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Based on medical record review and interview, it was determined that the facility failed to inform each patient or patient's representative of the patient's rights and obtain consent for treatment prior to providing care for six (6) of six (6) patients (Patients # 1, #2, #3, #4, #5 and #6).

The findings include:

During medical record reviews November 13 - 15, 2017, the following was revealed:
Patient # 2 was admitted on November 1, 2017 at 2:30 P.M. The consent for treatment and patient's rights acknowledgement was reviewed with Patient # 2's daughter during a phone conversation and witnessed by two staff members on November 3, 2017.

Patient # 3 was admitted on September 27, 2017 at 3:54 P.M. The consent for treatment and patient's rights acknowledgement was signed on September 28, 2017 at 2:15 P.M. by Patient # 3.

Patient # 4 was admitted on September 22, 2017 at 2:45 P.M. The consent for treatment and patient's rights acknowledgement was signed on September 25, 2017 at 12:30 P.M. by Patient # 4's daughter.

Patient #1's medical record was reviewed on 11/14/17 and 11/15/17. The record revealed Patient #1 was admitted on 9/20/17 but the consent for treatment was not signed by Patient #1 until 9/21/17. Patient #1 received medications, wound assessments and tube feedings among other forms of care prior to giving written consent to do so.

Patient #5's medical record was reviewed on 11/15/2017. The record revealed Patient #5 was admitted on 11/6/17 but the consent for treatment was not signed until 11/7/17 by Patient #5's spouse. Patient #5 received medications, tracheostomy care and tube feedings among other forms of care without giving written consent to do so.

Patient #6's medical record was reviewed on 11/15/2017. The record revealed Patient #6 was admitted on 10/31/17 but the consent for treatment was not signed until 11/1/17. Patient #6 received medications, wound assessments and tube feedings among other forms of care without giving written consent to do so.


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An interview with Staff Member # 5 on November 14, 2017 at 9:30 A.M. revealed that "the clinical team assesses the patient and determines if the patient is able to sign if not they will notify family to speak with him/her". Staff Member # 5 is responsible for having patient or patient's representative review and sign all admission paper work.

The facility policy provided by Staff Member # 4 on November 14, 2017 at 2:00 P.M. titled "Patient Registration" reads in part "Upon admission, meet with the patient and/ or family to review the demographics from the facesheet, provide and explain the elements of the patient packet and obtain all required signatures".

The findings were discussed with Staff Members # 1, #2 and #4 on November 15, 2017 at 2:00 P.M.

Based on document review and interview, it was determined the facility staff failed to ensure the attending physician co-signed a history and physical (H&P) conducted by a third year medical student within the facility's policy of 48 hours for one (1) of six (6) patients, Patient #1.

The findings include:

On November 14, 2017 and November 15, 2017 the medical record of Patient #1 was reviewed. Patient #1 was admitted on 9/20/17 and discharged on 10/10/17. On 9/21/17 the H&P was performed and signed by a third year medical student. The attending physician had not co-sign the H&P as of the day of the record review.

The policy titled Analysis of Medical Records/Chart Deficiencies with a revision date of 10/2014 was provided by Staff Member #1 who also stated, "(Name of attending physician) should have co-signed the H&P within 48 hours". The policy Purpose documents, "All entries should be dated and signed within 48 hours."

Based on document review and interview, it was determined the facility staff failed to ensure the medical records for two (2) of six (6) patients (Patient #1 and #2) were accurate.

The findings include:

1. The medical record of Patient #1 was reviewed on November 13, 2017 and November 14, 2017. Patient #1 was admitted on 9/20/17 and discharged on 10/10/17. On 10/6/17 and 10/7/17 it was documented in the medical record, "Wound Vac in place." Patient #1 never had a wound vac during the days of hospitalization.

Staff Member #1 stated, "They probably documented on the wrong record."


2. A medical record review for Patient # 2 on November 13, 2017 at 2:00 P.M. revealed Patient # 2 was admitted on November 1, 2017 at 2:30 P.M. The history and physical documented on November 1, 2017 at 9:08 P.M. by the physician reads "date of admission: 10/20/2017".

The findings were discussed with Staff Members # 1, #2 and #4 on November 15, 2017 at 2:00 P.M.

Based on observation and interviews, it was determined the facility staff failed to ensure the refrigerator used to store additional nutritional items for patients maintained the correct temperature of 34° to 40°F (Fahrenheit).

The findings include:

On 11/13/17 at approximately 12:10 P.M. during the initial tour of the facility the nourishment room was observed. The room had a cyberlock and could only be accessed by the staff. Upon entering the room, a log was posted on the refrigeration indicating that the temperature of the refrigerator was 40°F.

Staff Member #2 stated, "The temperatures are taken by the night staff at midnight." Staff Member #2 was asked if that was at the end of their shift or the beginning of the shift. Staff Member #2 stated, "I am not sure."

The refrigerator had a digital thermometer on the outside of the refrigerator. The thermometer registered the temperature as 57.2°F and registered the maximum temperature was 59.2°F. Inside the refrigerator was milk, sodas and other forms of nutrition. The milk was warm to touch.

Staff Member #2 stated, "I will get someone up here to look at the refrigerator." At approximately 2:00 P.M. Staff Member #2 stated, "The refrigerator is broken and is being replaced."

On 11/13/17 at approximately 11:30 A.M. Patient #5 was interviewed. During the interview Patient #5 complained of asking for milk to drink on occasion during his stay. Patient #5 stated, "The milk is always warm but one of the staff will bring me ice to pour it over."

Based on observation and interviews, it was determined that the facility failed to ensure that dietary, transport and four (4) other staff (Staff members #2, #10, #11, #12) maintained infection control by performing hand hygiene, changing gloves, cleaning dirty surfaces and not using cell phone as a flash light when assessing patients.

The findings include:

1. During initial tour of the facility on November 13, 2017 between 10:30 A.M. and 12:30 P.M. the following was observed:

On Pod three (3) at 11:25 A.M. Staff Member # 10 was observed touching a patients feet with ungloved hands then touching the computer cart with dirty hands. Then Staff Member # 2 was observed touching the same dirty computer cart with ungloved hands and not performing hand hygiene. Staff Member # 10 then wiped off mouse and top of the computer cart with sani cloths. The front of the computer cart that Staff Member # 10 touched with dirty hands was not wiped with the sani cloths. Staff Member # 10 removed dirty gloves and did not perform hand hygiene.

At 11:55 A.M. Staff Member #11 was observed wiping beside table with sani cloths and then wiping the wet bedside table with paper towels to dry table.

At 12:00 P.M. Dietary staff was observed delivering food trays to patients in Pod three (3). The trays were placed on the bedside tables in each room without cleaning the tables. The tables had patient care supplies, pitchers, cups, tissues and other miscellaneous items on them. The items were pushed to the side in order to place the food trays on tables.
At 12:05 P.M. staff members were observed bringing the patient to room # 786. Room # 786 was designated as "contact precautions". There were three (3) staff members transporting the patient. One staff member had on gloves and was providing breathing assistance. The two (2) other staff member did not have on gloves. After the patient was placed in the room, the transport staff member put on one (1) glove and obtained several sani cloths from container. The staff member wiped one (1) side rail and the top of the mattress then removed the one glove and performed hand hygiene.

At 12:15 P.M. Staff Member # 12 was observed taking the computer cart and the vital sign machine into Room # 787 with label "contact precautions". Staff Member # 12 donned clean gloves and then applied the blood pressure cuff that was already in the patient's room. Staff Member # 12 touched the computer cart and the vital sign machine with same dirty gloves. Staff Member # 12 rolled the vital sign machine and computer cart out of the room and went directly to the sani cloths. Staff Member # 12 touched the container with the same dirty gloves and obtained several sani clothes. Staff Member # 12 wiped the computer care and vital sign machine with same dirty gloves.

2. The sani cloth germicidal disposable wipe container directions provided by Staff Member # 2 at 12:30 P.M. reads in part "to disinfect and deodorize: to disinfect nonfood contact surfaces only: unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet a full two (2) minutes. Let air dry."

The facility policy provided by Staff Member # 1 on November 15, 2017 at 1:00 P.M. titled "Handwashing/hand hygiene/fingernail hygiene - infection prevention and control" reads in part: "examples of important hand hygiene opportunities before entering any patient room, upon exit of any patient room, after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient, and after glove removal."

The facility policy provided by Staff Member # 1 on November 15, 2017 at 1:00 P.M. titled "Environmental Aspects - Infection Prevention and Control" reads in part: " floors, fixtures, furniture and equipment are cleaned frequently and thoroughly. Nursing carts used for clinical supplies, must be cleaned between each patient."

The facility isolation precautions provided by Staff Member # 1 on November 15, 2017 at 1:00 P.M. reads in part: "Immediately wash hands with soap and water after exiting the room. Do not touch anything along the way."

The findings were discussed with Staff Members # 1, #2 and #4 on November 14, 2017 at 12:00 P.M.






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3. On 11/13/17 Patient #5 was interviewed. Patient #5 stated, "I had complained of a sore throat while (Name of Doctor) was here. He/She took their cell phone out of their back pocket and turned on the flashlight and looked at my throat. He/She said he/she keeps loosing his/her flashlight. That seemed like a real problem to me because I don't know where his/her phone has been."

Staff Member #1 provided a copy of the policy titled Cell Phone/Handheld Electronic Device Policy with a revision date of May 2, 2017. The policy documents the following under Personal Use of a Cell Phone/Handheld Electronic Device: "Physicians will be allowed to use cell phones throughout the hospital."
The rest of the policy only addressed the use of cell phones or electronic devices for making or receiving calls or texting. There is no mention of the use of a cell phone or electronic device in the diagnosing or examining of a patient.

Staff Member #1 stated, "I don't think we have ever considered the use of a phone for examining a patient. We have otoscopes for looking at someone's throat. (Name of Physician) knows not to use his/her phone to examine a patient."


TIME Health Your Cell Phone Is 10 Times Dirtier Than a Toilet Seat. Here's What to Do About It

By Abigail Abrams
August 23, 2017

Most people don't give a second thought to using their cell phone everywhere, from their morning commute to the dinner table to the doctor's office. But research shows that cell phones are far dirtier than most people think, and the more germs they collect, the more germs you touch.

In fact, your own hand is the biggest culprit when it comes to putting filth on your phone. Americans check their phones about 47 times per day, according to a survey by Deloitte, which affords plenty of opportunities for microorganisms to move from your fingers to your phone.

"Because people are always carrying their cell phones even in situations where they would normally wash their hands before doing anything, cell phones do tend to get pretty gross," says Emily Martin, assistant professor of epidemiology at the University of Michigan School of Public Health. Research has varied on just how many germs are crawling on the average cell phone, but a recent study found more than 17,000 bacterial gene copies on the phones of high school students. Scientists at the University of Arizona have found that cell phones carry 10 times more bacteria than most toilet seats.

Human skin is naturally covered in microbes that don't usually have any negative health consequences, and that natural bacteria, plus the oils on your hands, get passed on to your phone every time you check a text or send an email. It follows that most of the organisms found on phones are not pathogens that will make you sick, Martin says. Staphylococcus might be present, for example, but it's not typically the kind that will give you a staph infection.

But some bacteria should concern you. "We're not walking through a sterile environment, so if you touch a surface there could be something on that," says Susan Whittier, director of clinical microbiology at New York-Presbyterian and Columbia University Medical Center. "There are lots of environmental contaminants."

Studies have found serious pathogens on cell phones, including Streptococcus, MRSA and even E.coli. Just having these microbes on your phone won't automatically make you sick, Whittier says, but you still don't want to let them enter your system Viruses can also spread on phones if one person is sick with strep throat or influenza and coughs on their cell phone before handing it off to a friend.

NCBI (The National Center for Biotechnology Information) GMS Hyg Infect Control. 2015; 10: Doc03.
Published online 2015 Feb 2. doi: 10.3205/dgkh000246
Microbial contamination of mobile phones in a health care setting in Alexandria, Egypt

Aim: This study aimed at investigating the microbial contamination of mobile phones in a hospital setting.

Methods: Swab samples were collected from 40 mobile phones of patients and health care workers at the Alexandria University Students ' Hospital. They were tested for their bacterial contamination at the microbiology laboratory of the High Institute of Public Health. Quantification of bacteria was performed using both surface spread and pour plate methods. Isolated bacterial agents were identified using standard microbiological methods. Methicillin-resistant Staphylococcus aureus was identified by disk diffusion method described by Bauer and Kirby. Isolated Gram-negative bacilli were tested for being extended spectrum beta lactamase producers using the double disk diffusion method according to the Clinical and Laboratory Standards Institute recommendations.

Results: All of the tested mobile phones (100%) were contaminated with either single or mixed bacterial agents. The most prevalent bacterial contaminants were methicillin-resistant S. aureus and coagulase-negative staphylococci representing 53% and 50%, respectively. The mean bacterial count was 357 CFU/ml, while the median was 13 CFU/ml using the pour plate method. The corresponding figures were 2,192 and 1,720 organisms/phone using the surface spread method.

Conclusions: Mobile phones usage in hospital settings poses a risk of transmission of a variety of bacterial agents including multidrug-resistant pathogens as methicillin-resistant S. aureus. The surface spread method is an easy and useful tool for detection and estimation of bacterial contamination of mobile phones.

Keywords: mobile phones, bacterial contamination, hand hygiene, MRSA, ESBL

The constant handling of mobile phones by users in hospitals (by patients, visitors and HCWs, etc.) makes it an open breeding place for transmission of microorganisms, as well as health care-associated infections (HAIs). This is especially so with those associated with the skin due to the moisture and optimum temperature of human body especially our palms [2]. These factors and the heat generated by mobile phones contribute to harboring bacteria on the device at alarming levels. When we consider a phone's daily contact with the face, mouth, ears, and hands, the dire health risks of using germ-infested mobile devices are obvious [3].

Unlike our hands, which are easily disinfected using alcohol-based hand rubs (ABHRs) that are made available readily across all hospitals and medical facilities, our mobile phones are cumbersome to clean. We even rarely make an effort to disinfect them. As a result, these devices have the potential for contamination with various bacterial agents [4].

Doctors and healthcare staff working in critical areas as intensive care units (ICUs) and operating units are highly exposed to deadly micro-organisms. These mobile phones used by HCWs often become carriers and may serve as vectors and spread microorganisms wherever they are taken along [5]. Colonized micro-organisms on the devices of HCWs may be transmitted to patients even if patients do not have direct contact with mobile phones [6]. These organisms if pathogenic can be detrimental to the health of the patients especially those in critical care units and if the organisms transferred happen to be drug-resistant; the situation becomes even more grave as it becomes difficult to treat because of the limited drug options available [7].

HAIs affect more than 25 percent of admitted patients in developing countries. In U.S. hospitals, they cause 1.7 million infections per year and are associated with approximately 100,000 deaths. It is estimated that one third of these infections could be prevented by adhering to standard infection control guidelines [8]. Multidrug-resistant (MDR) bacteria are commonly implicated in HAIs and can be challenging to eliminate [9].

Based on medical record review and interviews, it was determined that the facility failed to discuss the results of discharge planning with patient or the patient's representative for six (6) of six (6) Patients (Patients #1, #2, #3, #4, #5 and #6).

The findings include:

During medical record reviews on November 13 - 15, 2017, the following was revealed:

1. Patient # 2 was admitted on November 1, 2017 at 2:30 P.M. On November 2, 2017 at 12:20 P.M. an admission review was documented by Staff Member # 14. The discharge plan is for skilled nursing facility (SNF) with no estimated date. There is no documentation that the discharge plan was reviewed the patient or the patient's representative. There is a continued stay review documented on November 2, 2017 at 12:46 P.M., November 6, 2017 at 11:34 P.M., and November 10, 2017 at 2:40 P.M. by Staff Member # 8. The discharge plan for each of the reviews is for a SNF with no estimated date. There is no documentation that the discharge plan on either of these reviews was discussed with the patient or the patient's representative. Wound care notes were reviewed and there is no documentation of a discharge plan or discussion. There is no documentation from the social worker. A review of Patient # 2's history and physical revealed the patient "has had persistent confusion and fluctuating level of arousal since late August 2017".

2. Patient # 3 was admitted on September 27, 2017 at 3:45 P.M. On September 28, 2017 at 4:39 P.M. the care coordination initial interview was documented by Staff Member #8. The discharge plan is for home with home health versus SNF with no estimated date. The interview was with Patient # 3. There is a continued stay review documented on September 28, 2017 at 4:51 P.M., October 2, 2017 at 4:05 P.M., October 6, 2-17 at 3:07 P.M., October 16, 2017 at 2:13 P.M., October 16, 2017 at 2:13 P.M., October 19, 2017 at 2:52 P.M., October 23, 2017 at 11:59 A.M., October 26, 2017 at 3:40 P.M., October 30, 2017 at 4:27 P.M., November 2, 2017 at 2:44 P.M., and November 10, 2017 at 3:20 P.M. by Staff Member # 8. The discharge plan for September 28, 2017 and October 2, 2017 is for home with home health versus SNF with no estimated date. The discharge plan for the remaining reviews is home with home health with no estimated date. There is no documentation that the discharge plan on either of the reviews was discussed with the patient or the patient's representative. There is a clinical update documented by Staff Member # 8 on October 11, 2017 at 3:48 P.M. stating "clinical update faxed and called to insurance provider". A clinical update on October 25, 2017 at 3:38 P.M. by Staff Member # 8 states "clinical update per request to insurance review. Authorization extended (10/25 - 112/7 with update 11/8)." A clinic update on November 7, 2017 at 3:53 P.M. by Staff member # 8 states "clinical update per request faxed to insurance review. Await review". A clinical update on November 7, 2017 at 4:19 P.M. by Staff Member # 8 states "CB from insurance. Auth extended x 14 days. update requested 11/21". Wound care notes were reviewed and there is no documentation of a discharge plan or discussion. There is no documentation from the social worker.

An interview on November 14, 2017 at 9:20 A.M. with Patient # 3 revealed "Nobody has addressed discharge plans". Patient # 3 stated that he/she had not seen a discharge planner or social worker since admission. Patient # 3 stated: "I am surprised that insurance hasn't kicked me out yet."

3. Patient # 4 was admitted on September 22, 2017 at 2:45 P.M. On September 22, 2017 at 5:23 P.M. the care coordination initial interview was documented by Staff Member # 8. Documentation reads "Discharge plan and options for ongoing care discussed with this patient and/or designees. Spoke with daughter over the phone and confirmed demographics. Asked daughter on next visit to have me paged." There is no documentation of an actual discharge plan or estimated date. There is a continued stay review documented on September 28, 2017 at 3:50 P.M., October 2, 2017 at 2:08 P.M., October 5, 2017 at 4:23 P.M., October 9, 2017 at 4:38 P.M., October 16, 2017 at 1:25 P.M., October 19, 2017 at 3:09 P.M., October 23, 2017 at 12:05 P.M., October 26, 2017 at 3:49 P.M., October 30, 2017 at 4:39 P.M., November 2, 2017 2:55 P.M., November 6, 2017 at 11:50 A.M., November 10, 2017 at 3:33 P.M. and November 14, 2017 at 3:40 P.M. by Staff Member # 8. The discharge plan for all of the reviews is SNF with no estimated date. There is no documentation that the discharge plan on either of the reviews was discussed with the patient or the patient's representative. Wound care notes were reviewed and there is no documentation of a discharge plan or discussion. There is no documentation from the social worker. Patient # 4's history and physical revealed the patient "Patient admitted for seizure like activity. Electroencephalogram (EEG) showed generalized slowing and Magnetic Resonance Imaging (MRI) showed chronic left parietal lobe infarct with hemosiderin deposition which had extended. Global volume loss, ischemic white matter disease, chronic lacunar infarcts in the basal ganglia and the right ventral pons".

During an interview on November 14, 2017 at 1:15 P.M. with Staff Member # 8 revealed "I see most patients within twenty-four (24) hours, if it's the weekend it will be on Monday. I try to keep everyone informed. I do discharge planning as well as utilization review and the social worker does the discharge plan". An interview on November 14, 2017 at 1:50 P.M. with Staff Member # 7 revealed "I come in closer to discharge but I review the record daily. Staff Member #8, the Wound nurses and I are all in the same office and we discuss discharge plans all the time."

The facility policy provided by Staff Member # 1 on November 15, 2017 at 1:00 P.M. titled "Transition (Discharge) Planning/Continuing Care" read in part "An Care Management Brochure will be provided to the patient or the patient's representative. The brochure explains the different levels of care. The integrated care management team will keep the patient and/or their representatives, caregivers, family and the involved hospital staff informed of transition (discharge) planning progress."

The findings were discussed with Staff Members # 1, #2 and #4 on November 15, 2017 at 2:00 P.M.



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4. Patient #1 was admitted on 9/20/17. A Care Coordination Initial Interview was conducted on 9/21/17 and documented by Staff Member #8. The documentation states, "Interviewed: Patient. Discharge plan and options for ongoing care discussed with patient and/or designees." There was no documentation in the medical record of contact with the patient and or family until 10/4/17. A note written on 10/6/17 by Staff Member #7 stated, "SW (Social Worker) notified by SNF (Skilled Nursing Facility) that pt (Patient) was denied by (Name of Insurance Company) for coverage for SNF placement as (he/she) is ambulating over 440' (feet) making him/her over qualified for rehab. Pt's son/daughter notified of denial and understands that plans for pt. to be d/ced (discharged) to his/her home in (Name of City child resides in) with home health will need to be pursued as well as continued trach (tracheostomy) and G-tube (for feeding patient) training." Patient was discharged on 10/10/17.

5. Patient #5 was admitted on 10/31/17. The Care Coordination Initial Interview was conducted with Patient #'5's spouse on 11/1/17. A meeting with spouse and sibling was held on 11/8/17 to discuss POC (Plan of Care) after spouse made a complaint about the care and serviced provided to Staff Member #1. There were no other notes indicating the POC had been discussed with Patient #5 or the family except a note on the day of discharge, which was 11/13/17.

6. Patient #6 was admitted on 11/6/17 and remains in the hospital. Patient #6's medical record contained an Admission Review, which was documented by Staff Member #15 who is not a member of the Care Coordination team which is Staff Member #7 and #8. The Care Coordination Initial Interview was documented on 11/8/17. A note was documented on 11/10/17 regarding the spouse of Patient #6 requesting to speak with Staff Member #8. The note did not contain any information related to discharge planning. As of 11/15/17 there were no notes in the medical record related to plans for discharge.

Patient #6 and spouse were interviewed on 11/13/17 and 11/14/17. On 11/14/17 the spouse of Patient #6 stated, "I don't know if it's because of you but I have been invited to attended the care plan meeting tomorrow (11/16/17) and I am thankful. I will be able to ask questions and to find out what the plan is for my (husband/wife)."

Staff Member #8 was interviewed on 11/14/17 at approximately 1:15 P.M. and stated, "I do most of the utilization reviews and (Name of Staff Member #7) does the discharge planning. Most of the information in the Care Coordination Initial Interviews are from the patient and or family. The rest of the information in the Continued Stay Reviews are from medical record reviews unless there is a question for the patient and or family. I don't know when (Name of Staff Member #7) contacts the patient and or family but I think it is within the first 24 hours if we are here. We are not here on weekends and holidays."

Staff Member #7 was interviewed on 11/14/17 at approximately 2:00 P.M. and stated, "(Name of Staff Member #8) and I just started working together in August (2017). The previous nurse I worked with and I did more cross covering. Now (Name of Staff Member #8) does the utilization review and I do most of the discharge planning. I do record reviews most of the time. If they are needing discharge planning, I can kinda of tell when that's coming up, so that's not until it gets closer to discharge I will have contact with the patient and or family. I would have been surprised if (Name of Insurance Company) approved additional time in the hospital or a nursing home. (Name of Patient #1) was walking over 400 feet, was and was alert and oriented."