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Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by:
1) Failing to ensure 1 of 1 patients on a Diprivan drip was receiving the correct dosage as ordered by the physician (Patient #12) and
2) Failing to ensure that patients were assessed by a nurse prior to and after administration of PRN medications for 3 (Patient #2, 16, 23) of 3 patients reviewed for PRN medications in a total sample of 30.
Findings:

1) Failing to ensure 1 of 1 patients on a Diprivan drip was receiving the correct dosage as ordered by the physician

Review of the hospital policy titled, Analgesia and Sedation (Policy number 9-2.15.1) revealed that sedatives will be administered and/or titrated per a physician's order. The Richmond Agitation Sedation Scale (RASS) is used to determine the level of sedation, anxiety, or agitation in a patient. Sedatives should be administered as needed per physician's order to attain therapeutic goal.

Review of the medical record for Patient #12revealed an admit date of 12/02/17 with diagnoses including sacral decubitus and multiple bacterial infections. Further review of the record revealed the patient coded on 12/05/17 and was placed on a mechanical ventilator.

Review of the physician orders dated 12/05/17 revealed for staff to see "Vent Bundle" orders. Review of the "Vent Bundle Orders" revealed an order for sedation with Diprivan continuous drip, begin with 5mcg/min infusion; titrate to patient comfort. There were no physician orders indicating the parameters for increasing/decreasing the Diprivan drip related to the patient's RASS score, as indicated in the hospital policy.

Review of the daily IV Titration Flow Sheets for the Diprivan drip revealed the nursing staff titrate the patient's flow rate and documented RASS scores until 12/11/17 at 8:00 a.m. when the nurse documented "Sedation Vacation-Diprivan off". Review of the nurses notes dated 12/11/17 at 9:30 a.m. revealed that the "Diprivan remains off; pulling a little more on vent-little nasal flaring".

On 12/12/17 at 3:30 p.m., interview with S10RN revealed that she had given the patient a "Sedation Vacation" the day prior and had left her off the Diprivan drip because she felt that she did not need the sedation anymore. When asked about the parameters related to the patient's RASS score and titration, she stated that there should be a physician order in the record for that. At that time, she looked through the patient's record and was unable to locate an order related to RASS score and titration. When asked about an order for a "Sedation Vacation", she stated that she was unable to locate one in the patient's record.

On 12/12/17 at 4:05 a.m., interview with S2DON confirmed that there were no physician orders related to titrating the patient's Diprivan drip related to the RASS scores. He further confirmed that there were no physician orders related to a "Sedation Vacation".

2) Failing to ensure that patients were assessed by a nurse prior to and after administration of PRN medications

Patient #2
Review of patient #2's December 2017 MAR revealed the patient received Dilaudid 1mg intravenous PRN on the following dates/times: 12/06/17 at 10:45 a.m.; 12/07/17 at 9:05 p.m.; 12/08/17 at 8:25 p.m.; 12/09/17 at 5:30 a.m., 10:30 a.m. and 2:50 p.m. There was no documented assessment prior to giving the Dilaudid or after administration of the medication to assess for effectiveness.

Patient #16
Review of patient #16's MAR revealed the patient received Hydrocodone 5/325 PRN on 12/11/17 at 1:30 a.m. and 12/12/17 at 3:45 a.m. There was no documented assessment prior to giving the Hydrocodone or after administration of the medication to assess for effectiveness.

Further review of the MAR revealed the patient received Klonopin 0.25mg PRN on 12/09/17 at 10:50 p.m., 12/11/17 at 9:00 p.m. and 12/12/17 at 9:35 p.m. There was no documented assessment prior to giving the Klonopin or after administration of the medication to assess for effectiveness.

Patient #23
Review of patient #23's MAR revealed the patient received Hydrocodone 5/325 PRN on the following dates/times: 12/05/17 at 8:25 p.m.; 12/06/17 at 6:00 a.m., 9:20 a.m., 1:50 p.m., and 6:45 p.m.; 12/09/17 at 5:00 a.m., 6:00 p.m. and 10:00 p.m.; 12/10/17 at 5:00 a.m. and 7:00 p.m. There was no documented assessment prior to giving the Hydrocodone or after administration of the medication to assess for effectiveness.

On 12/13/17 at 11:00 a.m., S2DON reviewed the above patient records and confirmed that there was no documented assessments prior to or after administering the PRN medications to the patients.

Based on record review, observation and interview, the hospital failed to ensure the nursing staff develops, and keeps current, a nursing care plan for 3 (Patient #2, 3, 12 ) of 8 sample patient's records reviewed for care plans of out a total sample of 30. The deficient practice was evidenced by the hospital failing to revise the patients care plan to reflect the patient's current health status that included identified problems, interventions, measurable goals, target dates for completion, the person responsible to implement the interventions for which the patient is being treated.
Findings:

Review of the hospital's policy, titled, "The Nursing Process - Care Planning" (Policy Number: 9-1.2.0) revealed in part:
Purpose: To provide each patient with an individual plan of nursing care. To provide effective communication among the nursing staff about the patient's care. To assist the nursing staff in documenting nursing interventions and evaluations appropriately in the patient's chart.

Nursing Plan of Care:
The nursing plan of care provides collaborative/systemic method of individualized care that focuses on the patient's response to an actual or potential alteration in health based on patient assessment ..... It communicates pertinent patient problems/needs, delineates appropriate medical and nursing interventions in the medical record.

Plan of Care Review and Update
The patient's plan of care shall be reviewed at least weekly by an RN or LPN. The plan of care will be reviewed/updated by an RN or LPN as needed as a result of ongoing assessment and interdisciplinary rounds including ...medical interventions, etc.

Patient #2
Review of the medical record for patient #2 revealed an admit date of 11/27/17 with diagnoses including small bowel resection with wound vac in place and debility. Review of the patient's plan of care revealed no documented evidence that the wound vac to the patient's wound was addressed.

On 12/13/17 at 10:00 a.m., interview with S2DON confirmed that the patient currently had a wound vac in place. He further confirmed that the wound vac was not addressed on the patient's plan of care.

Patient #3
A review of Patient # 3's medical record revealed in part, he was admitted to the hospital on 11/3/17 with diagnoses that included MSSA (Methicillin-susceptible Staphylococcus Aureus) Bacteremia and E. Coli Urinary Tract Infection. Further review of the medical record revealed a laboratory test dated 12/6/17 that indicated Patient #3 tested positive for C. Diff (Clostridium Difficile). Review of the Physician's Orders dated 12/7/17 at 7:45 p.m. revealed "Place in isolation for C. Diff."

Review of Patient #3's Care Plan revealed the following in part:
Initiated: 11/3/17
Nursing Diagnosis: Infection - Actual r/t (related to) Bacteremia UTI (Urinary Tract Infection).
Review/Revise: 12/9/17, 12/2/17, 11/18/17 ....

On 12/11/17 at 9:20 a.m., an observation of Patient #3's room revealed a PPE (Personal Protective Equipment) caddy attached to the front door that contained disposable gowns, gloves and a sign that read "Maximum Contact Precautions."

On 12/12/17 at 2:40 p.m., an interview was held with S1Asst Administrator. She explained the nurses were responsible for updating the patient's care plan. After review of Patient #3's Nursing Care Plan on 12/12/17 at 2:40 p.m., S1Asst Administrator verified the care plan should been revised to reflect the patient being placed on maximum contact isolation precaution for C. Diff.

Patient #12
Review of the medical record for patient #12 revealed an admit date of 12/02/17 with diagnoses including sacral decubitus, multiple bacterial infections and bilateral subclavian DVTs. Further review of the patient's medical record revealed the patient was on Heparin and Diprivan titrated drips and had a chest tube. Review of the plan of care revealed it did not address the titrated drips, chest tube or sacral decubitus.

On 12/13/17 at 8:55 a.m., interview with S2DON confirmed that the patient's plan of care did not address the titrated drips, chest tube or sacral decubitus.


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Based on policy review, observations and interviews, the hospital failed to ensure the infection control officer implemented measures for controlling infections and communicable diseases as evidenced by:
1) Failing to ensure the room of 2 of 2 (#3, #11) patienst infected with Clostridium Difficile was cleaned/disinfected by agents that were effective against the Clostridium Difficile pathogen,
2) Failing to ensure that staff adhered to appropriate hand hygiene, and
3) Failing to maintain a sanitary physical environment.
Findings:

1) Failing to ensure the room of a patient infected with Clostridium Difficile was cleaned/disinfected by agents that were effective against the Clostridium Difficile toxin

Review of the hospital's policy, "Management of Patients with Clostridium Difficile (Policy Number: 8-2.2.0) revealed in part: Policy: The following procedures will be adhered to fo all patients diagnosed with Clostridium difficile (C. difficile) infections.
Procedure: Cleaning and Decontamination
The environment (patient room) and reusable items must be thoroughly cleaned with a chlorine-containing agent ....

A review of Patient # 3's medical record revealed in part, he was admitted to the hospital on 11/3/17 with diagnoses that included MSSA (Methicillin-susceptible Staphylococcus Aureus) Bacteremia and E. Coli Urinary Tract Infection. Further review of the medical record revealed a laboratory test dated 12/6/17 that indicated Patient #3 tested positive for C. difficile (Clostridium Difficile). Review of the Physician's Orders dated 12/7/17 at 7:45 p.m. revealed "Place in isolation for C. Diff." Patient #3 had Maximum Contact isolation precautions in place and a sign attached to the door of her room (Room f).

A review of Patient #11's medical recored revealed in part, she was admitted to the hospital on 12/11/17 with diagnoses that included C. difficile. Patient #11 had Maximum Contact isolation precautions in place and a sign attached to the door of her room (Room c).

On 12/12/17 at 8:45 a.m., an interview was held with S7HSK. She stated that she had to clean 20 rooms, including the isolation room. S7HSK explained the cleaning included pulling trash, sweeping, dusting and mopping the floors. She stated she cleaned all surfaces (headboard, footboard, side rails, bathroom, air loss mattress pump) with Virex cleaning solution and mopped the floors with Stride cleaning solution. When asked if any other clean solution was used to mop the isolation room, S7HSK stated she only used Stride. S7HSK stated she had no way of knowing which patient was infected with C. difficile. After the interview, S7HSK presented manufacturer's information sheet on Virex II 256 and Stride solution. Neither cleaning solution shown documentation to effectively kill C. difficile microorganism.

On 12/13/17 at 2:37 p. m, an interview was held with S8HSK. S8HSK acknowledged he had cleaned and mopped the patients' rooms day. When asked, he explained he mopped the patient's room with Stride solution. S8HSK stated he mopped all of the isolation rooms with Virex only.

On 12/12/17 at 3:56 p.m., interview with S9HSK Dir. S9HSK Dir stated he oversought the operations of the facility. He stated the housekeeping staff was responsible for cleaning the entire patient's room that including the bed, side rails, foot board, head board, air loss mattress pump, the bathroom, toilet, shower, mopping the floors, etc. S9HSK Dir was asked of the process of cleaning a room after a patient with C. difficile had been discharged. He explained the housekeeping staff should clean all surfaces with bleach wipes and was instructed to call the Housekeeping managers to bring bleach to mop the floors. S9HSK Dir, then stated the mattress was cleaned with Virex. He stated he had been informed by a prior source to clean all areas with bleach except to use Virex on the mattress. S9HSK verified the isolation rooms that contained patients with C. difficile should be cleaned with bleach in its entirety.

In an interview on 12/13/17 at 9:25 a.m., with S6Dir of HSK, she verified the housekeeping staff should have been using bleach containing chlorine to clean and disinfect of patients with C. difficile.

Review of the hospital's policy, "Hand Hygiene" (Policy Number: 8-5.0.0) revealed in part:
Policy: Staff is required to perform Hand Hygiene prior to, ...and following contact or completion with a patient of a task ...
Procedure:
Staff will perform hand hygiene by washing hands with soap and water or using alcohol-containing antiseptic hand rub:
- Before direct contact with a patient
- Before and after glove use
- Upon completion of patient care and/or exiting the patient's room


2) Failing to ensure that staff adhered to appropriate hand hygiene.

Review of the hospital's policy, titled, "Isolation Precautions" revised 8/7/17 (policy #8-2.0.0) revealed in part:

Hand Hygiene
Wash hands after touching blood body fluids, secretions, and contaminated items whether or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and otherwise indicated to avoid transfer or microorganisms to other patients or environments ...

Gloves, Gowns, Eye Protection, Face Shield (Personal Protective Equipment (PPE)
...Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments.

Contact Precautions
Gloves, Gowns and Hand Hygiene
In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, nonsterile gloves are adequate when entering the room ..... Remove gloves before leaving the patient's room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent.

Maximum Contact Precautions
Includes all of the above stated indications that apply to Contact Precautions; however a gown will always be worn when entering the room.

On 12/11/17 at 1:00 p.m., observation revealed S3LPN exiting the room of a patient who had a sign on the door indicating contact precautions. S3LPN opened the door of the patient's room and removed her gown and then put it in the trash can on the housekeeping cart that was outside the door. S3LPN was then observed to go to the nurses station to chart. S3LPN was not observed to perform any hand hygeine.

On 12/11/17 at 1:05 p.m., S4CNA was observed exiting Room f on Hall b wearing gloves after assisting with a patient. She, then walked to Room e on Hall "a" to retrieve clean linen from the linen cart. Wearing the same gloves, she picked up the linen and placed the linen in her arms. A pillow case had dropped onto the floor. S4CNA was observed picking up the pillow case and placed it back into her arms. The CNA, then, walked to Room b, housing a patient identified as an contact isolation room on Hall "a". Still wearing the same pair of gloves and holding the linen, S4CNA donned a yellow disposable isolation gown. When asked, S4CNA stated she was going to change the patient's bed linen and proceeded into the room. S4CNA did not change her gloves or perform hand hygiene after and before entering a patient's room.

On 12/11/17 at 1:09 p.m., S5CNA had arrived to assist S4CNA changing the patient's bed linen in Room b on Hall a. S5CNA was observed donning a disposable gown and gloves without washing or sanitizing her hands prior to entering the patient's room.

On 12/11/17 at 1:10 p.m., observation revealed S11RN walking down the hall holding an IV bag of medication. She was observed to drop the bag in the hallway and then pick it up. She then was observed to don gloves and gown prior to entering the room of patient who had a sign on the door indicating contact precautions. S11RN was not observed to perform any hand hygiene prior to donning the PPE.

On 12/12/17 at 8:40 a.m., observation revealed S5CNA exiting the room of a patient on contact precautions. She was observed carrying the breakfast tray out of the room without wearing gloves. She then was observed to enter another patient's room without performing any hand hygeine.

On 12/13/17 at 1:40 p.m., an interview was held with S1Asst Administrator and S2DON,ICO. S2DON,ICO stated the staff should always don gloves when caring for a patient on isolation precautions and also perform hand hygiene before and after going into a patient's room. After S2DON,ICO was made aware of the observations, he verified should have donned on/off their gloves, washed and/or sanitized their hands before and after entering the patient's rooms. S1Asst Administrator and S2DON,ICO was also made aware of the findings in the physical environment. Both verified the floors and surfaces of the rooms of patients identified with having C. difficile should have been cleaned with an agent containing chlrorine. S1Asst Administrator and S2DON, ICO explained housekeeping has been an ongoing concern. Both expressed after reaching out to the housekeeping department multiple times, the cleanliness of the physical environment had not improved.

3) Failing to maintain a sanitary physical environment.

On 12/11/17 at 10:30 a.m., observations of the patient rooms revealed the following:
Room g - The side rails on the bed were coated with a thick build-up of dirt and grime. Dried red and brown substances were observed on the side rails. Multiple pieces of old tape were stuck to the side rails. A telemetry monitor was observed on the wall over the bed. Old tape and stickers were observed on the wires of the monitor. There was a long black hair in the bathroom sink and opened bottles of body wash/shampoo and an unidentified liquid left in the shower stall.

Room i - The side rails were coated with a thick build-up of dirt and grime. Old used pieces of tape were stuck to the side rails. A brown substance was observed on the television remote/call bell. Old used tape was observed stuck to the telephone.

Room c - There was a dried orange substance on the television remote/call bell. A build-up of dirt and grime was observed on the side rails. There was a dirty,smeared film over the entire surface of the bathroom mirror. Brown splatters were observed on the ceiling over the sink in the bathroom. A tube feeding pump was in the room wrapped in a clear plastic bag. The clear bag was removed by the surveyor and dried brown drips and spills were observed on the pump and down the base of the pump. At that time, interview with S3LPN revealed that a plastic bag wrapped around patient equipment indicates that it had been cleaned and ready for patient use.

Room d - A dried white substance was observed on the over bed table that was easily scraped off by the surveyor. There was a wound vac machine sitting in the window sill.

Room e - There was a build-up of dirt and grime on the side rails of the bed. The manual blood pressure cuff and tubing on the wall was coated with dust.

During tour of the hospital on 12/11/17 between 12:50 p.m. - 1:30 p.m., baseboards on Halls a, b and c were observed to contain thick gray furry build up.

On 12/12/17 at 9:25 a.m., S12CNA observed with the surveyor the microwave used to warm patient's food located in the Patient Nourishment room. The microwave contained a strand of hair and food splatter throughout the inside.

On 12/12/17 at 3:56 p.m., interview with S9HSK Dir. S9HSK Dir stated he over sought the operations of the facility. He stated the housekeeping staff was responsible for cleaning the entire patient's room that including the bed, side rails, foot board, head board, air loss mattress pump, the bathroom, toilet, shower, mopping the floors, etc. The housekeeping staff did not clean special medical equipment that needed to be removed by the nursing staff. He explained there were 8 indicators of cleaning that indicated the patient's room had been cleaned and ready for a new patients. S9HSK Dir gave examples of indicators that included V-tipping the toilet paper, blue water in the toilet, swans and prayer cards. He explained after the housekeeping staff conducted a final cleaning of a patient's room, the rooms may or may not be inspected for quality. When asked, S9HSK Dir stated there was no documentation available to indicate the patient rooms that were inspected. After being made aware of the physical environment observations, S9HSK verified the housekeeping staff should not have left the room until it was completely cleaned.

On 12/13/17 at 9:25 a.m. S6Dir of HSK observed the baseboards on Hall a, b and c verified the baseboards should have been cleaned.

On 12/13/17 at 2:40 p.m., an observation was made of the patient/visitor bathroom located across from the therapy department. S2DON,ICO was present. The observation revealed a half-dollar size red stain on the wall. When asked S2DON,ICO stated the red stain "looked like blood" Further observation also revealed several stains on the bathroom walls throughout and the ceramic tile baseboards contained a thick layer of gray furry substance.

On 12/13/17 at 1:40 p.m., an interview was held with S2DON,ICO. Both were made aware of the findings during the physical environment tour. S2DON,ICO explained housekeeping had been an ongoing problem. S2DON,ICO expressed after reaching out to the department multiple times, the cleanliness of the environment had not improved. S2DON,ICO verified the patient's room should be cleaned and mopped with bleach if the patient had C. difficile. S1Asst Administrator added the nursing staff should conduct a final inspections of the patient's rooms. S1Asst Administrator stated, "We need to check the rooms more often cleanliness since it has been an ongoing problem."


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