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Based on policy review, document review, observation and interview, it was determined the facility failed to ensure the Infection Control Officer implemented measures to maintain an active infection control surveillance program for the prevention, control and investigation of infections and communicable diseases.

The findings included:

1. The Infection Control Officer failed to ensure policies, procedures and plans to prevent sources and transmission of infectious and communicable diseases were maintained and implemented.
Refer to A 748

2. The facility failed to track and trend incidents related to infections and communicable diseases of personnel.
Refer to A 750

Based on policy review, medical record review, observation and interview, it was determined the facility failed to provide documentation to show less restrictive interventions had been attempted prior to the use of restraints for 1 of 1 (Patient #16) sampled patients with an Enclosed Bed restraint/lapboard.

The findings included:

1. Review of the facility's restraint policy documented the facility would utilize, "...measures to decrease or eliminate restraint use through least restrictive strategies..."

2. Medical record review for Patient #16 revealed "Restraint Assessment and Physician Order" forms dated 8/3/12, 8/4/12, 8/5/12, 8/6/12, 8/7/12, 8/8/12, 8/9/12, 8/10/12, 8/11/12, 8/12/12, 8/13/12 and 8/14/12 completed and signed by the physician for the patient to be placed in a Bed Enclosure and lapboard restraint. Under the area on the form titled "LESS RESTRICTIVE ALTERNATIVES (check all that apply)," the following were checked, "Increased supervision, monitoring, move the patient closer to nurses' station, upper side rails up for assistance with bed mobility and access to call bell, bed controls." There was no documentation increased patient supervision had been implemented, the patient had been moved closer to the nurses' station, or the patient's call light and bed controls had been placed within the patient's reach.

Review of the Daily Flowsheet/Treatment Records revealed under the area titled
Safety, the following non-restraint measures could be implemented prior to restraint use; bed alarm, chair alarm, self - releasing wheelchair belt, 2 or 3 side rails, low bed, and floor mats. There was no documentation these less restrictive alternatives had been attempted or implemented.

During an interview on 8/14/12 at 4:30 PM, the patient's wife stated she had never signed a consent form for the Bed Enclosure restraint and did not know what it was being used for.

During an interview in the conference room on 8/15/12 at 9:25 AM, when asked if Patient
#16 had sustained a fall since admission, the Chief Nursing Officer (CNO) stated, "Not that I'm aware of..." She further stated restraints may be used for patient safety, and for wandering in and out of their rooms. "Patients are free to roam about their room but if getting into roommate's things..."

During an interview in the conference room on 8/15/12 at 9:30 AM, the CNO verified the facility failed to have documentation to show less restrictive interventions were attempted prior to placing Patient #16 in the Enclosure bed or use of the lapboard.

Based on medical record review and interview, the facility failed to modify the care plan with interventions and monitoring for 1 of 1 (Patient #16) sampled patients with restraints.

The findings included:

1. Review of the facility's "Use of Restraints in Non-Psychiatric Hospital" policy revealed the following: "...Specific Interventions guiding the application and use of restraints and monitoring of patients in restraints will be incorporated into the patient's Plan of Care..."

2. Review of the plan of care for Patient #16 dated 8/7/12 revealed under the area titled Safety System, an Enclosure Bed restraint was being used on the patient. There was no documentation of specific interventions guiding the application and use of restraints, and no documentation how often the restraints would be monitored.

3. During an interview in the conference room on 8/14/12 at 3:30 PM, the Chief Nursing Officer verified the plan of care should document application guidelines, and how often assessments and monitoring should be done.

Based on review of facility policy, medical record review and interview, the facility failed to document all safety monitoring assessments for 1 of 1 (Patient #16) sampled patients with restraints.

The findings included:

1. Review of the facility's "Use of Restraints in Non-Psychiatric Hospital" policy revealed in the Monitoring column, "...Every 2 hour monitoring through observation, interaction, direct examination, Monitoring is to include: Level of distress/agitation, Mental status, Cognitive function Vital signs (as appropriate), Hydration, nutrition, elimination needs, Positioning needs, ROM, Circulation and skin condition..."

2. Medical record review for Patient #16 revealed no documentation on the Daily Flowsheet/Treatment Record dated 8/8/12 of skin circulation checks from 16:00 to 19:00.

On 8/12/12 there was no documentation of the patient's "Response to Safety Measures", and if the patient were "Calm, Agitated, Sleeping" from 16:00 to 23:00. There was no systematic documentation of supervised release of the restraints.

3. During an interview in the conference room on 8/14/12 at 3:30 PM, the Chief Nursing Officer verified the facility had failed to document every 2 hour monitoring for Patient #16 and failed to document supervised release of the restraints on a scheduled time basis.

Based on document review, medical record review, observation and interview, the facility failed to ensure nursing care was provided as ordered by the physician for 4 of 30 (Patients #7, 9, 11 and 22) sampled patients.

The findings included:

1. Review of the Governing Body minutes revealed a Memo to all employees dated January 31, 2012 regarding "Isolation Communication." The memo documented, "...In order to provide effective isolation communication to all departments, we will be implementing a new procedure: ...There will be an Infection Control Alert sign put on both the door to the patient's room...There will still be a strip located outside the patient's door as well... It will be necessary for the RN to... implement the steps listed above..."

2. Medical record review for Patient #7 revealed the patient was admitted to the facility on 8/8/12 with diagnoses that included Malignant Brain Neoplasm and Basal Cell Carcinoma. Documentation in the medical record revealed a recent significant weight loss of more than 20 pounds. Review of Physician Orders dated 8/9/12 revealed a physician's order to weigh the patient every day.

Review of the Clinical Information Record revealed no documentation of a recorded weight for the patient on 8/9/12, 8/10/12, 8/11/12 or 8/12/12.

During an interview in the conference room on 8/14/12 at 3:30 PM, the Chief Nursing Officer (CNO) verified the facility had failed to follow the physician's order to weigh the patient every day.

2. Medical record review for Patient #9 revealed the patient was admitted to the facility on 7/31/12. Review of Physician Orders dated 8/5/12 revealed, "O2 (oxygen) @ (at) 2 L (liters)/ (per) min (minute) BNC (by nasal cannula) ..."

Observation of the patient on 8/13/12 at 1:00 PM revealed the patient was in their room sitting in wheelchair, and in the Physical Therapy Department at 3:10 PM. There was no observation of oxygen in use.

During an interview on 8/13/12 at 1:05 PM, the patient confirmed oxygen is not used during the day but sometimes staff put it on at night.

During an interview in the conference room on 8/13/12 at 4:00 PM, the CNO verified the physician's order was written for the patient to wear the oxygen continuously. The CNO verified the facility failed to follow the physician's order.

3. Review of the medical record for Patient #11 revealed on a physician's order dated 8/6/12 for the patient to have, "...O2 @ 2L BNC - keeps O2 sats [saturations] >92%..." Review of the "Clinical Information Record" revealed no documentation O2 sats were performed 8/11/12 and 8/12/12.

During an interview at the nurses' station on 8/14/12 at 10:55 AM, the CNO was asked to review the patient's medical record. The CNO stated, "...Don't see O2 sats for 8/11 or 8/12 expect them to be done every day..."

4. Medical record review for Patient #22 revealed an admission date of 8/3/12. Review of physician's orders dated 8/6/12 included, "Add daily weights." Review of physician's orders dated 8/9/12 revealed, "...C. diff antigen (+) [positive]. Routine contact precautions..."

Review of the "Clinical Information Record" revealed no documentation patient weights were recorded on 8/6/12, 8/7/12 or 8/8/12.

Observations on 8/14/12 at 8:45 AM and at 9:30 AM in the patient's room revealed no isolation gowns in the room. There was no observations an isolation sign was on the door of patient's room.

Based on policy review, medical record review and interview, the facility failed to ensure care plans were updated to reflect current treatments and diagnoses for 5 of 30 (Patient #1, 3, 7, 9 and 22) sampled patients.

The findings included:

1. Review of the facility's "Plan of Care Policy" documented, "...Each body system or functional area will have identified problems documented, followed by specific interventions identified to meet the needs of the patient..."

2. Review of the Plan of Care for Patient #1 dated 8/13/12 revealed no documentation the patient had C-diff or gastrointestinal problems.

During an interview in the conference room on 8/14/12 at 10:25 AM, the Chief Nursing Officer (CNO) was asked to review Patient #1's Plan of Care. The CNO confirmed there was documentation of a plan of care for the patient's C-diff or gastrointestinal problems. The CNO stated, "...It is not there...Yes, she came in with it [C-diff] expect it to be on the care plan..."

3. Medical record review for Patient #3 revealed an admission order dated a 8/2/12 for a "Foley Catheter". Review of Patient #3's Plan of Care dated 8/2/12 revealed no documentation of problems with Genitourinary system or a Foley catheter.

During an interview in the conference room on 8/14/12 at 10:45 AM, the CNO was asked to review Patient #3's Care Plan. The CNO confirmed there was no documentation of a plan of care for the Foley catheter or the Genitourinary system.

4. Review of the physician's orders for Patient #7 dated 8/19/12 revealed an order to weigh the patient daily. There was no documentation on the Plan of Care to weigh Patient #7 every day.

During an interview in the conference room on 8/14/12 at 3:30 PM, the CNO verified the facility had failed to update the Plan of Care to weigh Patient #7 every day.

5. Medical record review for Patient #9 revealed a physician's order dated 8/5/12 for, "O2 [oxygen] @ [at] 2 L [liters] / [per] min [minute] BNC [Binasal Cannula]..."

Review of the plan of care revealed under the heading, "Assistive Devices," the area "Oxygen Use" was checked. There was no documentation of the frequency of oxygen use, the flow liter rate, or if it was to be administered by nasal cannula, mask, Tracheostomy, CPAP/BIPAP or ventilator.

During an interview in the conference room on 8/14/12 at 3:30 PM, the CNO verified the facility had failed to update the Plan of Care for Patient #9 to include the oxygen frequency, flow rate or means of administration, and had failed to document O2 sat results every 12 hours.

6. Medical record review for Patient #22 revealed an admission date of 8/3/12. Review of "Doctors Progress Notes" dated 8/6/12 revealed, "...loose stools reported...Diarrhea (check) for c. diff [Clostridium difficile]..." The 8/10/12 physician's progress notes documented, "...c/o [complain of] fecal incontinence 2 [secondary] c diff..." On 8/13/12, "...C diff - Vanc [Vancomycin] x [times] 7 days/diarrhea..." A physician's order dated 8/12/12 revealed the patient was "...incontinent dribbling and diarrhea causing burning pain..."

Review of the Interdisciplinary Plan of Care for Patient #22 revealed "Incontinence" was the only problem identified with the gastrointestinal (GI) system. 'Diarrhea' and 'C Difficile' were not identified or addressed as problems on the patient's plan of care.

Based on policy review, document review, observation and interview, it was determined the facility failed to secure confidential patient information.

The findings included:

1. Review of the facility's "Information Management Plan 2012" documented, "...Confidentiality and Security Information and Data Privacy, Confidentiality, Security and Integrity...Assures information and privacy are maintained for all patients..."

2. Observation at the nurses' station on 8/13/12 at 12:45 PM revealed an unattended "Interdisciplinary Team A Report" form on a clip board laying face up on top of medication cart A. The information on the report contained patient's room number, dx (diagnosis), diet, treatments and labs.

3. Observation at the nurses' station on 8/13/12 at 2:00 PM revealed an unattended "Interdisciplinary Team A Report" on a clip board laying face up on top of the medical record chart cart. The information on the report contained patient's room number, dx, diet, treatments and labs.

4. During an interview at the nurses' station on 8/13/12 at 12:45 PM, Nurse #2 was asked about the unattended clip board with her name on it with the Interdisciplinary Team A Report laying face up on top of the medication cart A. Nurse #2 stated, "...Oh, normally keep this turned over..."

Based on document review, medical record review and interview, it was determined the facility failed to ensure consultation reports were filed in the medical record for 1 of 30 (Patient #3) sampled patients.

The findings included:

1. Review of the facility's, "Content of Medical Record" policy revealed, "...The medical record must contain results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient...."

2. Review of the "Medical Staff Rules and Regulations" revealed, "...Consultation shall show evidence of a review of a patient's record By the consultant, pertinent findings on examination of the patient, and the consultant's opinion and recommendations. This report shall be recorded within 72 hours of the order..."

3. Medical record review for Patient #3 revealed the patient was admitted to the facility 8/2/12. A physician's order dated 8/7/12 revealed, "Psychology consult - cognitive eval [evaluation]." Medical record review on 8/14/12 revealed no documentation of a psychology consult for this patient.

4. During an interview in the conference room on 8/14/12 at 10:45 AM, the Chief Nursing Officer (CNO) verified there was no evidence a psychology consultation had been completed. She stated the nurse who noted the order was responsible for notifying the consulting physician and placing a copy of the order in the physician's box.

Based on policy review, observation and interview, it was determined the facility failed to keep medications secured and locked.

The findings included:

1. Review of the facility's "Medication Storage" policy documented, "...All approved medications shall be stored in a secure area upon time of receipt by an individual health care provider until time of admission...IV medication will be stored in a designated area, which will be kept locked at all times..."

2. Observation in the hall outside Room 318 on 8/13/12 at 12:40 PM, revealed an unlocked unattended wound treatment cart. In the top left drawer of the cart were two 5 ml prefilled syringes of Heparin Lock Flush 100 u (units)/ml (milliliter) and one 10 ml prefilled syringe Normal Saline. In the third drawer of the cart was an opened bottle of Normal Saline irrigation and an opened bottle of Hydrogen Peroxide.

3. During an interview in the hallway outside Room 318 on 8/13/12 at 12:40 PM, Nurse #3 confirmed the medication was in the unlocked, unattended wound treatment cart.

Based on document review, policy review, observations, and interview, it was determined the Infection Control Officer failed to ensure polices, procedures and infection control plans were implemented and maintained in order to ensure a sanitary environment to avoid sources and transmission of infectious and communicable diseases.

The findings included:


1. Review of the facility's "2011 Annual Infection Control/Employee Health Program Plan and 2012 Annual Infection Control/Employee Health Program Plan" documented, "...Direct observation of foley catheter insertion and foley catheter care...Blood-borne Pathogens develop a self study initial orientation packet...Review the isolation communication process between nursing, therapy and other pertinent disciplines..." The Annual Infection Control/Employee Health Program Plan were identical no revisions or modifications. There was no documentation that an evaluation had been performed of the 2011 Program Plan. Neither the 2011 or 2012 Annual Infection Control/Employee Health Program Plan had been signed off by the authors Infection Control Coordinator or the Medical Director.

During an interview in the conference room on 8/14/12 at 4:00 PM, when asked about the 2011 and 2012 Annual Infection Control/Employee Health Program Plan, the Infection Control Coordinator stated, "...No, I have not signed it nor has the Medical Director...No, I have not implemented or are performing surveillance as stated on the plan of direct observation of foley catheter insertions and foley catheter care...No, I am not doing surveillance of isolation patients and compliance of staff to wearing PPE...No, I don't review isolation communication between nurses and other disciplines...No, there is no self study initial orientation packet...No, I don't do surveillance of equipment disinfection..." The CNO stated, "...No, an evaluation of the 2011 Program had not been completed...Yes, the 2012 Program Plan was an exact replica of the 2011 Program Plan..."

2. Review of the facility's "2012 Infection Control Risk Analysis" documented, "Issue: Adherence to Isolation Policies...Total 9 [high priority]...Action: Isolation policies monitored; Isolation stations for all patients on precautions...Issue: Clostridium difficile (C-diff)...Total 8 [high priority]...Actions: Contact precautions: private room if active. Soap and water for handwashing...Issue: Adherence to Isolation Protocol...Total 8 [high priority]...Action: Isolation Protocols for infection..."

During an interview in the conference room on 8/14/12 at 4:00 PM, when asked based on what the facility identified as High Priority are these Isolation priorities being monitored, the Infection Control Coordinator stated, "...No, I don't do surveillance to see if the staff adhere to Isolation policies of staff wearing PPE, handwashing, signage or supplies...No, I don't monitor practice of staff with a patient in isolation or the cleaning of the equipment or the environment..."

During an interview in the conference room on 8/14/12 at 4:00 PM, when asked based on the "Risk Analysis" the facility identified as High Priority Isolation and Adherence to policies, practices and protocols was Isolation being monitored for this, the Chief Nursing Officer (CNO) stated, "...No, We don't have a process we need to work on this..."

3. Review of the facility's "Quality Metrics Report 2012" Infection Control department form documented, "...Target: TBD [to be determined]..." The following infection control indicators had no target or threshold for each infection control indicator and no documentation of any comments/negative variance explanation or action plans:
Healthcare Associated Infection Rate - Q [quarter] 1 results were 2.2, and Q 2 results were 2.9.
MDRO [multidrug resistant organism] C-diff - Q 1 results were 0.3, and Q 2 results were 0.3.
Surgical site Infections - Q 2 results were 0.8.
HA [hospital acquired] UTI [urinary tract infection] - indwelling catheter related - Q 2 results were 0.7.
HA UTI non catheter related - Q 1 results were 1.8, and Q 2 results 1.1.

During an interview in the conference room on 8/14/12 at 4:00 PM, the CNO and the Infection Control Coordinator confirmed for Infection Control Indicators there were no targets/thresholds documented and no comments/negative variance explanation or action plans. The CNO confirmed it was data with no plan or interventions documented based on the findings. The CNO stated, "...No, We don't have any infection control benchmarks, targets or thresholds documented..."

4. Review of the facility's "Safety/Risk Management/Infection Control Committee" minutes for 2012 contained no documentation of Infection Control reporting thresholds, benchmarks, action plans, interventions or evaluation of the program.

During an interview in the conference room on 8/14/12 at 4:00 PM, the CNO, Infection Control Coordinator and Quality Officer was asked if there was documentation of evaluation of the infection control program, indicators and if based on the data had any action plans or interventions been put in place. The CNO stated, "...No, there is no action plan, interventions or evaluations of interventions, just data..." The Quality Officer stated, "...No..."

5. Review of the facility's "Quality Council" minutes 4/19/12 contained no documentation in the minutes of the topic of Infection Control or discussions of Infection Control.

During an interview in the conference room on 8/15/12 at 9:40 AM, the Quality Officer confirmed there was no documentation in the Quality Council minutes on 4/19/12 of Infection Control.

6. Review of the facility's "Governing Body" minutes dated 5/24/12 and 8/2/12 contained no documentation of Infection Control reporting benchmarks, action plans, interventions or evaluation of the program.

During an interview in the conference room on 8/14/12 at 4:00 PM, the CNO confirmed the Board was not communicated with concerning benchmarks, action plans, interventions or evaluation of those interventions or of the Infection Control Program. The CNO stated, "...I know that is not adequate...We need to work on reporting more than data..."

7. Review of the facility's "Infection Control: Transmission Based Precautions" policy documented, "...Gloves and Handwashing: Wear gloves when entering the room...remove gloves before leaving the patient's environment and wash hands immediately with an antimicrobial agent...Gowns: When entering the room if it is anticipated that clothing will have substantial contact with the patient, environmental surfaces, items in the room, or if the patient is incontinent, has diarrhea..."

8. Review of the facility's "Isolation Precautions" policy documented, "...Handwashing: Even though gloves are worn, hands must be washed before and after caring for a patient on isolation precautions. Hands should always be washed between patients..."

9. Review of the facility's "Clostridium Difficile (C-diff) Discontinuation of Isolation Procedure" policy documented, "...All patients admitted to the facility with suspected C. diff shall be placed on Contact "STOP" Isolation until two (2) negative cultures are obtained or, after being treated with an appropriate course of antibiotics...Maintain Contact Isolation for all culture-positive patients or after appropriate antibiotic therapy...When they finish the recommended course of antibiotics and remain asymptomatic, isolation may be discontinued...Reinforce strict handwashing...Hands should be washed with antimicrobial soap and water...Alcohol hand sanitizers are not to be used..."

10. Medical record review for Patient #1 documented a physician's order dated 8/8/12 for C-Diff Isolation.

Observation in Patient #1's room on 8/14/12 at 8:25 AM, revealed Nurse #1 entered the room, administered a nebulizer treatment to the patient, and exited the room. There were no observations Nurse #1 washed her hands when entering the room, or wore personal protective equipment (PPE). Upon exiting the room, Nurse #1 used alcohol hand sanitizer instead of washing her hands with soap and water.

On 8/14/12 at 9:25 AM, Therapy staff #1 entered Patient #1's room. There were no observations the Therapy staff washed their hands upon entering, wore gloves while in the patient's room, or washed their hands prior to exiting the room.

On 8/14/12 at 9:30 AM, Nurse #1 entered Patient #1's room and changed the patient's clothes and bed linens. There were no observations the Nurse wore PPE while in the patient's room.

During an interview outside Patient #1's room on 8/14/12 at 8:25 AM, when asked what PPE should be worn when caring for a patient with C-diff in Contact Isolation and what handwashing is to be performed, Nurse #1 stated, "...I just put her on a neb [nebulizer] treatment...No, I did not wear gloves, I should have...No, there are no gowns in the room I would have to walk down the hall and get one from the other room...I only wear a gown if a lot of BM [bowel movement]...I used hand sanitizer to wash my hands I should have used soap and water..."

11. Medical record review for Patient #22 revealed an admission date of 8/3/12. Review of the physician's orders dated 8/9/12 revealed, "Vancomycin 250 mg [milligrams] TID [three times a day] x [times] 7 days. C. diff antigen (+) [positive]. Routine contact precautions..." Review of physician's orders dated 8/12/12 revealed, "...incontinent ...diarrhea causing burning pain..." Review of "Doctor's Progress Notes" dated 8/13/12 at 10:30 revealed, "...C diff - Vanc [Vancomycin] x 7 days/diarrhea..."

Observations on 8/14/12 at 8:45 AM revealed Patient #22 shared a room with 2 other patients. There was not an "Isolation Sign" on the patient's room door. There were no observations of PPE gowns in the patient's room. Certified nursing assistant (CNA) #1 was observed entering the patient's room and pulling open the curtain around Patient #22's bed, The CNA then left the room prior to washing his hands. CNA #1 returned to the room, put on a new pair of gloves prior to washing his hands, and picked up soiled linen from the patient's wheelchair. The CNA put heel-pads on the patient, and placed a blanket across the patient. CNA #1 then removed his gloves and proceeded to care for the patient without washing his hands. The CNA charted on the patient's chart prior to washing his hands. A nurse was observed carrying the soiled linen out of the patient's. There was no observation the nurse washed her hands after placing the soiled linen in the biohazard room.

Based on document review and interview, the facility failed to maintain a log of incidents related to employee infections and communicable diseases.

The findings included:

1. Review of the facility's "PTO [paid time off] Request form/Holiday request form" documented, "...for Illness tracking report diarrhea, nausea/vomiting, fever, flu/cold, sinus, scheduled Dr's Appt [appointment], personal/unable to explain..."

2. Review of the facility's "2012 Safety/Risk Management/Infection Control Committee", "2012 Quality Council" and "2012 Governing Body" minutes contained no documentation of employee infection control illness reporting, tracking or trending.

3. During an interview in the conference room on 8/15/12 at 11:25 AM, the Human Resource (HR) Director was asked if the facility maintained a log of incidents related to infections and communicable diseases of employees. The HR Director stated, "...We have the supervisors or employees fill out the PTO request form but I just keep the form in my office...I don't do anything with it...No, we are not tracking, logging, reporting or trending employee illness..."