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Based on observations, record reviews, and interviews, the hospital failed to meet the requirements for the Condition of Participation of Infection Control as evidenced by:


1) Failure to ensure the infection control officer was qualified by education, training or certification as evidenced by appointing an infection control officer (S2RN/DON) with no documented evidence of specialized education, training or certification in the development or oversight of an infection control program. (See findings at A-0748);


2) Failure to ensure a patient (#1) with Clostridium (C.) difficile remained in contact isolation, in her room, until diarrhea free for 2 days (as per hospital policy) for 1 (#1) of 1(#1) current patients on contact isolation out of a total sample of 32 patients. (See findings at A-0749);

3) Failure to ensure an incontinent, diapered patient (#1) experiencing acute diarrhea with a likely infectious, enteric pathogen cause had been placed in contact isolation pending culture (C.difficile) results. (See findings at A-0749);

4) Failure to ensure hospital staff had received infection control training based upon the needs of the patient population treated at the hospital. This deficient practice was evidenced by failing to train staff in transmission based precautions specific to C. difficile contact isolation. (See findings at A-0749).

Based on record review and interview, the hospital failed to develop a policy and procedure which dictated a timely response to a patient's or patient's representative grievance(s).


Findings:


Review of the policy and procedure, presented by S2RN as the current policy and procedure, revealed the time frame for the hospital to send a written response to a complainant was 30 days.


In an interview with 01/05/16, at 4:30 p.m., S2RN confirmed that the current policy and procedure for grievances stated that the time frame for responding to a patient's grievance was 30 days. S2RN also confirmed she was not aware of the regulatory requirements for resolving and notifying complainants in a timely manner.

Based on record review and interview, the hospital failed to develop and implement a policy and procedure relative to the grievance process which stated the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.


Findings:


Review of the policy and procedure, presented by S2RN as the current policy and procedure, revealed the policy and procedure for grievances did not include the following information was to be included in the written response to the complainant: the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.


In an interview with 01/05/16, at 4:30 p.m., S2RN confirmed that the current policy and procedure for grievances did not include the above-referenced requirements to be included in the written response to the complainant regarding a grievance. S2RN also confirmed she was not aware of the regulatory requirements for all components that were to be included in the written response to the complainant.

31048

Based on record review and interview, the hospital failed to ensure that a RN evaluated the nursing care furnished to each patient by (1) failing to have a RN complete the initial nursing assessment for 3 (#4, #6, #15) of 9 records reviewed for initial nursing assessment and (2) failing to verify physician orders for 1 (#5) of 9 records reviewed for verification of physician orders in a total sample of 30 records.


Findings:


(1) failing to have a RN complete the initial nursing assessment


Review of the LSBN's (Louisiana State Board of Nursing) "Administrative Rules Defining RN Practice LAC46: XLVII §3703. Definition of Terms Applying to Nursing Practice" revealed that the RN retains the accountability for the total nursing care of the individual and is responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she receives, regardless of whether the care is provided solely by the RN or by the RN in conjunction with other licensed or unlicensed assistive personnel. The RN shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. This assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required.


Review of the policy and procedure entitled "Nursing Documentation Guidelines" presented by S7RN as the current policy and procedure, revealed in part: "2. A Registered Nurse shall be responsible for the initial assessment and nursing care plan."


Patient #4

A review of the medical record for Patient #4 revealed Patient #4 was admitted on 12/30/15, at 3:00 p.m. Further review revealed a form entitled "Interdisciplinary Admission Evaluation" in which the initial nursing assessment is documented. Review of the form revealed the initial nursing assessment was conducted and documented by an LPN.


In an interview on 01/05/16, at 4:45 p.m., S2RN reviewed the medical record and confirmed Patient #4's initial nursing assessment had been conducted and documented by a LPN.


Patient #6

Review of the medical record for Patient #6 revealed an admission date of 11/5/15. Further review revealed Patient #6's initial nursing assessment had been been performed by a LPN.


Patient #15

A review of the medical record for Patient #15 revealed Patient #15 was admitted on 12/16/15, at 2:10 p.m. Further review revealed a form entitled "Interdisciplinary Admission Evaluation" in which the initial nursing assessment is documented. Review of the form revealed the initial nursing assessment was conducted and documented by a LPN.


In an interview on 01/05/16, at 4:50 p.m., S2 reviewed the medical record and confirmed Patient #15's initial nursing assessment had been conducted and documented by a LPN.



(2) failing to verify physician orders


Patient #5

A review of the medical record for Patient #5 revealed Patient #5 was admitted on 12/30/15, at 1:00 p.m. Diagnoses included Chronic Obstructive Pulmonary Disease Exacerbation, Viral Pneumonia, and Gastrointestinal Bleed. Review of the "Standing Admissions Orders" sheet, dated 12/30/15, at 10:30 a.m., taken as a verbal order from the admitting physician by a LPN, revealed in part, there were no physician orders documented as having been ordered by the admitting physician for vital signs assessments, oxygen therapy, or a prescribed diet for Patient #5. Further review of the medical record revealed Patient #5 had vital signs assessed at least once every 12-hour nursing shift; oxygen therapy was being administered at 2-3 liters per minute per nasal cannula on an as needed basis, and the patient was receiving a no added salt and no concentrated sweets diet.


In an interview on 01/05/16, at 10:20 a.m., S2 indicated the usual practice for a nurse to utilize the pre-printed standing admission order sheet was for the nurse to contact the admitting physician by phone (if the physician was not on site at the hospital) and review the transfer orders from the transferring facility with the patient's admitting physician and obtain/document the admission orders by checking off (placing a check mark) in the left side column of the pre-printed order sheet as directed by the admitting physician and/or to write a verbal order on a blank physician's order sheet. When S2 questioned as to how the Patient's diet, oxygen therapy, and vital signs was implemented without a physician's order, S2 stated the diet and oxygen therapy implemented for Patient #5 was most likely taken from the "Pre-admission Screen" form and/or the transfer/discharge orders from the referring facility, and vital signs were done, most likely, according to the hospital's "routine" which was at least once every nursing shift. S2 reviewed Patient #5's entire medical record and confirmed that the above referenced physician orders for vital sign assessments, oxygen therapy, and a prescribed diet was not documented in the medical record as having been obtained from the admitting physician, and S2 confirmed there should have been physician orders written for the above-referenced treatments/care provided to Patient #5.

31048

Based on record review and interview, the hospital failed to ensure comprehensive nursing care plans were developed, implemented, and updated/revised for 4 (#1, #2, #6, #15) of 15 records reviewed for nursing care plans in a total sample of 30 records.


Findings:


Review of a policy and procedure entitled "Individual Nursing Care Plan" presented by S7RN as the current policy and procedure in place, revealed, in part: "All patients will have an individualized nursing care plan. 3. The nursing care plan is updated and/or revised with changes in condition, orders, or functional status as needed by the RN or LPN."


Patient #1

Review of Patient #1's medical record revealed an admission date of 12/30/15. Further review revealed the patient had a positive stool culture for C. difficile on 12/30/15, and was placed on Contact Isolation Precautions. Review of Patient #1's plan of care revealed actual infection related to positive stool culture for C. difficile and Contact Isolation had not been addressed on the patient's care plan.


In an interview on 1/4/16, at 2:00 p.m., S2 confirmed Patient #1 had been placed in contact isolation for a positive C.difficile culture. S2 confirmed Contact Isolation Precautions and actual infection with C.difficile had not been addressed on the patient's care plan and agreed both should have been included as identified problems.


Patient #2

Review of Patient #2's medical record revealed an admission date of 12/29/15. Further review revealed Patient #2 was admitted for debility related to end stage renal disease. Additional review revealed he was currently receiving dialysis. Review of Patient #2's plan of care revealed end stage renal disease and dialysis treatment had not been addressed on the patient's care plan.


In an interview on 1/4/16, at 2:00 p.m., S2 confirmed Patient #2's renal failure and dialysis treatments had not been addressed on the patient's care plan and agreed both should have been included as identified problems.


Patient #6

Review of Patient #6's medical record revealed an admission date of 11/5/15. Further review revealed the patient was on Droplet Precaution Isolation on admission related to a positive sputum culture for MRSA. Review of Patient #6's plan of care revealed actual infection related to positive sputum culture for MRSA and Droplet Isolation had not been addressed on the patient's care plan.


In an interview on 1/4/16, at 2:00 p.m., S2 confirmed Patient #6 had been admitted with a positive sputum culture for MRSA. She also confirmed Patient #6 had been on Droplet Isolation Precautions. S2 confirmed Droplet Isolation Precautions and actual infection with MRSA had not been addressed on the patient's care plan and agreed both should have been included as identified problems.


Patient #15

Review of Patient #15's medical record revealed diagnoses which included Infected Right Knee Prosthesis, Atrial Fibrillation, Congestive Heart Failure, Hypertension, and Chronic Obstructive Pulmonary Disease. Review of Patient #15's nursing care plan revealed Patient #15's altered respiratory function and altered cardiac function were not addressed on Patient #15's nursing care plan.

In an interview on 01/05/16, at 4:50 p.m., S2 reviewed Patient #15's medical record and nursing care plan and confirmed Patient #15's altered respiratory function and altered cardiac function had not been included on the patient's care plan and it should have been included in the patient's nursing care plan.

Based on record review and interview, the hospital failed to 1) ensure medical records were properly stored in secure locations where they are protected from fire, water damage and other threats; and 2) ensure the effective implementation of hospital policies and/or medical staff bylaws relative to the prompt completion of medical records as evidenced by 6 Physicians (S8, S9, S10, S11, S13, and S14) failing to complete medical records within 30 days of a patients discharge.

Findings:

1. Failing to ensure medical records were properly stored in secure locations where they are protected from fire, water damage and other threats.

Review of the policy titled Storage and Retrieval, Section 3.07, III. Storage Space Specifications, revealed in part: Storage space shall be selected and maintained to protect records from unauthorized access, loss, and destruction ...protection against fire, including sprinkler system.

Observation on 01/05/16, at 11:30 p.m., revealed a locked room within the hospital with 12 open metal shelf units lining the wall containing medical records dating back to 2012. There was an overhead sprinkler located in the room. The medical records were uncovered resulting in the medical records being unprotected from water damage in the event of a fire sprinkler activation.

Observation on 01/05/16, at 12:50 p.m., of two storage units (located approximately 5 miles from the hospital) with S1Administrator revealed medical records were stored in the units. Unit #1 was noted to have approximately 133 cardboard banker boxes containing medical records stacked on the floor and on open metal shelves. Unit #2 was noted to have approximately 200 cardboard banker boxes containing medical records stacked on the floor and on open metal shelves. The medical records were noted to be laying on open shelves in a manner that would leave them unprotected from fire damage as there was no sprinkler system in the storage units.

Interview on 01/05/16, at 1:00 p.m., with S1Administrator confirmed that the medical records were not protected from fire and/or water damage. He further stated that if the records were destroyed they would be lost and there was no way to replace them.

2. Failing to ensure the effective implementation of hospital policies and/or medical staff bylaws relative to the prompt completion of medical records. This was evidenced by 6 Physicians (S8, S9, S10, S11, S13, and S14) failing to complete medical records within 30 days of a patients discharge.

Review of the Medical Staff By-Laws, Section E. Medical Records, 1. c., revealed in part: Chart shall not be considered delinquent until 30 days following discharge. All medical records shall be completed by the attending physician within 30 days of discharge. If records are not completed, the chairman of the Medical Records Review Committee or a committee member shall be notified by the Health Information Department, the involved physicians shall be allotted 7 days extension period ...if the records are not completed during this extension period, the Health Information Department shall notify the chairman of the Medical Records Review Committee or a committee member, that all elective admissions have been suspended until such time as the records are completed.

Review of the policy titled Medical Record Review Plan, Section 5.00, 3. Medical Executive Committee, revealed in part: a. Re-educates the medical staff when inefficient, deficient, and delinquent medical records, specifically the documentation in the medical records are found ...determines action to be taken if a physician has substantial deficient areas in their patient records.

S1Administrator was interviewed on 1/05/16, at 10:50 a.m. When asked who was the person in charge of the medical records department, S1Administrator reported that S6Medical Records Tech was the person who could answer all questions relative to the hospital's medical records department.

S6Medical Records Tech was interviewed on 01/05/16, at 10:00 a.m. When asked if there was a system in place to track delinquent medical records, S6Medical Records Tech indicated that she was not aware of a system to track delinquent medical records. When asked how many medical records were delinquent, S6Medical Records Tech stated that she did not have a current number of how many medical records were incomplete. S6Medical Records Tech further stated that she would have to count the medical records to give a number of how many records were incomplete. S6Medical Records Tech gave this surveyor a hand written list of delinquent medical records that were not completed within 30 days of discharge:

S8Physician - #13 records
S9Physician - #5 records
S10Physician - #23 records
S11Physician - #10 records
S13Physician - #5 records
S14Physician - #5 records

Interview on 01/06/16, at 9:00 a.m., with the S1Administrator confirmed that there was a problem with the delinquent records not being completed timely. S1Administrator further stated that letters are sent to the physicians to complete the delinquent records, and he would call the physicians but there was no formal follow up after the letters were sent.

Based upon observation, record review, and interviews, the hospital failed to ensure the employee designated as the responsible person for the contracted food services carried out daily management of the service.


Findings:


Observation of the food service area on 01/05/16, at 12:00 p.m., revealed the food was brought from contract dietary service and placed in warming trays. In the food service area was a binder that contained a daily check list that identified "This list is to be followed DAILY by every individual who is scheduled as dietary aide." The check list was to be completed daily, bi-weekly, and weekly. Review of the completed check list revealed the sheets had not been utilized since 2014.


Interview with S2RN/DON on 1/5/16, during the dietary observation, revealed S7RN was the designated dietary director. Interview with S7RN on 01/05/16, at 1:00 p.m. revealed she had been in this position for approximately 6 months and was not aware there was a dietary check list that was to be completed daily. Review of S7RN's personnel record revealed there failed to be a job description for the director of dietary services that described the responsibilities for management of the service.

Based upon record review and interview, the hospital failed to ensure the therapeutic dietary manual was approved by the dietitian and the medical staff. This was evidenced by the failure to have documentation in the manual and the Medical Staff Meeting Minutes that the manual was approved by the dietitian and Medical Staff.


Findings:


Review of the therapeutic dietary manual revealed there failed to be documented evidence the manual was approved by the contract dietitian or the Medical Staff. Review of the Medical Staff Meeting Minutes for the year 2015 revealed there failed to be documented evidence the Medical Staff approved the manual.


Interview with S2RN/DON on 01/05/16, at 12:35 p.m., revealed she did not know when the manual had been approved.

Based on record review and interview, the hospital failed to ensure the infection control officer was qualified by education, training or certification as evidenced by appointing an infection control officer (S2RN/DON) with no documented evidence of specialized education, training or certification in the development or oversight of an infection control program.


Findings:


Review of the personnel record for S2RN/DON revealed no documented evidence of specialized education, training or certification in the development or oversight of an infection control program.


In an interview on 1/6/15, at 9:00 a.m., with S2RN/DON, she confirmed she had not received any type of specialized education, training or certification in the development or oversight of an infection control program.

Based on record review, interview, and observation, the hospital failed to ensure the infection control officer developed a system for controlling infections and communicable diseases of patients and personnel. This deficient practice is evidenced by:

1) failing to ensure a patient (#1) with Clostridium (C.) difficile remained in contact isolation, in her room, until diarrhea free for 2 days (as per hospital policy) for 1 (#1) of 1(#1) current patients on contact isolation out of a total sample of 32 patients.;

2) failing to ensure an incontinent, diapered patient (Patient #1) experiencing acute diarrhea with a likely infectious, enteric pathogen cause had been placed in contact isolation pending culture (C.difficile) results for 1 (#1) of 2 (#1, #6) patients reviewed for isolation precautions out of a total sample of 32 patients.;

3) failing to ensure hospital staff had received infection control training based upon the needs of the patient population treated at the hospital. This deficient practice was evidenced by failing to train staff in transmission based precautions specific to C. difficile for 10 (S2RN/DON, S3RN, S4CNA, S5COTA, S16PhysicalTherapist, S17SpeechTherapist, S18OccupationalTherapist, S20LPN, S21RN, S22RN) of 10 direct care personnel records reviewed.;

4) failing to ensure hospital staff (S4CNA) donned appropriate PPE during waste removal from a contact isolation patient's room (Patient #1) that had positive cultures for C. difficile.;

5) failing to ensure hand hygiene and accepted standards of practice for infection control were followed during blood glucose monitoring for 1 (#R1) of 1 patients observed for glucose monitoring. This deficient practice is evidenced by improper hand hygiene and failing to properly disinfect a glucometer.;

6) failing to ensure hand hygiene and accepted standards of practice for infection control were followed during wound care for 1 (#2) of 1(#2) patients observed for wound care out of a total sample of 32 patients.;

7) failing to ensure hospital staff N-95 mask fit competencies were evaluated for 10 (S2RN/DON, S3RN, S4CNA, S5COTA, S16PhysicalTherapist,S17SpeechTherapist, S18OccupationalTherapist,S20LPN, S21RN,S22RN) of 10 direct care staff personnel records reviewed.

Findings:

1) Failing to ensure a patient (#1) with C. difficile remained in contact isolation, in her room, until diarrhea free for 2 days (as per hospital policy).

Review of hospital policy titled, "Clostridium difficile" revealed the following, in part:6. Prevention: C Diff patients must be put on contact precautions. Patients on contact precautions are asked to stay in their hospital rooms as much as possible. They should not go to common areas of the hospital. They are to receive therapy in their room until contact precautions are removed. Contact precautions may be removed when patient is diarrhea free for 2 days.

Review of Patient #1's medical record revealed an admission date of 12/30/15, for rehabilitation services which included both physical and occupational therapy. Further review revealed Patient #1 had a positive culture for C. difficile on 12/30/15 and was placed on contact isolation precautions after receipt of the positive culture result. Additional review revealed Patient #1 was incontinent of bowel (diarrhea), required a brief, and remained on contact isolation precautions as of 1/4/16.

In an interview on 1/4/16, at 2:00 p.m., with S2RN/DON, she confirmed Patient #1 was on contact isolation for C.difficile. She indicated the patient had been diagnosed with C. difficile after she was admitted to the rehabilitation hospital. She confirmed the patient had been to the gym for therapy while on contact isolation precautions. S2RN/DON said she had not realized the hospital policy indicated the patient had to receive in room therapy until the patient was diarrhea free for 2 days and contact precautions had been removed.

2) Failing to ensure an incontinent, diapered patient (#1) experiencing acute diarrhea with a likely infectious, enteric pathogen cause had been placed in contact isolation pending C.difficile culture results.

According to CDC Guideline Recommmendations titled,"Clinical Syndromes/Conditions Warranting Empiric Transmission Based Precautions (in addition to standard precautions) Pending Confirmation of Diagnosis," incontinent or diapered patients experiencing acute diarrhea with a likely infectious, enteric pathogen cause warrented implementation of empiric contact precautions while cultures are pending.

Review of the hospital's Infection Control Guidelines for Isolation Precautions revealed in part: Transmission based precautions are designed for patients documented or suspected to be infected with highly transmissable or epidemiologically important pathogens for which additional precautions beyond standard precautions are needed to interrupt transmission in hospitals. The guideline also lists specific clinical syndromes or conditions, in both adult and pediatric patients, that are highly suspicious for infection and identifies appropriate transmission-based precautions to use on an empiric, temporary basis until a diagnosis can be made; these empiric, temporary precautions are also to be used in addition to standard precautions.

Review of hospital policy titled, "Clostridium difficile" revealed no directive regarding placement of incontinent, diapered patients experiencing acute diarrhea (with a likely infectious, enteric pathogen cause) in empiric contact isolation precautions while cultures for C.difficile were pending.

Review of Patient #1's medical record revealed the patient was incontinent, diapered, and had been admitted from an acute care hospital with diarrhea on 12/30/15. Further review revealed no documented evidence that the patient had been placed on contact isolation precautions while the results of the C. difficile cultures (collected on 12/30/15) were pending.

In an interview on 1/4/16, at 2:00 p.m., with S2RN/DON, she confirmed Patient #1 had been admitted with diarrhea and required a brief. S2RN/DON also confirmed Patient #1 had not been placed in contact isolation while the C.difficile cultures were pending. She indicated it was not the hospital's practice to place patients with pending C.difficile cultures on contact isolation precautions. She agreed the patient should have been placed on contact isolation precautions while the cultures were pending.

3) failing to ensure hospital staff had received infection control training based upon the needs of the patient population treated at the hospital. This deficient practice was evidenced by failing to train staff in transmission based precautions specific to C. difficile contact isolation.

Review of the hospital's current list of patients on contact isolation, presented by S2RN/DON, revealed there was one inpatient (Patient #1) on contact isolation precautions for positive C. difficile cultures.

Review of the personnel records for S2RN/DON, S3RN, S4CNA, S5COTA, S16PhysicalTherapist, S17SpeechTherapist, S18OccupationalTherapist, S20LPN, S21RN, and S22RN revealed no documented evidence of hospital staff training in transmission based precautions specific to C. difficile contact isolation.

In an interview on 1/6/16, at 12:55 p.m., with S2RN/DON, she confirmed the hospital staff had not received transmission based training specific to C. difficile contact isolation. S2RN/DON confirmed that there was a patient (Patient #1) currently hospitalized with C. difficile. S2RN/DON also reported that they had treated 5 patients with C. difficile in 2015.

4) Failing to ensure hospital staff (S4CNA) donned appropriate PPE during waste removal from a contact isolation patient ' s room (Patient #1) that had positive cultures for C. difficile.

Review of hospital policy titled, "Clostridium difficile" revealed the following, in part: Purpose: To ensure employee compliance and knowledge with proper precautions, environmental cleaning and monitoring to prevent Clostridium difficile hospital acquired infections.

Procedure: 2. Modes of transmission: Patient reservoir (symptomatic/asymptomatic); Environmental Reservoir (Direct/ indirect contact with contaminated environment or hands/gown of healthcare worker); Environment/devices get contaminated by shedding of spores from patient and/or healthcare worker's hands). 6. Prevention: C diff patients must be put on contact precautions. Healthcare providers will put on gloves and wear a gown over their clothing while taking care of patients with C.diff.

On 1/4/16, at 4:12 p.m., an observation was made of S4CNA pulling trash from the trash container that was located in Patient #1's room. Patient #1 was in contact isolation for C. difficile. S4CNA was not wearing a gown as required for contact isolation.

In an interview on 1/6/16, at 12:55 p.m., with S2RN/DON, she confirmed she had seen S4CNA pulling trash from Patient #1's room without donning a gown. She confirmed S4CNA should have been wearing a gown as proper PPE for a patient on contact precautions for C. difficile.

5) Failing to ensure hand hygiene and accepted standards of practice for infection control were followed during blood glucose monitoring.

Review of the manufacturer's suggested infection control procedure for disinfection of the blood glucose monitoring device revealed in part: Cleaning procedure: to disinfect the meter, dilute 1 milliliter of household bleach in 9 milliliters of water to achieve a 1:10 dilution.

Review of the hospital policy titled,"Handwashing" revealed in part: Personnel shall wash their hands to prevent the spread of infections: before applying and after removing gloves.

Review of the hospital policy titled, "Hand Hygiene Guidelines" revealed in part: Procedure: 1. Indications for handwashing and hand antisepsis: C. Decontaminate hands before having direct contact with patients; J. Decontaminate hands after removing gloves.

An observation was made on 1/5/16, at 11:10 a.m., of S20LPN obtaining a blood glucose reading on Patient #R1. S20LPN failed to perform hand hygiene prior to donning her gloves. S20LPN was then observed placing the glucose meter into a plastic storage box immediately following performance of the blood glucose reading. S20LPN failed to disinfect the device prior to returning it to the storage box. S20LPN was questioned as to the hospital policy regarding disinfection of the device and she indicated the device was to be cleaned with "wipes" between patients. S20LPN said, "the glucose monitoring device really doesn't touch the patient" . She then retrieved the device and wiped it with a paper towel and hand sanitizer. She indicated the hand sanitizer was alcohol based. S20LPN then returned the device to the storage box.

In an interview on 1/6/16, at 12:55 p.m., with S2RN/DON, she confirmed it was not appropriate to clean the glucose meter with alcohol hand gel. She indicated the device should be cleaned between patients before and after use.

6) Failing to ensure hand hygiene and accepted standards of practice for infection control were followed during wound care for 1 (#2) of 1(#2) patients observed for wound care out of a total sample of 32 patients.

Review of the hospital's Infection Control policies and procedures revealed in part: Wearing gloves does not replace the need for handwashing because: gloves may have small unapparent defects or be torn during use; hands can become contaminated during removal of gloves; and failuer to change gloves between patients is an infection control hazard.

On 1/4/16, at 3:45 p.m., an observation was made of S3RN performing wound care on Patient #2. S3RN double gloved and failed to perform hand hygiene during the wound care procedure. S3RN placed the cotton tipped applicator she had used to apply ointment to the patient's open heel wound on the bedside table with the soiled tip touching the table. She did not clean the bedside table after discarding the soiled items/packages of supplies used to perform wound care. S3RN was also observed pulling her bandage scissors out of her scrub pockets with her soiled, gloved hands. She opened the door with her soiled, gloved hands and did not perform hand hygiene after glove removal, prior to leaving the room.

In an interview on 1/6/16, at 12:55 p.m., with S2RN/DON, she confirmed double gloving was not a substitute for performing hand hygiene during wound care. She also confirmed the bedside table should have been cleaned. S2RN/DON also confirmed retrieval of bandage scissors from scrub pockets with soiled gloves was an infection control breach.

7) Failing to ensure hospital staff N-95 mask fit competencies were evaluated.

Review of the personnel records for S2RN/DON, S3RN, S4CNA, S5COTA, S16PhysicalTherapist, S17SpeechTherapist, S18OccupationalTherapist, S20LPN, S21RN, and S22RN revealed no documented evidence that N-95 mask fit competencies had been evaluated for the above referenced direct care hospital staff.

In an interview on 1/6/16, at 12:55 p.m., with S2RN/DON, she confirmed she had not been evaluating hospital staff N-95 mask fit competencies.

Based upon record review and interviews, the hospital failed to ensure a physician was appointed as the director of respiratory care services. This was evidenced by the review of physician credential files, Medical Staff Meeting Minutes, and staff interviews.


Findings:


Review of the Medical Staff Meeting Minutes for the year 2015 and review of active physician credential files revealed there failed to be documented evidence a physician was appointed the director of respiratory care services.


Interview with S1/Administrator on 01/05/16, at 9:30 a.m., revealed when asked if there was a physician appointed as the director of respiratory care services, he replied "no".