HospitalInspections.org

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Infection Control as evidenced by:

1) Failing to place a patient with a urine culture dated 10/17/18 (6 days after admit) that revealed >100,000 gram negative rods ESBL positive on contact precautions in accordance with hospital policy and direction from the lab for
1 (#10) of 3 (#1, #6, #10) patient records reviewed for patients requiring isolation from a sample of 29 patients.

2) Failing to ensure the hospital's system for identifying, reporting, and controlling infections and communicable diseases of patients and personnel was implemented in accordance with acceptable standards of practice. This deficient practice was evidenced by multiple observations of breaches in infection control practices on 10/22/18 and 10/23/18 related to hand hygiene, maintaining a sanitary environment, and maintaining contact precautions for patients identified to be on contact precautions. (see findings in tag A0749)

Based on record reviews and interview, the governing body failed to ensure services performed under contract were provided in a safe and effective manner as evidenced by having no documented evidence that the services provided by Company B and Company C had been evaluated or included in its QAPI program.

Review of the "Performance Improvement Monthly Meeting Minutes" for 07/13/18, 08/10/18, and 09/14/18, presented as the most recent QAPI meeting minutes by S10LPN, revealed no documented evidence that Company B and Company C were included in the contracted services being evaluated.

In an interview on 10/24/18 at 12:50 p.m., S1DON confirmed Company B and Company C were not included in the contracts being evaluated.

Based on interview, the governing body failed to ensure the medical staff had written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate since emergency services were not provided at the hospital as confirmed in interview on 10/24/18 at 12:50 p.m.
Findings:

In an interview on 10/24/18 at 12:50 p.m., S1DON confirmed the hospital did not have an emergency department. She confirmed the hospital did not have policy and procedure approved by the medical staff for appraisal of emergencies, initial treatment, and referral when appropriate.

Based on record reviews and interviews, the hospital failed to ensure the patient or his/her representative had the right to make informed decisions regarding his/her care as evidenced by failing to have documented evidence of a discussion with a patient and/or his family explaining the basis for and consequences of an ordered DNR in accordance with hospital policy for 1 (#5) of 1 patient record reviewed with an order for DNR from a sample of 29 patients.
Findings:

Review of the policy titled "Do Not Resuscitate (DNR)", presented as a current policy by S1DON, revealed the patient's attending physician "and a consulting physician (optional)" must determine if a DNR or a Terminal Care Order is medically appropriate based on the patient's underlying terminal illness or irreversible medical condition. If the attending physician and the consulting physician determine that a DNR or a Terminal Care order is medically appropriate, the physician must then discuss the matter with the patient explaining the basis for and the consequences of either order. If the patient is incompetent, this discussion must be held with the patient's family or legal guardian. All such discussions must be noted on the patient's medical record. The notation of such discussions should include at least the following information: persons present; information conveyed by the physician; decision of the family and legal guardian. If the patient is competent, the patient must consent to the entry of the order. If the patient is not competent, the patient's family members and legal guardian must consent to the order. In either case, the attending physician must indicate on the patient's medical record that consent has been witnessed by at least one hospital employee.

Review of Patient #5's medical record revealed an order was written by S6MD on 10/08/18 at 2:40 p.m. as "Pt (patient) is a DNR." Further review revealed no documented evidence in the medical record of a discussion by S6MD with Patient #5 or her family explaining the basis for and the consequences of the DNR order, consent by the patient or family for the DNR order, and indication in the medical record that consent had been witnessed by at least one hospital employee.

In an interview on 10/22/18 at 3:53 p.m., S1DON reviewed Patient #5's hard-copy and electronic medical record and confirmed there was no documented evidence that S6MD had documented a discussion with Patient #5 or her family regarding a DNR order.

In an interview on 10/23/18 at 12:25 p.m., S6MD confirmed he didn't document anything in Patient #5's medical record about a conversation he had when he made her a DNR. S6MD then asked "is there was a problem with that?" After review of the hospital's DNR policy, S6MD indicated he was not aware of the hospital's policy. He indicated he spoke with the person, "think it's her daughter, who has power of attorney", but he didn't document anything. He indicated even though he documented a discussion in the chart, "it wouldn't protect me."

Based on record reviews and interview, the hospital failed to ensure data collected in its QAPI program was used to take action at performance improvement. QAPI data did not include the goal to be met for each indicator to be used to determine if the goal was met and did not include actions to be taken to improve improvement.
Findings:

Review of the "Performance Improvement Monthly Meeting Minutes" for 07/13/18, 08/10/18, and 09/14/18, presented as the most recent QAPI meeting minutes by S10LPN, revealed each quality indicator had the problem identified, discussion/intervention, rationale, status, total, and results. There was no documented evidence that a target goal was established that could be used to measure performance to determine whether the goal was met for each indicator. Further review revealed no documented evidence the action to be taken to improve performance was included. Further review revealed the medical record quality indicator for consults completed within 72 hours had 80% compliance in July 2018 and 56% compliance in August 2018 with no documented evidence of an action plan developed to address the decreased compliance. Further review revealed there no hospital acquired infections in July and August 2018, and there were 4 in September 2018 with no documented evidence of an action plan developed to address the increase in hospital acquired infections.

In an interview on 10/24/18 at 12:50 p.m. with S1DON and S10LPN present, S1DON indicated they discuss if the interventions have to be changed, but they don't document the action needed for improvement.

Based on record reviews and interview, the hospital failed to conduct performance improvement projects that included the reason for conducting the project and the measurable progress achieved on the project as evidenced by having no documentation of an ongoing performance improvement project and having no documented evidence of the reason for conducting the completed project on falls and the measurable progress achieved on the project related to falls.
Findings:

Review of the completed PI project presented by S1DON revealed the study period was from 01/01/17 to 12/31/17 and included tracking of all falls to review that safety policies were in place. Further review revealed the results included the number of falls, the time of day of the fall, the staff involved, trends identified, and opportunities for improvement. There was no documented evidence the documentation included the reason the PI study was chosen, actions or interventions to be taken by staff, and the measurable progress achieved during the study to determine if actions/interventions had to be revised.

In an interview on 10/24/18 at 12:50 p.m. with S1DON and S10LPN present, S1DON indicated they started a PI project related to medication error about 3 months ago, but she doesn't have it documented as a PI project. She confirmed the documentation of the PI project on falls documented in 2017 did not include the reason the study was chosen, actions/interventions to be taken, and measurable progress achieved throughout the study to determine if actions/interventions had to be revised.

Based on record reviews and interviews, the hospital failed to ensure each physician/practitioner providing services in the hospital, including radiologists performing telemedicine (radiology) services, was credentialed and privileged as evidenced by failure to have documented evidence the radiologist providing telemedicine services had been privileged for 1 (S12MD) of 3 (S11MD, S12MD, S13MD) radiologist's credentialing files reviewed.
Findings:

Review of the list of current credentialed staff as of 10/24/18 revealed no documented evidence S12MD had been privileged and approved by the governing body to perform Tele-Radiology.

On 10/23/ 18 at 11:00 a.m. a Review of Patient #18's medical record revealed he was admitted on 08/31/18 with orders noted for CT Head on 09/19/18, ordered by S6MD. The test was completed on 09/19/18, and the CT was read by S12MD on 09/19/18 at 11:07 a.m.

In an interview on 10/23/18 at 1:15 p.m., S16RHIT confirmed S12MD read the CT, and he had not been credentialed or privileged by the medical staff/governing body.

Based on observations, record reviews, and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:

1) Failing to ensure the nursing staff documented all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications as per the hospitals policy titled Pharmacy First Dose Verification effective 04/15 for 4 (#3, #6, #9, #12) of 4 (#3, #6, #9, #12) patient admit orders reviewed for first dose review from a sample of 29 patients.

2) Failing to ensure the nursing staff followed the hospital policy for falls as evidenced by failing to perform frequent neurologic assessments on a patient with obvious injuries following a witnessed fall for 1 (#20) of 2 patient records reviewed who experienced a fall from a sample of 29 patients.

Findings:

1) Failing to ensure the nursing staff documented all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed:
A review of the hospital policy titled, Pharmacy First Dose Verification effective 04/15, revealed in part:
Procedure: New order during pharmacy business hours: all new orders and admit orders should be faxed to the pharmacy as usual. The order will then be stamped with a fax date and time by the nurse. The nurse should then call the pharmacy after approximately one hour for verbal verification if the pharmacy has not already approved the orders. The nurse would then write the pharmacist name, date and time under the fax stamp on the original order. This indicates that the order was verified and is approved to be placed on the MAR. The medication may be started after these steps are complete. Note, any order that was entered into the dispensing cabinet software by the pharmacy is presumed approved. New order after pharmacy business hours: all new orders should be faxed to the pharmacy as usual. The nurse should also call the pharmacy after hours' number. The nurse should be prepared to give the pharmacist the patient's name, allergies, and other medications as well as the new order. The pharmacist will then give a verbal authorization to start the order or decline. Document the pharmacist, date and time below the fax stamp on the original order. The order may be put on the MAR after these steps are complete.

A review of the medical records of Patient #3, #6, #9 and #12 revealed the admit orders failed to contain the required first dose verification documentation per policy.

In an interview on 10/ 23/18 at 11:30 a.m., S10LPN reviewed the medical records of Patients #3, #6, #9, and #12 and confirmed the nursing staff failed to document the first dose verification per hospital policy.

2) Failing to ensure the nursing staff followed the hospital policy for falls:
A review of the hospital policy titled Neurological Assessment dated 03/2016 revealed, in part, the following:
The policy is to perform a neurological assessment on patients when a fall occurs, to follow the progression of a disease, when any type of trauma occurs. Included in the procedure is to perform frequent neurologic assessments: Initial assessment followed by complete vital signs; every 15 minutes for 1 hour; every 30 minutes for 1 hour; every hour for 2 hours; and every shift for 72 hours. Neurological assessments include (at a minimum) pulse, respiration, and blood pressure measurements; assessment of pupil size and reactivity; and equality of hand grip strength.

A review of an incident report dated 11/29/17 at 4:13 p.m. completed by S17RN revealed Patient #20 stood without assistance and fell in the bathroom. The incident resulted in a 2-3 cm hematoma lateral to her left eyebrow and a small abrasion on her left thumb after she hit her head on the wall. Vital signs: Pulse 93; Blood Pressure 156/80; Respirations 20/minute; and Temperature 97.9. No neurological exam documented.

A review of the medical record for Patient #20 revealed she was a 78 year old admitted on 11/20/17 following a stroke with left sided weakness. Further review revealed no documented evidence of an assessment of her neurological status after her fall on 11/29/17. Further review revealed there was no documented evidence of continued neurological assessments and vital signs as required by ;policy.

On 10/23/18 at 3:30 p.m., in an interview with S10LPN, she verified there was no documentation in the progress notes neurological assessments following the fall of Patient #20. S10LPN stated the lack of documentation and lack of following the policy was a problem among the nursing staff.






39791

Based on hospital policy, record reviews, and interview, the hospital failed to ensure identified medication errors were documented in the patient's electronic medical record for 2 (#19, #24) of 3 patients' (#19, #22, #24) electronic medical records reviewed for hospital-identified medication errors from a sample of 29 patients.
Findings:

Review of the hospital's policy Incident Report Effective 04/01, Revised 12/15 revealed, in part:
Procedure:
12.The next screen is the Action tab.
b. A progress note must be filled out with details of what occurred. Do not use the term INCIDENT. This is part of the medical record.

Patient #19
A review of the hospital's Incident Report Form dated 07/01/18 revealed Patient #19 had a discharge order from Hospital A for Cipro. S23MD rounded on 06/28/18 and said to give a total of 7 days. Patient was admitted on 06/26/18 but the Cipro was started on 06/21/18 at Hospital A. No stop date was entered for 06/28/18, and the patient received 5 extra doses.

A review of Patient #19's electronic medical record failed to reveal documentation of the medication error.

Patient #24
A review of the hospital's Incident Report Form dated 04/18/18 revealed Patient #24 had a discharge order for Lovenox 40mg qd on the discharge medication list from Hospital A, but the order was not added to the active orders.

A review of Patient #24's electronic medical record failed to reveal documentation of the medication error.

On 10/23/18 at 3:30 p.m., S10LPN verified the medication errors for Patients #19 and #24 were not documented in the patients' electronic medical records. She also verified if the nurses completed the Incident Report Forms according to the policy, the information would have automatically carried over into the patients' medical records.

Based on interviews, the hospital failed to ensure a formulary system was established by the medical staff to assure quality pharmaceuticals at reasonable costs.
Findings:

On 10/23/18 at 9:45 a.m. in an interview, S14RPh verified the hospital does not have or utilize a formulary.

On 10/23/18 at 12:40 p.m. in an interview, S6MD verified the hospital does not have or utilize a formulary.

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39791

Based on observations, record reviews, and interviews, the infection control officer failed to ensure the infection control plan was implemented to control infections and communicable diseases of patients and personnel as evidenced by:

1) Failing to place a patient with a urine culture dated 10/17/18 (6 days after admit) that revealed >100,000 gram negative rods ESBL positive on contact precautions in accordance with hospital policy and direction from the lab for
1 (#10) of 3 (#1, #6, #10) patient records reviewed for patients requiring isolation from a sample of 29 patients.

2) Failing to ensure the hospital's system for identifying, reporting, and controlling infections and communicable diseases of patients and personnel was implemented in accordance with acceptable standards of practice. This deficient practice was evidenced by multiple observations of breaches in infection control practices on 10/22/18 and 10/23/18 related to hand hygiene, maintaining a sanitary environment, and maintaining contact precautions for patients identified to be on contact precautions.

3) Failing to ensure expired wound care dressings were not available for staff use.

Findings:

1) Failing to follow hospital policy by not placing a patient in contact isolation:
Observation on 10/23/18 at 7:50 a.m. revealed Room "d" did not have isolation supplies on the door or a contact precaution sign on it (Patient #10 who was assigned to Room "d" was on contact precautions for gram negative rods and ESBL in the urine).

An observation on 10/23/18 at 8:00 a.m. revealed no isolation supplies outside Patient #10's room. Further observation revealed the door was open, and the patient was not in the room.

Review of the hospital policy titled Contact Precautions dated 03/01/12 revealed in part, wear gloves when entering all Contact precaution rooms. Change gloves during the course of care for one patient and after contact with infective material. Remove gloves before leaving the patients room. Wash your hands immediately with antimicrobial hand wash or apply alcohol hand rub before leaving the patients room. After glove removal and hand washing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room, to avoid the transfer of microorganisms to other patients or environments. Wear a gown when entering all Contact precautions rooms. After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental surfaces .... Limit the movement/transport of patients from the room for essential purposes only. During transport, ensure that infected or colonized areas of the patient's body are covered and contained. Remove and dispose of contaminated PPE in the patient's room and perform hand hygiene prior to leaving the room.
The patient's therapeutic needs may require therapy or activity outside of the room. In this case the Infection Prevention Committee may be consulted if questions or concerns arise. When possible, dedicate the use of noncritical patient-care equipment for each patient. If use of common equipment is necessary, then adequate cleaning and disinfection is required prior to the use for another patient.

Review of the hospital's Pending Cultures Policy and Procedure dated 12/12 revealed in part:
Procedure:
1) Upon any physician ordering a culture (i.e. urine, respiratory, wound, etc.), Nursing shall initiate Contact Precautions on patient in the following manner:
2) The patient shall be treated as infected.

Review of CDC's "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings" revealed contact precautions were intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment. Healthcare personnel caring for patients on Contact Precautions were to wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. Hand hygiene was to be performed before having direct contact with patients, after contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings, after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient), if hands will be moving from a contaminated-body site to a clean-body site during patient care, after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient, and after removing gloves.

Review of Patient #10's medical record revealed he was a 91 year old male who was admitted on 10/11/18 with a diagnosis of Parkinson's disease and UTI-enterococcus faecalis. Further review revealed he started treatment on 10/10/18 (pre-admission) for Enterococcus bacteria in his blood and urine.

Review of the History and Physical by S6MD dated 10/12/18 revealed, "After assessment he was found to be septic with possible urine versus GI etiology".

Further review of the Laboratory record revealed a Urine Culture was collected 10/17/18 and reported 10/19/18 as: >100,000 gram negative rods; sensitivity and identification determined the bacteria to be enteric gram negative rod and ESBL Positive. Further review revealed a notation of "USE CONTACT ISOLATION".

Review of the Physician's Orders revealed no order in the medical record for Contact Isolation.

On 10/22/18 at 3:45 p.m. in an interview with S10LPN, she indicated Patient #10 should have been on isolation precautions upon admission with a blood infection.

On 10/23/18 at 7:40 a.m. in an interview with S1DON, she verified ESBL documented in the medical record of Patient #10's urine culture which states order contact precautions and no order for Contact Isolation in the medical records.

On 10/23/18 at 7:50 a.m. in an interview with S10LPN, she verified ESBL documented in the medical record of Patient #10's urine culture which states order contact precautions and no order for Contact Isolation in the medical records.

On 10/23/18 at 12:30 p.m. in an interview with S6MD regarding Patient #10, he indicated "ESBL, it's not that contagious and I would not have put him on isolation". S6MD verified the lab had documented "Contact Precautions" as listed above.

On 10/24/18 at 1:30 p.m. in an interview S1DON, she indicated Patient #10 should have been put on isolation.

On 10/24/18 at 2:20 p.m., the above findings were verified by S1DON and S10LPN, the Infection Control Officer.

2) Failing to ensure the hospital's system for identifying, reporting, and controlling infections and communicable diseases of patients and personnel was implemented in accordance with acceptable standards of practice:
Breaches in contact precautions:
Observation on 10/22/18 at 11:05 a.m. revealed Room "b" had a holder containing isolation supplies attached to the door with no observation of a sign designating the type of isolation to be maintained and directions for staff and visitors to follow.

Observation on 10/23/18 at 7:50 a.m. revealed Rooms "b" and "c" have isolation supplies mounted on the door. Both rooms had open doors, and Patient #1 (on contact precautions for MRSA and assigned to Room "b") and Patient #6 (on contact precautions pending a urine culture per hospital policy and assigned to Room "c") were not present in the rooms. Further observation revealed both rooms had a large, uncovered biohazard box with a red plastic liner at the entrance of the room. There was no observation of a contact precaution sign on the door of Room "c". Further observation revealed Room "d" did not have isolation supplies on the door or a contact precaution sign on it (Patient #10 who was assigned to Room "d" was on contact precautions for gram negative rods and ESBL in the urine).

Observation on 10/23/18 at 8:05 a.m. in Room "i" revealed Patient #1, Patient #6, and Patient #10, all who were on contact precautions (reason for precaution listed above), were seated at tables with other patients. Continuous observation revealed Patient #1's family member was present, touch his head and hands with her ungloved hands, walked to the counter and obtained a cup from the column of cups, drew water from the tap, drank the water, and tossed the cup in the trash can. She then returned and touched Patient #1's hands. S2LPC was observed standing at Patient #1's side speaking to him and his family member and touched his shoulder before leaving his side. S2LPC was observed leaving Room "i" without performing hand hygiene after having touched Patient #1's shoulder.

Observation on 10/23/18 at 9:07 a.m. in Room "f" revealed S4OTA touched Patient #6's wheelchair (who was on contact precautions) with gloved hands, reached for her walker from the wall by touching another walker with gloved, contaminated hands.

Observation on 10/23/18 at 9:14 a.m. in Room "f" revealed S7SLP was observed working ungloved with Patient #1 who was on contact precautions for MRSA with materials on an over bed table. Further observation revealed when she was finished, the over bed table was rolled to the other side of the room, and observation revealed it was not disinfected. At 9:15 a.m. S3COTA assisted Patient #1 to his wheelchair which had a tear in the cushion which makes it unable to be disinfected. S3COTA, with ungloved hands, touched the mat where he was seated, touched his left leg, grabbed the gait belt, and touched his arm to help him into the chair. She rolled the wheelchair and placed him on the other side of the room.

Review of the hospital policy titled Contact Precautions dated 03/01/12 revealed in part, wear gloves when entering all Contact precaution rooms. Change gloves during the course of care for one patient and after contact with infective material. Remove gloves before leaving the patients room. Wash your hands immediately with antimicrobial hand wash or apply alcohol hand rub before leaving the patients room. After glove removal and hand washing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room, to avoid the transfer of microorganisms to other patients or environments. Wear a gown when entering all Contact precautions rooms. After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental surfaces .... Limit the movement/transport of patients from the room for essential purposes only. During transport, ensure that infected or colonized areas of the patient's body are covered and contained. Remove and dispose of contaminated PPE in the patient's room and perform hand hygiene prior to leaving the room.
The patient's therapeutic needs may require therapy or activity outside of the room. In this case the Infection Prevention Committee may be consulted if questions or concerns arise. When possible, dedicate the use of noncritical patient-care equipment for each patient. If use of common equipment is necessary, then adequate cleaning and disinfection is required prior to the use for another patient.

A review of Patient #6's medical record revealed a clean catch urinalysis ordered on 10/19/18 at 5:16 p.m. and resulted on 10/19/18 at 5:29 p.m. as positive for +4 bacteria, Culture? Yes. The final report resulted on 10/21/18 at 8:25 a.m. suggested, recollect, probable contaminant. Further review revealed an in-and-out catherization urinalysis ordered on 10/23/18 at 10:35 a.m. and resulted on 10/23/18 at 10:43 a.m., Culture? Not indicated. The test was negative for bacteria.

In an interview on 10/22/18 at 11:05 a.m., S25LPN indicated Patient #1 (in Room "b") was on contact precautions and confirmed the room did not have a sign designating Patient #1 was on contact precautions.

In an interview on 10/23/18 at 9:23 a.m., S3 COTA confirmed Patient #1 is on contact precautions, and she should have worn gloves while treating him. She indicated she thought Patient #1 was the only patient on contact precautions. When told that Patient #6's room door had isolation supplies on the door, she indicated she must be on precautions if supplies were on her door. She indicated patients on contact precautions were able to be taken to Room "f", as long as they're kept 2 feet from another patient.

In an interview on 10/24/18 at 12:50 p.m. with S1DON and S10LPN present, they both confirmed the observations documented above for 10/23/18 at 7:50 a.m., 8:05 a.m., 9:07 a.m., and 9:14 a.m. were breaches in contact precautions.

On 10/24/18 at 1:20 p.m. in an interview, S1DON stated Patient #6 has a pending urine culture, and the facility places patients with cultures ordered on contact precautions as a precautionary measure per their policy.

Hand hygiene:
On 10/22/18 at 11:09 a.m., an observation revealed S18LPN performed an accucheck on Patient #4 with the following steps: Accu-check taken, removed gloves, placed in pocket, no hand hygiene, and placed accucheck on desk in the nursing station.

Observation on 10/23/18 at 7:52 a.m. revealed S8CPh was in Room "e" drawing blood on Patient #17. The room door was open, observation revealed the phlebotomy tray was placed on the over bed table next to the patient's urinal. Upon completion of the blood draw, S8CPh was observed to remove her gloves, write on 3 labels and attach them to the 3 blood tubes ungloved, walk to the wall and turn off the light, pick up the phlebotomy tray, and exit the room without performing hand hygiene. She then walked to the nursing station and placed the contaminated phlebotomy tray on the nursing station counter and walked to the sink to wash her hands.

Observation on 10/23/18 at 9:11 a.m. in Room "f" revealed S9PTA removed her gloves after placing a weight on the rack. There was no observation of hand hygiene being performed after removing her gloves.

Review of CDC's "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings" revealed hand hygiene was to be performed before having direct contact with patients, after contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings, after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient), if hands will be moving from a contaminated-body site to a clean-body site during patient care, after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient, and after removing gloves.

In an interview on 10/23/18 at 7:55 a.m., S8CPh confirmed she didn't perform hand hygiene after removing her gloves before starting the next task, she had the phlebotomy tray next to Patient #17's urinal, and she placed the contaminated phlebotomy tray on the ledge of the nursing station. She confirmed these were breaches in infection control practice.

In an interview on 10/23/18 at 9:30 a.m., S9PTA confirmed she didn't perform hand hygiene after removing her gloves until she got to the nursing station. She confirmed that she should have done hand hygiene before leaving Room "f".

On 10/24/18 at 2:20 p.m., the findings related to S18LPN's failure to perform hand hygiene were verified by S1DON and S10LPN.

Sanitary environment:
On 10/22/18 between 11:00 a.m. and 11:15 a.m. the housekeeper was observed to don gloves, gown, and mask with a shield in the hall, enter Room "b", and exit the room with same PPE to get more cleaning supplies from the housekeeping cart in the hall. Continuous observation revealed the same procedure was conducted when the housekeeper entered and exited Rooms "c" and "g".

Observation on 10/22/18 at 10:40 a.m. in Room "a" revealed the dryer screen had an accumulation of lint. Further observation revealed a staff member exited the bathroom attached to Room "a". Further observation revealed the bath tub had a brown stain against the wall near the faucet. This observation was confirmed by S2LPC who was present during the tour. She confirmed the staff should not use the bathroom attached to Room "a".

Observation in Room "f" on 10/22/18 at 10:50 a.m. revealed a torn pillow on the bed/mat that prevented it from being disinfected. Further observation revealed the freezer had 2 large cold packs and had ice accumulated on both shelves. The temperature was observed to be 20 degrees F. when the log revealed that it should be maintained at < 0 degrees F. Further observation revealed next to the hand washing sink was 5 drinking tumblers, a pitcher, and 3 plastic storage containers, 2 of which had a lid. There was also a container with an unidentified liquid that contained combs, clippers, and scissors next to the sink. These observations were confirmed by S2LPC who was present during the tour.

On 10/22/18 observations between 10:40 a.m. and 11:15 a.m. revealed Room "c" had non-bagged respiratory tubing and and an oxygen concentrator without a label, and the respiratory tubing was laying on the table. Further observation revealed the wheelchair contained an oxygen tank on the back with a non-bagged respiratory tubing wrapped around the tank. Continuous observation revealed Room "g" had a non-bagged and unlabeled respiratory tubing on the oxygen concentrator.

Room "h"
Room "h" had non-bagged and unlabeled respiratory tubing on oxygen concentrator.

Observation on 10/23/18 at 8:03 a.m. revealed the freezer in Room "f" remained with a build-up of ice.

Observation on 10/23/18 at 9:14 a.m. in Room "f" revealed the cushion in the wheelchair being used by Patient #1 had a tear in the cushion which makes it unable to be disinfected.

In an interview on 10/22/18 at 10:50 a.m., S24TT indicated the liquid in the container with combs, clippers, and scissors was a disinfectant. She confirmed it was not labeled with the name of the liquid and the date when the disinfectant needed to be changed.

In an interview on 10/23/18 at 9:23 a.m., S3 COTA confirmed the wheelchair cushion was torn with the foam cushion exposed.

On 10/24/18 at 2:20 p.m., the related to the observations of the housekeeper were verified by S1DON and S10LPN.

3) Failing to ensure expired wound care dressings were not available for staff use:

On 10/22/18 at 11:05 a.m., an observation of the bottom drawer of the Wound Care Cart revealed 8 Adaptic Touch Non Adhering Silicone Dressings had expired 05/31/18 and were available for staff use.

In an interview on 10/22/18 at 11:05 a.m., S1DON verified the dressings were expired and available for staff use.

Based on record reviews and interviews, the hospital failed to ensure PT, OT, and ST services were provided by qualified therapists and assistants as evidenced by failure to have documented evidence of an evaluation of competency to perform specific skills for each discipline that was conducted by a staff member qualified to evaluated the competency for 4 (S3COTA, S4OTA, S5PTOT, S7SLP) of 4 staff/contracted therapists' and assistants' personnel files reviewed for competency.
Findings:

S3COTA
Review of S3COTA's personnel file revealed she was contracted on 01/16/13. Further review revealed her competency was evaluated on 04/11/18 by S2LPC. Further review revealed the evaluation included an evaluation of therapeutic interventions related transfers, positioning, feeding, splinting, paraffin bath, cryotherapy, and treatment approaches according to OT protocols and policies. S2LPC did not have the qualifications to evaluate the competency of a COTA.

S4OTA
Review of S4OTA's personnel file revealed she was contracted 03/06/17. Further review revealed her competency was evaluated on 04/12/18 by S2LPC. Further review revealed the evaluation included an evaluation of therapeutic interventions related transfers, positioning, feeding, splinting, paraffin bath, cryotherapy, and treatment approaches according to OT protocols and policies. S2LPC did not have the qualifications to evaluate the competency of an OTA.

S5PTOT
Review of S5PTOT's personnel file revealed he was contracted on 04/20/10. Further review revealed his PT and OT competency was evaluated on 04/12/18 by S2LPC and included an evaluation of precautions related to pressure relief, bed rest limitations, and hip precautions, use of safe treatment techniques related to transfers, positioning, feeding, splinting, paraffin bath, and cryotherapy, and utilization of treatment approaches according to established OT protocols and policies. Further review revealed S2LPC evaluated S5PTOT's competency related to his PT skills related to safety and treatment planning. S2LPC did not have the qualifications to evaluate the competency of a PT or OT. Further review revealed is PT competency was evaluated on
04/20/10 by a former staff PT. Further review revealed S5PTOT's personnel file revealed documentation of his PT and OT competency that was conducted by his supervisor at the agency from which he was contracted. There was no documented evidence that S5PTOT was evaluated for competency by a qualified hospital staff member in performing OT skills.


S7SLP
Review of S7SLP's personnel file revealed she was hired on 04/25/18. Further review revealed her competency assessment was conducted by S2LPC on 07/25/18 and included an assessment of following the medical regimen developed for patients, utilizing team approaches according to established SLP protocols and policies, selecting the proper diagnostic material to assess all aspects of communications or swallowing function, interpreting test correctly and making accurate assessments after considering pertinent information, and scheduling special procedures such as video fluoroscopy for modified barium swallows. S2LPC did not have the qualifications to evaluate the competency of a SLP.

In an interview on 10/24/18 at 10:10 a.m., S2LPC confirmed she supervises the therapists, and the Human resource Director manages their personnel files. She confirmed she had no competency evaluations for the therapist staff that had been performed by a qualified staff member. S2LPC acknowledged that she was not qualified to evaluate the competency of an OT, PT, COTA, and OTA.

Based on record reviews and interview, the hospital failed to ensure therapy services were provided under the orders of a qualified and licensed practitioner who was responsible for the care of the patient, acting within his/her scope of practice, as evidenced by having the OT initial evaluation conducted by a COTA rather than an OT for 2 (#2, #5) of 11 (#1 - 10, 12) patient records reviewed for an OT initial evaluation from a sample of 29 patients.
Findings:

Review of the policy titled "Occupational Therapy Scope Of Service", presented as a current policy by S1DON, revealed a responsibility of the OT was to perform an initial evaluation of each patient for whom rehabilitative services were ordered. There was no documented evidence that the policy allowed the initial evaluation to be conducted by a COTA.

Patient #2
Review of Patient #2's "Occupational Therapy Initial Progress Note" revealed the evaluation was documented and electronically signed by S3COTA on 10/18/18.

Patient #5
Review of Patient #5's "Occupational Therapy Initial Progress Note" revealed the evaluation was documented and electronically signed by S3COTA on 10/18/18.

In an interview on 10/22/18 at 3:53 p.m., S1DON confirmed the above OT evaluations were documented and signed by S3COTA. She further indicated the record revealed the evaluation was created by S5PTOT and revised by S3COTA. She confirmed there was no documented evidence, such as a signed OT evaluation, that S5PTOT had conducted the initial OT evaluation for Patients #2 and #5.