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Based on observation, interview and record review, the facility failed to ensure hemodialysis machines in use in the facility for hemodialysis treatment of patients' dialysate solution had electrolyte analysis ( verification of electrolytes in the dialysate solution) done by an outside laboratory in 7 of 9 hemodialysis observed in use in the facility: 3, 5, 7, 8, SKOSA756, IKOS166266, and KOS141988

Findings:

Observation on 01/23/2018 at 12;30 P.M of the facility's hemodialysis suite located on unit #400 ( Campus) 1) revealed there were four Fresenius K hemodialysis machine in place. Hemodialysis machine #s 3, 5, 7 and 8.

The Surveyor requested documentation that verification of the electrolyte in the dialysis solutions were done by a laboratory.
Review of the contracted hemodialysis facility's hemodialysis log revealed no documentation of electrolyte analysis by a laboratory.

Interview with Contracted Chief Biomedical Technician ( #95) via the telephone on 01/23/2018 at 10:00 a.m. revealed the contracted hemodialysis company follows AAMI guidelines and that the verification of the electrolyte in the dialysis solution were not done. He also stated that he had no knowledge of when the hemodialysis machines were put in service in the facility.

Review of the Manufacturer's recommendation for hemodialysis machine 200k, Page 13 of of the Operators Manual directs users as follows;"Check the composition (i.e., Na, Cl, K, Ca, Mg, HCO ) and pH of the dialysate3 solution after the machine is installed or after the machine is modified for different concentrate types. Check the conductivity and approximate pH of the dialysate solution with an independent device before initiating dialysis. Improper conductivity or pH could result in patient injury or death."


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Observation on 1/24/18 at 10:00 am of the facility's dialysis suite at Hospital #2 revealed there were 3 'Fresenius K' dialysis machines in use; Hemodialysis machine #2KOSA756, where patient # 34 was currently receiving treatment, hemodialysis machine # 1KOS166266, where patient # 35 was currently receiving treatment, and hemodialysis machine # 9KOS141988, where patient # 36 was currently receiving treatment.


Record review on 1/24/18 of the facility's hemodialysis logs revealed there was no documentation of electrolyte analyses ( verification of electrolyte in dialysate solution) performed for 3 out of the 3 hemodialysis machines that were currently in use.


In an interview on 1/24/18 at 10:15 am with Patient Care Technician staff# 88, he stated he had no knowledge about electrolyte analyses( verification of electrolyte in dialysate solution) being performed on any of the 3 out of the 3 hemodialysis machines in use in the facility.

In an interview on 1/24/18 at 10:25 am with Contracted Dialysis Nurse Manager # 87, he stated he was unaware of, nor had any knowledge about required electrolyte analysis prior to using dialysis machines for patients.

In a telephone interview on 1/24/18 at 10:30 am with chief Biomedical staff # 95, he stated he had never heard of electrolyte analyses ( verification of electrolyte in dialysate solution) and the reports generated by these analyses, and could not advise where or if any documentation regarding this requirement was met for the machines that were currently in use at time of survey.

Based on interview and record review, the facility failed to ensure nursing care plans were evaluated by the Registered Nurse 1 of 4 ICU patients (ID #s 30).

Findings include:

Patient # 30 on the ICU floor did not have an updated nursing care plan addressing health status and needs.

Record review on 1/23/18 of patient's (ID#30) medical record at Campus #2 on the ICU floor revealed that the patient had been admitted on 12/22/17 with respiratory failure, CHF (congestive heart failure) and in the history and physical dated 12/22/2017 revealed patient had a past medical history of a seizure disorder.
Nursing Care Plan for Patient (ID#30) did not have documented seizure precautions.

Interview on 1/23/18 at 10:00 am with RN ID# 85 reported that the care plan should have addressed the seizure precautions from time of admissions on 12/22/2017 in the nursing care plan for Patient #30 and there was none.

Based on observation, interview and record review, the facility's nursing staff failed to administer hemodialysis treatment and medication as ordered by the physician in 3 of 38 sampled patients. Patient #s 12, 16, 29. The facility's respiratory staff failed to administer nebulizer treatment as ordered in 1 of 38 sampled patients. Patient #5.

Findings:

Review of the Facility's Current Policy and Procedure on Administration of Oral Medication, Policy # H-MM-05-007, released 06/2017 directed staff as follows: "The individual administering the medications (s) must document all medications after administration in the patient's record."

Patient #12
Patient (#12) was observed in the intensive care unit of the facility on 01/22/2018 at 11:30 a.m. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/ minute and dialysate flow rate of 700 mls/ minute. The patient was utilizing a Fresenius 180 Optiflux dialyzer for her hemodialysis treatment.


Review on 01/22/2018 of the patient's clinical record located in the bedside computer, revealed a physician's order dated 01/22/2018 for Fresenius 160 dialyzer.

The Surveyor immediately notified Contracted Registered Nurse (#62) that the patient was not utilizing the dialyzer prescribed by the physician.

Contracted Registered Nurse (#62) said the facility did not have Fresenius 160 Optiflux dialyzer available when he started hemodialysis treatment on the patient, so that was the reason why the patient was not using the correct dialyzer.


Patient #12
Review on 01/22/2018 of Patient (#12's) clinical record revealed a physician's order dated 01/05/2018 and renewed for 01/13/2018 for Vancomycin 250 mcg every four hours.

Review of the Patient's clinical record (Medication Administration Record) dated 01/21/2010 at 2:21 a.m. and 01/22/ at 6:00 a.m. revealed documentation which indicated that the medication was not administered to the patient as prescribed.
Documentation in the record indicated the following entries by the assigned nurse "Not done patient asleep."

Interview on 01/22/2018 at 11:50 a.m. with Patient (#12) , she stated " Although the medication is nasty tasting I never refused."



Patient #16
Review on 01/23/2018 of Patient (#16's) clinical record revealed a physician's order dated 1/12/2018 for Meropenem 500 mgs every 8 hours.

Review of the Patient's clinical record (Medication Administration Record) and Nurses' notes dated 01/21/2018 revealed no documentation that the medication was administered to Patient (#16) on 1/21/2018 at 2:00 P.M as scheduled.


Interview on 01/23/ 2018 at 11:56 a.m with the Facility's Chief Pharmacist revealed the medication was sent up by the pharmacy but there was no indication that the medication was administered to the patient.


Patient #29
On 01/24/2018 at 12:40 p.m revealed Patient (#29) was observed in room #6 in the facility's intensive care unit. The Patient was alert and oriented to person, place and time.


Review on 01/24/2018 of Patient (#29's) clinical record revealed a physician's order for Famotidine 20 mgs orally daily.
Review of the Patient's clinical record (Nurses' notes and Medication Administration Record) revealed the following entries at 08:43 a.m and 18:11 p.m. "Not done medication not available"

Further entry in the nurse's notes dated 01/14/2018 were as follows;" Famotidine (Pepcid) : 20 mg at 9:00 on 01/14/18 not done., cancel this execution medication unavailable."


Interview with the Facility's Chief Pharmacist on 01/24/2018 at 11:50 a.m. revealed the facility's pharmacy is opened from 8 a.m. to 6:00 p.m. daily and when not opened medication is available in the medication dispenser.




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Patient #5

Record review of patient (ID# 15) medical record on 1/23/2018 revealed medication order of Albuterol Sulfate: inhalation 3 milliliters, via nebulizer every four (4) hours, start 1/12/2018 19:30, stop after forty-five (45) days.
Review of Medication Administration Record revealed documentation that on 1/13/2018 3:15 PM treatment not done (patient bed/chair being exchanged), 1/17/2018 1:58 PM the treatment was not done (patient being cleaned post bowel movement), 1/17/2018 6:13 PM the treatment was not done (patient being cleaned with bloody bowel movement).


Review of the Patient's clinical record revealed no documentation that the Respiratory staff had attempted to administer the medication to the Patient after care was completed.


During an interview with director of respiratory services (ID# 72) 1/23/2018 at 1:15 PM, she stated that it is the "General Rule" if something is going on with a patent to try three (times), but at least one (1) more time to administer before canceling the treatment.

Based on observation, interview and record review the, facility's direct care staff failed to wash/ sanitize hands after direct contact with patients and contaminated items , the facility's dietary staff failed to maintain a clean and sanitary environment in the facility's kitchens, (Staff #s 61, 62 and 69) and the facility failed to ensure opened multi-dose medications were labeled according to policy.

Findings:

Review of the facility's current policy and procedure on Infection Prevention and Control Practices # H-IC-006 released 05/2015 direct staff as follows:
"The policy of - is to ensure the following:
" Five moments for Hand Hygiene Will Be Performed as Follows:
(a) Before touching a patient
(b) Before a clean aseptic/ procedure
(c) After touching a patient
(d) After body fluid exposure
(e) After touching a patient's surroundings/ environment."


Patient #11

Interview on 01/22/2018 at 11:08 a.m with Registered Nurse (#61 ) revealed Patient # 11 was on contact isolation for MRSA of the Sputum and urine and pseudomonas of the sputum, currently on intravenous antibiotic therapy.

On 01/22/2018 at 11:20 a.m Registered Nurse (#61) was observed in the intensive care unit at room 208.
Observation revealed Registered Nurse (61) entered Patient ( #11's) room, donned a pair of clean gloves, reset the patient's intravenous pump and touched the patient's intravenous lines. After direct contact with contaminated equipment in Patient #11's room, Registered Nurse (61) walked from the room to the hallway, wearing her contaminated gloves. She then used her contaminated gloved hands to retrieve clean gown from a stock of gown stored in the cupboard located on the wall outside the patient's room.

After retrieving the gown, a box of masked stored in the cupboard fell to the floor. Registered Nurse (#61) picked up the box of mask and returned them to the clean supply cupboard.

The Surveyor immediately notified Registered Nurse ( #61) that she had cross contaminated the clean supply with her contaminated gloved hands.
Registered Nurse (#61) stated " I will throw out the gown"

Patient #16
Review on 01/23/2018 of Patient #16's clinical record, (History and Physical ) dated 1/05/2018 revealed a diagnosis of C diff colitis.

On 01/23/2018 at 11:45 a.m. revealed Certified Nursing Assistant (#69) was observed in room 402 which housed patient #16.
The sign on the door to the patient's room indicated that the patient was on isolation and directed staff to wash hands with soap and water.
Observation revealed Certified Nursing Assistant (#69) was observed wearing a pair of gloves and holding a Nova blood glucose monitor while in the patient's room.

Observation revealed Certified Nursing Assistant (#69) removed the contaminated gloves, walked from Patient #16's room with the Nova blood glucose monitor in her hands, placed the contaminated blood glucose monitor on the clean shelf in the corridor.
The Patient Care Technician did not wash her contaminated hands after removing her contaminated gloves.

The Surveyor immediately notified Certified Nursing Assistant (#69) that she did not wash her hand with soap and water after exiting the Patient's room with the contaminated blood glucose monitor. .
Certified Nursing Assistant stated "Oh"


Patient #29
On 01/24/2018 at 11:40 a.m Contracted Registered Nurse (#62) was observed in room # 6 in the intensive care unit of the facility. The Registered Nurse was initiating hemodialysis treatment on Patient #29 and removing the hemodialysis needles after cannulating the Patient's left upper arm fistula.



Observation revealed Registered Nurse (#62) removed the patient's hemodialysis needles from the fistula because the hemodialysis machine was non - functional.
Observation revealed Registered Nurse (#62 ) removed the contaminated needle filled with blood, placed it on the patient's over-bed table. The Patient was instructed to hold his contaminated access site with his ungloved hand. After holding his fistula , Registered Nurse (#62) did not provide or encourage the patient to wash or sanitize his contaminated hand used to hold his vascular access site.

The Registered Nurse was not wearing protective eye wearing during cannulating and removal of the needles from the patient's vascular access.

Subsequent observation on 1/24/2018 at 12:45 p.m revealed droplet of blood was observed on the patient # (29's) over-bed table where the contaminated needle was placed by Registered Nurse (#62).
On 01/24/2018 at 12:46 p.m the Surveyor notified Registered Nurse (#62 ) of her observation.

Registered Nurse (#62 ) stated "I have a cap on the needle."


Kitchen: Campus #1

Review of the facility's current policy and procedure on Cleaning and Sanitizing Food Service Equipment and Work Surface; Policy # HD H-NCS 07-008 directed staff as follows ; " Sanitizing Stationary Equipment. Clean food contact surfaces of the equipment with an approved detergent : Use an approved cleaning tool as needed ( e.g., nylon brush or a cloth towel.) "


Observation on 01/22/2018 at 2:10 p.m of the facility's dietary area ( including the kitchen hospital #1) revealed a commercial stove and oven in the kitchen.
Observation revealed the stove top had an accumulation of black caked on material on the stove.
The oven had an accumulation of dried food particles .

The Surveyor immediately notified the Facility's Dietary Supervisor of her observation.

Interview with the Facility's Dietary Supervisor on 01/22/2018 at 2:11 p.m revealed the oven is not utilized but he will have the stove top cleaned.




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Observed on 1/22/18 at 10:00 am revealed Wound Care RN ID #57 performed a wound vac dressing change without sanitizing or hand hygiene before re-applying new gloves She removed the soiled dressing from the right shoulder with her left gloved hand. Proceeded then to remove the soiled dressing from the right lower quadrant wound without changing gloves which allowed for cross contamination to the lower right wound.

Interview on 1/22/18 with RN #57 immediately following the wound-vac dressing change, she reported that she did not wash or sanitize between glove changes and realized she cross contaminated the second wound by not removing the soiled gloves from wound on right shoulder.

Radiology- Campus #1

Observed on 1/23/18 at 11:00 am in the radiology department on the clean linen cart, no barrier on the bottom shelf .

Interview on 1/23/18 with Radiology Tech (RT) ID#67 at the time of observation revealed he was not aware that the linen cart was missing the barrier.

Observed on 1/23/18 at 11:30 am in the procedure room revealed a lead apron that had multiple barium stains on the front of it .

Interview on 1/23/18 with RN ID#51 and RT#67 at the time of the observation reported the apron should have been removed.

Kitchen Campus #2

Finding include:

Observation on 01/23/2018 at 9:30 am of the facility's dietary area (including the kitchen storage, refrigerator, freezer) revealed the following:
A. Commercial stove and oven in the kitchen with accumulation of caked on black material
B. The floor had moderate amount of water on the floor with no spill signage available to warn of potential for falls.
C. Clean pot hanging from over head rack with grease on bottom of pan when surveyor ran hand across bottom check for cleaned.
D. Cleaned stainless steel tray with dried food on the side
E. Refrigerator had unwrapped slices of cheese, not dated, wrapped in saran wrap turkey slices dried out (2) not dated, Brown lettuce, open in box no covering, Brown box of Kale open, Tray of uncovered salad mixture, no date and brown in color
F. Freezer contained open large stainless steel container with open scattered frozen vegetables, i.e. peas, corn on the cob frozen to the stainless steel container, no date, other frozen vegetables in a closed bag.

In an interview with RN,ID#85 and Pharmacist ID# 84 on 1/23/18 at 3:00 PM both reported that they were with the Surveyor on the tour of the Dietary area and witnessed all of the above mentioned observations.

Record Review of policy titled: Personal Hygiene, Safety, Cleaning & Sanitation dated 02/2014 reads:
Policy establishes guidance for individuals handling food using good personal hygiene to minimize the risk of contaminating food, which may result in a foodborne illness.

Review of the facility's current policy and procedure on Cleaning and Sanitizing Food Service Equipment and Work Surface; Policy # HD H-NCS 07-008 directed staff as follows ; " Sanitizing Stationary Equipment. Clean food contact surfaces of the equipment with an approved detergent : Use an approved cleaning tool as needed.

Record review of facility policy titled: " Safety Practices" read:
Policy;
1. All personnel are required to use "Wet Floor" signs when mopping, spot mopping, scrubbing, stripping and finishing floors. It is stress to personnel too be on the lookout for spills ("Clean as Go") which are to be cleaned up immediately.


Observed on 1/23/18 at 10:00 am at Campus #2's Pharmacy had 1 opened vial of Insulin (R) not timed, not dated in the refrigerator sitting in a tray for patient use.


In an interview on 1/23/18 with Pharmacist ID #84 at 10:00 am reported that no open vials of any medication is to be in the pharmacy refrigerator, and that (1) vial of opened insulin (R) was removed.

Record review of policy titled: " Storage and Destruction of Expired or Unusable Medications", dated, 1/2007 revealed:
Policy: To ensure that
(1) Damaged expired, or otherwise unusable medications are not dispensed to patients
(2) Damaged, expired or otherwise unusable medications are segregated in the pharmacy and destroyed or disposed of according to this policy.

Record Review of policy titled: " Beyond Use Dating of Injectable Multi-Dose Medications, dated 01/2007 revealed:
Policy:
1. The multi-dose injectable medication will be disposed of once empty, when suspected or visible contamination occurs, or when the manufacturer's stated expiration date is reached (provided the manufacturer's storage conditions have been adhered to).

2. The expiration date of multi-dose injectable medication will be 28 days after first use unless otherwise referenced in the the package insert. DATE of expiration will be noted on container by pharmacy upon dispensing.