HospitalInspections.org

Based on observation, interview, and record review the facility failed to ensure the Infection Control system controlled infections by:
-ensuring staff wore proper personal protective equipment (PPE) and stored supplies in a manner to prevent the spread of infection when caring for patients on contact isolation;

-ensuring staff performed hand hygiene after contact with contaminated areas and when providing direct patient care;

-ensuring Foley catheter was secured in a manner to prevent the introduction of infection;

-ensuring a clean environment and clean multiuse items;

-ensuring linen was transported in a manner to prevent cross contamination;

-ensuring infection control process in the kitchen to prevent the spread of infections.

These failed practices had the potential for the spread of infections to patients. Citing random observations in the ICU, kitchen, and Medical Surgical Units.

Findings include:

Observation on 5/5/2014 at 11:30 am on the Intensive Care Unit (ICU) revealed room 101 had a sign on the door that Patient (#25) was on Contact Isolation.

Observation revealed Staff ( #90) Physician Assistant was wearing a laboratory(lab) coat that was opened down the front. She was examining the patient in her bed. Her lab coat was in contact with the patient's bed. The staff had a stethoscope around her neck which she used to examine the patient. After use, she returned the stethoscope around her neck and left the room without sanitizing the stethoscope and did not change her lab coat. The staff was not wearing the personal protective equipment(PPE) that was required when caring for a patient on contact isolation.

The Nurse Manager who was present at the time of the observation spoke to the Staff. The staff stated she did cover the bell of the stethoscope with a glove.

Review of progress notes dated 5/4/2015 for Patient (# 25) revealed she was on contact isolation for Pseudomonas of her urine.

Observation on 5/5/2015 at 11:35 am on the ICU revealed a sign on the door of room 103 that Patient (#24) in the room was on contact isolation.

Staff (# 91) Registered Nurse (RN) pushed a dialysis machine into the room. There was dialysis supplies, a log book, clipboard and portions of the patient's paper record on the top of the hemodialysis machine . On the base of the hemodialysis machine there were two (2) containers of disinfectant wipes and a bottle labeled paracetic acid.

Staff (#91) was observed setting up the dialysis machine with gloved hands. After contact with supplies and equipment in the patient's room without changing her gloves she removed the machine log and paper chart from the dialysis machine. She placed the paper record and log book on a towel covered stool located less than a foot from hemodialysis machine with dialyzer and connections.

During an interview on 5/5/2015 at 12:15 PM with Staff (91) she stated the containers with the disinfectant wipes were multi use containers and would be sanitized after use and returned to the dialysis storage room.

During an interview on 5/5/2015 at 12:30 PM with the Nurse Educator she stated the paper charts are placed in the medical record at the completion of the hemodialysis treatment. She stated the record is clean and should not be in the patient's room because she was on contact isolation.

Review of progress notes dated 5/4/2015 for Patient (# 24) revealed she was on contact isolation for Klebsiella of abdominal wound.

Review of the facility's Infection Control Policy/procedure # H-IC-02-002 dated 12/2013 documented the following information:
"Direct contact transmission involves skin-to skin contact and physical transfer of micro-organisms to a susceptible host from an infected or colonized patient (turning, bathing and other patient care activities or patient to patient contact).

Indirect contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate ,in the patient's environment.

Personal Protective Equipment (PPE) is utilized to reduce the risk of transmission and/or prevent the transmission of pathogenic organism from patient to health care worker and from health care worker to patient. PPE is utilized when there is a potential for contamination from skin to skin contact, with blood or other body fluids and splashing is anticipated".


23032



Hand Hygiene:

Observation on 05-05-15 at 11:30 a.m. revealed Patient # 9 laying in bed, awake and alert. Continued observation revealed Certified Nurse Aide (CNA) # 63 prepared to obtain a fingerestick glucose using a glucometer. CNA # 63 failed to sanitize her hands prior to donning clean exam gloves and performing the finger stick on Patient # 9. After the procedure, CNA # 63 failed to sanitize her hands after removing the contaminated gloves.

Interview with CNA # 63 immediately following the procedure, she stated " I should have sanitized my hands before and after the gloves changes."

Record review of facility policy titled: "Hand Hygiene," dated 08/2012, read: "...Policy: Hand antisepsis is achieved through the use of antimicrobial hand sanitizer and hand washing is achieved thought the use of antimicrobial soap and water. ...Hand Hygiene will be performed as follows:...DJ. Before donning and after removal of gloves..."

Indwelling Catheter Not Secured:

Observation on 05-05-15 at 10:30 a.m. revealed Patient # 4 sitting up in bed, awake and alert. Further observation revealed Patient # 4 had an indwelling urinary catheter draining clear yellow urine to bedside drainage.

During this same observation, Registered Nurse (RN) # 52 lifted the bed linen to reveal Patient # 4's indwelling catheter was not secured to his leg. RN # 52 stated " he should have a 'statlock' to secure the Foley; not sure why he does not."

Environmental :

Observation on 05-05-15 during initial tour of the facility between 10:00 a.m. and 11:45 a.m. revealed the following environmental infection control issues:

Second Floor Patient Unit:

"Tub Room:"

*floor was dirty with dirt build-up in corners and gray stains on floor.

*plastic spoon; used washcloth, and a plastic bath basin was observed on the floor.

* handwashing sink was dirty; a roll of adhesive bandage tape was observed on the sink by the faucet.

*An upright patient scale was observed in the corner of the tub room. The bottom of the scale had dirt , debris, and stains on it.

* Directly outside the tub room door, a dirty floor mop was observed against the wall with the 'dirty end' pointed up. The end of the mop was covered with a large amount of brownish dust & dirt. The mop was located directly adjacent to the patient hallway.

Interview with RN # 52 at the time of observation, she stated the mop should have been stored in the Housekeeping Closet.

Third Floor Patient Care Unit:

1. Observation on 05-05-15 at 11:00 a.m. in Patient # 8's room: visibly soiled oral suction device located on the counter by the sink.

2. Patient # 5 was observed laying in bed, awake, alert; with an indwelling urinary catheter to bedside drainage. Further observation revealed the catheter drainage bag located directly on the floor. Interview with RN # 51 at the time of observation, she acknowledged the catheter drainage bag should not have been on the floor. RN # 51 connected the bag to the patient's bedframe.

3. Bath basin was observed directly on floor under the bed in Patient # 6's room

Nourishment Room (3rd floor) :

Microwave oven used for patients food was dirty ; contained dried food particles and stains.

A thick layer of dust was observed on top of the refrigerator used to store patients' food.

Record review of facility policy titled " 8-Step Cleaning Process," undated, read: "...3 High dust everything above shoulder level or out of reach..Include all rooms...damp wipe everything you are able to reach with disinfectant or bleach product...start with the door and work around the room...damp mop or vacuum..mop out corners to prevent build up..."

Linen :

Observation on 05-05-15 at 1:15 p.m. in the Intensive care Unit (ICU) revealed Patient # 24 laying in bed, ventilator-dependent, with multiple intravenous lines and fluids. There was a green-colored sign posted outside the door that read: "Contact Precautions." Continued observation revealed RN # 86 entered the room carrying a bundle of "clean linen" directly next to her scrub uniform.

Interview at the time of observation with Nurse Manager #51, she stated clean linen should not be transported next to the staff's uniform.

Review of facility policy titled: "Clean Linen Handling," undated, read: "...Handling of Clean Linen: Once laundry has been decontaminated; every effort must be made to maintain its quality and cleanliness..."


16838


Kitchen

Observations on 5/7/15 at 9:45 a.m. to 10:30 a.m. of the facility's kitchen with Quality Director #55 revealed the following:

-Dietary Aide (DA) #59 walked into the dirty side of the dish cleaning area and moved a food cabinet that had just been unloaded of used lunch dishes through the doorway between the dirty and clean dish cleaning area. She parked the cabinet against the wall across from the steam table where the lunch trays were to be plated. She began cleaning the cabinet.

- Dietary Aide (DA) #58 was on the dirty side of the dish cleaning area. She had been removing the used dishes from a food cabinet, scrapping the dishes and putting them in trays to run in the dish machine. She had on a pair of gloves. Without removing the gloves and performing hand hygiene, she walked through the doorway between the dirty and clean side, touched a vial of testing strips, removed one strip and tested the sanitizer on the clean side. She then went back to the dirty side and continued to put the dirty dishes in trays and putting them into the dish machine. There was a hand sink on the dirty side which was difficult to reach because the food cabinet was in front of it. There was no sanitizing hand gel dispenser in the room. The vial of testing strips had been put back on a rack in the dirty area without being sanitized.

Interview at this time with DA #58, she said DA #59 should have cleaned the cabinet at the doorway before she took it into the main kitchen area.

Interview at this time with Quality Director #55, she said she could see how getting to the sink could be difficult in the dirty area. She said the facility could put a hand sanitizing dispenser at the doorway between the clean and dirty area for better access for the staff to perform hand hygiene.

Further observations on 5/7/15 at 11:30 a.m. to 12:00 p.m. revealed Chef #61 was in the food preparation area and had a light blue and green cutting board in front of him. There was a red cutting board next to him with a kitchen knife on the board.

Interview at this time with Chef #61, he was asked what food items could be used on each board. He said the light blue board was for chicken, the red board was for beef or red meat, and the green one could be used for vegetables, beef or chicken.

During an interview on 5/7/15 at 12:00 p.m. with Food Service Manager #62, she was asked what food item each colored board should be used for. She said red was for red meat, green was for vegetables, yellow was for poultry, and she did not know what the light blue was for. Food Service Manager #62 was asked for the Policy and Procedure (P&P) for use of cutting boards. She looked through the policies and said she did not have one for the cutting boards.

Further observations during this time revealed Cook #60 was plating food from the steam table. He had on gloves. He left the steam table and took off his gloves. He went to the food preparation area and got another pair of gloves. He put on these gloves without performing hand hygiene. He went back to the steam table and continued to plate food.

Record review of the facility's P&P for Proper Use of Gloves dated January 2010 revealed the following:
"Gloves are not a substitute for hand washing."

Record review of the facility's P&P for Handwashing dated January 2010 revealed the following:
"PROCEDURE:
Frequent hand washing by personnel is of prime importance in the prevention of infections. Hands must be washed:...
3. Between handling of dirty dishes or equipment, and handling clean food or utensils, i.e. dish machine....
12. Each time gloves are changed..."

Based on record review, and interview the facility failed to provide documentation that discharge planning evaluation was discussed with a patient. Citing one (1) of 2 inpatients. Patient (# 26).

Findings:

During observation on 5/6/2015 at 10:10 am on third floor Medical/Surgical Unit, Patient (# 26) was observed in room 319 sitting at the edge of his bed. The patient had intravenous antibiotics infusing.

During an interview on 5/6/2015 at 10:15 am with the patient regarding discharge planning he stated he was not told by any staff about discharge plans. He stated he had been in the hospital for two(2) weeks and there was no discussion regarding what the next step is after his antibiotics treatment is completed.

Review of the History and Physical notes for Patient (# 26) revealed he was admitted to the facility on 4/19/2015 with history of Diabetes, End Stage Renal Disease and septic right shoulder. He had a hardware removal and was admitted for prolonged intravenous antibiotics and wound care. Discharge planning notes documented discharge plan was initiated on 4/27/2015.

There was no documentation the discharge plan was discussed with the patient.

During an interview on 5/6/2015 at 11:45 am with the Director of Case Management who was present in the patient ' s room she stated the patient is scheduled for discharge on 5/11/2015. She said it was evident no Case Manager had seen the patient, if they did, at a minimum the patient would have said he had a Case Manager.

Review of the facility's Discharge Planning Policy/procedure # H-ML-10-013 dated 8/20/2012 revealed the following information:
"Once an assessment and evaluation is completed the Case Manager(or if applicable the Social Worker) will develop a discharge plan, in collaboration with the patient, family, physician, ancillary staff and specialists."

Based on record review and interview the facility failed to document in the discharge plan that review of medication and medication reconciliation was done with patients or responsible party on discharge. Citing 1of 1 patient discharged to home.Patients # 18.

Findings:

Patient (# 18).

Review of admission records for Patient (# 18) revealed he was admitted to the facility on 4/13/15 with diagnosis of generalized septicemia. He was admitted to the facility for two weeks of intra venous antibiotics.

Review of discharge planning notes dated 5/5/2015 revealed the patient was discharged home with Home Health Services.

Review of the patient's discharge medication revealed he was going home with new medications that were not listed on his admission home medication list.

There was no information on his discharge notes that the patient was educated that there were changes to the medication regime.

During an interview on 5/7/2015 at 11:25 am with the Director of Case management she stated the Case Manager is to ensure medication reconciliation and teaching is done prior to discharge and should document as such.

Review of the facility's Discharge Planning Policy/procedure # H-ML-10-013 dated 8/20/2012 revealed the following information:
"Nurses provide patient and family/caregiver with discharge instructions sheet on prescribed treatment, medications(including food/drug interactions), the nutrition plan, activity level, and scheduled follow-up appointments. Document discharge related activities in the medical record".

Based on record review and interview, the facility failed to provide documentation that pertinent medical information was sent to a facility for patients who were transferred from the hospital for continuing care. Citing two (2) of two (2) patients, (#s 22 and #20).

Findings:

Patient (# 22).

Review of closed record for patient( # 22) revealed the patient was admitted to the facility on 1/24/2015 with severe multiple medical problems including progressive renal failure, congestive heart failure, and dementia.

The discharge plan included palliative care and inpatient hospice. There was documentation dated 2/17/2015 the patient was admitted to (FG) Hospice Service.

Review of discharge planning notes dated 2/17/2015 revealed documentation a report was called to the receiving hospital. There was no documentation the patient's medical record was sent to the facility.

Patient (# 20).

Review of admission records for Patient (# 20) revealed he was admitted to the facility on 2/19/2015 with history of congestive heart failure, coronary artery disease and dementia. He was admitted to the facility for Physical Therapy, occupational Therapy and to continue his intra venous (IV).

Review of discharge planning notes revealed the patient resides in a nursing home.

Review of discharge plans dated 3/10/2015 revealed the patient was discharged to a Skilled Nursing Facility. There was no documentation the patient's medical information was sent to the nursing home.

During an interview on 5/7/2015 at 9:35 am with the Director of Case management she stated the staff should have documented that the medical records were sent to the receiving facilities. She stated the records are usually faxed to the facilities.

Review of the facility's Discharge Planning Policy/procedure # H-ML-10-013 dated 8/20/2012 revealed the following information:
"Case Manager(or if applicable the Social Worker) will:

Confirm transfer arrangements if the patient is being transferred to another facility, and then send the required medical records".

Prior to discharge from LTAC, Case Manager (or if applicable, Social Worker) documents plans, interventions, outcomes of interventions, and accepting physician (if applicable) in the progress notes.