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Based on record review and interview, the hospital failed to meet the requirements for the Condition of Participation for Patient Rights by failing to ensure patients had the right to be free from restraints. This deficient practice is evidenced by the hospital's use of restraints as a fall prevention measure as evidenced by placing a patient (#3) in soft wrist restraints from 4/7/15 until 4/22/15 and a Vail bed (canopy like bed with zipped nylon netting to enclose patients) from 4/22/15 until 5/18/15. This was noted for 1 (#3) of 1 patient reviewed for restraints. While in restraints, the patient was documented as having fallen 5 times resulting in a laceration to his head on 4/22/15 that required staples. There was no indication that staffing was increased as a result of the patient's falls (see findings in tag A-0154).

Based on record review and interview, the hospital failed to meet the Condition of Participation for Nursing Services as evidenced by:

1) failing to ensure a registered nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by failing to ensure each patient was assessed at least every 24 hours by a RN as required by the Louisiana State Board of Nurse's Practice Act as evidenced by having patient care provided by LPNs (licensed practical nurses) without documented evidence of a RN assessment at a minimum of every 24 hours for 3 (#1, #R1, #R10) current patients and 1 (#3) discharged patient out of a total sample of 8 patients. (see findings tag A-0395);

2) failing to ensure patients had been assessed to determine if they met the criteria for delegation of nursing care by the RN (registered nurse) to the LPN (Licensed Practical Nurse) according to the LSBN's "Administrative Rules Defining RN Practice LAC46: XLVII §3703. Definition of Terms Applying to Nursing Practice". This deficient practice was evidenced by the RN assigning responsibility for 1 (#R9 ) unstable ventilated patient receiving a continuous infusion of Levophed (medication to increase blood pressure) to a LPN out of a total of 2 ventilated patients (see findings tag A-0397).

3) failing to ensure drugs and biologicals were administered as per hospital policies and acceptable standards of practice. This deficient practice is evidenced by S4RN taping an unlabeled syringe and needle containing narcotic waste to an unsupervised sharps container in Patient #2's room. S4RN then later administered the remaining narcotic to Patient #2 several hours later (see findings tag A-0405).

Based on observation, interview and record review, the hospital failed to meet the requirements for the Condition of Participation of Infection Control as evidenced by failing to implement and maintain an active hospital wide program for the prevention, control and investigation of infections and communicable diseases related to Clostridium difficile (C. difficile) putting all patients at risk.

An Immediate Jeopardy Situation was identified on 6/26/15 at 4:54 p.m. due to the hospital:

1) failing to track and trend hospital acquired infections since April 2015.

In an interview on 6/26/15 at 1:30 p.m. with the Infection Control officer, she stated Patient #4's Hospital Acquired Clostridium difficile had not been investigated to her knowledge.

In an interview on 6/26/15 at 2:45 p.m., S1CEO verified there had been a lapse in tracking and trending infections in the past several months.

There are currently 19 patients on census at the main campus. 14 of the patients are described on the Patient Indicator Sheet provided by the hospital as having complex wounds. There are currently 11 patients on census at the main campus with contact precautions.

2) failing to ensure staff adhered to contact precautions specific to Clostridium difficile patients.

An observation was made on 6/24/15 at 9:15 p.m. at the main campus of S6LPN providing patient care to Patient #5 who was admitted on 6/19/15 with Clostridium difficile. S6LPN was observed obtaining a capillary blood glucose reading with a glucometer. After the procedure, she failed to clean the glucometer and was observed placing the glucometer on a common use medication cart in the hall. While providing care to Patient #5, S6LPN was observed changing her gloves three times but not performing hand hygiene between changes. She also obtained saline filled syringes from her pocket with her gloved hand after having touched the patient. She also was observed touching the bedside pump without wearing gloves. Further observation revealed she failed to disinfect the blood pressure machine after use on Patient #5. S6LPN pushed the blood pressure machine into the hall and walked away from the room. Observation of a canister of disinfecting wipes in the patient's room revealed they were not effective against Clostridium difficile.

An observation on 6/26/15 at 12:30 p.m. revealed S8CNA was retrieving a food tray from Patient #5's bedside table with no gloves. She then set the tray down, washed her hands for approximately 5 seconds, picked up the tray with her bare hands, placed the tray on a cart with other patients' trays and then went to the next patient's room.

3) failing to ensure housekeeping staff disinfected rooms of Clostridium difficile patients using chemicals that were effective in killing spores.

An interview with the contracted housekeeping service representative on 6/26/15 at 9:30 a.m. revealed the product used to clean the patient's rooms at the hospital did not contain chemicals effective against Clostridium difficile spores. She said all patient rooms were cleaned the same way and Clostridium difficile rooms were not cleaned differently. She also said she used hand sanitizer after the Clostridium difficile rooms because the contact precaution sign on the door did not specify to wash hands.

4) failing to ensure the contact isolation signs posted on the 4 patients with Clostridium difficile at 2 campuses had the correct instructions to wash hands with soap and water after removing PPE (Personal Protective Equipment).

Observation of the Yellow Contact Precaution signs on the doors of the 4 patients with Clostridium difficile (2 at Main campus on 6/24/15 at 9:00 p.m. and 2 at Regional campus on 6/24/15 at 11:30 p.m.) revealed the signage did not advise to wash hands with anti-microbial soap. Further review revealed Green Contact Precaution signs were on other patient ' s rooms that advised to wash hands with anti-microbial soap and to wash hands upon leaving and after removing gloves.

Interviews with staff (S3RN and S7RN) on 6/24/15 at 9:15 p.m. revealed they were unaware of what the different colored contact precaution signs indicated. They said they did not know the signs were different.

5) failing to ensure a current patient admitted on 6/9/15 at the main campus did not acquire Clostridium difficile while receiving treatment as an inpatient at the main campus.

Review of the medical record for Patient #4 revealed she had been admitted to the hospital on 6/9/15 with no signs and symptoms of C. difficile on admit. Further review revealed she had a stool culture for C. difficile on 6/19/15 that resulted in a positive culture the same day. There are currently 2 patients (Patient #4 and Patient #5) at the main campus and 2 patients (Patient #R7 and Patient #R8) at the Regional campus with C. difficile. No data has been presented for hospital acquired infections in May 2015.


S1CEO and S12CorporateQuality presented a corrective action plan to lift the Immediate Jeopardy on 6/29/15 at 8:25 a.m. As a result of the corrective actions instituted by the hospital, as set forth below, the Immediate Jeopardy situation was removed on 6/29/15 at 3:30 p.m.:

Review of the corrective action plan to lift the Immediate Jeopardy situation revealed the following:

1. The Quality Director is tracking and trending all infections utilizing 100% surveillance on all patients on an on-going basis. The Quality Director will report monthly to the Quality Assurance Performance Improvement (QAPI) committee and a quarterly report will presented to the Medical Executive Committee (MEC) and Governing Board.

An Infection Control Data Form is now being utilized on all patients. An observation was made of the documentation at the time of presentation of the corrective action plan. An infection control data form was completed for all inpatients with positive cultures of any kind.

2. All suspected Hospital acquired infections will be investigated by the Quality Director, Chief Clinical Officer (CCO), and the Infection Control Physician. Findings and actions will be reported to the QAPI committee, MEC and governing board.

Review of the information presented revealed data had been entered for the one current Hospital Acquired infection. Further review revealed S1CEO and S2InfectionControl/Quality Director had investigated the hospital acquired C. difficile infection in an attempt to identify, track and trend the source of the infection. The findings and actions relative to the investigation of the hospital acquired infection will be presented at the QAPI meeting that is scheduled for July 7th, 2015.

3. The Quality Director will train multiple qualified staff to assure there is a continuous and real time tracking, trending and investigation of all infections. The CCO and the clinical director have been designated and will be trained no later than 7/3/15 to perform the backup duties related to infection control monitoring. A list of patients on isolation precautions will be maintained at the nurses' station for quick identification.

There is a clinical supervisor at each campus that is responsible for the infection control data collection. They will report their findings to S2InfectionControl Officer. The Clinical Director for the main campus is hired, the clinical director will begin at Park Place on July 15, 2015 and they are recruiting for Regional. The Clinical Director from the main campus will float to Regional until someone is hired. S2InfectionControl Officer will routinely go to the other campuses.

4. On 6/27/15, the Quality Director and CEO reviewed all patients for May and June for tracking and trending of Hospital Acquired Infections. Identified Hospital Acquired Infections will be put into the action cue for reporting and trending purposes.

Review of the data collected, tracked and trended as part of the corrective action plan from the three hospital campuses revealed the C. difficile patient (Patient#4) at the main campus was the only Hospital Acquired Infection during the months of May 2015 and June 2015.

2) Failing to ensure staff adhered to contact precautions specific to C. difficile.

1.The CCO will insure all staff with potential patient contact will be reeducated on the cleaning of equipment using cleaner designed to kill C. difficile. Reeducation was initiated on 6/26/15. The reeducation will continue for all staff with potential patient contact. All staff receiving reeducation are required to perform skills competencies prior to being allowed to work their next shift. The reeducation was conducted using Power Point presentations on C. difficile, orientation to the new isolation precaution signage, PPE used for all types of isolation precautions, kill time for disinfectants, Microkill bleach wipe for disinfection of all patients' equipment. Evaluation of staff knowledge post in-service was assessed with a post- test. The staff education was ongoing at the time the corrective action plan was presented for lifting of the IJ. S1CEO indicated the following technique would be utilized for staff education/disciplinary actions for failed compliance: Educate, Verbal warning for 1st failure to comply-re-educate, written warning for 2nd failure to comply-re-educate, final written warning for 3rd failure to comply-re-educate and termination if further non-compliance was witnessed. Staff education on proper hand hygiene performance and proper use of PPE (personal protective equipment) began with training on 6/26/15 and training was ongoing on 6/29/15. Administrative staff was observed auditing staff performance/adherence to isolation precautions on 6/29/15. Microkill with bleach is now being used to clean the glucometer after every use.

On 6/29/15 at 8:15 a.m., an observation was made of the housekeeper's cart. The cart was noted to have a bleach solution for mopping in one of the containers. Blue top Microkill Bleach wipes were noted on the cart. A covered container was noted on the cart for discarding used mop heads and towels. The bleach solution was confirmed, in interview with S21Housekeeping, to be a 1:10 dilution (1cup bleach to 9 cups of water).

On 6/29/15 at 8:20 a.m. an observation was made of the hospital's medication carts, equipment carts and inpatient rooms. Microkill bleach wipes were readily available to all staff for use in disinfection of equipment.

6/29/15 10:30 a.m., an observation was made of S21Housekeeping cleaning a patient's room on contact precautions. She was mopping the floor with a 1:10 bleach solution. She was observed using 3 single use Velcro mop heads to mop the floor, discarding the mop heads after each pass. She did not put the mop heads back into the mop water after passing them on the floor. She had donned a gown and gloves to clean the room/mop the floor. Hospital Administrative staff was noted to be conducting an observation of her performance and completing an audit.

On 6/29/15 at 11:07 a.m. a.m. observation was made of S11CNA performing a capillary blood glucose on Patient #4 (C. difficile pt. at the hospital's main campus). She cleaned the glucometer with Microkill bleach wipes and allowed it to air dry. She also assessed the patient ' s vital signs utilizing the blood pressure machine. She used a disposable blood pressure cuff and cleaned the blood pressure machine with Microkill bleach wipes after use. She allowed the machine to air dry.

On 6/29/15 at 1:15 p.m., an observation was made of 2 radiology technicians ( S19Radiology and S20Radiology) performing an x-ray on a patient (Patient #R5) on precautions for C. difficile at the Park Place hospital campus. They cleaned the x-ray plate with Microkill bleach wipes both prior to and after patient use.

6/29/15 at 8:30 a.m. an interview with S21Housekeeping, she indicated all patient rooms were to be cleaned with a 1:10 bleach solution. She also indicated a gown and gloves was to be worn when cleaning the room. She said hands should be washed before, during and between glove changes with soap and water.

In an interview on 6/29/15 at 9:58 a.m. with S10LPN, she indicated both the glucometer and the blood pressure machine should be cleaned after use and between uses with the bleach Microkill wipes. She said both the blood pressure machine and the glucometer should be allowed to air dry.

2. The staff with potential patient contact will be reeducated on the hospital hand hygiene policy.

Reeducation was initiated on 6/26/15 and will continue for all staff with potential patient contact. All staff with potential patient contact will receive the education and perform competencies prior to being allowed to work their next shift. Staff education was ongoing and was being conducted on 6/29/15. S1CEO indicated the following technique would be utilized for staff education/disciplinary actions for failed compliance: Educate, verbal warning for 1st failure to comply, written warning for 2nd failure to comply, final written warning for 3rd failure to comply and termination if further non-compliance was witnessed.

On 6/29/15 at 11:07 a.m. an observation was made of S11CNA performing a capillary blood glucose on Patient #4 (at the hospital ' s main campus). She washed her hands prior to, in-between and after each glove change and prior to exiting the patient's room.

On 6/29/15 at 1:15 p.m., an observation was made of 2 radiology technicians
(S19Radiology and S20Radiology) performing an x-ray on a patient (Patient #R5) on precautions for C. difficile at the Park Place hospital campus. They both performed hand hygiene (hand washing) prior to, in-between, and after glove changes. She also indicated hand washing should be performed prior to exit from the room, after PPE has been removed.

On 6/29/15 at 1:25 p.m. an observation was made of S15LPN hanging an antibiotic infusion on Patient #R6 (on contact isolation for C. difficile). She washed her hands prior to donning her gloves and washed her hands after glove removal. She confirmed, in interview, at the time of the observation, that hand washing with soap and water was required when caring for patients on C. difficile precautions. She indicated had washing should be performed before, in-between, and after glove changes.

In an interview on 6/29/15 at 9:58 a.m. with S10LPN, she indicated hand hygiene (hand washing with C. difficile patients) was performed prior to, in-between, and after glove use. She also indicated hand washing should also be performed prior to exit from the room, after PPE has been removed.

3. The staff with potential patient contact will be reeducated on the hospital's policy for isolation precautions. Reeducation was initiated on 6/26/15 and will continue for all staff with potential patient contact. All staff with potential patient contact will receive the education and perform competencies prior to being allowed to work their next shift.

Documentation of staff reeducation sign in sheets, initiated on 6/26/15, was reviewed. S9RN, S10LPN, S11CNA, S15LPN, S19Radiology, S20Radiology and S21Housekeeping were interviewed during random observations at the main campus and the Park Place campus. The above referenced staff were knowledgeable of the different types of isolation precautions and the need for hand washing/use of bleach to clean /disinfect the rooms/equipment of patients on contact isolation for C.difficile.

4. The staff with potential patient contact will be reeducated on the proper techniques of removing food trays for patient rooms that are on precautions. Reeducation was initiated on 6/26/15 and will continue for all staff with potential patient contact. All staff with potential patient contact will receive the education and perform competencies prior to being allowed to work their next shift.

On 6/29/15 at 8:20 a.m. an observation was made of removal of food trays from patient rooms. No trays were removed from rooms where patients were on precautions for C. difficile. S1CEO confirmed, in interview, at that time, that the trays and dinnerware/utensils were disposable and were discarded in the patient's rooms. He said they should never have been removed in the first place and the staff who had removed the trays had not followed hospital policy.

5. The Quality Director or designee will perform 10 weekly random reviews upon each shift for compliance. Failure of the staff to comply with the hospital policy and procedures will result in disciplinary action. Audits will be reported to Quality Committee, MEC and the Governing Board.

3) Failing to ensure housekeeping staff disinfected rooms of Clostridium difficile patients using chemicals that were effective in killing spores.

1. As of 6/26/15 the hospital has removed all housekeeping cleaning products that are not effective against Clostridium spores.
2. As of 6/26/15 housekeeping is using a product that is effective against Clostridium difficile to perform the daily cleaning of patient rooms and during the terminal cleaning of all patient rooms. All staff will be educated and perform competencies on the use cleaning products to kill C diff prior to being allowed to work their next shift.
3. Housekeepers will be reeducated on the identification of patients on isolation precautions. Reeducation was initiated on 6/26/15 and will continue for all housekeeping.
Review of the educational materials for the in-services revealed the Housekeeping staff was educated in a bi-lingual format (both English and Spanish) utilizing a Spanish translated videotaped in-service and Spanish translated handouts.

The handouts given to staff for education was reviewed and the sign in sheets were also reviewed. The in-services were ongoing and continued on 6/29/15.

Cleaning checklists for housekeeping staff observations were initiated on the weekend f 6/26/15. The charge nurse is responsible for completing the check offs daily. Administrative staff was observed assessing housekeeping staff and performing audits on 6/29/15.

4. Housekeepers will be reeducated on the utilization of proper hand washing techniques when cleaning the room of a patient with C. difficile. Reeducation was initiated on 6/26/15 and will continue for all housekeeping staff. All housekeeping staff will receive the education and perform competencies prior to being allowed to work their next shift.

5. The Quality Director or designee will perform 10 weekly random reviews upon each shift for compliance with isolation precautions, hand hygiene, and proper cleaning of equipment. Failure of the staff to comply with the hospital policy and procedures will result in disciplinary action. Audits will be reported to QAPI, MEC, and Governing Board.

Review of the re-education documentation revealed the reviews had been initiated on 6/26/15 and they were to remain ongoing.

On 6/29/15 during the morning, midday and afternoon hours hospital administrative staff were observed conducting and documenting housekeeping staff performance audits.

4) Failing to ensure the contact isolation signs posted on the 4 patients with C. difficile at 2 campuses had the correct instructions to wash hands with soap and water after removing PPE.

1.On 6/26/15 new isolation precaution signage including new contact precaution signage that advises to wash with antimicrobial soap was initiated within the hospital for patients with C. difficile.

On 6/29/15 at 8:40 a.m. an observation was made of all patient rooms. The signage for the different types of isolation precautions was noted on patient rooms. The signage was confirmed to be appropriate to the type of infection/isolation precautions order for each patient.

2. All staff with potential patient contact and housekeeping staff will be educated on the new isolation precaution signage. Reeducation was initiated on 6/26/15 and will continue for all staff with potential patient contact and housekeeping staff. All nursing and housekeeping staff will receive the education and perform competencies prior to being allowed to work the next shift.

Documentation of staff reeducation sign in sheets from 6/26/15 through 6/29/15 were reviewed. In-service content was also reviewed.

5) Failing to ensure a current patient admitted on 6/9/15 at the main campus did not acquire C. difficile while receiving treatment as an inpatient at the main campus.

1.On 6/28/15 the Quality Director, CCO and CEO reviewed and trended all infection related data for May 2015. Identified areas of concern will be entered into the Action Cue system and brought to the full QAPI committee for immediate action. Analysis of May and June data will be discussed in the next QAPI committee meeting.

S1CEO presented documentation of the analysis of the May and June data of all three campuses and the Hospital Acquired C. difficile infection at the main campus (Patient #4) was the only Hospital Acquired infection. He said they initiated an investigation to attempt to track, trend and identify the source of the infection. S1CEO indicated they could identify no correlation with cross infection from another patient source or from a specific room location. He indicated their findings were going to be presented at the next MEC meeting on July 7th, 2015.


The immediacy had been lifted though there was not enough evidence to determine sustainability of Compliance for the Condition of Infection Control to be cleared. Non-compliance remains at the Condition level.

Based on record review and interview, the hospital failed to ensure patients had the right to be free from restraints. This deficient practice is evidenced by the hospital's use of restraints as a fall prevention measure as evidenced by placing a patient (#3) in soft wrist restraints from 4/7/15 until 4/22/15 and a Vail bed (canopy like bed with zipped nylon netting to enclose patients) from 4/22/15 until 5/18/15. This was noted for 1 (#3) of 1 patient reviewed for restraints. While in restraints, the patient was documented as having fallen 5 times resulting in a laceration to his head on 4/22/15 that required staples. There was no indication that staffing was increased as a result of the patient's falls (see findings in tag A-0154).

Findings:

Review of the hospital policy titled Fall Prevention, Policy Number: II.I9.03, revealed in part:
Fall prevention program- A comprehensive program designed to prevent the falls of patients, which includes assessment, intervention, and education of patients, families and visitors.
Procedure: If at any time a staff member feels that a patient is at imminent risk for falling, they will immediately notify the charge nurse. Do not leave the patient unattended. The charge nurse and caregivers will develop and implement an immediate plan for safety. This will likely be restraints or 1:1 observation by staff.

Review of the Restraint Order Sheet used by the hospital revealed in part the following instructions at the top of the page: "All patients are assessed on admission and ongoing basis for their potential to fall. Patients considered at high risk for falls may necessitate the use of refrain devices."

Review of the medical record for Patient #3 revealed he was a 52 year old man admitted on 4/7/15 and discharged on 5/18/15. Review revealed he had not taken his medicine for two years. Further review revealed he had been diagnosed with Cryptococcal Meningitis and was newly blind due to the effects of the meningitis on his optic nerve.

Review of the nurse's notes for Patient #3 revealed an entry dated 4/7/15 at 6:45 p.m. (admitted at 3:30 p.m.): Pt (patient) trying to get out of bed without assistance. Increased agitation noted at time. Patient confused, also reoriented. Verbal order per S13MD. Bilateral wrist restraints for safety. Will continue to monitor.

Review of a physician's order dated 4/7/15 at 6:45 p.m. for Patient #3 revealed a verbal order for bilateral soft wrist restraints.

Review of a physician's order dated 4/22/15 at 10:10 a.m. for Patient #3 revealed an order to place Patient #3 in a vail bed. Further review revealed that once in the vail bed the staff could discontinue the bilateral wrist restraints.

Review of a list of hospital incident reports revealed Patient #3 had falls on 4/13/15 at 4:20 p.m., 4/20/15 at 2:55 p.m., 4/22/15 at 6:45 a.m., 4/22/15 at 2:05 p.m. and on 4/23/15 at 3:15 a.m.
Review of the hospital restraint log revealed Patient #3 was placed in soft wrist restraints from 4/7/15 through 4/22/15. Further review revealed he was then placed into a vail bed from 4/22/15 until 5/18/15.

Review of nurse's notes revealed the following entries:
4/13/15 at 4:30 p.m. - Pt (patient) OOB (out of bed) and sitting on floor. No complaints of pain or hitting head. Assisted up and back to bed.

4/20/15 at 2:55 p.m. - Pt was found sitting on floor beside his bed. No complaints of pain or discomfort. No injuries noted. Side rails up x 2.

4/22/15 at 6:45 a.m. - Pt (patient) found on floor. PICC (peripherally inserted central catheter) line to R (right) arm is out. Noted 1 ½ inch laceration to top of pts head- actively bleeding. Ileostomy appliance off with feces smeared across floor.
6:50 a.m. - Pt cleaned, assisted to bed. BP (blood pressure) 106/72, P (pulse) 103, R(respirations) 16, T (temperature) 98. Pt confused x 2. Pressure applied to laceration. Paged S14MD.
7:07 a.m. - S14MD called, orders received to transfer to Hospital " A " . Ambulance Company " B " notified for transport.
9:00 a.m. - Report called from Hospital " A " ER (emergency room). Pt CT (computerized tomography) of brain (-) and 2 staples placed to laceration of head.
1:50 p.m. - OOB again, but only fell on fall mat. No complaints of injury or pain, sister witnessed fall stating, " He crawled over rails and laid on mat. " Repositioned in bed and told to ask sister or to use call bell for any meds. Will continue to monitor.
3:00 p.m. - Vail bed brought and set up in room. Bed made and patient assisted to bed.

4/23/15 at 2:40 a.m. - Pt found on floor. Bed was zipped but pt figured out how to unzip from inside. No injury observed, VS (vital signs) within normal limits (see incident reports). MD (medical doctor) called. New Orders given. All safety measures maintained.

4/29/15 at 6:20 a.m. - Pt noted to be in Vail bed due to increased falls.

5/2/15 at 6:15 p.m. - Pt. in vail bed due to multiple falls.

Review of a physician ' s order dated 4/21/15 at 8:57 a.m. for Patient #3 revealed an order for an x-ray of his right knee. (Interview with S3RN on 6/26/15 at 12:49 p.m. revealed the x-ray was ordered after a fall)

In an interview on 6/26/15 at 11:01 a.m. with S1CEO, he verified there was no increased supervision for Patient #3 to prevent falls. He also verified the restraints used on Patient #3 were for fall prevention.

In an interview on 6/26/15 at 12:49 p.m. with S3RN, she said Patient #3 was in restraints as a fall prevention measure and there was no increased supervision. S3RN said he was placed in wrist restraints to keep him from crawling out of the bed. S3RN said they asked the previous DON if Patient #3 could have a 1:1 sitter and she said only if the physician ordered it. S3RN said the doctors would not give an order for a sitter. She said Patient #3 was in wrist restraints until he was placed into the Vail bed as a restraint. S3RN said the restraints did not prevent Patient #3's falls but nothing else was done to prevent them.

Based on record review and interview, the hospital failed to ensure the use of restraints were in accordance with a written modification to the patient's plan of care for 1 (#3) of 1 patient sampled with restraints.
Findings:
Review of the hospital policy titled Restraints, Policy Number: II.K.11.07, revealed in part:
Care Plan: The patient's care plan will be modified to reflect the need for restraint.

Review of the medical record for Patient #3 revealed he was a 52 year old man admitted on 4/7/15 and discharged on 5/18/15. Further review revealed he had been diagnosed with Cryptococcal Meningitis and was newly blind due to the effects of the meningitis on his optic nerve.

Review of a physician's order dated 4/7/15 at 6:45 p.m. for Patient #3 revealed a verbal order for bilateral soft wrist restraints.

Review of a physician's order dated 4/22/15 at 10:10 a.m. for Patient #3 revealed an order to place Patient #3 in a Vail bed. Further review revealed that once in the Vail bed the staff could discontinue the bilateral wrist restraints.

Review of the hospital restraint log revealed Patient #3 was placed in soft wrist restraints from 4/7/15 through 4/22/15. Further review revealed he was then placed into a Vail bed from 4/22/15 until 5/18/15.

Review of the Interdisciplinary Plan of Care for Patient #3 initiated 4/7/15 revealed no problem had been identified and care planned for restraints.

Based on record review and interview, the hospital failed to ensure a registered nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by:

1) failing to ensure each patient was assessed at least every 24 hours by a RN as required by the Louisiana State Board of Nurse's Practice Act as evidenced by having patient care provided by LPNs (licensed practical nurses) without documented evidence of a RN assessment at a minimum of every 24 hours for 3 (#1, #R1, #R10) current patients and 2 (#3, #5) discharged patient out of a total sample of 8 patients.

2) failing to report a change in condition to the physician as evidenced by no documentation in the medical record of rectal bleeding being reported to a physician for 1 (#R4) of 2 (#R4, #R9) patients reviewed for a change in status.

Findings:

1) Failure to ensure each patient was assessed at least every 24 hours by a RN as required by the Louisiana State Board of Nurse's Practice Act as evidenced by having patient care provided by LPNs (licensed practical nurses) without documented evidence of a RN assessment at a minimum of every 24 hours.

Review of the LSBN's Practice Act revealed that RNs may delegate select nursing interventions to the LPN provided the patient is assessed by a RN every 24 hours.

Patient #1
Review of the daily Nursing Assessment Sheets for Patient #1 revealed no RN assessments were documented during the 24 hour shifts from 6/22/15 through 6/23/15.

Patient #3
Review of the daily Nursing Assessment Sheets for Patient #3 revealed no RN assessments were documented during the 24 hour shifts from 5/6/15 through 5/12/15.

In an interview on 6/25/15 at 11:00 a.m. with S1CEO, he verified a RN had not documented that an assessment had been completed by a RN every24 hours from 5/6/15 through 5/12/15 on Patient #3.

Patient #5
Review of the daily Nursing Assessment Sheets for Patient #5 revealed no RN assessments were documented during the 24 hour shifts from 6/20/15 through 6/24/15.

Patient #R1
Review of the daily Nursing Assessment Sheets for Patient #R1 revealed no RN assessments were documented during the 24 hour shifts from 6/22/15 through 6/24/15.

Patient #R10
Review of the medical record for Patient #R10 revealed no documented assessment by a RN for 24 hours from 6/28/15 at 6:00 a.m. until 6/29/15 at 6:00 a.m.

In an interview on 6/25/15 at 11:00 a.m. with S1CEO, he verified a RN did not document that an assessment had been completed by a RN every 24 hours on the above referenced patients. He said the nurse's notes had previously had a place to sign that an assessment had been done by the RN, but it had accidently been removed. He verified a registered nurse should have been assessing and documenting their assessment of each patient on their nursing flow sheets.


2) Failing to report a change in condition to the physician.

Review of the medical record for Patient #R4 revealed a nurse's note dated 6/20/15 at 12:20 a.m.: Called to room by CNA (certified nursing assistant). Blisters noted on buttock and between legs. Dressing applied. Also blood noted running from buttocks. CNA changed pt. (patient) had another BM (bowel movement) with blood clots. No documentation could be located in the medical record that the physician had been notified.

In an interview on 6/29/15 at 12:35 p.m. with S22CCO, she said she could not locate documentation in Patient #R4' s medical record that the physician had been notified after blood was discovered with a bowel movement on 6/20/15. S22CCO verified the physician should have been notified.


30984

Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current individualized and comprehensive nursing care plans for each patient for 4 of 4 (#1, #3, #5, #R1) patients sampled for care planning.
Findings:
Review of the hospital policy titled Individual Plan of Care, Policy Number: I.C.3.38, effective date: 11/27/12, revealed the following:
I.Policy: To establish a comprehensive, goal oriented, individualized plan for each patient served. All patients will have an individualized plan of care that is individually tailored, integrated and coordinated.
Patient #1
Review of the medical records for Patient #1 revealed he was admitted on 6/17/15 with diagnoses which included multiple pressure ulcers Stages I, III, IV and unstageable , infected sacral/perineal ulcer (Klebsiella and Enterococcus),and complicated urinary tract infection with Klebsiella, Pseudomonas and Enterococcus. .
Review of Care Plans for Patient #1 revealed no problem identified for actual infections and contact isolation. Further review revealed the only wound care planned was the patient's sacral wound. Additional review of care plans for Patient #1 revealed they were documented on a pre-printed form with various choices for nursing diagnosis, interventions, goals and outcomes. The care plans were not specific, individualized, and contained no measurable goals.
Patient #3
Review of the medical record for Patient #3 revealed he was a 52 year old man admitted on 4/7/15 and discharged on 5/18/15.
Review of the hospital restraint log revealed Patient #3 was placed in soft wrist restraints from 4/7/15 through 4/22/15. Further review revealed he was then placed into a Vail bed from 4/22/15 until 5/18/15.
Review of the Interdisciplinary Plan of Care for Patient #3 initiated 4/7/15 revealed no problem had been identified and care planned for restraints.
Patient #5
Review of the medical records for Patient #5 revealed she was admitted on 6/19/15 with diagnoses which included actual infection-C. difficile , anxiety, depression and hypertension.
Review of Care Plans for Patient #5 revealed no problem identified for actual infection with C. difficile and C. difficile contact isolation precautions . Further review revealed anxiety, depression and hypertension were not addressed as problems on the patient ' s plan of care. Additional review of care plans for Patient #5 revealed they were documented on a pre-printed form with various choices for nursing diagnosis, interventions, goals and outcomes. The care plans were not specific, individualized, and contained no measurable goals.
Patient #R1
Review of the medical records for Patient #R1 revealed he was admitted on 6/12/15 with diagnoses which included gram negative rod sepsis urinary tract infection and COPD (Chronic Obstructive Pulmonary Disease). Further review revealed the patient had orders for placement on isolation precautions on 6/19/15. Review of Patient #R1's plan of care revealed contact isolation, actual infection and COPD were not addressed as problems in the patient 's plan of care.
In an interview 6/25/15 at 9:33 a.m. with S2InfectionControl , she agreed the above referenced patients ' care plans were not comprehensive, individualized and lacked measureable goals.

Based on interview and record review, the hospital failed to ensure patients had been assessed to determine if they met the criteria for delegation of nursing care by the RN (registered nurse) to the LPN (Licensed Practical Nurse) according to the LSBN's "Administrative Rules Defining RN Practice LAC46: XLVII §3703. Definition of Terms Applying to Nursing Practice". This was evidenced by the RN assigning responsibility for 1 (#R9 ) unstable ventilated patient receiving a continuous infusion of Levophed (medication to increase blood pressure) to a LPN out of a total of 2 ventilated patients. There were 17 total inpatients in the unit at that time.

Findings:

Review of the LSBN's "Administrative Rules Defining RN Practice LAC46: XLVII §3703. Definition of Terms Applying to Nursing Practice" revealed that the RN retains the accountability for the total nursing care of the individual and is responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she receives, regardless of whether the care is provided solely by the RN or by the RN in conjunction with other licensed or unlicensed assistive personnel. The RN shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. This assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. Any situation where tasks are delegated should meet the following criteria:
a) the person has been adequately trained for the task;
b) the person has demonstrated that the task has been learned;
c) the person can perform the task safely in the given nursing situation;
d) the patient's status is safe for the person to carry out the task;
e) appropriate supervision is available during the task implementation;
f) the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all.
Further review revealed the RN may delegate to LPNs the major part of the nursing care needed by individuals in stable nursing situations, i.e., when the following three conditions prevail at the same time in a given situation:
a) nursing care ordered and directed by the RN or physician requires abilities based on a
relatively fixed and limited body of scientific fact and can be performed by following a
defined nursing procedure with minimal alteration, and responses of the individual to the
nursing care are predictable; and
b) change in the patient's clinical conditions is predictable; and
c) medical and nursing orders are not subject to continuous change or complex
modification.

Review of the Declaratory Statement by the Louisiana State Board of Nursing on the Role and Scope of Practice of Registered Nurses Delegating IV (Intravenous ) Therapy Interventions, adopted 5/12/99, reaffirmed, revealed the following, in part:

-Based on the agency's written policy, the RN's assessment of the patient and availability of the RN to supervise the implementation of the delegated intervention and evaluate the patient's response to therapy, the RN may delegate certain IV therapy interventions to an LPN. An RN may delegate to an LPN the major part of the nursing care needed by individuals in stable nursing situations, when the three conditions (a, b & c referenced above) prevail at the same time, in a given situation.
-The following nursing intervention may not be delegated in any practice setting, in accordance with the Board's rules (LAC 46: XLVII.3703.c):
-Furthermore, the RN may not delegate the administration of medications requiring both titration and continuous patient assessment.
-Based on the RN's assessment and accordance with the Board's rules on managing and supervising the practice of nursing, when the RN determines that the patient's condition is unstable, since the RN is accountable for the total nursing care rendered, the RN may initiate changes in nursing care or assignment of the nursing personnel and documentation.
-Based on the RN's assessment and in accordance the Board believes that an RN may delegate an LPN selective IV therapy nursing interventions provided that RN supervision is readily available during implementation of the intervention, the patient's condition is determined non-complex and the LPN's level of competence is documented in said LPN's file.

Review of Patient #R9's medical record revealed he was admitted on 5/22/15. The patient had the following diagnoses: MRSA (methicillin resistant staphylococcus aureus), Aspiration Pneumonia and CHF (Congestive Heart Failure). Further review revealed the patient had required intervention from the rapid response team (code team) on 6/2/15 at 8:45 a.m. The patient's vital signs at the time of the rapid response activation were as follows: Blood Pressure: 215/110, Heartrate: 72, Oxygen Saturation: 72%. The patient received Propofol 50 mg (milligrams) IV (intravenous) push. He was intubated and placed on mechanical ventilation.

Review of Patient #R9's physician's orders revealed the following entries:
6/2/15 10:40 a.m. stat chest x-ray;
6/2/15 2:30 p.m. Titrate Levophed (increases blood pressure) to keep MAP (mean arterial pressure) greater than 60;
6/2/15 4:00 p.m. Continue to titrate Levophed drip to keep MAP greater than 60.

Review of Patient #R9's medical record revealed the following nurses' notes entry, in part:
6/2/15 9:10 a.m.: Oxygen saturation 82 % on ventimask. Bagging patient now and Propofol 50 mg IV push. Intubated per physician.
6/2/15 6:00 p.m.: assumed care of patient, assessment per checklist. ET (endotracheal) tube at 23 at lip. Levophed drip in progress, titrating to keep MAP greater than 60. The entry was signed by a LPN.
6/2/15 03:20 a.m.: Continue titrate Levophed, 3 micrograms at present. Entry was signed by a LPN.

Review of the frequent vital signs documentation sheet (used to monitor vital signs and/or titration of doses during Levophed administration) revealed two entries on 6/2/15 at 8:35 p.m. and 9:35 p.m. The entries were signed by the LPN assigned to care for the patient.

In an interview on 6/29/15 at 1:52 p.m. with S15LPN, she indicated that she had monitored patients receiving continuous infusions of medications.

In an interview on 6/29/15 at 2:23 p.m. with S17RN (charge nurse) she confirmed the above referenced patient was unstable. She agreed an unstable patient on a Levophed infusion should not be delegated to a LPN.

In an interview on 6/29/15 at 4:40 p.m. with S1CEO, he confirmed the LPN staff were not trained in administration of continuous medication infusions requiring titration. He also acknowledged LPNs monitoring medication infusions requiring titration was not within the scope of practice of LPNs.

Based on record review, interview and observation, the hospital failed to ensure drugs and biologicals were administered as per hospital policies and acceptable standards of practice. This deficient practice is evidenced by S4RN taping an unlabeled syringe and needle containing a narcotic waste to an unsupervised sharps container in Patient #2's room. S4RN then later administered the remaining narcotic to Patient #2 several hours later.

Findings:

Review of the hospital policy titled ADC: Removal, Return and Waste, Policy Number: N.14.12.05, revealed in part:
Controlled substances or medications that have been removed from their packaging or are otherwise compromised must be discarded. Controlled substance disposal requires a second authorized person to witness the destruction.

Review of the hospital policy titled Administration of Medication, Policy Number: II.K.11.31, revealed in part:
I. Policy: Medication Administration
D. All medications must be properly stored /secured at all times prior to administration. Prepared medications must never be left unattended.
F. Medication will be prepared or obtained, taken directly to a patient, and administered without any break in process.
G. All unused portions of controlled substances will be wasted in the appropriate receptacle and the waste witnessed by a second licensed staff person. Virtual witnessing is prohibited (signing waste was witnessed when the waste was not witnessed).

Review of the physician ' s orders for Patient #2 dated 6/18/15 revealed an order for Ativan 1mg IV every 4 hours PRN (as needed) for anxiety.

In an interview and observation on 6/24/15 at 11:15 p.m. with S4RN, she said she had drawn up 1 ml (2 milligrams) of Ativan for Patient #2 and had only given 0.5 ml (1 milligram). When asked where the remainder (waste) of the medication was kept, she walked into Patient #2 ' s room and came out with the remainder of the Ativan in an unlabeled syringe with a needle attached. S4RN said she had taped the syringe to the side of the sharps container in Patient #2 ' s room after the 9:40 p.m. administration. S4RN verified the Ativan had been unlabeled and unwitnessed while taped to the sharps container in Patient #2 ' s room for over an hour.

Review of Omnicell (medication dispensing machine) report for S4RN revealed that on 6/24/15 at 9:31 p.m. she had removed 2mg/1ml Ativan. 1 mg was administered and no waste was recorded.

Review of the MAR (Medication Administration Record) for Patient #2 revealed the following documentation:
1 mg of Ativan IV (intravenous) administered on 6/24/15 at 9:40 p.m.
1 mg Ativan IV administered on 6/25/15 at 3:45 a.m.

In an interview on 6/25/15 at 10:00 a.m. with S1CEO, he verified S4RN should have wasted the narcotics with another staff member and should not have taped a syringe with narcotics on a patient ' s sharps container.

In an interview on 6/26/15 at 8:16 a.m. with S4RN, she said on 6/24/15 she had diluted Ativan in 9 ml of normal saline to make a total of 10 ml. She had given 5ml to Patient #2 and then taped the 5 ml remaining in the syringe to the sharps container in the patient ' s room. She said later in the night (6/25/15) Patient #2 was becoming anxious. S4RN said the Ativan syringe had been in her pocket since 11:15 p.m. the previous night (6/24/15) after she had removed it from the sharps container, so she pulled it out of her pocket and gave the remainder of the dose to Patient #2 at 3:45 a.m. on 6/25/15. S4RN said she did not pull out a new Ativan from the Omnicell because she did not want to be responsible for another wasted dose of narcotics. She said she had left saline flushes for medications on the sharps containers in the past.

Based on record review and interview, the hospital failed to ensure medical records were accurately written as evidenced by documentation of a patient's fall not being in the medical record for 1 (#6) of 2 (#3, #6) patients reviewed for falls.

Findings:

Review of an incident report (not a part of the medical record) for Patient #6 revealed she had fallen on 6/20/15 at 5:15 p.m. while attempting to get out of bed.

Review of the medical record for Patient #6 revealed no documentation of the patient falling on 6/20/15.

In an interview on 6/29/15 at 12:35 p.m. with S22CCO, she said she was unable to find documentation in Patient #6's medical record that she had fallen on 6/20/15. S22CCO verified Patient #6's fall should have been documented in her medical record.

Based on record review, observation and interview, the hospital failed to ensure there were current and accurate records kept on the receipt and disposition of all scheduled drugs as evidenced by failing to have systems in place to track narcotic wastage and diversions.

Findings:

S4RN

Review of the hospital policy titled Pharmacist Review of Orders, number N.14.11.10, revealed in part:
Controlled substances or medications that have been removed from their packaging or are otherwise compromised must be discarded. Controlled substance disposal requires a second authorized person to witness the destruction.
Partially used or otherwise unusable controlled substances must be discarded in the presence of a witness.

In an interview on 6/24/15 at 11:15 p.m. with S4RN, she said when a narcotic was administered and some of the medication needed to be wasted, she had to hold the waste until the morning when another RN that was not in the recovering nurse program (RNP) was in the building to waste with her. S4RN said S5RN was working with her and she could not waste narcotics with her because she was in the RNP. When asked if she had given any narcotics that needed wasting tonight, she said she had drawn up 1 ml (2 milligrams) of Ativan for Patient #2 and had only given 0.5 ml (1 milligram). When asked where the remainder (waste) of the medication was kept, she walked into Patient #2's room and came out with the remainder of the Ativan in an unlabeled syringe with a needle attached. S4RN said she had taped the syringe to the side of the sharps container in the patient's room. S4RN said she had taped narcotic waste to the sharps containers in the patient's rooms in the past when she had to wait until the day shift arrived to waste the medications with her.

Review of the restrictions placed on S5RN by the Louisiana State Board of Nursing revealed she had a restriction to not carry controlled substance/narcotics keys or administer the same.

In an interview on 6/25/15 at 3:19 p.m. with S18Pharmacist, he said a weekly report was generated to S22CCO and the Pharmacist if the narcotic count was off in the machine (vials not amounts). He said they did not have a system in place to catch when narcotics were not wasted. S18Pharmacist agreed there seemed to be narcotic discrepancies that had gone unnoticed with S4RN. He said he would expect the wastage of narcotics to be documented immediately.

Review of an Omnicell (medication dispensing machine) report dated 4/25/15 through 6/24/15 generated by the contracted pharmacy of the hospital revealed 10 narcotic medications that had been removed from the Omnicell by S4RN that required part of the dose to be wasted but had not been: 4/30/15 at 8:30 p.m. - Hydromorphone 2mg/ml (milligrams/milliliter); 5/1/15 at 1:10 a.m. - Hydromorphone 2mg/ml; 5/1/15 at 5:00 a.m. - Hydromorphone 2mg/ml; 5/4/15 at 9:04 p.m. - Hydromorphone 2mg/ml; 5/5/15 at 7:18 p.m. - Hydromorphone 2mg/ml; 5/5/15 at 11:35 p.m. - Hydromorphone 2mg/ml; 5/10/15 at 3:06 a.m. - Hydromorphone 2mg/ml; 5/12/15 at 5:21 a.m. - Hydromorphone 2mg/ml; 6/19/15 at 8:26 p.m. - Ativan 2mg/1ml; 6/24/15 at 9:31 p.m. - Ativan 2mg/1ml.

S23LPN

Review of an investigation by the hospital of S23LPN (Licensed Practical Nurse) revealed he had been reported to the previous CCO by two nurses that had worked with him on the night of 3/19/15 and said he was acting abnormally. After reviewing his narcotic usage from the previous night, the CCO and S1CEO noted irregularities in his narcotic usage. S23LPN admitted to the diversion of narcotics and self-reported to the LPN board on 3/24/15.

No report was provided by the hospital on an investigation of the exact amount or extent of narcotic discrepancies by S23LPN.

In an interview on 6/29/15 at 5:10 p.m. with S18Pharmacist, he said there was a LPN diverting drugs at the Park Place campus that was reported by the staff. He verified the diversion was not discovered by the hospital pharmacy. He said there is a report that can be generated with dispensing habits but that report was not currently being generated. He said the only method currently being used to track narcotic discrepancies was looking at override reports weekly. He said when they found out about S23LPN diverting narcotics, they looked at his narcotic withdrawal for a short time frame. He said once S23LPN self-reported the diversions to the board of nursing the pharmacy did not do any more investigation or put anything into place to identify future similar discrepancies. He also said the discrepancies were not discussed in the hospital quality program.

In an interview on 6/29/15 at 4:45 p.m. with S1CEO, he verified the pharmacy had a system breakdown for tracking narcotic discrepancies.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist, before the first dose was dispensed, for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.

Findings:

Review of the Louisiana Administrative Code, Professional and Occupational Standards,
Title 46:LIII, Pharmacist, Chapter 15, Hospital Pharmacy, §1511. Revealed in part:
Prescription Drug Orders
A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial
dose of medication, except in cases of emergency.

Review of the hospital policy titled Pharmacist Review of Orders, Policy Number: N.14.11.10, revealed in part:
A pharmacist shall review the prescriber's original order before the initial dose is dispensed.
If the order is written when the pharmacy is closed or the pharmacist is otherwise available, it will be reviewed by a pharmacist as soon thereafter as possible, preferably within 24 hours, but not more than 72 hours following preparation.

Review of the pharmacy hours provided by S1CEO revealed the contracted pharmacy operated Monday thru Friday from 7:00 a.m. until 10:00 p.m. and on Saturday & Sunday from 8:00 a.m. until 2:00 p.m.

In an interview on 6/25/15 at 3:19 p.m. with S18Pharmacist, he said he was the pharmacist in charge. He said they were currently not reviewing the first dose of medications for appropriateness if the orders are written at night or when the pharmacy hours were shortened on the weekend or holidays. He said they did a retrospective review of the medications.

In an interview on 6/25/15 at 4:32 p.m. with S1CEO, he verified there was not a first dose review of medications ordered at night.

Based on observation, interview and record review, the hospital failed to implement and maintain an active hospital wide program for the prevention, control and investigation of infections and communicable diseases. This deficient practice was evidenced by:
1) failing to track and trend Hospital Acquired infections since April 2015;
2) failing to ensure staff adhered to contact precautions specific to Clostridium difficile patients for 1 (#5) of 2 (#4, #5) current patients with Clostridium difficile at the main campus.
3) failing to ensure housekeeping staff disinfected rooms of Clostridium difficile patients using chemicals that were effective in killing spores;
4) failing to ensure the contact isolation signs posted on the 4 patients (#4, #5, #R7, #R8) with Clostridium difficile at 2 campuses (Main and Regional) had the correct instructions to wash hands with soap and water after removing PPE (Personal Protective Equipment);
5) failing to ensure a current patient admitted on 6/9/15 at the main campus did not acquire Clostridium difficile while receiving treatment as an inpatient at the main campus for 1 (#4) of 2 (#4, #5) patients at the main campus with Clostridium difficile;
6) failing to ensure medications remained free of potential contamination as evidenced by nursing staff administering a medication in an unlabeled syringe that had been taped to a sharps container (receptacle for needles). The syringe had been unobserved by nursing staff for over an hour;
7) failing to ensure patients on contact precautions were gowned and/or protected in some way, when leaving their rooms, as they moved about the hospital and went outdoors to smoke.
8) failing to initiate contact isolation precautions on Patient #R1 when ordered as evidenced by contact precautions being ordered by the physician on 6/19/15 and not documented as having been initiated until 6/21/15.

Findings:

1) Failing to track and trend Hospital Acquired infections since April 2015.

Review of the infection control documentation presented by S2InfectionControl revealed no documented evidence of tracking and trending of infections since April 2015.

There are currently 19 patients on census at the main campus. 14 of the patients are described on the Patient Indicator Sheet provided by the hospital as having complex wounds. There are currently 11 patients on census at the main campus with contact precautions.

In an interview on 6/26/15 at 1:30 p.m. with the S2Infection Control, she stated Patient #4's Hospital Acquired Clostridium difficile had not been investigated to her knowledge.

In an interview on 6/26/15 at 2:45 p.m., S1CEO verified there had been a lapse in tracking and trending infections in the past several months.


2) Failing to ensure staff adhered to contact precautions specific to Clostridium difficile patients.

An observation was made on 6/24/15 at 9:15 p.m. at the main campus of S6LPN providing patient care to Patient #5 who was admitted on 6/19/15 with Clostridium difficile. S6LPN was observed obtaining a capillary blood glucose reading with a glucometer. After the procedure, she failed to clean the glucometer and was observed placing the glucometer on a common use medication cart in the hall. While providing care to Patient #5, S6LPN was observed changing her gloves three times but not performing hand hygiene between changes. She also obtained saline filled syringes from her pocket with her gloved hand after having touched the patient. She also was observed touching the bedside pump without wearing gloves. Further observation revealed she failed to disinfect the blood pressure machine after use on Patient #5. S6LPN pushed the blood pressure machine into the hall and walked away from the room. Observation of a canister of disinfecting wipes in the patient ' s room revealed they were not effective against Clostridium difficile.

An observation on 6/26/15 at 12:30 p.m. revealed S8CNA was retrieving a food tray from Patient #5's bedside table with no gloves. She then set the tray down, washed her hands for approximately 5 seconds, picked up the tray with her bare hands, placed the tray on a cart with other patients' trays and then went to the next patient's room.

In an interview on 6/25/15 at 3:15 p.m. with S2Infection Control she confirmed staff should be performing hand hygiene before, in between, and after glove changes. She also confirmed hadwashing should have been the type of hand hygiene performed when caring for a patient with C. Difficile. She agreed staff should not be carrying flush in their pockets nor should they touch anything in their pockets with their gloved hands after touching the patient on contact isolation. S2InfectionControl indicated she had observed S6LPN's failure to disinfect the blood pressure machine after she had used it to assess Patient #5's vital signs. S2InfectionControl also confirmed the glucometer should have been disinfected with a bleach based disinfectant after use on a C. difficile patient. S2infectionControl also confirmed S8CNA should have discarded Patient #5's food tray in the patient's room. She said the food tray and dinnerware used for Patient #5 was disposable and was not meant to leave the patient's room nor was it supposed to be placed on a rack with the other patients' trays.


3) Failing to ensure housekeeping staff disinfected rooms of Clostridium difficile patients using chemicals that were effective in killing spores.

An interview with the contracted housekeeping service representative on 6/26/15 at 9:30 a.m. revealed the product used to clean the patient 's rooms at the hospital did not contain chemicals effective against Clostridium difficile spores. She said all patient rooms were cleaned the same way and Clostridium difficile rooms were not cleaned differently. She also said she used hand sanitizer after the Clostridium difficile rooms because the contact precaution sign on the door did not specify to wash hands.

On 6/26/15 at 10:00 a.m. an observation was made of the label of the cleaning solution used to clean all hospital rooms (as indicated by S21Housekeeping). The solution was not bleach based and the label did not indicate it was effective against C. difficile spores. An interview was conducted at the time of the observation and S21Houskeeping confirmed the " all purpose" cleaner was the disinfectant used to clean all patient rooms, including patients on contact isolation for C. difficile. She also confirmed the "red top" pop up wipes were used to clean surfaces in all patient rooms, including patients on contact isolation for C. difficile . The "red top" pop up wipes were observed at that time and the label did not indicate that it was effective against C. difficile spores.


4) Failing to ensure the contact isolation signs posted on the 4 patients with Clostridium difficile at 2 campuses had the correct instructions to wash hands with soap and water after removing PPE (Personal Protective Equipment).

Observation of the Yellow Contact Precaution signs on the doors of the 4 patients with Clostridium difficile (2 at Main campus on 6/24/15 at 9:00 p.m. and 2 at Regional campus on 6/24/15 at 11:30 p.m.) revealed the signage did not advise to wash hands with anti-microbial soap. Further review revealed Green Contact Precaution signs were on other patient ' s rooms that advised to wash hands with anti-microbial soap and to wash hands upon leaving and after removing gloves.

Interviews with staff (S3RN and S7RN) on 6/24/15 at 9:15 p.m. revealed they were unaware what the different colored contact precaution signs indicated. They said they did not know the signs were different.

In an interview on 6/25/15 at 3:15 p.m. with S2InfectionControl she confirmed the signage that had been posted on the C. difficile patients' rooms on 6/24/15 at the main campus and at the Regional campus had been incorrect and had not indicated handwashing was the type of hand hygiene required for staff caring for patients on contact precautions for C. difficile. She also confirmed the signage had lacked direction to disinfect equipment with bleach based wipes.

In an interview on 6/26/15 at 2:07 p.m. with S3RN she indicated she had not received training regarding the different color signs indicating different types of isolation. She confirmed the signage posted on Patient #4 and Patient #5's rooms, on 6/24/15, had been yellow (standard contact isolation precautions) instead of green (C. difficile specific precautions). She said no one in infection control had educated staff regarding C.difficile. S3RN also indicated there had been no staff audits for handwashing or donning of PPE. She said they put information in the communication book. No audits regarding initiation of isolation precautions.

5) failing to ensure a current patient admitted on 6/9/15 at the main campus did not acquire Clostridium difficile while receiving treatment as an inpatient at the main campus.

Review of the patient census for the main campus revealed there were currently 2 patients (Patient #4 and Patient #5) with a diagnosis of C. difficile.

Review of the medical record for Patient #5 revealed she was admitted on 6/19/15 with a diagnosis of C. difficile.

Review of the medical record for Patient #4 revealed she had been admitted to the hospital on 6/9/15 with no signs and symptoms of C. difficile on admit. Further review revealed a stool culture for C. difficile collected on 6/19/15 was resulted as positive on the day of collection.

Review of infection control documentation presented as current by S2InfectionControl revealed no documented evidence of an investigation to track/trend the potential source of Patient #4's Hospital Acquired.

Review of the infection surveillance documentation presented by S2InfectionControl revealed no documented evidence of investigation of the source of Patient #4's Hospital Acquired C. difficile infection.

In an interview on 6/26/15 at 1:30 p.m. with the S2Infection Control, she stated the source of Patient #4's Hospital Acquired Clostridium difficile infection had not been investigated to her knowledge.



6) failing to ensure medications remained free of potential contamination as evidenced by nursing staff administering a medication in an unlabeled syringe, that had been taped to a sharps container (receptacle for needles). The syringe had been unobserved by nursing staff for over an hour.

Review of the physician ' s orders for Patient #2 dated 6/18/15 revealed an order for Ativan 1mg IV every 4 hours PRN (as needed) for anxiety.

In an interview and observation on 6/24/15 at 11:15 p.m. with S4RN, she said she had drawn up 1 ml (2 milligrams) of Ativan for Patient #2 and had only given 0.5 ml (1 milligram). When asked where the remainder (waste) of the medication was kept, she walked into Patient #2 ' s room and came out with the remainder of the Ativan in an unlabeled syringe with a needle attached. S4RN said she had taped the syringe to the side of the sharps container in Patient #2's room after the 9:40 p.m. administration. S4RN verified the Ativan had been unlabeled and unwitnessed while taped to the sharps container in Patient #2's room for over an hour.

Review of Omnicell (medication dispensing machine) report for S4RN revealed that on 6/24/15 at 9:31 p.m. she had removed 2mg/1ml Ativan. 1 mg was administered and no waste was recorded.

Review of the MAR (medication Administration Record) for Patient #2 revealed the following documentation:
1 mg of Ativan IV (intravenous) administered on 6/24/15 at 9:40 p.m.
1 mg Ativan IV administered on 6/25/15 at 3:45 a.m.

In an interview on 6/25/15 at 10:00 a.m. with S1CEO, he verified S4RN should have wasted the narcotics with another staff member and should not have taped a syringe with narcotics on a patient's sharps container. He agreed administering the narcotics that had been taped to the sharps container was a breach of infection control practice.

In an interview on 6/26/15 at 8:16 a.m. with S4RN, she said on 6/24/15 she had diluted Ativan in 9 ml of normal saline to make a total of 10 ml. She had given 5ml to Patient #2 and then taped the 5 ml remaining in the syringe to the sharps container in the patient ' s room. She said later in the night (6/25/15) Patient #2 was becoming anxious. S4RN said the Ativan syringe had been in her pocket since 11:15 p.m. the previous night (6/24/15) after she had removed it from the sharps container, so she pulled it out of her pocket and gave the remainder of the dose to Patient #2 at 3:45 a.m. on 6/25/15. S4RN said she did not pull out a new Ativan from the Omnicell because she did not want to be responsible for another wasted dose of narcotics. She said she had left saline flushes for medications on the sharps containers in the past.


7) Failing to ensure patients on contact precautions were gowned and/or protected in some way, when leaving their rooms, as they moved about the hospital and went outdoors to smoke.

Patient #R1
An observation was made on 6/25/15 at 8:30 a.m. of the Contact precaution signage on Patient #R1's room and it read as follows: Gown if patient or environmental contact is expected.

On 6/25/15 at 8:35 a.m. an observation was made of Patient #R1 (on contact isolation, for Methicillin Sensitive Staphylococcus Aureus of a sacral/trochanter wound) smoking on the patio. The patient was noted to have a catheter, hanging uncovered, with dependent loops. He also had a wound vac. The patient was not gowned or gloved.

On 6/25/15 at 12:36 p.m. another observation was made of Patient #R1 smoking on the patio. The patient's catheter was hanging uncovered, with dependent loops. He was not gowned or gloved.


Patient #R2

On 6/25/15 at 8:30 a.m. an observation was made of the signage on Patient #R2 ' s door. The signage read as follows: Gown: if patient or environmental contact is expected.


On 6/25/15 at 8:35 a.m. an observation was made of Patient #R2. He was outside on the patio. Patient #R2 was on contact precautions for Methicillin Resistant Staphylococcus Aureus -Blood. The patient was not gowned.

On 6/25/15 at 10:00 a.m. an observation was made of Patient #R2. He was outside on the patio. Patient #R2 was on contact precautions for Methicillin Resistant Staphylococcus Aureus -Blood. The patient was not gowned.

On 6/25/15 at 11:00 a.m. an observation was made of Patient #R2. He was outside on the patio. Patient #R2 was on contact precautions for Methicillin Resistant Staphylococcus Aureus -Blood. The patient was not gowned.

Patient #R3
On 6/25/15 at 9:30 a.m. an observation was made of signage on Patient #R3 's door. The signage revealed the following: Gown: if patient or environmental contact is expected.

On 6/25/15at 9:40 a.m. an observation was made of Patient #R3. He was outside on the patio. The patient was on contact precautions for MRSA of the left leg. Patient was not gowned.

On 6/25/15 at 1:22 p.m an observation was made of Patient #R3. He was outside on the patio. The patient remained on contact precautions for MRSA of the left leg. Patient was not gowned.

On 6/25/15 at 4:40 p.m. an observation was made of Patient #R3, going out into front lobby, out of front door to get a news magazine. The patient remained on contact precautions for MRSA of the left leg. Patient was not gowned.

In an interview on 6/26/15 at 9:40 a.m. with S2InfectionControl she confirmed the above referenced patients were on contact precautions. She also agreed if gowning was required to enter the room of a patient on contact precautions, then the reverse was true as well. She also agreed the patient's catheter bag should have been covered in some way.

8) Failing to initiate contact isolation precautions on Patient #R1 when ordered as evidenced by contact precautions being ordered by the physician on 6/19/15 and not documented as having been initiated until 6/21/15.


Patient #R1
Review of Patient #R1's medical record revealed he was admitted on 6/12/15 with an admission diagnosis of gram negative rod urinary tract infection. Further review revealed the patient had wound cultures that were positive for pseudomonas and proteus mirabalis. Additional review revealed an order for contact isolation dated 6/19/15.

Review of Patient #R1's nurses notes revealed no documented evidence of initiation of contact isolation precautions until 6/21/15.

In an interview on 6/25/15 at 10:40 a.m. with S2InfectionControl she confirmed, after review of Patient #R1's medical record, that contact isolation had been ordered by the patient's physician on 6/19/15. She also confirmed there was no documentation of initiation of contact precautions until 6/21/15. S2InfectionControl also confirmed she had not identified that a delay had occurrred in initiation of the contact precautions for Patient #R1. She agreed isolation precautions should be initiated, without delay, when ordered.

Based on record review and interview, the chief executive officer, medical staff, director of nursing and infection control officer failed to ensure that the hospital-wide quality assessment and performance improvement (QAPI) program identified infection control problems as evidenced by:

1) failing to track and trend hospital acquired infections since April 2015; and

2) failing to investigate the source of a hospital acquired Clostridium difficile infection for 1
(#4) of 2 (#4, #5) current patients with Clostridium difficile.

Findings:

1) Failing to track and trend hospital acquired infections since April 2015.

Review of the infection control documentation presented by S2InfectionControl revealed no documented evidence of tracking and trending of infections since April 2015.

There are currently 19 patients on census at the main campus. 14 of the patients are described on the Patient Indicator Sheet provided by the hospital as having complex wounds. There are currently 11 patients on census at the main campus with contact precautions.

In an interview on 6/26/15 at 1:30 p.m. with the S2Infection Control, she stated Patient #4's hospital acquired Clostridium difficile had not been investigated to her knowledge.

In an interview on 6/26/15 at 2:45 p.m., S1CEO verified there had been a lapse in tracking and trending infections in the past several months.


2) Failing to investigate the source of a hospital acquired Clostridium difficile infection.

Review of the patient census for the main campus revealed there were currently 2 patients (Patient #4 and Patient #5) with a diagnosis of Clostridium difficile.

Review of the medical record for Patient #4 revealed she had been admitted to the hospital on 6/9/15 with no signs and symptoms of Clostridium difficile on admit. Further review revealed a stool culture for Clostridium difficile collected on 6/19/15 was resulted as positive on the day of collection.

Review of infection control documentation presented as current by S2InfectionControl revealed no documented evidence of an investigation to track/trend the potential source of Patient #4's hospital acquired infection.

Review of the infection surveillance documentation presented by S2InfectionControl revealed no documented evidence of investigation of the source of Patient #4's hospital acquired Clostridium difficile infection.

In an interview on 6/26/15 at 1:30 p.m. with the S2Infection Control, she stated the source of Patient #4's hospital acquired Clostridium difficile infection had not been investigated to her knowledge.