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Based on observation, policy and procedure review, record review, and staff interview, the Hospital failed to ensure a patient received the correct medication as per physician's orders (refer to A395); failed to provide the necessary care and services for a patient with a hospital acquired pressure ulcer (refer to A395); failed to educate nursing staff on the expected procedure for cleansing a gastrostomy tube site (refer to A395); and failed to ensure proper verification and documentation of blood products (refer to A409).

These failures resulted in an incorrect dose of medication; a hospital-acquired pressure ulcer, inconsistent gastrostomy tube site cares, and unsafe blood administration practices.

Based on observation, review of professional literature, policy and procedure review, record review, and staff interview, the Hospital failed to prevent transmission of multi-drug resistant organisms (MDROs) for 1 of 1 closed patient (Patient #18) record reviewed who acquired two different MDROs while hospitalized; failed to ensure staff followed professional standards of care regarding infection control practices for 7 of 13 patients (Patient #1, #5, #7, #8, #10, #12, and #13) observed; failed to provide education on infection control practices to agency staff caring for patients within the Hospital for 2 of 2 agency personnel (#12 and #13) files reviewed; and failed to implement a system to identify, report, investigate, and control infections and communicable diseases among all patients and personnel of the Hospital (Refer to A-749).

These failures may allow transmission of organisms and pathogens among patients, healthcare personnel, visitors, and environments; and contributed to the transmission of a MDRO to Patient #18 while hospitalized.

Findings include:

TRANSMISSION OF MDROS:

Review of Patient #18's closed medical record occurred on 01/21/15 and identified the facility admitted the patient on 10/06/14 with diagnoses of progressive myotonic dystrophy (muscle wasting and weakness) and aspiration pneumonia. A microbiology report, with a collection date of 10/14/14, identified the patient was negative for Enterobacter cloacae (CRE) (a family of germs difficult to treat due to high levels of resistance to antibiotics) and Vancomycin-resistant enterococci (VRE) (a type of bacteria resist to many antibiotics, especially vancomycin). A second microbiology report, with a collection date of 11/17/14, identified the presence of CRE and VRE. Patient #18 acquired both CRE and VRE while a patient at the facility.

HAND HYGIENE/HANDWASHING/STANDARD PRECAUTIONS/TRANSMISSION BASED PRECAUTIONS:

Review of the policy, "Initiation of Transmission based Precautions" occurred on 01/22/15. This policy, dated September 2013, stated, "PURPOSE: To reduce the risk of transmission of epidemiologically important pathogens for which additional precautions beyond Standard Precautions are needed. To successfully interrupt spread from patients who are known or suspected to be infected or colonized by such microorganisms to other patients and healthcare workers. . . . PROCEDURE: 1. . . . a. Transmission of infection within hospital requires three elements: 1) Source: Human . . . 3) Inanimate environmental objects that have become contaminated, including equipment and medications. . . . c. Transmission: Microorganisms are transmitted in hospitals by several routes . . . 1) Contact transmission - the most important and frequent mode of transmission of infection: a) Direct contact - involves direct body surface-to-body surface contact and physical transfer of microorganisms between a susceptible host and an infected or colonized person. b) Indirect contact - involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, such as contaminated instruments, needles, dressings, or contaminated hands that are not washed and gloves that are not changed between patients. . . 3. Fundamentals of Transmission Based Precautions: a. Hand Hygiene and gloving: 1); Hand hygiene is frequently called the single most important measure to reduce the risks of transmitting organisms from one person to another or from one site to another on the same patient. 2) Washing hands as promptly and thoroughly as possible between patient contacts and after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them is an important component of infection prevention and control and transmission based precautions. 3) Gloves are worn for three important reasons in hospitals. a) To provide protective barrier and prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin. . . . b) To reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to patients during invasive and other patient care procedures that involve touching a patient's mucous membranes and non-intact skin. c) To reduce the likelihood that hands of personnel contaminated with microoganisms from a patient . . . can transmit these microorganisms to another patient; in this situation, gloves must be changed between patient contacts, and hands washed after gloves are removed. 4) Wearing gloves does not replace the need for hand hygiene: a) Gloves may have small non-apparent defects or be torn during use. b) Hands can become contaminated during removal of gloves.
5) Failure to change gloves between patient contacts is an infection control hazard. . . ."

Review of the "2014 Skills Fair" education occurred on 01/22/15. This education, provided to hospital staff on 10/24/14, included infection prevention. The segment regarding contact precautions stated:
"Contact Precautions:
*Use for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment.
*Examples of such illnesses include: Gastrointestinal, respiratory, skin, or wound infections or colonization with multidrug-resistant bacteria or prolonged environmental survival.
Gloves and Hand washing:
*In addition to wearing gloves as outlined under Standard Precautions, wear gloves when entering the room.
*During the course of providing care for a patient, change gloves after having contact with infective material that may contain high concentrations of microorganisms (fecal material and wound drainage). . . .
*After glove removal and hand hygiene, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room to avoid transfer of microorganisms to other patients or environments.
Gown:
*In addition to wearing a gown as outlined under Standard Precautions, wear a gown when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room.
*Or if the patient is incontinent or had diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing. . . .
*After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients or environments and perform hand hygiene."

- Review of Patient #1's active medical record occurred on 01/20/15 and identified the Hospital admitted the patient on 12/31/14 for wound care and IV antibiotics due to amputation of all toes on bilateral feet. A wound consult, dated 01/08/15, identified incisional wounds to the tops of bilateral feet from amputation and bilateral heel wounds. The record showed an order for wound care and dressing changes to bilateral feet twice a day. Due to a history of methicillin resistant staphylococcus aureus (MRSA), the hospital placed the patient in contact isolation.

Observation on 01/21/15 at 10:00 a.m., showed a staff nurse (#6) donned a gown and gloves and entered Patient #1's room to perform wound care and a dressing change. The nurse (#6) removed the dressing to the patient's right foot and removed his gloves. He immediately donned new gloves, cleansed Patient #1's incision and heel wound with normal saline soaked gauze, placed lidocaine ointment on a piece of gauze and spread the ointment on the incision and wound, grabbed a clean piece of gauze and dipped the gauze in a container of silvadene cream, and spread the cream on the patient's heel wound. Next, the nurse (#6) opened a package containing an adaptic dressing and placed the dressing on the bottom of the patient's foot; then cut open a package containing a xeroform dressing with a scissor and placed the dressing over the incision on the top of the patient's foot. He then opened a package of kerlix and used this as a dressing to wrap Patient #1's foot, secured the kerlix with tape, and removed his gloves. At this point, the nurse (#6) donned gloves, removed the dressing to the patient's left foot, removed his gloves, donned new gloves, and proceeded to perform the exact same steps as stated above to Patient #1's left foot. Observation showed minimal bloody drainage to the patient's bilateral heel wounds.

Immediately upon finishing the dressing change and wrapping/securing the kerlix to the patient's left foot, the nurse (#6) (still wearing the gloves used to place the ointment/cream/dressings on the patient's foot) placed all supplies (bottle of normal saline, scissor, lidocaine ointment, silvadene cream, tape, etc.) in a plastic bin and placed the bin on a shelf in the closet. The nurse (#6) then placed pillows under Patient #1's legs, moved the bedside table within reach of the patient, turned off the lights in the room, removed his gown and gloves, and washed his hands prior to leaving the room.

The nurse (#6) failed to perform hand hygiene or handwashing after the removal of gloves; failed to remove gloves and perform hand hygiene or handwashing after contact with potential body fluids and performing wound care, prior to placing a clean dressing; and failed to remove gloves and perform hand hygiene or handwashing after completion of a dressing change prior to moving onto new tasks.

- Review of Patient #7's active medical record occurred on all days of survey and identified the hospital admitted the patient on 01/14/15. Medical diagnoses included bilateral below the knee amputations, decubitus ulcers to right and left ischial regions (stage 4), decubitus ulcers to right and left amputation stumps (stage 3), diabetes, colostomy, suprapubic catheter, tracheostomy and diabetes. The record showed an order for wound care and dressing changes to bilateral stump wounds and bilateral ischial wounds twice a day. Due to positive cultures for CRE, MRSA, and VRE on admission (and history of same positive cultures on previous admissions), the hospital placed the patient on contact precautions. Record review identified Patient #7 currently receiving IV antibiotic therapy.

Observation on 01/21/15 at 10:45 a.m. showed a staff nurse (#11) donned a gown and two pairs of gloves (double-gloved) and entered Patient #7's room to perform wound care and a dressing change. The nurse (#11) removed the dressing from the patient's right ischial area and removed one pair of gloves. The nurse (#11) then applied a new pair of gloves over the first pair of gloves. The nurse (#11) cleansed with wound first with normal saline, then with sterile water/Dakon's solution on gauze pads, and then normal saline again to rinse the area. The nurse (#11) removed both pairs of gloves, (did not perform hand hygiene) went outside the room, obtained a handful of gloves from the glove box outside the door, and came back to the room. The nurse (#11) applied one pair of gloves and then applied Xeroform dressings to the right ischial wound. After repositioning the resident, and without changing gloves or performing hand hygiene, the nurse (#11) then applied a new dressing to the patient's left ischial area. The nurse (#11) removed her gloves, donned new gloves (no hand hygiene), and emptied Resident #7's catheter bag into a graduate cylinder, which she then emptied into the toilet. The nurse (#11) removed her gloves, and without performing hand hygiene, replaced garbage bag liners in the room, placed dressing supplies into a container on the bedside table, and then placed the container of supplies into a locker in the room. The nurse (#11) went outside the room, applied gloves, (no hand hygiene) and retrieved a disinfectant wipe to clean the bedside table. After cleaning the table, the nurse (#11) removed her gloves and then wiped the resident's eye glasses with tissue, placed the glasses on the patient, and positioned the call light and television control within reach of the patient. The nurse (#11), without gloves on, then opened a carton of milk for the resident, using her gown to cover her hands. The nurse (#11) removed the gown, exited the room, and then performed hand hygiene using hand sanitizer.

Observation on 01/21/15 at 3:00 p.m. showed a staff nurse (#11) donned a gown and two pairs of gloves (double gloved) and entered Patient #7's room to perform a gastrostomy tube (G-tube) dressing change. The nurse (#11) removed the dressing, soiled with drainage, from the G-tube site and removed one pair of gloves. The nurse (#11) donned a new set of gloves over the first set of gloves. The nurse (#11) touched and assessed the skin around the G-tube, removed both pairs of gloves, and then washed her hands in the bathroom. The nurse (#11) donned one pair of gloves and cleaned G-tube site with gauze pads soaked with sterile water. The nurse removed her gloves (no hand hygiene), donned a new pair of gloves, and applied a new dressing around the G-tube site.

Observation on 01/20/15 at 11:10 a.m. showed a nurse (#10) donned a gown and two pairs of gloves (double gloves) and entered Patient #7's room to disconnect the patient's IV antibiotics and to flush the central line. The nurse (#10) stated, "I have a habit of double-gloving because if something happens, I can take one (pair) off."

- Review of Patient #8's active medical record occurred on all days of survey and identified the hospital admitted the patient on 01/09/15. Medical diagnoses included acute respiratory failure, multi-drug resistant pneumonia, tracheostomy, encephalopathy, and deconditioning. Due to a positive culture for VRE on admission (and history of CRE), the hospital placed the patient on droplet precautions.

Observation on 01/21/15 at 4:20 p.m. showed two staff nurses (#17 and #19) performed perineal cares after Patient #8 had a large, loose, incontinent bowel movement. The nurse (#17), wearing gloves, cleaned Patient #8 of stool and provided rectal cares. After the staff members (#17 and #19) turned Patient #8 on her back, the nurse (#17), wearing the same gloves, provided frontal peri-cares and applied lotion. The nurse (#17) removed her gloves, (no hand hygiene) donned new gloves and then assisted with oral cares.

- Observation on 01/21/15 at 9:55 a.m. showed a nurse (#16) and CNA (#13) donned gloves and gowns and entered Patient #12's room to provide incontinence cares. Observation showed the patient's frontal perineal area soiled with feces. Both the nurse (#16) and the CNA (#13) provided pericares. The staff members then rolled the Patient #12 to her side and the CNA (#13) cleansed her buttocks and rectal area. Observation showed a wound dressing on the patient's coccyx and another close to her rectal area. Without removing her soiled gloves and applying clean gloves, the CNA (#13) removed both dressings. The CNA (#13) and nurse (#16) then changed sides of the bed and the nurse (#16), without removing her soiled gloves and applying clean gloves, applied a new dressing to the patient's coccyx. The nurse (#16) removed her gloves and gown, sanitized her hands, and exited the room to obtain another wound dressing. While the CNA (#13) waited for the nurse to return, she stood at the head of the Patient #12's bed touching the patient and the side rails with her soiled gloves. When the nurse (#16) returned, the CNA (#13) remove her gown and gloves and sanitize her hands.

- Observation on 01/20/15 at 11:20 a.m. showed Patient #13 (on Contact Precautions) crawled out of bed and sat on the mat next to his bed. The nurse (#15), lifted the patient off the floor and placed him back in bed. The nurse (#15) wore gloves but failed to don a gown. Observation showed Patient #13's gown and bedding wet with urine. A certified nursing assistant (CNA) (#13) donned gloves and a gown and entered Patient #13's room. At this time, the nurse (#15) also donned a gown. The nurse (#15) and CNA (#13) removed Patient #13's soiled hospital gown and bedding and without changing gloves, placed a clean gown on the patient and clean bedding on the bed. The CNA (#13) cleansed the patient's perineal area and without changing gloves, applied calmoseptine cream to the area. After completion of cares, both the nurse (#15) and the CNA (#13) removed their gloves and gown and performed hand hygiene.

Observation on 01/20/15 at 1:30 p.m. showed the nurse (#13) donned gloves, measured Patient #13's temperature, and stated, "He has a temp [temperature] right now." The nurse (#13) failed to don a gown before having contact with Patient #13.

Observation on 01/20/15 at 4:30 p.m. showed Patient #13 attempting to exit the bed. The nurse (#13) donned gloves and assisted the patient back to bed. The nurse failed to don a gown before having contact with Patient #13.

- Observation on 01/20/15 at 10:30 a.m. showed a certified nursing assistant (CNA #9) entered Patient #10's room (on Contact Precautions) wearing a gown and gloves. After testing Patient #10's blood glucose level, the CNA (#9) removed her gown and gloves and exited the room. Without performing hand hygiene after checking Patient #10's blood glucose level and exiting a contact precautions room, the CNA (#9) then donned a gown and gloves and entered another patient's room (Patient #9) room to perform blood glucose testing.

- Observation on 01/20/15 at 10:50 a.m. showed a CNA (#9) entered Patient #8's room (on Droplet Precautions) wearing a gown, mask, and gloves. After testing Patient #8's blood glucose level, the staff member removed her gown, mask, and gloves and exited the room. Without performing hand hygiene, the CNA (#9) then donned a gown and gloves and entered another patient's room (Patient #14's) room.

During an interview on 01/21/15 at 1:35 p.m., an infection control nurse (#2) stated staff must follow contact precautions for patients in isolation and confirmed this included donning a gown and gloves upon entering the patient's room, and removing the gown and gloves and performing hand hygiene or handwashing prior to leaving the isolation room. Two administrative nurses (#1 and #3) stated staff must complete hand hygiene or handwashing immediately after the removal of gloves and stated staff should move from "dirty" to "clean" areas, changing gloves and performing hand hygiene or handwashing in between.



19410


TRACHEOSTOMY CARE:

Review of the policy, "Tracheostomy Care" occurred on 01/22/15. This policy, dated 02/06/14, stated, "PROCEDURE: This procedure is applicable to all personnel concerned with tracheostomy care. Procedure will consist of cleaning stoma and inner cannula with mixture of 3% hydrogen peroxide unless otherwise specified. 1. Assemble equipment: a. Tracheostomy Care Kit - which contains: . . . Hydrogen Peroxide package . . . Tracheostomy dressing pre-slit . . . 4x4 gauze sponges . . . Cotton tip applicators . . . b. 2nd pair of gloves c. Disposable inner cannula of appropriate size, if required. . . . 6. Don gloves and remove soiled dressing. Discard gloves and dressing. 7. Pour hydrogen peroxide mixture and sterile water into separate compartment of trays. 8. Don gloves. Dampen sterile applicators in hydrogen peroxide and swab secretions from area around tracheostomy. . . . 9. Continue until tracheostomy area is completely clean of secretions. 10. Swab tracheostomy area to remove hydrogen peroxide residue. . . . 11. Dry tracheostomy area thoroughly using 4x4 gauze sponge. . . . 14. Apply new tracheostomy dressing using aseptic technique. . . ."

Observation on 01/21/15 at 10:10 a.m. showed a respiratory care staff member (#8) provided trachestomy cares to Patient #7 (Contact Precautions due to positive cultures for CRE, VRE and MRSA on admission). The staff member (#8) removed and discarded Patient #7's soiled tracheostomy dressing. Without changing gloves or performing hand hygiene, the staff member (#8) moistened the 4x4 gauze pads in a cup with the hydrogen peroxide/water mixture, and then cleaned underneath the tracheostomy area with the gauze pads. The staff member (#8) moistened the sterile applicators in the hydrogen peroxide/water mixture, cleaned around the tracheostomy, dried the area with 4x4 gauze, and then applied a new tracheostomy dressing. The staff member (#8) failed to remove gloves and perform hand hygiene after removing the soiled dressing and before cleaning the tracheostomy area.

INTRAVASCULAR CATHETER CARE:

A report from The Centers for Disease Control and Prevention (CDC), titled, "Guidelines for the Prevention of Intravascular Catheter-Related Infections," dated 2011, page 7, stated, ". . . These guidelines are intended to provide evidence-based recommendations for preventing intravascular catheter-related infections. . . ." page 54, stated, ". . . Needleless Intravascular Catheter Systems. Recommendations. . . . 4. Minimize contamination risk by scrubbing the access port with an appropriate antiseptic . . . and accessing the port only with sterile devices . . ."

Review of an article in the American Journal of Infection Control, titled, "APIC [Association for Professionals in Infection Control and Epidemiology] position paper: Safe injection, infusion, and medication vial practices in health care," dated April 2010, volume 38, pages 167-172, copyright 2010 by APIC, stated, ". . . The transmission of bloodborne viruses and other microbial pathogens to patients during routine health care procedures continues to occur because of the use of unsafe and improper injection, infusion . . . practices by health care professionals in various clinical settings . . . Breaches in safe injection, infusion . . . practices continue to result in unacceptable and devastating events for patients. . . . APIC strongly supports adherence to the following safe injection, infusion . . . practices. . . . IV [Intravenous] Solutions: . . . Disinfect IV ports . . . by wiping and using friction with a sterile 70% isopropyl alcohol, ethyl/ethanol alcohol, iodophor, or other approved antiseptic swab. Allow the port to dry before accessing. . . ."

Review of the policy, "Central Venous Access Device (CVAD) Care and Maintenance" occurred on 01/22/15. This policy, dated July 2013, stated, ". . . PURPOSE: To provide guidelines for the following: . . . C. Accessing and flushing central venous catheters D. Administering drugs and infusions via a CVAD. . . . 2. Flushing CVADs . . . 1. Equipment . . . 2. Procedure: a. . . . 3) disinfect cannula port with alcohol prep. . . ."

- Observation on 01/20/15 at 11:10 a.m. showed an agency nurse (#10) entered Patient #7's room to disconnect the patient's IV antibiotic. The nurse (#10) disconnected the antibiotic IV tubing, flushed the central line port with normal saline, clamped the tubing, and then cleansed the hub of the central line with alcohol at the end of the procedure. The nurse (#10) failed to cleanse the hub with alcohol prior to flushing the central line with normal saline.

- Observation on 01/21/15 at 11:00 a.m., showed a staff nurse (#7) entered Patient #5's room to administer an IV antibiotic. The nurse (#7) cleansed the hub of the patient's peripherally inserted central catheter (PICC) with alcohol, attached a syringe and flushed the PICC with normal saline, then connected IV tubing to the hub of the PICC for administration of the antibiotic. The nurse (#7) failed to cleanse the hub with alcohol prior to the connection of the IV tubing.

During an interview on 01/21/15 at 1:35 p.m., an administrative nurse (#2) stated staff must cleanse intravenous or central line ports/hubs with alcohol prior to accessing the line whether for medication administration, flushing, or attaching IV tubing.


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CONTAMINATED SURFACES:

Observation on 01/21/15 at 3:00 p.m. showed a nurse (#10) donned a gown, mask, and gloves and entered Patient #8's room (Droplet Precautions due to history of CRE and positive cultures for VRE on admission). The nurse (#10) removed the soiled dressing around the patient's percutaneous endoscopic gastrostomy (PEG) tube (a feeding tube) site and cleansed the area with soap and water and placed three soiled washcloths on the bedside stand. The nurse (#10) failed to sanitize the bedside stand after she placed the soiled washcloths in a bag.

During an interview on 01/21/15 at 1:35 p.m., two administrative nurses (#1 and #3) stated staff should clean surfaces that come into contact with soiled or contaminated items with a disinfectant.


27645


EDUCATION:

Review of personnel files occurred on the morning of 01/22/15. The file of two agency CNA's (CNAs) (#12 and #13) lacked evidence the employees received education on the facility's infection control policies and procedures.

During an interview on 01/22/15 at 2:40 p.m., a human resources staff member (#14) confirmed the facility did not provide infection control education to the two agency CNAs (#12 and #13). The staff member stated the Hospital does not include agency staff in their education or invite agency staff to their annual education/skills fair.

MEDICATION ERRORS:

1. Based on record review and staff interview, the Hospital failed to ensure a patient received the correct medication as per physician's orders for 1 of 3 (Patient #18) closed patient records reviewed. Failure to ensure patients receive the right dose of medications may adversely affect the desired benefits of the medications or cause unwanted side effects for the patients.

Findings include:

Review of Patient #18's closed medical record occurred on 01/21/15 and identified the facility admitted the patient on 09/24/14 with diagnoses of progressive myotonic dystrophy (muscle wasting and weakness), acute respiratory failure, and pneumothorax. Admission orders for Patient #18's medications included Provigil (modafinil) (used to treat sleepiness) 200 milligrams (mg) daily.

The Medication Administration Record (MAR) identified the patient received modafinil 100 mg daily (rather than the ordered dose of 200 mg).

Patient #18 transferred to an acute care facility on 09/26/14. The facility readmitted the patient on 10/06/14. Admission orders for the patient's medications included Provigil 100 mg daily which the patient received during her entire stay. Patient #18's medication orders upon discharge included Provigil 100 mg daily.

During an interview on 01/21/15 at 2:25 p.m., an administrative nurse (#1) stated nursing staff failed to identify the medication error, therefore the facility lacked a medication variance report on the incident.

During an interview on 01/21/15 at 2:55 p.m., a pharmacy staff member (#4) stated she failed to identify the medication error which resulted in the incorrect dose of Provigil transcribed to the MAR, dispensed, and administered to the patient. At 4:50 p.m., the pharmacy staff member (#4) stated Patient #18 returned on 10/06/14 from an acute care facility on Provigil 100 mg daily. The pharmacy staff member (#4) stated she suspected Vibra's error during Patient #18's first admission resulted in the Provigil permanently staying at the decreased dose of 100 mg.


22495


PRESSURE ULCERS:

2. Based on observation, record review, review of hospital policy, and staff interview, the Hospital failed to provide the necessary care and services for 1 of 1 active inpatient record (Patient #13) reviewed with a hospital acquired pressure ulcer. Failure to initiate pressure ulcer prevention interventions for patients at risk for skin breakdown and ensure implementation of the interventions resulted in Patient #13 acquiring a pressure ulcer to the heel and coccyx.

Findings include:

Review of the hospital's "CORE COMPETENCY/DEMONSTRATION" for registered nurses occurred on 01/21/15. A component of the competency included wound and dressing changes and stated, "Assesses patient's skin upon admission and then routinely for any new wounds. . . . Practices wound prevention measures. . . ."

- Review of Patient #13's active medical record occurred on all days of survey and identified an admission date on 01/02/15 for intravenous therapy following maxillofacial abscesses and weight loss. The record identified a new pressure ulcer to the patient's coccyx on 01/15/15.

Patient #13's care plan failed to identify any skin problem/pressure ulcers and failed to identify specific interventions to prevent/improve pressure ulcers.

Patient #13's wound assessment notes stated the following:
*01/03/15 (Late Entry) - "Admit: admitted 1/2/15 . . . Wounds: RLE [right lower extremity] - multiple areas largest 2 x 0.5 x 0 [2 by 0.5 centimeters (cm) in size] 100% [percent] brown dry. LLE [left lower extremity] - multiple areas of trauma largest 2 x 0.5 [cm] 100% black dry. R) [right] foot trauma multiple areas largest 0.4 x 0.4 x 0 [cm] 100% black dry. L) [left] foot trauma multiple areas largest 0.5 x 0.8 x 0 [cm] 100% black dry. . . . foam mattress, moves some per self in bed, . . ."
*01/08/15 (Late Entry) - ". . . RLE 0.5 x 0.5 x 0 [cm] 100% black dry. LLE 2 x 0.5 x 0 [cm] 100% black dry. R) foot 0.4 x 0.4 x 0 [cm] 100% black dry. L )foot 0.5 x 1.4 x 0 [cm] 100% black dry . . . foam mattress, remind to turn [every two hours], heels off bed."
*01/15/15 - "Update: pt [patient] confused, lethargic, . . . RLE healed, LLE healed, R) foot healed, L) foot healed, elbow friction 100% black dry . . . L) heel 3 x 2 x 0 [cm] 100% purple dry, coccyx 0.8 x 0.4 x .2 [cm] pressure Stage 2, order for air mattress, heel boots, elbow protectors, turn [every two hours]."

Review of Patient #13's physician's orders identified the following:
*01/15/15 - "1) Air mattress with bolsters today. 2) Medihoney, mepilex border [a type of treatment and dressing] to coccyx wound . . . 3) L) elbow apply medihoney, mepilex border . . . 4) Bilateral elbow pads 5) Mepilex border to R) heel . . . 6) Blue foam heel protector boots bilateral feet . . . 10) Mepilex to R) elbow . . ."
*01/19/15 - ". . . 2) D/C [discontinue] mepilex to bilateral elbows. Cont. [continue] elbow protectors. 3) No briefs on [incontinence product] . . . 6) D/C mepilex to coccyx. [change] to calmoseptine & aloevesta combination cream BID [twice a day] & PRN."

During an interview on 01/21/15 at 8:20 a.m., the wound nurse (#2) stated the mepilex dressing and briefs were discontinued on 01/19/15 due to Patient #13's incontinence.

Observation on 01/20/15 from 10:30 a.m. to 5:50 p.m. showed Patient #13's blue heel boots and elbow protectors on the chair next to his bed and not on his feet and elbows as ordered.

Observation on 01/20/15 at 11:20 a.m. showed Patient #13 seated on the floor next to his bed. A nurse (#15) placed the patient back in bed and noted the bedding soiled with urine. A certified nursing assistant (CNA) (#13) entered the room and assisted the nurse (#15) to change the bedding and clean Patient #13. During perineal cares, observation showed the patient's buttocks reddened and a pressure ulcer on his coccyx. The CNA (#13) applied calmoseptine cream to the patient's rectal area but failed to apply the cream to the pressure ulcer.

Observation on 01/21/15 at 9:35 a.m. showed Patient #13 in bed and incontinent of urine. Two nurses (#16 and #17) changed Patient #13's soiled bedding and hospital gown. The nurse (#16) provided perineal cares and applied a barrier cream to the patient's coccyx and rectal area rather that the ordered calmoseptine cream. The nurse (#16) stated Patient #13 did not have any calmoseptine in his drawer.

The hospital failed to implement pressure ulcer prevention interventions proactively to prevent pressure ulcers and failed to apply heel boots and elbow protectors consistently after Patient #13 developed a pressure ulcer.

GASTROSTOMY TUBE CARE:

3. Based on observation and staff interview, the hospital failed to educate nursing staff on the expected procedure for cleansing a gastrostomy tube (a feeding tube) site for 2 of 2 active records (Patient #8 and #7) reviewed. Failure to provide hospital staff with a policy and procedure related to gastrostomy tube site cleansing resulted in inconsistent care.

Findings include:

- Observation on 01/21/15 at 3:00 p.m. showed a nurse (#10) removed the soiled dressing around Patient #8's percutaneous endoscopic gastrostomy (PEG) tube site, cleansed the area with soap and water with a washcloth, rinsed the area with water and another washcloth, and dried the area with another washcloth.

Observation on 01/21/15 at 3:00 p.m. showed a nurse (#11) removed the soiled dressing around Patient #7's gastrostomy tube site, cleansed the area with gauze pads soaked in sterile water and applied a new dressing.

During an interview on the morning of 01/22/15, an administrative nurse (#1) stated the hospital does not have a policy related to cleansing a gastrostomy tube site and she expected nurses to follow nursing standards of practice.

Based on record review, review of hospital policy and procedure, and staff interview, the hospital failed to ensure proper verification and documentation of blood products for 1 of 4 active inpatient records (Patient #12) reviewed. Failure to verify the right patient received the right blood products, document the completion time of the blood transfusion, amount administered, any adverse reactions, and vital signs has the potential for the patient to receive the wrong blood products and may cause adverse transfusion reactions.

Findings include:

Review of the hospital policy titled "Blood Product Administration" occurred on 01/21/15. This policy, revised July 2013, stated, ". . . Blood Component Administration . . . 2. Two RNs [registered nurses] or an RN and LPN/LIP [licensed practical nurse] must verify all identifying information at the bedside. . . . 5. Record on the Blood Transfusion Record: . . . Signature of transfusionist and witness. . . . 9. Document patient vital signs (Minimally-temperature, pulse, respirations, and blood pressure) on the Blood Transfusion Record: . . . F. Upon completion of transfusion G. One hour post transfusion completion. . . ."

Review of Patient #12's active medical record occurred on January 21-22, 2015 and identified an admission date of 01/06/15 for respiratory failure. A physician's order, dated 01/10/15, stated to administer two units of packed red blood cells (PRBCs).

The "Blood Transfusion Record" identified Patient #12's second unit of PRBCs started on 01/10/15 at 11:20 p.m. The record failed to show two nurses verified the patient and blood products and documented the completion time, the amount of blood administered, any adverse reactions, and vital signs at the completion of the transfusion and one hours after the transfusion.

During an interview on the afternoon of 01/21/15, an administrative nurse (#1) stated hospital staff are expected to follow hospital policy when administering blood products and to complete the Blood Transfusion Record.

Based on review of the infection control log, monthly culture reports, national healthcare safety network (NHSN) reports, Quality Assurance (QA) committee meeting minutes, and staff interview, the Hospital failed to implement a system to identify, report, investigate, and control infections and communicable diseases among all patients and personnel of the Hospital for 9 of 9 months (May 2014 through January 2015) reviewed. Failure to identify and address infections among all patients and personnel has the potential for infections to go unreported and to spread and/or reoccur, affecting the health of all patients and personnel of the Hospital.

Findings include:

Review of the infection control log, monthly culture reports, NHSN reports, and QA meeting minutes occurred on 01/22/15.

The daily infection control log (listing of current hospitalized patients) identified whether the patient exhibited a history of methicillin resistant staphylococcus aureus (MRSA), vancomyocin resistant enterococcus (VRE), carbapenem resistant enterobacteriaceae (CRE), or clostridium difficile (C.Diff); admitted with MRSA, VRE, CRE, or C.Diff; or acquired MRSA, VRE, CRE, or C.Diff post admission. The log did not identify the site of the infections.

The monthly culture reports from May-September 2014 and December 2014-January 2015, identified only those patients with positive results.

The NHSN reports from August 2014-January 2015 identified data collection on specific reportable conditions as required such as pneumonia, urinary tract infection (UTI), central line associated bloodstream infection (CLABSI), catheter associated urinary tract infection (CAUTI), and blood stream infection (BSI).

QA meeting minutes from the past two quarters (July-December 2014) identified a summary of information collected from the above log and reports.

During an interview on 01/22/15 at 1:25 p.m., an infection prevention nurse (#2) stated she focused her review and surveillance on the patients identified in the above infection control log and reports and presented this information to the QA committee. The nurse (#2) confirmed she did not comprehensively track other incidents of infections or illnesses (i.e. upper respiratory infections, influenza, gastrointestinal, etc.).

Further review of the Hospital's infection control program identified the failure to include incidents of illnesses and/or infections among personnel. During an interview on 01/22/15 at 1:25 p.m., an infection prevention nurse (#2) stated staff reported illnesses to the chief clinical officer and stated she did not receive notification of the illnesses. The nurse (#2) confirmed the Hospital failed to include personnel as part of the infection control program.

The Hospital lacked a system or process to document and report suspected cases of infections among patients and personnel to the infection control nurse for further investigation, monitoring, and recommendations. The Hospital failed to include all incidents of infections among patients and personnel in it's review and surveillance activities.