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Based on observation, document review, and staff interviews conducted between January 5, 2018 and January 9, 2018, it was determined that the facility failed to ensure a safe environment was maintained.

Findings include:

1. The facility failed to implement policies and procedures for for the safe transfilling of liquid oxygen in accordance with the 2012 edition of the National Fire Protection Association's Life Safety Code. Cross refer to Tag A 0709.

Based on medical record review, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure patients were included in the revision of their plan of care.

Findings include:

1. Review of Medical Record #17 revealed the following:

a. Patient #17 was placed on contact precautions on 12/30/17.

b. Patient #17's plan of care was not revised to address contact precautions.

c. There was no evidence that contact precautions were discussed with the patient.

2. Review of Medical Record #18 revealed the following:

a. Patient #18 was placed on contact precautions on 1/02/18.

b. Patient #18's plan of care was not revised to address contact precautions.

c. There was no evidence that contact precautions were discussed with the patient.

3. The above findings were confirmed with Staff #9.

Based on document review and staff interview, it was determined that the facility failed to show evidence of measurable progress achieved on their Performance Improvement project, conducted by the Nutrition Services Department.

Findings include:

1. During interview, on 1/9/2018, Staff #20 was interviewed regarding Performance Improvement projects being conducted in the Nutrition Services Department. He/she provided an untitled spread sheet with a Quality Performance Indicator goal, of "Patients will receive their food at desired temperatures."

a. Staff #20 was unable to explain the outcome process of desired food temperatures or how the facility measured the desired food temperatures.

i. Staff #20 was unable to provide the expected food temperature ranges at the "point of meal tray delivery to the patient."

ii. Staff #20 stated that the facility does not check the food temperatures at the "point of meal tray delivery to the patient."

2. The above findings were confirmed by Staff #20.

Based on observation and staff interview conducted on January 5, 2018, it was determined that the facility failed to ensure that intravenous infusion solutions are properly labeled.

Findings include:

1. At approximately 11:00 AM, two (2) intravenous bags of 0.9% Sodium Chloride and two (2) vials of Vancomycin, 1gram were found, enclosed in a plastic bag, in the medication room of the West Wing.

a. One of the bags of intravenous solution had a pharmacy label affixed. The label indicted the contents of the bag was Vancomycin 1 gm in 500 ml 0.9% Sodium Chloride. The other bag of intravenous solution had a partially affixed label indicting the contents of the bag was Vancomycin 1gm in 500ml of 0.9% Sodium Chloride.

b. Upon interview, Staff #6 confirmed that neither bag contained Vancomycin. The nurse would be adding the Vancomycin prior to drug administration.

c. Staff #6 confirmed that the intravenous solutions were mislabeled.

Based on observation, staff interview and review of facility policies and procedures, it was determined that the facility failed to ensure all outdated drugs were not available for patient use.

Findings include:

Reference #1: Facility policy titled "Destruction of Drugs" states, "Purpose: To ensure all drugs in the facility are within date and that drugs will be disposed of in a safe and legal manner. Policy: All drugs that are outdated, deteriorated, or not useable for any reason will be removed from stock and destroyed or returned for credit."

Reference #2: New Jersey Administrative Code Title 13 Law and Public Safety Chapter 39 State Board of Pharmacy 13:39-9.23 Storage and Security states, "...C. Procedures shall be established to assure the immediate and efficient removal of all outdated and recalled drugs from patient care areas and from the active stock of the pharmacy. The pharmacist-in-charge shall develop written policies and procedures governing the removal from the facility of outdated or recalled drugs."

1. On January 3, 2018 at 10:20 AM, during a tour of the Central Supply Room, the following was observed:

a. There were multiple storage shelves with patient care supplies.

i. One of the shelves contained seven (7), one-liter Intravenous (IV) bags of 10% Dextrose.

ii. The expiration dates on the IV bags were November, 2017.

iii. The IV bags were available for use.

Based on observation, facility document review, and staff interview, it was determined that the dietary service failed to comply with the New Jersey State Sanitation Code: "Sanitation in Retail Food Establishments and Food and Beverage Vending Machines (Chapter 24)" of the NJ State Sanitary Code NJAC 8:24.

Findings include:

Reference #1: N.J.A.C. 8:24-6.5(a) states, "The physical facilities shall be maintained in good repair."

Reference #2: N.J.A.C. 8:24-6.5(b) states, "The physical facilities shall be cleaned as often as necessary to keep them clean."

Reference #3: N.J.A.C. 8:24-4.8(k) states, "A test kit or other device that accurately measures the concentration in mg/l of sanitizing solutions shall be provided." 8:24-4.8(i) states, "Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device."

Reference #4: N.J.A.C. 8:24-4.9 (i) states, "The temperature of the wash solution in spray type warewashers that use hot water to sanitize shall not be less than: ... For multi-tank, conveyor, multi-temperature machine, 150 degrees Fahrenheit. N.J.A.C. 8:24-4.9 (k) states, "In mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be more than 194 degrees Fahrenheit, or less than ... 180 degrees Fahrenheit."

1. During a tour of the facility on January 9, 2018, at approximately 10:40 AM, in the presence of Staff #10, the following observations were made:

a. The dry storage room had three (3) stained ceiling tiles. (Refer to reference #1 and #2)

b. Staff #23 was using QT-40 sanitizer strips, expired February 17, 2017, to measure the pot washing solution concentration.

i. During interview, Staff #20 stated he/she was not aware the pot washing sanitation solution testing strips expired. (Refer to reference #3)

c. The refrigerator next to the pot washing area, had three (3) boxes very close to the ceiling area. (Refer to reference #1)

d. The ware-washer temperature reached a maximum temperature of 132 degrees fahrenheit during the wash cycle. (Refer to reference #4)

e. The entrance door to the kitchen, from the cafeteria, was propped open with a fork during meal service, to facilitate food truck entry and exit from the kitchen.

i. During interview, Staff #20 stated the magnet behind the door was malfunctioning, thus the door was propped open with a fork during meal service. (Refer to reference #1)

2. The above findings were confirmed by Staff #20.

Based on observation, staff interview, and document review, it was determined that the facility failed to ensure transfilling of liquid oxygen is conducted in accordance with the National Fire Protections Association's Life Safety Code, 2012 edition and Health Care Facilities Code, 2012 edition.

Findings include:

Reference #1: 2012 edition of the National Fire Protection Association's Life Safety Code, "101:2.1 ... General. The Documents referred in this chapter, or portions of such documents, are referenced within this code, shall be considered part of the requirements of this code, and the following shall also apply: ... 2.2 NFPA Publications ... NFPA 99, Health Care Facilities Code, 2012 edition ..."

Reference #2: 2012 edition of the National Fire Protection Association's Life Safety Code, "101:19.3.2.4, Medical Gas. Medical gas storage and administration shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing."

Reference #3: National Fire Protection Association's Health Care Facilities Code, 2012 edition, "99:9.3.7.4 Transfilling area shall be provided with ventilation in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code."

Reference #4: National Fire Protection Association's Compressed Gases and Cryogenic Fluids Code, 2010 edition, "55:8.13.1.3 Cryogenic Fluids. Cryogenic fluids in stationary or portable containers stored indoors shall be stored in buildings, rooms, or areas constructed in accordance with the building code."

Reference #5: National Fire Protection Association's Compressed Gases and Cryogenic Fluids Code, 2010 edition, "55:8.13.1.4 Ventilation. Ventilation shall be in accordance with Section 6.15."

Reference #6: National Fire Protection Association's Compressed Gases and Cryogenic Fluids Code, 2010 edition, "55:6.15 Ventilation. Indoor storage and use areas and storage buildings for compressed gasses and cryogenic fluids shall be provided with mechanical exhaust ventilation or natural ventilation ..."

Reference #7: National Fire Protection Association's Compressed Gases and Cryogenic Fluids Code, 2010 edition, "55:6.15.1 Mechanical Ventilation. Where mechanical ventilation is provided, the system shall be operational during the time the building is occupied."

Reference #8: National Fire Protection Association's Compressed Gases and Cryogenic Fluids Code, 2010 edition, "55:6.15.3 Mechanical Ventilation Rate. Mechanical ventilation shall be at a rate of not less than 1 cubic foot per minute per square foot of floor area over the area of storage or use."

Reference #9: National Fire Protection Association's Compressed Gases and Cryogenic Fluids Code, 2010 edition, "55:6.15.5 Shutoff Controls. Where powered ventilation is provided, a manual shutoff switch shall be provided outside the room in a position adjacent to the principal access door to the room or in an approved location."

Reference #10: National Fire Protection Association's Compressed Gases and Cryogenic Fluids Code, 2010 edition, "55.6.15.6 Manual Shutoff Switch. The switch shall be the break-glass or equivalent type and shall be labeled as follows: WARNING: VENTILATION SYSTEM EMERGENCY SHUTOFF"

Reference #11: National Fire Protection Association's Compressed Gases and Cryogenic Fluids Code, 2010 edition, "55:6.15.8 Floor level Exhaust. The location of both the exhaust and the inlet air openings shall be designed to provide air movement across all portions of the floor or room to prevent the accumulation of vapors."

Reference #12: Companion Liquid Oxygen Systems, Owners Manual B-701417-00 Rev.D, Page ii. "Be sure to read and understand this instruction manual completely before attempting to operate your Companion Liquid Oxygen system. Do not permit anyone who has not read and understand these instructions to handle or operate this equipment. ... Page 15, Caution, Clean and dry the fill connectors on both the Stationary and Portable units to prevent freezing and possible equipment failure. ...2. Using a clean dry, lint-free cloth, dry the male fill connector and female connector."

1. On January 9, 2018 at 12:00 PM, in the presence of Staff #2, two (2) 46 liters capacity Companion Liquid Oxygen Stationary Units, used for transfilling of liquid oxygen, where located in the Medical Gas Storage Room located adjacent to the Patient Shower Room.

a. During interview, Staff #2 and Staff #11 confirmed the following:

i. Liquid oxygen units are used for transfilling liquid oxygen into smaller portable liquid oxygen units carried by patients.

ii. Nursing Staff and Technicians perform the transfilling operation daily.

iii. Annual competencies do not contain information from the Manufacturer's instruction for use or from the Compressed Gas Association, as required by NFPA 99.

iv. Staff #11 stated, "I received training years ago when I first was hired. I train new staff myself recalling from memory what I remember from my initial training."

2. On January 9, 2018 at 12:15 PM, in the presence of Staff #2 and Staff #11, the Medical Gas Storage Room lacked the following:

a. Powered ventilation. Refer to Reference #6, Reference #7, Reference #8, Reference #9, and Reference #10.

b. Manual shutoff switch labeled and located outside the room. Refer to Reference #6, Reference #7, Reference #8, Reference #9, and Reference #10.

c. Exhaust and the inlet air openings designed to provide air movement across all portions of the floor and room to prevent the accumulation of vapors. Refer to Reference #11.

3. During interview, Staff #11 confirmed the following:

a. He/She had not read and understood the Companion Liquid Oxygen Systems, Owners Manual.

b. He/She does not use a clean dry, lint-free cloth to dry the male fill connector and female connector prior to transfilling.

A. Based on observation and staff interview, it was determined that the facility failed to ensure equipment is maintained to an acceptable level of safety and quality.

Findings include:

1. During a tour of the Wheelchair Room, conducted on January 5, 2018, in the presence of Staff #12 and Staff #38, the following was revealed:

a. There were three (3) solid wood boards used for wheelchair seats. All three (3) boards were uncleanable raw wood, without a finish, and rough splintered edges.

i. Staff #38 confirmed that every patient admitted to the facility is assigned a wheelchair unless the are admitted to the facility with their own device. The solid wood board is placed on the wheelchair seat, and then a patient-specific cushion is placed atop the wood board.

b. There were five (5) padded lift boards with torn and frayed covers which exposed non-cleanable cushions and wood.

c. There were two (2) amputee boards with torn and frayed covers, that exposed non-cleanable cushions and wood.

2. The above findings were confirmed with Staff #12 and Staff #38.

B. Based on observation and staff interview, it was determined that the facility failed to ensure supplies were stored in such a manner to protect against damage or contamination.

Findings include:

1. The Wheelchair Room had four (4) boxes of unopened supplies stored directly on the floor.

i. Staff #38 confirmed the unopened supplies contained new patient wheelchair pads.

2. The above was confirmed with Staff #12 and Staff #38.

A. Based on observation and document review conducted on January 5, 2018, it was determined that the facility failed to ensure the development and implementation of policies and procedures for cleaning and disinfecting the glucometer, in accordance with manufacturer's instructions for use.

Findings include:

Reference #1: Facility policy titled Glucose Monitoring Bedside, Accu-chek states, "All personnel using the Accu-chek System II will clean and properly disinfect glucometer after each use...While carefully avoiding the meter/base connectors and the base unit circuitry, gently wipe exposed surfaces of the meter and the base unit...Allow meter to air dry."

Reference #2: The Accu-chec Informed System Operator's Manual, provided by the facility for review, has separate directions for cleaning and disinfecting the meter. First, the meter is cleaned with an appropriate wipe, then the meter is disinfected with an appropriate disinfectant wipe.

1. The facility policy, referenced above, is a one-step, not a two-step cleaning and disinfecting process. It is not in accordance with the manufacturer's recommendations.

2. During an observation on 1/5/18, at approximately 10:30 AM, Staff #34 wiped the glucometer with one disinfectant wipe. He/she did not clean with one wipe and then disinfect with another wipe, as indicated in the manufacturer's instructions for use.

3. This finding was confirmed by Staff #6.

B. Based on observation, it was determined that the facility failed to ensure implementation of policies and procedures addressing hand hygiene.

Findings include:

Reference: Facility policy titled, "Hand Hygiene/Hand Cream Use" states, "Procedure: I. Indications for handwashing...and hand antisepsis...B. ...2. ALWAYS Decontaminate hands before donning gloves. ......9. Decontaminate hands after removing gloves."

1. During an observation on 1/5/18, at approximately 10:30 AM, Staff #34 failed to perform hand hygiene upon removing his/her gloves, after performing a blood glucose fingerstick.

C. Based on observation and document review, it was determined that the facility failed to ensure the implementation of policies and procedures addressing the use of gloves.

Findings include:

Reference: Facility policy titled Glucose Monitoring Bedside, Accu-chek states, "...Infection Control: Standard Precautions must be used when using the Accu-chek Inform II System. Gloves must be worn at all times..."

1. During an observation on 1/5/18, at approximately 10:30 AM, Staff #34 failed to don gloves prior to cleaning the Accu-chek glucometer that he/she had used to test a patient's blood glucose.

2. This finding was confirmed by Staff #6.


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D. Based on observation, staff interview, review of facility policies and procedures, and nationally recognized guidelines and recommendations, it was determined that the facility failed to implement its infection control policies, procedures, and guidelines.

Findings include:

Reference #1: Guideline for Hand Hygiene in Health Care Settings: Recommendation of the Healthcare Infection Control Practices Advisory Committee[HICPAC] and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force, published in the CDC (Centers for Disease Control and Prevention) Morbidity and Mortality Weekly Report at MMWR 2002; 51 (No. RR-16) page 32 states,
"Recommendations: 1. Indications for Handwashing and Hand antisepsis... B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C-J Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items 1C-J. ...F. Decontaminate hands after contact with a patient's
intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient). G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled. ...J. Decontaminate hands after removing gloves.

Reference #2: Facility policy titled, "Hand Hygiene/Hand Cream Use" states, "Procedure: I. Indications for handwashing...and hand antisepsis...B. ...2. ALWAYS Decontaminate hands before donning gloves. ...6. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. ...9. Decontaminate hands after removing gloves."

1. On January 3, 2018 at 10:15 AM, Staff #7 confirmed that the facility's Infection Control program is based on Center for Disease Control (CDC), Occupational Safety and Health Administration (OSHA), Association for Professionals in Infection Control (APIC), Society for Healthcare Epidemiology of America (SHEA), and New Jersey Division of Health and Senior Services (NJDHSS) guidelines, regulations, and recommendations.

2. On January 3, 2018, in Room #E2, Staff #28 donned gloves, took the MRC-700 Bladder scanner probe, and scanned Patient #12's urinary bladder.

a. Staff #28 then wiped the gel from the head of the scanner probe with a tissue, placed the probe back in the probe holder, removed his/her gloves and exited the patient's room.

i. Staff #28 failed to perform hand hygiene after removing his/her gloves, prior to exiting the patient's room.

Reference #3: Facility policy Number D-3 titled, "Surgical Dressings" states, "...Responsibility: It is the responsibility of nursing personnel to adhere to policy and procedure...Procedure: Steps...4. Remove old dressing...5. Remove soiled gloves. 6.Wash hands. 11. Apply sterile gloves. 12. Refer to Lippincott: Cleansing Simple Wounds... 13. Cover with sterile dressing and secure with tape. 16. [sic] Remove gloves...17. Wash hands. ..."

1. On January 5, 2018, in patient room #N35, during an observation of wound care on Patient #31's right lower extremity ulcer, and left upper inner thigh wound, the following was revealed:

a. At 13:23 PM, Staff #44 donned clean gloves, removed the old dressing from the right lower extremity ulcer, removed his/her soiled gloves, and failed to perform hand hygiene prior to retrieving a new pair of gloves.

i. Staff #44 donned the clean gloves, performed wound care on the right lower extremity ulcer, applied a sterile dressing, removed his/her soiled gloves, and failed to perform hand hygiene prior to retrieving a new pair of gloves.

ii. Staff #44 donned the clean gloves, removed the old dressing from the left upper inner thigh wound, and failed to remove his/her soiled gloves prior to performing wound care on the inner thigh wound.

iii. Staff #44 failed to perform hand hygiene between changing the right lower leg dressing and the left upper thigh dressing, potentially contaminating the second wound.

iv. Staff #44 failed to follow facility policy and wear sterile gloves during wound care.

b. The above findings were confirmed by Staff #24.

Reference #4: Facility policy titled, "Disinfectants and Cleaning Agents" states, "Purpose: To define hospital approved cleaning and disinfecting agents. ...Procedure: ...3. Once approved by the Infection Control Committee, the list of cleaning and sanitizing agents will be available from EVS (Environmental Services)."

1. On January 3, 2018, facility staff were observed using PDI Sani-Cloth Bleach Germicidal Disposable Wipes and PDI Sani-Cloth AF3 Germicidal Disposable Wipes to clean and disinfect.

a. At 12:00 PM, the list of approved cleaning agents was requested.

i. The facility document titled, "EVS Cleaning/Sanitizing" was reviewed and neither the PDI Sani-Cloth Bleach Germicidal Disposable Wipes nor the PDI Sani-Cloth AF3 Germicidal Disposable Wipes were on the approved list of cleaning agents.

ii. The above finding was confirmed by Staff #3.

E. Based on observation, staff interview, and review of manufacturer's Instructions For Use (IFU), and CDC Guidelines, it was determined that the facility failed to ensure cleaning products were used according to manufacturer's instructions.

Findings include:

Reference #1: Manufacturer's IFU for Clorox Healthcare Bleach Germicidal Wipe 110 count bucket states, "...Dispenser Directions: Remove Lid and discard seal. Insert corner of center sheet through flap opening on lid. DO NOT push finger through opening. Replace lid and pull wipe at an angle. The next sheet pops up automatically. When finished, close flap to retain moisture."

Reference #2: CDC [Centers for Disease Control and Prevention] Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 page 85 states, "...C. Recommendations... 5. Cleaning and Disinfecting Environmental Surfaces in Healthcare Facilities...c. Follow manufacturers' instructions for proper use of disinfecting (or detergent) products --- such as recommended use-dilution, material compatibility, storage, shelf-life, and safe use and disposal."

1. On January 3, 2018 at 10:15 AM, Staff #7 confirmed that the facility's Infection Control program is based on Center for Disease Control (CDC), Occupational Safety and Health Administration (OSHA), Association for Professionals in Infection Control (APIC), Society for Healthcare Epidemiology of America (SHEA), and New Jersey Division of Health and Senior Services (NJDHSS) guidelines regulations and recommendations.

2. On January 3, 2018 at 11:00 AM, Staff #18 was observed cleaning and disinfecting Room #W22.

a. On a housekeeping cart outside of Room #W22, there was a large 110 count refill bag of Clorox Healthcare Bleach Germicidal Wipes inside of a Clorox Healthcare Bleach Germicidal Wipes bucket.

i. The large bag of Clorox Healthcare Bleach Germicidal Wipes was placed in a bucket that did not have a lid.

ii. Staff #18 donned gloves, removed several wipes from the large bag of Clorox Healthcare Bleach Germicidal Wipes, and proceeded to clean and disinfect Room #W22's bathroom, including the toilet and patient shower chair.

iii. Staff #18 was then observed reaching back into the large bag of Clorox wipes, with his/her soiled gloves on, to remove more wipes.

iv. Staff #18 confirmed the bucket has a dispensing lid, but it was not on because it is not user friendly.

v. Staff #18 failed to remove soiled gloves and donn clean gloves, prior to reaching back into the large bag of Clorox Wipes.

3. The facility failed to ensure staff follow manufacturer's IFU's and dispense wipes through the lid.

F. Based on observation, staff interview, and review of facility documentation and CDC Guidelines, it was determined that the facility failed to ensure Center for Disease Control and Prevention (CDC) and Hospital Infection Control Practices Advisory Committee (HICPAC) guidelines for Prevention of Catheter-Associated Urinary Tract Infections were implemented.

Findings include:

Reference: CDC Guideline For Prevention of Catheter-Associated Urinary Tract Infections 2009, states, "...III. Proper Techniques for Urinary Catheter Maintenance A. Following aseptic insertion of the urinary catheter, maintain a closed drainage system (Category IB) (Key Question 1B and 2B)... E. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based in clinical indications such as infection, obstruction, or when the closed system is compromised. ...Q2B.3. Closed vs. open drainage systems...Recent data also include the finding that disconnection of the drainage system is a risk factor for bacteriuria."

1. On January 3, 2018 at 10:15 AM, Staff #7 confirmed that the facility's Infection Control program is based on Center for Disease Control (CDC), Occupational Safety and Health Administration (OSHA), Association for Professionals in Infection Control (APIC), Society for Healthcare Epidemiology of America (SHEA), and New Jersey Division of Health and Senior Services (NJDHSS) guidelines regulations and recommendations.

2. On January 3, 2018 at 11:40 AM, Patient #4 was observed having a urinary drainage leg collection bag attached to his/her right leg.

a. During interview with Staff #7, the following was confirmed:

i. Patients' urinary catheter bags are converted during the day from a larger sized collection bag to a smaller leg bag.

ii. At night, the leg bag is converted back to a large bag.

iii. To change bags, the catheter tubing is disconnected from the bag, the bag is discarded, and a new bag is attached to the catheter tubing.

iv. The quality improvement project for this year is to eliminate changing urinary collection bags daily and to use a smaller sized leg bag to maintain a closed system.

b. On January 11, 2018 at 13:52 PM, Staff #3 confirmed there is no policy addressing the changing of urinary drainage bags daily.

G. Based on observation, staff interview, review of facility policies and procedures, and nationally recognized guidelines, it was determined that the facility failed to maintain a sanitary hospital environment to control infections.

Reference #1: Facility policy titled, "Infection Control Materials Management" states, "Procedure: ...E. Receiving and Reprocessing Contaminated Equipment...2. All reusable equipment (e.g. Suction Machines, Feeding Pumps, IV (Intravenous) Pumps, Heating Pumps & etc.) will be cleaned of gross contamination before leaving the nursing unit. ...These items will be bagged after cleaning and sent to the Materials Management Department. 3. All equipment will be received in Material Management and wiped down for the second time with a hospital approved disinfectant."

1. On January 3, 2018 at 10:20 AM, during a tour of the Central Supply Room, the following was observed:

a. A shelf that contained multiple suction machines, Sequential Compression Devices (SCD), K-pad machines, Wound Vac machines, and Intravenous (IV) poles with pumps attached.

i. The above patient equipment contained visible dust accumulation.

ii. Staff #7 confirmed, that after patient use, the equipment is cleaned and disinfected on the nursing unit, by Environmental, placed in a plastic bag, and taken to materials management for a second cleaning.

iii. Staff #17 confirmed the equipment on the shelf had already been cleaned and disinfected, and was ready for patient use.

iv. Staff #7 and Staff #17 confirmed the clean equipment on the shelf is not covered.

Reference #2: Facility policy titled, "Equipment Cleaning" states, "Purpose: To reduce the risk of infection associated with reusable medical equipment and devices. Procedure: Patient care equipment will be cleaned follows: ...Miscellaneous items (i.e.: [sic] stethoscopes, BP [Blood Pressure] cuffs, thermometer units, etc.)-Nursing shall wipe personal stethoscopes with alcohol pad between patients, and clean other low-level, non-critical medical devices with hospital-approved disinfectants (use soft damp cloth), hospital-approved cloths, or alcohol pads between patients."

Reference #3: Center for Disease Control and Prevention (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities 2008, states, "...C. Recommendations...3.Indications for Sterilization, High-Level Disinfection, and Low-Level Disinfection...c. Perform low-level disinfection for noncritical patient-care surfaces (e.g., bedrails, over-the-bed
table) and equipment (e.g., blood pressure cuff) that touch intact skin...4. Selection and Use of Low-Level Disinfectants for Noncritical Patient-Care Devices...c. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly). ..."

1. On January 3, 2018 at 10:15 AM, Staff #7 confirmed the facility's Infection Control program is based on Center for Disease Control (CDC), Occupational Safety and Health Administration (OSHA), Association for Professionals in Infection Control (APIC), Society for Healthcare Epidemiology of America (SHEA), and New Jersey Division of Health and Senior Services (NJDHSS) guidelines regulations and recommendations.

2. On January 5, 2018 at 13:35 PM, in Room #N35, Staff #45 was observed taking vital signs of a patient.

a. Staff #45 removed the Blood Pressure (BP) Cuff and Pulse Oximeter probe from the patient, and placed them both back on the mobile cart.

i. Staff #45 then pushed the mobile cart out of the room and into the hallway, making it available for use on another patient.

ii. Staff #45 failed to clean and disinfect the BP cuff and Pulse Oximeter Probe after patient use.

Reference #1: Facility policy titled, "Disinfectants and Cleaning Agents" states, "Purpose: To define hospital approved cleaning and disinfecting agents. ...Procedure: ...3. Once approved by the Infection Control Committee, the list of cleaning and sanitizing agents will be available from EVS (Environmental Services)."

1. On January 3, 2018 at 10:20 AM, in the Central Supply area, multiple containers of PDI Sani-Cloth Bleach Germicidal Disposable Wipes and PDI Sani-Cloth AF3 Germicidal Disposable Wipes were observed on a shelf.

a. Staff #7 confirmed the above wipes are used throughtout the facilty to clean and disinfect.

b. At 13:55 PM, in patient room #E2, Staff #28 was observed cleaning the MRC-700 ultrasound probe with a wipe.

i. Upon interview Staff #28 confirmed the wipe was a PDI Sani-Cloth AF3 Germicidal Disposable Wipe.

c. At 12:00 PM, the list of approved cleaning agents was requested.

i. The facility document titled, "EVS Cleaning/Sanitizing" was reviewed. Neither the PDI Sani-Cloth Bleach Germicidal Disposable Wipes, nor the PDI Sani-Cloth AF3 Germicidal Disposable Wipes, were on the approved list of cleaning agents.

ii. The above finding was confirmed by Staff #3.


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H. Based on observation, document review, and staff interview, it was determined that the facility failed to ensure infection control procedures were implemented according to facility policies.

Findings include:

Reference #1: Facility policy, Isolation (by order of Physician), states, "Procedure ... The Charge Nurse or Primary Nurse will visit each patient at the time that isolation is ordered to discuss and instruct the patient; the reason necessitating isolation, the role of the patient in isolation, review of handwashing techniques and information regarding the organisms requiring the isolation."

Reference #2: Facility policy, Contact Precautions, states, "Protective Equipment: 1. Gloves ... wear clean non-sterile gloves when entering the room ... 2. Gowns ... wear clean non-sterile gown when entering the room if you anticipate ANY contact with the patient or the environment / objects in the room."

Reference #3: Facility policy, Isolation Precautions, states, "Gowns: Wear a gown (clean non-sterile) to protect skin and prevent soiling of clothing ..."

1. At 11:16 AM on January 5, 2018, during a tour of the West unit, the following was revealed:

a. Patient #17 was on contact precautions.

b. A visitor in Patient #17's room, was wearing a paper gown.

i. The paper gown was hanging off his/her shoulders, exposing his/her street clothes.

2. A review of Medical Record #17 revealed the following:

a. Patient #17 was placed on contact precautions December 30, 2017.

b. There is no evidence that the patient received instruction, in the following areas, at the time isolation was ordered:

i. The reason the patient was placed on isolation.

ii. The patient's role while he/she is on isolation.

iii. Review of handwashing techniques.

iv. Information regarding the organisms requiring the isolation.

3. Review of Medical Record #18 revealed the following:

a. Patient #18 was placed on contact precautions on January 2, 2018.

b. There was no evidence that the patient received instruction, in the following areas, at the time isolation was ordered:

i. The reason the patient was placed on isolation.

ii. The patient's role while he/she is on isolation.

iii. Review of handwashing techniques.

iv. Information regarding the organisms requiring the isolation.

4. The above findings were confirmed with Staff #9.


39228

I. Based on observation, review of facility policy and procedure, review of manufacturers instruction for use and nationally recognized guidelines, it was determined that the facility failed to ensure infection control procedures were implemented according to facility policy and Center for Disease Control and Prevention (CDC) guidelines.

Findings include:

Reference #1: Guideline for Hand Hygiene in Health Care Settings: Recommendation of the Healthcare Infection Control Practices Advisory Committee[HICPAC] and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force, published in the CDC (Centers for Disease Control and Prevention) Morbidity and Mortality Weekly Report at MMWR 2002; 51 (No. RR-16) page 32 states, " Recommendations: 1. Indications for Handwashing and Hand antisepsis... B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C-J Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items 1C-J. ... J. Decontaminate hands after removing gloves.

Reference #2: Facility policy titled, "Hand Hygiene/Hand Cream Use" states, "Procedure: I. Indications for handwashing...and hand antisepsis...B. ...2. ALWAYS Decontaminate hands before donning gloves. ......9. Decontaminate hands after removing gloves."

Reference #3: Facility policy titled "Infection Prevention" states, "Procedure ... Miscellaneous items (i.e.: ..., BP cuffs, ..., etc.) - Nursing shall wipe ..., and clean other low-level, non critical medical devices with hospital - approved disinfectants, hospital- approved cloths, ... between patients."

Reference #4: Facility policy titled "Respiratory Care" states, "Policy ... 12. All disposable equipment put into patient use must be labeled with the patient's initials and date. ..."

Reference #5: PDI "Sani-Cloth Bleach Germicidal Disposable Wipe" Manufacturer's Instructions for Use (IFU) states, "... Treated surface must remain visibly wet for a full four (4) minutes. Use additional wipe(s) if needed to assure continuous four (4) minute wet contact time. Let air dry."

1. On January 5, 2018 at 11:10 AM, during observation of equipment cleaning and disinfection, in the Main Physical Therapy (PT) Gym, the following was revealed:

a. Staff #37 failed to perform hand hygiene prior to, and after donning and doffing gloves.

2. On January 3, 2018 at 11:00 AM, during a tour of the Cardiac Pulmonary room on the East Wing, the following was revealed:

a. A therapeutic punching bag, located in the corner of the room next to the sink, contained a layer of dust covering the top portion of the bag.

3. At 11:15 AM, during a tour of the West Wing unit, the following was observed:

a. In Room #11 a bag containing disposable nebulizer treatment equipment, was hanging on the wall next to the bed.

i. The equipment was not labeled with the patient's initials or date.

4. The above findings were confirmed by Staff #11.

5. On January 5, 2018 at 11:10 AM, in the Main Physical Therapy (PT) Gym, the following was revealed:

a. Staff #37 was observed and interviewed regarding the cleaning and disinfecting of an orange colored exercise band and two blood pressure cuffs, with a PDI Sani-Cloth Bleach, Germicidal Disposable Wipe.

i. Staff #37 stated,"wet time for cleaning blood pressure cuffs and exercise bands is five (5) seconds."

ii. The wet time was observed to be less than one (1) minute.

iii. Staff #37 was observed waving the orange colored exercise band and the two (2) blood pressure cuffs to quickly dry them for approximately 20 seconds and then proceeded to fold them over a hanging rack which is used for equipment storage.

Based on staff interview, it was determined that the facility failed to ensure that a list of home health agencies was available and presented to all patients requiring home health care upon discharge.

Findings include:

1. Upon interview on January 3, 2018, Staff #30 revealed the following:

a. When a patient requires home health care upon discharge, he/she verbally reviews four (4) agencies in which to chose.

b. A list is provided to the patient if requested.

2. The above finding was confirmed with Staff #3.

Based on review of facility documents and staff interview, it was determined that the facility failed to provide evidence that a Director of Respiratory Care Services was on staff.

Findings include:

Reference #1: The facility policy and procedure "Medical Direction of Respiratory Care Services" stated, ..."Procedure: 1. A physician from the active medical staff, who is qualified by special training and/or experience, shall be appointed as Medical Director of the Respiratory Care Department. ..."

Reference #2: The "Minutes of: Governing Board Meeting Q3 2017" on November 7, 2017 stated, ..."Staff #15 [name of staff member] has formally accepted this leadership role, and will begin her HealthSouth Toms River Medical Director position on 12/1/17. ..."

Reference #3: A "Draft" of the "Governing Board Meeting Agenda Q4, 2017- January 29, 2018-1:00 PM" stated, ..."Vote for Hospital Medical Director with Responsibilities for Medical and Clinical Hospital Services-Voting Governing Board Member ..."

Reference #4: The "HealthSouth Rehabilitation Hospital of Toms River Organizational Chart" stated, ..."Staff #15 [name of staff member] Hospital Medical Director, Staff #51 [name of staff member] Internal Medicine-Program Medical Director, Staff #12 [name of staff member] Director of Therapy Operations. ..."

Reference #5: The "Medical Direction Services Agreement" stated, ..."Section 1. Medical Direction Services to be provided by the Group. The Group agrees to provide the services of its physician-employee, Staff #15 [name of staff member] (the "Director") to provide medical direction and other administrative services at the Hospital,"...The term of this Agreement shall commence as of December 1, 2017 (the "Effective Date"), ..."

1. Staff #1 and Staff #2 stated that Staff #15 is the Director of Respiratory Care Services.

a. Reference #2, "Governing Board Body Meeting Minutes Q3," identifies Staff #15 in the role of Medical Director.

b. Reference #3, "Governing Body Board Meeting Agenda Q4," stated "Voting" for the Hospital Medical Director.

c. Reference #4, the facility "Organizational Chart," identifies Staff #15 as the Hospital Medical Director.

d. Staff #15 has a signed contract for the "Director" as per Reference #5.

e. When multiple staff members were questioned as to whom the Director of Respiratory was, staff were unable to correctly state and confirm.

f. There is no evidence of an active medical staff member in the role of Director of Respiratory Care Services as per Reference #1.