HospitalInspections.org

Cross refer to:
A0619
A0749

Cross refer to:

A0749
A0756

Based on observation, interview and record review the facility failed to provide quality patient care when Patient #22's Peripherally Inserted Central Venous Catheter (PICC) Line dressing change was not performed according to the facility's policy; placing the patient at risk of infection or occlusion of the central line.

Findings include;

An observation on 6/28/16 at 9:20 a.m. revealed Staff #33, Central Line Nurse changing out a Peripherally Inserted Central Venous Catheter (PICC) Line. Staff #33 was wearing disposable blue gloves; Staff #33 cleaned the bedside table, touched the bed rails and the patient's dirty dressing. Staff #33 did not removed the contaminated gloves or wash her hands. Staff #33 then opened the blue draped sterile packaging, and reached into the sterile field with the soiled gloves to remove two face masks; placing items in the sterile field at risk of cross contamination.

Further observation revealed Staff #33 changed the catheter injection ports; she had a 10 ml syringe with normal saline, she attached the new injection port and injected 2 ml of saline through the new port, then drew back until blood appeared in the syringe. Staff #33 flushed the line with approximately 6 ml of saline. Staff #33 did not flush with the required 20 ml saline flush, as the facility policy required, preventing blood from remaining in the injection port and increasing the risk of infections or occlusion of the central line.

During an interview on 6/28/16 at 10:00 a.m. Staff #33 stated, "Everything within the blue drape is sterile, that's why I only touched the outside corners."

Staff #5, Infection Control Nurse, stated, "The dressing needs to be changed." When asked how the staffs reach into the sterile field to retrieve the masks, Staff #5 stated, "We might have to look at how we package the supplies." When asked if the facility had a specific procedure Staff #5 stated, "I'm not sure if there is a procedure for the Central line changes."

During an interview on 6/28/16 at 2:35 p.m.in the facility's conference room, Staff #38, Clinical Compliance, stated, "We don't have a specific procedure for the central line changes; we follow "Mosby" for clinical procedures."

Review of the facility provided document "Guide for Maintaining, Accessing, and Flushing Central Lines ..." (Dated 4/2016) reflected; "saline Flushing to lines is done per details below ...After Lab Draw, 20 ml saline flush ..."

Based on observation, policy review, and staff interview the facility failed to ensure contracted staff in the dialysis unit followed the hospital guidelines in the care of the patient on contact isolation.

Findings were:

Observation in the dialysis care unit on 6/27/16 revealed 3 of 3 staff members, staff #34, #35, and #36, did not follow isolation practices as per facility policy in the care of patients in contact isolation. The following deficient practices were observed:
* Staff #34, 35, and 36 were observed donning the isolation gown over the regular PPE (personal protective equipment) gown.
* Staff were observed taking the isolation gown off and disposing of it and the gloves used on the isolation patient in 3 different trash cans outside of the patient care station for the patient on dialysis.
* Staff #34, 35, and 36 were observed pushing the sleeves up on the regular PPE gowns with hands that had not been sanitized after caring for the isolation patient.
* Staff then proceeded to wear the regular PPE gown into the dialysis station of patients who were not on contact isolation after wearing this same gown into the dialysis station of patients on contact isolation.
* Staff #35 was observed removing a clipboard from the isolation area and placing it on a clean computer cart that was then moved to other patients in the dialysis treatment room.
* Staff #35 was observed placing supplies from the isolation area station onto a clean supply area prior to fully disinfecting the entire surface of the supplies. This was a container that had dialysate fluid in it that was being placed back into the supply room to be used on another patient.
* Staff #34 was observed placing blue plastic clamps brought out of the isolation area station and placed on the dirty supply cart with other patient supplies prior to disinfecting/cleaning the supplies.
* Staff #34 and #35 were observed going to clean the machine used on the isolation patient with PPE gown that was then worn to care for patients not on isolation.

Facility policy titled "Standard and Isolation Precautions" states in part "Contact Precautions: This isolation category requires the use of gloves and gown to enter the room regardless of patient contact." "Contact/Contact Enteric Precautions: Gloves: Remove gloves and perform hand hygiene before leaving the patient care environment. Gowns: Don gown upon entry into the room or cubicle. Remove gown and perform hand hygiene before leaving the patient care environment." "Equipment/Supplies: Use disposable noncritical patient care equipment or implement patient-dedicated equipment. If common use of equipment for multiple patients is unavoidable, clean and disinfect before use on another patient."

In an interview with staff #34, #35, and #36 all acknowledged the above deficiencies at the time of the finding and stated they were following hospital policy on infection control.

Staff #34, #35, #36, and #37 stated they were not aware the isolation gown, used on the isolation patients, could not be put on over the regular PPE gown that was then used to perform care on other dialysis patients.

Based on observation, record review and interview the facility failed to provide the dietary services in a safe and sanitary manner when; the facility's kitchen floor drains were backing up; causing flying insects and sewage to come up into the food production areas. The flying insects were landing on kitchen surfaces; placing all patients receiving food from the kitchen, at risk for cross contamination and possible gastrointestinal illness.
Findings Include:
Observations made during a tour of the facility's kitchen on 6/27/16 at 11:15 a.m. revealed the floor drain in front of the dish machine, the pot washing station, the ice machine, the walk in refrigerator and freezer, and adjacent to the food production table with brown dirty water. Food and grease debris was floating in the water. The water smelled of sewage. There were small winged insects flying around the kitchen and were landing on the food production work counters and in the dirty water on the floor. The kitchen floor had several wet tracks, where the staffs had walked in the dirty water.

During an interview on 6/27/26 at 11:30 a.m. when the surveyor asked about the dirty water in the rinse sink Staff #15, Manager of Dietary Services stated, "They started to drain it but the floor drains started backing up." "The drains had backed up last month." "I better call maintenance."

During an interview on 6/27/16 at 11:45 a.m. Staff #3, Dietary Cook, stated, "The flies came up with the water." When asked had the drains backed up before, Staff #3 stated, "The drains backed up on Saturday." (6/25/16)

Staff #18, Maintenance personnel was observed lifting a floor grate out of the dirty water with his bare hands, Staff #18 stood up and pushed an opened patient food transport cart with his contaminated bare hand. The food transport cart was filled with patient trays; each tray had uncovered silverware, napkins, and plastic covered dessert and drinks. The cart was ultimately transported out of the kitchen. Staff #18 did not wash his hands before leaving the kitchen and possibly contaminating areas outside of the kitchen. The surveyor brought it to the kitchen staff's attention, they wiped down the cart; they did not dispose of the possible insect contaminated items.

Further observation revealed ten patient trays sitting across a counter, the silverware and the napkins were not wrapped and could possibly be contaminated by the flying insects, gnats. The Dietary Managers instructed the staff to remove the trays from the kitchen. The trays were placed in a patient transport cart sitting in the outer hall and taken down to the patient halls; the (10) trays and the trays in the opened cart, were used to distribute food to patients.

During an interview on 6/27/16 at 12:00 p.m., in the facility's kitchen, Staff #5, Infection Control (IC) Nurse halted the use of the food being served from the Facility's kitchen. Staff #5 stated, "We will have the food sent from Memorial Hospital."

During an interview on 6/27/16 at 1:00 p.m., on the 1st floor nurse's unit nourishment room, when asked about the trays sitting on the counter in the kitchen being uncovered and then sent to the patient's rooms, Staff #5 stated, "The trays should not have been used, they could be contaminated." Staff #5 requested, from Staff #15, Manager of Dietary Services (MDS) the names of the patients receiving the trays, in order to monitor for possible illness.

Based on observation, policy review, and staff interview the facility failed to have a system to audit and identify that contracted staff in the dialysis unit did not follow the hospital guidelines in the care of the patient on contact isolation.

Findings were:

Observation in the dialysis care unit on 6/27/16 revealed 3 of 3 staff members, staff #34, #35, and #36, did not follow isolation practices as per facility policy in the care of patients in contact isolation. The following deficient practices were observed:
* Staff #34, 35, and 36 were observed donning the isolation gown over the regular PPE (personal protective equipment) gown.
* Staff were observed taking the isolation gown off and disposing of it and the gloves used on the isolation patient in 3 different trash cans outside of the patient care station for the patient on dialysis.
* Staff #34, 35, and 36 were observed pushing the sleeves up on the regular PPE gowns with hands that had not been sanitized after caring for the isolation patient.
* Staff then proceeded to wear the regular PPE gown into the dialysis station of patients who were not on contact isolation after wearing this same gown into the dialysis station of patients on contact isolation.
* Staff #35 was observed removing a clipboard from the isolation area and placing it on a clean computer cart that was then moved to other patients in the dialysis treatment room.
* Staff #35 was observed placing supplies from the isolation area station onto a clean supply area prior to fully disinfecting the entire surface of the supplies. This was a container that had dialysate fluid in it that was being placed back into the supply room to be used on another patient.
* Staff #34 was observed placing blue plastic clamps brought out of the isolation area station and placed on the dirty supply cart with other patient supplies prior to disinfecting/cleaning the supplies.
* Staff #34 and #35 were observed going to clean the machine used on the isolation patient with PPE gown that was then worn to care for patients not on isolation.

Facility policy titled "Standard and Isolation Precautions" states in part "Contact Precautions: This isolation category requires the use of gloves and gown to enter the room regardless of patient contact." "Contact/Contact Enteric Precautions: Gloves: Remove gloves and perform hand hygiene before leaving the patient care environment. Gowns: Don gown upon entry into the room or cubicle. Remove gown and perform hand hygiene before leaving the patient care environment." "Equipment/Supplies: Use disposable noncritical patient care equipment or implement patient-dedicated equipment. If common use of equipment for multiple patients is unavoidable, clean and disinfect before use on another patient."

In an interview with staff #34, #35, and #36 all acknowledged the above deficiencies at the time of the finding and stated they were following hospital policy on infection control.

Staff #34, #35, #36, and #37 stated they were not aware the isolation gown, used on the isolation patients, could not be put on over the regular PPE gown that was then used to perform care on other dialysis patients.







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Based on observation, interview and record review the facility failed to develop and implement policies and procedures to address techniques for pest control and the maintenance of a sanitary physical environment when;

A.) The kitchen's sewer drains were routinely backing up, exposing patients to possible gastrointestinal illness from cross contamination. The facility did not put a procedure in place to halt the production of food during these incidents;

B.) the exterior doors, adjacent to the kitchen, did not properly close and were missing the weather stripping, exposing daylight, allowing access to pests;

C.) soiled linens were stored uncovered on carts located by the exterior doors, in close proximity to the kitchen, creating an unsanitary environment.

Findings include;

A.) Observations made during a tour of the facility's kitchen on 6/27/16 at 11:15 a.m. revealed the floor drain in front of the dish machine, the pot washing station, the ice machine, the walk in refrigerator and freezer, and adjacent to the food production table backing up with brown dirty water. Food and grease debris were floating in the water. The water had a foul odor. There were small winged insects flying around the kitchen and were landing on the food production work counters and in the dirty water on the floor. The kitchen floor had several wet tracks, where the staffs had walked in the dirty water.

During an interview on 6/27/26 at 11:30 a.m. when the surveyor asked about dirty water in a sink, Staff #15, Manager of Dietary Services stated, "They started to drain it, but the floor drains started backing up." "The drains had backed up last month." "We had to shut the kitchen for two weeks ...." "I better call maintenance."

Review of the facility provided document Sanitation Checklist dated May 2016 and June 2016 reflected; "Kitchen Down 5/20/16 through 6/4/2016.

During an interview on 6/27/16 at 11:45 a.m. Staff #3, Dietary Cook, stated, "The flies came up with the water." When asked had the drains backed up before, Staff #3 stated, "The drains backed up on Saturday." (6/25/16)

Review of the facility's maintenance repair logs reflected;
6/8/16, 10:53 a.m., Floor drains backing up, 1.132 Dietary
6/24/16, 3:24 p.m. Had to plunge floor drain and finally got it to clear and ran hot water from several sinks for 10 minutes to make sure clog cleared
6/25/16, 3:36 p.m. Came in, unclogged drain and cleaned up mess

During an interview on 6/27/16 at 3:00 p.m., in the facility's conference room, Staff #24, Environment of Care (EOC) Manager, stated, "I wasn't aware it backed up on Saturday."(6/25/16) "I should be informed of the sewer backing up."


B.) Observations during a tour of the facility on 6/27/16 at 12:25 p.m. revealed approximately 20 feet from the facility's kitchen entrance, the double doors leading to the back loading dock had a large gap between the doors; allowing daylight through. Additionally, the doors self- closure mechanism was out of adjustment, leaving the door open two inches when it was not manually shut. The door's openings could allow insects or small rodents' access to the facility and the kitchen. The facility dumpster, located approximately 50 feet from the facility's back door, was left open, creating an environment for flies and rodents. Staff #24 stated, "I didn ' t notice that on my EOC round, I do rounds bi-annually. I rely on the Infection Control nurse to round weekly"

C.) Further observation revealed (3) Three large, over six feet tall, uncovered dirty linens carts; each were full of bagged and partially bagged soiled linens. The linens smelled of urine and were open to rodents and insects, creating an unsanitary environment.

During an interview on 6/27/16 at 2:00 p.m. Staff # 16, Hospitality Service Supervisor stated, "The dirty linens are picked up daily." "They don ' t pick it up on Saturday or Sunday." When asked was this where they are stored, Staff #16 stated, "We don ' t have anywhere else to put them."

Further interview, on 6/27/16 at 12:25 p.m., Staff #24, EOC manager was asked about the (3)three large bins of dirty linens stored uncovered by the facility's back door, Staff #24 stated, "That's the first I've heard of that. I see the concern" Staff #24 confirmed the finding.

An observation on 6/28/16 at 1:15 p.m. revealed (1) one large, over six feet tall, open dirty linens cart filled with bagged and partially bagged soiled linens sitting by the facility's back door. The linens smelled of urine and were open to rodents and insects, creating an unsanitary environment. The facility continued to store the dirty linens uncovered.

Based on observation, interview and record review the facility failed to assess the effectiveness of actions taken, and revise corrective actions as needed when the facility's kitchen sewer drains continued to back up (3) out of (4) days.( 6/24/16, 6/25/16, and 6/27/16)

Findings include;

Observations made during a tour of the facility's kitchen on 6/27/16 at 11:15 a.m. revealed the floor drain in front of the dish machine, the pot washing station, the ice machine, the walk in refrigerator and freezer, and adjacent to the food production table backing up with brown dirty water. Food and grease debris were floating in the water. The water had a foul odor. There were small winged insects flying around the kitchen and were landing on the food production work counters and in the dirty water on the floor. The kitchen floor had several wet tracks, where the staffs had walked in the dirty water.

During an interview on 6/27/26 at 11:30 a.m. when the surveyor asked about dirty water in a sink, Staff #15, Manager of Dietary Services stated, "They started to drain it, but the floor drains started backing up." "The drains had backed up last month." "We had to shut the kitchen for two weeks ...."

During an interview on 6/27/16 at 11:45 a.m. Staff #3, Dietary Cook, stated, "The flies came up with the water." When asked had the drains backed up before, Staff #3 stated, "The drains backed up on Saturday." (6/25/16)

During an interview on 6/27/16 at 12:00 p.m., in the facility's kitchen, during a discussion about the sewage and flies and possible contamination, Staff #5, Infection Control Nurse stated, "We need to shut the kitchen. We can't serve food from the kitchen."

During an interview on 6/27/16 at 3:00 p.m., in the facility's conference room, Staff #24, Environment of Care (EOC) Manager, stated, "I wasn't aware it backed up on Saturday."(6/25/16) "I should be informed of the sewer backing up." When asked about the previous kitchen drain repairs and the service of food, Staff #24 stated, "During the initial meeting we discussed how the kitchen would be organized. All the food would be prepared at Memorial Hospital." When asked if a plan was written to address the drain back-ups, Staff #24 stated, "No, we just discussed it."

Review of the facility's maintenance repair logs reflected;
6/8/16, 10:53 a.m., Floor drains backing up, 1.132 Dietary
6/24/16, 3:24 p.m. Had to plunge floor drain and finally got it to clear and ran hot water from several sinks for 10 minutes to make sure clog cleared
6/25/16, 3:36 p.m. Came in, unclogged drain and cleaned up mess

During an interview on 6/27/16 in the afternoon, in the facility conference room Staff #17, Chief Nursing Officer stated, "I thought we had fixed it. I didn't know it was still backing up."