HospitalInspections.org

Based on observation, interview, review of the facility's Corporate Oversite Review, review of Policies and Procedures, and review of the facility's Quality Monitoring Data, the facility's QAPI plan failed to:

A. monitor staff competencies and education as required by facility policy, placing patients at risk of staff not providing appropriate care. (See Tag A0283)

B. report data for February, March, and April 2021 (See Tag A0283)

C. implement performance improvement activities that track hospital acquired pressure ulcers, analyze their causes, and implement prevention activities. (See Tag A0286)

Based on observation, interview, review of medical records, and review of facility-based policies, the facility failed to have an effective nursing service organization when:

a) The nursing staff failed to provide ongoing documentation throughout the shift to reflect personal care, turning and repositioning (See Tag A0386)


b) Once realizing equipment for medical emergencies were not functional, nursing administration failed to ensure the equipment was in proper working order, placing patients at risk for a delay in emergency response, resulting in heart muscle damage and possible death. (See Tag A0386)

c) The nursing administration did not ensure all licensed nursing staff had completed the facility competencies before providing patient care. This resulted in patient #3 failing to be on appropriate Enteric precautions for over 8 days and nursing staff failing to don appropriate PPE before going into isolation rooms, placing patients and other staff at risk of acquiring an infectious disease. (Staff #1 and #2) (See Tag A0398)

d) The nursing staff failed to document the required 2-hour restraint release (which included skin assessments and re-application) for a patient with bilateral mittens. (See Tag A0205)

e) The nursing administration did not conduct the surveillance of hospital acquired infections and did not provide the information to the QAPI committee, preventing the committee from being able to look for trending HAIs and to put any needed action plans into place. This failure was evidenced when a patient, pending the results of a C-Diff stool culture, required Enteric Isolation precautions. The patient remained in a room for 8 days with 3 other acutely ill patients, placing the other patients at risk of contracting C-difficile. (See Tag A0283)

f) The nursing staff failed to implement performance improvement activities and preventive measures when 9 of 20 patients reviewed developed hospital acquired pressure ulcers (Patients #7, #8, #9, #10, #11, #12, #13, #14, and #15) (See Tag A0286)

g) The nursing administration did not provide appropriate educational events when a new Infection Control Policy was implemented and the facility started processing community Covid-19 tests, placing patients and other staffs at risk of acquiring an infectious disease. (See Tag A0308)

Based on observation, interview, and record review, the facility failed to ensure the Code Blue light was in working order. The Code Blue light, used to alert staff a patient is requiring cardiac resuscitation, was not functional during a cardiac arrest and was not repaired. In addition, the cardiac defibrillator monitor and the bed's deflating button did not work, placing patients at risk of delayed response and treatment during a cardiac arrest, possibly resulting in heart muscle damage and death.


Findings:

Review of the facility's Cardiac Arrest Code Blue Evaluation Performance Improvement Worksheet (dated, 2/16/2021) reflected, "Equipment failure, code lights need to be addressed urgently for quality codes to continue ...Code Buttons Don't work, monitor died, air bed didn't deflate when CPR button Pressed to use, disconnected line to deflate faster for compressions."


On 4/26/21 at 1:00 pm, the surveyor requested all Code Blue call lights be tested to ensure that they were in proper working order. An observation on 4/26/21 at 1:20 pm revealed, Staff #5, DON enter the patient's room 508A. The Code Blue light did not light above the door and did not alarm at the Nurse's station. Staff #5, DON stated, "Didn't it come on?" Staff #5 was not aware the Code Blue light had not alarmed. Staff #5 stated, "508 is for high acuity (high medical risk) patients."


On 4/26/21 in the administrator's office, when asked if Room 508's Code Blue light and the bed not deflating, had been fixed, Staff #6, Administrator stated, "I don't have anything to show it was fixed. I didn't know anything about the bed."

Based on a review of documentation and interview, the facility failed to monitor the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy.

Findings:

Facility policy entitled, "Restraint Use" stated in part,

"(Medical Restraint) - Restraint used for medical reasons: Use of restraint is driven by an acute medical problem and/or to promote physical healing in patients exhibiting nonviolent/ non-self-destructive behavior ...

RESTRAINTS USED FOR MEDICAL REASONS (MEDICAL RESTRAINT) ...

B. Patient Monitoring:

o Individuals with documented competency within their scope of practice may assess clinical condition and the ongoing need for restraints, monitor safety, address physical needs, apply restraints, and remove restraints at the earliest opportunity. ·

o Patient assessment is ongoing throughout the episode of restraint use. Attention to the patient's physical needs and assessment of continued need for restraint is documented per specific to the patient population and the behavior for which the restraint use was initiated.

C. On-going assessment includes: Minimally every 2 hours or more frequently if condition warrants. The patient's safety and other needs are assessed and documented within the medical record.

o Interventions as appropriate

o Restraint release and re-application

o Circulation and skin integrity not compromised

o Patient is repositioned, limb restraint removed or rotated

o Active/passive ROM is facilitated and/or provided

o Physical comfort is addressed

o Privacy/Modesty/Dignity are preserved

o Nutrition and fluid needs provided or addressed

o Elimination needs are addressed

o Personal hygiene needs are addressed."


Review of 2 of 2 patients in medical restraints (#15 and 16) during April 2021 revealed the following:

*Patient #15 had bilateral mittens untied in place on 04/24/21.

*Nursing note on 0900 at 04/24/21 stated in part, "Pts mittens released ...Pts mittens placed on hands again."

*The restraint flowsheet on 04/24/21 had missing documentation of the q 2-hour elements for monitoring restraints from 0700-1900, all monitoring elements were blank. On 1900 only "visual/safety check" marked.


*Patient #16 had bilateral mittens untied in place on 04/25/21.

*Nursing note on 0700 at 04/25/21 stated in part, "mittens in place".

*The restraint flowsheet on 04/25/21 had lines drawn through all the q 2-hour elements for monitoring restraints from 0700-0600. There was no indication that the q 2-hour monitoring was completed per policy.


During observation of patient care on 04/28/2021, surveyor reviewed the daily nursing flowsheets for Patient#15 at 10:30 AM. This patient continued to have an order in place for bilateral mittens untied. The patient was observed with mittens in place. The restraint flowsheet on 04/28/21 was blank. In interview on 04/28/21, staff member #13 verified doing q 2-hour checks on Patient #15 at 0700 and 0900, per policy but not documenting in the medical record "yet". The staff member stated, "I should have check it off".


*Patient #16 had bilateral mittens untied in place on 04/09/21.

*The restraint flowsheet on 04/09/21 had missing documentation of the q 2-hour elements for monitoring restraints from 0900-1400. From 0700-0800 and 1500-1900, only repositioning and skin integrity checks were documented. There was no indication that all the q 2-hour monitoring tasks were completed per policy for this date.

*Patient #16 had bilateral mittens untied in place on 04/10/21.

*Nursing note on 0700 at 04/10/21 stated in part, "has mittens X 2".

*The restraint flowsheet on 04/25/21 had lines drawn through all the q 2-hour elements for monitoring restraints from 0700-1800. There was no indication that the q 2-hour monitoring was completed per policy for the time period of 0700-1800.


In interview on 04/28/21, staff member #5 verified that the above documentation was not correct and that staff are expected to document every 2 hours on all medical/non-violent restrained patients.

Based on observation, interview, review of the facility's Corporate Oversite Review, review of Policies and Procedures, and review of the facility's Quality Monitoring Data, the facility failed to implement, collect, and conduct an analysis of Quality data to ensure Quality Care activities when:

a.) Agency staff were not aware of isolation procedures and isolation signs were not posted for a patient waiting for a C-diff. result, placing patients and staffs at risk of acquiring an infectious disease.

b.) QAPI data was not reported for February 2021, March 2021, and the current month of April 2021, preventing the committee from being able to look for trending HAIs, and to put any needed action plans into place.


Findings:

a) Review of the facility provided Premier Onsite Review (dated October 1, 2020) attendances by the facility's CEO, Regional HR specialist, Corporate DON, Corporate Infection Control, corporate Director of Operations, and the facility Administrator reflected,

"Action Items:

Every Employee and agency staff must have completed orientation and competencies.

Isolation signs will be posted on necessary patient room. Staff received education on what isolation signs meant.

QAPI data must be reported from every department head monthly."


Interviews with staff #1 and #2 on the morning of 4/26/21 revealed they were unfamiliar with facility policy related to isolation precautions.


Review of Staff #1's & #2's personnel file revealed a fast track orientation completed on 1/25/21 and 10/5/20, respectively.

Review of the fast track orientation records reflected; Droplet Precautions did not address whether staff were able to enter isolation rooms without donning PPEs and did not detail the PPE that was required.


When asked for Staff #1 and #2's competency check-off form, Staff #5, DON stated, "I wasn't the DON then, I can't find their competency check offs."


Observations on the mornings of 4/26/21 and 4/28/21 revealed room 517 A & B, and 518 A & B, which were in the same large open space, had 4 patients in the room, one of which was Patient #3.


On 4/28/21, review of Patient #3's physician's order, dated 4/20/21 at 1:44 pm, reflected, "1.) Stool for C-diff 2.) Stool Cultures."


On 4/28/21, surveyor informed Staff #5, DON of the order and that it had been 8 days since the order was written. Staff #5 stated, "We need to send the sample." Surveyor asked if the patient also needed to be isolated from the other patients in the room until the results of the test are determined. Staff #5 agreed. Staff #5, DON was unable to provide a system to monitor for the isolating of patients pending results for infectious diseases or the monitoring for delinquent tests.


During a telephone interview on 4/28/21, when asked what the staff should do for a patient pending the results of a C-Diff culture sample, Staff #9, Corporate Infection Control nurse stated, "They should be placed on Enteric Precautions. You isolate the patient, especially for C-diff., until you get the results."


There was no QAPI data regarding agency staff orientation and competencies.

b.) Review of the facility provided QAPI minutes (dated February 22,2021), attended by the Staff #5, acting DON, Staff #6, Administrator, and Staff #14, CMO, and Staff #15, former Infection Preventionist/Quality, reflected there was no Quality Data information for CAUTIs, CLABSIs, Pressure wounds, or Communicable Diseases.

On 4/27/21, in the administrative office, Staff #5, DON stated, "We didn't have a meeting in March, I believe Staff #15 was off." When asked for the facility's quality data, the facility did not provide evidence of quality monitoring data for February, March and the current month of April.

When asked if the CEO is aware of the facility's QAPI's monitoring, Staff #8, CEO stated, "The facility is tracking for falls, CLABSI's, CAUTI's and HR turnover." When informed the facility had provided the surveyors one blood transfusion and three patient admission records as evidence of quality monitoring, Staff 8#, CEO stated, "I don't know why they chose those. When we went in, we gave them the tools, we gave them the information. I'm in constant communication with them."

Based on review of medical records, policies and procedures, and staff interviews, the facility failed to implement performance improvement activities that track hospital acquired pressure ulcers, analyze their causes, and implement prevention activities.

Findings:

*Review of patient's medical records showed 9 patients out of 20 developed a hospital acquired pressure ulcer.

*Patients #7, #8, #9, #10, #11, #12, #13, #14, and #15 developed hospital acquired pressure ulcers while in facility, requiring wound care treatment.

*Staff #7 validated that hospital acquired pressure ulcers happen "a lot" in the facility, during an interview on 4/28/21 at 1030 in conference room. Staff #7 stated, "I place an incident report for every patient that I find who has developed a pressure ulcer."

*During an interview on 4/27/21 at 1420, Staff #5 stated, "Yes I am aware of the issue. I have a plan to address it but we haven't started it yet."

Facility lacks a Quality program. Unable to validate an improvement plan. Without implementing performance improvement activities, analyzing their causes, and implementing prevention activities, all patients are at increased risk of developing hospital acquired pressure ulcers.

Based on interview, review of the facility's Quality Monitoring records, review of the Community Covid-9 testing, and review of the Governing Board Bylaws and meeting minutes, the facility's Governing Body failed to ensure the facility's management was effectively communicating and monitoring the services and programs being provided by the facility when:

a.) The facility's Plan of Correction, for the findings of a complaint survey on 9/26/20, reflected the facility was no longer processing Covid-19 tests in the facility as of 10/16/20. Surveyor found the facility continued to process Community Covid-19 tests on the facility's premises until 4/23/21; the facility did not have policies or procedures and did not include this service in its QAPI program, to ensure the safe handling of contaminated supplies. The facility continued to process community Covid-19 laboratory tests, despite the CEO halting the program, placing patients at risk of contracting Covid-19 from the transporting of the spent tests that were being transferred down the patient halls.

b.) The facility failed to repair a known, broken patient's Code Blue light, placing patients at risk for delayed resuscitative treatment, heart muscle damage and possible death.


Findings:


a.) Review of the facility provided Governing Board Bylaw (undated) reflected,

"A. The Governing Board of the Hospital is a closed Board.

B. The Board will be comprised of the following members:

l. CEO of the Hospital - Chairman of the Board

2. President/Chief of the Medical Staff

3. VP of Operations (or designee) from the facility's Management Company.

4. Director of Hospital Operations from the facility's Management Company.

5. Program Director from the facility appointed by the Board ...


Performance Improvement Responsibilities

The Hospital is committed to establishing and promoting a culture of continuous quality improvement. The Board supports this commitment through resource allocation, active involvement in the performance improvement process and recognition of performance improvement efforts by leadership and hospital staff.

A. The Board has the responsibility for performance improvement, risk management and outcomes. Using the principles of continuous improvement, the Board has empowered Hospital leadership and staff to accomplish these functions.

B. The Board oversees the performance of these functions through its appointment and reappointment responsibilities, receiving and acting on reports that summarize the activities of performance improvement, Risk Management, Safety, Human Resources, Budget and other hospital-based functions, as well as input and reports from Hospital customers and the community. In making appointment and reappointment decisions, criteria related performance and quality are considered...

D. If the Hospital leadership or the staff fails to meet the performance standards established, the Board will provide leadership in designing and implementing an improvement plan that will guide the Hospital in meeting and exceeding
established performance standards ..."


On 4/27/21, during a telephone interview at 4:00 pm, Staff #8, confirmed she is the CEO and lives in Denton, Texas and is on the Governing Body. When asked how she provides oversight of the facility while living in another city approximately 640 miles away, Staff #8, stated, "The facility has been talking with my team by telephone. I used to go once a month, then Covid came. I went in September, after your last visit, and again on March 23rd and April 7 through the 9th (2021) ...We usually have someone to provide oversight for each department in all our facilities. We have a Corporate nurse for nursing and have a Corporate Infection Control nurse helping assist Staff #15, former Infection Control Nurse."

When asked if the facility was processing community Covid tests, Staff #8, CEO stated, "We left in October, we told them to stop running the tests. I even put the sign on the machine, 'Do not use.' When we returned in March (2021) we saw the equipment wrapped up." When informed the facility had test results that had been run up until March 23,2021, Staff #8, CEO stated, "I didn't know they were still running the tests."


b) Review of the facility provided Cardiac Arrest Code Blue Evaluation Performance Improvement Worksheet, (dated 2/16/2021) reflected, "Equipment failure, code lights need to be addressed urgently for quality codes to continue ...Code Buttons Don't work, monitor died, air bed didn't deflate when CPR button Pressed to use, disconnected line to deflate faster for compressions."


On 4/27/21, Staff #8, CEO stated, "Staff #6, Administrator is my direct contact. He tells me when there are concerns, if they need to purchase supplies, I approve them. When the surveyor informed Staff #8, CEO that the facility's Code Blue call light in room 517 had not been working since 2/12/21, Staff #8, CEO stated, "Staff #6 should have informed me, that is a high priority that needed to be corrected immediately."

Based on observation, interview, review of medical records, and review of policies, the facility failed to provide Nursing Services in a safe and organized manner when:

a.) The nursing staff failed to provide ongoing documentation throughout the shift to reflect personal care, turning and repositioning, placing patients at risk for decreased circulation and skin injuries.

b.) Once realizing equipment for medical emergencies were not functional, nursing administration failed to ensure the equipment was in proper working order, placing patients at risk for a delay in emergency response, resulting in heart muscle damage and possible death.


Findings:


a.) Facility policy titled, "Nursing Medical Record Documentation" stated in part, "B. Ongoing documentation throughout the shift should reflect intake and output, vital signs, personal care, turning and repositioning, nutrition, and activity of the patient."


During observation of patient care on 04/28/2021, surveyor reviewed the daily nursing flowsheets for 10 patients at 10:30 AM.

* 5 (#4, 5, 15, 18, and 23) of 10 patients had no documentation present on their flow sheets for 04/28/21. Patients #4, 5, 15, 18, and 23 nursing flowsheets were completely blank from 0700-1000 for 04/28/21 at 10:30 AM. In an interview on 04/28/21 staff member #13 verified that these patients were assigned to them for nursing care. They reported they had performed assessments but had not completed documentation due to being occupied doing medication pass.

* 5 (#14, 19, 20, 21, and 22) of 10 patients had some documentation present on their flow sheets (nursing plan and vitals). However, these 5 records did not have patient turning or oral care documented at 10:30 AM when the flowsheets were reviewed. In an interview on 04/28/21 staff member #12 verified she had completed assessments, turned patients, and performed oral care, but had not completed documentation due to being medication pass. Staff member #12 stated, "I just finished medication pass and will fill them out."

In an interview on 04/28/21 staff member #5 (Director of Nursing) was asked when nursing staff is expected to complete charting in the medical record. Staff member #5 stated that nursing staff are expected to document every shift. "They can chart throughout the shift or at the end." This staff member was unaware the facility policy specified ongoing documentation throughout the shift.


b.) Review of the facility provided Cardiac Arrest Code Blue Evaluation Performance Improvement Worksheet, (dated 2/16/2021) reflected, "Equipment failure, code lights need to be addressed urgently for quality codes to continue ...Code Buttons Don't work, monitor died, air bed didn't deflate when CPR button Pressed to use, disconnected line to deflate faster for compressions."

On 4/26/21 at 1:00 pm, the surveyor requested all Code Blue call lights be tested. An observation on 4/26/21 at 1:20 pm revealed Staff #5, DON enter the patient's room 508A. The Code Blue light did not light above the door and did not alarm at the Nurse's station. Staff #5, DON stated, "Didn't it come on?" Staff #5 was not aware the Code Blue light had not alarmed. Staff #5 stated, "508 is for high acuity (high medical risk) patients."

On 4/26/21 in the administrator's office, when asked if Room 508's Code Blue light and the bed not deflating, had been fixed, Staff #6, Administrator stated, "I don't have anything to show it was fixed. I didn't know anything about the bed."

Nursing staff documented the emergency equipment was not in working order on 2/16/21. At the time of the survey on 4/26/21, the equipment still had not been fixed.

Based on review of facility documents, observations, and staff interview, the facility failed to ensure all licensed nurses that provided services in the hospital adhered to the policies and procedures of the hospital.

Findings:

Review of the facility's Premier Onsite Review (dated 10/1/20) reflected, "Human Resources Action Item, every employee and agency staff must have completed orientation and competencies."

An observation on 4/26/21 at 10:50 am, revealed Staff #1, RN entering room 508; the room had a Droplet Precaution sign on the door, reflecting the need for a gown, mask, and gloves. Staff #1 did not don the PPE. When the staff exited the room and was asked why she did not put on the PPEs, Staff #1 stated, "I just went in to turn off the beeping ...I was supposed to gown up ...It's Droplet Precautions."

During an interview on 4/26/21 at 10:55 am, Staff#2 was sitting outside of room 508, when asked how they would know what PPE would be required to enter room 508, Staff #2, LVN stated, "If I didn't get it in report, I wouldn't know what kind of precautions to use." When the surveyor pointed out the Droplet Precautions signage by the door, Staff #2 stated, "It depends on what I was going to be doing in the room ...You don't have to gown up if you are 5 feet away." When asked where he was taught this procedure, Staff #2 stated, "In nursing school." When asked if he could decide whether to wear PPE, Staff #2 stated, "Yes."

Review of Staff #1's personnel file revealed a fast track orientation completed on 1/25/21.

Review of Staff#2's personnel file revealed a fast track orientation completed on 10/5/20.

Review of the fast track orientation records reflected; Droplet Precautions did not address whether staff were able to enter isolation rooms without donning PPEs and did not detail the PPE that was required.

When asked for Staff #1 and #2's competency check-off form, Staff #5, DON stated, "I wasn't the DON then, I can't find their competency check offs."

During a telephone interview, on 4/28/21, when asked what PPE staff should wear when entering a patient's isolation room, Staff #9, Corporate Infection Control Nurse, stated, "There is a sign on the door of what they need to wear." When asked do they have to wear the full PPEs every time they enter the room, Staff #9 stated, "Yes, ask me why ...The nurse doesn't know what they will find when they enter the room. They may go in for one thing but have to do something else, then they aren't prepared."

Based on observation, review of facility documents, and staff interview, the facility failed to ensure competency-based training and education of hospital personnel and staff on the practical applications of infection prevention and control guidelines, policies, and procedures when:

a.) Patient #3, pending the results of a stool culture for possible C-Difficile, remained in a room with 3 other high acuity patients; there was no signage for the use of PPEs to prevent the spread of this highly infectious communicable disease, that leads to severe bouts of diarrhea, which can cause dehydration, and worsening of an already compromised patient's health.

b.) A Staff nurse entered the room of a patient on Droplet Precautions; the staff did not don the facility required PPEs and a second nurse did not know the facility's isolation policy, placing non-infected patients at risk of contracting multi-drug resistant infectious diseases through cross contamination, worsening an already compromised patient's health

Findings:

a.) Review of the CDC's Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) found at: https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html stated in part, "Determine patient placement based on the following principles:

Route(s) of transmission of the known or suspected infectious agent

Risk factors for transmission in the infected patient

Risk factors for adverse outcomes resulting from a HAI in other patients in the area or room being considered for patient-placement

Availability of single-patient rooms

Patient options for room-sharing (e.g., cohorting patients with the same infection)"


Review of the facility's Isolation Precautions Policy IC.02.01.01(last reviewed 12/2016) on 4/26/21 reflected, "Transmission Based lsolation Precautions

A. There are two tiers of isolation precautions recommended by the Hospital lnfection Control Practices Advisory Committee (HICPAC), a division of the Centers for Disease Control and Epidemiology (CDC). ln the first, and most important, tier are [sic] those precautions designed for the care of all patients in hospitals, regardless of their [sic] diagnosis or presumed infection status. implementation of these "Standard Precautions" is the primary strategy for successful health care acquired infection control. The second tier, "Transmission Based Precautions", are for those patients known or suspected to be infected by epidemiologically important pathogens spread by airborne, droplet or contact.

1. Standard Precautions

Standard Precautions apply to all patients receiving care in the facility, regardless of their diagnosis or presumed infection status. This applies to all blood or body fluids, secretions, and excretions, except sweat, regardless of whether or not they contain:

a. visible blood

b. non-intact skin

c. mucous membranes

These precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in the facility. These precautions include the following:

a. Hand Hygiene -- perform hand hygiene after contact with contaminated items. Also perform hand hygiene between patients, before and after gloving or when indicated by obvious contamination.

b. Gloves --- Wear gloves (clean non sterile [sic]) when entering the room. During the course of providing care for a patient, change gloves after having contact with infective material that may contain high concentrations of microorganisms. Remove gloves immediately, dispose of in the appropriate container, [sic] and perform hand hygiene.

c. Mask, eye protection, face shield -- These items are worn to protect the eyes, nose and mouth mucous membranes during procedures that cause spraying or aerosolization.

d. Gown, protective apparel --- Wear gowns, aprons, or other protective apparel (clean non sterile [sic]) to protect skin and clothing if contact with or splashing blood, body fluids, excretions is likely. Remove soiled apparel and dispose of appropriately, then perform hand hygiene as soon as possible.

e. Patient care equipment -- Dispose of single use items appropriately after use. Be sure that reusable items are appropriately cleaned and disinfected before leaving the room for reprocessing before using again.

f. Linen -- Handle soiled, contaminated linen as little as possible and bag at the place of its use.

g. Occupational health and bloodborne pathogens ...3. Droplet Precautions Droplet transmission involves contact of conjunctivae or mucous membranes of the nose or mouth with large particles (>5 microns) droplets which contain infectious organisms. Coughing, sneezing, talking, or participating in procedures such as bronchoscopy or suctioning are the primary sources of droplet
transmission. Transmission occurs when close contact (up to 3 feet or less) between the source and the recipient.

Mask -- A surgical mask is to be worn when entering the room if you are going to be performing task that will take you into close contact with the patient (i.e., bathing, turning, etc.). Be sure to dispose of the mask before leaving the room ... ln addition to Standard Precautions, use Droplet Precautions for patients known or suspected to have serious illness transmitted by large particle droplets ..."


Observations on the mornings of 4/26/21 and 4/28/21 revealed, room 517 A & B, and 518 A&B, which were in the same large open space, had 4 patients in the room, one of which was Patient #3.

On 4/28/21, review of Patient #3's physician's order, dated 4/20/21 at 1:44 pm, reflected, "1.) Stool for C-diff 2.) Stool Cultures."

On 4/28/21, surveyor informed Staff #5, DON of the order and that it had been 8 days since the order was written. Staff #5 stated, "We need to send the sample." This surveyor asked if the patient also needed to be isolated from the other patients in the room until the results of the test are determined. Staff #5 agreed.


During a telephone interview, on 4/28/21, when asked what the staff should do for a patient pending the results of a C-Diff culture sample, Staff #9, Corporate Infection Control nurse, stated, "They should be placed on Enteric Precautions. You isolate the patient, especially for C-diff., until you get the results." Staff #9 was informed the infection control policy does not address Enteric precautions or the isolating of patients until test results have come in. When informed the facility provided Isolation Precautions Policy IC.02.01.0, Staff #9, stated, "I don't know what that policy is, none of our policies have numbers."


During a telephone interview, on 4/28/21, when asked what PPE staff should wear when entering a patient's isolation room, Staff #9, Corporate Infection Control Nurse, stated, "There is a sign on the door of what they need to wear." When asked do they have to wear the full PPEs every time they enter the room, Staff #9 stated, "Yes, ask me why ...The nurse doesn't know what they will find when they enter the room. They may go in for one thing but have to do something else, then they aren't prepared." When asked what the staff should do for a patient pending the results of a C-Diff culture sample, Staff #9 stated, "They should be placed on Enteric Precautions. You isolate the patient, especially for C-diff., until you get the results."


Review of the facility provided policy Management of Patients with Clostridium Difficile Infection Prevention & Control (dated 02/2021) reflected, "1. When a patient with diarrhea (3 or more loose stools in a 24 hour Period) follow the Diarrhea Decision Tree Algorithm ...they should be placed on Enteric Precautions."


On 4/28/21, the facility's additional Infection Control Policy (approved by the Governing Board and Medical Executive committees on 2/25/21) reflected, " ...In addition to Standard Precautions, use Contact Precautions for patients know [sic] or suspected to have serious illness easily transmitted by direct patient contact or contact with items in the patient's environment ...Enteric infection with a low infectious dose or prolonged environmental survival, including: Clostridium difficile ..." The facility did not provide evidence of training on this policy.


b.) An observation on 4/26/21 at 10:50 am, revealed Staff #1, RN entering room 508; the room had a Droplet Precaution sign on the door, reflecting the need for a gown, mask, and gloves. Staff #1 did not don the PPE. When the staff exited the room and was asked why she did not put on the PPEs, Staff #1 stated, "I just went in to turn off the beeping ...I was supposed to gown up ...It's Droplet Precautions."


During an interview on 4/26/21 at 10:55 am, Staff#2 was sitting outside of room 508, when asked how they would know what PPE would be required to enter room 508, Staff #2, LVN stated, "If I didn't get it in report, I wouldn't know what kind of precautions to use." When the surveyor pointed out the Droplet Precautions signage by the door, Staff #2 stated, "It depends on what I was going to be doing in the room ...You don't have to gown up if you are 5 feet away." When asked where he was taught this procedure, Staff #2 stated, "In nursing school." When asked if he could decide whether to wear PPE, Staff #2 stated, "Yes."