HospitalInspections.org

Based on observations, staff interview and review of documentation, the Hospital failed to have an effective governing body who is legally responsible for the conduct of the hospital. Finding include:

During interview on 11/5/15 at 1:00 P.M., the President of the Governing Body (GB) stated that the GB is responsible for the overall conduct of the hospital.

The governing body failed to effectively ensure the hospital:

1. Had an effective Quality Assessment and Performance Improvement Program which was clearly defined, implemented and maintained.

See A0263

2. Had an active program for the prevention, control, and investigation of infections and communicable diseases.

See A747

3. Maintained a unified Nursing Service under the direction of one Director of Nursing (DNS) which had clearly delineated lines of authority and accountability to the hospital administration. The hospital maintained two DNS, each with independent authority over different sides of the hospital (Mental Health and Medical Services). The lines of authority for one DNS who oversaw the medical services reported directly to the hospital's Chief Executive Officer. The mental health DNS had lines of authority and accountability outside the hospital's administration.

See A385.

Based on staff interviews, and review of Quality Assessment and Performance Improvement (QAPI) indicators and meeting minutes, the Hospital failed to ensure there was an effective, ongoing, hospital-wide, data-driven program to ensure the safety and well-being of the patients. Findings include:

1. The Hospital failed to provide evidence that the (QAPI) program was ongoing program that shows measurable improvement in Quality Indicators to improve health outcomes and quality of life for the patients regarding Infection Control, Physical Environment, Medication Errors, Storage of medications and expired medications, falls and prevention of wounds.

Please refer to A-0273.

2. The Hospital failed to ensure that medication errors and poor techniques during medication administration were consistently analyzed for a cause, and that effective preventative actions and mechanisms with feedback and education throughout the hospital were conducted through the QAPI Program with an emphasis on patient safety.

Please refer to A-0286.

Based on observations, staff interview, review of clinical record review and review of hospital documents, the facility failed to ensure the Hospital had an organized nursing service to provide unified and appropriate care to all patients. Findings include:

1. The Hospital failed to ensure that there was only one Director of Nursing services who is responsible to oversee the nursing care to all areas of the hospital.

Please refer to A-0386.

2. The Hospital failed to provide adequate nursing staff to meet the needs of patients as evidenced by failure to provide safe patient care and to implement hospital policy and procedure due to lack of adequate staffing.

Please refer to A-0392.

3. The Hospital failed to ensure that a registered nurse (RN) evaluated the nursing care for two sampled patients (#13 and #27), to ensure that patients received care in accordance with hospital policy and procedure and to prevent physical decline and/or to ensure evaluation, care and response to nursing interventions.

Please refer to A-0395.

4. The Hospital failed to ensure that for five sampled patients (#11, #13, #27, #28 and #35), and for five out of ten non-sampled patients (NS A, NS B, NS H, NS I and NS J), that licensed staff prepared and administered medications in accordance with orders and accepted standards of practice.

Please refer to A-0405.

5. The Hospital failed to ensure a patient assessment and care plan were developed to ensure that one sampled patient (#9) was competent to self- administer medications.

Please refer to A-0412.

Based on observation, record review and interview, the Hospital failed to have an adequate system in place in order to provide a sanitary environment that avoided sources of infection and potential transmission of infections and communicable diseases. The Hospital Infection Control Program failed to be active in the prevention and control of the potential spread of infections and communicable diseases. Findings include:

1. The Hospital failed to ensure a negative pressure room, used for isolation of tuberculosis (TB) patients, was functioning for five days, while caring for an active TB patient (#2), placing staff and visitors at risk for exposure

2.) The Hospital failed to ensure three staff (RN #11 and RN #20 and LPN #1) properly disinfected blood glucose monitors between patient use for two patients (#9 and #24) to prevent transmission of blood borne infections..

3.) The Hospital failed to maintain a safe, clean and sanitary environment in the kitchen, on the 7 North and 7 South units (respiratory/ventilator units), affecting NS patients B and C and Patients #27, #28, #29, #32, and #33, in a total sample of 37, and in two of three active operating rooms (OR #2 and #3), to decrease the risks of spreading infection.

4.) The Hospital staff (Registered Nurses (RN)) #5, 6, and #24 and Respiratory Therapist (RT) #1, failed to perform glove changes and perform hand hygiene when appropriate, to decrease the spread of infection.

5.) The Hospital failed to ensure that two staff, Physician #4 and Operating Room Technician #1 (OR Tech #1), utilized Personal Protective Equipment (PPE) appropriately.

6.) The Hospital failed to ensure two staff ( RN #9 and Certified Nurses Aide (CNA) #1) utilized aseptic technique and followed hospital procedures in the changing of central line dressings for one nonsampled patient (NS D) and one sampled patient (#11).

7.) The Hospital failed to ensure that for 6 of 14 personnel health records reviewed (RT #3, #4 and #5, RN #2 and RN #25 and OR Tech #1), employees were screened annually for TB per Hospital policy.

Please refer to A-749.

Based on record review and staff interview, the hospital failed to ensure that for two patient (#3 and #15), in a total sample of 37, the patients and/or their legal representatives were fully informed in advance of their health status, given information necessary to make health care decisions and/or involved in the care planning and treatment. Findings include:


1. For Patient #3, the hospital failed to ensure informed consent for an anti-psychotic medication was obtained.

Record review indicated Patient #3 was admitted to the hospital with a physician's order to receive the anti-psychotic medication, Seroquel. The patient is alert and oriented to person, place and time and is responsible for self.

Further review of the clinical record indicated there was no evidence that informed consent for the use of the anti-psychotic medication had been given by the patient prior to the administration of the medication.

On 11/10/15 at 11:30 P.M. the 6th floor Unit manager said that consent had not been obtained prior to the administration of the anti-psychotic medication.




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2. For Patient #15, the hospital failed to ensure that an amended Rogers treatment plan (a court ordered treatment plan for a patient that has been deemed incapacitated to make these decisions) for the use of antipsychotic medications was obtained.

Review of the clinical record indicated the presence of a court ordered Rogers treatment plan for the use of specific antipsychotic medications. The patient's mother was listed as the permanent guardian as well as the Rogers monitor. The role of the Rogers monitor is to ensure the treatment plan is being followed. The Rogers monitor does not have the authority to a change of the treatment plan, that falls under the authority of the court.

The treatment plan included the following:
Primary Antipsychotic Medication/Dosage and/or dose range:
Aripiprazole 20 milligrams (mg)/day; up to 30 mg/day

Alternative Antipsychotic Medication:
Clozapine 25 to 600 mg/day
Lurasidone 2 to 120 mg/day

Review of the physician orders dated October 2015 indicated the use of the following antipsychotic medications:
Haloperidol 10 mg (1 tablet) by mouth three times daily
Loxitane 50 mg every for hours as needed for severe agitation Quetiapine 300 mg tablet (1 tablet) by mouth twice a day
Quetiapine 50 mg (1 tablet) by mouth twice a day

Review of a physician's progress note, dated 7/23/15, included the following:

The patient's mother provided us with documentation that there is in fact a guardianship with a Rogers treatment plan, the mother is the monitor of the Rogers treatment plan and permanent guardian. It did not contain the three antipsychotic medications Patient #15 was currently receiving: Haloperidol, Quetiapine, and loxitane (as needed). Together with the hospital attorney and the mother/guardian, she agreed it would not be in her child's best interest to take him/her off the current medications at this time. Instead we (the facility) will pursue a revision of the treatment plan to include them.


On 11/4/15, during further review of the clinical record, there was no evidence that a revision (amendment) of the Rogers treatment plan had been submitted to the court for review.


During interview on 11/4/15 at 10:30 A.M., Physician #6 said that Patient #15 had recently become his patient. He said that he recalls the patient was admitted in 7/2015, he/she was admitted on Haloperidol and Quetiapine. He said approximately 2 weeks after admission the patient's mother (who is also the court appointed guardian and Rogers treatment plan monitor) brought in all the legal paperwork, which included the Rogers treatment plan. Physician #6 continued to say that the patient's mother/guardian agreed to keep the patient on the medications he/she was currently receiving (despite the court ordered Rogers treatment plan which did not include Haloperidol or Quetiapine).

During interview on 11/14/15 11:00 A.M., Physician #6 returned and said he followed up and per the hospital legal department, the changes to the court ordered Rogers treatment plan would take place when the hospital filed for the annual review in 1/2016.

The hospital failed to ensure an amendment to the Rogers treatment plan was obtained in 7/2015.

Based on observation, record review and staff interview, the hospital failed to ensure a safe environment by allowing 1 patient (#9) with aggressive behaviors to be in the possession of a hypodermic needle and syringe, out of a total sample of 37 patients.

Patient #9 was admitted to the hospital in 7/2015, with diagnoses which included schizoaffective disorder, personality disorder and insulin dependent diabetes. The patient is alert and oriented.

Review of the patient's clinical record included the following progress notes:

8/28/15 Placed in four point restraints for pushing a female staff person hard up against the wall with intent to hurt.
9/16/15 Punched wall, hurting his/her right hand.
9/23/15 Placed in four point restraints for throwing a chair against the wall and punching a mental health worker (MHW) in the stomach.

Review of the most current master treatment plan, dated 10/30/15, included the following:
* Behavioral Issues-Intrusive, provocative. None this month.
* Risk Management-History of sexually problematic and violent behaviors.
* Insight/Judgement-Limited insight, poor judgement.


On 11/2/15 at 4:15 P.M., during medication observation, Nurse #11 was positioned inside the medication administration room with the upper half of a door opened into a main corridor for patients to come and receive their medications.

Patient #9 walked up to the other side of the half door and Nurse #11 handed him/her a lancet (sharp metal object). Patient #9 then pricked his/her finger and performed a blood glucose test. Patient #9 returned the used lancet to Nurse #11. Nurse #11 handed Patient #9 a hypodermic needle/syringe, alcohol prep pad and a vial of insulin. The patient prepared the insulin, and injected the insulin into his abdomen. During this procedure another patient was standing directly behind Patient #9.

During interview on 11/3/15 at 8:45 A.M., Charge Nurse (CN) #12 said that Patient #9 does not self-administer his/her own insulin and if he/she did, it would have to be done in a private safe environment, not in a hallway with other patients close by because of Patient #9's unpredictable behavior and history of assaulting other people.

Based on observation, record review and interview, the Hospital failed to ensure that one applicable patient (#28), in a total sample of 37, did not have restraints imposed as a means of convenience for staff and once imposed, the restraint was discontinued at the earliest time possible. Findings include:

Patient #28, was a non-English speaking patient with diagnosis of respiratory failure, Alzheimer's dementia and psychosis who had a tracheostomy and a gastrostomy tube (GT) for feeding.

The Hospital policy for mechanical and physical restraints, last reviewed on 8/2006, stated mechanical and physical restraints may only be used in cases of emergency such as the occurrence of/or serious threat of personal injury, extreme violence or attempted suicide. The physician's assessment of the need for restraints must be documented in the patient's chart on the seclusion/ restraint order form and, at a minimum, should include the following; date and time of assessment, description of the emergency situation, nature of the restraint, reason for the continuation of the restraints and clinical indications for the type of restraint selected. Restraint/seclusion orders may not exceed 24 hours without written approval of the administrator. The policy for nursing care of the patient in mechanical/physical restraints indicated the patient required one to one supervision to be maintained at all times. The patient must remain in full view of the one-to-one staff person at all times.

On 11/9/15 at 10:30 A.M., the Surveyor observed the patient to be in bed with bilateral wrist restraints on, that were tied to the bed frame. There were matts on the floor on both sides of the bed and no staff was observed to be supervising the patient, who was in a private room.

On 11/9/15 at 1:30 P.M., the patient was observed out of bed in the bedside chair with a vest restraint on and no wrist restraints. Again there was no staff supervising the patient.

Review of the daily physician orders for restraints from 10/20/15 through 11/10/15 indicated a new order was stamped in the record by the Registered Nurse (RN) every day at 9:00 A.M., for soft wrists/Posey vest and mitten restraints for safety. There was no indication when each restraint should be used or for how long. The stamped order was signed but not timed, later by the rounding practitioner.

Review of the restraint assessment, dated 10/29/15, indicated the restraints were used to prevent the patient from pulling at the GT and trach. Record review of respiratory notes indicated the tracheostomy had been removed on 11/3/15 and the patient only had a stoma (hole in neck). No new restraint assessment had been done to address the patient's change in status.

During an interview on 11/9/15 at 11:00 A.M., Registered Nurse (RN) #4 said all the ordered restraints are in place to be used "if needed them". RN #4 said that staff could choose the most appropriate restraint to use for the given situation. RN #4 said the patient doesn't need mittens or wrist restraints all the time and only used the vest when out of bed in the chair because she/he tried to get up without help. RN #4 said that staff were using restraints on an as needed basis and orders were obtained in a fashion so nurses could chose what type of restraint they felt was needed based on the situation.

Based on observation, record review and interview, the Hospital staff failed to determine the least restrictive alternatives to mechanical restraint for one applicable patient (#28), in a total sample of 37. Findings include;

Patient #28, was a non-English speaking patient with diagnosis of respiratory failure, Alzheimer's dementia, psychosis who had a tracheostomy and a gastrostomy tube for feeding.

On 11/9/15 at 10:30 A.M., the Surveyor observed the patient to be in bed with bilateral wrist restraints on that were tied to the bed frame. On 11/9/15 at 1:30 P.M., the patient was observed out of bed in the bedside chair with a vest restraint on and no wrist restraints. No staff was observed supervising the patient.

Review of the restraint assessment,dated 10/29/15, indicated the restraints were used to prevent the patient from pulling at the GT and trach. The least restrictive alternative listed as "verbal redirection."

During an interview, on 11/10/15 at 9:15 A.M., the charge nurse, RN #7, said staff did not speak the patient's language so they could not verbally redirect him and that no other less restrictive alternative, such as a abdominal binder, had been determined to be ineffective. RN #7 said the pulling of the tracheostomy tube was no longer a problem and should have been reassessed in relation to the patient's use of restraints.

Based on observation record review and interview, the hospital staff failed to implement its restraint policy for one applicable Patient #28, who was in mechanical restraints, in a total sample of 37, by not providing one-on-one supervision for the patient while in restraint, not using restraints in an "as needed" manner, failing to reassess the time, duration and reasons for the restraint, not obtaining consent from the administrator for use of restraints for 24 hours and failed to determine a less restrictive alternative to mechanical/physical restraints. Findings include:

Patient #28, was a non-English speaking patient with diagnosis of respiratory failure, Alzheimer's dementia, psychosis who had a tracheostomy and a gastrostomy tube for feeding.

The Hospital policy for mechanical restraints, last reviewed on 8/2006, stated mechanical and physical restraint may only be used in cases of emergency such as the occurrence of/or serious threat of personal injury, extreme violence or attempted suicide. The physician's assessment of the need for restraints must be documented in the patient's chart on the seclusion/ restraint order form and, at a minimum, should include the following; date and time of assessment, description of the emergency situation, nature of the restraint, reason for the continuation of the restraints and clinical indications for the type of restraint selected. Restraint/seclusion orders may not exceed 24 hours without written approval of the administrator. Nursing care of the patient in mechanical is restraints indicates the patient requires one to one supervision to be maintained at all times. The patient must remain in full view of the one-to-one staff person at all times.

On 11/9/15 at 10:30 A.M., the Surveyor observed the patient to be in bed with bilateral wrist restraints on that were tied to the bed frame. On 11/9/15 at 1:30 P.M., the patient was observed out of bed in the bedside chair with a vest restraint on and no wrist restraints. No staff were observed to be supervising the patient while he/she was in restraints according to hospital policy.

Review of the physician orders for restraints from 10/20/15 through 11/10/15 indicated a new order was stamped and completed by the nurse every day at 9:00 A.M. for soft wrists/Posey vest and mitten restraints for safety. The order was signed but not dated by the rounding practitioner each morning. According to the policy the order was the reassessment but the stamped order did not given any clinical indication when each restraint should be used or for how long. The order stated use for "safety."

There was no evidence in the clinical record that the administrator had granted approval for the use of 24 hour restraints per the policy.

Review of the restraint assessment,dated 10/29/15, indicated the restraints were used to prevent the patient from pulling at the GT and trach. Record review also indicated the tracheostomy had been removed on 11/3/15 and the patient only had a stoma (hole in neck). No new restraint assessment had been done to address the patient's change in status.

During an interview on 11/9/15 at 11:00 A.M., Registered Nurse (RN) #4 said all the ordered restraints are in place to be used if needed. Staff can choose the most appropriate restraint to use for the given situation. RN #4 said the patient doesn't need mittens or wrist restraints all the time. RN #4 said that the rounding practitioner signed the stamped orders but did not time the orders. RN#4 said she did not know about the need for any documentation from the administrator for the use of 24 hour restraint.

Based on observation, record review and interview, the hospital staff implemented mechanical restraints for one applicable Patient (#28), in a total sample of 37, using a standing order philosophy in which staff used their choice of restraints on an as-needed basis. Findings include:

The Hospital policy for mechanical restraints, last reviewed on 8/2006, stated orders for mechanical or physical restraint will not be written as P.R.N." or "as required."

On 11/9/15 at 10:30 A.M., the Surveyor observed Patient #28 to be in bed with bilateral wrist restraints on that were tied to the bed frame. On 11/9/15 at 1:30 P.M., the patient was observed out of bed in the bedside chair with a vest restraint on and no wrist restraints. No staff were observed during this time to be supervising the patient while he/she was in restraints per the hospital policy.

Review of the physician orders for restraints from 10/20/15 through 11/10/15 indicated a new order was stamped on the physician order sheet every day at 9:00 A.M., for soft wrists/Posey vest and mitten restraints for safety. The order was signed but not dated by the rounding practitioner each morning. According to the policy the order was the reassessment but the stamped order did not given any clinical indication when each restraint should be used or for how long. The order stated use for "safety."

During an interview on 11/9/15 at 11:00 A.M., Registered Nurse (RN) #4 said all the ordered restraints are in place to be used if needed. Staff can choose the most appropriate restraint to use for the given situation. RN #4 said the patient doesn't need mittens or wrist restraints all the time.

Based on observation and staff interview, the Hospital failed to provide evidence that the (QAPI) Quality Assessment and Performance Improvement Program was an ongoing program that shows measurable improvement in Quality Indicators to improve health outcomes and quality of life for the patients in the areas of infection control, medication errors, falls, wound prevention and storage of medications and expired medications.

On 11/10/15 at 1:00 P.M., the surveyor requested that the two Hospital identified Directors Of Nursing (DONs), one from the Department of Public Health (DPH) side and one from the Department of Mental Health (DMH) side of the Hospital, attend a QAPI discussion with the Surveyor.

During discussion, the DPH DON and DMH DON told the Surveyor that both departments rarely meet together to discuss common issues, nor do they always have the same Quality Indicators. They told the Surveyor that the 2 departments meet separately for quality assurance/performance improvement issues.

The DPH DON told the surveyor that she had been conducting audits on handwashing and changing gloves, and that the audits indicated there were no issues; however during the survey, there were numerous observations of staff not changing gloves or handwashing between tasks on all units. The DPH DON told the surveyor that obviously the audits were inaccurate and that there would be new observation infection control audit tools developed as soon as possible to ensure accuracy and completeness.

Further review of the QAPI minutes also indicated that there was no evidence that the storage of medications and expired medications were discussed at the meetings despite there being numerous expired items found during the survey that had been expired for months.

Review of QAPI minutes indicated there was no performance improvement plans in place to reduce the number of medication errors. The QAPI minutes indicated the Hospital had an increase in the number of medication errors from 7/2015 to the present. Review of QAPI minutes indicated there was no plan in place to reduce the number of medication errors globally throughout the Hospital.

Further discussion with the DONs indicated that the DMH units had no data collection regarding wound care and falls. On 11/10/15 at 1:25 P.M., during interview, the DMH DON told the surveyor that tracking and trending of pressure sores and falls were not discussed at their (separate) meetings. The DMH DON said that the emphasis is on behaviors and that the patient as a whole is not closely looked at. He also told the surveyor that he did not know where all the past QAPI meeting minutes were filed because he was new in this position. The DMH QAPI minutes could not be located during the survey for review.

See A-396 regarding pressure sores

On 11/10/15 at 2:15 P.M., both DONs said that the two QAPI programs have never been integrated.

Based on interview, medication administration observations and techniques of numerous staff members, the Hospital failed to ensure that medication errors and poor techniques during medication administration were identified and analyzed for a cause, and that effective preventative actions and mechanisms with feedback and education throughout the hospital were conducted through the QAPI (Quality Assessment and Performance Improvement) Program with an emphasis on patient safety.

During discussion on 11/10/15 at 1:45 P.M., the DPH and DMH Directors of Nursing (DONs) told the Surveyor that there was no evidence of medication administration audits or documented education. The DONs said that medication errors are brought to QAPI and discussed, but that there is no evidence of hospital wide education. They told the surveyor that each individual is educated, but then no follow-up is done, such as observations of medication passes. Both DONs said that there are issues every month with medication errors and that there has been an increase since 7/2015.

Please refer to A-0405.

Based on staff interview and review of hospital documentation, the hospital failed to ensure that there was only one Director of Nursing services who is responsible to oversee the nursing care to all areas of the hospital.

Review of 2 Organizational Charts and the Hospital's Inter-departmental Contact List provided to the surveyors, indicated the Hospital was divided into 2 areas:
- Metro Boston Mental Health Units (MBMHU) and
- DPH (Department of Public Health)

Each of the above had there own separate Organizational Charts with 2 separate Directors' of Nursing (DONs).

During discussion on 11/3/15 at 8:00 A.M., the DON of DPH said that she is the DON of only the DPH side and does not become involved with the MBMHU side of the hospital, and visa versa.

During discussion on 11/5/15 at 7:15 A.M., the DPH DON told the surveyor that she is responsible for the unit Managers accountability and meets with all the DPH managers weekly. The DPH DON also said that she calls her units daily for the current census and new admissions to determine staffing needs for the DPH units.

During discussion on 11/10/15 at 11:00 A.M., the Chief Operating Officer (COO) for MBMHU, and the hospital's interim Chief Executive Officer (CEO) told the surveyors that there are two separate entities in the hospital each with their own DONs with separate policies and procedures. They told the surveyors that this is an issue that will be examined and corrected.

On 11/10/15 the surveyor requested a meeting with both DONs at 1:00 P.M. Both DONs indicated that each one of their departments are run differently from one another and that each DON is not aware of the others policies and procedures.

Based on observation, record review and interview the hospital failed to provide adequate nursing staff to meet the needs of patients as evidenced by failure to provide safe patient care and failure to implement hospital policy and procedure due to lack of adequate staffing. Findings include:

1. There was insufficient staff to monitor the integrity of sterile fields in the operating rooms.

On 11/03/15 between 9:30 and 11:00 A.M., the Surveyor observed that operating room (OR) suite #2 had the sterile field set up for the orthopedic case scheduled as the surgeon's third case of the day. The sterile field was covered in blue drapes and was not monitored by anyone. Staff, such as the anesthesiologist, were observed to enter and leave the OR room #2 during the two hour period.

On 11/4/15 at 8:00 A.M., the surveyor observed OR room #1 to have the sterile field set up and covered with blue drapes without being monitored by staff. The patient was not brought to the room for surgery until 8:44 A.M.

Review of the nursing schedules for the OR indicated there were nine registered nurses, two who were nurse managers (NM) and six Registered Nurse (RNs) who served as circulators and scrub nurses for three active operating suites. During the week of November 2 through 11/06/15 one RN was on vacation and one RN only worked three days a week (MWF).This left only 3 RNs to act as scrub and circulating nurse for 3 ORs on 11/3 and 11/5 and 4 RN's. During an interview, on 11/4/15 at 8:00 A.M., the OR nurse manager said she assists in the OR by giving relief, acting as a runner for items needed during a case and helping with patients in the room.

Review of the Hospital OR policy, titled "Preparing, Maintaining and Monitoring a Sterile Field", last revised on 3/15, the policy indicated that sterile fields will be constantly monitored and once created a sterile field will not be left unattended until the operative or other invasive procedure is completed. The policy also indicated when there is an unanticipated delay or during periods of increased activities such as patient transfer to the procedural bed, a sterile field that has been prepared and will not be immediately used may be covered with a sterile drape.

During an interview on 11/5/15 at approximately 8:00 A.M., the OR Nurse Manager said they do not have enough staff to prepare the sterile fields just prior to surgery or to monitor the covered sterile field once it is set up. The OR NM said the policy dies say that sterile fields will be constantly monitored and not left unattended and does not allow for covered fields to be left unmonitored.


2. There was insufficient staff to monitor telemetry patients.

The 7 North and has four telemetry ( cardiac arrthymia) beds that are monitored in the ICU (Intensive Care Unit) unit on the 3rd floor. In the 7 North nurses station is a telephone dedicated to the telemetry monitoring communication with the ICU, as explained by the Nurse Manager (NM) of the 7 North unit on 11/2/15 at 9 AM. The NM said that someone is always in the nurses' station to take the call from the ICU should there be any problems with patients on telemetry.

On 11/5/15 at 12:00 P.M., the Surveyor observed only one nurse at the 7 North nursing station. Several call bells were ringing and there were no staff responding. The nurse said to the Surveyor "I have to respond to some call bells I will be back shortly" and left the nursing station. A few minutes later the telemetry phone began to ring and rang 8 times. The nurse did not return to answer it.

There was one patient on the unit identified as being on telemetry who recently transferred from the ICU.

When the nurse returned, she said staff were at lunch or break but there was a nurse documenting in the medication room. The surveyor said no one answered the telemetry phone after 8 rings. The nurse said there was only one telemetry phone and it was the one at the nurses' station.

Based on observation, record review and staff interview, the hospital failed to ensure that a registered nurse (RN) evaluated the nursing care for two sampled patients (#13 and #27), in a total of 37 sampled patients, to ensure that patients received care in accordance with hospital policy and procedure, to prevent physical decline and/or to ensure evaluation care and response to nursing interventions were initiated. Findings include:

1. For Patient #13, the facility failed to evaluate for a decline in swallowing, mobility (wheelchair bound) and weight loss. Patient #13 developed a pressure ulcer.

Patient #13 was admitted to the facility in 11/2013 with diagnoses of paranoid schizophrenia, dysphasia and severe dementia.

Review of the clinical record (Nursing Notes) indicated that on admission, the patient's skin was intact, weight was stable, and the patient was able to ambulate on the unit. The continence status upon admission is not known, it was not assessed.

A Physical Therapy note of 2/27/15 indicated the patient was wheelchair bound and was issued a cushion at that time; however, the patient would remove the cushion (ineffective intervention).

Review of the Monthly Weight Record for Patient #13 indicated there were no recorded weights for 3/2015, 4/2015, or 5/2015. In 7/2015 the weight was 172.8. There were no further weights until the Surveyor asked the Nurse #17 what the patient's current weight was. Nurse #17 said the patient would be weighed today (4 months since the last recorded weight, and not monthly per Physician's admission order). Nurse #18 told the Surveyor that the patient would be seen by the Nutritionist.

Review of the Monthly Update of 9/25/15 (Care Plan) indicated the patient had "some ambulation" skills, and that the patient was receiving total care for activities of daily living, and required the use of a wheelchair (decline in mobility). The main issues on the Update were Guardianship and that the patient would "participate in routine and necessary medical treatment/assessments as recommended by the team." There was no care plan regarding the decline in mobility or incontinence episodes.

Review of a Hospital Wound Management Consult Report of 10/26/15 indicated that a new pressure sore was found on the patient's left buttock. The patient had been complaining of pain in that area for approximately 7-10 days. The facility obtained an order for an x-ray, which was negative. Staff then found an area on the left buttock where the patient had complained of pain.

The 10/26/15 Wound Consult indicated the patient, "was found to have an open lesion on the left buttock. He/she has a 1 (cm.) centimeter x 1 cm. stage II pressure ulcer on the left ischial area..." The consultant indicated the wound bed was covered with superficial yellow necrotic tissues (inability to assess the wound bed is an indication that the wound is unstageable, not a stage II according to Federal Pressure Ulcer Guidelines.

The Wound Consultant recommended:
- apply the debriding agent Santyl and the anti-infective ointment Bactroban to the wound, then cover with a foam dressing.
- Apply a pressure relief cushion on the wheelchair.
- Apply a pressure-relief mattress on the bed.

Review of the Unit's Initial Assessment (11/2015) and Monthly Updates indicated that the nursing assessments did not include skin breakdown risk, incontinence, and the weights were not recorded.

A Nutrition Note of 11/4/15 indicated that Patient #13's November weight was 166.7 which is a significant weight loss of 4.8% in 4 months. The previous weight was 172.8 pounds in 7/2015. The Nutritionist indicated that Magic Cups (nutritional supplements) would be added to meals twice daily, and would consider weekly weights for nutrition assessment purposes.

During interview on 11/5/15, the Director of Nursing (DON) on the DMH (Department of Mental Health) side of the Hospital said that he is now "totally aware that staff missed the nursing piece of the program", and that Patient #13's pressure sore was preventable.

Please refer to A-0396.




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2. According to the hospital policy for enteral feeding or tube feeding, last updated in 6/2015 prior to administering medications or for feeding and flushes staff are to check the patency and positioning of the Gastrostomy (GT). They are to do this by removing the plug or cap from the tube and using a syringe, inject 10 mL of air through the tube, at the same time, auscultate the patient's stomach with a stethoscope and listen for a whooshing sound to confirm the position of the tube in the stomach. Staff should also aspirate stomach contents to confirm patency and placement. Medications can be administered through the feeding tube. Crushed tablets or open capsules and dilute in water before administering them. Flush the tubing afterwards to ensure full installation of medications.

For Patient # 27, the hospital staff failed to check the placement of the G/JT tube prior to administering medications.

During the med pass observation on 11/3/15, at 2:00 P.M. , the Surveyor observed RN #6 administer medications to Patient # 27. Patient # 27 received medications via a gastrostomy tube (GT). The patient is also on droplet and contact precautions. RN #6 was observed to pour Midodrine 5 mg one tablet and crush it; poured Reglan 10 mg per 10 cc's and drew up 5 cc's into a syringe and then labeled the syringe.

Patient #27's GT tube is a double lumen GT/ jejunostomy tube(JT). Only the JT is used for medications and feeding per review of the physician's order. During the medication administration, RN #6 was not observed to check placement of the tube by either listening to air introduced into the stomach with a stethoscope or by aspiration of stomach contents.

When asked, at the end of the medication pass, RN #6 said that she was not sure what the policy was for checking placement of the JT part of the double lumen tube.

On 11/3/15 at 12:00 P.M., the policy for checking or position of the J-tube was requested from the Director of Nursing (DNS). At 3:00 P.M., on 11/03/15, the DNS said there was no written policy related to assessing the J-tube placement so the nursing service refers to the Clinical Nursing Skills Manual by Smith, Druel and Martin, Eighth Edition. Review of the manual with the DNS indicated that staff are to check the residual volume of the J-tube regularly. If the J-tube residual volume is greater than 50 mL it may indicate displacement of the J-tube upward from the bowel into the stomach. If this occurs, the physician should be immediately notified.

The DNS said the nurse should have checked the placement of the J-tube prior to administration of medications.

Based on record review, policy review and staff interview, the Hospital failed to ensure that 2 patients (#9 and #13), in a total sample of 37 patients, had care plans developed regarding self administration of medications and the development of pressures sores. Findings include:

1. Patient #9 was admitted to the hospital 7/2015, with diagnoses which included schizoaffective disorder, personality disorder and insulin dependent diabetes. The patient is alert and oriented.

Review of the patient's Master Treatment Plan, dated 10/30/15, included the following:
Medical Issue: Diabetes, hyperlipidemia
What will patient do? Patient needs to take medications as prescribed and follow recommended diabetic diet and treatment.
What will staff do? Nursing will administer medications, test finger sticks twice a day and monitor for glycemia and address per sliding scale as needed.
* Insight/Judgement-Limited insight, poor judgement.

On 11/2/15 at 4:15 P.M., during medication observation, Patient #9 was observed self-administering his/her insulin injection and performing his/her own blood glucose fingerstick.

During interview on 11/2/15 at 4:30 P.M., Nurse # 11 said that Patient #9 likes do give him/herself the insulin injection, and she doesn't want to argue with him/her. The surveyor asked if Patient #9 had been assessed to ensure he/she could competently perform this procedure, Nurse #11 said she wasn't sure, but the patient did okay.

During interview on 11/3/15 at 8:45 A.M., Charge Nurse (CN) #12 said that Patient #9 does not self-administer his/her own insulin and if he/she did, it would have to be done in a private safe environment, not in a hallway with other patients close by because of his/her unpredictable behavior. When the surveyor told Nurse #12 that Patient #9 performed his/her own blood glucose testing and insulin administration last evening, CN #12 said he had never seen Patient #9 do it. CN #12 said that a care plan for self administration of medications was not developed for this patient.





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2. For Patient #13, the Hospital failed to identify and care plan the risk of pressure sores such as, weight loss, decline activities of daily living including mobility, and incontinence of bowel and bladder. As a result, Patient #13 developed a unstageable pressure sore on the left buttock/ischial area measuring 1.0 x 1.0 centimeters.

Review of the 10/13/15 Monthly Update had no changes except that the patient was attending social/recreational activities. There was no care plan regarding the patient's decline in mobility or incontinent episodes (increased risk for the development of pressure sores).

During interview on 11/5/15, the Director of Nursing (DON) on the DMH (Department of Mental Health) side of the hospital was in agreement with the Surveyor's findings. He said that he is now "totally aware that staff missed the nursing piece of the program", and that Patient #13's pressure sore was preventable.

Based on observation, record review and staff interview, the Hospital failed to ensure that for five sampled patients (#11, #13, #27, #28 and #35), in a total sample of 37 and for five out of ten non-sampled patients (NS #A, NS #B, NS #H, NS #I and NS #J), licensed staff prepared and administered medications according to the orders of the practitioner responsible for patients' care and accepted standards of practice. Findings include:

1. For Patient #13, the facility failed to obtain a medication order to ensure that the enteric coated (not able to be crushed) medication Ferrous Sulfate was not crushed.

Patient #13 was admitted to the hospital in 11/1013. Diagnoses include: anemia, severe dementia and paranoid schizophrenia.

During review of the patient's clinical record, the Surveyor observed that there was a Physician's order to crush all of the patient's medications. The Surveyor also observed that Patient #13 was receiving the medication Ferrous Sulfate 324 milligrams (mg) daily. Ferrous Sulfate is enteric coated and is designated as non-crushable on the label.

On 11/3/15 at 12:10 P.M., during interview, Nurse #17 said that Patient #13 was receiving Ferrous Sulfate and that the enteric coated medication was being "crushed anyways."

On 11/3/15, the Physician was notified regarding the enteric coated form of Ferrous Sulfate being crushed for Patient #13. The Physician ordered that the Ferrous Sulfate be discontinued, due to the patient's anemia being stable.

2. For Patient #11, the facility failed to medicate the patient as ordered prior to a dialysis treatment.

Patient #11 was admitted to the hospital in 10/2015. Diagnoses included end stage renal disease,requiring hemodialysis, pleural effusion, fluid leakage secondary to diaphragm leak and a chest tube.

During observation and interview on 11/04/15 at 9:30 A.M., Patient #11 said that he/she always is given the narcotic pain relieving medication Oxycodone at 8:00 A.M., for pain where the chest tube had been inserted.

Review of the current Physician's order indicated that Patient #11 was to receive Oxycodone 25 mg. by mouth three times daily for left chest wall pain.

During interview on 11/4/15 at 9:50 A.M. Nurse #15 ( hemodialysis nurse) said that she called the nursing unit and spoke with Patient #11's nurse. Nurse #15 said she asked the unit nurse to bring the patient's pain medication to the dialysis unit. Nurse #15 said to the Surveyor that the patient will receive the medication upon return to the nursing unit after dialysis. Nurse #15 continued to say she would call the pharmacy and have the Oxycodone placed in the Pyxis machine (medication distribution center), and that she would administer the Oxycodone to Patient #11.

On 11/4/15 at 10:00 A.M. the Surveyor observed Nurse #15 administer the Oxycodone medication to Patient #11, two hours later than when the patient requested it.



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3. For Patient #28, the Hospital staff administered liquid Colace without a complete order for amount to be administered.

The hospital policy for medication administration stated that a complete medication order contains the medication name, route, dose, frequency and right patient for which the medication is ordered.

Review of the Medication Administration Records (MAR) for October and November 2015 indicated Patient #28 was to receive Colace liquid twice a day through the gastrostomy (GT). Nursing staff signed off administering Colace twice a day for both despite the fact that no amount of the drug was specified on the MAR to be given such as 10 cc's or 100 milligrams.

Review of the physician's order for Colace also lacked the amount of Colace to be administered.

During an interview, on 11/9/15 at 10:00 A.M., RN #7 said the order was not complete and she did not know how much the patient was to be getting but would clarify it with the physician. RN #4, also present during the interview with RN #7, said she had been giving 10 cc' s or 100 milligrams(mgs.).

4. According to the hospital policy for the Administration of Medications, last updated on June 2015, if medications are to be administered intravenously (IV) and or via the enteral route (NGT/GT/JT), by irrigations or by peritoneal dialysis (CAPD), two (2) licensed staff must reconcile/trace the tubing to ensure accuracy of the route of administration. Staff are to check the medication against the MAR three times after removing it from the Pyxis and before placing it in the medication cup for delivery to the patient. The MAR must be brought to the patient's room when medications are to be administered to the patient.

During a medication pass on 11/2/15 at 2:00 P.M., the Surveyor observed RN #22 prepare Methadone 10 milligrams (mgs), Neurontin 1200 mgs, Dilaudid 2 mgs for Non-sampled patient (NS) #A. NS#A was also to receive Cefazolin, 2 grams (g), in 50 cubic centimeters (cc's) of D 5 W, intravenously (IV). The Surveyor observed that RN #22 did not check the pills three times against the MAR per the medication policy, when she removed them from the automated medication system (Pyxis) and placed them in the medication cup . The Surveyor followed RN #22 to NS#A's room and observed the RN did not take the MAR into the patient's room per the medication policy. NS#A took the oral medications and the nurse hung the intravenous medication without another nurse to check the IV to ensure accuracy of the route of administration per the policy.

5. The Surveyor observed RN # 23 on 11/2/15, at approximately 2:10 P.M. , prepare Nafcillin, 2 g IV, for Non-sampled Patient #B. The Surveyor observed RN # 23 take the medication to the patient's bedside. The patient refused the IV medication however, there was not a second RN with RN #23, to check the IV to ensure accuracy of the route of administration per the policy should the patient have accepted the medication.

6. During the med pass observation on 11/3/15, at 2 PM, the Surveyor observed RN #6 administer medications to Patient #27. Patient # 27 received his/her medications via a gastrostomy tube. The patient is also on droplet and contact precautions. RN #6 was observed to pour Midodrine 5 mg one tablet and crush it; pour Reglan 10 mg per 10 cc's into a cup and draw up 5 cc's into a syringe and then labeled it.

Patient #27's GT tube is a double lumen GT/ jejunostomy tube (JT). Only the JT is used for medications and feeding per review of the physician's order. During the medication administration, RN #6 was not observed to check placement of the tube by either listening after instillation of air into the stomach or aspirating stomach contents. No other nurse was observed to check the j-tube per policy to ensure accuracy of the route of administration.


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7. For NS #H, NS #I and Patient #35, the hospital staff failed to follow the hospital medication administration policy by not documenting medications given in the Medication Administration Record (MAR) when administer. For example:

Review of the hospital policy, titled, Administration of Medications, updated 6/2015, indicated that the nurse must document the administration of medication immediately after it is administered, by noting initials beside the time of day the medication was administered.

A. During the med pass observation on 11/2/15 at 3:45 P.M., the Surveyor observed Nurse #14 administer the following medications for Non-Sampled Patient H (NS H):
Metformin 1,000 mg by mouth.

Nurse #14 took a medicine cup out of the medication drawer (which contained the prepackaged Metformin), removed the medication from the packaging and administered the Metformin to NS H. Nurse #14 performed hand hygiene and without documenting the administration in the MAR, began to administer medication to another patient.

B. During the med pass observation on 11/2/15 at 3:50 P.M., the surveyor observed Nurse #14 administer the following medications for Patient #35:
Sulfasalazine 500 mg tab give 1,000 mg (2 tablets) by mouth four times a day.

Nurse #14 took a medicine cup out of the medication drawer (which contained the prepackaged sulfasalazine), removed the medication from the packaging and administered the sulfasalazine to Patient #35. Nurse #14 performed hand hygiene and without documenting the administration in the MAR, began to administer medication to another patient.

C. During the med pass observation on 11/2/15 at 4:00 P.M., the surveyor observed Nurse #14 administer the following medications for Non-Sampled Patient I (NS #I):

Baclofen 10 mg give 20 mg two tablets by mouth three times a day
Gabapentin 100 mg 1 capsule by moth three times a day
Perphenazine 4 mg one tablet by mouth three times a day
Perphenazine 8 mg one tablet by mouth three times a day
Nurse #14 took a medicine cup out of the medication drawer (which contained the prepackaged Baclofen, perphenazine), removed the medication from the packaging and administered the sulfasalazine to NS # I. Nurse #14 performed hand hygiene and began to open the medication drawer to administer medication to another patient.

During interview on 11/2/15 at 4:10 P.M., Nurse #14 said that the patients are in a rush and don't want to wait. She said she signs off the MAR after she completes her medication pass.

10. During a medication pass observation, on 11/4/15 at 8:30 A.M., in the dialysis unit, Nurse #15, was preparing the following mediation for Non-Sampled Patient # J:
CathFlo (medication used to restore function of a clotted central venous access device) 2 mg/2.2 ml sterile water.

Nurse #15 gathered her supplies to prepare the medication which included a needle/syringe, alcohol prep and the CathFlo and sterile water. Nurse #15 placed these items on the nurses station desk, which was cluttered with paper, office supplies and containers of medical supplies. Nurse #15 did not prepare the medications in the designated med prep area or disinfect the nurses desk prior to preparing the medication which could increase the risk of cross contamination.

During interview on 11/4/15 at 9:00 A.M., Nurse #15 said it was her first day in the hospital and was not aware that there was a medication prep area in the next room.

Based on record review and staff interview, the hospital failed to ensure one patient (#9), in a total sample of 37, was properly assessed to self administer medications.

Patient #9 was admitted to the hospital in 7/2015, with diagnoses which included schizoaffective disorder, personality disorder and insulin dependent diabetes. The patient is alert and oriented.

Review of the hospital policy, titled, Self Administration of Medication, dated 8/22/15, indicated the following:
A patient may self administer medications under the following conditions:
* A physician's order must state that the patient may self medicate.
* The medication is labeled with name, date, dosage, and time to be taken.
* All dose taken are recorded on the medication administration record and patient care plan for self-administration of medications.


Review of the physician orders, dated 10/2015, showed no evidence of a physician's order to self medicate.

Review of the patient's Master Treatment Plan, dated 10/30/15, included the following:
Medical Issue: Diabetes, hyperlipidemia
What will patient do? Patient needs to take medications as prescribed and follow recommended diabetic diet and treatment.

What will staff do? Nursing will administer medications, test finger sticks twice a day and monitor for glycemia and address per sliding scale as needed.
* Insight/Judgement-Limited insight, poor judgement.

On 11/2/15 at 4:15 P.M., during medication observation, Nurse #11 was positioned inside the medication administration room with the upper half of a door opened into a main corridor for patients to come and receive their medications.

Patient #9 walked up to the other side of the half door and Nurse #11 handed him/her a lancet (sharp metal object). Patient #9 then pricked his/her finger and performed a blood glucose test. Patient #9 returned the used lancet to Nurse #11. Nurse #11 handed Patient #9 a hypodermic needle/syringe, alcohol prep pad and a vial of insulin. The patient prepared the insulin, and injected the insulin into his abdomen. During this procedure another patient was standing directly behind Patient #9.

During interview on 11/2/15 at 4:30 P.M., Nurse # 11 said that Patient #9 likes to give him/herself the insulin injection, and she doesn't want to argue with him/her. The surveyor asked if Patient #9 had been assessed to ensure he/she could competently perform this procedure, Nurse #11 said she wasn't sure, but the patient did ok.

During interview on 11/3/15 at 8:45 A.M., Charge Nurse (CN) #12 said that Patient #9 does not self-administer his/her own insulin and if he/she did, it would have to be done in a private safe environment, not in a hallway with other patients close by because of Patient #9's unpredictable behavior. When the surveyor told CN #12 that Patient #9 performed his/her own blood glucose testing and insulin administration last evening, CN #12 said that he had never seen Patient #9 do it before.

Based on observation and interview, the hospital failed to ensure that drugs or biologicals were kept in a secure and in a locked area when appropriate.
The findings include:
On 11/4/15 at 1:45 P.M., during a tour of the Intensive Care Unit's (ICU) nursing station, the surveyor opened an unlocked cabinet and found the following:
* 1 vial of Meropenem 500 milligram (mg)
* 1 10 milliliter (ml) vial of sterile water
* 1 open vial of Novolog insulin
* 1 open vial of Novolin R insulin

During interview on 11/4/15 at 2:00 P.M., ICU Unit Manager said that all cabinets containing medications should be locked at all times. He continued to say that the nursing staff have keys to this closet.

Based on observation and interview, the Hospital failed to ensure anesthesia carts in the operating suite were kept locked within a secure area when they contained anesthesia medication kits with Schedule II, II, IV and V class drugs and medications drawn into syringes for impending cases. Findings include:

1. On 11/03/15 between 9:30 A.M. and 11:00 A.M., the Surveyor observed in OR room
#2, the anesthesia cart was unlocked and unattended. The anesthesia cart contained the anesthesia medication kit which contained Schedule II-V drugs such as but not limited to; Propofol, a sedative; Narcan , a reversal agent for opioid overdose; Lidocaine, a topical anesthetic; epinephrine, a vasopressor; heparin, a blood thinner; Labetalol, an antihypertensive medication; several paralytic agents; anti-inflammatory drugs, reversal agents for paralytic agents and inhalers for respiratory spasm. The cart was left unattended by any staff and not monitored by other personnel during this time.

2. On 11/4/15 at 8:00 A.M., the Surveyor observed that OR room #2 was set up with the sterile field covered and observed that the medication kit was in the unlocked anesthesia cart. The Surveyor opened the top drawer of the anesthesia cart and found Propofol (anesthetic/sedative) drawn into a syringe and labeled. There was approximately 20 cc's in the syringe. Anesthesiologist #7 stated, during an interview on 11/4/15 at 8:30 A.M., that he had drawn up the Propofol and left it in the unlocked drawer. He said the carts were not locked because no one had keys and that the carts were safe within the OR. He said he was in doing another case and had set up the cart for the case pending in OR #2.

3. During an interview, on 11/3/15 at 2:45 PM, the Chief of Anesthesia stated that keys to the anesthesia carts get lost so they did not lock the anesthesia carts because he felt they were safe within the OR suite. The Chief of Anesthesia stated he signs out all the narcotics and that the medication kits are signed out by an anesthesia technician who puts the kits on the anesthesia carts.

Based on record review, observation and interview, the facility failed to ensure that for two of six nonsampled patients (NS E and NS F), outdated, mislabeled, or otherwise unusable drugs and biologicals were not available for patient use.

Findings include:

1. During the initial tour of the facility's 5 North Unit on 11/2/15 at 9:30 AM., 4 vials of insulin were in use that were past their listed expiration dates.

a. For Non-Sampled E, vials of Lantus insulin and Novolog insulin were dated by facility staff as expiring on 10/26/15. Per review of the medication administration record in the presence of the 5 North Unit Manager, NS E was administered both types of insulin on, at minimum, a daily basis. The 5 North Unit Manager said that there were no other vials of insulin that could have been used between 10/26/15 and 11/2/15 and that the patient was administered the expired insulin from both vials.

b. For Non-Sampled Patient F, vials of Lantus insulin and Novolog insulin were dated by facility staff as expiring on 10/30/15. Per review of the medication administration record in the presence of the 5 North Unit Manager, NS F was administered both types of insulin on, at minimum, a daily basis. The 5 North Unit Manager said that there were no other vials of insulin that could have been used between 10/30/15 and 11/2/15 and that the patient was administered the expired insulin from both vials.

c. During interview on 11/2/15 at 9:30 AM., the 5 North Unit Manager said that it was the responsibility of the nursing staff to note the insulin expiration date, that was clearly labeled on a large red sticker on the vial of insulin, and call the pharmacy to get a refill.

d. During interview on 11/2/15 at 3:00 P.M., the facility Director of Pharmacy said that facility policy was that insulin was good at room temperature for 28 days once opened for administration and that the policy applied to all brands of insulin. The facility Director of Pharmacy said that it was the nursing staffs' responsibility to note the expiration dates and obtain refills from the pharmacy.



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2. During the initial tour of the Outpatient Department on 11/5/15, two 1000 milliliter (ml) bags of expired Lactated Ringers Solution were observed in the storage area. These bags of solution had expired on 8/2015 and 10/2015.

The Director of Outpatient Service confirmed the solutions were out of date and said on 11/5/15 at 10:30 A.M., that the nursing assistants were responsible for reviewing the stock solutions and pulling any outdated solutions from the stock shelves.



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3. On 11/4/15 at 1:45 P.M., during tour of the Intensive Care Unit (ICU), the Surveyor observed seven, 50 milliliter bags of 5% dextrose and water (D5W) for intravenous use with expiration dates of 8/2015.

During interview on 11/4/15 at 2:00 P.M., the ICU Unit Manager said that the hospital has a pharmacy technician that is supposed to removed all expired medications and that he must of missed the bags of D5W.

Based on observation and staff interview, the hospital failed to ensure that the condition of the physical plant and overall hospital environment was maintained in a manner to ensure the safety and well being of patients.

Findings include:

1. Observation on 11/2/15 and 11/5/15 and 11/9/15, of the 7 North and 7 South units (both respiratory care/ventilator units) indicated in 3 of 3 observed patient rooms on 7S, and 10 of 16 rooms on 7N with window air conditioners, the safety screens covering the windows in front of the AC units, were coated with a thick black substance. These rooms included rooms with patients who had tracheotomies, gastrostomy tubes for feeding, intravenous lines for hydration and open wounds. The air conditioner units were blowing air through the dirty screens directly onto the patients.

During an interview on 11/9/15 at 11:00 A.M., Environmental Services Worker #1 said that the screens were not on a regular cleaning schedule.

2. Observation of the operating (OR) rooms #1 and #2, on 11/03/15, indicated that the interior doors and door frames of the doors leading to the scrub sink hallway, were gauged and scraped and in disrepair. The condition of the doors made it impossible for operating room staff to terminally disinfect/sanitize the OR rooms.

3. Observation of the decontamination room for the gastrointestinal suite (GI) on 11/4/15 at 1:15 P.M., revealed that the paint around the window above the clean sink area was severely chipped and peeling. The paint could easily fall into the clean sink during decontamination of endoscopes causing an infection control or mechanical contamination problems during cleaning of the scopes.

On 11/4/15 at 1:15 P.M., during an interview, the SPD (Sterile Processing Department) supervisor said he had put in a work order two weeks ago for repair of the chipped paint area and was still waiting for maintenance to repair the window's chipped paint.

4. Observation of the female bathroom on 7 South on 11/16/15 at 1:30 P.M., indicated there was chipped paint on all the window frames and black substance under the chipped paint and in the shower tiles.



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5. On 11/9/15 observations of the following units, 6 South, 6 North and 10 South indicated the following:

On 6 South at 10:50 A.M.:

a. In the laundry room, the ceiling over the dryer, was bulging with large pieces of peeling paint. The security window screen behind the dryer had a build up dust. The dryer lint screen had a large build up of lint indicating it had not been cleaned after each use as per facility policy. The tub of the washing machine had instructions for cleaning after each use with a disinfectant spray. There was no disinfect spray available for the patients to use as per facility policy. Staff said that patients and family are allowed to wash thier own personal laundry items on each floor with staff permission.

b. In the large shower room on the T Wing, the ceiling had an area of peeling paint over the bath tub. The privacy curtains on the shower stalls had missing curtain hooks. The light bulbs were burnt out in 3 of the 3 shower stalls. In 2 of the 3 shower rooms, the shower drains were dirty with what appeared to be clumps of hair.

c. In the male and female shower rooms on the main wing, the privacy curtains had missing curtain hooks, with one shower hook replaced with a paper clip. The mirror in the male shower room, was damaged.

d. In the soiled utility room, there were missing floor tiles throughout the room. The condition of the floor prevented adequate cleaning. The cabinet drawers and the shelf were rusted. The door was scraped and gouged.

e. A patient room, used for patients on airborne precautions, (not occupied at time of survey) had a build up of dirt/dust on the window security screen. The window fan in the room had an excessive build up of dust. The window frame had chipped paint that was flaking off.

f. The housekeeping closet was unlocked, a germicidal cleaning agent, was stored in this unlocked closet.

On 6 North at 11:20 A.M.:

a. In the laundry room on the T Wing, the door was scraped and gouged. The window's security screen was dirt laden and dusty. The window frame had chipped paint and the window sill had a build up of paint chips. A faint odor of urine was detected and found to be coming from seizure pads, stored on the counter, that were labeled "clean, ready for use". The ceiling vent was dusty. The ceramic wall tiles were not in good repair with several tiles broken or cracked. The floor edges were dirty. The handwash sink dripped continuously.

b. The door to the soiled utility room had a door that was gouged and scraped.

c. The housekeeping closet was observed to be unlocked and contained food items, clothing, a cloth purse and other personal belongings that were stored with chemicals.

On 10 South at 2:30 P.M.:

a. In the soiled utility room on the T Wing, a ceiling light was burnt out. The window's security screen was dirt laden and dusty. There were two cardboard boxes stored on the floor.

b. In the laundry room, the handwash sink had no soap and no paper towels. The base of the faucet leaked. The window security screen was dirty and dusty. The laundry room door was scraped and gouged.

c. In the supply room, the security window screen was dirty and the ceiling vent was dusty.

d. In the male shower room, water was pooling on the floor. The floor was not even, so the water did not drain properly, resulting in the pooling of the water on the shower room floor. The female shower room had a window security screen and a fan that was laden with dust.

e. In the solarium, the heater cover, which had 2 screens/vents on top of the unit, was dirty with dust and food particles caked on top of the unit.

Based on observation and interview, the Hospital did not maintain the Food Service Department in a manner to ensure an acceptable level of safety and quality.

1. On 11/3/15 at 8:20 A.M., during a tour of the Food Service Department with the Food Service Operations Manager, the following was observed:

a. The Hospital failed to clean fans, fan covers and areas of high dust. The cook's box and the prepared food's walk-in refrigerators had fan blower covers that had a build up of dust and dirt. A fan on the counter in the sandwich preparation room and a large fan in the pot and pan area directed at the pot/pan sink were dusty. The electrical cords to the warmer and the tray line refrigerator that were plugged into overhead outlets had large amounts of dust present. Two electrical cords in the preparation area that were not connected to any equipment had a build up of dust.

b. The Hospital failed to maintain all the equipment in the food preparation area. A pipe to the steam kettle was dripping which allowed water to pool on the floor. Water was also pooling on the floor under the Steamer. A convection steamer was not working and the Operations Manager indicated that it had been out of service for a year. A padded cloth wrapped around a pipe in the food preparation area was torn and pulling away from the pipe. Leaking faucets were observed at the 3 bay sink and at the sink in the ingredient control room. The eye wash station had no caps to protect the eyewash spraying heads from dirt and splash. A floor drain in the ingredient control room had clogged earlier in the day and had been cleaned out that morning. However, the ingredient control room was odorous and the floor around the recently cleaned floor drain was greasy and black. The bottom shelf in the walk-in freezer was broken.

c. The Hospital failed to maintain the kitchen walls in good condition. The ceramic wall tiles by the utensil rack had large areas of missing grout. The ceramic wall tiles in the cart wash area were broken. A corner of a wall in the food store room was in poor repair with a wall sleeve separating from the wall. The door frames throughout the kitchen were paint worn and/or chipped. The door of the electrical panel box had a broken hinge.

d. The Hospital failed to maintain the nourishment kitchens in good condition.

1. The 10 South Kitchen had cabinet drawers with worn paint and scratched surfaces that would prevent effective cleaning. The microwave interior was dirty. The paper towel dispenser knob was missing and replaced with a make shift knob of masking tape. Packages of crackers were stored in a dirty plastic container that was not issued by the main kitchen. A box of brillo pads was stored in one of the food storage cabinets. The refrigerator log indicated that the refrigerator temperature was out of range on 11/1 and 11/2/15 with no documentation of corrective action taken.

2. The 9 North Kitchen had a dirty microwave oven. Bread dated 10/15/15 was stocked in the cabinet.

3. The 9 South Kitchen had ceiling tiles above the microwave that were stained and bulging. Outdated packages of crackers (5/1/15) and ground coffee (10/21/15) were stored in the cabinet.

4. The 6 North Kitchen had cabinet drawers with worn paint and scratched surfaces that would prevent effective cleaning. The exterior sides of the ice dispenser had large amounts of dust present.

5. The 6 South Kitchen had a microwave that was stained and odorous. The hand wash sink did not work.

Based on observation, record review and interview, the hospital staff failed to a) maintain a pharmacy refrigerator within recommended temperature range to maintain safety of pharmaceuticals and b) failed to ensure adequate lighting in all food service areas.

Findings include:

1. The Surveyor observed on 11/2/15 at 9:30 A.M. that the medication refrigerator on the 7 South unit did not maintain the recommended temperature range of 36 to 45°F per the refrigerator log on the following dates:

On October 2 - 8 P.M. temperature was 49°
On October 3 - 8 A.M. temperature was 49°
On October 4 - 8 A.M. temperature was 49°
On October 15 - 8 A.M. temperature was 46°
On October 31 - 8 A.M. temperature was 26°

According to the log if the temperature is out of range, corrective action must be taken. The instructions indicated that if the temperature is out of range, it must be rechecked in two hours. If it is still out of range, annotate the temp and adjust the control and mark the adjustment and notify the supervisor. Recheck in two hours if the temperature remains out of range for greater than four hours, contact facilities management. Contact the pharmacy for medication refrigerators that are out of range for greater than four hours

There was no indication on the log that the temperature was rechecked in two hours as indicated by the instructions for the abovw days when the pharmacy refrifgerator was out of range. There was no indication that facilities management was contacted and no indication that pharmacy was contacted for the three day period 10/2/15 through10/4/15 when the pharmacy refrigerator was out of range. Medications in the refrigerator not held at proper temperature over time can loose their effectiveness.

During an interview on 11/2/15 at 10 A.M., Registered Nurse (RN) # 20 said she didn't know if anything had been done about the temperatures being out of range on the above listed days.






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2. The Hospital failed to ensure adequate lighting in all food service areas.

On 11/3/15 during the tour of the Food Service Department, the Surveyor observed that the lights in the following areas were not working:

Three ceiling lights in the food preparation area.
One light in the Hood above the food preparation equipment.
One broken light cover in the pot/pan sink area.
One ceiling light in the dishmachine area.
Refrigerator light bulbs were burnt out in 5 South, 6 North, 9 South kitchens.

Based on observations, review of policies and procedures and staff interviews, the Hospital failed to provide a sanitary environment to avoid sources of infection and potential transmission of infections and communicable diseases as evidence by: failure to ensure (1) negative pressure room was functioning when caring for an one active patient (#2) with tuberculosis (TB); (2) three staff (Registered Nurse (RN) #11 and #20 and Licensed Practical Nurse (LPN) #1 disinfected blood glucose monitors between patients to prevent transmission of blood borne pathogens; (3) maintain a safe, clean and sanitary environment in the kitchen, on 7 North, 7 South, in the operating room, affecting two of ten Non-sampled (NS) patients (NS B and NS C) and five Patients ( #27, #28, #29, #32, and #33), in a total sample of 37; (4) staff (Registered Nurses (RN) #5, 6, and #24 and Respiratory Therapist (RT) #1, failed to perform glove changes and perform hand hygiene when appropriate, to decrease the spread of infection; (5) staff utilized Personal Protective Equipment (PPE) appropriately for three staff, Physician #4 and Operating Room Technician #1 (OR Tech #1) and Clinical Certified Hemodialysis Technician #1; (6) staff ( RN #9 and CCHT #1) utilized aseptic technique in the changing of central line and central venous catheter dressings for one sampled patient #11 and one nonsampled patient (NS D); and hospital failed to ensure (7) that for 6 of 14 personnel health records reviewed (RT #3, #4 and #5, RN #2 and RN #25 and OR Tech #1)staff were screened annually for TB per Hospital policy. Findings include:


1. For Patient #2, the facility failed to check the negative pressure in the room of a patient who was on airborne precautions for active tuberculosis, as per facility policy.

Patient #2 was admitted to the hospital on 10/23/15 with a diagnoses including active tuberculosis, and placed in a negative pressure room (this is a room designed to control the airborne flow of the pathogen/infection outside the room).

Facility policy indicates that patients with a diagnosis of active TB, will be in a negative pressure room and the pressure of the room will be tested daily by the staff at the hospital.

Review of the hospital logs of the room checks for negative pressure indicated that Patient #2's Room had not been checked for negative pressure until 10/27/15.

Patient #2's room had gone for 4 days before the room was checked by the facility to ensure that the room was in negative pressure.

On 11/10/15 at 7:50 A.M. the Environmental Services Person #2 said that the testing had not been completed daily, beginning when the patient is admitted, as per facility policy.

2. The hospital failed to ensure proper infection control practices were observed while performing blood glucose fingerstick monitoring.
Review of The Centers for Communicable Disease Center best practices, titled "Infection Prevention during Blood Glucose Monitoring and Insulin Administration" updated May 2012, indicated the following:
Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. The Manufacterer's instructions said the meter could be disinfected with the Hospital's SaniWipes which are germicidal and Tuberculocidal.

a. During observation of a finger stick blood sugar test on 11/2/15 at 4:15 P.M., RN #11 was observed using a blood glucose meter that is used for multiple patients for Patient #9. She donned gloves and placed the test strip in the blood glucose meter and allowed Patient #9 to perform the blood glucose test. After obtaining this patient's blood sugar results, RN #11 placed the contaminated lancet and test strip into a sharps biohazard container, and removed her gloves. Without disinfecting the blood glucose meter, RN #11 placed the meter into a plastic case containing clean blood glucose testing supplies and left the medication room.
During interview on 11/2/15 at 4:30 P.M., Nurse #11 said she thought she had disinfected the meter but apparently forgot.

b. During observation of a finger stick blood sugar test on 11/10/15 at 9:00 A.M., on the 5 South Unit, LPN #1 was observed using a blood glucose meter that is used for multiple patients for Patient #24. The nurse washed her hands gathered the blood glucose meter, test strip, lancet and alcohol pads and brought them into the patient's room. She donned gloves and placed the test strip in the blood glucose meter and performed the blood glucose test. After obtaining this patient's blood sugar results, LPN #1 placed the contaminated lancet and test strip into a sharps biohazard container, and removed her gloves. She washed her hands and left the patient's room. Without disinfecting the blood glucose meter, LPN #1 placed the meter onto a charging station at the nurses' station and left the area.

During interview on 11/10/15 at 9:15 A.M., LPN #1 said she didn't clean it after she used it and would do so now.

c. On 11/3/15 at 11:37 A.M., the Surveyor asked Nurse #20 what the procedure was for cleaning glucometers. Nurse #20 said, "I get a gauze pad and put warm water on it, then I wipe over the glucometer." Nurse #20 demonstrated what she does to disinfect a glucometer. She brought a 4 x 4 gauze pad in her hand, and put warm water on it, then wiped it over one of the glucometers that had already been disinfected by another nurse. Nurse #20 was not disinfecting the glucometer between uses, in accordance with manufacturer's directions for use.

During interview on 11/5/15 at 9:30 A.M., the Nursing Director of DMH said that the procedure that Nurse #20 was using was totally incorrect, and that the disinfecting agent Sani-Wipe Plus is the hospital's choice for disinfecting glucometers.

3. a. The Hospital failed to maintain a clean and sanitary environment in the respiratory care units to prevent the spread of infection to trached, vented, tubed and lined patients who were susceptible to infections based on their medical condition.

Observation on 11/5/15 and 11/9/15 and 11/10/15, of the 7 North and 7 South units (both respiratory care/ventilator units) indicated in 3 of 3 observed patient rooms on 7S, and 10 of 16 rooms on 7N with window air conditioners, the safety screens covering the windows in front of the AC units, were coated with a thick black substance. These rooms included rooms with patients who had tracheotomies, gastrostomy tubes for feeding, intravenous lines for hydration and open wounds. Sampled patients observed with the dirty screens with AC units blowing on to them included #27, #28, #29, #32, and #33. The air conditioner units were blowing air through the dirty screens directly onto the patients. This posed a potential risk of infection for these patients.
a. Patient #27 was vented with a tracheostomy, gastrostomy tube for feeding and was bedbound.
b. Patient #28 had a tracheostomy, was restrained in bed and chair and confused.
c. Patient #29 had a diagnosis of endocarditis and was on Intravenous antibiotics via a peripherally inserted central line catheter.
d. Patient #32 was a vented patient status post cardiac arrest with a anoxic brain injury. Patient #32 had a tracheostomy, gastrostomy tube for feeding and was a insulin dependent diabetic.
e. Patient #32 had respiratory failure with a tracheostomy. The patient had open wounds and was an insulin dependent diabetic.

Each of these patients' conditions put them at high risk for infections. Their risk was compounded by the AC units blowing the black substance directly on to them through the safety screens.

On 11/9/15, at approximately 1:30 P.M., the Infection Control Preventist (ICP) and the Surveyor observed the black substance on the safety screens of nonsampled patients B, C and Patient #28 on unit 7 South. The patients in these rooms both had tracheotomies and gastrostomy tubes for feeding. The Surveyor asked the ICP what she thought the black substance was. The ICP said the black substance could be mildew or mold and she would see that housekeeping removed it immediately from the screens.

b. The Hospital failed to insure that the 20 ice machines in the facility were cleaned, sanitized and maintained to minimize the potential risk of infections.

On 11/3/15 at 8:20 A.M. during a tour of the Main Kitchen, the Surveyor asked about the cleaning and maintenance of the two open "scoop type" ice machines in the Main Kitchen. The Operations Manager indicated that the Food Service Department does not clean and maintain the ice machines in the Main Kitchen and to check with the Facilities Department.

On 11/3/15 at 11:00 A.M., during a tour of the Nourishment Kitchens, the Surveyor asked about the cleaning and maintenance of the ice dispensers in the Nourishment Kitchens. The Operations Manager indicated that the Food Service Department does not clean and maintain the ice dispensers in the Nourishment Kitchens and to check with the Facilities Department.

On 11/4/15, during an interview with the Chief Financial Officer (CFO), the Surveyor asked to review documentation of the cleaning and maintenance performed on the ice machines and the ice dispensers. The CFO had no documentation to show that the ice machines and ice dispensers were cleaned and maintained according to the manufacturers' guidelines which recommended monthly cleaning, inspection and maintenence.

After Surveyor inquiry, the CFO provided the Surveyor a Work Order dated 11/3/15 for scheduled cleaning, monthly maintenance and inspection of the 20 ice machines in the building.

4. Hospital staff were observed not to perform hand hygiene when removing gloves or before donning gloves and failed to don and wear personal protective equipment (PPE) in a manner that protected them from blood and other potentially infectious material or chemical contaminants.

a. During a medication pass on 7 South, on 11/02/15 at approximately 1:45 P.M., the surveyor observed that RN #5 failed to perform hand hygiene prior to donning gloves. RN #5 was in the process of preparing to hang intravenous medications (IV) for NS Patient A.
b. During a medication observation on 11/3/15 at 2:00 P.M. on 7 North RN #6 asked an unidentified certified nursing assistant (CNA) from the hallway to assist her with repositioning Patient #27. The CNA had already donned a gown and mask to go into another patient's room. The CNA entered Patient #27's room, did not wash her hands and donned gloves to assist RN #6. Patient #27 was on contact plus precautions and droplet precautions. Signage on the door indicated all people entering the room needed to wash their hands with soap and water prior to entering and leaving the room and prior to donning/removing gloves.
c. The surveyor observed, with the Operating Room Nursing Manager (OR NM), on 11/3/15 at 10:20 AM, the gastrointestinal (GI) suite of the operating room (OR). Physician #4 was observed to be wearing his mask and face shield combination, around his chin and neck, while performing a colonoscopy. This made Physician #4 vulnerable to enteral sprays in the face during the colonoscopy.
The OR NM said Physician #4 was not correct in his wearing of the PPE and went in the GI suite and immediately corrected his behavior.
d. The Surveyor observed, on 11/3/15 at 2:30 P.M., OR Technician #1, during cleaning of OR #3 after a case. OR Tech #1 was cleaning the OR with Wexcide, a chemical disinfectant. OR Tech #1 was wearing a gown, gloves and a mask that was not covering his nose and he was not wearing a faceshield.
During an interview, on 11/3/15 at 2:00 P.M., the OR NM said that OR Tech #1 was required to wear full PPE including a face shield and a mask that covered his nose per OR policy for working with chemicals.
e. The Surveyor observed Respiratory Therapist (RT) #1 failed to perform hand hygiene on 11/4/15 at 1:15 P.M. when she changed gloves after adding sterile water to a humidifier. After she changed gloves without performing hand hygiene, RT #1 put a new sterile suction catheter on the suction machine.
f. On 11/4/15 at 9:30 A.M., RN #24 was observed decontaminating an endoscope in the endoscope cleaning and processing room. The processing room has a double sink with a clean and dirty side. RN #24 moved the scope from the dirty sink after enzymatic cleaning, to the clean sink. Without changing her gloves and performing hand hygiene, RN #24 moved back to the dirty sink, to clean small parts, after rinsing the scope in the clean sink. RN #24 moved back and forth between the clean and dirty sink three times without changing gloves and performing hand hygiene. This contaminated the clean scope.
During an interview, RN #24 said she usually had two people to help do the decontamination process, one to work the dirty side of the sink and one to work the clean side. She said she did not realize she needed to change gloves between clean and dirty sides.

g. RN #11 was observed performing a finger stick blood sugar glucose test, on 11/2/15 at 4:15 P.M. When RN #11 completed the test and discarded the blood stained lancet, she failed to remove her contaminated gloves and then placed her gloved hand into a bin full of clean insulin needles/syringes, contaminating the clean supply of needles/syringes.


5. A tour with the Clinical Director of Respiratory Services, RT#1, was completed on 11/3/15 at 10:00 A.M. RT#1 brought the surveyor to a room on the "T" wing off the 7 North unit. RT#1 said that clean supplies for the many respiratory patients, including those with ventilators, tracheostomies and other respiratory needs were stocked in the room. The room was labeled "laundry room." Inside the room was a built-in cabinet to the right of the entry door. The top half of the cabinet had closing glass doors. The bottom half of the cabinet had shelving open to the room air. Clean respiratory supplies were located throughout the cabinet.

Also located in the room was a used, and presumed by RT #1, dirty pulse oximetry device. There was also an old, dirty, rusty transport cart. Further, toward the back of the room was a washing machine and a dryer. RT#1 said that patients on the unit had the ability to use the washer and dryer to launder their clothes if desired, and that patients or families often did wash their own clothes in the machines.

After Surveyor inquiry about possible cross contamination between dirty equipment storage and dirty laundry being brought into a room where clean respiratory supplies were stored, RT #1 requested that the supplies be stored in another room that was used exclusively for clean supplies.


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6. Staff ( RN #9 and CCHT #1) failed to utilize proper aseptic technique in the changing of central line and central venous catheter (CVC) dressings for Patient #11 and nonsampled patient (NS D).

a. For NS Patient D, observation of an aseptic technique (applies the strictest rules of infection control to prevent contamination from microorganisms) dressing change for a Peripheral Inserted Central line Catheter (PICC), in the patient's room at 10:00 A.M. on 11/3/15 indicated the following breech in infection control practices.:

NS Patient D had a PICC in place in the Left arm for the administration of antibiotics. The nursing staff had observed that there was bleeding under the Tegaderm Dressing (a transparent dressing covering the PICC insertion site) and requested the Intravenous (IV) Team to assess the area.

The IV Nurse #1 assessed the area and determined a dressing change needed to be performed. IV Nurse #1 proceeded to set up the sterile field and followed infection control practices in regards to hand washing, masking, etc...The procedure calls for the insertion site to be cleansed with the Chloral Prep antiseptic solution, and then allow the solution to air dry. Do not rub or blot dry. IV Nurse #1 cleansed the area with the antiseptic solutions and then "fanned" the area with a piece of 4x4 gauze so as to speed up the drying process. The area should have been let to air dry. This was also observed by the 6th floor Unit Manager.

On 11/3/15 at 2:30 P.M. the IV Nurse #1 and the 6th floor Unit Manager said that the area should have been let to air dry, and should not have been "fanned" dry.

b. Patient #11 was admitted to the hospital in 10/2015 with a diagnosis of end stage renal disease and Hepatitis B infection.

On 11/4/15 at 8:00 A.M., the surveyor observed CCHT (Certified Clinical Hemodialysis Technician) #1 initiate the dialysis of Patient #11 in the isolation room.

On 11/4/15 at 8:30 A.M., CCHT #1 removed the dressing from the CVC (Central Venous Catheter) site. CCHT #1 wiped the area from center and outwards with Betadine. Then with an alcohol prep pad, CCHT #1 wiped off the Betadine (negating the antimicrobial actions of the Betadine). The CVC site was covered with a sterile dressing.

CCHT #1 scrubbed the hubs of the CVC ports with one alcohol pad per port. She scrubbed each port for 5-7 seconds and not 15 seconds per policy.

During the actual initiation of dialysis CCHT #1 did not wear an impervious gown, nor was the door closed in the case of spurting of blood per policy.

During interview on 11/4/15 at 9:10 A.M., the Education Nurse (EN) for dialysis said that CCHT #1 should never have wiped off the Betadine used to clean a CVC site, and that if a patient does not want Betadine, then the anti-infective agent should be ChloraPrep swabs. The Education Nurse also said that only impervious gowns should be worn to protect staff from becoming splashed with infected blood, and that the door to the Isolation Room should be closed during initiation and termination of dialysis. During this interview, the EN told the surveyor that the hubs have to be scrubbed with a sterile alcohol pad for 15 seconds each and not 5-7 seconds. The EN was unable to provide the policies for the surveyor, but was able to articulate that CCHT #1 was not following protocol.




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7. For 6 of 14 employee health records reviewed annual tuberculosis (TB) tests or screening questionnaires were not completed annually as required by hospital policy.

According to hospital policy V.22 annual tuberculosis screening requirements, all hospital employees are to be screened annually for TB. If the employee has a history of positive TB test and a negative chest x-ray, employees will complete an annual TB surveillance questionnaire for symptoms of TB.

a. For Respiratory Therapist (RT) #3 review of the health record indicated RT #3 had no annual TB test or annual questionnaire since the date of hire in November 2014.
b. For RT #4, with a date of hire in November 2014, review of the health record indicated the patient had only one TB surveillance questionnaire with no date.
c. For RT #5, review of the health record indicated there was a TB surveillance questionnaire dated 10/27/14. The therapist was due for an annual questionnaire no later than November 1, 2015 and as of review of the record on 11/11/15, the annual questionnaire had not been completed.
d. For RN #2, review of the health record on 11/11/15 indicated there was no evidence of a TB test or a surveillance questionnaire completed.
e. For OR tech #1, review of the health record on 11/11/15 indicated the employee required an annual TB questionnaire. The health record contained no annual TB questionnaire as required.
f. For RN#25, review of the health record indicated the last annual TB test was performed on 10/31/14. The TB test was due no later than 11/1/15 and as of 11/11/15 had not been performed.

8. Observation of the operating room (OR) rooms #1 and #2, on 11/03/15, indicated that the interior doors and door frames of the doors leading to the scrub sink hallway, were gauged and scraped and in disrepair. The condition of the doors made it impossible for operating room staff to terminally disinfect/sanitize the OR suites.




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Based on record review and staff interview, the hospital failed to ensure that an ongoing staff education program was in place relating to organ donation issues.

Findings include:

1. Record review of all personnel files across all departments indicated that the hospital did not provide ongoing education to employees on organ donation and procurement.

2. During an interview on 11/9/15 at 5 :15 P.M., the Director of Quality Management, said that the hospital did not provide ongoing staff education relating to Organ Procurement.

Based on observation review of policies and interviews the surgical services failed to follow its policy for maintenance and monitoring of the sterile field. Findings include:


Review of the Hospital OR policy, titled "Preparing, Maintaining and Monitoring a Sterile Field", last revised on 3/15. the policy indicated that sterile fields will be constantly monitored and once created a sterile field will not be left unattended until the operative or other invasive procedure is completed. The policy also indicated when there is an unanticipated delay or during periods of increased activities such as patient transfer to the procedural bed, a sterile field that has been prepared and will not be immediately used may be covered with a sterile drape. When sterile fields are covered they must be covered in a manner that allows the cover to be removed without bringing the part of the cover that falls below the sterile field above the sterile field.

On 11/03/15 between 9:30 A.M. and 11:00 A.M., the Surveyor observed that operating room (OR) suite #2 had the sterile field set up for the orthopedic case scheduled as the surgeon's third case of the day. The sterile field was covered in blue drapes and was not monitored by anyone. Staff, such as the anesthesiologist,were observed to enter and leave the room one durng the two hour period.

On 11/4/15 at 8:00 A.M., the surveyor observed OR room #1 to have the sterile field set up and covered with blue drapes without being monitored by staff. The patient was not brought to the room for surgery until 8:44 A.M.

During an interview on 11/5/15, at approximately 8:00 AM, the OR Nurse Manager said they do not have enough staff to prepare the sterile fields just prior to surgery and to monitor the covered sterile field once it is set up. They set up the rooms with the sterile fields in advance to save time sometimes, hours, in advance of cases.

Based on observation, record review, and interview, the hospital's surgical service failed to provide two of four outpatients (#2 and #3), with an updated examination, and review of the history and physical (H & P), within 24 hours after the patient's registration when the history and physical, and examination were completed within 30 days prior to admission or registration for the planned procedure. Findings include:

1. For Patient #2, the H & P was completed by a nurse practitioner (NP) , at an outside clinic, on 10/28/15. The patient was admitted for outpatient surgery to the hospital on 11/4/15. The surgeon signed the H&P, previously completed on 10/28/15 at 7:30 A.M., there was no update to the physical and no indication that this history was reviewed with the patient for any changes. There was a set of vital signs written in on the physical with no date and no time and no initials as to who wrote the vital signs.

2. For Patient #3, the H&P was completed by a NP at an outside clinic on 10/27/15. Patient #3 was admitted for outpatient surgery to the hospital on 11/4/15. Review of the H&P indicated the surgeon signed the H&P on 11/4/15 at 8:00 A.M. There was no update to the physical and no indication that this history was reviewed with the patient for any changes.

3. During an interview on 11/9/15 at 8:15 A. M. The Chief of Surgery said he did not think that outpatient surgery cases required a review of the H&P and another exam.

Based on record review and staff interview the hospital failed to provide one of three patients (#27), receiving Physical Therapy (PT), in a total sample of 37, with PT services as ordered, due to lack of staff. Findings include:

1. For Patient #27, admitted 9/15/15, the patient did not receive physical therapy services as ordered on 10/18/15, until 11/4/15.

Patient #27 was admitted with respiratory failure on mechanical ventilation with a tracheostomy, chronic obstructive lung disease, multiple drug-resistant infections, had a gastrostomy tube (GT) for feeding and was on contact precautions. The patient was alert and oriented and did not speak English. On 10/18/15, the patient was evaluated by physical therapy (PT) which recommended skill therapy 30 minutes a day two days a week for the next 6 to 8 weeks.

Record review on the morning of 11/4/15, indicated the patient had not received any skilled PT up to and including on 11/4/15. There were no progress notes from PT in the record. At 2:30 P.M., on 11/4/15, the Surveyor asked the Nurse Manager why the patient had not received any PT and the NM said she would find out.

On 11/5/15, review of the record indicated PT had put in a progress note on 11/4/15 at 3:30 P.M. that stated the patient had been refusing the PT. The note indicated that the patient was not seen the week of 10/18 due to a "conflict" and for the week of 10/25, the patient refused the rehab aide due to not feeling well. The note indicated the patient was seen by PT on 11/4/15 for 30 minutes for therapeutic exercises and the Patient exhibited markedly impaired activity intolerance.

During an interview on 11/5/15 at 2:00 P.M., PT #1 said that the conflict, the week of 10/18/15 that caused the patient not to be seen, was a lack of staff. PT#1 said that the Rehab Manager was aware and asked all the therapists to document when they could not see patients due to lack of staff.