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Based on staffing schedule review and interview, the hospital failed to ensure the RN was assigned to one unit to provide immediate availability for bedside care of a patient. This deficient practice was evidenced by having S2RN assigned as charge nurse for both the rehabilitation hospital and the skilled nursing facility.

Findings:

Review of the staffing schedules for September 2021 revealed S2RN (contract nurse) was working on 09/30/2021.

S2RN was interviewed on 09/30/2021 at 9:30 a.m. during observations of the inpatient care area of the rehabilitation hospital. S2RN confirmed she was assigned as charge nurse for both the rehabilitation hospital and the skilled nursing facility. She explained she worked for a staffing agency that provided nursing coverage for the hospital and was not directly employed by the hospital. She further explained she worked at this hospital and also had travel assignments


In an interview on 10/01/2021 at 11:00 a.m., with S3DON, she confirmed S2RN was assigned as charge nurse for the skilled nursing facility side and the rehabilitation hospital side. S3DON further confirmed S2RN was an agency nurse.

Based on observation, record review and interview, the registered nurse failed to ensure the nursing care for each patient was supervised and evaluated. This deficient practice was evidenced by failure to ensure the appearance of PICC insertion sites and PICC line dressing changes were documented in the patient record, per hospital policy,
for 2 (#1, #3) of 3 (#1, #2, #3) sampled patients reviewed for indwelling PICC lines from a total patient sample of 5.

Findings:

Review of the hospital policy titled,"Central Line Management", revealed the following: 1. Dressing Changes: b. Procedure: xvi. Document the dressing changes and site appearance in the medical record. d. Dressing change intervals iii. The hospital will determine the day of standard dressing changes changes: every Sunday (every 7 days).

Patient #1
On 09/30/2021 at 9:30 a.m., Patient #1's left upper arm PICC line was observed. The dressing was clean, dry and intact. Further observation revealed the dressing was labeled as being changed on 09/26/2021 and initialed by the nurse that changed the dressing.

Review of Patient #1's nursing assessment for 09/26/2021 revealed no documentation of the dressing change for the PICC line and no documentation of the appearance of the insertion site once the dressing was removed during the dressing change.

An interview was conducted with S1QA/IC on 09/30/2021 at 2:00 p.m. She reported if the PICC line dressing was indicated as changed on 09/26/2021, the nursing assessment for 09/26/2021 should indicate the dressing was changed and a description of the PICC line site. S1QA/IC confirmed with review of the nursing documentation for 09/26/2021, there was no documentation the PICC line dressing was changed and no documentation of the PICC line insertion site.

Patient #3
On 09/30/2021 at 12:48 p.m. Patient #3's Left upper arm PICC line was observed. The dressing was clean, dry, and intact. Further observation revealed the dressing was not labeled to indicate the date and time the dressing had been placed and also failed to have the initials of the staff member who had dressed the PICC line.

Review of Patient #3's medical record revealed an admission date of 09/15/2021. Further review revealed the patient had a PICC line in her left upper arm. Additional review revealed no documented evidence that PICC dressing changes, including the appearance of the insertion site, had been performed and documented in the patient's medical record as of 09/30/2021.

In an interview on 10/01/2021 at 8:30 a.m. with S1QA/IC, she reported PICC dressing changes were performed every 7 days, on Sunday, by the RN Charge Nurse. She further confirmed PICC dressing changes, including the appearance of the insertion site, should have been documented in the patient's medical record. S1QA/IC reported the RN Charge Nurse must have forgotten to document the dressing changes in the patients' medical records.

In an interview on 10/01/2021 at 11:00 a.m. with S3DON, she confirmed PICC dressings are changed every 7 days. S3DON indicated she did not chart PICC line dressing changes in the patients' medical records when she performed dressing changes.

Based on record review and interview, the RN failed to ensure the nursing care of each patient was asssigned to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the available nursing care staff. This deficient practice was evidenced by:
1.failure to maintain documented evidence of skills competency evaluations for performing nebulizer respiratory treatments , including disinfection of the nebulizer after patient use, for 4 (S2RN, S3DON, S5RN, S6LPN) of 4 personnel reviewed for nebulizer respiratory treatment competencies; and 2. failure to maintain documentation of new employee skills compency evaluations for 1 (S6LPN) of 1 new employee personnel records reviewed.

Findings:

1.Failure to maintain documented evidence of skills competency evaluations for performing nebulizer respiratory treatments, including disinfection of the nebulizer after patient use.

Review of personnel records for S3DON, S5RN, and S6LPN revealed no documented evidence of skills competency evaluations for performing nebulizer respiratory treatments, including disinfection of the nebulizer after patient use.
S2RN, a non-employee licensed nurse did not have a hospital personnel record to review and had no hospital skills competencies for review per S7Adm.

In an interview on 10/01/2021 at 11:00 a.m. with S3DON, she confirmed nursing staff performed patients' nebulizer respiratory treatments. S3DON reported she wasn't sure if nurses were assessed for competency in performance of nebulizer respiratory treatments during orientation and she did not remember competency evaluations for nebulizer use in the hospital's annual skills fair. S3DON indicated using a nebulizer is a skill you usually learn in nursing school. S3DON reported disinfection of re-useable equipment, such as nebulizers, was not covered in orientation and was not part of the annual skills fair either.

2. Failure to maintain documentation of new employee skills competency evaluations.
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Review of S6LPN's personnel documents, provided by S7Adm, revealed no documented evidence of skills competency evaluations.

In an interview on 10/01/2021 at 1:30 p.m. with S1QA/IC, she reported S6LPN was a new employee and had been working at the hospital for 2 weeks. S1QA/IC indicated S6LPN had 30 days to complete her skills competency checklists. S1QA/IC reported skills competency checklists for new employees were kept by the nurse being oriented and the hospital did not keep a copy. She said new employees brought their checklists to work with them when they work and they are checked off by their preceptor when tasks have been completed. S1QA/IC indicated S6LPN was not working on 10/01/2021 so they did not have a copy of her skills competency checklist for the surveyor to review.

In an interview on 10/01/2021 at 1:50 p.m. with S7Adm, he indicated new nurses usually had 3 days with a preceptor and then they worked independently. S7Adm indicated S6LPN was assigned different preceptors when she worked. S7Adm confirmed new nurses worked independently prior to completing their skills competency evaluations due to having 30 days to complete their skillls competency checklists.

Based on observation, record review, and interview, the hospital failed to ensure non-employee licensed nurses working in the hospital were oriented and evaluated for competency for 1 (S2RN) of 1 sampled contracted staff personnel record reviewed.

Findings:

On 09/30/2021 at 9:50 a.m. S2RN was observed working in the inpatient rehabilitaiton hospital.

Review of the hospital staffing schedule for 09/2021 revealed S2RN had worked on 09/02/2021, 09/03/2021, 09/08/2021, 09/13/2021 - 09/15/2021, 09/23/2021 - 09/26/2021, and 09/30/2021.

In an interview on 09/30/2021 at 9:50 a.m. S2RN reported she was an agency nurse and she was assigned as charge nurse for both the rehabilitation hospital and the skilled nursing facility. She explained she worked for a staffing agency that provided nursing coverage for the hospital and was not directly employed by the hospital. She further explained she worked at this hospital but also had travel assignments.

On 10/01/2021 at 10:50 a.m. S2RN's personnel file was requested for review from S7Adm. S7Adm reported he did not have a personnel file for S2RN. He confirmed the hospital had not performed skills competency evaluations for S2RN. He indicated he would request S2RN's skills competency evaluation from the staffing agency.

In an interview on 10/01/2021 at 11:00 a.m. with S3DON, she indicated agency nurses (non-employee licensed nurses) received no hospital orientation and skills competency evaluations of agency staff were not performed through this hospital. S3DON further indicated she wasn't sure if the staffing agency provided documentation of skills competencies for agency nurses to the hospital.

On 10/01/2021 at 2:20 p.m. S7Adm reported the staffing agency had only sent over documentation of S2RN's current RN licensure and had failed to provide documentation of S2RN's agency skills competency evaluation.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with accepted standards of practice, the orders of the practitioner responsible for the patient's care and hospital policy. This deficient practice was evidenced by failure to administer medications as ordered by the pracitioner for 2 (#2, #4) of 5 (#1, #2,#3,#4, #5) sampled medical records reviewed for medication administration.

Findings:

Review of the hospital policy titled, "Unavailable Medications", revealed the following, in part: This facility shall use uniform guidelines for unavailable medications.
Policy Explanation and Compliance Guidelines:
1. The facility maintains a contract with a pharmacy provider to supply the facility with routine, as needed, and
emergency medications.
2. A STAT supply of commonly used medications is maintained in-house for timely initiation of medications.
3. The facility shall follow established procedures for ensuring patients have a sufficient supply of medications.(See Medication Reordering Policy.)
4. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable.
a. Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication.
b. Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring patients while medication is on hold.
c. Determine whether patient has a home supply. Obtain orders to use home supply.Administer first dose after pharmacist has verified that the medication is correct with respect to name, dose,and form of medication.
5. If a patient misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the patient for adverse reactions to omission of the medication.

Patient #2
Review of Patient #2's medical record revealed the patient was admitted on 09/22/2021.

Review of Patient #2's MAR, dated 09/22/2021, revealed 7:00 p.m. doses of Prograf, ordered as 4 mg po every am and evening and Cellept ordered as 250 mg po BID were circled (indicating the medications were not given) with handwritten notes by each medication indicating the medications were not available. Further review revealed no documented evidence that the contracted pharmacy had been contacted to inquire about whether the medications could be provided. Additional review revealed there was no documented evidence the physician had been notified about the unavailability of the ordered medications.

In an interview on 09/30/2021 at 2:00 p.m. with S1QA/IC, she reviewed Patient #2's medical record and indicated she was not sure why the medication doses were circled as not given and marked as unavailable. She indicated the nurse should have called the hospital's contracted pharmacy to find out if the medications could be provided. She reported if the medication could not be delivered then the physician should have been notified and orders obtained to hold the dose. She confirmed notification should have been documented in the chart and verified it was not documented.

In an interview on 10/01/2021 at 8:30 a.m. with S1QA/IC, she indicated an incident report should have been generated for missed doses of medications, transcription errors, or late administration of medications. She confirmed there was no incident report generated for Patient #2's missed doses of medication on 09/22/2021 at 7:00 p.m.

In an interview on 10/01/2021 at 10:13 a.m. with S4Pharm, he reported the contracted pharmacy is available 24 hours a day/7 days a week, including weekends and holidays. He further reported scheduled medication deliveries to the facility occurred 2 times a day Monday - Friday and deliveries on Saturday and Sunday were as needed and not at set scheduled times like on weekdays. S4Pharm indicated they can deliver at other times between or after scheduled delivery times and if it is something the hospital needs right away they can get it from another local contracted pharmacy. He explained they also have a relationship with an area hospital for medications that they don't have at his pharmacy. If a medication is a new order due before the next scheduled delivery and they are made aware of it, they may send out an earlier stat delivery. S4Pharm was asked specifically about the medications Prograf and Cellept indicated as not available at 7:00 p.m. on the day of admit for Patient #2. He reported they would have had Prograf and Cellept in stock. He indicated the facility could have called them to ask if it was out for delivery and when the delivery was projected to arrive. He indicated his pharmacy could have called the driver to find out what their expected time of arrival was. S4Pharm reported they could have sent someone back or called the local pharmacy they were contracted with and could have gotten it from there. He explained if it was something non-formulary, or otherwise unavailable, then the hospital should have notified the physician to get approval to hold the dose.

In an interview on 10/01/2021 at 11:00 a.m. with S3DON, she indicated the hospital's contracted pharmacy was available 24 hours a day/7 days a week. S3DON reported if she needs a medication that is not in her stock she calls the pharmacy and asks them to bring the medication. S3DON further reported she would also call the physican if the medication is unavailable. She confirmed all communications should be documented in the patient's medical record. S3DON indicated, in theory, a missed dose incident report should be generated when medication doses are missed.
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Patient #4
Review of the MAR dated 09/24/2021 for Patient #4 revealed no documentation the patient's day shift medications (7:00 a.m. to 6:59 p.m.) were administered. The following medications were scheduled for 07:00 a.m. on 09/24/2021: ASA 81 mg po daily, Bupropron 300 mg po daily, Escrtalopram 30 mg po daily, Fluticasone 50 mcg 1 spray each nares daily, Lasix 40 mg po daily, Metoprolol 25 mg po daily, Omeprazole 40 mg po daily, Macrobid 100 mg po BID, Novasc 5 mg po daily and Lantus 10U SQ BID. Senna 17.2 mg po daily was scheduled for 5:00 p.m. and was not documented as administered.

An interview was conducted with S1QA/IC on 09/24/2021 at 2 p.m. Patient #4's MAR dated for 09/24/2021 was reviewed with S1QA/IC, she was unable to determine if Patient #4 was administered her medications on the day shift of 09/24/2021.


30984

30984


Based on observation, record review, and staff interview, the hospital failed to ensure the infection prevention and control program, as documented in its policies and procedures, employed methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings.This deficient practice was evidenced by:
1. failure to ensure PICC dressings were dated, timed, and initialed when the lines were inserted and/or dressings changed, as per hospital CLABSI Prevention Guidelines for PICC lines, to reduce the risk of catheter associated blood line infections for 2 (#2, #3) of 3 sampled patient PICC lines observed; and
2. failure to ensure extended use IV tubing was dated, timed, and initialed when hung, as per hospital policy, to reduce the risk of IV associated infections for 3 (#1, #2, #3) of 3 observed sampled patients receiving antibiotics.

Findings:

1.Failure to ensure PICC dressings were dated, timed, and initialed when they were inserted and/or changed, as per hospital policy.

Review of the hospital's CLABSI Prevention - PICC Care Competency Checklist for infection control in PICC lines revealed the following: Change dressing every 7 days and when soiled or dressing is loose. Clean site with Chloraprep for 30 seconds and allow to dry. Clean from insertion site to distal extremity using friction. Label dressing with date, initials, and catheter type.

Patient #2
Review of Patient #2's medical record revealed an admission date of 09/22/2021.

On 09/30/2021 at 12:45 p.m. an observation was made of Patient #2's PICC line located in his right upper arm. The PICC dressing was not labeled with the date, time, or initials of the person who dressed the line. Patient #2 was interviewed during the observation and he reported the PICC line had just been placed on 09/28/2021 for antibiotics.

Patient #3
Review of Patient #3's medical record revealed the patient was admitted on 09/15/2021. There was no documented evidence the patient's medical record that PICC line dressing had been changed since the patient's admission.

On 09/30/2021 at 12:48 p.m. Patient #3's left upper arm PICC line was observed. Further observation revealed the dressing was not labeled to indicate the date and time the dressing had been placed and also failed to have the initials of the staff member who had dressed the PICC line.

In an interview on 10/1/2021 at 08:30 a.m. with S1QA/IC, she confirmed PICC dressing changes were performed by the charge nurse every 7 days, on Sunday. She reported she thinks the charge nurse must have forgotten to document the dressing changes. She confirmed saff should be documenting dressing changes in the patients medical records including appearance of PICC insertion site. She further confirmed the dressings should have the date, time, and initials of the person changing them in order to identify when the dressing was last changed.

In an interview on 10/01/2021 at 11:00 a.m. with S3DON, she indicated the hospital's policy for PICC line dressing changes was to change the dressings every 7 days, on Sunday. S3DON reported the PICC line dressings were changed by the charge nurse. She confiirmed the dressings should be labeled with the date, time and initials of the staff inserting the PICC line as well as by the staff performing the dressing change.

2. Failure to ensure extended use IV tubing was dated, timed, and initialed when hung, as per hospital policy.


Review of the hospital policy titled, "Central Line Management", revealed the following: f. Management of IV tubing, f. All other continuous IV tubing must be changed every 96 hours. g. All tubing must be changed under the following conditions: i. whenever tubing tip touches any non-sterile surface, ii. has been left unattended and exposed, iii. any obvious contamination, iv. when there is no information or tags that identify when the tubing was hung (unable to determine when 96 hours expires).

Patient #1

On 09/30/2021 at 9:30 a.m. an observation was made of Patient #1's IV tubing used for the piggy back administration of Micafungin 100 mg IV. The tubing was not labeled with the date and time it had been hung and also was not initialed by the staff member who had hung the tubing.

Patient #2
On 09/30/2021 at 12:45 p.m. an observation was made of Patient #2's extended use IV tubing for Ceftaz IV piggyback antibiotic infusions to the patient's PICC line. The tubing was not labeled with the date and time it had been hung and also was not initialed by the staff member who had hung the tubing.

Patient #3
On 09/30/2021 at 12:45 p.m. Patient #3's extended use IV tubing used for piggy back administration of Cefepine, to the patient's PICC line, was observed. The tubing was not labeled with the date and time it had been hung and also was not initialed by the staff member who had hung the tubing.


In an interview on 10/1/2021 at 08:30 a.m. with S1QA/IC, she confirmed IV tubing changes were every 96 hours unless it TPN, then it is changed every 24 hours. She also confirmed tubing should be labeled with the date and time it had been hung and also was not initialed by the staff member who had hung the tubing.

In an interview on 10/01/2021 at 11:00 a.m. with S3DON, she indicated the policy for IV tubing changes was to change out tubing every 72 hours. She confirmed if the IV tubing was not labeled it should it be changed out. S3DON also indicated IV tubing should be changed out if it is found uncapped or on floor.