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Based on observation, interview and record review the facility failed to provide a sanitary environment for 38 occupied beds in the facility. Findings include:

On 3/29/11 during the observational tour at approximately 0950 a patient ready room was identified. The following were found in room 205, a private room:
1). a used and marked bedpan and measurement carafe was found in the bathroom
2). the floors of the bathroom and the patient care room were soiled
3). the footboard of the bed was soiled with a reddish/brown splatter
4). three of the four siderails were soiled with a blackish brown material that could be scraped off with the finger
5). the overbed table was soiled with a white crust-like substance that also could be chipped off with the gloved fingernail
6). horizontal surfaces above the patient bed had accumulated dust
7). the locked medication cabinet had accumulated soil in the bottom of the cabinet
8). the locked medication cabinet had a bin with dried flaked reddish/brown material, uncovered 2 x 2 gauze and a scissors
9). the bedside table had a yellowish stain on the bottom drawer's handle.

Interview with staff D confirms that the room had residual soiling as described above. Staff D called their contracted environmental services manager to remediate the room before accepting a new patient.

On 3/30/11 at approximately 0815 record reveiw of the contract services policy 7.05 titled Discharge Room Cleaning, procedure specifies "remove patient resident room trash from the cans..","...Using germicidal cleaner and a clean cloth, sanitize all patient contact surfaces starting with the bed...". "Clean the head of the bed, moving to the bed rails and bed controls, then the foot of the bed and opposite side rails...".

On 3/29/11 during facility tour at approximately 1100, the alcohol based hand sanitizer (ABHS) dispenser inside of rooms 201, 203 and 207 were determined to be non functional. Interview with staff D confirms that these dispensers need to be fixed. Staff D stated that the ABHS that is mounted inside of patient care rooms is the responsibility of Select Specialty staff, the ABHS mounted outside of the room is the responsibility of the hosting facility".


15195

During the initial tour, on 3/29/11 at approximately 1015, it was noted that Room #239 had a "Contact Precautions C" outside the door. Interview with Charge Nurse #E at that time revealed that the 'C' stood for c. difficule pathogens and that soap and water was required for hand hygiene after patient contact. At approximately 1040, Host Radiology Techs #F and #G were noted coming out of the room #239 (after PICC line placement x-ray procedure) rubbing their hands. Interview of the Radiology Techs confirmed that they had used alcohol hand sanitizer instead of soap and water. Further interview with Charge Nurse #E and Radiology Techs #F and #G verified that they should have washed hands with soap and water for the c. difficile precautions for patient #1. The facility Policy: IC III-5 Enhanced Contact Precautions, Specific Procedures #5. documented "If hands are visibly soiled or if contact isolation is in place for C-Diff then hand washing with soap and water must be completed."


29314

On 3/31/2011 at approximately 0815 during observations, it was observed that staff P had completed cleaning a contact isolation room, room 205. He then removed his gown, and picked up the soiled duster and rag and walked to room 209, which was also a contact isolation room. He did not remove or change his gloves from the previous room or perform hand hygiene before entering and beginning to clean room 209. He also was observed to begin cleaning room 209 with the same rag and duster that he had used in room 205.

On 3/31/2011 at approximately 0815 during an interview with staff P regarding the above observations, the staff responded "They (the patients) are both in contact isolation precautions, so I don't have to change my gloves or get new supplies."

On 3/31/2011 at approximately 0900 during observation of a medication pass, it was observed that staff S did not perform hand hygiene before administering medications to patient #32. This observation was confirmed with staff S who stated "I usually do, I must have forgot this time."

Based on record review and interview, the facility failed to furnish the Medicare Important Message within two days of admission for 1 (#1) of 15 patients. Findings include:

Record review of patient #1's medical record revealed that she was admitted on 3/10/11 and was a Medicare patient. Review of the record with the Charge Nurse #E, on 3/29/11 at approximately 1030, revealed that the Medicare Important Message regarding discontinuing patient care was not documented in the record. Interview with the Admissions Coordinator #H, on 3/29/11 at approximately 1200, verified that the message had not been given. Review of the Admission Coordinator's documentation log at that time revealed that the patient was errantly classified as "not applicable".

Based on policy, medical record review and interview, the facility failed to ensure that all patient medical record entries were completed with the correct date and time, by the physician responsible for providing the service, in 2 out of 3 clinical records reviewed (#10, #11). Findings include:

On 3/31/2011 at approximately 1145 during review of the policy titled Orders, Physician it was documented on page 2 under section 5 C "Written Orders - All written orders are to be dated and timed..."

On 3/29/2011 at approximately 1030 during medical record review of patient # 10 it was revealed that the physician did not date and/or time four out of eight orders.

On 3/30/2011 at approximately 1015 during medical record review of patient # 11 it was revealed that the physician did not date and/or time six out of nine orders.

On 3/29/2011 at approximately 1045 it was confirmed with staff E that the physician orders for patient #10 was not dated and/or timed according to policy.

On 3/30/2011 at approximately 1030 during an interview with staff L it was confirmed that the physician orders for patient # 11 was not dated and/or timed according to policy.

Based on open record review and interview, seven of the seven focused reviews on open patient charts revealed the facility failed to ensure that all verbal orders taken by the physician were authenticated within the 48 hour time frame Findings include:

Review of patient #30's orders on 3/30/11 at 1320 revealed that the following verbal orders that were not signed within 48 hours: On 3/21/11 at 1750 "On 3/21/11 at 1750 "D/C TPN Lipids, D/C NGT and feedings". On 3/22/11 at 1845 "Accuchecks AC/HS, Chem 7 on 3/23/11 am, F/U on stool for C.diff with physician." On 3/23/11 at 0322 "Hold oral diet 2 hours to decreased respiratory status until speech re-eval."

Review of patient #29's orders on 3/30/11 at 1340 revealed that the following verbal orders that were not signed within 48 hours: On 3/27/11 at 1455 "Bumex 1 mg IV, Activity as tolerated with L foot with surgical shoe on, fall precautions, H&H, BMP" and on 3/27/11 at 1730 "hold Coumadin today, PT/INR in the AM."

Interview with Charge Nurse #E at the time of above record reviews verified that the physicians had been in daily but failed to authenticate the verbal orders.



15195

Review of patient #1's orders on 3/29/11 at 1030 revealed that the following verbal orders were not signed within 48 hours: On 3/18/11 "Hespan 500 ml IV wide open; Ativan 2 mg IVP q 2 hours prn anxiety; Tube feeding to gravity".

Review of patient #2's orders on 3/29/11 at 1120 revealed that the following verbal orders were not signed within 48 hours: On 3/26/11 "Change Albuterol/Atrovent treatment frequency to q 6 hours prn..." and on 3/27/11 at 1110 "Give 2 Gm Mag Sulfate IVPB x one dose"

Interview with Charge Nurse #E at the time of above record reviews verified that the physicians had been in daily but failed to authenticate the verbal orders.


29314

On 3/29/2011 at approximately 1030 during medical record review of patient #10's it was revealed that the telephone orders were not signed within 48 hours: On 3/25/2011 "Change Albuterol and Atrovent to MDI's Q 4 hrs PRN." and on 3/26/2011 "D/C coumadin, CBC, Mg, PO4."

On 3/30/2011 at approximately 1015 during medical record review of patient #11's chart, the following was revealed, verbal orders were not signed within 48 hours: on 3/26/2011 "Stat chest Xray/ ABG per protocol." on 3/26/2011 at 1700 "Versed 4 mg prn X1 for intubation, Dilaudid 2 mg prn X1 for intubation, Dopamine gtt titrate to SBP > 90." and on 3/26/2011 at 1735 "Rate on vent 14, TU 450, titrate FIO2 for sats 88-92%; Versed 2 mg IVP Q2hrs prn vent comfort, Morphine 2 mg IVP Q2hrs PRN vent comfort, D/C Dilaudid."

On 3/30/2011 during an interview with staff L the above findings were confirmed, and she stated, "Yes, we have problems with these two doctors. They always seem to... forget."




29774

On 3/30/11 at approximately 1530 during record review patient #16 record had a verbal order dated 3/27/11 to increase respiratory treatments to 4 hours daily. The verbal order was not signed within 48 hours. Staff #L confirmed that the verbal order should have been signed earlier.

Based on observation at 10:42 am on 03/30/2011 the facility failed to maintain the facility to promote control of airborne infectious agents. Findings include:

The airborne infectious isolation room monitors (both at the room and the nurse station) were visually signaling an alarm, indicating loss of pressurization and therefore loss of captive air flow into the room to help prevent the spread of disease. Staff person (B) indicated that the exhaust fan had failed " some time ago " resulting in net air flow out of the room.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the Life Safety Code.

See the K-tags on the CMS-2567 dated March 31, 2011 for Life Safety Code.

Based on observation and interview, the facility failed to provide an adequate hand washing sink in rooms where patients are being dialyzed using the hand sink faucet as a water source. Findings include:

On 3/31/11 during observational tour at approximately 0815, observed staff R assembling the portable dialysis machine in rooms 67 bed one and 59 bed one. Staff R hooked up the portable dialysis machines as follows:
1). she hooked up a water source by using a Y connector on the hand hygiene sink
2). she taped the effluent flow tubing to the toilet seat where effluent flows from the machine into the toilet.
3). The hand hygiene Y attachment had a screw type valve that opens a valve for use for hand hygiene.

Upon trying to use the Y attachment for hand hygiene there was much spray and splatter that whetted the area around the sink, the healthcare worker, and the mirror. It was impossible to wash one's hands without spray contamination or touch contamination of the tubing attaching the water source to the portable dialysis machine. Interview with staff R confirms that the facility may have up to 8 patients on dialysis at one time, and patients are not placed according to where there are existing dialysis ports. At times according to staff R, patients needing dialysis may also be in contact isolation requiring hand hygiene using soap and water ( Contact Isolation C), in which case " we may go into another patient room to wash our hands or just use the alcohol based hand sanitizer". When asked how the roommate of a patient having portable dialysis needs may use the bathroom, staff R responded that "these patients don't usually use the bathroom, or if they do, a portable commode would be made available".

Based on observation and interview, the hospital failed to ensure that supplies were maintained to ensure an acceptable level of safety. Findings include:

On 3/26/10 at approximately 1035 during a tour of the facility an Argyle Salem sump tube was found opened, with the following instructions on the package "Sterility Guaranteed unless opened, do not use if opened." The package was placed back in the supply container for patient use.

On 3/26/2011 at approximately 1045 a Mepilex dressing was found opened and placed back in the wound supply cart for patient use. The package instructions stated "Sterility Guaranteed unless opened, do not use if opened."

On 3/26/2011 during the tour the above findings were confirmed with the CEO when the items were identified as opened and replaced and available for patient use.



02902

1. Based on observation at 8:17 am on 03/30/2011, only bedside dialysis is available and none of the 4 dialysis machines in the equipment storage room had been equipped with reduced pressure zone backflow preventors that are needed to protect the hospital ' s potable water supply from the potential high hazard backflow contamination associated with dialysis.

2. Based on observations such as at 8:33 in the pharmacy and 9:13 in the staff lounge, housekeepers failed to maintain a clean environment. Examples include:
a. Heavy accumulations of dust on the floor in gaps around systems furniture in the pharmacy;
b. Food debris on the countertop around the sink in the staff lounge;
c. Food debris on the floor around the small refrigerator in the staff lounge;
d. Food debris was evident across the entire floor of the staff lounge.

Based on observation, policy review, chart review, and interview, the facility failed to ensure that the RN administered medications according to the practitioner's orders. The focus review was for one of five patients assigned to RN #O. Findings include:

On 3/29/11 at 1045 a chart review of patient #8 was conducted. The medication administration record did not show whether medications had been given or held. RN # O was quieried about medication administration for patient #8 and she stated "Oh, I held those because the patient was nauseated." At 1055 RN #O was questioned about the patient's blood glucose level at 0800 as it coordinated with the 0800 insulin order. RN #O stated "Oh, I wrote that down on my sheet." RN #O was unable to show any documentation showing the patient's blood glucose level.

At approximately 1145 RN# O was questioned about administration of PRN IV Zofran administration and she stated at that time "Oh, I forgot to chart that I gave that at 0930." At 1150 Charge nurse #E was asked to verify the time that PRN Zofran was dispensed from the pyxis machine. Charge nurse #E verified that the medication was dispensed at 0930. Charge nurse #E verified that both the 0800 held medications and 0930 administration of Zofran had not been documented on the medication administration sheet.

According to the facility's policy M01-N medication administration #9 "Blood sugar results must be documented on MAR (medication administration record)". According to the facility's policy under documentation #B. "All scheduled medications on the MAR must have corresponding charting. A given medication dose will be designated by placing a slash (/) throught the time followed by the administrator's intitials." #C. "When a medication dose is NOT administered due to the patient's condition or other unavoidable factor, the individual responsible for administering the medication will circle does NOT given and note reason on the MAR."