HospitalInspections.org

Based on observation and interviews, the facility failed to:

A. maintain a sanitary environment in 8 (Patient Rooms 404 and 405, Medication Rooms 1 and 2, Biohazard Room, Linen Room, and Patient Supplies/ Emergency Room) out of 8 areas viewed.

B. educate and monitor staff on proper use of Personal Protective Equipment (PPE).

Refer to Tag A0749

The facility failed to recognize the failure of housekeeping in maintaining a sanitary environment for the patients or the proper use of Personal Protective Equipment (PPE) with contracted staff. There was no evidence that the QAPI was aimed at identifying, taking action, implementing, tracking or measuring success of improvements, or its sustainability.

A tour of the facility was conducted in the afternoon on 5-30-19. The following findings were observed:

Patient Room #5

Patient room #5 was terminally cleaned and ready for a patient admission. (Terminal cleaning is a cleaning method used in healthcare environments to control the spread of infections. ... Terminal cleaning methods vary, but usually include removing all detachable objects in the room, cleaning lighting and air duct surfaces in the ceiling, and cleaning everything downward to the floor.)

There were three trash cans in the room next to each other. Two trash cans and one bio hazard trash can. The trash cans were heavily soiled on the outside with dirt, hair, and dust. A piece of clean linen for the patient bed was found lying across the dirty cans.

The threshold from the patient room and bathroom was coated in a thick black residue. The surveyor took a pen and scrapped the debris from the floor.

The toilet had a paper cover over the lid to show the commode was clean, but the inside of the bowl was dirty with unidentifiable brown spots.

The commode chair sitting in the shower was found to be rusted on the legs and bottom of the chair. Underneath the chair seat was found to be soiled.

Inside a drawer of the bedside table revealed a princess phone. The cord on the phone was heavily soiled with dirt and sticky substance.

The bedside tray table was soiled in the track of the drawers with food particles and debris.

An IV pump was found covered in plastic. The plastic was removed. The pump was heavily soiled with dust, spilled yellow liquids and unidentifiable dried liquids. The base of the pump was heavily soiled in a dried brown liquid. Staff #4 confirmed the nursing staff are to sanitize the equipment in the room.

A Respirator was covered in the room with plastic. The plastic was removed, and the device was soiled with dried liquids, dust and rust.

A wall suction had a plastic container holder on the wall. The canister was covered in dust and hair.

On the wall behind the patient bed was a plastic bumper to protect the wall from the bed. The plastic bumper was cracked approximately 12 inches.

The patient bed headboard was found soiled with dirt, hair and unidentifiable dried liquids.

Sitting on the floor next to the patient bed footboard was a Hill-Rom pump. The pump allows the air mattress to stay at a certain firmness. The pump had hooks on it to allow the pump to hang from the footboard to avoid it from sitting on the floor. One of the hooks was broken and was not removed from the room. The device was soiled with dust.

A wooden chair was found in the corner of the room. The varnish and stain were worn from the arms of the chair. The wood was exposed and unable to be cleaned properly. The bottom rail on the chair was soiled with heavy dust and hair.

A vinyl recliner was found next to the bed. The chair was found to have paper and dust between the cushions. Under the recliner the sides of the chair were heavily coated in dirt, hair, food particles, and heavy dust.


Patient Room #404

A walker found in patient room 404 was currently being used by the patient. The bottom of the walker was covered in linen napkins and secured with medical tape. The bottom of the napkins was black with dirt and dust balls were attached to it. The patient uses the walker down the hallways and is brought back into her room.

A sheet was found covering the patients rolling recliner. The sheet had been on the chair so long that it was black on the bottom from dirt and filth.


Patient Supplies/Emergency Room

In the supply room a stretcher and emergency equipment were found. The Staff #4 stated the supply room and emergency treatment room was blended together.

In the supply room a stretcher and emergency equipment were found. A standing light was found in the corner of the room. The base of the light was heavily soiled with dirt and dust.

The stretcher was soiled on the frame and dusty.

The HVAC vent in the ceiling was heavily coated in mildew and mold. The ceiling tiles had water spots from a leak. The vent was blowing on the patient supplies.

Patient supplies were found on the floor and under the shelving on the floor.

An interview was conducted with Staff #1, #2, #3, and #4 in the afternoon of 5-30-19. Staff #4 stated there was some identified issues of staff not wearing or changing PPE when entering patient isolation rooms. Staff #4 stated he talked to the staff and verbally would warn and educate. Staff #4 reported that the contracted service (used to pick up sharps containers out of patient rooms) were not using PPE appropriately. The contracted employees, had been seen by Staff #4, going in and out of isolation rooms with the same PPE on. Staff #4 and Staff #3 were not able to provide any information that the issues were being brought through Quality. There was no Performance Improvement (PI) process in place to address the identified issue.

Review of the facility's Quality Assurance Performance Improvement (QAPI) revealed the facility was collecting data on "Housekeeping Services Infection Control Compliance." From January 2019 thru April 2019 there was a numerator of 4 and a denominator of 4. The target value was <=0.9. Each month the score was 1.000. Review of the "Quick Quarter Comparison" revealed the 1st quarter of 2019 "maintained or improved in all areas" including housekeeping.

The only PI projects provided to the surveyor was Patient Satisfaction Scores, A central line-associated bloodstream infection (CLABSI), and Nutrition Service Food Temperatures. There was no information or data collected concerning the failure of staff using PPE in isolation rooms, or contracted services going in and out of isolation rooms, without using proper robing and disrobing of PPE.

Based on review and interview the facility failed to have a written nursing staffing plan. The nurse staffing schedule revealed there was 10 out of 26 shifts inadequately staffed.

Review of the facility's nurse staffing schedule and matrix dated 5/16/19 to 5/29/19 revealed there was inadequate nursing staff on the following dates and shifts:

5-17-19: 7AM-7PM short 1 LVN
7PM-7AM short 1 LVN
5-18-19: 7AM-7PM short 1 LVN
7PM-7AM short 1 LVN
5-19-19: 7PM-7AM short 1 LVN
5-20-19: 7AM-7PM short 1 RN
7PM-7AM short 1 RN
5-21-19: 7PM-7AM short 1 LVN
5-22-19: 7AM-7PM short 1 LVN
7PM-7AM short 1 RN AND 1 LVN

Review of the staffing schedule revealed there was 10 out of 26 shifts short staffed. Review of the staffing grid revealed from 20-22 patients the grid calls for 2.5 RN's per shift. The grid does not explain where the .5 nurse comes in and how that nurses time is counted.

An interview was conducted with staff #2 on 5/30/19. Staff #2 explained the grid was based on an "hour per patient per day scale." The grid had LVNs to be scheduled but Staff #2 stated she had only one LVN and the grid had not been adjusted. Staff #2 was unable to explain the .5 nurse and how that would be utilized in the staffing schedule. Staff # 2 stated that she just pools all the staff together. Staff #2 confirmed the staffing schedule was not following the written grid.

The facility failed to have a nurse staffing plan. Review of the policy and procedure "Staffing Guidelines for Nursing Services" stated,

"POLICY: Each Director of Nursing shall outline a staffing plan that shall be used to determine the personnel recommended for each shift as outlined in the unit's core coverage and as necessary to provide the scope of services. The plan shall also establish general guidelines as to the qualifications of staff assigned to provide patient care. Core coverage recommendations are to be reviewed annually or more often if needed." Staff #2 confirmed the facility did not have a written staffing plan.

Based on review, observation and interviews the facility failed to:

A. A process to ensure narcotics are wasted in a safe and secure manner in 2 of 2 medication rooms.

B. educate the nursing and pharmacy staff on the facility's policy and procedure concerning proper wastage of narcotics.

A tour was conducted in the afternoon on 5/30/19 with Staff #2, #4, #6 and #7. Review of the drug storage and medication preparation area (Medication Room #1) revealed there was no visual drug disposal system noted for wasting narcotics.

An interview was conducted with Staff #6. Staff #6 was asked how the nurse wasted narcotics. Staff #6 reported that the liquids are wasted in the sink and signed off by two nurses. Staff #6 was asked what about a tablet or a patch such as a morphine patch. Staff #6 reported the pills were placed in the sharps containers and the patches were just put in the regular trash. Staff #6 confirmed the red box was the plastic red container that hangs on the wall in the patient's room. The container is for used sharps such as needles. The containers were not locked down and had an opening for access.

Staff # 4 and #6 confirmed the waste disposal company came into the facility and took the containers. Staff #4 was asked if the waste company was aware of narcotics in the red sharps containers. Staff #4 reported he did not know. Review of the contracted service for disposal revealed there was no agreement to dispose of narcotics.

An interview was conducted with Staff #7(Pharmacist) on 5/30/19 in the afternoon. Staff #7 reported that his understanding was the nurse was to put the wasted narcotics in the red sharps container or down the sink. Staff #7 stated the patches should be flushed down the toilet.

An interview was conducted with Staff #2 in the afternoon of 5-30-19. Staff #2 reported the narcotics should be disposed of in the black sharps container in the medication room. Review of the black container revealed it was not locked and had an access available. On the front of the black container it clearly stated, "No controlled substances." Staff #2 was shown the container. Staff #2 was not aware that controlled substances could not be placed in the container.

Review of the facility's policy and procedure Storage and Control of Medications stated, "Controlled Substance Waste If necessary to administer a partial dose of a controlled substance, an authorized witness must observe the entire waste. The disposal must render the product unrecoverable. The nurse removing the controlled substance from the automated medication dispensing cabinet and the witness, a Registered Nurse (RN) or Licensed Practical Vocational Nurse (LPN/LVN), must document the waste in the automated medication dispensing cabinet. The waste must be documented in the automated dispensing cabinet prior to administering the prescribed dose of medication to the patient. Exception: if patient refuses controlled substance medication at the bedside, the nurse will return to the medication room with the drug, ask another nurse to witness wasting the medication, and then document the waste in the medication dispensing cabinet.

A partial dose of a controlled substance will not be "saved" to be administered later.

Controlled substance patches should be folded in half with the adhesive sides together and disposed of in the sharps container. The nurse removing the patch should be careful not to touch the adhesive side of the patch. Document the waste of the removed patch on the patient's MAR (medication administration record). A witness and signature are required.

IV tubing containing a controlled substance shall be evacuated thoroughly and discarded."

The sharps containers were still vulnerable due to opening and had the potential for entry and possible drug diversion. The facility does not have a proper process or procedure for controlled substance disposal.

Based on observation and interviews, the facility failed to:

A. maintain a sanitary environment in 8 (Patient Rooms 404 and 405, Medication Rooms 1 and 2, Biohazard Room, Linen Room, and Patient Supplies/ Emergency Room) out of 8 areas viewed.

B. educate and monitor staff on proper use of Personal Protective Equipment (PPE).

A tour of the facility was conducted in the afternoon on 5-30-19. The following findings were observed:

Patient Room #405

Patient room #405 was terminally cleaned and ready for a patient admission. (Terminal cleaning is a cleaning method used in healthcare environments to control the spread of infections. ... Terminal cleaning methods vary, but usually include removing all detachable objects in the room, cleaning lighting and air duct surfaces in the ceiling, and cleaning everything downward to the floor.)

There were three trash cans in the room next to each other. Two trash cans and one bio hazard trash can. The trash cans were heavily soiled on the outside with dirt, hair, and dust. A piece of clean linen for the patient bed was found lying across the dirty cans.

The threshold from the patient room and bathroom was coated in a thick black residue. The surveyor took a pen and scrapped the debris from the floor.

The toilet had a paper cover over the lid to show the commode was clean, but the inside of the bowl was dirty with unidentifiable brown spots.

The commode chair sitting in the shower was found to be rusted on the legs and bottom of the chair. Underneath the chair seat was found to be soiled.

Inside a drawer of the bedside table revealed a princess phone. The cord on the phone was heavily soiled with dirt and sticky substance.

The bedside tray table was soiled in the track of the drawers with food particles and debris.

An IV pump was found covered in plastic. The plastic was removed. The pump was heavily soiled with dust, spilled yellow liquids and unidentifiable dried liquids. The base of the pump was heavily soiled in a dried brown liquid. Staff #4 confirmed the nursing staff were to sanitize the equipment in the room.

A Respirator was covered in the room with plastic. The plastic was removed, and the device was soiled with dried liquids, dust and rust.

A wall suction had a plastic container holder on the wall. The canister was covered in dust and hair.

On the wall behind the patient bed was a plastic bumper to protect the wall from the bed. The plastic bumper was cracked approximately 12 inches.

The patient bed headboard was found soiled with dirt, hair and unidentifiable dried liquids.

Sitting on the floor next to the patient bed footboard was a Hill-Rom pump. The pump allows the air mattress to stay at a certain firmness. The pump had hooks on it to allow the pump to hang from the footboard to avoid it from sitting on the floor. One of the hooks was broken and was not removed from the room. The device was soiled with dust.

A wooden chair was found in the corner of the room. The varnish and stain were worn from the arms of the chair. The wood was exposed and unable to be cleaned properly. The bottom rail on the chair was soiled with heavy dust and hair.

A vinyl recliner was found next to the bed. The chair was found to have paper and dust between the cushions. Under the recliner the sides of the chair were heavily coated in dirt, hair, food particles, and heavy dust.


Patient Room #404

A walker found in patient room 404 was currently being used by the patient. The bottom of the walker was covered in linen napkins and secured with medical tape. The bottom of the napkins was black with dirt and dust balls were attached to it. The patient uses the walker down the hallways and is brought back into her room.

A sheet was found covering the patients rolling recliner. The sheet had been on the chair so long that it was black on the bottom from dirt and filth.


Medication Room #1

In the medication room #1, two sharps containers were found sitting on a metal dolly that were covered in dirt, dust, and hair.

A rolling medication cart was found next to the medication preparation area. The cart was on rusted and soiled metal wheels. The top of the cart had a top with chipped paint and covered in dry liquids. Below the top was a set of two rows of small plastic drawers. The drawers had old stickers on them. Some of the stickers were worn off and some torn off. The cart drawers were soiled with powder residue and dried liquids.

The pill crusher was soiled with powder residue, dirt, and dust.

The plastic containers on the counter, holding patient supplies, was found to be soiled with dust and hair.

A stack of plastic drawers was found with room numbers on them. A tablet of metoclopramide (Dopamine antagonist) 10 mg was found in the drawer. The patient in 404 was not on this medication. The charge nurse was unable to tell the surveyor why the medication was in the drawer and if it belonged to the patient in 404 or to another patient. The drawers were soiled with dust and sticky substances.

Spoons and straws were found in soiled drawers of dust and old sticky tape.

The baseboards in hallway and next to the nurse's station were missing, exposing old wood and sheetrock.

The HVAC vents in the ceiling across from the nurse's station was found soiled with mildew.

Inside the biohazard room the floors were heavily soiled with a black substance, dirt, dust and hair. The back of the wall had tape removed from the wall exposing sheetrock. Clean and dirty containers were mixed with each other. Linen containers were rolled in and out of that room down the patient hallways. A counter in the back of the room held bags of patient belongings. Some in plastic bags and some in paper bags. A child's stuffed animal was found open to the room and sitting next to the biohazard trash full of infectious diseases. Staff #2 stated they stored patient belongings there till the patients could come back for them.

Inside the biohazard room the linen containers were rolled in and out of that room down the patient hallways. The containers had trash and dirty gloves in the bottom of them.

Next to the door on the inside of the biohazard room was a bag of Personal Protective Equipment (PPE) to put on to handle the soiled trash, linen and any biohazard materials. The PPE was sitting above the soiled materials and contaminated.

Housekeeping had come to the unit to clean the biohazard room. Dirty biohazard containers that were sitting on the heavily soiled floor was moved out into the patient hallway floor. The containers holding hazardous materials were at risk of potentially exposing any patient or guest walking by.


Linen Room

The clean linen room was found to have a rolling cart with shelves. The shelves were grated and had unidentifiable dried brown liquid spilled all over the shelves.

The bottom of the rolling linen shelves were covered in crusted unidentifiable filth and dirt.

The linen was stacked on shelves in the linen room uncovered. A HVAC vent was blowing on the clean uncovered linen.

Linen was found on the floor in the linen room. The floors were dusty and soiled with dirt, paper and hair.

The tile on the wall of the linen room was broken and missing exposing the sheetrock.

Wooden pallets were found on the floor of the linen room holding shelves. A curtain to close off the room had multiple large tears and was soiled with dust.


Medication Room #2

The medication room #2 had a counter with open storage underneath. Patient supplies were in open plastic containers on both levels of the counter. The counter and shelves were heavily soiled with dust, dirt and spilled dried liquids.

Tiles were missing from the floor around the baseboard.

A plastic guard was attached to the wall. The guard was soiled with old tape and splashed dried liquids. The floor was soiled with dust and dirt.

The plastic trash can was heavily soiled on the outside with a heavy brown substance. The trash can was broken with another trash can stuffed inside.

Under the open sink, the walls were covered in spilled liquids and the pipes were coated in dirt and sticky substances.

The medication refrigerator was soiled with spilled liquids and trash.


Patient Supplies/Emergency Room

In the supply room a stretcher and emergency equipment were found. The Staff #4 stated the supply room and emergency treatment room was blended together.

In the supply room a stretcher and emergency equipment were found. A standing light was found in the corner of the room. The base of the light was heavily soiled with dirt and dust.

The stretcher was soiled on the frame and dusty.

The HVAC vent in the ceiling was heavily coated in mildew and mold. The ceiling tiles had water spots from a leak. The vent was blowing on the patient supplies.

Patient supplies were found on the floor and under the shelving on the floor.

An interview was conducted with Staff #1, #2, #3, and #4 in the afternoon of 5-30-19. Staff #4 stated there was some identified issues of staff not wearing or changing PPE when entering patient isolation rooms. Staff #4 stated he talked to the staff and verbally would warn and educate. Staff #4 reported that the contracted service (used to pick up sharps containers out of patient rooms) were not using PPE appropriately. The contracted employees, had been seen by Staff #4, going in and out of isolation rooms with the same PPE on. Staff #4 and Staff #3 were not able to provide any information that the issues were being brought through Quality. There was no Performance Improvement (PI) process in place to address the identified issue.