patient #21 who had positive C difficile results. Registered Nurse (S) did not wear gloves and gown and did not sanitize the scanner used in the patient's room or wash his contaminated hands after direct contact with Patient #21. The scanner is used for the general patient population on the unit.

(c) On 03/16/2016 at 9:50 a.m. revealed Medical Doctor (DD) was observed on the intensive care unit, in the room 382. The room was occupied by Patient # 22. The Patient was on isolation for multi drug resistant organism. The Medical Doctor did not wear protective gown. He was observed leaning against the patient's side rail and touching the bed linen with his street clothing while examining the patient.


Cross Reference A 749

Based on observation, interview, and record review, the facility's governing body failed to implement its policy and procedure on Employee Orientation, to ensure contract staff received facility based orientation in 3 of 4 contract staff observed in the facility. Contract staff E, U, and CC

Findings:

Review of the facility's current policy and procedure on Employee Orientation, # 307 F, reviewed by the facility on 07/2015 directs staff as follows: "Staff and contract employee should be scheduled for general orientation during pre-employee process. Employee should not work for more than two weeks without completing orientation. Each employee is required to complete a general hospital orientation preferably on their first day of hire and/ or assignment to the facility. The Chief Human Resources Officer ( CHRO) and the Hospital Administrator for the assigned department must approve any exceptions to attendance at General Hospital Orientation on the first day of hire. Contract Agency Staff can become compliant with this policy by completing an approved orientation packet and process with their manager or an assigned designee."

Review of the manufacturer's direction for use for E-Z Chek Sensitive Total Chlorine & Chloramines Test Strips directs users as follows:
"Using sample cup provided, fill with approximately 20 ml of water. Discard contents and re-fill before testing.
2. Immerse indicator pad in sample solution and move test strip back and forth vigorously for 10 seconds. The indicator pad must be perpendicular to the direction of strip movement. Remove strip from solution, do not shake. Wait a full 30 seconds. While waiting, fold the white plastic handle of the test strip under the aperture (as in Figure 2 below) so that it provides a consistent viewing background.
4. After the 30 second wait period, immediately compare the strip color to the K100-0106 color chart to determine the Total Chlorine level in the sample."

Contract Registered Nurse (E)
Patient #1
Interview on 03/15/2016, at 10:35 a.m., with Registered Nurse (A) revealed Patient #1 was on isolation for MRSA.

Observation on 03/15/2016, at 10:35 a.m., revealed Contract Registered Nurse (E) was observed on the intensive care unit, in room #381. The room was occupied by Patient #1. Observation revealed Contract Registered Nurse (E) was observed touching the drain bucket of Patient ( #1) who had completed hemodialysis treatment. Contract Registered Nurse (E) picked up the contaminated drain bucket with his ungloved hands. After handling the contaminated drain bucket with his ungloved hands, Contract Registered Nurse (E) walked to the nurses' station and picked up the telephone with his contaminated hands.

Contract Registered Nurse (E) did not wash/sanitize his contaminated hands after touching the contaminated drain bucket which was utilized for Patient #1.

Interview on 03/15/2016, at 10:40 a.m., with Contract Registered Nurse (E), the Surveyor informed Contract Registered Nurse (E) that he did not wash or sanitize his contaminated hands after touching the contaminated drain bucket and leaving the isolation room of the patient with MRSA.

Review of Contract Registered Nurse (E's) personnel and training record, provided by Facility's Human Resources staff, revealed no evidence that Contract Registered Nurse (E) completed facility based orientation and orientation to the facility's operational policies and procedures.

Interview on 03/18/2016, at 7:55 a.m., with the Facility's Human Resources Director revealed she did not have any evidence of general orientation of contract staff or orientation to the facility's policies and procedures, emergency and fire procedures.

Contract Registered Nurse (U)
On 03/16/2016, at 10:20 a.m., revealed Contract Registered Nurse (U) was observed on the intensive care unit, in room 383. The Contract Registered Nurse was observed checking the water for total chlorine, in preparation for initiation of hemodialysis on patient #3. The Contract Registered Nurse was using the E-Z Chek Sensitive Total Chlorine & Chloramines Test Strips.

Observation revealed Contract Registered Nurse (U) collected 25 mls of water in a sample cup, swirled the E-Z Chek Sensitive Total Chlorine & Chloramines Test Strip in the water, and then immediately read the result of the test strip.

The Surveyor immediately notified Contract Registered Nurse (U) that she observed that she did not follow the manufacturer's direction for use when testing the water for total chlorine.
Contract Registered Nurse (U) said "Yes you are right."

Review of Contract Registered Nurse (U's) personnel and training record, provided by the the Facility's Human Resources Director revealed no evidence of facility based orientation and orientation to the facility's operational policies and procedures.

Interview on 03/18/2016, at 7:55 a.m., with the Facility's Human Resources Director revealed she did not have any evidence of general orientation of contract staff or orientation to the facility's policies and procedures, emergency and fire procedures.

Contract Registered Nurse (CC)
On 03/17/2016, at 8:15 a.m., revealed Contract Registered Nurse (CC) was observed on the intensive care unit, in room 381. The Contract Registered Nurse was observed checking the water for total chlorine, prior to initiation of hemodialysis treatment on Patient #1. The Contract Registered Nurse was using the E-Z Chek Sensitive Total Chlorine & Chloramines Test Strips.

Observation revealed Contract Registered Nurse (CC ) collected 10 mls of water in the cup, swirled the the E-Z Chek Sensitive Total Chlorine & Chloramines Test Strip in the water for 30 seconds then read the result of test strip after 5 seconds.

During an interview on 03/17/2016, at 8:20 a.m., the Surveyor asked Contract Registered Nurse, how much water was in the sample cup, how long should she keep the test strip in the water and how soon should the result be read.

Contract Registered Nurse ( CC) informed the Surveyor that 20 mls of product water was in the specimen container. She said the test strip should be swirled for 30 seconds then the results read after five seconds.

The Surveyor informed Contract Registered Nurse (CC) that the manufacture directs the user to collect 20 mls of water, swirl the test strip for 10 seconds then wait 30 second to read the results.

The Facility's Chief Nursing Officer was present outside the patient's room. The Surveyor showed her the water in the sample cup and asked to validate the amount of water in the sample cup. She stated "it' s approximately 10 - 12.5 mls."

Review of Contract Registered Nurse (CC's) personnel and training record, provided by the Facility's Human resources Director revealed no evidence of facility based orientation and orientation to the facility's operational policies and procedures.

Interview on 03/18/2016, at 7:55 a.m., with the Facility's Human Resources Director revealed she did not have any evidence of general orientation of contract staff or orientation to the facility's policies and procedures, emergency and fire procedures

Based on observation, interview, and record review, the facility's contract registered nurses failed to follow manufacturer's direction for use when testing water used for hemodialysis treatment of patients for total chlorine in 2 of 2 contract staff observed checking water for total chlorine: Contract Registered Nurses U and CC

Findings:

Review of the manufacturer's direction for use for E-Z Chek Sensitive Total Chlorine & Chloramines Test Strips' directs users as follows:

"Using sample cup provided, fill with approximately 20 ml of water. Discard contents and re-fill before testing.

2. Immerse indicator pad in sample solution and move test strip back and forth vigorously for 10 seconds. The indicator pad must be perpendicular to the direction of strip movement. Remove strip from solution, do not shake. Wait a full 30 seconds. While waiting, fold the white plastic handle of the test strip under the aperture (as in Figure 2 below) so that it provides a consistent viewing background.

4. After the 30 second wait period, immediately compare the strip color to the K100-0106 color chart to determine the Total Chlorine level in the sample."

Contract Registered Nurse (U)
On 03/16/2016 at 10:20 a.m. revealed Contract Registered Nurse (U) was observed on the intensive care unit, in room 383. The Contract Registered Nurse was observed checking the water for total chlorine, in preparation for initiation of hemodialysis on patient #3. The Contract Registered Nurse was using the E-Z Chek Sensitive Total Chlorine & Chloramines Test Strips

Observation revealed Contract Registered Nurse (U) collected 25 mls of water in a sample cup, swirled the E-Z Chek Sensitive Total Chlorine and Chloramines test strips in the water, and then immediately read the result of the test strip.

The Surveyor immediately notified Contract Registered Nurse (U) of her observation of her not following the manufacturer's direction for use.

Contract Registered Nurse (U) said " Yes you are right. "

Contract Registered Nurse (CC)

On 03/17/2016 at 8:15 a.m. revealed Contract Registered Nurse (CC) was observed on the intensive care unit, in room 381. The Contract Registered Nurse was observed checking the product water for total chlorine, prior to initiation of hemodialysis treatment on Patient #1. The Contract Registered Nurse was using the E-Z Chek Sensitive Total Chlorine & Chloramines Test Strips.

Observation revealed Contract Registered Nurse (CC ) collected 10 mls of water in the cup, swirled the E-Z Chek Sensitive Total Chlorine & Chloramines Test Strip in the water for 30 seconds then read the result of the test strip after 5 seconds.

During an interview on 03/17/2016 at 8:20 a.m., the Surveyor asked Contract Registered Nurse, how much water was in the sample cup, how long should she keep the test strip in the water and how soon should the result be read.
Contract Registered Nurse (CC) informed the Surveyor that 20 mls of product water was in the specimen container. She said the test strip should be swirled for 30 seconds then the results read after five seconds.

The Surveyor informed Contract Registered Nurse (CC) that the manufacture directs the user to collect 20 mls of water, swirl the reagent strip for 10 seconds then wait 30 seconds to read the results.

The Facility's Chief Nursing Officer was present outside the patient's room. The Surveyor showed the Facility's Chief Nursing Officer the water in the sample cup and asked to validate the amount of water in the sample cup. She stated " it's approximately 10 - 12.5 mls. "

Chlorine has the potential to cause harm to hemodialysis patients if the level of chlorine in water used for hemodialysis patients is above the recommended range.

Based on observation, interview and record review, the facility's nursing staff failed to release restraints and assess the arms of a patient wearing bilateral arms restraints in 1 of 1 patient monitored with bilateral arm restraints from 23 sampled in - patients: Patient #3

Findings:

Patient #3
Observation on 03/16/2016 at 9:00 a.m. - 12:00 noon. revealed Patient #3 was observed lying in bed in semi- fowlers position with bilateral arm restraints tied to the sides of the bed.
The restraints remained in placed to the patient's arms. The patient was observed attempting to move his extremities while the restraints were in place. The restraints were not released and the patient's arms assessed.

On 03/16/2016 at 12:01 p.m. the Surveyor informed Registered Nurse (O)who was assigned to the patient, that the restraints to the patient's arms were not released or the patient's extremities assessed.
She stated " You are correct. It should be released every two hours "

Review on 03/16/2016 of the Patient's clinical record revealed a Physician's order dated 03/16/2016 for "Restraint evaluate need to continue after 24 hours."

Review of the Facility's current Policy and Procedure on Restraint and Seclusion; Policy # 11:210:07; revised 4/12/2014 directs staff as follows : "Results of restraint monitoring will occurs at regular intervals according to the individual's assessed needs but not to exceed 2 hour between intervals "

Based on observation, interview and, record review the facility failed to ensure there was adequate numbers of supervisory nurses for all patient care units on all shifts.

This failed supervision practice had the potential for nursing staff to provide patient care in an unsafe manner .

Findings:


Observation at the facility on 3/15/2016 at 9:35 a.m. revealed there were three (3) distinct patient care units currently in use.
There was the Medical Surgical Unit on the fourth floor and the ICU (Intensive Care Unit) and the IMU (Intermediate Care Unit)s on the third floor.
Observation at that time revealed there was one (1) Registered Nurses (RN) acting in the role as House Supervisor.
Further observation revealed none of the three (3) patient care units on the two (2) floors had a charge nurse or unit supervisor.

During an interview on 3/15/2015 at 10:20 a.m. with the Chief Nursing Officer (CNO) regarding staffing on the patient care units she stated there was one (1) House Supervisor on each shift that covers all the units. She stated none of the units was assigned a charge nurse.
The CNO stated the nursing staff consisted of Licensed Vocational Nurses (LVN), Registered Nurses and Patient Care Technicians (PCT).
The CNO stated the House Supervisor was responsible for oversight of all staff on the three units located on both floors.
Review of nursing schedules dated 3/15/2016-3/18/2016 revealed there were two (2) twelve (12) hour shifts from 7:00 am to 7:00 pm and from 7:00 pm to 7:00 am .
One(1) Registered Nurse was assigned as House Supervisor on each of the twelve hour shifts and covered both floors with the three (3) patient care units.

During an interview on 3/16/2016 at 12:30 p.m. in the conference room at the facility, Staff (A) Registered Nurse House Supervisor, stated she was the only Nurse Supervisor for the three units and her duties took her from the third to the fourth floor during her twelve hour shift. (7:00 am-7:00 pm).
During the survey on 3/15/2016-3/18/2016 the lack of adequate RN Supervision of staff resulted in multiple unsafe infection control practices on the patient care units.
There was no supervision of Contract staff to ensure they provide hemodialysis treatment according to the physicians orders.

Based on observation, record review and interview, the facility's staff failed to ensure physicians' orders for administration of patients' medications are accurate, in 2 of 3 sampled patients observed with a percutaneous endoscopic gastrostomy (PEG) tube, from a sample of 23 in -patients; Patient #s 2 and 22

Findings:

Patient #2

On 03/15/2016 at 11:15 a.m. revealed Patient #2 was observed on the intensive care unit, in room 385. The Patient had a PEG tube in place to his abdomen. Observation revealed Registered Nurse (C) was observed administering crushed medication mixed in a slurry via the PEG tube.

Review of the Patient's clinical record (operative record) revealed documentation which indicated that Patient #2 had a PEG tube inserted on 12/18/2015.

Review of Patient #2's clinical record revealed the following current physicians' orders:
" Folic Acid I mg =I tab oral BID, Ethambutol 200 mg, 2 tab oral daily, 800 mg Ethambutol 2 tab oral daily, Cholecalciferol ( vitamin D3) 400 Int units, I tab oral Q 12 hours, Protonix 40 mg oral suspension NG tube BID.

Interview on 03/18/2016 at 9:40 a.m. with the Registered Nurse (A) revealed Patient #2's medications are administered via the PEG tube.

The Patient's physicians' orders and medication administration records, indicated that Patient # 2 was was receiving medications via his mouth, nasogastric tube and PEG tube.

Observation on 03/15/2016 and interview with staff revealed, Patient #2 receives his medications via the PEG tube and intravenously. The Patient was not administered medication orally ( via the mouth) or via a naso- gastric tube.

Patient #22

On 03/15/2016 at 10:58 a.m. revealed Patient # 22 was observed on the intensive care unit, in room 382. The Patient was observed with a naso- gastric tube to low wall suction. The patient also had a PEG tube in place.

Interview on 03/15/2016 revealed the Patient's feed was on hold due to high residual volume. She said the patient gets medications and feeding via a PEG tube.

Review on 03/18/2016 of the Patient's clinical records revealed the following current physicians' orders: "Aspirin 325 mg 1 tab oral daily, Amlodipine 10 mg = 1 tab oral q 24 hours. "

Interview on 03/18/2016 at 09:35 a.m. with the Registered Nurse (A), Facility's Nursing Supervisor, revealed Patient #22 gets her medications via the PEG tube. She said the Patient was admitted with the PEG tube.

The Patient's physicians' orders and medication administration records indicated that Patient # 22 was was receiving medications via the mouth, and PEG tube.

Observation and interview on 03/15/2016 with facility's staff revealed Patient #22 receives medications via the PEG tube.

Interview on 03/18/2016 at 9:45 a.m. with the Facility's Pharmacy Director revealed, facility's staff conducts interdisciplinary team meeting weekly. She said as the Pharmacist she relies on the nursing staff to notify the Pharmacist when there is a change in the route of administration of medication. She said there is a clinical pharmacist who reviews patients' clinical records. She said the facility did not identify that physicians' orders were written with various routes of administration for patients receiving medications via the PEG tubes.

Based on observation, interview and record review, the facility's staff failed to prepare medication in a clean / sanitary environment; failed to clean septum of medication vials; failed to wash/ sanitize hands after direct contact with patients and contaminated equipment; failed to wash/ sanitize hands after removal of contaminated gloves , failed to wear personal protective equipment when having direct contact with patients on isolation, failed to discard contaminated supplies, and failed to clean equipment after use for patients on contact isolation and prior to using for another patient. Citing 18 of 26 sampled, monitored facility's staff ( B, D, E, F, G, S, O, DD, Q, R, V,W,L,HH JJ,X,K and Z).



Findings:


Review on 03/18/2016 of the facility's current policy and procedure on Hand Hygiene; Policy # 06:039:06 directs staff as follows: " The Hospital has adopted the Centers for Disease Control and Prevention Guidelines for Hand Hygiene in Healthcare Settings with enhancement from the world Health Organization (WHO) Guidelines on Hand Hygiene in Healthcare 1,2.
Indications for hand washing and hand antisepsis include:
At the beginning of the work day,
Before and after direct contact with patients, blood/ body fluids or equipment and environment tal items touched by patients.
Before handling medication or food
Before eating drinking or smoking
After coughing sneezing or using the restroom
Prior to donning gloves and after removing gloves."


Review of the facility's current Policy and Procedure on Infection Control Transmission Based Precautions (also Known as Specific Precautions). Policy # 06/055:05, revised by facility on 7/15 direct staff as follows: " Contact precautions:"
"MRSA, VRE, MDRO, Diarrhea of suspected infectious etiology: Private room. Gloves required upon entry into the room. Hand washing or hand hygiene is required. Gown required when skin or clothing may be in contact with patient or equipment. Special notes: Remove gloves and wash hands upon leaving the room. Pay strict attention to cleaning and disinfection of environmental surfaces. Do not share patient care equipment. "

Review of the Center for Disease Control recommendation to practitioners on Healthcare Associated Infections; C Diff, documented the following :
"Isolate patients with C. difficile immediately. Wear gloves and gowns when treating patients with C. difficile, even during short visits. Hand sanitizer does not kill C. difficile, and although hand washing works better, it still may not be sufficient alone, thus the importance of gloves."

Interview on 03/15/2016 at 10:35 a.m. with Registered Nurse (A) revealed, Patient #1 was on isolation due to positive culture for MRSA.


Contract Registered Nurse (E)


On 03/15/2016 at 10:50 a.m. revealed, a vial containing Mannitol was observed stored on Patient # (1's) contaminated hemodialysis machine, post hemodialysis treatment of the Patient. Some clean syringes and medication of Heparin was observed stored directly on top of the soiled linen cart.

After terminally cleaning the contaminated hemodialysis machine, Contract Registered Nurse (E) picked up the vial of Mannitol, Heparin and syringes that were stored on the contaminated hemodialysis machine and soiled linen cart and left the unit with them.

During an interview on 03/15/2016 at 11:45 a.m. with Contract Registered Nurse (E), the Surveyor asked Contract Registered Nurse (E) what he did with the medication that was stored on the patient's hemodialysis machine and on the soiled linen cart. Contract Registered Nurse (E) stated. " I took them downstairs to the dialysis area and placed them in the medication box where medication is stored "


Registered Nurse (S)

Observation on 03/16/2016 at 8:50 a.m. revealed Registered Nurse (S) was observed in the intensive care unit at the nurses' station. Registered Nurse ( S) was observed crushing oral medication and preparing intravenous medication for Patient # 21.
Observation revealed Registered Nurse (S) crushed the medication in a medication pill crusher stored directly adjacent to the Accucheck machine which is used to check patient's blood glucose level.
Registered Nurse (S) also prepared intravenous medication of Protonix for Patient # 21. Registered Nurse (S) scratched his head, then went in the medication cart and picked up solution in a syringe to dilute the Protonix. Registered Nurse (S) did not wash or sanitize his contaminated hands prior to preparing oral and intravenous medications for Patient #21.


Registered Nurse (O)

On 03/16/2016 at 8:55 a.m. Registered Nurse (O) was observed in the intensive care unit (ICU) at the nurses' station. Registered Nurse (O) was observed preparing medication to be administered to Patient #1 via his percutaneous endoscopic gastrostomy ( PEG) tube.
During the preparation, Registered Nurse (O) removed the tablets from the packets and held them in her ungloved hands. She then placed them in a medication pill crusher which was stored directly adjacent to the Accucheck machine which is used for blood glucose testing.



Handwashing:

Patient #1, Registered Nurse ( E)
Interview on 03/15/2016 at 10:35 a.m. with Registered Nurse (A) revealed Patient #1 was on isolation due to positive culture for MRSA.


Observation on 03/15/2016 at 10:35 a.m. revealed Contract Registered Nurse (E) was observed in room 381. The room was occupied by Patient # 1. Observation revealed Contract Registered Nurse (E) was observed touching the drain bucket of Patient ( #1) who had completed hemodialysis treatment. Contract Registered Nurse (E) touched the drain bucket with his ungloved hands, he then walked to the nurses' station and picked up the telephone with his contaminated hands.
Contract Registered Nurse (E) did not wash/sanitize his contaminated hands after touching the contaminated drain bucket, which was utilized during hemodialysis treatment of Patient #1. Patient # 1 has a positive culture for MRSA.

During an interview on 03/15/2016 at 10:40 a.m., the Surveyor informed Contract Registered Nurse (E) that he did not wash or sanitize his contaminated hands after touching the contaminated drain bucket and after leaving the isolation room of the patient with MRSA.
Registered Nurse (E) stated " Oh really. "

CNO ( D), Patient #1

Observation on 03/15/2016 at 10:50 a.m. revealed the Facility's Chief Nursing Officer ( D) was observed in the room of Patient #1 who was on isolation for MRSA. The Chief Nursing Officer removed her contaminated gown, placed the gown under her arm and picked up syringes and medication of Heparin stored on the dirty linen cart in the patient's room. The Chief Nursing Officer picked up the medication and syringes from off the soiled linen cart and gave it to a staff outside the room. She then placed it on the counter at the nurses station.

During an interview on 03/15/2016 at 10:51 a.m. with the Facility's Chief Nursing Officer, the Surveyor informed the Chief Nursing Officer that she the Surveyor had a concern that medications removed from the room of a patient on isolation was placed on the nursing station, utilized by nurses on the unit who care for the general patient population.
The Facility's Chief Nursing Officer (D) stated " I do have a concern with that too. "

The Facility's Chief Nursing Officer then picked up the medication and syringes and returned it to Contract Registered Nurse (E) who was in Patient #1's room.

Physical Therapist (F), Patient #2
Observation on 03/15/2016 at 11:20 a.m. revealed Physical Therapist (F) was observed on the intensive care unit, in room 385. The room was occupied by Patient # 2.
Physical therapist ( F) was observed providing wound care to the patient. The Patient had a wound to his sacral area. The Physical Therapist removed the dirty dressing covering the patient's sacral wound, removed her gloves and applied clean gloves. She then cleaned, packed and dressed the sacral wound of the patient.
After completing the wound care, Physical Therapist ( F) used her contaminated gloved hands that she had used to clean and dress the patient's sacral wounds to reposition the patient, touched the patient's Foley catheter, picked up the left over wound cleaning supply and placed them in the clean drawer. The Physical Therapist did not remove her contaminated gloves and wash/ sanitize her contaminated hands after cleaning and dressing the patient's sacral wounds.

Review of Patient #2's clinical record ( Microbiology cultures), revealed the following laboratory values: Wound culture done 03/14/2016, positive for MRSA, respiratory cultures done 03/05/2016, positive for E- Coli (Escherichia coli) and MRSA.

Patient #21, Registered Nurse (S)
Interview on 03/16/2016 at 8:40 a.m. with Registered Nurse (S) revealed Patient # 21 was on isolation for C Diff and other infections.

On 03/16/2016 at 8:40 a.m. revealed Registered Nurse (S) was observed entering room #388 to administer intravenous antibiotic to Patient #21.
Registered Nurse (S) hung the intravenous medication on Patient # 21. He removed his gloves, sanitized his hands with alcohol and left the room. Registered Nurse (S) did not wash his hands after providing care to patient #21 who has a diagnosis of C Diff.

Subsequent observation on 03/16/2016 at 8:50 a.m. revealed Registered Nurse (S) re-entered the patient's room with the scanner and scanned the patient's armband. The scanner is used for the general patient population on the unit.
Registered Nurse (S) was not wearing a gown or gloves. He then exited the patient's room and returned the scanner to the medication station on wheels, which was parked outside the patient's room door. He did not clean/ sanitize the contaminated scanner and he did not wash/ sanitize his contaminated hands after preparing and administering medication to Patient #21.
He exited the room and returned to the medication, computer cart on wheel and continued preparing medication.
Registered Nurse (S) then proceeded to prepare oral medications for the patient. During preparing of the medication, a packet containing medication fell to the floor. He picked it up, returned it to the medication station on wheels.
He did not wash or sanitize his contaminated hands after retrieving the packet from the floor. He then donned a pair of clean gloves and went in the patient's room where he administered oral and intravenous medication to patient #21.

During an interview on 03/16/2016 at 9:10 a.m., the Surveyor informed Registered Nurse (S) that he had entered the patient's room who was on isolation without wearing personal protective equipment, that he had used the scanner in the patient's room and that he did not sanitize the scanner or wash/sanitize his contaminated hands after leaving the room.

Registered Nurse (S) stated " I was going back in the room. That is why I did not put on a gown or gloves. "

Review of the Patient # 21's clinical record revealed the following microbiology results : Laboratory report for stool showed positive results for Toxigenic C difficile and VRE screen done on 02/27/2016 showed VRE colonization present.

The Patient's clinical record indicated physicians' orders dated 03/13/2016 for antibiotic of Meropenem 125 mg every six hours, Metronidazole 500 mgs intravenous every 8 hours and a physician's order dated 3/15/2016 for Vancomycin 500 mg Q 6 hours for enterocolitis.

Patient # 23, Registered Nurse P, CRNA Q, and Operating Technician (R)

On 03/16/2016 at 9:15 a.m. CRNA (Q), Registered Nurse (P) and Operating Room Technician (R) were observed in room # 387. The room was occupied by Patient #23 who was on isolation
The staff present in the room were preparing the patient to be transferred to a procedure and were providing manual ambu bagging of the patient. They walked from the patient's room and entered the nurses' station. They did not wash or sanitize their hands after leaving the patient's room.

Review of a sign on the patient's door revealed the following instructions: " gown and gloves. " CRNA (Q), Registered Nurse (P) and Operating Room Technician (R) were not wearing gowns or gloves.

On 03/16/2016 at 9:20 a.m. the Surveyor informed CRNA (Q) of her observation, that she and the other staff members entered the patient's room without wearing gloves or gown and that they did not wash/ sanitize their hands after leaving the room. She stated " I am not touching anything."

Review of the Patient's clinical record revealed a microbiology laboratory result dated 03/04/2016. The record indicated that the patient's blood culture was positive for Vancomycin Resistant Enterococcus.
Review of the Patient's clinical record revealed a physician's order for Meropenem 500 mg intravenous every 12 hours.

Medical Doctor (DD) Patient # 22

Interview on 03/15/2016 at 10:58 a.m. with Registered Nurse (A) revealed Patient #22 was on contact isolation for Multi drug Resistant Organism in her urine.

On 03/16/2016 at 9:50 a.m. revealed Medical Doctor (DD) was observed in the room 382 on the intensive care unit. The room was occupied by patient #22 who was on isolation for multi drug resistant organism. Observation revealed Medical Doctor (DD) donned a pair of gloves and entered the patient's room. He then examined the patient's chest and back with his stethoscope. The Medical Doctor was not wearing a protective gown, he was observed leaning against the patient's side rail and touching the bed linen with his street clothing while examining the patient.

The Surveyor immediately notified Nursing Supervisor(M) of her observation. She stated "Yes he is examining the patient and he is not wearing a gown. "
Observation revealed Medical Doctor (DD) left the room and came to the nurses station wearing his street clothing that had direct contact with the patient who was on isolation for multi drug resistant organism.

Medication Preparation
Registered Nurse (S)

On 3/16/2016 at 8:40 a.m. Registered Nurse (S) was observed at the nurse's station, on the intensive care unit. Registered Nurse (S) was preparing intravenous medication (Protonix) to administer to Patient (#21 )
The Registered Nurse used a needle and syringe and withdrew the intravenous medication from a vial. He did not clean the septum of the vial prior to inserting the needle.

During an interview on 03/16/2016 at 9:10 a.m. with Registered Nurse (S) the Surveyor informed the Registered Nurse that he did not clean the septum of the vial prior to entering it with the needle. He responded " It is new"



17028

Contaminated equipment not sanitized after use

Staff V, Registered Nurse

Observation on 3/16/2016 at 8:35 am on the IMU (Intermediate Medical Unit) revealed Staff (V) Registered Nurse was observed in the nurses' station preparing medication for a patient.
The Staff took a drawer from the medication cart that contain medication for all the patients on the unit (15) and placed it on the Work Station on Wheels (WOW).
On the top of the work station was a pill crusher, alcohol swabs, a scanner and other supplies.
Staff (V) took the WOW into the room of Patient (#14) on the door to the patient's room was a notice that read "Contact Isolation".
The Nurse placed the WOW next to the patient's bed. Through the opened door of the patient's room, Staff (V) was observed touching the patient, his bed linen and other equipment in the room with gloved hands.
The Staff was touching items on the WOW, removing medication from the medication drawer, using the scanner and computer located on the WOW with the same gloved hands.
After completing her tasks in the patient's room Staff (V) took the WOW to the nursing station and did not clean and sanitize it.
The Staff put the soiled medication drawer back into the medication cart and did not clean and sanitize the drawer.
Staff (V) removed two(2) paper patient records from a rack, placed them on the dirty WOW while checking orders. She then returned the records to the rack.
Staff (V) proceeded to prepare medication for another patient. She took a drawer of medication from the medication cart and placed it on the dirty work station on wheels (WOW).
After preparing the medication on 3/16/2016 the Staff took the dirty WOW containing the medication drawer with medication, the scanner and left over supplies she used in the room of Patient (# 14) to the room of Patient (#6).
At 10:30 am 3/16/2016 the Staff administered parenteral and oral medication to the patient using supplies and equipment (scanner) from the dirty work station on wheels (WOW).
Review of medical record for Patient (#14) revealed an order dated 2/7/2016 to place the patient on contact isolation for positive VRE( Vancomycin-resistant Enterococcus) bacteria of the stool.
Review of Medication Administration Record for Patient (# 6) revealed she was admitted to the facility with Diagnoses of Urinary Tract Infection, Malnutrition, and Gastropods.
(This patient was susceptible to infections).

Staff (W) Registered Nurse

Observation on 3/16/2016 at 11:45 am on the Intermediate Medical Unit (IMU) revealed Staff (W) Registered Nurse took her work station on wheels (WOW) into the room of Patient (#30) who was on Contact Isolation.
The Staff left the WOW just inside the patient's room away from the patient's equipment,however, Staff (W) accessed the WOW multiple times with the gloved hands she used to touch the patient, his bed linen, and his equipment while she was providing care.
After leaving the patient's room Staff (W) took the work station on wheels from the room of Patient(#30) who was on contact isolation to the room of Patient (# 29) and did not clean and sanitize the WOW after use and prior to taking the it into another patient's room.
Review of culture report for Patient (#30) dated 3/2/2016 and 3/16/2016 revealed the culture was positive for Streptococcus Aureus of sacral wound.
Review of history and physical for Patient (# 29) revealed the patient was admitted to the facility on 11/23/2015 for Altered Mental Status, Acute Kidney Injury and Urinary Tract Infection.

Medication preparation
On 3/16/2016 at 10:25 am staff (V) Registered Nurse was observed in the room of Patient (# 6) administering medication to the patient.
The staff used a needle and syringe and withdrew hydrocortisone from a vial and did not clean the septum of the vial prior to inserting the needle.
The Staff did not clean the injection port on the IV(Intravenous) line prior to injecting the medication.

Hand Washing
Staff (L ), Patient Care Technician

Observation on 3/15/2016 on the IMU ( Intermediate Medical Unit ) at 11:10 am revealed Staff (L) Physical Therapist was providing care to patient (#31). The staff was touching the patient, the patient's bed linen and equipment in the room.
After completing care for the patient Staff (L) removed his soiled gloves and did not wash his hands.
The Staff took gloves from the clean gloves box with dirty hands.

Staff (HH), Physician

Observation on 3/16/2016 at 11:50 am on the IMU revealed Physician JJ went into the room of Patient (# 30) in room 365 who had a sign on the door to his room which read "contact Isolation".
Physician JJ did not wear a gown and gloves when he entered the patient's room. He left the patient's room and went to the Nurses' station where he was making notes on the computer at the desk.
The physician did not wash/sanitize his hands when he went into the patient's room or after leaving the room.
During an interview on 3/16/2016 at 12:05 PM on the unit with Physician (HH) he stated ''wearing PPE(Personal Protective Equipment) in the room of a patient on contact isolation is not necessary unless you are touching something in the room, he stated the requirement for PPE is overrated.''

Staff JJ,Physician

Observation on 3/16/2016 at 12:30 pm on the IMU revealed Staff (HH) Physician, went into the room of Patient (#30) who was on contact isolation.
The physician examined the patient then removed his gown and gloves, went to the Nurses station and began documenting on the computer without sanitizing his hands.

During an interview on 3/16/2016 at 12:10 pm on the IMU with the Infection Control officer who was present at the observations she stated all staff were required to wear PPE when entering the room of a patient on contact isolation and wash or sanitize their hands after exiting the patient's room.

Soiled Linen

Staff (X), Patient Care Technician

Observation on 3/15/2016 at (10:40 AM) on the IMU revealed Staff (X) Patient Care Technician, placing soiled linen in bags in a patient's room. The Staff tied the linen bags together with her soiled gloved hands, the staff removed the soiled gloves and removed the bags of soiled linen from the patient's room without wearing gloves to handle the soiled linen bags.

During an interview on 3/15/2016 at 11:15 am with Staff (X) she stated she was taught not to wear gloves outside the patient's room because she could contaminate the handle of doors.

During an interview on 3/15/2016 at 12:15 pm with the facility's infection Control Officer, she stated staff were taught to handle soiled linen and receptacles with gloved hands. The Staff stated infection control re-education would be done for all staff.

During an interview on 3/17/2016 at 1:45 pm in the conference room at the facility with the Chief Nursing Officer she stated she realized there were some widespread problems with infection control measures and the facility is taking it seriously and will address the problems.


33438


Sodium Chloride
Observation on 03/15/2016 at 10:05 a.m. made, during the quick tour on the Medical floor of the Facility, the Surveyor went to a room ready for admission. Inside Room #481, the Surveyor opened the bedside drawer, it revealed 2- 10 ml of Normal Saline pre-filled syringes unwrapped from plastic container with Lot #5316542 and 5316550.

Interview made on 03/15/2016 at 10:10 a.m. with one of the Staff Directors (G), the Surveyor showed the 2 unwrapped normal saline prefilled syringes inside the drawer, she said "I will take it out." She grabbed and brought those with her.


Sharp Container

Observation on 03/15/2016 at 10:12 a.m. made, during the quick tour on the Medical floor of the Facility, the Surveyor went to the Nurses Station of Units 471-483. The Nurses' Station had 1 full sharp red container.

Interview made on 03/15/2016 at 10:18 a.m. with one of the Staff nurses (B) (G), the Surveyor showed the full sharp red container to her and to the Staff Director (G), the Surveyor verified with her if that container could still be used, she said "Usually, it is us nurses who change the sharp container, but I can do it later. Yes, we cannot use it any longer. It is closed, and above the line."



35028


Observation on 03/15/2016 at 11:10 of Patient #17's room (#480) on the fourth floor revealed a " Contact Isolation " sign on the door frame of the room. Further observation revealed that MD K went into Patient #17's room without gown or gloves. He stood at the foot of the bed, spoke with the patient and returned to the nurse's station. He neither washed his hands prior to going into the room nor upon returning to the nurse's station.


Observation on 03/17/2016 at 11:30 of Patient #4's room (#475) on the fourth floor revealed a " Contact Isolation " sign on the door frame of the room. Further observation revealed that MD Z was standing in Patient #4's room with gown and gloves on. He moved away from the bed, removed and disposed of his gown and gloves, then turned back to talk with the patient. He adjusted the drapes surrounding the patient's bed with his bare hands. He then exited the room.


In an interview with CNO D on 03/15/2016 at 11:10, she stated that staff are to gown and glove when they go into the room of a patient on "Contact Isolation."


Record review of the policy and procedure 06:055:05, " Infection Control Transmission-Based Precautions (Also Known as Specific Precautions), " dated 07/2015, revealed: " ... 3. CONTACT PRECAUTIONS ... Gloves required upon entry into the room. Hand washing or hand hygiene is required. Gown required when skin or clothing may be in contact with patient or equipment. "

Based on record review and interview the facility failed to have an agreement with at least one organ donation organization to ensure the donation of organ when available.


Findings:


Observation at the facility on 3/15/2016 at 9:45 am revealed the Long Term Acute Care (LTAC) Hospital was a hospital within a hospital.The host hospital ( Hospital PP) is an acute care hospital.
Review of the organ donation contract that was presented by the facility staff on 3/18/2016 revealed the agreement signed and dated November 7, 2012 was between the host hospital (Hospital PP) and Life Gift. The LTAC was not included in the agreement.
During an interview on at the facility on 3/18/2016 at 11:20 am with the Chief Nursing Officer regarding the agreement, she stated the agreement is with Hospital PP and Life Gift. The LTAC did not have an independent agreement with Life Gift or any other Donor Organization.