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Based on hospital policy review, open medical record review, observation and patient and staff interviews, the hospital nursing staff failed to ensure 1 of 1 (#4) hearing impaired patient received written medication education materials to ensure participation in the patient's plan of care.

Findings include:

Review of hospital policy on 03/24/2016 revealed "Communicating Information to Persons with Sensory Impairments" revised 01/01/2010. Review of the policy revealed "Hospital will take such steps as are necessary to ensure that persons with sensory impairments or speaking skills, receive effective notice concerning benefits or services or written material concerning waivers of rights or consents to treatment. All aids needed to provide this notice (sign-language interpreters, readers, etc.), are provided without cost to the person being served. . . 3. All program information will be provided to hearing-impaired persons in writing. Printed materials and written materials are available. . ."

Open medical record review for Patient #4 on 03/23/2016 revealed a hospital admission date of 03/02/2016. Diagnoses included ventilator dependent respiratory failure with a tracheostomy (surgical opening in throat for breathing). Review of the initial nursing assessment, conducted 03/02/2016 at 1944, revealed the patient was a 21 year old hearing impaired college student prior to admission. Review of nursing documentation for patient/family teaching, conducted every shift 03/03/2016 through 03/22/2016, revealed no indication written education materials had been provided for the patient or family. Review of the Interdisciplinary Treatment Plan, initiated on 03/09/2016 and reviewed/updated on 03/16/2016, revealed interventions submitted by the following disciplines: Nursing, Wound Care, Respiratory Therapy, Nutrition, Occupational Therapy, Physical Therapy, Speech Therapy and Case Management. Continued review revealed no indication written materials had been provided to the patient or family.

Observation on 03/24/2016 at 0915, during a physician visit with patient and family, revealed the family member had multiple questions for the physician regarding medications.

Interview with Patient #4, using a dry erase board, and a family member on 03/24/2016 at 0930 revealed the patient could read and answer questions appropriately. The interview revealed the patient had been deaf for "about a year" due to surgery. The interview revealed the patient or family had not received written medication education materials.

Interview with the Chief Nursing Officer on 03/24/2016 at 0950 revealed written medication education materials were available for patients but the materials had not been provided for Patient #4.

Based on hospital medical record forms, observation, and staff interview, the hospital failed to ensure personal privacy for 1:1 patients observed in restraints (Patient #7).

The findings include:

Review on 03/24/2016 of the hospital's "Patient Rights" medical record form (revised 05/2013) revealed "8. Privacy. You have the right to expect staff to respect your right to privacy and conduct treatments with discretion, providing as much modesty as possible..."

Observation on 03/22/2016 at 1500 revealed Patient #7 in bilateral soft wrist restraint (SWR) lying semi-crossed in the bed with his left leg hanging slightly out of the bed. Observation revealed Patient #7's gown was pulled up to mid chest, exposing the lower part of the body. Observation revealed Patient #7 was not capable of covering the exposed area due to the SWR. Observation revealed Patient #7 was repositioned and the exposed area was covered after prompting. Observation revealed family members of the patient in the neighboring room were in and out of the room, walking past Patient #7's doorway. Observation revealed Patient #7's door was open, providing direct visualization.

Interview on 03/22/2016 at 1505 with the hospital's Case Manager (CM) #1 revealed, "No, it is not acceptable for any of our patient's to be exposed like that, especially those in restraints and unable to cover themselves." Interview revealed it was unknown how long Patient #7 was exposed. Interview revealed Patient #7's right to privacy and dignity was violated.

Based on review of hospital policy, observation and staff interviews, the hospital nursing staff failed to label intravenous (IV) (direct access into the blood stream) and enteral feeding tubes (used for the delivery of nutrition into the gut) for 6 of 7 patients (Patient #s 7, 11, 12, 13, 14, and 15) and to ensure enteral feedings were changed according to physican orders for 1 of 2 patients (#11).

The findings include:

Review on 03/23/2016 of hospital's "Intravenous Therapy: Peripheral IV Therapy Protocol" (revised 01/01/2015) revealed "...I. All IV Catheters...B. Maintenance Care: 2. IV tubing is labeled with date, time and initials... II. Peripheral Lines (IV)...6. Change tubing every 72-96 hours by coordination with first bag change of the day, and labeling the tubing with date of change..."

Review on 03/23/2016 of the hospital's "Gastric/Duodenal Tube (device used to provide direct access to the gut) Guidelines: PEG (percutaneous endoscopic gastrostomy: device used to provide direct access to the gut), Gastrostomy Tube (device used to provide direct access to the gut), Small-bore nasal Tube (device used to provide direct access to the gut) Nasogastric Tube (device used to provide direct access to the gut) Orogastric (device used to provide direct access to the gut) " policy (revised 10/01/2015) revealed "...Attachment...Guidelines for Maintaining Continuous Enteral Feedings...4. All enteral tube feeding equipment should be handled utilizing clean technique. The feeding bags (if applicable) and tubing will be changed every 24 hours.

1. Observation on 03/22/2016 at 1340 revealed Patient #11 receiving IV therapy with no evidence of a label with date and time on the primary tubing or secondary tubing used for the delivery of prescribed antibiotics. Observation revealed Patient #11 was also receiving supplemental enteral feeding. It was noted the feeding tube had "03/20/2016 at 1600, change 03/21/2016 written on the label."

Observation revealed the feeding tube and supplement were not changed within the 24 hours timeframe indicated in the hospital's "Gastric/Duodenal Tube Guidelines...." policy.

2. Observation on 03/22/2016 at 1350 revealed Patient #13 receiving IV therapy with no label noted on the tubing.

3. Observation on 03/22/2016 at 1400 revealed Patient #7 receiving IV therapy with no evidence of a label on the tubing.

4. Observation on 03/22/2016 at 1500 revealed Patient #12 receiving IV therapy and enteral feeding with no evidence of a label noted on the tubing.

5. Observation on 03/23/2016 at 0920 revealed Patient #15 receiving enteral feeding with no evidence of a label on the feeding tubes.

6. Observation on 03/23/2016 at 0930 revealed Patient #14 receiving IV therapy with no label noted on the tubing.

Observations revealed hospital nursing staff are not labeling IV or enteral tubes as outlined in the hospital's "Intravenous Therapy: Peripheral IV Therapy Protocol" and "Gastric/Duodenal Tube Guidelines..." policies.

Interview on 03/22/2016 at 1400 with the hospital's RN #3 revealed IV and enteral feeding tube labels should include the date and time of initiation as well as initials of the staff member implementing the prescribed therapy and the date for the next tubing change. Interview revealed, "No, there's no label. It (failure to label tubing with date, time, and initials) is not acceptable practice and does not align with our policy." Interview revealed the hospital's "Gastric/Duodenal Tube Guidelines:... " and "Intravenous Therapy: Peripheral IV Therapy Protocol" policies were not followed.

Based on hospital policy review, observation, and staff interview, the hospital nursing staff failed to maintain a sanitary environment for the delivery of patient care by 1. failing to perform hand hygiene for 3 of 3 observations during entrance and exit from a patient room, 2. failing to ensure suction canisters were changed when soiled for 1 of 4 suction canisters observed, and 3. failing to prevent multidose insulin vials from potential contamination for 1of 1 medication administrations observed.

The findings include:

Review on 03/24/2016 of the hospital's policy "Hand Hygiene" (revised 10/2015) revealed, "....Policy: How...Before and after every patient contact...Before going into a patient room and before leaving a patient room..."

Review on 03/24/2016 of the hospital's "Labeling of Medications" policy (revised 07/2011), presented as the policy that would contain the hospital's expectations for the use of multidose vials, revealed it does not outline the hospital's expectation for use of multidose vials in the patient care area.

1. Observation on 03/24/2016 at 1020 revealed RN (registered nurse) #1 entered and exited Patient #16's room three times without performing hand hygiene. Observation revealed RN #1 did not wash her hands or use hand sanitizer upon entering or exiting the patient's room. Observation revealed RN #1 performed charting or obtained patient care supplies each time she entered and left the room. Observation revealed upon the second occurrence, RN #1 assisted with patient care without performing hand hygiene.

Interview on 03/24/2016 at 1025 with RN #1 revealed, "To be honest, I was so focused on trying to get blood started on the patient that I failed to wash my hands." Interview revealed, "No, I did not perform hand hygiene, and that's not normal practice for me and it is not acceptable practice. I did touch the patient once and did not wash my hands or use hand sanitizer." Interview revealed RN #1 did not follow the hospital's "Hand Hygiene" policy.

2. Observation on 03/22/2016 at 1210 revealed a suction canister in Patient #17's room with dried reddish/brown substance down the inside walls of the canister. Observation revealed approximately 50 ml (unit of measurement) of a solidified, reddish/brown, flaky substance in the canister.

Interview on 03/22/2016 at 1210 with RN #3 revealed, "It looks like dried blood to me." Interview revealed, "It looks like it's been there for some time and it should be changed."

Interview on 03/22/2016 at 1230 with RN #2 revealed, "That (suction canister) is not from today. The patient assigned to that room has not required suctioning to my knowledge." Interview revealed, "It (reddish/brown substance) looks like dried spittle. I didn't notice it this morning." Interview revealed the suction canister "should not be in the patient's room."

3. Observation on 03/22/2016 at 1230 revealed a portable computer used for documentation in the hospital's electronic medical record (EMR) with seven drawers dedicated for individual patient use and one for multidose vials of insulin. Observation revealed a 10 ml (unit of measurement) vial of Lantus insulin (used to treat diabetes) and two, 3 ml vials of Humalog insulin (used to treat diabetes). Observation revealed RN #2 had the portable computer inside Patient #13's room while preparing the scheduled medication. Observation revealed RN #2 prepared the medication on the portable computer once inside the patient room.

Interview on 03/24/2016 at 1500 with the facility's interim infection control Preventionist (ICP) revealed portable computers are allowed in the patient's room if he or she is not on any type of precaution. Multidose insulin vials are used throughout the hospital and are present in each portable computer, in the designated medication drawer. Interview revealed multidose insulin vials are taken into multiple patient rooms via the portable computer and are not labeled/designated for individual patient use. If insulin administration is indicated, it is prepared in the patient's room, at the portable computer. Interview revealed, "We need to look into purchasing single dose vials and dedicating them to each individual patient, or keep the portable carts outside the room period." Interview revealed the current practice and use of multidose vials increases the potential for cross contamination.

NC00115491, NO00115173