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Based on observations, record reviews, and interviews, nursing staff failed to update the patient's care plan for 1 of inpatient charts reviewed for care plans. (Inpatient 2)


The findings included:


Observations on 2/26/18 at 5:25 p.m. revealed a dinner tray delivered to Inpatient 2's room which showed a pureed diet. Observations on 2/27/18 at 8:43 a.m. revealed Inpatient 2 lying in bed with Oxygen infusing at 2 Liters via nasal cannula. Review of the patient's physician orders dated 2/18/16 at 5:00 p.m. revealed Inpatient 2's diet was changed from a mechanical soft diet to a pureed diet. Review of a physician ordered dated 2/17/18 with an end date of 2/24/18 revealed "Boost with meals", and a physician order for a change to Ensure with each meal was initiated on 2/27/18. A physician ordered "Titrate oxygen via n/c (nasal cannula) to keep sats(saturation) greater than 90%(percent)" was dated 2/17/18.

Review of Inpatient 2's nursing care plan(s) on 2/27/18 revealed the nursing care plans had been signed by the nursing staff each shift since admission indicating the patient's care plan was reviewed and updated by nursing. Review of Inpatient 2's care plan showed a mechanical soft diet with ground meats, a respiratory intervention that showed Inpatient 2 was on room air instead of Oxygen, and there was no documentation on the patient's care plan reflecting any dietary supplements such as Boost or Ensure. The findings were verified by Registered Nurse 5 on 2/27/18 at 3:22 p.m. and Licensed Practical Nurse 1 on 2/28/18 at 9:35 a.m..

Based on observations, record reviews, and interviews, the hospital failed to ensure 1 of 1 patient's who was ordered a nutritional supplement received the nutritional supplement (Boost). (Inpatient 2)


The findings included:


On 2/26/2017 at 4:14 p.m., review of Inpatient 2's chart revealed the patient was admitted on 2/16/17 with diagnoses including, but not limited to, Dehydration, Urinary Tract Infection, and Decubitus Ulcer. Review of the patient's Nutritional Assessment dated 2/19/18 revealed the patient had poor intake, difficulty chewing, and appeared underweight. Review of the patient's nutrition goals included to improve protein status, promote wound healing, and to promote weight change (gain) and recommended the patient receive Promod 30 milliliters(ml) three times daily. Review of the physician orders dated 2/17/2018 revealed an order for Boost with meals.

During an interview on 2/28/18 at 10:00 a.m., the Dietary Manager pulled the "Tray line Reports" for Inpatient 2. Review of the tray line reports dated 2/17/18 and 2/18/18 revealed the patient was ordered Boost with Meals. The tray line report dated 2/26/18 did not include the Boost with meals or any supplement, but observations of that meal service revealed Boost was included on the patient's tray card that accompanied the meal, but no Boost was on the tray. The Dietary Manager reported dietary was responsible for providing the Boost supplement with meals for the patient, but dietary didn't have Boost in stock from 2/17/2018 to 2/24/2018 and still had no Boost in stock as of 2/26/2018. The Dietary Manager verified the dietary department had not provided the patient with a Boost supplement with all meals from 2/17/18 - 2/24/18 because the dietary department did not have Boost in stock. A review of physician orders dated 2/27/18 revealed the patient's supplement was changed to Ensure on 2/27/18.

On 2/28/18 at 09:15 a.m., review of the patient's MAR, Licensed Practical Nurse (LPN) 1 stated that there was no documentation that nursing provided the Boost or Ensure supplements to the patient. Review of nursing notes in the patient's chart revealed there was no documentation that any supplements were provided to the patient. During an interview on 2/28/18 at 9:35 a.m., LPN 1 reported Boost/Ensure supplements are provided by dietary if ordered by the physician. After reviewing the patient's MAR, LPN 1 reported there was no documentation of nursing providing Boost or Ensure to the patient. Review of the nursing notes in the patient's chart revealed there was no documentation that any supplements were provided by the nursing staff. LPN 1 reported there was no documentation that Boost or Ensure supplements were added to the patient's care plan either.

Based on observations, interview, and a review of the hospital's policy, the hospital failed to ensure expired lab supplies were removed in one of one laboratories.

The findings are:

Observations in the hospital's laboratory on 2/27/18 between 3:38 p.m. and 4:15 p.m. revealed expired lab supplies:
27 Benzalkonium Chloride Antiseptic towelettes expired 10/17
1 red blood tube expired 8/31/17
43 Specimen Collection Swabs (Endocervical/Urethral) expired 1/31/18
1 unopened bottle of Methylene Blue expired January 2018
Review of the hospital's policy, entitled, "Disinfection of work area", revealed, "Work areas will be disinfected and checked for expired supplies regularly to provide a clean and safe environment in the laboratory." The findings were verified by the Lab Director on 2/27/2018 at 4:15 p.m. at the time of the observation.

Based on observations, record reviews, review of the hospital's policies and procedures, and review of manufacturer's recommendations, the hospital failed to ensure the supervision and monitoring of high risk problem prone areas in its operating area decontamination processes.

The findings are:

Cross Reference to A 0749: The hospital failed to adhere to acceptable principles of infection control to minimize the potential transmission of infectious agents in the decontamination room setting for 1 of 1 Certified Surgical Technician (CST 1).

Cross Reference to A 0756: The hospital failed to ensure its Infection Control Officer had an active system in place for monitoring its operating room decontamination and sterilization processes and assessment of its decontamination staff's competencies and adherence to the hospital's policies and procedures.

Cross Reference to A 0942: The Operating Room Supervisor failed to ensure the monitoring of staff in the hospital's decontamination area for infection control procedures related to post use care of the hospital's surgical equipment and failed to ensure an active ongoing infection control surveillance program in the operating room.

Based on observations, interviews, review of the facility policies and procedures, and manufacturer guidelines, the hospital failed to adhere to acceptable principles of infection control to minimize the potential transmission of infectious agents in the decontamination room setting for 1 of 6 Registered Nurses (RN 4), 1 of 1 Certified Registered Nurse Anesthetists (CRNA 1), and 1 of 1 Certified Surgical Technician (CST 1).

The findings are:


On 2/27/18 at 10:15 a.m., observations in the procedure room revealed Certified Surgical Technician (CST) 1 placed a dirty scope on the table beside stretcher, picked up the dirty Colonoscope wearing gloves, walked across the room to the scope cleaning room, and placed the scope in the sink without pre-rinsing or wiping the scope or placing the scope in a container. CST 1 filled the sink to the fill line which CST 1 stated holds ten (10) gallons of water. CST 1 stated, "The sink leaks." CST 1 pumped enzymatic cleaner into the water in the sink with 10 pumps of enzymatic cleaner. CST 1 reported, "Our scopes do not sit. They come from the room to be washed immediately." CST 1 washed and suctioned the dirty Colonoscope. CST 1 retrieved a coiled brush from the edge of the sink and began to brush the channels of the dirty scope. CST 1 stated, "I use the same brush all day." On 2/27/18 at 2:30 p.m., observations in the decontamination room revealed a wire brush in a tray at the top of the washing sink. CST 1 stated, "I use the brush to scrub some of the operating room instruments. I have been here for 10 years, and this brush has been here as long as I have."

Hospital OLYMPUS Reprocessing Instruction manual, reads, " ..... 5.2 Pre-cleaning the endoscope and accessories. .....Pre-clean the endoscope and the accessories at the bedside in the patient procedure room immediately after each patient procedure .... Perform the following pre-cleaning steps at the patient bedside ....2. Prepare a clean one thousand (1,000) milliliter (ml) container of water, fresh potable tap water or water that has been processed. Dip a clean, lint free cloth or sponge and wipe the entire insertion section of the endoscope. Wipe from the boot at the control section toward the distal end .... Aspirate water ....3. Lower the forceps elevator by turning the elevator control lever and immerse the distal end of the insertion section in the water. Depress the suction valve on the endoscope and aspirate the water through the endoscope for thirty (30) seconds ....5. Remove the distal end from the water. Depress the suction button and aspirate air for 10 seconds ...." Review of the packaging of the cleaning brush revealed "Halyard" single-ended cleaning brush with specifications of single use only.

On 2/27/18 from 10:30 a.m. and 2:30 p.m., observations in the scope processing room and the decontamination room revealed the sinks have gray/white material around both sinks.

Hospital policy and procedure, titled, "Decontamination and Care of Instruments, Scopes, and Powered Surgical Instruments", reads, ....C. Immediately after the surgical procedure all instruments should be contaminated. 1. The contaminated instruments should be covered in a covered container and transported to the decontamination room" ....

Hospital policy and procedure, titled, "Dirty Instrument Contamination, Transportation and Processing", reads, "C. Instruments ....4. Instruments are scrubbed with a nylon brush for the removal of any foreign matter, lumens flushed, and then placed in a perforated tray and rinsed".

Hospital policy and procedure, titled, "General Guidelines for Cleaning and Decontamination", reads, ...."2. All equipment and environmental and working surfaces shall be cleaned and decontaminated after contact with blood or other potentially infectious materials" ....

On 2/27/18 at 9:47 a.m., observations in procedure room revealed Certified Registered Nurse Anesthetist (CRNA 1) failed to disinfect equipment when connecting the Inpatient 1 to the monitor. When connecting the patient to the monitor, CRNA 1 gathered the monitor wires in her/his hands and the monitor wires fell to the floor. CRNA 1 retrieved the monitor wires from the floor and laid the monitor wires across the patient's stretcher without cleaning them. CRNA 1 opened a sterile syringe, opened a new vial of medication and withdrew the medication with the syringe, but failed to clean the medication vial's rubber septum before withdrawing the medication. CRNA 1 inserted the syringe into the patient's intravenous line without disinfection of the port prior to attaching the syringe. After the procedure was completed, CRNA 1 disconnected the patient from the monitor, removed his/her gloves, unlocked the stretcher, and left the procedure room with the patient without performing hand hygiene. On 2/27/18 at 2:15 p.m., CRNA 1 verified the findings.

Hospital policy and procedure, titled, "Handwashing/Hand Hygiene", reads, " ....8. After removing gloves ....E. Gloves are to be removed and discarded when the task is completed followed immediately by handwashing" .....

On 2/27/18 at 10:45 a.m., random observations in Operating Room (OR) 2 revealed 2 Yankeur connected to tubing in the bottom drawer of the anesthesia cart that was not in the packaging. Review of packaging, revealed, "Yankeur Bulb Tip, No Vent with Tubing; Do not use if package is opened or damaged". On 2/27/18 at 2:15 p.m., CRNA 1 verified the findings and stated, "I try to throw these away when I see this".

The facility's policy and procedure "General Guidelines for Cleaning and Decontamination" reads ...."2. All equipment and environmental and working surfaces shall be cleaned and decontaminated after contact with blood or other potentially infectious materials" ....




28883

Observations of Registered Nurse (RN) 4 in the provision of wound care to Inpatient 2 showed RN 4 failed to perform hand hygiene after removing and donning gloves during the provision of wound care for Inpatient 2. Observations on 2/27/18 from 9:15 a.m. to 10:00 a.m. revealed RN 4 retrieved the patient's Foley catheter bag and handed it to Certified Nursing Assistant 1. RN 4 removed the soiled gloves and donned a clean pair of gloves without performing hand hygiene. Wearing gloves, RN 4 removed the patient's sacral dressing and discarded the soiled dressing in the trash. RN 4 removed the soiled gloves and donned a clean pair of gloves without performing hand hygiene. RN 4 cleaned the patient's sacral wound with Normal Saline, removed the soiled gloves, and donned clean gloves 3 times without performing hand hygiene in between gloving. After cleaning the wound, RN 4 removed the soiled gloves, washed hands, and donned a clean pair of gloves. RN 4 placed Dakins soaked wet dressings in the patient's wound and placed dry gauzes and tape over the wound, removed the soiled gloves and donned clean gloves 5 times without performing hand hygiene between gloving. After performing hand hygiene and donning a clean pair of gloves, RN 4 assisted Certified Nursing Assistant(CNA) 1 to turn the patient and placed the patient's Foley catheter bag on the opposite side of the patient's bed. Wearing the same gloves, RN 4 removed the soiled dressing from the left hip wound and disposed of the soiled dressing in the trash. Without performing hand hygiene, RN 4 removed the soiled gloves and donned a clean pair of gloves and cleaned the patient's wound with Normal Saline and gauze. After performing hand hygiene and donning a clean pair of gloves, RN 4 placed Dakins soaked gauzes over the patient's hip wound along with a dry dressing and tape. RN 4 failed to perform hand hygiene 2 times after removing soiled gloves and donning clean gloves. In the provision of wound care to the patient's right heel, RN 4 removed the soiled gloves and donned clean gloves 3 times without performing hand hygiene between gloving episodes. In the provision of wound care to the left heel, RN 4 removed the soiled gloves and donned clean gloves twice without performing hand hygiene between gloving episodes. After completing the patient's wound care, RN 4 removed gloves and did not perform hand hygiene. On 2/28/18 at 10:35 a.m., RN 4 was informed of the concerns about his/her hand hygiene during the provision of patient care. RN 4 reported hand hygiene should be performed when changing gloves.

Review of the hospital's policy,entitled, "Handwashing/Hand Hygiene:, reads, "To provide guidelines to reduce the risk of transmission of microorganisms via the hands of employees." The policy included information that "A. All employees are to wash their hands in situations including, but not limited to: ....5. after contact with contaminated surfaces or equipment, 6. before donning and after removal of gloves...".


31672

On 2/27/18 at 2:35 p.m., an observation in the dirty instrument room revealed a single sink. CST 1 demonstrated the procedure for cleaning dirty instruments. CST 1 ran water into the sink. When asked how much water and cleaner should go into the sink, CST 1 stated, "I have no idea. I just run warm water in the sink until it is filled and then put two pumps of the enzymatic cleaner in it." Observations revealed 2 wire-steel bristle brushes in a silver container sitting on the back of the sink. CST 1 stated,"Those are what I clean the instruments with. They are old, but I have used them over and over. These are the only brushes we've had in here since I've worked here, and that's been ten years. "

Hospital Policy, titled, "Dirty Instrument Contamination, Transportation, and Processing", reads "....A. All instruments, equipment and supplies to be used for patient care and operative procedures must be appropriately processed to assure their sterility or that they are free form infectious bacteria....B. After use....will be washed and processed according to need to be used for patient use....".

Based on review of the hospital's infection control meeting minutes and interview, the hospital failed to ensure its Infection Control Officer had an active system in place for monitoring its operating room decontamination and sterilization processes and assessment of its decontamination staff's competencies and adherence to the hospital's policies and procedures.

The findings are:
On 2/28/18 from 10:45 to 11:20 a.m., the Hospital's Infection Control Officer (ICO) reported the hospital convenes quarterly quality meetings for the hospital's department directors to present their infection control data. The infection Control Officer reported that the only infection control data received from the Operating Room(OR) was the number of surgical cases. The Infection Control Officer stated, "I'm not sure how long it's been since I completed a focused survey of the OR, but it's been at least 4 years. There is a check list that I use for infection control audits with the Nurse Manager in the OR. I will have to focus more on this area." The Infection Control Officer stated, " It is not okay to ever re-use any single use items (brushes) for more than one task. Single use items should be thrown out after each use."

On 2/28/18 at 11:45 a.m., the Infection Control Officer submitted the agenda and meeting minutes from the hospital's last Infection Control meeting dated on 3/27/17. There was no data in the meeting minutes reflecting monitoring of the operating room's decontamination procedures or monitoring the competencies of the staff in the performance of these procedures.

In and interview with the Infection Control Officer on 2/28/18 at 11:45 a.m., the Infection Control Officer verified that 3/27/17 was the last date that an Infection Control meeting was convened, and stated, "This is an opportunity to improve. We will definitely have to make sure we have more meetings."

Based on observations, interviews, and review of the hospital's policies and procedures, the Operating Room Supervisor failed to ensure the monitoring of staff in the hospital's decontamination area for infection control procedures related to post use care of the hospital's surgical equipment and failed to ensure an active ongoing infection control surveillance program in the operating room.

The findings are:

Cross Reference to A 0749: The hospital failed to ensure the necessary supervision in its operating room monitored staff for adherence to acceptable principles of infection control to minimize the potential transmission of infectious agents in the decontamination room setting for 1 of 1 Certified Surgical Technician (CST 1).

Cross Reference to A 0756: The hospital failed to ensure the necessary supervision in its operating room ensured the operating room had an active system in place for monitoring its operating room decontamination and sterilization processes and assessment of its decontamination staff's competencies and adherence to the hospital's policies and procedures.

Based on record reviews and interview, the hospital failed to complete the patient's plan of care for 2 of 3 inpatients receiving rehabilitation services. (Inpatient 4 and 5)

The findings are:

On 2/28/2018 at 9:40 a.m., review of Inpatient 4's chart revealed the patient's plan of care for physical therapy did not have the patient's diagnosis. On 2/28/2018 at 9:45 a.m., review of Inpatient 5's chart revealed the patient's plan of care for physical therapy did not have the patient's diagnosis. On 2/28/2018 at 9:50 a.m., Director 3 verified the findings.