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Based on observation, interview, record review, and policy review, the facility failed to provide adequate nursing personnel to staff the units which resulted in the following failures:
- Medications were not administered to patients in a timely manner (refer to A-0392 and A-0405).
- Wound care was not performed as ordered (refer to A-0392).
-Patients were not repositioned every two hours as ordered to prevent potential skin breakdown (refer to A-392).
- Staff did not follow the facility's policy, "Medication Management-Glycemic Management," when staff did not utilize two nurses to verify insulin orders and doses prior to medication administration (refer to A-0392).
- Ensure nursing staff documented monitoring of patients that received blood transfusions (refer to A-0409).
-Staff did not administer medications by the ordered route (refer to A-405)
These deficient practices and systemic failures had the potential to place all patients' health and safety at risk.

These systemic failures contributed to the facility's failure to meet the minimum requirements for the Condition of Participation: Nursing Services.

The facility census was 57.

Based on observation, interview, record review and policy review, the facility failed to ensure that:
- Staff followed their policy for Hand Hygiene (to cleanse hands with either soap and water or hand sanitizer).
- Staff followed their policy for Transmission Based Precautions (wearing Personal Protective Equipment-PPE) when indicated.
- Staff followed their policy for Dressing Change-Central Line/PICC Line for.
- Staff provided appropriate staff education regarding the handling of meal tray from an isolated patient with multi-drug resistant organisms (MDRO.)
- One of one room where soiled linen was stored for pickup by the laundry service was ventilated with negative pressure.
- The pest-entry points (cracks and crevices that cause a breach or penetration in the facility outer wall) were controlled and dead pest carcasses were removed from one of one nurses station (3 North) and the Soiled Utility room of one of one surgery suites.
- The clean air intake and exhaust vents of two of two surgical suites were free of debris to preserve a sanitary environment.
- The shower, toilet room and changing lounge were clean where staff changed into appropriate attire for surgery.
- All equipment used in one of one surgical suites was free of rust and soil to preserve the sterile environment.
Refer to A-0749 for examples of the above deficient practices.

These failed practices increased the risk of infections and cross contamination and placed all patients, visitors, and personnel at increased risk for hospital acquired infections (HAI) and contracting communicable diseases.

These systemic failures contributed to the facility's failure to meet the minimum requirement for the Condition of Participation: Infection Control.

The facility census was 57.

Based on interview and record review the facility failed to ensure sufficient numbers of licensed nursing staff was available to provide essential nursing care that included:
-Wound care to three current patients (#15, #16 and #25) and two discharged patients (#13, #14) of five patients reviewed for wound care.
- Patients being repositioned every two hours as ordered to prevent potential skin breakdown for four patients (#3, #4, #17 and #15) of four patients reviewed.
- Verifying insulin orders and dosage prior to administration for one current patient (#22) of one patient observed that received insulin medication.
These deficient practices had the potential to negatively effect wound healing and increase the safety risk for patients receiving insulin (a high risk medication). The facility census was 57.

Findings included:

1. Record review of the facility's policy titled, "Local Policy: Staffing Plan Policy," revised 11/2013 showed the Nursing Services staffing plan used the following:
- A combination of the patient census and each patient's acuity (severity of illness) to determine the number of staff needed for any shift.
- A Core Staffing of one nurse to every four to six patients on the second floor.
- A (computerized) acuity weight system (Kindred Hospital Acuity Tool or KHAT) was developed to determine patient needs during a 24 hour period.
- At the end of the shift, each nurse inputs information about the patients she was assigned by selecting a descriptive selection from a computerized list.
- The Nursing Supervisor used the KHAT system information compiled at the end of each shift to determine the staffing needs for the next shift.

Record review of the undated facility document titled, "KHAT Screening Definitions," showed 23 categories, used to determine acuity, including need for wound care. The category called, "Wound Dressing Changes (performed by nursing)," showed three descriptive choices. Each of the three selections was a description of the patient's wound status and helped the assigned nurse to determine the amount of time required to complete the care.

Further review of the "KHAT Screening Definitions," document showed the three choices under the category called, "Wound Dressing Changes (performed by nursing)" were:
- None - No wounds of direct nursing care; nursing staff did not perform wound care this shift;
- Simple - Less than or equal to 10 minutes - Direct care nursing staff performs simple wound care. Not applicable if the Wound Care Team or Wound Care Coordinator performs the wound care; and
- Complex/Multiple wounds- Greater than 10 minutes - Direct care nursing staff performs wound care on complex or multiple wounds that requires greater than 10 minutes. Not applicable if the Wound care Team or the Wound Care Coordinator performs the wound care. Does not include negative pressure wound therapy (a mechanical device creating suction to draw off drainage).

2. Record review of the facility's Nurse Staff Meeting minutes dated 07/2014 showed nursing administration had identified and discussed with staff at the meeting the results of medical record auditing that showed nursing staff was not consistently completing patient skin assessments and were not providing patient dressing changes as ordered by physicians. Further review showed the proposed resolution to the identified problem was the following:
- Beginning 07/28/14, staff were to print off documentation showing dressing changes were completed as ordered;
- Staff were expected to perform a head to toe skin assessment of each patient on each shift;
- Staff would complete all treatments and dressing changes as ordered by physicians;
- Dressing changes would include initials of the nurse completing the dressing and date of the completion; and
- All dressing changes following the pathway (protocols) to provide a wound assessment and description would be completed on all patients with dressing change orders.

3. Record review of current Patient #15's admission history and physical showed:
- The patient was admitted on 12/15/14 from another hospital with diagnosis of pancreatitis (inflammation of the pancreas that produces digestive fluids), debilitation and inability to eat by mouth (was on, total parenteral nutrition, or TPN, nutrition given through the veins).
- On physical examination, the patient was not mobile, had spinal cord injury, was unable to raise the right leg off the bed and had decreased strength in the left leg.
- The patient had a pressure ulcer (open area through the skin caused by pressure) on the coccyx (commonly called the tailbone) with foul odor and 100% covered with nonviable (dead) tissue.

Record review of the patient's nurse's notes dated 12/20/14 for the 7:00 AM through 7:00 PM shift showed Staff LL, Registered Nurse (RN), took handoff report at 7:24 AM from the off-going nurse. There was no documentation by Staff LL regarding the patients' condition until an assessment note at 3:11 PM that did not include wound assessment.

During an interview on 01/13/15 at 3:50 PM Staff LL, RN, stated that:
- The facility was sometimes short of staff.
- The weekend shifts had the most shortages.
- She had been on duty on 12/20/14 for the 7:00 AM to 7:00 PM shift on 2 Center and 2 South and was assigned 11 patients.
- She was not able to do any wound care during her shift, for the patients she was assigned.
- Her patient assignment included Patient #15.

Review of the Wound Care physician's progress note dated 12/23/14 showed the following:
- The sacral [the coccyx wound) wound had slough (moist yellow or white tissue that adheres to the wound in strings or in thick clumps) and the odor had improved.
- The plan of care was to continue wound care to the area twice a day and as needed due to wound care dressage soilage.

4. Record review of current Patient #16's admission history and physical showed the following:
- The patient was admitted on 11/06/14 from another local hospital;
- The patient required wound care for an open sternal (sternum or breast bone) wound;
- The patient had recent past history of coronary artery bypass graft (CABG or open heart surgery to repair blocked heart vessels);
- History of wound dehiscence (a surgical complication in which a wound ruptures along surgical suture) after CABG;
- A surgical flap (A reconstructive plastic surgery where tissue is moved from a donor site to a recipient site with an intact blood supply. It is done to fill a defect such as a wound resulting from injury or surgery when the remaining tissue is unable to rebuild.);
- The distal and proximal (top and bottom) portions of the wound had been closed but the middle of the wound was left open (unknown reasons);
- A recent past history of respiratory infection;
- A need for mechanical ventilation;
- Chronic debilitation and diabetes; and
- A plan including continue antibiotics; blood sugar monitoring; a wound vac (wound care to suction off drainage); and wean off the ventilator.

During an interview on 01/13/15 at 3:50 PM Staff LL, RN, stated that she was not able to do any wound care during her shift, for the patients she was assigned, which included Patient #16.

5. Observation on 01/13/15 at 2:30 PM showed Staff V, Licensed Practical Nurse (LPN), and Staff PP, Nursing Student, entered the room of Patient #25 to change four pressure sore (decubitus ulcers) dressings. Three of the ulcers were stage IV (extent of wound) and one was unstageable (the wound was closed so depth could not be determined and therefore unstageable).

During an interview on 01/13/15 at 2:30 PM, Staff V stated that the patient's wound dressings were ordered by the physician to be changed every shift. She stated that the dirty dressing bandages she removed were the same ones that she put on the day before and that the patient's dressings had not been changed on the prior shift. The wound dressings were not marked with her initials or dated per facility policy. Staff V stated that she recognized her technique of dressing application and the amount of exudate (fluid that escapes from a wound) on the dirty dressings. She also stated that the patient was scheduled for surgery on two of the ulcers the following day due to their severity and lack of healing. Staff V stated that she had worked at the facility for four weeks as an agency nurse. She stated that she had eight patients on this shift and currently had three patients that had been waiting 45 minutes for their pain medications.

Record review of Patient #25's nurses' notes showed documentation that the previous shift had changed the bandages as ordered.

During an interview on 01/13/15 at 3:20 PM, Staff V stated that information in the nurses' notes for dressing changes for Patient #25 was not correct.

Record review of the staffing schedule for 01/12/15 7:00 PM to 7:00 AM showed a zero in the KHAT score which reflected no dressing change had been performed for Patient #25 on the shift.

6. Record review of discharged Patient #13's physician's discharge summary dated 12/22/14 showed the patient was admitted on 11/10/14 with the following:
- Multiple medical problems including quadriplegia; and respiratory failure with need for mechanical ventilation;
- A Stage IV (full thickness skin loss with extensive destruction, tissue death or damage to muscle, bone or supporting structures) sacral decubitus (pressure ulcer or bed sore to the skin at the base of the spine and/or upper buttock) with superimposed infection;
- A need for Stage IV sacral decubitus flap; and
- A Stage III (full thickness skin loss involving loss or death of subcutaneous tissue; may extend down to but not through underlying layers of ) scrotal ulcer.

Although requested twice through the survey, no nurse's notes of the patient's wound care on 12/20/14 were provided.

7. Record review of discharged Patient #14's admission history and physical dated 12/14/14 showed the patient was admitted with multiple medical problems, insulin dependent diabetes and a chronic infection of a left foot diabetic ulcer.

Record review of the patient's nurse's notes dated 12/20/14 at 4:02 PM showed Staff LL, day shift RN documented that she assessed the patient however failed to document any dressing changes to the patient's diabetic foot ulcer.

During an interview on 01/13/15 at 3:50 PM Staff LL, RN, stated the following:
- She had been on duty on 12/20/14 for the 7:00 AM to 7:00 PM shift on 2 Center and 2 South and was assigned 11 patients.
- The only other RN on 2 Center and 2 South was assigned 12 patients.
- The scheduled Nurse Supervisor had to work in the ICU.
- Other Nursing Supervisors and Staff A, Chief Clinical Officer (CCO, an RN) came in later in the shift after 11:00 AM.
- She was not able to do any wound care during her shift, for the patients she was assigned.
- Her patient assignment included Patients #13 and #14.

8. Record review of the Nursing Daily Schedule dated 12/20/14 for the 7:00 AM to 7:00 PM shift showed:
- One nurse to eight patients on 2 North (not the four to six directed by the Core Staffing of the Nurse Staffing Plan Policy);
- One nurse to 11 patients on 2 Center with one additional patient on 2 South (not the four to six directed by Core Staffing);
- One nurse to 12 patients on 2 Center and on 2 South (twice the maximum directed by Core Staffing);
- One Nursing Supervisor in the Intensive Care Unit (ICU) with three patients (taking that supervisor away from direct supervision and taking away the ability to assist on duty staff nurses on the under staffed units);
- An off duty Nursing Supervisor, who came in from 11:00 AM to 2:00 PM to work as regular staff, assisted on the second floor by taking over the care of some of Staff LL's patients; and
- A third Nursing Supervisor, who came in from 11:30 AM to 7:00 PM to work as regular staff, also assisted by taking of the care of some of Staff LL's patients.

During an interview on 01/12/15 at approximately 2:40 PM, Staff G, Nurse Supervisor, stated that the facility was understaffed four to five times in a week usually due to staff "calling in" (scheduled to work but telephoned prior to the shift to say they would not be working as scheduled).

During an interview on 01/12/15 at 3:00 PM, Staff F, RN, stated that:
- The facility used the KHAT system to determine the number of nursing staff needed per shift.
- The posted schedule was not always an accurate reflection of the work that was required because the schedule did not reflect the patient admissions, discharges and unit to unit transfers through the shift (sometimes she discharged one patient but had to admit two or had to take a transferred patient from another unit in the facility).
- The amount of time needed to admit and initially assess a new (or new to her) patient's needs varied but, usually took a few hours.

During an interview on 01/12/15 at 3:15 PM, Certified Nurse Aide (CNA), stated that the facility was frequently short of staff with the worst shortage being on the weekends and nights (7:00 PM to 7:00 AM shift).

During an interview on 01/12/15 at 3:25 PM, Staff L, LPN, stated that:
- The facility is "short staffed".
- Staffing is based on patient acuity and the facility used the KHAT tool to staff the units.
- Weekends are short staffed more than weekdays due to staff call ins.
- Normal patient to staff ratio is five to six patients to one nurse.

During an interview on 01/12/15 at 3:40 PM, Staff M, CNA, stated that:
- Overall the facility is short staffed for both CNAs and professional nursing staff (RNs and LPNs).
- Because of the short staffing, patients do not get their medications administered on time or get their dressings changed.
- If a patient required one on one observation and the floor was short, the staff providing one on one would be pulled to work the floor.
- Management has been informed of staffing problems but no change has occurred to date.

During an interview on 01/12/15 at 3:42 PM, Staff I, RN, stated that:
- She was routinely assigned to another unit and was on this unit due to staff calling in sick;
- Most days the facility was short of staff;
- She had been assigned as many as eight patients during a shift;
- Wound care (dressing changes for pressure sores and/or surgical wounds) was usually expected to be done during the day shift (7:00 AM to 7:00 PM); and
- If she had eight patients assigned to her and she could not get all the wound care done, she would stay over and try to get it done.

9. During an interview on 01/12/15 at 2:55 PM, Patient #4 stated that he could not reposition himself.

Record review of the nurses notes showed he was supposed to be turned every two hours.

Observation showed Patient #4 lying on his back. During the four hours of intermittent observation, he remained on his back.

10. Observation on 01/2/15 at 4:00 PM showed Patient #3 lying on her back. During the four hours of intermittent observation, she remained on her back. This patient was unable to communicate.

Record review of the nurses notes showed she was supposed to be turned every two hours.

11. Observation on 01/13/15 at 9:15 AM showed Patient #17 lying on her back.

During an interview on 01/13/15 at 9:30 AM, Patient #17's daughter stated that she was at her mothers bedside every day since admission on 12/01/14. She stated that her mother had never been repositioned during that time except one time on 01/12/15.

12. Record review of current Patient #15's nurse's notes showed the patient was not mobile and had a spinal cord injury. The nurse's notes dated 12/20/14 for the 7:00 AM through 7:00 PM shift showed a CNA documented that the patient was to be repositioned approximately every two hours and was supine (on his back) at 8:00 AM. The CNA documented the patient was still supine at 1:55 PM and at 2:35 PM that the patient remained supine.

During an interview on 01/12/15 at 6:25 PM Staff T, Nursing Supervisor, stated that:
- Nurse staffing use to be better (more staff per shift, in the past);
- In the past the ratio had been one nurse to usually five patients; and
- Recently the normal staffing had been eight to 10 patients per nurse.

During an interview on 01/13/15 at 9:15 AM, Staff EE, RN, stated that he felt like the facility is short staffed and due to the staff shortage it has had a negative impact on patient care, for example, patient medications are administered late and wound dressings do not get changed as ordered. Staff EE stated that physicians had complained about the facility being short staffed.

During an interview on 01/13/15 at approximately 10:00 AM, Staff GG, CNA, stated that:
- Staffing at the facility has been "bad and short staffed" for the past year.
- The patient to staff ratio is 10 to 13 patients to one CNA and six to seven patients to one nurse (RN/LPN).
- Staffing being short has impacted patient care by patients not getting medications on time or dressings not getting changed.
- Physicians have complained about staff being short staffed.

During an interview on 01/14/15 at 10:30 AM, Staff NN, RN, stated that the facility is often short staffed and it impacts patient care because medications are administered late and at times dressings do not get changed.

13. Record review of the facility's policy titled, "Medication Management- Glycemic Management," dated 08/14, showed the following direction for facility staff: Two nurses will verify all insulin orders and doses prior to medication administration. One of the two verifying nurses must be the nurse who will administer the insulin to the patient.

14. Observation on 01/13/15 at 9:15 AM showed Staff EE, RN, entered Patient #22's room to administer morning medications. Staff EE selected 10 units of Aspart (fast acting) insulin per insulin pen and 34 units of Detemir (long acting) insulin per insulin pen. Staff EE checked the insulin dosage against the electronic medication record and administered the two doses of insulin. Staff EE did not have another nurse verify the orders or dosages prior to administering the insulin to the patient.

During an interview on 01/15/15 at 11:30 AM, Staff YY, Director of Pharmacy, stated that two nurses are expected to check the insulin prior to administration due to it being a high risk medication. Staff YY stated that her expectation is that two professional staff checked insulin before administration to the patient.

During an interview on 01/15/15 at 11:50 AM, Staff EE, RN, stated that:
- Two nurses are to check insulin before it is administered to the patient.
- He did not have a second nurse verify Patient #22's insulin doses before he administered it to the patient.
- He administered insulin without a second nurse verification approximately four times a month.
- The reason he did not have a second nurse verify insulin dose prior to administration was because of the lack of availability of nursing staff to check the dose before administration.
- Sometimes staff had difficulty in documenting the verification (staff experienced difficulty in documenting the verification in the patient's electronic medication record).











18018




27029




27727

Based on interview and record review the facility failed to ensure:
- Medications were administered as ordered to three current patients (#1, #15, and #16) of three patients observed.
- Time critical medications, as identified in facility policy, were administered in a timely manner to one current patient (#17) and three discharged patients (#8, #14, and #18) reviewed for timely medication administration.
- Staff obtained from the physician the correct medication route for one patient (#17) of three patients observed.
These deficient practices had the potential to cause harm and/or ineffective medication therapy to patients admitted to the facility. The facility census was 57.

Findings included:

1. Record review of the facility's policy titled, "Timely Administration of Scheduled Medications," dated 02/2014 and a facility specific addendum to the policy dated 03/2012 showed the following direction for staff:
- The policy provided guidelines for timely administration of scheduled medication while maintaining patient safety and the required therapeutic effect of administered medication.
- Time critical scheduled medication shall be administered within 30 minutes before or after the scheduled dose time.
- Time critical medications lists will include a limited number of drugs that if delayed or early administration of more than 30 minutes may cause harm or sub-therapeutic effect.
- The addendum listed, "Fentanyl" (a synthetic narcotic pain medication)with a notation that specified administer only scheduled doses;
- The policy identified anti-diabetic medication (drugs used in diabetes treat diabetes mellitus by lowering glucose levels in the blood) as time critical; and
- The addendum listed, "Insulin Lispro/Aspart" (an anti-diabetic medication) with a notation that the specific administration times were associated with meals.

2. Record review of current Patient #15's admission history and physical showed the physician assessed the patient was admitted on 12/15/14 with multiple diagnoses including pancreatitis (inflammation of the pancreas); anemia (The condition of having a lower-than-normal number of red blood cells or quantity of hemoglobin) and recent past history of peritonitis (a potentially fatal inflammation of the abdomen's lining).

Record review of the patient's document titled, "Uncharted/Overdue Medication Administration," dated 12/21/14 showed staff failed to administer the intravenous antibiotic, Ampicillin (synthetic penicillin, an antibiotic to fight infection) and an oral ferrous sulfate (iron preparation used in the treatment of iron deficiency), which were scheduled at 6:00 PM.

Record review of a facility document titled, "Uncharted/Overdue Medication Administration," dated 01/01/15 through 01/12/15, provided by Staff A, Chief Clinical Officer (CCO), showed Patient #15's physicians had ordered 325 doses of scheduled medications during that time to be administered to him. Further review showed staff omitted or missed three of those and staff administered 28 doses at least one hour later than the scheduled time (outside the 30 minute limit which permitted only 30 minutes of tardiness).

3. Record review of current Patient #16's admission history and physical showed the physician assessed the patient was admitted on 11/06/14 with multiple medical diagnoses including respiratory failure requiring mechanical ventilation and recent past history of lower respiratory tract infection and treatment with antibiotics.

Record review of the patient's "Uncharted/Overdue Medication Administration," dated 12/19/14, showed staff failed to administer an inhaler and a medication to loosen mucous to the patient, which was scheduled at 8:00 PM.

Record review of a facility document titled, "Uncharted/Overdue Medication Administration," dated 01/01/15 through 01/12/15 showed Patient #16's physicians had ordered 750 doses of scheduled medications during that time to be administered to him. Further review showed staff omitted or missed 14 of those and staff administered 81 doses at least one hour later than the scheduled time (outside the 30 minute limit which permitted only 30 minutes of tardiness).

4. Record review of Patient #1's face sheet showed admission to the facility on 01/06/15 with diagnosis of sepsis (whole body inflammation by infection).

During an interview on 01/12/15 at 3:29 PM, the patient stated the facility was short of staff a lot which caused the staff to be tardy with his medication. The patient also stated the weekend staffing was the worst causing his medications to be late frequently at those times.

Record review of a facility document titled, "Uncharted/Overdue Medication Administration," dated 01/01/15 through 01/12/15, and provided by Staff A, CCO, showed Patient #1's physicians had ordered a total of 142 doses of scheduled medications to be administered to him. Further review showed staff omitted or missed three of those and staff administered 18 doses at least one hour later than the scheduled time (outside the 30 minute limit which permitted only 30 minutes of tardiness).

5. Record review of current Patient #17's admission history and physical showed the patient was admitted to the facility on 12/01/14 with diagnosis of respiratory failure, treatment of an abdominal wound and had a tracheotomy (a surgically created opening through the neck into the windpipe to allow direct access to the breathing tube instead of the mouth or nose).

Record review of the patient's "Uncharted/Overdue Medication Administration," dated 12/20/14 showed staff was scheduled to administer Fentanyl (synthetic opioid narcotic analgesic used for pain control) to the patient at 10:00 AM and actually provided the medication at 11:55 AM. This time critical medication was administered one hour and 55 minutes late.
Record review of a facility document titled, "Uncharted/Overdue Medication Administration," dated 01/01/15 through 01/12/15 showed Patient #17's physicians had ordered a total of 430 doses of scheduled medications to be administered to him. Further review showed staff omitted or missed three of those and staff administered 67 doses at least one hour later than the scheduled time (outside the 30 minute limit which permitted only 30 minutes of tardiness).

6. Record review of discharged Patient #8's admission history and physical showed the physician assessed:
- The patient was admitted on 12/19/14 with multiple medical conditions;
- The patient was on insulin with fluctuating blood sugars;
- The patient had swallowing problems and was not eating well, so a nasogastric feeding tube (tube placed through the nose to the stomach and used to provide liquid nutrition) was inserted;
- The patient was also on oral diet with thickened liquids.

Record review of the patient's "Uncharted/Overdue Medication Administration," dated 12/20/14 through 12/24/14 showed staff was scheduled to administer Insulin at 7:30 AM, 12:00 Noon and 5:00 PM. This time critical medication was administered late nine times out of 15 scheduled doses (all nine were from one to two hours and 15 minutes late).

During an interview on 01/15/15 at 9:30 AM, Staff B, Director of Quality Management reviewed the patient's insulin administration and confirmed staff had failed to administer the insulin in a timely manner.

7. Record review of discharged Patient #14's admission history and physical showed the patient was admitted on 12/13/14 with non-healing left foot diabetic ulcer and required medications including insulin.

Record review of the patient's "Uncharted/Overdue Medication Administration," dated 12/19/14 showed staff was scheduled to administer Insulin at 7:30 AM, 11:00 AM and 4:00 PM. The dose scheduled for 7:30 AM was administered at 9:49 AM (2 hours and 19 minutes late); the 11:00 AM dose was administered at 1:00 PM (two hours late) and the 4:00 PM dose was administered at 5:30 PM (one hour and 39 minutes late). Insulin is a time critical medication.

8. Record review of discharged Patient #18's admission history and physical showed the patient was admitted on 11/28/14 with multiple medical problems including chronic respiratory disease; chronic pain syndrome; chronic lower back pain and opioid (narcotic pain medication) dependences.

Record review of the patient's "Uncharted/Overdue Medication Administration," dated 12/19/14 showed staff was scheduled to administer Fentanyl (a time critical medication) at 10:00 AM but did not administer the medication until 2:25 PM (four hours and 25 minutes after the scheduled time).

During an interview on 01/15/15 at 11:40 AM, Staff YY, Director of Pharmacy, stated that insulin was a high risk medication and insulin as well as all medications on the time critical list should be administered as ordered.

9. Record review of the facility policy titled, "Administration of Medications," release date of 08/2014, showed the directive to staff to administer medications using the "Right" route which is one of the seven "Rights" of medication administration.

10. Record review of current Patient #17's admission history and physical showed the patient was unable to swallow or take medications by mouth due to a previous history of cancer of the throat.

Record review of the Medication Administration Record (MAR) showed that four PO (by mouth) medications had been prescribed by the physician. The remaining nine medications were ordered "per feeding tube" by the physician.

During an interview on 01/13/15 at 9:50 AM, Staff CC, Registered Nurse (RN) stated that she had given all medications, including the four medications prescribed by the physician as PO through Patient #17's Jejunostomy (J-tube), a tube that is inserted through the abdomen into the jejunum (the second part of the small bowel) to assist with feeding and nutrition. The patient had been given four "by mouth" medications through the feeding tube since admission on 12/01/14 because she was unable to swallow.

The staff neglected to call the physician to have these medications ordered by the correct route.



























27727












18018

Based on observation, interview, record review and policy review the facility failed to follow their policy and procedure for monitoring patients during blood transfusions for two current patients (#9 and #21) of two patients who received blood transfusions. This failure had the potential to put all transfused patients at risk for undetected blood transfusion reactions and/or fatal transfusion errors. The facility census was 57.

Findings included:

1. Record review of the facility's policy titled, "IV Therapy: Infusion Therapies," dated 11/2009, showed direction to staff for safe blood and blood product transfusion:
- A Registered Nurse (RN) will perform the care and monitoring of the patient receiving the blood and/or blood component.
- Vital signs (VS) will be observed and documented at minimum at the following intervals/times: Check VS at 15, 30 minute intervals and one hour after start of transfusion for the first hour then check VS hourly until the transfusion is complete, at the conclusion of the transfusion and one hour after the transfusion.
- Observe patient continuously for signs of transfusion reaction during the first 15 minutes, then every hour during the transfusion.
- Document in the patient's permanent medical record the signs and symptoms of reaction observed, component administered, amount infused, time of physician notification, medication and treatment ordered and administered, patient's response to procedure and interventions and patient's outcome.

2. Observation on 01/12/15 at 2:40 PM showed Staff W, RN, and Staff V, Licensed Practical Nurse (LPN), prepared to infuse blood to Patient #9. Staff V left the patient's room after the transfusion was started at 3:15 PM and Staff W remained in the room for 15 minutes and took the patient's VS. Staff W then left the room and the patient was left alone in the room with the door closed. The patient was not being monitored electronically during that time. The patient remained alone and the time was 3:47 PM and VS had not been obtained. Staff V took the patients VS at 4:00 PM which was 15 minutes later than required.

During an interview on 01/12/15 at 2:40 PM, Staff W stated that Patient #9 had never received a blood transfusion so the possibility of a negative reaction was not known.

During an interview on 01/12/15 at 2:30 PM, Staff V stated that she:
- Had never participated in a blood transfusion;
- Had never monitored a patient during a blood transfusion;
- Had never been trained by the facility on blood transfusions;
- Did not have blood transfusion education in the facility's orientation, which was four weeks prior;
- Had never read the facility's policy and procedure on blood administration; and
- Wasn't sure if she knew how to access the facility's policies and procedures for reference.

During an interview on 01/12/15 at 6:50 PM, Staff W, RN, stated that she had just read the policy and procedure for blood transfusion administration and that it stated that an RN had to perform the patient care and monitor the patient during a blood transfusion. She stated that she knew that LPN's had monitored patients before and didn't realize that the facility's policy and procedure stated RN's only. She stated that if she had to transfuse another patient with blood that she wouldn't leave the patient alone or in the care of anyone but an RN.

3. Record review of Patient #21's Blood Administration Flow Sheet dated 12/25/14 showed facility staff failed to document the following:
-Vital Signs one hour after start of transfusion.
-Continued monitoring for signs and symptoms of transfusion reactions; vital signs hourly and as indicated.
-Transfusion stopped date, time and initials of staff.
-Vital Signs at the end of the transfusion.
-Vital Signs one hour post transfusion.
-Amount Infused, Signs and/or Symptoms of Transfusion Reaction.

During an interview on 01/13/15 at 11:11 AM, Staff B, LPN, Director of Quality Management (DQM), stated that Patient #21's Blood Administration Flow Sheet showed that staff did not document continued assessment of the patient during blood administration because staff failed to document vital signs, continued monitoring, transfusion stop date/time, vital signs at the end of the transfusion and one hour post transfusion and failed to document amount infused and any signs/symptoms of transfusion reaction.

4. Record review of the facility's blood administration records showed that the facility performed 400 blood transfusions in the last 12 months and 67 in the last 45 days. Of the 67 blood transfusions in the last 45 days, 33 of the Blood Administration Flow Sheets were missing some required information:
- Not signed by two nurses for verification of the patient's blood type;
- The VS monitoring was not performed timely; and/or
- The one hour post VS were not performed.

5. During an interview on 01/15/15 at 9:50 AM, Staff A, RN, Chief Clinical Officer (CCO), stated that:
- Patient #21's Blood Administration Flow Sheet documentation was incomplete.
- She expected staff to complete patients' Blood Administration Flow Sheet and that the nursing supervisor for the shift is responsible to check and make sure the documentation is completed for blood administration.
- The facility does perform audits for the Blood Administration Flow Sheet and had noticed issues with staff documentation approximately two months ago.
- The Nurse Supervisor audits the Blood Administration Flow Sheets for accuracy and to ensure documentation is completed.
- She didn't know that 33 of the documents were inaccurate or missing information.





18018

Based on observation, interview, record review and policy review, the facility failed to ensure that:
- Staff followed their policy for Hand Hygiene (to cleanse hands with either soap and water or hand sanitizer) for five patients (#2, #12, #22, #25 and #29) out of five patients observed.
- Staff followed their policy for Transmission Based Precautions (wearing PPE-Personal Protective Equipment) when indicated for three patients (#4, #9 and #24) of three patients observed and for Staff FF, Housekeeper, that was observed cleaning a Contact Isolation (precautions taken to prevent transmission of contagious diseases) room.
- Staff followed their policy for Dressing Change-Central Line (a line placed into a large vein used to administer medications or fluids and to obtain blood)/PICC Line (a line place in a vein used for prolonged period), for one current patient (#28) of one patient observed during Central Line dressing change.
- Staff provided appropriate staff education regarding the handling of a meal tray from an isolated patient with multi-drug resistant organisms (MDRO) for one patient (#11) of one patient observed.
- One of one rooms where soiled linen was stored for pickup by the laundry service was ventilated with negative pressure.
- The pest-entry points (cracks and crevices that cause a breach or penetration in the facility outer wall) were controlled and dead pest carcasses were removed from one of one nurses station (3 North) and the Soiled Utility room of one of one surgery suites.
- All equipment used in one of one surgical suites was free of rust and soil to preserve the sterile environment.
- The clean air intake and exhaust vents of two of two surgical suites were free of debris to preserve a sanitary environment.
- The shower, toilet room and changing lounge were clean where staff changed into appropriate attire for surgery.
These failed practices increased the risk of infections and cross contamination and placed all patients, visitors, and personnel at increased risk for hospital acquired infections (HAI) and contracting communicable diseases. The facility census was 57.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene," revised 08/2013, directed facility staff: Hand Hygiene Will Be Performed As Follows:
- Before performing invasive procedures;
- Before and after patient contact;
- Between patients;
- After situations during which microbial (a microscopic living organism)contamination of the hands is likely to occur (i.e. contact with potentially contaminated environmental surfaces); and
- Before donning (putting on) and after removal of gloves.

2. Observation on 01/13/15 at 9:15 AM showed:
- Staff EE, Registered Nurse (RN), entered Patient #22's room to administer medications.
- Staff EE performed hand hygiene and put on gloves and went to the bedside of the patient and touched the patient's arm and identification (ID) band. Wearing the same gloves, Staff EE:
- Typed on the bedside computer keyboard, unlocked the medication cabinet and retrieved the medication bin.
- Touched the computer screen to verify the medications against the electronic medication record and removed the medications from the medication bin.
- After he removed the medication wrappers, placed the medications in a plastic cup and handed the medication cup to the patient.
- Staff EE then touched the computer screen and keyboard to chart the medications.

Staff EE did not change gloves or perform hand hygiene after he touched the patient and potentially contaminated environmental surfaces.

3. Observation on 01/13/15 at 9:20 AM showed:
- Staff X, RN, entered Patient #12's room for medication administration.
- Staff X performed hand hygiene and put on gloves then typed on the computer keyboard.
- She opened seven pill containers and placed them in a medicine cup.
- She put her contaminated gloved finger into the pill cup and removed the medication one by one and placed them on the patient's tongue. This practice continued for all seven pills.
- Staff X dropped one of the pills onto the floor and picked it up and typed on the computer keyboard.
- She opened and closed the toilet lid then removed her gloves.
- Staff X closed the patient medicine cabinet and locked it before she performed hand hygiene.
- She went to the pharmacy window and procured a replacement pill for the pill that she had dropped on the floor.
- She went into the patient's room and put on gloves but did not perform hand hygiene.
- She opened the medication package and dropped the pill into the medicine cup.
- She then took the pill out of the cup and placed it on the patient's tongue.
- Staff X turned off the lights and typed on the computer before she removed her gloves but did not perform hand hygiene.

During an interview on 01/13/15 at 9:40 AM, Staff X stated that she changed gloves and performed hand hygiene when giving treatments but not when passing medications.

4. Observation on 01/13/15 at 2:30 PM showed Staff V, Licensed Practical Nurse (LPN), and Staff PP, Nursing Student, entered the room of Patient #25 to change the dressings on four pressure sores (decubitus ulcer - a skin ulcer that comes from lying in one position too long so that the circulation in the skin is compromised by the pressure). Staff V changed her gloves nine times during the four dressing changes but did not perform hand hygiene after she removed the gloves and putting on a clean pair. Staff PP changed gloves two times during the dressing changes but did not perform hand hygiene between glove changes.

During an interview on 01/13/15 at 2:30 PM, Staff PP stated that she had been a student for three months.

During an interview on 01/13/15 at 3:20 PM, Staff QQ, Student Nursing Instructor, responded to the observation and stated, "Yeah, they're new".

During an interview on 01/13/15 at 3:25 PM, Staff V stated that she should have performed hand hygiene between glove changes and did not.

5. Observation on 01/13/15 at 3:45 PM showed Staff EE, RN, entered Patient #2's room to do a dressing change and completed the following tasks.
- Put on a gown and gloves and entered the patient's room but did not perform hand hygiene.
- Gathered the needed supplies for the dressing change, turned on the over-the-bed light, raised the bed height, lowered the head of the bed and turned off the air mattress.
- He did not remove his gloves or perform hand hygiene after touching various items and objects in the room.
- Removed the patient's brief and old dressing. The old dressing had a moderate amount of light red/pink drainage.
- He did not remove his gloves or perform hand hygiene after he removed the patient's brief and old dressing.
- Then he touched the trash can and moved it closer to the bed and did not change his gloves or perform hand hygiene after he touched the trash can. - Cleansed the wound wearing the same gloves.

During an interview on 01/13/15 at 3:45 PM, Staff EE, RN, stated that he had never thought about performing hand hygiene after touching items, for example, patient ID arm bands, computer screen, keyboard or prepping medications for oral administration. Staff EE stated that staff are to foam in/foam out.

6. Observation on 01/14/15 at 11:00 AM, showed Staff VV, CRT (Certified Respiratory Therapist), entered Patient #29's room to administer aerosol (the delivery of medication during the inhalation phase of respiration) therapy, suctioning (to remove oral/mouth secretions that a person is unable to remove by coughing) his tracheostomy (an opening surgically created through the neck into the trachea-windpipe), and change the tracheostomy dressing.
- With gloved hands Staff VV unlocked the medication cabinet in the patient's room and removed the needed aerosol medication.
- Staff VV did not remove her gloves or perform hand hygiene after she unlocked the medication cabinet or removed the aerosol medication.
- Staff VV touched the patient's arm to check his identification (ID) band and after she confirmed the patient's ID, she suctioned the patient and then administered the aerosol treatment wearing the same pair of gloves.
- Wearing the same gloves, Staff VV then gathered the needed supplies to change the patient's tracheostomy dressing.
- Staff VV changed her gloves and performed hand hygiene and put on another pair of gloves, removed the old dressing and performed tracheostomy care around the site. Staff VV did not remove her gloves or perform hand hygiene after she removed the old dressing or before she cleansed the site or applied a clean dressing.

During an interview on 01/14/15 at 11:00 AM, Staff VV, CRT, stated that she should have removed her gloves and performed hand hygiene after she touched and unlocked the medication cabinet in the patient's room and before providing other care for the patient.

During an interview on 01/14/15, Staff AA, Infection Control Officer (ICO), stated that she is constantly educating staff on hand hygiene and glove wear. She stated that the nurses have been educated on proper hygiene but it was a constant battle to work for compliance.

7. Record review of the facility's policy titled, "Transmission Based Precautions," revised 12/2013, gave the following direction:
- Transmission-Based Precautions are for patients with documented or suspected infection or colonization (presence of bacteria on a body surface without causing disease) with highly transmissible or epidemiologically (the science that studies the patterns, causes, and effects of health and disease conditions in populations) important pathogens for which additional precautions are needed to prevent transmission.
- Appropriate personal protective equipment is used per Standard Precautions.
- Hand Hygiene: Is the most important method of control to prevent transmission.
- Gloves: Wear gloves whenever touching the patient's intact skin or surfaces and articles in close proximity to the patient (e.g., medical equipment, bed rails). Don gloves upon entry into the room or cubicle.
- Gowns: Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Don gown upon entry into the room or cubicle if exposure is anticipated. Remove gown an observe hand hygiene before leaving patient-care environment. Wear a gown for direct patient contact if the patient has uncontained secretions or excretions. Remove gown and perform hygiene before leaving the patient's environment.
- Masks are worn when: Performing splash generating procedures (e.g., wound irrigation, oral suctioning, intubation or during resuscitation efforts); and
-Performing care for patients with an open tracheostomy and the potential for projectile secretions.
- Patients may not be strictly confined to their room, though movement and transport of the patient from the room should be limited to medically necessary purposes.
- If a patient must leave his or her room, ensure that precautions are maintained during the transfer.

8. Record review of the Centers for Disease Control and Prevention (CDC) publication titled, "Management of Multidrug-Resistant Organisms In Healthcare Settings," dated 2006, give the following direction: Contact Precautions. Contact Precautions are a set of practices used to prevent transmission of infectious agents that are spread by direct or indirect contact with the patient or the patient's environment. Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased transmission risk. Multidrug-resistant organisms (MDROs, bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria, such as Methicillin-resistant Staphylococcus aureus (MRSA). Standard Precautions are a combination and expansion of Universal Precautions and Body Substance Isolation. Standard Precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions includes hand hygiene, and depending on the anticipated exposure, use of gloves, gown, mask, eye protection, or face shield.

9. Observation on 01/12/15 at 2:40 PM showed Staff W, RN, and Staff V, LPN, prepared to infuse blood to Patient #9 who was in contact isolation. They put on a PPE gown and gloves but did not put on PPE masks. Masks should be worn as part of PPE wear when there is a risk of blood exposure.

During an interview on 01/12/15 at 2:40 PM, Staff V stated that she didn't need to put on a mask because the patient's MDRO was on her foot. When it was explained to the nurse that a blood transfusion had a high risk of blood exposure or spatter she stated, "True" and put on a mask.

10. Record review of the facility's document titled, "Transporting Contact Isolation precaution Patients Tip Sheet," dated 07/19/12 gave the following direction:
- Before transporting staff will apply or have patient don isolation gown and gloves.
- If transporting per wheelchair, change gloves prior to assisting patient to wheelchair.
- To exit patient room, staff will don fresh gown and gloves to transport patient.

11. Record review of Patient #24's medical record showed he was in contact isolation for MRSA and MDRO.

Observation on 01/12/15 at 5:50 PM showed Patient #24 propelling himself down the hallway in his wheel chair and entering room #309 posted as contact isolation precautions. Patient #24 was not accompanied by staff and had on street clothes.

During an interview on 01/12/15 at 5:55 PM, Staff EEE, RN, stated, "Sometimes we don't have much control, we can't make them stay in".

12. Record review of Patient #9's medical record showed that she was on contact isolation for MDRO.

13. Observation on 01/13/15 at 9:45 AM showed staff pushing Patient #9 in a wheel chair to the elevator after stopping at the nurses' station to tell them that the patient was being taken to surgery. The patient had on a hospital gown and the staff had on regular work clothes but no PPE gown or gloves to indicate the patient was on contact isolation. The staff used the public elevator to transport the patient which put the community and staff at high risk for infection transmission.

During an interview on 01/15/15 at 8:50 AM, Staff AA, ICO, stated that patients could be instructed but could not be forced to follow isolation precautions. She stated that staff should be following the Tip Sheet for Transporting Contact Isolation Precaution Patients that is located at the nurses' station.

14. Observation on 01/12/15 at 2:55 PM showed Staff N, RN, entered the Contact Isolation room of Patient #4 and suctioned the patient. She wore no mask to prevent unexpected accidental splashes from the tracheotomy (a surgically created opening through the neck into the windpipe to allow direct access to the breathing tube instead of the mouth or nose).

15. Observation and concurrent interview on 01/12/15 at 5:45 PM showed Staff VV, CRT, entered the Contact Isolation room of Patient #4. She drew blood gases (insertion of a thin needle into an arterial vein) from the patient and removed her PPE gown from her left side as she walked away from the patient's bed. She then approached the patient's bed with the gown partially off and removed a sticker from the bed railing. Staff VV stated that she was throwing trash away.

16. Observation on 01/12/15 at 6:00 PM showed Staff R, Registered Respiratory Therapist, (RRT), entered the Contact Isolation room of Patient #4. She did not have gown, gloves or a mask on. She exited the room after Staff VV spoke to her. She reentered the room with gown and gloves on.

During an interview on 01/12/15 at 6:15 PM, Staff R stated that the patient had not been on Contact Isolation the day before and she did not see the [Contact Isolation] sign which was on the door.

During an interview on 01/15/15 at 2:57 PM, Staff AA, ICO, stated that she would wear a mask if there was a possibility of a splash with suctioning and expected staff to do the same.

17. Review of the facility's board approved Environmental Services Policy, Standard Operating Procedure EVS 403 titled, "Occupied Isolation Room Cleaning," showed staff are to wear "Personal Protective Equipment as indicated by type of isolation/precautions and follow the facility's procedures including requirements posted on signage."

18. Observation and concurrent interview on 01/12/15 at 5:45 PM showed Staff FF, Housekeeper, entered room 210 to clean it after the patient had been discharged. On the door was posted a red MDRO-Contact Isolation Precaution sign. Staff FF had on gloves but did not have a gown on when she entered the room to clean it. Staff FF stated that she did not need to wear a gown to clean the room. Staff FF stated that she is responsible for cleaning the bed, siderails, floor, over-the-bed table, night table, and the bathroom.

During an interview on 01/14/15 at 4:30 PM Staff XX, Resource Supervisor, stated that their personnel are trained and oriented to all of the housekeeping and cleaning procedures and they are expected to follow those procedures. She stated that all the policies and procedures used by Environmental Services (aka Housekeeping) had been approved by the board prior to use.

19. Record review of the facility's policy titled, "Dressing Change-Central Line/PICC Line," dated 04/2014, directed facility staff that: The procedure for central line dressing changes will be performed under strict aseptic (a technique used to prevent the spread of infection) technique.

20. Observation on 01/14/15 at 10:30 AM, showed Staff NN, RN, entered Patient #28's room to perform a central line dressing change. Staff NN was observed doing the following:
- Performed hand hygiene, put on non-sterile gloves, took a Sani Wipe (sanitizing surface wipes) and cleaned off the over-the-bed table.
- Wearing the same pair of gloves she flushed the central line and did not remove the gloves.
- Wearing the same gloves, she moved the trash can closer to the patient's bed but did not remove her gloves.
- Wearing the same gloves, she removed the outer wrapping from the sterile kit, removed the outer wrapper from three 10 millimeters (mL) syringes filled with normal saline and the outer wrapping of the sterile dressing.
- Wearing the same gloves she again touched the trash can but she did not remove her gloves after she moved the trash can.
- Wearing the same gloves, she removed the old caps from the three lines, cleansed the openings, placed new caps on and removed the old dressing covering the insertion site.
- After removal of the old dressing, she removed her gloves, performed hand hygiene, removed her mask, applied the sterile mask from the kit, opened the outer wrapper that contained sterile gloves and put them on but failed to perform hand hygiene before donning the sterile gloves.

During an interview on 01/14/15 at 10:30 AM, Staff NN, RN, stated that she should have removed her gloves and performed hand hygiene:
- After she cleaned the over-the-bed table,
- After touching/moving the trash can;
- Before removing the sterile packing;
- After removal of the central line caps;
- Before removal of the outer wrapping off the three 10mL syringes with normal saline;
- After removing the old central line dressing;
- After putting on the mask from the sterile kit; and
- Before changing the three central line caps and flushing the lines.

During an interview on 01/14/15 at 2:45 PM, Staff AA, RN, ICP, stated that she expected staff to follow the facility's infection control policy and procedures. Staff AA stated that she expected staff to change gloves and perform hand hygiene after touching objects in the patients environment, for example, over-the-bed table.

21. Observation on 01/13/15 at 9:55 AM showed Staff X, RN, entered Patient #11's room. The room was posted with a sign of contact isolation for MDRO. Staff X exited the room a few minutes later with the patient's contaminated breakfast tray and stood at the elevator. When the elevator did not respond, Staff X placed the contaminated patient tray in the common public hall on a bedside table.

During an interview on 01/13/15 at 10:15 AM, Staff X stated that it was OK to leave the contaminated patient tray in the hall and stated, "Dietary will come and get it."

During an interview on 01/13/15 at 11:28 AM, Staff JJ, Director of Dietary and Registered Dietitian stated the following:
- Dietary staff do not enter the rooms of patients who were in isolation:
- Nursing staff should retrieve the tray after a meal was consumed and return the tray to the Dietary tray carts stored in the hallways;
- If the tray was retrieved after routine meal service times, the soiled tray of the isolated patient was to be place on a Dietary cart left on the unit;
- Dietary department had a policy directing staff on how to handle trays from isolated patients;
- Staff JJ had not provided the policy to nursing staff on the units; and
- Staff JJ did not know how the nursing staff would know where the tray for the isolated patient should be stored if there was no Dietary cart left in the hallway.

22. Record review of the Center for Disease Control's Morbidity and Mortality Weekly Report dated June 6, 2003, recommended rooms used for holding or processing soiled linen be maintained continuous negative air pressure in relation to the air pressure in the corridor and monitor air pressure periodically, preferably daily. This recommendation is also endorsed by The American Institute of Architects. The purpose of this is to ensure that potential airborne contaminants are exhausted outdoors or at a minimum through a High Efficiency Particulate Air filter before being released back into the hospital environment.

23. Observation on 01/12/15 at 1:30 PM of the soiled linen holding room showed positive pressure air flow out of the room into the corridor rather than from the corridor into the room. Air flow from the soiled linen holding room into the corridor potentially exposed all patients, staff and visitors to airborne particulates agitated during transfer of soiled linen.

During an interview on 01/12/15, Staff B, Director of Quality Management, acknowledged the observation and stated that she would check with Maintenance and the Director of Plant Operations.

During an interview on 01/13/15 at 9:30 AM, Staff WW Director of Plant Operations, stated that Maintenance workers found a bearing had burned out in the ventilation fan located on the roof. He stated that workers make regular preventive maintenance rounds quarterly and have smoke tested rooms or areas where ventilation was uncertain.

24. Observation on 01/13/15 at 3:00 PM and 01/15/15 at 9:30 AM of the 3 North corridor showed 14 dead flies in the four overhead lights above the nurse's station.

25. Observation on 01/14/15 at 2:45 PM showed 11 dead bugs which looked like hornets in the light covers of Surgery's Soiled Utility room.

During an interview on 01/15/15 at 10:30 AM, Staff WW, Director of Plant Operations, acknowledged the insects and stated that they did have a past problem with insects, but he felt like it was resolved now

26. Observation on 01/12/15 at 5:50 PM showed in Operating Room (OR) #1, rusty caster wheels on a large, stainless two-shelf table, movable metal stand, and two of three linen cart frames.

27. Observation on 01/12/15 at 5:55 PM showed in OR #2, rusty caster wheels on two large two-shelf stainless steel tables, movable metal stand, trash ring, and soiled linen stand.

28. Policy review of the board-approved Environmental Services contract dated 04/11/2014 showed cleaning specifications for sterile areas (Surgical Services) but did not specify or include the cleaning of ventilation covers in the surgical suite.

29. Observation on 01/14/15 at 2:30 PM of the surgery suite showed dense deposits of black soot, lint and fuzz had accumulated on all air intakes and exhaust vents in the two operating rooms (OR #1 and OR #2) and sub-sterile areas, which included the soiled utility (surgical equipment wash) room and sub-sterile corridor as follows:
- Two wall vent covers in OR #1.
- Two wall vent covers in OR #2.
- Wall vent cover in sterile utility room located in the surgery suite and adjacent to OR #1.
- Four of four overhead vent covers in the ceiling of the sub-sterile corridor.
A damp paper towel applied to vanes of the same vents showed the dark soils wiped off of the painted vents and left a clean white surface. Rust spots were also noted on the intake and exhaust vents supplying two of two OR's.

During an interview on 01/14/15 at 4:30 PM Staff XX, Resource Supervisor, acknowledged the findings and stated that none of their procedures for terminal cleaning of the surgical area addressed the cleaning of ventilation covers.

30. Observation of the Staff Changing Room on 01/14/15 at 3:00 PM showed dried white calcium deposits on the ceramic tiles in the shower, and dark stains embedded in the cement grout between the tiles. The tile and grout around the lower half of the shower and entire shower floor was dark and stained. Several large-diameter (dinner plate sized) brown stains spotted the blue carpet of the unisex changing room lounge, and the carpet smelled soured. An area of vinyl tile, three feet wide by two foot deep, behind the toilet and sink in the bathroom of the unisex changing room was buckled, stained and separated about one 16th of an inch, and partially exposed tacky black adhesive.

During interviews on 01/14/15 at 9:00 AM and 3:00 PM, Staff RR, RN, Surgery Manager, stated that the shower also serves as the emergency shower because they get splashed (with potentially contaminated blood and biological residue) all the time, but no one will go in there (the shower) because it's too dirty.





















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