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Based on interview, record review, policy review and video review, the facility failed to:
- Ensure staff provided safe and competent nursing care, free from abuse or neglect, for three facility staff (C, E, and V) and one agency staff (HH).
- Ensure the crash cart (mobile cart which contains emergency medical supplies and medications) was secured and contents were not accessible to patients, visitors or unauthorized personnel.
- Ensure staff performed daily checks on the crash cart defibrillator (a device that activates a shock to the heart when indicated) to ensure it was functioning correctly in case of a cardiac (heart related) emergency.
- Document and report one patient's (#16) complaint related to alleged inappropriate treatment by staff.
- Complete necessary information related to 21 incidents, so they could be appropriately reviewed and prevented from reoccurrence.
- Direct all staff to wear identification badges with picture identification.
- Direct all staff to stop and question anyone not wearing a hospital identification tag to include visitors and vendors.

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Patient's Rights 42 CFR §482.23 The severity and cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety.

Please refer to A-0144.

Based on observation, interview, record review and policy review, the facility failed to ensure:
- Verification of nursing staff licensure for three staff (C, F and V) reviewed for verification of valid license. (A-0394)
- Dressing changes were performed according to policy for one patient (#1). (A-0395)
- A dressing change was completed with oversight by competent nurse for one patient (#16). (A-0395)
- Facility wide orientation was provided to one contracted nursing staff (HH). (A-0398)
- One contracted nursing staff (HH) had completed job specific orientation. (A-0398)
- Safe and appropriate medication administration for three patients (#3, #6 and #12). (A-0405)
- Timely medication administration for one current patient (#7) and one discharged patient (#21). (A-0405)

These failures created an unsafe environment and had the potential to place all patients at increased risk for their health and safety.

The severity and cumulative effects of these systemic practices resulted in the overall non-compliance with
CFR §482.23, Condition of Participation (CoP): Nursing Services.

Based on observation, interview, record review and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards when they failed to:
- Maintain sterile technique (specific practices and procedures performed to make equipment and areas free from all microorganisms to maintain sterility) with a peripheral inserted central catheter (PICC line a long flexible tube that is inserted into a peripheral vein to infuse fluids, blood products, and medications) for one patient (#1).
- Follow infection control practices during wound care for three patient's (#1, #10 and #16) dressing changes observed.
- Ensure one direct patient care staff (E) did not wear artificial nails.
- Appropriately use Personal Protective Equipment (PPE, such as gowns, gloves, and masks) for one patient (#22).
- Clean the work station on wheels (WOW, a mobile cart on wheels with drawers for supplies and a computer for recording tasks) after contamination and in between patients for two patients (#1 and #7).
- Leave personal belongings out of patient rooms and appropriately clean those items to prevent cross contamination and spread of germs for one patient (#3).
- Ensure nursing station countertops were intact and a cleanable surface for two nursing stations observed.
- Clean the Patient's snack room.
- Appropriately label intravenous (IV, within the vein) tubing to ensure they were changed weekly per facility policy for four patients (#1, #3, #6 and #17).
These failures had the potential to place all patients, staff and visitors at risk for cross contamination and illness. The facility census was 16.

The cumulative effects of these systemic failures resulted in the facility's non-compliance with 42 CFR 482.42 Condition of Participation: Infection Control and resulted in the facility's failure to ensure safe infection control practices to prevent infections and communicable diseases.

Please refer to A-0749.

Based on observation, interview, record review and policy review the facility failed to:
- Ensure staff provided safe and competent nursing care, free from abuse or neglect, for three staff (C, E, and V) of five facility nursing staff and one agency staff (HH) of one agency staff whose personnel records were reviewed.
- Ensure the crash cart (mobile cart which contains emergency medical supplies and medications) was secured and contents were not accessible to patients, visitors or unauthorized personnel.
- Ensure staff performed daily checks on the crash cart defibrillator (a device that activates a shock to the heart when indicated) to ensure it was functioning correctly in case of a cardiac (heart related) emergency.
- Document and report one patient's (#16) complaint, of one patient who reported he had lodged a complaint related to care received by patient care staff.
- Complete incident investigations for 21 out of 25 incident reports reviewed.
- Direct all staff to wear identification badges with picture identification.
- Direct all staff to stop and question anyone not wearing a hospital identification tag to include visitors and vendors.
These failures had the potential to place all patients in an unsafe environment. The facility census was 16.

Findings included:

1. Review of facility policy titled, "Suspected Abuse and Neglect," dated 11/2018, showed:
- All employees are pre-screened during the application process to ensure those with a record of abuse and neglect are not hired or retained as employees.
- To ensure employees are educated on the recognition and process for reporting potential abuse and neglect, all employees will be provided training upon hire through general hospital orientation and annually thereafter.
- In addition to education, training will be validated through an initial competency and annually thereafter.

Review of the facility's policy titled, "Suspected Abuse or Neglect," dated 11/2018, showed that the facility was to provide staff training and education on the recognition of abuse or neglect, the process for reporting abuse or neglect, and was to be validated through an initial competency, and annually thereafter, with 100% competency required.

Review of the undated facility document titled, "General House-wide Orientation (GHO)," showed the agenda for the orientation session, which included facility policies for abuse and neglect, infection control, and nursing procedures, with a skills check off day to ensure competency.

Review of the facility orientation check off showed the following areas were to be completed during the GHO, initialed by employee and presenter, with original copy sent to Human Resource (HR) upon completion of the 90 day evaluation period:
- Department Specific Guidelines;
- Materials management/Plant maintenance;
- Respiratory Therapy;
- Pharmacy;
- Wound Care;
- Rehabilitation;
- Nursing;
- Administration;
- Business Office;
- Dietitian Role;
- Health Information Management; and
- Information Technology.

Review of the personnel record for Staff V, Licensed Practical Nurse (LPN), showed that she worked ten shifts between 08/09/19 and 11/02/19, and started a new position as the Wound Care Nurse on 11/04/19.

During an interview on 11/07/19 at 11:44 AM, Staff DD, Human Resources (HR) Assistant, stated that Staff V was not scheduled for GHO until 11/21/19.

Review of the personnel record for Staff C, RN, showed missing documentation for a background check, job specific orientation, current Basic Life Support (BLS, level of medical care which is used for victims of life-threatening illnesses or injuries, until they can be given full medical care by more qualified individuals, or at a facility that offers advanced life support) certification (a requirement of all nursing staff), and periodic retraining for nursing skills, infection control and restraint training. Staff C's hire date was 03/2011.

Review of the personnel record for Staff HH, RN, Contracted Agency Nurse, showed missing documentation for job specific orientation. Staff HH's hire date was 05/2019.

Review of the facility document titled, "Employees that Attended GHO," showed three dates of 09/26/19, 10/24/19 and 11/21/19 for GHO classes. A full time RN with a hired and start date of 07/05/19 did not attend the GHO class until 09/26/19. A full time LPN with a hired and start date of 07/15/19 did not attend the GHO class until 10/24/19. Staff E, LPN with a hired and start date of 07/14/19 was scheduled to attend the GHO class on 11/21/19.

During an interview on 11/07/19 at 1:07 PM, Staff A, Risk/Quality Director, stated that nursing staff were hired, given a drug screen and then started work. He stated that the new hires were scheduled for the next GHO, and did not complete the GHO prior to patient care.

During an interview on 11/07/19 at 11:44 AM, Staff DD, HR Assistant, stated that there wasn't a GHO class in July and August because there was no HR staff to organize it, and stated that she began her employment at the facility in the middle of August 2019. Staff DD stated that newly hired staff, including nursing staff, had 90 days to complete the GHO class from their hire date.

Nursing staff were allowed to deliver patient care without verification of required licensure/certification, competency, or education to policies and procedures related to care of the patient, and prevention of abuse and neglect, which created an unsafe environment for patients.

2. Review of the facility policy titled, "Emergency Drugs, (Crash Carts)," dated 01/2009, showed the following:
- Emergency drugs will be secured but readily available to the patient-care staff but not accessible to patients, visitors, and unauthorized personnel.
- The pharmacy may use a breakable seal or other system designed to assure the continued security and integrity of the drugs between periods of use.
- Seals, if used, will be controlled by the pharmacy and will not be available to nursing service and others who use the drug (unless there is a numbered and trackable system in place).
- Departments, units, and users should notify the pharmacy as soon as possible when the container is opened or the seal is broken, emergency drugs have been used, drugs are missing, or other irregularities are identified or suspected.

Observation and concurrent interview on 11/04/19 at 1:10 PM, showed the crash cart located in the hallway next to the nurses station was unsecured. The top drawer contained needles, intravenous (IV, in the vein) supplies, and syringes. The remaining drawers contained oxygen tubing, miscellaneous supplies and intubation (insertion of a tube into a patient's body, especially that of an artificial ventilation [breathing] tube into the trachea [windpipe] required to restore a patient's breathing) supplies. On top of the cart was an unlocked tackle style box that contained 20 various emergency medications. Staff B, RN, Contracted Charge Nurse, stated that the crash cart was to be checked daily and the medication box was to be secured with a plastic break-away lock.

Observation and concurrent record review on 11/05/19 at 9:40 AM of the same crash cart observed on 11/04/19, showed that it remained unlocked, and there were no additional staff initials on the crash cart checklist to indicate it had been checked since 11/04/19.

During an interview on 11/05/19 at 4:15 PM, Staff F, RN, stated that it was the responsibility of the night charge nurse to check the crash cart defibrillator, run a test strip and verify that the crash cart was secured.

During an interview on 11/05/19 at 4:20 PM, Staff R, Pharmacist, stated that the pharmacy was responsible for the tackle box on top of the crash cart that contained emergency medications. He stated that the tackle box was to be secured and staff were to alert pharmacy when it was opened, otherwise the pharmacy checked the box monthly. Staff R was not aware that the medication tackle box had been unsecured since the previous day.

During an interview and concurrent observation on 11/05/19 at 4:28 PM, Staff K, RN, Charge Nurse stated that the crash cart and medication box were to be locked. after the interview, she verified that the crash cart drawers and medication box were both unsecured, returned to her computer and began to type, without securing the medications or supplies.

Observation on 11/06/19 at 7:15 AM, showed the same crash cart and medication box remained unsecured.

Staff B, RN, Contracted Charge Nurse, Staff R, Pharmacist and Staff K, RN, Charge Nurse were all aware that the crash cart and medication tackle box were unsecured but did not take any measures to immediately secure them. The crash cart and medication tackle box remained unlocked for the first three days of the survey. The actual time frame these were unsecured was unknown.

3. Review on 11/04/19 of the crash cart defibrillator test strips, showed there were no test strips for the dates of 10/24/19, 10/25/19, 10/26/19, 10/27/19, 10/29/19, 10/30/19, 10/31/19, 11/01/19 and 11/02/19 (this indicated that the defibrillator was not checked/tested).

Review on 11/04/19 of the facility document titled, "Emergency Crash Cart Checklist, November 2019," showed there were no staff initials for 11/01/19, 11/03/19 or 11/04/19 documented (this indicated that the crash cart was not checked).

The defibrillator testing and overall inspection of the crash cart was not performed on a consistent basis to ensure it was functioning appropriately in case of an emergency situation.

Review of facility document titled, "2019 Incident Report Summary," dated 07/19/19, showed that the crash cart, which was brought to a rapid response (a changing situation that requires more staff to address the current needs of the patient), was not secured.

4. Review of the facility's policy titled, "Security Management Plan," dated 09/2009, showed directives for the facility to:
- Direct the Risk Manager to determine the root cause (detailed look into the causes of incidents that result in or almost result in a negative outcome) of incidents, and report recommendations (to prevent them from reoccurring)
to the Safety Committee.
- Direct staff to complete an event/incident report by the employee involved, or witness, within 24 hours of the event/incident.
- Direct staff to complete an event/incident report for all disturbances involving patients, visitors or employees.

Review of the facility's policy titled, "Suspected Abuse or Neglect," dated 11/2018, showed the following three examples as part of the definition of internal abuse and neglect: indifference, carelessness or intentional failure to respond to patient needs and unnecessary rough treatment by the staff.

During an interview on 11/05/19 at 1:30 PM, in Patient #16's room, Patient #16 stated that his patient care technicians treated him roughly on nightshift. He stated that he dreaded when 6:00 PM came around (the patient began crying as he spoke of the nightshift) since he knew he would not be treated as well. He reported two night shift employees to the day shift charge nurse, and never received any follow-up from the facility.

During an interview on 11/07/19 at 2:00 PM, Staff B, RN, Contracted Charge Nurse, stated that when any incident with a patient occurred she expected nursing to check on the patient, fill out the incident reports completely and then notify the Risk Manager.

During an interview on 11/07/19 at 8:20 AM, Staff A, Risk Manager, stated that Patient #16 did not have any event/incident reports or complaints related to staff treatment documented.

Review of Patient #16's medical record showed no documentation of the patients complaints of rough treatment by the patient care technicians.

During an interview on 11/04/19 at 2:20 PM, Patient #6 stated that a nightshift nurse hurt him each time she provided care and did not treat his pain.

During an interview on 11/05/19 at 2:30 PM, Patient #9 stated that nightshift's call light response took a long time and that employees were rough.

During an interview on 11/06/19 at 10:30 AM, Patient #8's spouse stated that the nightshift staff were not gentle with her husband.

5. Review of incident reports for the past six months showed that 21 out of 25 reviewed were not completed according to the facility's policy. These were missing key elements that included patient labels (name, date of birth and identification number), times, locations, physician notification and witness information, as related to the incident.

During an interview on 11/07/19 at 2:37 PM, Staff A, Risk Manager, stated that event/incident reports were not being completed with all necessary information.

The facility failed to ensure that allegations of inappropriate staff treatment were documented on an event/incident report and communicated to Risk Management for investigation, and failed to ensure event/incident reports were completed in a manner to provide the information necessary to allow adequate review and investigation, so a root cause could be determined, and recommendations could be made to prevent their reoccurrence.

6. Review of the facility's policy titled, "Security Management Plan," dated 09/2009, showed directives for the facility to direct all staff to wear identification badges with picture identification and to direct all staff to stop and question any person not wearing a hospital identification tag, to include visitors and vendors.

Review of the facility's job descriptions for staff, undated, showed that the job performance standard expectations were for staff to consistently and properly wear a name badge.

Observations between 11/04/19 and 11/07/19, showed the following staff members failed to wear identification badges for security per policy:
- Staff C, Wound Care Nurse;
- Staff M, Occupational Therapy Assistant;
- Staff I, Respiratory Therapist;
- Staff B, Charge Nurse;
- Staff R, Pharmacist;
- Staff U, Hospitalist; and
- Staff T, Wound Care Physician.

Between 11/04/19 and 11/07/19 no staff questioned the staff that failed to wear their identification badges and showed that this was normal for the facility. The identification badges were important for the safety of patients and guests to be aware of staff who performed patient care.

























32280

Based on interview, record review and policy review, the facility failed to ensure verification of nursing staff licensure for three staff (C, F and V) of six nursing staff personnel records reviewed for verification of valid nursing license. This failure had the potential to expose all patients to staff who were not authorized to provide patient care. The facility currently employed 29 Registered Nurses (RN) and 14 Licensed Practical Nurses (LPN). The facility census was 16.

Findings included:

1. Review of the facility policy titled, "Professional Licensure/Certification," reviewed 05/2015 showed the following:
- Policy purpose was to ensure licensed and credentialed professional staff members meet national and state requirements for their position.
- The Human Resource Department is responsible for monitoring primary source verification of all licensed and certified personnel and maintaining a copy in the employee's personnel file.
- Professional employees must present their license to the Director of Human Resources (HR) upon renewal and a copy will be filed in the personnel file.
- Any professional employee who has an expired or revoked license will not be allowed to work until such license is restored to a current status.

Review of the personnel records for Staff C, RN, Staff F, RN and Staff V, LPN showed no verification or copy of current nursing license.

During an interview on 11/06/19 at 11:05 AM, Staff DD, HR Assistant, stated that the facility had no process for ensuring licensed staff had current licenses. She stated that the licensed staff were responsible for submitting a copy of their license or license renewal to the HR office.

During an interview on 11/06/19 at 12:11 PM, Staff GG, Chief Clinical Officer and Interim Chief Executive Officer, stated that she thought the nursing licensure verification was done at the corporate office.

Based on observation, interview, record review and policy review, the facility failed to perform dressing changes according to policy for one patient (#1) and failed to ensure a dressing change was completed with oversight by a competent nurse for one patient (#16) of two patients observed who required dressing changes.
These failures had the potential to lead to infection and could impact patient outcomes for all patients who required dressings. The facility census was 16.

Findings included:

1. Review of the facility's policy titled, "Nursing Scope of Services," dated 11/2015, showed the directive for staff to change Peripherally Inserted Central Catheter (PICC) dressings every seven days, and as needed.

Observation on 11/05/19 at 9:30 AM, showed Patient #1's PICC line dressing date was to be changed by 11/03/19, and wasn't changed until 11/05/19.

During an interview on 11/07/19 at 2:00 PM, Staff B, Contracted Charge Nurse, stated that it was unacceptable for PICC dressings to not be changed weekly.

2. Observation on 11/06/19 at 8:00 AM, showed Staff C, Wound Care Nurse Preceptor (instructor/teacher), Staff V, Wound Care Nurse Orientee (an employee/student who is new to the unit), Staff W, Patient Care Technician (PCT) and Staff T, Wound Care Physician, perform Patient #16's dressing change while the following was observed:
- The patient had no dressing covering his wounds, which were exposed to a soiled pad (the patient had a bowel movement and without a protective dressing, the wounds were in direct contact with stool).
- Staff C, cleansed the wounds and proceeded to lay a paper measuring tape (retrieved from Staff T's bag [contaminated inanimate object]) directly on top of both open wounds, which contaminated the wounds.
- The physician and Staff C left the room.
- Staff V, Wound Care Nurse orientee, proceeded with the dressing change without her preceptor, Staff C.
- Staff V washed her hands, double gloved, and laid a clean pad on the patient's bed.
- Staff V laid contaminated packages on the clean pad, then opened the packages.
- She put skin prep on the skin around the wounds, she placed Alginate (natural wound dressing made from seaweed and used for heavily draining wounds) on the wounds, then removed one pair of gloves.
- Without washing her hands, she placed the ordered dressing on the wounds and placed tape over them (dressing change orders state that no tape was to be used).

During an interview on 11/06/19 at 3:15 PM, Staff C, Wound Care Preceptor, stated that it was not appropriate for Patient #16 to be without a dressing and that Staff V, Orientee, should not have double-gloved during the dressing change. She also stated that she didn't always stay with her orientee and that she didn't have an orientation checklist for her, to document whether Staff C was competent in wound care.

During an interview on 11/07/19 at 2:00 PM, Staff B, Contracted Charge Nurse, stated that she expected nurse preceptors to stay with orientees, and to have an orientation checklist during the orientation period.

Based on interview and record review, the facility failed to provide facility wide orientation to one contracted nursing staff (HH) of two contracted nursing staff personnel records reviewed. The facility also failed to verify that Staff HH had completed job specific orientation. These failures had the potential to allow contracted nursing staff to provide patient care without education related to hospital policies, and ensure staff delivered competent care. The facility census was 16.

Findings included:

1. Review of the personnel record for Staff HH, Registered Nurse (RN), showed a hire date of 05/2019 for a contracted agency nursing position. There was no job specific orientation checklist or job description in her personnel file.

Review of the undated facility document titled, "General House-wide Orientation (GHO)," showed the agenda for the orientation session which included facility policies for abuse and neglect, infection control, and nursing procedures with a skills check off day to ensure competency.

Review of the facility orientation check off showed the following areas to be completed during GHO, initialed by employee and presenter, with the original copy to be sent to Human Resources (HR) upon completion of the 90 day evaluation period:
- Department Specific Guidelines;
- Employee Handbook and Review;
- Materials management/Plant maintenance;
- Respiratory Therapy;
- Pharmacy;
- Wound Care;
- Rehabilitation;
- Nursing;
- Administration;
- Business Office;
- Dietitian Role;
- Health Information Management; and
- Information Technology.

During an interview on 11/07/19 at 1:34 PM, Staff DD, HR Assistant, stated that the agency nursing staff did not complete the GHO as the facility employed nursing staff did. She stated that they only had one agency nurse which was Staff HH.

During an interview on 11/06/19 at 12:11 PM, Staff GG, Chief Clinical Officer and Chief Executive Officer, stated that there had been approximately 18 contracted agency nursing staff in the facility over the past six months.

Over the past six months the facility had approximately 18 contracted agency nursing staff, including Staff HH, who performed direct patient care without general house-wide orientation which included specific nursing policies and procedures, as well as other information pertinent to work performed within the facility.

Based on observation, interview, record review and policy review, the facility failed to perform safe and appropriate medication administration for three patients (#3, #6 and #12) of three patients observed, and failed to administer medications in a timely manner per facility policy for one current patient (#7) of three current patients observed, and one discharged patient (#21) of one discharged patient reviewed.
These practices failed to provide a safe and effective medication administration that potentially damaged the medication integrity and/or quality for all patients at the facility. The facility census was 16.

Findings included:

1. Review of the facility's titled, "Drugs Administration: General," dated 09/2009, showed that:
- Medication administration should comply with all applicable laws, rules and regulations.
- Staff administering the medication should visually inspect the drug for integrity (no discoloration, particulates or other physical abnormalities).
- Medication doses were considered "on time" if administered within one-half hour before or one-half hour after the scheduled time.

Observation on 11/04/19 at 2:20 PM in Patient #3's room, showed an unclean pill crusher (a device used to crush medications into a fine powder) coated with old medication from a previous administration.

Review of Patient #3's medication administration record (MAR) showed that the patient's current medications administered through the percutaneous endoscopic gastrostomy (PEG, a tube inserted through a person's abdomen directly into the stomach to provide a means of feeding when oral intake is not possible) tube were:
- Amiodarone (antiarrhythmic, used to treat heart rhythm problems) twice a day;
- Aspirin (blood thinner that can also treat pain, fever, headache and inflammation) once a day;
- Atorvastatin (reduces the amount of cholesterol in the blood, to reduce the risk of cardiac problems) at bedtime;
- Lansoprazole (used to treat ulcers and heartburn) extended release (releases medication slowly, over a long period of time) once a day;
- Melatonin (a hormone used to treat sleep disorders) at bedtime;
- Mirtazapine (antidepressant, medication to reduce the constant feeling of sadness or hopelessness) at bedtime;
- Sevelamer Carbonate (used to control phosphorus levels in chronic kidney disease) twice a day; and
- Oxycodone (synthetic pain medication with a high risk for misuse) every four hours as needed.

Observation on 11/04/19 at 1:50 PM in Patient #6's room, showed an unclean pill crusher coated with old medication from a previous administration.

Review of Patient #6's MAR showed that the patient's current medications administered through the PEG tube were:
- Aspirin (anticoagulant prophylactic, used to prevent blood clots) once a day;
- Atorvastatin at bedtime;
- Bupropion (antidepressant, medication to reduce the constant feeling of sadness or hopelessness) twice a day;
- Calcium-vitamin D (used for bone formation and maintenance) three times a day;
- Clopidogrel (used to prevent blood clots) once a day;
- Lactobacillus acidophilus (used to introduce good bacteria into intestines) twice a day;
- Acetaminophen (pain medication, also used to reduce fever) every six hours as needed; and
- Guaifenesin (used to thin mucus) every six hours as needed.

Observation on 11/05/19 at 9:20 AM in Patient #12's room, showed Staff E, Licensed Practical Nurse (LPN) prepared medication by using an unclean pill crusher and administered the medication to the patient. Also on the counter were two unclean pill crushers coated with old medication from previous administration.

Review of Patient #12's MAR showed that the patient's current medications administered through the PEG tube were:
- Amlodipine (used to treat high blood pressure and chest pain) once a day;
- Aspirin once a day;
- Carvedilol (used to treat high blood pressure and heart failure) twice a day;
- Hydrochlorothiazide (used to treat high blood pressure and fluid retention) once a day;
- Lactobacillus acidophilus twice a day;
- Pregabalin (used to treat nerve and muscle pain, as well as seizures) twice a day;
- Seroquel (an anti-psychotic medication used to treat certain mental/mood conditions) at bedtime;
- Requip (used to treat restless leg syndrome or a disease noted by stiffness, tremors, muscle spasms and poor muscle control) at bedtime;
- Zoloft (used to treat depression, obsessive-compulsive disorder, posttraumatic stress disorder, anxiety disorder and panic disorder) once a day;
- Simethicone (used to relieve excessive gas) four times a day;
- Acetaminophen every six hours as needed;
- Oxycodone ordered per tube every four hours as needed; and
- Miralax (used to treat constipation) ordered per tube one time a day.
The administration of medication for vulnerable (one in need of special care, support or protection because of age, disability or situation) patients was critical to the healing process and any excessive dosage had the potential to be detrimental to their health. The medications left in the pill crushers had the potential to mix the current amounts with the amount left in the pill crushers and create an excessive amount given to the patient and had the potential for detrimental drug interactions.

During an interview on 11/05/19 at 10:15 AM, Staff E, LPN, stated that she saw dirty pill crushers frequently when she arrived for her shifts.

During an interview on 11/07/19 at 2:00 PM, Staff B, Registered Nurse, (RN), Contracted Charge Nurse, stated that she expected all nurses to clean the pill crushers after every use.

During an interview on 11/07/19 at 9:10 AM, Staff R, Pharmacist, stated that his expectation was for staff to clean the pill crushers after every use so as not to mix the medications improperly.
The patients at this facility were skilled nursing patients that were extremely compromised with many comorbidities (the presence of one or more additional medical diagnoses co-occurring with a primary condition). The potential to overmedicate a patient by leaving old crushed medication in the same pill crushers without cleansing them could compromise the vulnerable patients.

2. Observation and concurrent interview on 11/05/19 at 9:46 AM showed Staff L, RN prepared to administer three medications to Patient #7: Lasix (medication used to treat water retention, swelling, and high blood pressure); potassium chloride (medication used to treat and prevent low levels of potassium [a mineral needed for your body to function properly]); and insulin (a hormone that regulates the amount of sugar in the blood). Staff L stated that the medications were late because she was fairly new and was still getting her routine down. She stated that she started working at the facility in 09/2019.

Record review of Patient #7's medication administration record showed:
- Lasix was scheduled to be administered at 8:00 AM, with an actual administration time of 9:51 AM.
- Potassium chloride was scheduled to be administered at 8:00 AM, with an actual administration time of 9:49 AM.
- Insulin was scheduled to be administered at 8:00 AM, with an actual administration time of 9:55 AM.

Record review of an event/incident report dated 09/20/19 showed Staff L, RN had missed a dose of insulin for discharged Patient #21.

Staff L, RN administered three medications to Patient #7 approximately one hour and 49 minutes after the scheduled dose time, including insulin that should be given in correlation to food intake to prevent a drop in blood sugar that could be detrimental to a patient's health.

During an interview on 11/07/19 at 1:58 PM, Staff B, RN, Contracted Charge Nurse, stated that she expected medications to be given at the ordered/scheduled time and that she had counseled Staff L after the missed insulin dose in 09/2019.























32280

Based on observation, interview, record review and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards when they failed to:
- Maintain sterile technique (specific practices and procedures performed to make equipment and areas free from all microorganisms to maintain sterility) with a peripherally inserted central catheter (PICC line a long flexible tube that is inserted into a arm, leg or neck vein to infuse fluids, blood products, and medications, or to withdraw blood for testing) for one patient (#1) of one PICC line insertion observed.
- Follow infection control practices during wound care for three patients (#1, #10 and #16) of three dressing changes observed.
- Ensure direct patient care staff did not wear artificial nails for one staff (E) of one staff observed with artificial nails.
- Appropriately use Personal Protective Equipment (PPE, such as gowns, gloves, and masks) for one patient (#22) out of one observed.
- Clean the workstation on wheels (WOW, pertaining to a computer, supplies, medications, etc. on a wheeled stand, that can be moved from patient to patient) after contamination, and in between patients, for two patients (#1 and #7) of two patients observed.
- Leave personal belongings out of patient rooms and appropriately clean those items to prevent cross contamination and spread of germs for one patient (#3) of one patient observed.
- Appropriately label intravenous (IV, within the vein) tubing to ensure they were changed weekly per facility policy for four patients (#1, #3, #6 and #17) of eight patients.
- Ensure nurses station countertops were intact and had a cleanable surface for two of two nursing stations observed.
- Clean the patient's snack room.

These failures had the potential to place all patients, staff and visitors at risk for cross contamination and illness. The facility census was 16.

Findings included:

1. Review of facility policy titled, "Hand Hygiene," revised 09/2015, showed the following direction for staff:
- Hands must be cleansed by hand washing with soap and water or by hand asepsis with alcohol-based rubs before and after contact with all patients, after contact with the source of microorganisms (organisms, such as bacteria, too small for the naked eye), after removing gloves and before performing invasive procedures, whether or not sterile gloves are worn.
- Gloves should be used as an adjunct to, not a substitute for, hand washing.
- All types of artificial nails are prohibited for patient contact or when job description includes the potential for such contact.

Review of the facility's policy titled, "Nursing Scope of Services," dated 11/2015, showed the directive for staff to change central line and PICC dressings, using sterile technique and a central line dressing kit.

Observation on 11/05/19 at 9:30 AM, showed Staff E, Licensed Practical Nurse (LPN), performed Patient #1's PICC line dressing change which showed the following:
- She washed her hands, gloved and placed a mask on herself and the patient.
- She placed a clean pad on the patient's bed and laid the dressing package on it (contaminating the pad).
- She placed an unclean pillow (contaminated object) under the patient's arm for the dressing change.
- She removed the old dressing, cleaned the site and applied the new dressing to the patient's arm that rested on the contaminated pillow case.
During the dressing change, the patient's PICC line site was open to air and touched the contaminated pillow case.

During an interview on 11/05/19 at 10:15 AM, Staff E, LPN, stated that she should have placed the clean towel under Patient #1's arm.

2. Review of the facility's policy titled, "Wound Care Scope of Services," dated 06/2018, showed that the Wound Care Nurse:
- Coordinates the skin and wound care program including patient management and ongoing treatment.
- Promotes and adheres to infection control practices.
- Educates healthcare providers on best practices to reduce risk factors.

Review of Patient #16's medical record showed the physician's wound care order stated to:
- Cleanse the wound with wound cleanser;
- Apply skin prep to the wound;
- Apply Alginate (natural wound dressing made from seaweed and used for heavily draining wounds) to entire wound bed (base of the wound);
- Cover with Optilock (non-adhesive absorbent dressing) super absorbent pads and secure with mesh undergarment;
- Do not use tape; and
- Change daily and as needed for soiling.

Observation on 11/06/19 at 8:00 AM, showed Staff C, Wound Care Nurse Preceptor (instructor/teacher), Staff V, Wound Care Nurse Orientee (an employee/student who is new to the unit), Staff W, Patient Care Technician (PCT) and Staff T, Wound Care Physician perform Patient #16's dressing change, which showed the following:
- The patient had no dressing covering his wounds, which were exposed to a soiled pad (the patient had a bowel movement and without a protective dressing, the wounds were in direct contact with stool).
- Staff C, cleansed the wounds and proceeded to lay a paper measuring tape (retrieved from Staff T's bag [contaminated inanimate object]) directly on top of both open wounds, contaminating them.
- Staff V washed her hands, double gloved, and laid a clean pad on the patient's bed.
- Staff V laid contaminated packages on the clean pad, then opened the packages.
- She put skin prep on the skin around the wounds, placed Alginate on the wounds, then removed one pair of gloves.
- Without washing her hands, she placed the ordered dressing on the wounds and placed tape over them (dressing change orders state that no tape was to be used).

During an interview on 11/06/19 at 3:15 PM, Staff C, Wound Care Preceptor, stated that it was not appropriate for Patient #16 to be without a dressing and that Staff V, Orientee, should not have double-gloved during the dressing change.

During an interview on 11/06/19 at 11:00 AM, Staff T, Wound Care Physician, stated that there should have been a dressing on Patient #16's wound and that he was not sure if placing the measuring tape directly on the wound was appropriate.

Observation and concurrent interview on 11/05/19 at 10:52 AM Staff P, LPN entered Patient #10's room to perform a dressing change. She placed her supplies onto the uncleaned bedside table and proceeded to remove the old dressing. Staff P sprayed the wound with a cleansing solution and wiped the excess with wash cloths, then placed the dirty wash cloths on the seat of the patient's wheelchair. After the dressing change, Staff P removed the dirty wash cloths from the wheelchair seat but failed to clean the seat's surface. Staff P stated that she should have cleaned the bedside table before she placed the supplies on it and should have placed the dirty wash cloths into the laundry hamper.

3. Review of the facility's policy titled, "Transmission Based Precautions," reviewed 02/2014 showed the following directives regarding contact isolation (precautions used to minimize the risk of infection spreading through touching an infected person or contaminated object):
- Complete hand hygiene using alcohol-based gel/foam or soap and water prior to entering patient room.
- An isolation gown should be worn upon entry to the room.
- Gloves should be worn upon entry to the room.

Observation on 11/07/19 at 9:30 AM in Patient #22's contact isolation room, showed Staff C, Wound Care Preceptor and Staff II, Nurse Practitioner, failed to wear PPE.

4. Although requested the facility failed to provide a policy regarding the cleaning of the Workstations on Wheels (WOW's).

Observation and concurrent interview on 11/04/19 at 1:45 PM, Staff E, LPN, completed medication administration in Patient #1's room, and without removing her gloves, walked into the hallway and typed on the WOW keyboard. She then removed her gloves and touched the WOW and pushed it down the hallway without cleaning the keyboard. Staff E was also noted to have what appeared to be artificial nails on. She confirmed that she did have artificial nails, and stated that the WOW's were cleaned at the beginning of the shift, that she didn't usually clean the WOW during the day and didn't realize that she contaminated the keyboard with her gloved hands.

Observation on 11/05/19 at 10:00 AM showed Staff L, Registered Nurse (RN), in Patient #7's room, who prepared to administer medication to the patient and obtain a blood glucose reading. Staff L placed all of the needed supplies onto the patient's uncleaned bedside table, touched the patient's arm, then typed on the WOW keyboard (positioned in the hallway) with gloved hands. Without changing gloves, she returned to the patient's bedside and proceeded to perform the blood glucose test with the same contaminated gloves.

During an interview on 11/05/19 at 10:20 AM Staff L, RN stated that she considered the bedside table a clean surface because her supplies were in their original package unopened. She stated that the WOW's were cleaned at the beginning and end of the shifts and that she did not clean them throughout the day.

During an interview on 11/07/19 at 1:58 PM, Staff B, RN, Contracted Charge Nurse stated that she expected staff to place supplies for patient care onto a clean surface prior to using and that staff should not wear artificial nails per facility policy.

During an interview on 11/07/19 at 2:37 PM, Staff A, Infection Control Officer stated that:
- He expected staff to follow facility infection control policies.
- Staff should place supplies for patient care onto cleaned surfaces.
- WOW's were only cleaned once, at the beginning of a shift, but he expected staff to clean the keyboards if they had contaminated them.

5. Observation on 11/05/19 at 10:00 AM, Staff F, RN, prepared to perform dialysis (clinical purification of the blood, as a substitute for the normal function of the kidneys) in Patient #3's room. Staff F had his personal water bottle inside the patient's room on the counter next to the sink. Staff F was gowned, gloved and masked to begin the dialysis when Staff K, RN, Charge Nurse walked to the doorway with Staff F's personal cell phone. Staff F walked to the doorway and with gloved hands grabbed his phone, touched the screen with his fingers and checked a message, and then handed the phone back to Staff K and she returned it to the nursing station.

During an interview on 11/06/19 at 4:15 PM Staff F stated that he shouldn't have taken his personal water bottle into a patient's room and should have removed his gloves and washed his hands before touching his personal cell phone.

6. Review of facility policy titled, "Nursing Structure," dated 11/2015, showed that all IV tubing will be labeled with a date and time of expiration.

Observation on 11/04/19 at 1:45 PM, showed Patient #1's IV tubing with a green label with the word "Wednesday" handwritten on it in black marker. The tubing did not have a specific date.

Observation and concurrent interview on 11/05/19 at 9:07 AM, showed Patient #3's IV tubing with a green label with the word "Wednesday" written on it. The tubing did not have a specific date. Staff F, RN, stated that the IV tubing was supposed to have the specific date on the label so that the staff would know when it needed to be changed.

Observation on 11/04/19 at 1:50 PM, showed Patient #6's IV tubing with no label.

Observation on 11/05/19 at 1:40 PM, showed Patient #17 had two IV tubing's with no date or time of expiration.

During an interview on 11/07/19 at 2:37 PM, Staff A, Infection Preventionist, stated the following:
- Nurses should have placed dressing supplies on a clean surface and not the patient's bed.
- It was inappropriate to place a contaminated measuring tape directly on an open wound.
- Double gloving was not allowed.
- The outside of the dressing packages were contaminated objects.
- The patient's snack room should have been cleaned.
- Nurses should have used a clean pad to change the dressings on.
- The IV tubing should have been dated.

7. Observation on 11/05/19 at 8:45 AM of the 100 Hall nursing station, showed one corner of the countertop approximately 3" in length, chipped, with the particle board visible. A second area approximately 12" in length was also chipped off, with the particle board visible.

These areas were not cleanable surfaces and had the potential to harbor bacteria that could be spread to patients, staff and visitors.

8. Review of the facility's policy titled, "Infection Prevention and Control Committee," dated 09/2015, showed the direction for infection prevention was to facilitate services and equipment that allowed staff to maintain efficacy in infection prevention and control.

Review of the facility's policy titled, "Ice Machines, Ice and Infection Control," dated 07/15/17, showed the direction for staff to prevent the growth of microorganisms during the handling and storage of ice on the unit used for patient consumption.

Observation on 11/06/19 at 10:30 AM, in the Patient snack room, showed the following:
- The ice machine was dirty with hard-water deposit and actively dripping;
- The cabinets were unclean with drip marks down the front of the cabinets;
- The countertops were visibly dirty; and
- Behind the faucets was a brown colored residue.

During an interview on 11/07/19 at 8:37 AM, Staff EE, Housekeeper, stated that she cleaned the floors and wiped down the counters in the patient snack room daily.

During an interview on 11/07/19 at 8:40 AM, Staff Y, Materials Management, stated that the patient snack room was supposed to be cleaned daily and that they should have maintained a cleaning log.

Although requested, no cleaning log was provided.










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