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Based on interview and record review the facility failed:
-To develop and maintain an effective Quality Assessment and Performance Improvement (QAPI) Program that included all hospital departments and all contracted services.
-To develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program focused on specific indicators related to improving health outcomes.
-To ensure the Chief Executive Officer (CEO), Medical Staff members and administrative leaders showed accountability for the effectiveness of the QAPI program by failing to ensure the facility performance indicators listed in the QAPI Plan were monitored through appropriate data collection, analysis, activities and projects that were related to improving patient care.
-To ensure the CEO, Medical Staff and Administrative Leaders guaranteed the QAPI plan included assessment of performance of contractors which were specific to the Long Term Acute Care (LTAC, patients with serious medical problems that require intense, special treatment for an extended time) facility patient care services.

The severity and cumulative effect of these deficient practices resulted in the facility's non-compliance with the requirements found at 42 CFR 482.21 Condition of Participation: Quality Assessment and Performance Improvement Program.

Please refer to A-0273 and A0309

Based on interview and record review the facility failed to incorporate 32 of 32 contracted services including Dialysis Services, Radiology Services, Pharmacy Services and Rehabilitation Services for Long Term Acute Care Services into the hospital-wide Quality Assessment and Performance Improvement (QAPI) Program. This had the potential to affect all patients receiving care in the facility. The facility census was 27.

Findings included:

1. Record review of the facility's document titled, "Quality Assurance and Performance Improvement Plan" revised 02/05/13, showed the following:
- Purpose of Quality Management: The purpose of quality management is to promote the fulfillment of the hospital's mission by facilitating achievement of optimal patient outcomes in a cost effective and efficient manner. To accomplish this purpose, systemic quality management provides a means of continuously analyzing and improving the delivery system of patient services and the hospital functions, processes, and structures that support that delivery system with a data driven quality assessment.
- The QAPI Committee is responsible for general oversight of the CQI (Continuous Quality Improvement) process.
- The Infection Control Committee is responsible for the surveillance, prevention, and control of infections among patients.
- The QAPI Committee compiles this information on a quarterly bases for the purpose of analysis and to identify trends and patterns and uses this information to identify opportunities for improvement and to select priorities for intensive quality improvement activity. The committee draws conclusions based on the findings, makes recommendations based on the conclusions, plans actions to implement the recommendations, and evaluates the effectiveness of actions taken.

The QAPI Plan did not address contracted services.

2. Record review of the facility's document titled, "Medical Executive Committee Meeting Minutes" dated 01/21/13, showed the following outcome/actions for QAPI reporting:
- All committee reports accepted as presented.

No analysis of the reported findings, data review, revised action or implementation was documented by the Medical Executive Committee or the QAPI Committee.

3. Record review of the facility's document titled, "Quality Assurance and Performance Committee" dated 01/16/13 showed the following:
- QAPI Plan Review: Started with 36 Patient and Organizational Focused Functions.
- Of the 36 Focus Areas, eight areas have consistently attained the facility's goal.
(The 36 Focused Functions were not listed and were not specific to the facility's patients but included all patients who were provided services by the contractors.)
- Dialysis (a contracted service, which is the process of cleansing the blood by passing it through a special machine) Water Analysis reported two cultures for 09/12 showed water bacteria and another showed the presence of Endotoxin (any of a group of poisonous lipopolysaccharides, a substance including fats and carbohydrates, found in the outer membranes of certain bacteria).
- Follow-up/Further Action Required: Routine Water Cultures and Endotoxin testing monthly.

The QAPI Committee failed to implement any new actions to ensure water quality or patient safety.

4. Record review of the facility document titled, "Quality Sub-Committee (Quality Project)" dated 02/08/13 showed the following:
- Response [call light] times are improving but will continue to be monitored;
- Ten additional phones have been ordered;
- A quality report/project is required each year and it must be measurable.
- OUTCOME/ACTION: Call light response times will continue to be monitored.

The Committee did not review data collection, data analysis, patient outcomes, implement new strategies or develop any further projects.

5. During an interview on 03/12/13 at 1:00 PM, Staff L, Registered Nurse (RN), QAPI, stated that she had no specific or specialized training for her position as the QAPI nurse in charge of the program. She stated that there was not a formal QAPI Committee and members were not named, but she did have a subcommittee. The documents provided by Staff L are titled QAPI Committee because there were meetings for QAPI that were documented. Staff L stated there was no list of QAPI projects for the hospital departments and the only 2013 project was on call light response times. She stated this was also the only project for 2012 that was documented. Staff L stated that the contracted services collect their own data and send it to her but she had nothing to do with their project choices, data collection, data analysis or data reporting. Staff L stated that the Infection Control Nurse did report some data to her on handwashing but didn't believe that was a QAPI project. The QAPI that are reported by the contracted services are scorecard analysis that include another facility and lump them together with the Long Term Acute Care (LTAC) patients (patients with serious medical problems that require intense, special treatment for an extended time). The scorecard analysis and findings are not specific to the LTAC patients.

6. Record review of the Infection Control Data for Employee Handwashing showed the following:
- Three months of monitoring forms were completed for a total of 22 observations.
- Twenty-one of the 22 observations collected were completed and signed by Staff FF, Unit Secretary.
Record review of the personnel file for Staff FF showed no medical training or specific training on infection control or handwashing and possessed no medical license or certification.

7. During an interview on 03/14/13 at 9:43 AM, Staff K, Licensed Practical Nurse (LPN), Infection Control Officer stated monitoring of staff for correct hand hygiene, and Personal Protective Equipment (PPE) (gown, gloves, mask) was done twice weekly either by herself or Staff FF, Unit Secretary. She stated that immediate corrective action was done if staff were observed doing it incorrectly. She stated if Staff FF was the one monitoring and she observed incorrect actions, she would go and get Staff K and she would then do the corrective action. If Staff K is absent then Staff FF would leave her a note of the staff member and the incorrect action. Staff K could not provide evidence of any corrective action.

8. During an interview on 03/14/13 at 10:15 AM, Staff FF, Unit Secretary, stated that she performed observations of staff for proper use of PPE's when directed by Staff K, LPN, Infection Control Officer. Staff FF stated she had no medical training or certification and her position was the Unit Secretary. She stated she was trained to observe by Staff K. Staff FF stated she observed from the hallway, never entered the patient's rooms, and if she witnessed incorrect use of the PPE's, or failure to do hand hygiene, she immediately reported it to Staff K. If Staff K was absent then Staff FF would leave her a note. Staff FF stated she would give "verbal" action to "my peers, the staff I work with but I would never tell a doctor or dietary staff, or other departments if they were doing it wrong".

9. During an interview on 03/13/13 at 2:00 PM, Staff SS, Director of Rehabilitation,a contracted service, stated that QAPI was done for the facility but was not done separately for the LTAC but would do so.

10. During an interview on 03/13/13 at 10:05 AM, Staff AA, Radiology Team Leader, stated that they were contracted by the facility to perform all necessary radiological testing for their patients. He stated that there were several QAPI Projects for the Radiology Department and the data was reported to the facility for review. Staff AA stated that the data was not specific to the facility patients but included all patients treated by the department in various locations.

11. Record review of the Radiology Performance Measures titled, "Annual Performance Results FY (fiscal year) 2013", showed that "Critical test results [within a timeframe allowing prompt attention and appropriate action to be taken] read back and verified" failed to meet the Departments goal of 90 percent four out of the seven months reported.

12. During an interview on 03/14/13 at 9:00 AM, Staff W, Pharmacist, stated that he did not have any QAPI projects and did not collect, analyze or report any data to the facility QAPI Program.



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Based on interview and record review the Chief Executive Officer (CEO), Medical Staff members and administrative leaders failed to show accountability for the effectiveness of the Quality Assessment and Performance Improvement (QAPI) Program by failing to ensure the facility performance indicators listed in the QAPI Plan were monitored through appropriate data collection, analysis, activities and projects that were related to improving care and reduction of medical errors and the CEO, Medical Staff and Administrative Leaders failed to ensure the QAPI plan included assessment of performance of contractors which were specific to the Long Term Acute Care (LTAC, patients with serious medical problems that require intense, special treatment for an extended time) facility patient care services. The facility census was 27.

Findings included:

1. Record review of the facility's document titled, "Quality Assurance and Performance Improvement Plan" revised 02/05/13, showed the following:
- Purpose of Quality management: The purpose of quality management is to promote the fulfillment of the hospital's mission by facilitating achievement of optimal patient outcomes in a cost effective and efficient manner. To accomplish this purpose, systemic quality management provides a means of continuously analyzing and improving the delivery system of patient services and the hospital functions, processes, and structures that support that delivery system with a data driven quality assessment.
- The QAPI Committee is responsible for general oversight of the CQI (Continuous Quality Improvement) process.
- The Infection Control Committee is responsible for the surveillance, prevention, and control of infections among patients.
- The QAPI Committee compiles this information on quarterly bases for the purpose of analysis and to identify trends and patterns and uses this information to identify opportunities for improvement and to select priorities for intensive quality improvement activity. The committee draws conclusions based on the findings, makes recommendations based on the conclusions, plans actions to implement the recommendations, and evaluates the effectiveness of actions taken.

The QAPI Plan did not address contracted services.

2. Record review of "Medical Executive Committee Meeting Minutes" dated 01/21/13, showed the following outcome/actions for QAPI reporting:
- All committee reports accepted as presented.

No analysis of the reported findings, data review, revised action or implementation was documented by the Medical Executive Committee.

3. Record review of the facility's document titled, "Quality Assurance and Performance Committee" dated 01/16/13 showed the following:
- QAPI Plan Review: Stated with 36 Patient and Organizational Focused Functions.
- Of the 36 Focus Areas, eight areas have consistently attained the facility's goal.
The 36 Focused Functions were not listed and were not specific to the facility's patients but included all patients that were provided services by the contractors.

4. Record review of the facility document titled, "Quality Sub-Committee (Quality Project)" dated 02/08/13 showed the following:
- Response [call light] times are improving but will continue to be monitored;
- A quality report/project is required each year and it must be measurable.

The Committee did not analyze data, patient outcomes, implement new strategies or develop any further actions for this project. This was the only project documented or reported by the committee.

5. During an interview on 03/12/13 at 1:00 PM, Staff L, Registered Nurse (RN), QAPI, confirmed the facility QAPI plan did not include contracted services. She also stated that there was no formal QAPI Committee but only a subcommittee that reviewed QAPI processes. The QAPI that are reported by the contracted services are scorecard analysis that include another facility and were lumped together with the LTAC patients. The scorecard analysis and findings are not specific to this facility's LTAC patients.

Based on interview and record review the facility failed to develop comprehensive individualized care plans for 12 patients (#2, #3, #7, #10, #13, #15, #20, #22, #23, #24, #25, #26) of 14 patient records reviewed. The facility census was 27.

Findings included:

1. Review of the facility policy, "Interdisciplinary Care Planning Standard" effective 02/09 showed direction for the patient's care plan to be individualized based on initial assessment upon admission and are reviewed and/or revised based on patient reassessment and appropriate to meet the patient's needs.

2. Record review of Patient #2's medical record showed the patient had a diagnosis of ongoing respiratory failure and Chronic Obstructive Respiratory Disease (COPD, a progressive disease that makes it hard to breathe). The patient was receiving 2.5 liters of oxygen. The care plan did not address the supplemental oxygen.

3. Record review of Patient #3's medical record showed the patient was in Contact Isolation (measures taken to prevent contagious diseases from being spread from a patient to other patients, health care workers, and visitors) for Vancomycin Resistant Enterococcus (VRE, a bacteria which is resistant to the antibiotic vancomydin). The care plan did not reflect the patient's contact isolation status.

4. Record review of Patient #7's care plan showed the patient was on contact isolation for Pseudomonas-Carbapenem (a bacteria that is resistant to the antibiotics imipenem and meropenem. The care plan did not reflect the patient's contact isolation status.

5. Record review of Patient #10's care plan showed the patient was on contact isolation for Stenotrophomonas Maltophilia (a multi drug resistant bacteria). The care plan did not reflect the patient's contact isolation status.

6. Record review of Patient #13's vancomycin-resistant enterococci (VRE) (bacteria that are resistant to the antibiotic Vancomycin). The care plan did not reflect the patient's contact isolation status of droplet precautions.

7. Record review of Patient #15's care plan showed the patient was on contact isolation for Methicillin Resistant Staph Aureus (MRSA, a strain of staph bacteria that's become resistant to the antibiotics commonly used to treat ordinary staph infections). The care plan did not reflect the patient's contact isolation status.

8. Record review of Patient #20's care plan showed the patient was on contact isolation for MRSA. The care plan did not reflect the patient's contact isolation status.

9. Record review of Patient #22's care plan showed the patient was on contact isolation for Stenotrophomonas Maltophilia. The care plan did not reflect the patient's contact isolation status.

10. Record review of Patient #23's care plan showed the patient was on contact isolation for MRSA. The care plan did not reflect the patient's contact isolation status.

11. Record review of Patient #24's care plan showed the patient was on contact isolation for MRSA. The care plan did not reflect patient's contact isolation status.

12. Record review of Patient #25's care plan showed the patient was on contact isolation for MRSA. The care plan did not reflect the patient's contact isolation status.

13. Record review of Patient #26's care plan showed the patient was on contact isolation for MRSA. The care plan did not reflect patient's contact isolation status.

14. During an interview on 03/13/13 at 3:00 PM Staff B, Director of Nursing, stated that the care plans did not address the oxygen use or contact isolation of the patients.

Based on observation, interview and record review the facility dietary staff failed to:
-Clean and maintain kitchen equipment to protect foods used in patient food service to prevent cross contamination.
-Keep floors clean and free of food.
-Date food which had previously been opened. The facility census was 27.

Findings included:

1. Record review of the facility policy titled, "Food: Dating, Handling Outdated, Recalled Food and Food Brought in for Patient" effective 02/09 showed direction for the staff to cover and date food in the refrigerators.

2. Record review of the US Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code, Chapter 4-601.11 (A) showed: Equipment, Food-Contact Surfaces and utensils shall be clean to sight and touch.

3. Observation on 03/13/13 at 12:45 PM showed two can openers with gummy food debris and unknown debris around the blade, gears and behind the blade.

4. During an interview on 03/13/13 at 12:47 PM Staff GG, Lead Dietitian, stated that she did not know how often the can openers were cleaned. She confirmed the presence of the debris on the can openers.

5. Observation on 03/13/13 at 12:50 PM in the walk in freezer showed three trays of biscuits stacked one on top of another, a pan of polish sausage and a pan of beef lasagna with no date as to when they were prepared.

6. During an interview at 03/13/13 at 12:55 PM, Staff G, Lead Dietitian stated that the biscuits were for Wednesday's (03/13/13) supper and confirmed that the food did not have a date written on the plastic covering.

7. Observation on 03/13/13 at 12:55 PM showed dry food littering the floor of the large walk in refrigerator.

8. During an interview on 03/13/13 at 12:55 PM Staff G, Lead Dietitian, stated that this floor was cleaned once a week on Wednesday.

Based on observation, interview, record review and policy review, the facility failed to follow the Infection Control Policies and Procedures and the Centers for Disease Control and Prevention (CDC) Guidelines for droplet precautions for two patients (#10 and #22) of two patients observed. This had the potential to affect all patients, visitors and staff and put them at higher risk for infectious disease transmission. The facility census was 27.

Findings included:

1. Record review of the facility's policy titled, "Infection Prevention & Control Plan" undated (provided from an electronic printout), showed the following:
- STANDARDS: Infection Prevention and Control standards are based on recognized guidelines, applicable laws and regulations, and address measure to prevent the transmission of infections among patients, care partners, medical staff, volunteers, visitors, and the general public. Standards have been developed that define surveillance, prevention and control measures in all patient care, support and service areas, and identify method effective in reducing the risk of transmission or microorganisms while increasing patient safety.
- The CDC is the recognized authority for HAI (Healthcare Associated Infections, infections associated with healthcare delivery) surveillance in the United States. Definitions published by the CDC and NHSN (National Healthcare Safety Network) system are the standard for use in hospitals.
- Defining Indicators for Infections: Centers for Disease Control's (CDC) Guidelines.

Record review of the facility's policy titled, "Contact Precautions" numbered IC0004, dated 03/2011, showed the following:
- Contact Precautions are designed to prevent infections that are transmitted by direct or indirect contact. Contact transmission is the most frequent means of transmitting healthcare associated infections, including those caused by Multi-Drug Resistant Organisms (MDRO), i.e., Stenotrophomonas maltophilia (an opportunistic and uncommon bacteria and human infection, difficult to treat because of its resistance to most penicillins and also to cephalosporins and aminoglycosides (antibiotics).
- Personal Protective Equipment (PPE): Gloves and gowns are to be worn when entering the patient room. Physician or infection preventions [preventionists] may require mask to be worn if organism is transmitted by droplets.

Record review of the facility's Policy and Procedure titled, "Isolation Guidelines (Infection Prevention) numbered IC0004, revised 11/07/12, showed the following:
- The Isolation Guidelines are based on current recommendations published by the CDC and the Hospital Infection Control Practices Advisory Committee (HICPAC).
- Guidelines contain two tiers of precautions. The first and most important is the use of Standard Precautions designed for the care of all patients.
- The second tier, Transmission-based precautions, is designed only for the care of specified patients. They are used in addition to Standard Precautions for patients known or suspected to be infected or colonized (when a person carries the organism/bacteria but shows no clinical signs) with epidemiologically [the incidence and prevalence of disease in large populations and with detection of the source] important pathogens that can be transmitted by airborne, droplet, or contact transmission.
- Infection prevention & Control will assume the responsibility for making the determination to discontinue isolation according to collaboration with the patient's caregiver and the recommended guidelines appropriate for the disease, illness or condition.
- Droplet Precautions are designed to prevent infections that are transmitted primarily by large droplet transmission at short distances. Droplets are generated during coughing, sneezing, or talking, and when performing certain procedures, such as suctioning. Transmission may also occur by contact with respiratory secretions (or articles freshly soiled with respiratory secretions).
- Personal Protective Equipment (PPE): Mask is required for all healthcare personnel entering the room.
- Gowns, gloves and/or eye protection may be necessary for close contact with patient or contaminated environment.

Record review of the CDC document titled, "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings" showed the following:
- Categories of precautions developed by the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Centers for Disease Control and Prevention (CDC) and provides guidance for their application in various healthcare settings. The categories of Transmission-Based Precautions are unchanged from those in the 1996 guideline: Contact, Droplet, and Airborne. One important change is the recommendation to don the indicated personal protective equipment (gowns, gloves, mask) upon entry into the patient's room for patients who are on Contact and/or Droplet Precautions since the nature of the interaction with the patient cannot be predicted with certainty and contaminated environmental surfaces are important sources for transmission of pathogens.
- Droplet transmission - Droplet transmission is, technically, a form of contact transmission, and some infectious agents transmitted by the droplet route also may be transmitted by the direct and indirect contact routes. However, in contrast to contact transmission, respiratory droplets carrying infectious pathogens transmit infection when they travel directly from the respiratory tract of the infectious individual to susceptible mucosal surfaces of the recipient, generally over short distances, necessitating facial protection. Respiratory droplets are generated when an infected person coughs, sneezes, or talks.
- Epidemiologically (the study of the causes, distribution, and control of disease in populations) important organisms - Any infectious agents transmitted in healthcare settings may, under defined conditions, become targeted for control because they are epidemiologically important. In determining what constitutes an "epidemiologically important organism", the following characteristics apply:
- Difficult to treat because of innate or acquired resistance to multiple classes of antimicrobial agents (e.g., Stenotrophomonas maltophilia).

Record review of the facility's document titled, "Inpatients currently on contact isolation and the diagnosed organism" undated, but provided by Staff K, LPN, Infection Control Officer, on 03/12/13, showed Patients #10 and #22 were both infected with Stenotrophomonas Maltophilia, both on Contact Precautions and were HAI (CDC/NHSN SURVEILLANCE DEFINITION OF HEALTHCARE-ASSOCIATED INFECTION: For the purposes of NHSN surveillance in the acute care setting, a healthcare-associated infection is a localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that was not present on admission to the acute care facility e.g. hospital acquired infections).

2. Observation on 03/12/13 at 8:46 AM showed a Droplet Precautions sign on Patient #10's door. The sign read: STAFF: Wear MASK at all times when within three feet of patient.

Observation on 03/12/13 at 8:46 AM showed Staff M, Registered Nurse (RN), donned PPE (Personal Protective Equipment, a gown, gloves and possibly a mask) but did not don a mask and stated "You don't have to wear a mask". Staff M could not explain why the patient was on droplet precautions but offered to look it up on the computer. The nurse looked up the pathogen (something that causes disease) and stated it was Stenotrophomonas Maltophilia but she couldn't explain what the pathogen was or how it was transmitted. She said she took care of the patient all the time and didn't wear a mask.

Observation on 03/12/13 at 9:15 AM showed a Contact Precaution sign had replaced the Droplet Precaution sign on Patient #10's door.

3. During an interview on 03/12/13 at 9:20 AM, Staff K, Licensed Practical Nurse (LPN), Infection Control Officer, stated she changed the sign for Patient #10 because, "he is getting ready to go home and probably isn't infected anymore because he isn't coughing or anything". She stated there were no new laboratory tests done to confirm that decision.

4. During an interview on 03/13/13 at 9:00 AM, Staff P, Medical Doctor (MD), Infection Control Physician, stated that he was not aware that Steno (Stenotrophomonas Maltophilia) is stated specifically by the CDC as being Droplet Precaution but would look it up. He also agreed that isolation signs should not be changed without first determining if the patient was still infected.

5. During an interview on 03/14/13 at 9:00 AM, Staff B, RN, Director of Nursing (DON), stated, "it was deemed by our guidelines that he [Patient #10] needed to be on contact isolation not droplet [precautions]".

6. Observation on 03/12/13 showed a contact isolation sign on Patient #22's door.

Record review of the medical record for Patient #22 showed that the patient had never been on droplet isolation precautions for Stenotrophomonas Maltophiliaas as recommended by CDC Guidelines.

Based on observation, interview and record review the facility failed to follow the Policy and Procedure for Hand Hygiene as it pertained to glove use for eight patients (#1 #7, #9, #10, #15, #18, #20 and #26) of 12 patients observed. Staff also failed to wear Personal Protective Equipment (PPE, gown and mask), correctly for two patient's (#10 and #20) of five patients observed. This had the potential to affect all patients in the facility for a higher risk of infection transmission. The facility census was 27.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene" (Infection Prevention) IC0005 revised 03/04/13, showed the following:
-Purpose: To define the basic elements and procedures for hand hygiene and follow the hand hygiene guidelines published by the Centers for Disease Control and Prevention (CDC).
-Hand hygiene is the single most important measure for preventing transmission of infection, disease and illness.
-Either hand washing with soap and water or hand antisepsis with alcohol based hand sanitizer: Before having direct contact with patients; after contact with a patient's intact skin; after contact with inanimate objects; and after removing gloves.

Record review of the facility's policy titled, "Isolation Guidelines" (Infection Prevention) IC0004 revised 11/07/12, showed the following:
-The Isolation Guidelines are based on current recommendations published by the CDC and the Hospital Infection Control practices Advisory Committee (HICPAC).
-Guidelines contain two tiers of precautions, first and most important is the use of Standard Precautions designed for the care of all patients, regardless of the diagnosis.
- Standard Precautions reduce the risk of transmission of organisms from both recognized and unrecognized sources of infection through its emphasis on hygiene and the barrier protection.
-The second tier, Transmission-based Precautions, is designed only for the care of specified patients. Used in addition to the Standard Precautions for patients known or suspected to be infected or colonized with epidemiologically important pathogens that can be transmitted by airborne, droplet, or contact transmission.

Record review of the CDC document titled "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007" showed the following:
-Isolation gowns - Isolation gowns are used as specified by Standard and Transmission-Based Precautions, to protect the Health Care Worker (HCW) arms and exposed body areas and prevent contamination of clothing with blood, body fluids, and other potentially infectious material.
-When applying Standard Precautions, an isolation gown is worn only if contact with blood or body fluid is anticipated. However, when Contact Precautions are used (to prevent transmission of an infectious agent that is not interrupted by Standard Precautions alone and that is associated with environmental contamination), donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental surfaces.
-Isolation gowns are always worn in combination with gloves, and with other PPE when indicated. Gowns are usually the first piece of PPE to be donned. Full coverage of the arms and body front, from neck to the mid-thigh or below will ensure that clothing and exposed upper areas are protected.
-Gowns should fully cover the torso from neck to knees, arms to end of wrist, and wrap around the back and fasten in back at neck and waist.

2. Observation on 03/11/13 at 1:40 PM showed Staff G, Registered Nurse (RN), don contact isolation PPE and go into Patient #7's room. Staff G touched the patient's bare skin and her central venous line (catheter or tube which is passed through a vein to end up in the chest portion of the vena cava [the large vein returning blood to the heart] or in the right atrium of the heart). Staff G, wearing the same gloves, touched the patient's abdomen under the bed covers where the surgical wound was documented as gaping, macerated (wet and soft) with green drainage. She then touched the bedding and without changing gloves or performing hand hygiene set up the patient's lunch tray, opened milk cartons and touched the silverware.

3. Observation on 03/11/13 at 2:00 PM showed Staff D, RN, entered Patient #1's room and proceeded to access the computer; then listened to the patient's lungs and heart sounds and moved the call light which was lying on the bed. She then donned gloves without performing hand hygiene. She checked the fluid tubing, suctioned the patient and then repositioned the patient wearing the same gloves. She removed the gloves and without performing hand hygiene accessed the computer

4. Observation on 03/11/13 at 2:07 PM, showed Staff R, RN, donned PPE gown, loosely tied at the neck and not tied at the waist and entered Patient #20's room, on contact isolation precautions for Methicillin-resistant Staphylococcus aureus (MRSA, a type of staph bacteria that is resistant to certain antibiotics). She touched the patient's lunch tray items then reached into her pocket, under the PPE gown, and retrieved her cellular telephone with her gloved hand and answered it. She did not clean the telephone before placing it back into her pocket under the PPE gown. With the same gloves she assisted the patient with items on his tray.

5. During and interview on 03/11/13 at 2:15 Staff R, RN, stated she didn't realize the PPE gown should cover the back and didn't think about answering her phone or the need to clean it afterwards.

6. Observation on 03/11/13 at 2:50 PM, showed Staff S, Licensed Practical Nurse, (LPN), entered Patient #20's room with PPE gown loosely tied at neck and waist with mid section of her back exposed.

7. Observation on 03/12/13 at 9:10 AM, showed Staff S, LPN, entered Patient #20's room for medication administration. She donned PPE with the gown loosely tied at the neck and the waist exposing mid section of her back. She first charted on the computer, opened medications and administered them to the patient then touched items on patient's breakfast tray including patient's water glass. She proceeded to open a bag of Intravenous (within the vein) solution and connected it to the patient's peripheral inserted central catheter (PICC, a catheter that is inserted into one of the large veins of the arm, near the elbow, and is advanced into the vein until the tip sits in a large vein just above the heart, used for medications and fluid administration) line then went back to the computer and charted. These tasks were all performed without changing gloves.

8. During an interview on 03/12/13 at 9:45 AM, Staff S, LPN, stated that she didn't realize the need to change gloves in between tasks and thought it was "ok, since it was all in the same room". She stated she didn't realize that her back was exposed and didn't know that the entire back should be covered with the gown.

9. Observation on 03/12/13 at 1:15 PM showed Staff T, Dietary Aide, standing beside Patient #20's bed, who was in contact isolation, after delivering lunch tray. The PPE gown was not tied at the neck and the top portion of the gown was hanging forward resting on her forearms. She removed gown and gloves without performing hand hygiene prior to exiting the room.

10. During an interview on 03/12/13 at 1:17 Staff T asked "did I do it wrong" and "do I need to tie it?" She was unable to explain the proper use of the PPE and stated she only knew to put it on because of the sign outside the door. Staff T did not respond as to why she did not perform hand hygiene.

11. Observation on 03/11/13 at 2:55 PM, showed Staff P, Medical Doctor (MD), Infection Control Physician, entered Patient #20's room with PPE gown tied at the neck, and not tied at waist, allowing sides of the gown to move freely as he moved about the room.

12. During an interview on 03/12/13 at 2:25 PM, Staff P, MD, Infection Control Physician, stated that it was not practical to tie PPE gowns. He stated that if it is tied at the waist the gown gets caught on the bedside table and he knocks things over in the patients' rooms.

13. During an interview on 03/13/13 at 9:00 AM, Staff P, MD, Infection Control Physician, stated that PPE gowns were supposed be tied at the neck and waist. He also stated that the back of a person's clothing didn't need to be completely covered by a gown and that it was alright to have it open in back.

14. Observation on 03/12/13 at 8:30 AM showed Staff E, RN, entered Patient #26's room who was on Contact Isolation for MRSA. She donned gloves and administered oral medications, moved the bedside tray, listened to lung and heart sounds, and moved the breakfast tray using the same gloves. This increased the probability of spreading infection to the patient.

15. During an interview on 03/12/13 at 9:15 AM Staff E, RN, stated that she would not change gloves in a contact isolation room unless she was going to do wound care.

16. Observation on 03/12/13 at 8:35 AM showed Staff M, RN, donned PPE and entered Patient #9's room who was on contact isolation precautions. Staff M removed a nicotine patch (a transdermal patch that releases nicotine into the body) from the patient's right shoulder. Staff M then removed an ink pen from her pocket under the PPE gown and opened the package of a new nicotine patch and without cleaning the ink pen put it back into her pocket underneath the PPE gown. She removed her gloves and without performing hand hygiene donned another pair of gloves and then placed the nicotine patch on the patient's left shoulder before she typed on the computer. She removed the PPE inside the patient's room but carried it out into the hall and discarded it.

17. Observation on 03/12/13 at 8:47 AM showed Staff M, RN, donned PPE but did not put on a mask as directed by the Droplet Isolation Precaution sign for Patient #10. She typed on the computer, touched the patients arm, prepared the medications for administration, touched the patient's arm and again typed on the computer. Staff M did not change gloves or perform hand hygiene between these tasks.

18. Observation on 03/12/13 at 9:20 AM, showed Staff S, LPN, entered Patient #18's room for medication administration. She donned gloves, poured liquid medication and handed it to the patient. She then opened medicated powder and pulled the patient's gown up to expose patient's perineum (the area that includes the penis) and sprinkled the powder over the area, rubbing it on the perineum then replaced patient's gown. She removed gloves, donned new gloves, without performing hand hygiene, administered nasal spray and charted on the computer.

19. Observation on 03/12/13 at 9:40 AM showed Staff D, RN, entered Patient #1's room and donned (put on) gloves and flushed and administered medication through an IV port. She then doffed (removed) the gloves and without performing hand hygiene donned another pair of gloves. She crushed medication and wearing the same gloves checked the residual of the tubing that goes from the patient's nose to the stomach (used for supplemental nutrition and medications). Wearing the same gloves, she picked up a container of water and mixed some of it with the medications; administered the meds through the tubing and flushed the tubing. She then doffed (removed) the gloves and without performing hand hygiene accessed the computer. She then donned gloves without performing hand hygiene and flushed the PICC line and administered an intravenous medication through the PICC line port. This increased the probability of spreading infection to the patient.

20. During an interview on 03/12/13 at 10:15 AM Staff D stated that she should have used hand hygiene between each glove change and when going from the patient to an inanimate object such as the computer.

21. Observation on 03/12/13 at 10:00 AM showed Staff M, RN, don PPE to enter Patient #9's room for a dressing change. Staff M removed the dirty bandage and discarded it along with her gloves. She did not perform hand hygiene and donned another pair of gloves. She cleaned the wound with saline (a salt solution) and dabbed it dry with gauze. Staff M changed gloves but did not perform hand hygiene. She placed a clean bandage on the patient's wound, removed her gloves; no hand hygiene was performed until she exited the room.

22. During an interview on 03/12/13 at 10:12 AM, Staff M, RN, stated that she thought she had performed hand hygiene between glove changes. She stated she didn't like using the hand hygiene gel because it irritated her skin.

23. During an interview on 03/12/13 at 10:10 AM, Staff K, LPN, Infection Control Officer, Wound Care Nurse, stated that she expects all staff, including physicians to properly wear PPE's, and do correct hand hygiene in between glove changes. She stated that all staff are monitored twice weekly for correct use of PPE's. Staff K stated if she was unable to do monitoring herself that Staff FF, Unit Secretary, had been trained to do this monitoring.

24. Observation on 03/12/13 at 10:15 AM showed Staff O, MD, outside Patient #10's room donning PPE. The physician failed to tie the gown at the neck or waist and it hung loosely around his shoulders.

25. During an interview on 03/12/13 at 10:25 AM, Staff O, MD, stated, "Sorry, I thought I covered myself adequately".

26. Observation on 03/13/13 at 8:45 AM, showed Staff V, RN (Wound Care Nurse in Staff K's absence), entered Patient #15's room for a dressing change. The patient was on contact isolation precautions for MRSA. She donned PPE prior to entering the room, removed the dirty dressing, then removed gloves and donned new pair without performing hand hygiene.

27. During and interview on 03/13/13 at 9:02 Staff V, RN, stated she was nervous and didn't realize she hadn't performed hand hygiene in between glove changes.


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27029

Based on interview and record review the facility failed to ensure medical records stored in the medical records room were secured from unauthorized access. This had the potential to affect the confidentiality of all medical records stored in the medical records room. The facility census was 27.

Findings included:

1. Review of the facility policy titled" Medical Record Storage" effective 01/12 showed that unauthorized individuals should not gain access to the patient records in the medical records area.

2. Observation of the medical records area showed a room approximately eight feet by 20 feet with approximately 10 file cabinets with locks lining one wall. There were approximately five medical charts lying on a desk.

3. During an interview on 03/13/13 at 9:15 AM, Staff HH, Health Information Technician, stated that about 10 people had access to the medical records area because they needed access to the copier. She stated that all the files were kept locked and she hid the key to unlock the file cabinets in a coffee cup which was in full view on a far desk. She stated on occasion there might be patient medical records on her desk that she was reviewing.