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Based on record review and interview, the Governing Body failed to ensure the hospital had a system in place to evaluate the quality of the hospital's Contract Services to assure that each contracted service was provided in a safe and effective manner. This failed practice was evidenced by no QAPI (Quality Assurance Performance Improvement) quality assurance indicators for contract services that were implemented and approved by the Governing Body for the hospital's Contract Services, to evaluate the contracted services for quality and performance. The hospital had a total of 30 Contract Services listed in their Contract Service Manual.

Findings:
A review of the hospital's Contract Service Manual, provided by S1ADM, as the most current, revealed a "Contract Evaluation" form that included a list of all the contracted hospital services. The "Contract Evaluation" form included the name of the contracted service along with the contracted service's score for 2014 (score rating scale of 1-5 with "1" being unacceptable and "5" being consistently exceeds standard). A further review of the hospital's "Contract Evaluation" form revealed no other documented evidence that identified quality assurance indicators/monitoring activities to evaluate the contracted services and/or how the contracted service's rating score was achieved/evaluated.

A review of the Governing Body meeting minutes, from 2014 to present, revealed no documented evidence that identified quality assurance indicators/monitoring activities that evaluated the contracted services for quality and performance and/or indicated how the hospital's Contract Service's rating scores were achieved and/or evaluated..

In an interview on 1/21/15 at 3:30 p.m. with S1ADM, she indicated that she was a member of the Governing Body. S1ADM was asked about the Governing Body's quality assurance indicators for the hospital's Contract Services, that were approved by the Governing Body. S1ADM indicated that the Governing Body used a "Contract Evaluation" form for the contracted hospital services. S1ADM indicated that she would discuss the Contract Services with the hospital staff and if no hospital staff member had any issues/concerns with that contracted service, then S1ADM would give the Contract Service a favorable rating and would recommend to the Governing Body that the Contract Service be continued. S1ADM indicated that there were no QAPI quality assurance indicators developed for the hospital's Contract Services. S1ADM further indicated that the Governing Body had no established system in place to evaluate the quality of the hospital's Contract Services to assure that each contracted service was provided in a safe and effective manner.

Based on record review and interview, the Governing Body failed to ensure the hospital's QAPI (Quality Assessment Performance Improvement) program reflected the hospital's organization and services by not having all the hospital's departments and services, including those services furnished under contract, included in the QAPI Plan. This failed practice was evidenced by no QAPI quality assurance indicators for contracted services that were implemented and approved by the Governing Body for the hospital's Contract Services. The hospital had a total of 30 Contract Services listed in their Contract Service Manual.

Findings:
A review of the hospital's QAPI documentation revealed no documented evidence that all the hospital's Contract Services had been included in the QAPI Plan.

In an interview on 1/21/15 at 3:30 p.m. with S1ADM she indicated that there were no QAPI quality assurance indicators developed for the hospital's Contract Services, that were established/approved by the Governing Body.

In an interview on 1/23/15 at 11:00 a.m. with S2DON/QA/IC, she indicated that she was the Quality Assurance officer for the hospital. S2DON/QA/IC was asked about the QAPI's quality assurance indicators for the hospital's Contract Services. S2DON/QA/IC indicated that there were no QAPI quality assurance indicators developed for all the hospital's Contract Services. S2DON/QA/IC further indicated that she was not aware that the hospital's Contract Services had to be incorporated into the hospital's QAPI plan.

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Based on record review and interview, the hospital failed to ensure the nursing staff developed and maintained a current nursing care plan, based on each patient's nursing care needs and not solely on those needs related to the admitting diagnosis. This failed practice was evidenced by the nursing staff failing to develop a comprehensive, individualized care plan for 3 (#1, #7, #24) of 4 (#1, #5, #7, #24) patients reviewed for care plans out of 30 sampled patients. The facility's census was 32 patients.

Findings:
Review of the hospital policy titled, "The Nursing Process-Care Planning", revised on 3/01/14 and provided by S3ADON as the most current, revealed in part: The nursing plan of care provides a collaborative/systematic method of individualized care that focuses on the patient's response to an actual or potential alteration in health based on patient assessment. This plan reflects all disciplines involved in providing care to the patient. It communicates pertinent patient problems/needs, delineates appropriate medical and nursing interventions to meet these needs, and documents the effectiveness of those interventions in the medical record.

Patient #1
Review of the medical record for Patient #1 revealed the patient was a 66 year old male admitted to the hospital on 1/16/15 with a diagnosis of Acute Bacterial Meningitis, Arthritis, Hypertension and Diabetes. Review of the physician's orders dated for 1/16/15 revealed the patient had orders for Lantus 25 units subcutaneous (SQ), Apidra to Sliding Scale (SS), and Capillary Blood Glucose after meals and bedtime (AC & HS).

Review of the Interdisciplinary Plan of Care dated 1/16/15 revealed no documented evidence of any care plan goals or interventions that addressed the patient's Diabetes.

Interview with S2DON/QA/IC on 1/20/15 at 4:45 p.m. verified that the patient's care plan did not reflect a plan of care for Patient #1's diabetes. S2DON/QA/IC indicated that the patient's care plan should include all the patient's diagnosed medical conditions.

Patient #7
Review of the medical record for Patient #7 revealed the patient was admitted to the hospital on 1/12/15 with diagnoses to include in part: transverse colon bleeding and ischemia, and colitis. The medical record further revealed that the patient received multiple units of blood while in the hospital.

Review of the patient's Interdisciplinary Plan of Care dated 1/12/15, and updated 1/15/15, revealed no documented evidence of any care plan goals or interventions that addressed the patient's colon bleeding or ischemic colon.

Interview with S3ADON on 1/21/15 at 11:30 a.m. verified that the patient's care plan did not reflect a plan of care for Patient #7's colon bleeding or ischemic colon. S3ADON indicated that the care plan should include all the patient's diagnosed medical conditions.

Patient #24
A review of the medical record for Patient #24 revealed the patient was an 80 year old female admitted to the hospital on 1/17/15 with diagnoses to include in part: metabolic encephalopathy with change of mental status, infected sacral decubitus ulcer, sepsis with leukocytosis, hypertension and uncontrolled hyperglycemia (diabetes).

A review of Patient #24's MAR (medication administration record) revealed the patient was being administered medications to include in part: Norvasc 10 mg daily, Lantus 15 units daily, Diovan 160 mg daily, and Glucophage 500 mg twice a day.

A review of Patient #24's care plan dated 1/17/15 with no revision date, revealed the patient was care planned for: impaired physical mobility, wound care, potential for infection, impaired skin integrity, and risk for injury. There was no documented evidence that the patient was care planned for hypertension or diabetes (uncontrolled hyperglycemia).

In an interview on 1/22/15 at 2:45 p.m. with S26RN, she indicated that she performed the initial nursing assessment on Patient #24 upon admit. S26RN was asked for the care plan with the goals and interventions for Patient #24's hypertension and diabetes (uncontrolled hyperglycemia). S26RN indicated that she did not develop a plan of care for Patient #24's hypertension or diabetes (uncontrolled hyperglycemia). S26RN further indicated that the patient's hypertension and diabetes (uncontrolled hyperglycemia) should have been care planned.

In an interview on 1/22/15 at 3:15 p.m. with S2DON/QA/IC and S3ADON, Patient #24's care plan was reviewed. S2DON/QA/IC and S3ADON indicated that a patient's care plan should be comprehensive and should include all the patient's diagnosed medical conditions





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Based on record review and interview, the hospital failed to ensure that drugs and biologicals were administered according to physician orders and hospital policy for 3 of 3 patient medical records (#21, #22, #26) reviewed involving the administration of a sedative (Propofol) in a total sample of 30.

Findings:
Review of the hospital policy "Analgesia and Sedation", policy number 9-2.15.1 (effective date 3/01/14) revealed the following:
- Sedatives will be administered and/or titrated per a physician's order.
- The Richmond Agitation Sedation Scale (RASS) is used to determine the level of sedation, anxiety or agitation in a patient.
- Patients should be assessed hourly for level of sedation and pain.

Patient #21:
Review of the medical record revealed that Patient #21 was admitted to the hospital on 11/12/14 with diagnoses of infected left lower extremity and acute renal failure. The medical record revealed the patient was placed on the ventilator on 11/27/14 with an order (telephone order) to titrate Propofol for sedation. There was no physician order for the starting dose of the Propofol or the rate of titration.

Review of the IV (Intravenous) Titration Flow Sheet revealed hourly documentation of the Propofol rate, with frequent titrations per nursing staff. Further review of the Flow Sheet revealed no documented evidence that the patient's level of sedation was assessed hourly, per policy. Review of the patient's nurses notes revealed no documented hourly assessments of the patient's sedation level. The patient remained on the titrated Propofol until 12/19/14.

On 1/22/15 at 10:15 a.m., an interview with S31RN revealed that the patient did not have a physician order indicating the dosage to begin the Propofol or the rate of titration. S31RN stated that he titrated the Propofol drip by the patient's vital signs. He further confirmed that there was no physician order to do this, but this was how he had always titrated Propofol drips. S31RN revealed that he did not perform hourly sedation assessments per the Richmond Agitation Sedation Scale (RASS). S31RN further revealed that he was unaware of the hospital's policy regarding sedation.

On 1/22/15 at 10:30 a.m., an interview with S2DON/QA/IC confirmed that the hospital policy for sedation was not being followed. She further confirmed that the patient did not have a physician order for the beginning dose of Propofol and that nursing staff was titrating the dosage without specific parameters per a physician order.


Patient #22
Review of the medical record for Patient #22 revealed an admit date of 10/17/14 with a diagnosis of acute respiratory failure. Review of a verbal order dated 10/20/14 revealed orders to begin a Propofol drip and titrate for comfort (start at 5mcg/kg/min {micrograms per kilogram per minute}). There were no physician orders for the parameters for titration.

Review of the patient's IV Titration Flow Sheet revealed documentation of the patient's hourly Propofol rate, with frequent titrations in dosage. There were no documented hourly assessments of the patient's sedation with the use of the RASS, per policy.

On 1/22/15 at 1:40 p.m., an interview with S2DON/QA/IC confirmed the nursing staff were titrating the patient's Propofol drip without physician's orders for parameters. S2DON/QA/IC further confirmed that hourly sedation assessments were not performed, per policy, while the patient was on the Propofol drip.


Patient #26
Review of the medical record for Patient #26 revealed an admit date of 11/03/14 with diagnoses of tracheostomy and ventilator dependency. Review of the verbal physician's orders dated 11/03/14 revealed an order to initiate Vent Bundle Orders.

Review of the Vent Bundle Orders, dated 11/03/14, revealed they addressed the following areas: arterial blood gas, sedation, stress ulcer prophylaxis, head of bed position, nutritional support, hyperglycemic control protocol and routine oral care. Further review of the orders revealed that only the head of bed position and routine oral care was circled as ordered. There were no physician orders for the administration of Propofol.

Review of the medical record revealed an IV Titration Flow Sheet, documenting that a Propofol drip was initiated on the patient on 11/06/14. There was no documented order for this medication. Further review revealed no sedation assessments were performed.

On 1/22/15 at 1:50 p.m., an interview with S2DON/QA/IC confirmed that the patient did not have a physician order for the Propofol drip.









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Based on record review and interview, the hospital failed to ensure medical record entries were authenticated, dated and timed, in written or electronic form, by the person responsible for providing or evaluating the service for 2 of 2 (#6, #7) medical records reviewed for authentication out of a total sample of 30 medical records.

Findings:
Review of the policy titled, "Document and Authentication", Document Number 5-2.3.0, revised 3/01/2014 revealed in part: D. Timed, Dated and Authentication Signatures. All orders, including verbal orders, must be timed, dated, and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and is authorized to write orders. All verbal orders will be authenticated within 10 days.
Patient #6
Review of Patient #6's medical record revealed the following incomplete entries:
Medication Reconciliation Form dated 12/29/2014.
Wound care orders dated 12/30/2014 not authenticated by the physician.
Medication order for Cipro 400 milligrams intravenous daily not authenticated by the physician.

Patient #7
Review of the medical record revealed the following incomplete entries:
1/12/15 wound care orders authenticated, but not dated or timed.
1/15/15 physician orders authenticated, but not dated or timed.
1/17/15 dialysis medication orders authenticated, but not dated or timed.
1/17/15 physician orders authenticated, but not dated or timed.
1/18/15 blood transfusion orders authenticated, but not dated or timed.
An interview with S3ADON on 1/21/15 at 11:30 a.m. confirmed that the patient's medical record entries were not dated or timed. Further interview with S3ADON confirmed that the hospital was having problems with the physicians authenticating, signing and dating all orders.

Based on record review and interview, the hospital failed to develop policies and procedures that addressed proper safety precautions against radiation hazards for the safety of staff and patients during radiological procedures performed in the hospital.

Findings:
Review of the contracts provided by S1ADM revealed the hospital had a contract with an outside hospital to provide Radiology services to the hospital.

Review of the hospital's Policy and Procedure manuals provided by S1ADM, as the hospital's current policies, revealed no documented evidence of any policies and procedures related to radiology services.

In an interview on 01/22/15 at 10:30 a.m., S1ADM confirmed the hospital had no policies and procedures that addressed proper safety of staff and patients during radiological procedures preformed in the hospital. S1ADM indicated policies and procedures have been implemented and will not be effective until 02/01/15.

Based on observations and interviews, the hospital failed to ensure the hospital's facilities, supplies, and equipment were maintained in a clean manner to ensure an acceptable level of safety and quality as evidenced by dusty and soiled equipment/supplies and clean supplies stored in dirty/unsanitary containers in the clean supply room.

Findings:
An observation 01/20/15 at 2:10 p.m. revealed the following:
a). Two (#1 & #2) crash-carts located in the hallway with visible dust noted on the top portion of the carts and on the screen of the AEDs (Automated External Defibrillators).
b). Dinamap (vital sign) machine located in the hallway was noted to have drippings/drip marks on the screen, visible dust in the storage compartments ( temperature probes) and base with purple colored drip marks and visible dust.
In an interview 01/20/15 at 2:10 p.m. S3ADON confirmed the above observations.

Observation of the hospital's Central Supply (clean storage) area on 01/20/15 at 3:00 p.m. revealed the following:
a). A locked medication cart with a large amount of white specks of matter and gray dust on the top portion of the cart.
b). Glucometer case was noted to have visible dust in all storage compartments, in which the glucometer machine, controls (2), strips, and alcohol wipe packets are stored.
c). Storage of patient care supplies in plastic blue and yellow storage bins, noted to contain visible dust, small brown pieces of wood fragments, hair, and white flecks of paper. The bins were noted to contain the following patient supplies:
Suction canisters, canister lids, suction catheter trays, tracheostomy care kits, stool cup and lids, 20 ga. (gauge) IV (intravenous) catheters, sterile IV caps, electronic thermometer probe covers, bodywash and shampoo, aloe vesta skin conditioner, sensi-care fabric reinforced surgical gowns, syringes: 30 cc (cubic centimeter)- l l (leur- lock), 20 cc- l l, 60 cc -l l, sterile 4 x 4 tray, ABD (abdominal dressing) gauze pads), kerlix (gauze rolls), luki- tubes (sputum collection), restraints (soft extremities), AED pads -adult & child, 24-hour oral care kits, ballard care system and ace wraps (all cotton elastic wraps).

In an interview on 01/20/15 at 3:30 p.m., S3ADON indicated the hospital had no one assigned responsibility for Central Supply. S2DON/QA/IC reported it was the responsibility of the entire nursing staff. S3ADON confirmed that the supplies storage bins were in need of cleaning, the supplies should not have been stored in the dirty containers, and nothing dirty should be stored with clean items.




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Based on policy review, observations and interviews, the infection control officer failed to implement a system for identifying and controlling infections. This deficient practice is evidenced by:
1) failing to ensure correct isolation precautions were put into place on patients as evidenced by implementing contact precautions for Patient #2 instead of droplet precautions, and not implementing facility's "extra precautions" that included only handwashing, not use of hand hygiene gel, for patients with possible C-difficile (C-diff) infections; and
2) failing to ensure staff (S21RN/Dialysis) performed hand hygiene and use of PPE (personal protection equipment) correctly during patient care; and
3) failing to ensure that housekeeping staff (S27Hker, S28Hker) followed infection control practices as evidenced by not wearing PPE (personal protective equipment), i.e. gloves, when handling trash from patient's rooms;

Findings:
Review of facility policy and procedure # 8-2.0.0, titled "Isolation Precautions", with an effective date of 3/01/14, provided by S3ADON as current, revealed in part the following:...Rationale For Precautions... Human sources of the infecting microorganisms in hospitals may be patients... and may include persons with acute disease, persons in the incubations period of a disease, persons who are colonized by an infectious agent but have no apparent disease or persons who are chronic carriers of an infectious agent. ... Droplet Transmission will be considered a separate route of transmission in this guideline. Droplets are generated from the source person primarily during coughing, sneezing, talking and during the performance of certain procedures such as suctioning ...
Note: The (name) Group hospitals recognize that there are multi-drug resistant organism and other increasingly problematic organisms that may be associated with hospital infections. For that reason, each facility will recognize enhanced contact precautions designated as "Maximum Contact Precautions"... they are to be used in addition to standard precautions.
Summary of Transmission-Based Precautions:...
Maximum Contact Precautions: Standard Precautions, and * gloves, *gown.
Further review revealed no documentation of instructions to use only handwashing (as opposed to alcohol based hand gel) for hand hygiene after contact or care of a person with C-difficile.

Review of hospital policy and procedure # 8-5.0.0, titled Hand Hygiene, and provided by S2DON/QA/IC (Director of Nursing/Quality Assurance/Infection Control) as current, revealed in part:...
NOTE: When providing care to patients with Clostridium difficile associated diarrhea, health care personnel will perform hand washing technique prior to and after direct patient care activities or interaction with any potentially contaminated environmental surfaces or items. Gloves will be worn during any patient care activities or interaction with any potentially contaminated environmental surfaces or items....

1) failing to ensure correct isolation precautions were put into place on patients as evidenced by implementing contact precautions for Patient #2 instead of droplet precautions, and not implementing facility's "extra precautions" that included only handwashing, not use of hand hygiene gel, for patients with possible C-difficile (C-diff) infections;

Patient #2
Review of the medical record for Patient #2 revealed she was admitted to the facility 1/19/15 with a diagnosis of Pseudomonas/Strep pneumonia, with MDRO (Multi-Drug Resistant Organism) Pseudomonas. The patient was awake and oriented, ambulatory with assistance, and used a ventilator at night related to Muscular Dystrophy. Review of Patient #2's orders revealed the following, in part:
1/19/15- Admission orders... Isolation Precautions indicated for:________(blank) Choose one- Contact (box with "X") ( Maximum Contact, Droplet, and Airborne boxes were not marked). The entire (two lined) Isolation Precautions order had a diagonal line drawn through it with two initials by the line. The admission orders were written/signed as telephone orders by S25RN.
1/20/15 at 8:53 a.m.: (1) Immodium 1 mg (milligram) PO (by mouth) TID (three times a day) PRN (as needed) diarrhea. (2) Collect stools (feces) x(times) 3 for C-Diff (Clostridium difficile bacteria).
1/20/15 at 10:30 a.m.: Stool x 1 for C-Diff.

Review of a nursing admission assessment dated 1/19/15 at 5:34 p.m. revealed documentation that included, under "Precautions Initiated" , "Contact" marked.
Nursing daily flowsheet for 1/20/15 revealed the patient had Diarrhea (no time noted). Review of Patient #2's graphic sheet dated 1/20/15 revealed 3 stools documented during the day shift.

In an interview on 1/20/15 at 4:00 p.m. with S12RN, she indicated that she was the charge nurse that day (1/20/15). S12RN was asked about Patient #2's isolation precautions. A review, with S12RN, was made of the front cover of Patient #2's medical record. The front cover of the patient's medical record revealed a sticker that indicated that Patient #2 was on "contact precautions". A review of the Infection Control log sheet for 1/20/15, provided by S12RN, indicated that Patient #2 was on "droplet precautions". S12RN was unable to explain the discrepancy on Patient #2's type of isolation precautions.

In an interview on 1/21/15 at 1:50 p.m. S27Hker reported she thought that Patient #2 was on droplet precaution isolation, but had been on only contact precautions the day before. S27Hker demonstrated different colored isolation stickers, of which C-diff was brown, she should find on the door of a patient in isolation. The housekeeper reported that she did not think Patient #2 was on the extra precautions required with C-diff. S27Hker reported that with the extra precautions with C-diff, handwashing was required instead of the option of waterless hand gel. S27Hker also reported that when a patient was on droplet precautions, different "kill times" or length of time a cleaner had to sit on a surface, in order to ensure it killed bacteria, viruses, or spores, as different. She reported that the cleaning agents used for someone on precautions for C-diff were different as well. S27Hker reported that she was not aware, and did not think Patient #2 was on isolation precautions for C-diff.
An observation made with S27Hker on 1/21/15 at 1:55 p.m. revealed only droplet and contact precaution isolation signage on the door of Patient #2. Further observation revealed no indication that special precautions or handwashing were in place.

In an interview on 1/21/15 at 2:00 p.m. S3ADON reported that Patient #2 was now on droplet precautions related to her diagnosis of Pneumonia with a MDRO. S3ADON further confirmed Patient #2 was on contact precautions on admission, but should have been on droplet precautions immediately on admission because of her sputum being positive for Pseudomonas aeruginosa (MDR-PSAR) . S3ADON reported that the patient's isolation precautions were changed from contact to droplet after being questioned by a surveyor. S3ADON reported that Patient #2 did not have extra precautions in place, although she was being tested for C-diff. S24RN, present at the interview, reported that you could not put a patient in isolation without a confirmed diagnosis. When asked how the facility would prevent the transmission of C-diff during the time between the symptoms/ordered stool culture and the time the results came back, S24RN offered no answer.

An interview on 1/21/15 at 2:10 p.m. was conducted with S12RN and S3ADON. S12RN reported the original admission orders had the isolation precaution orders lined out, but after a phone call from S25RN reporting that the patient needed to be on contact precautions because of her pneumonia and sputum culture results, S12RN changed the lined through orders and initialed it. S12RN and S3ADON both agreed that was not the correct procedure to write a new order, or clarify an order. Both staff agreed that as the order was written, one could not be sure what order was to be carried out.

In an interview on 1/21/15 at 2:15 p.m. S25RN reported that she was a nurse liaison for the hospital and had completed Patient #2's preadmission information and admission orders. S25RN, after reviewing Patient #2's chart, reported that the patient was not on isolation precautions before admission to this hospital, and the nurses at the previous hospital had called her to give her (S25RN) the results of the patient's sputum culture. S25RN reported she had verified the original orders with the physician, but when she received information from the sending hospital's nurses, she did not confirm and write a telephone order from the physician. S25RN verified that with newly received culture results for Patient #2 ,the patient should have been on droplet precautions.

Review of a list of patients with laboratory orders for stool cultures for C-diff the week of January 19- 21, 2015; ordered because of symptoms of diarrhea for the month of January, revealed two patients, Patient #2 and Patient #14.

Review of a list of patients on some type of isolation precautions for the month of January revealed Patient #2's name with Droplet precautions listed. Further review revealed Patient #14 listed on contact precautions for MRSA (Methicillin Resistant Staph Aureus) in his blood. Neither patient had a notation of a change or discontinuation of a specific type of precaution(s).

In an interview 1/22/15 at 2:10 p.m. S2DON/QA/IC verified that the hospital policy and procedure did not specify that patients with suspected infections should have isolation protocols implemented while waiting for laboratory confirmation. S2DON/QA/IC agreed that Patients #2 and #14 should have had extra precautions implemented while awaiting results of C-difficile cultures.

2) failing to ensure staff (S21RN/Dialysis) performed hand hygiene and use of PPE (personal protection equipment) correctly during patient care:
Patient #15
Observation on 1/21/2015 at 9:45 a.m. revealed Patient #15 receiving dialysis in his room per contracted services. During initiation of the access site, S21RN/Dialysis, with gloved hands, removed the needle from the patient and with the same gloved hands went to the water treatment cart and removed a large plastic box that contained extra supplies. S21RN/Dialysis, without removing gloves, opened the box and touched several items inside the box removing 2 x 2 gauze pads and returned the box to the bottom shelf of the cart. Never changing gloves, S21RN/Dialysis opened the gauze and applied it to the patient's access site. S21RN/Dialysis then stated that the access site was new and he was unable to access. S21RN/Dialysis reported another nurse would come to access the site. Observation at 9:50 a.m. revealed S22RN/Dialysis entered Patient #15's room, donned gloves, then removed a plastic box from the water treatment cart and removed access needles from the box. S21RN/Dialysis returned to the patient's room after access site was accessed and, with gloved hands, connected the patient to the hemodialysis machine. S21RN/Dialysis, without removing gloves from his hands, walked around the bed to the blood pressure (B/P) machine and applied the cuff to the patient's arm and used the thermometer to check the patient's temperature, touching the surface of the machine.
Interview on 1/21/2015 at 10:30 a.m. with S21RN/Dialysis confirmed that he did not perform proper hand hygiene during initiation of dialysis and he should not have touched a clean storage area with dirty gloves or the B/P machine.

3) failing to ensure that housekeeping staff (S27Hker, S28Hker) followed infection control practices as evidenced by not wearing PPE, i.e. gloves, when handling trash from patient's rooms:

Findings:
An observation on 1/21/15 at 2:00 p.m. was made of S27Hker and S28Hker handling patient trash without wearing gloves. S27Hker was observed in the "Dirty Linen" room placing plastic bags containing trash from patient rooms into the dirty trash bin without the use of gloves. An observation was also made on 1/21/15 at 2:00 p.m of S28Hker in the hallway transporting trash from patient rooms in a trash container without wearing gloves.

In an interview on 1/21/15 at 2:10 p.m. S27Hker and S28Hker indicated that they were responsible for removing patient trash from the patient rooms and then placing the patient trash bags in the "Dirty Linen" room in the appropriate bin. S27Hker and S28Hker were asked about the use of PPE, i.e. gloves, when handling patient trash. S27Hker and S28Hker indicated that they were instructed not to wear gloves in the hallways.

In an interview on 1/22/15 at 10:00 a.m. with S2DON/QA/IC, she indicated that she was the Infection Control officer. S2DON/QA/IC was made aware of the observations and interviews with S27Hker and S28Hker. S2DON/QA/IC indicated that staff were instructed not to wear "soiled" gloves in the hallways. S2DON/QA/IC indicated that the housekeepers misunderstood the hospital's policy on the "wearing of gloves".




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