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Based on interview and record review the facility failed to obtain a History and Physical (H&P) (a term used to describe a doctor's examination of the patient) record for one (Patient 9) of 21 patients sampled within 24 hours after an admission in accordance with hospital policy and procedure.

This failure had the potential for the medical team not having the most up to date information during the care of the patient.

Findings:

During a concurrent interview and record review, on 8/15/2024 at 9:25 a.m., with Staff Registered Nurse (RN 1), Patient 9's medical record was reviewed. Patient 9 had been admitted to the hospital on 7/22/2024 at 10:08 pm for management of stroke (a loss of blood flow to part of the brain, which damages brain tissue), tracheal bleeding (blood around a tube inserted the neck to aid with breathing) and mechanical ventilator (a machine that helps with breathing) care. Patient 9 had a medical H&P completed on 7/26/2024 at 9:24 a.m.

During an interview on 8/16/24, at 9:55 a.m., with the Chief Medical Officer (CMO), the CMO stated, per hospital policy, the H&P should be done within 24 hours of admission. The CMO stated, it appears the H&P was not completed within 24 hours but closer to 96 hours. The CMO stated, the H&P needs to present for the medical team have the information to care for the patient.

During a review facility's policy and procedure (P&P) titled, "Concurrent Audits of Medical Records", 4/1/2013, the P&P indicated "... New admissions will be checked daily to verify a History & Physical is on the chart within 24 hours of admission ... "

Based on observation, interview, and record review, the hospital failed to ensure all licensed nurses adhered to the hospital's policy and procedures (P&P) when the Wound Care Nurse Supervisor (WCS) did not document communication, recommendations and consultation with the provider for wound care in accordance with the hospital's P&P's titled "Wound Care Team Policy" and "Wound Care Nurse Job Description" for one of one sampled patients (Patient (Pt) 6).

This failure potentially placed patients at risk of wounds not being treated with the whole medical team.

Findings:

During a concurrent interview and record review, on 8/13/2024 at 2:50 p.m. with Staff Registered Nurse (RN 1), Pt 6's medical record was reviewed. Pt 6 had been admitted to the hospital on 10/23/2023 at 8:00 pm for intravenous antibiotics (medications through the veins), acute rehabilitation, hemodialysis (therapy used to replace kidney function of filtering the blood of waste products), management of multiple wounds and mechanical ventilation (therapy used for assisting with breathing). Pt 6 had orders placed on 10/17/2023 for a wound consult by the Wound Consult Team. The wound care team took pictures and assessed the wounds of Pt 6 on 10/24/23 at 4:00 p.m using a document titled, "Photographic Wound Documentation." Thirteen wounds were identified and assessed for type of wound, measurements, drainage, odor, color, and location. No recommendations were found in the medical record about communication of the wound care team with the provider. RN 1 validated no wound care progress notes were in the electronic medical record.

During a concurrent interview and record review, on 8/13/2024 at 3:15 p.m. with Wound Care Supervisor (WCS), Pt 6's medical record was reviewed. WCS stated, he assessed the wounds of Pt 6 and was involved with taking the pictures on 10/24/23 at 4:00 p.m. using the form, "Photographic Wound Documentation." WCS stated, no other progress notes are made in the medical record for communication with the provider about any recommendations. WCS stated, he talks to the doctor of the patient and enters the orders into the electronic medical record but does not document the communication.

During a follow up concurrent interview and record review, on 8/16/2024 at 10:50 a.m. with Wound Care Supervisor (WCS) and Chief Executive Officer (CEO), the record titled, "Wound Consult Audit," not dated, was reviewed. WCS stated, a book with the recommendations were written on the "Wound Consult Audit". WCS stated, the book allows the nurses to see the current recommendations for the patient. WCS stated, no progress notes are made in the medical record for patients with the recommendations for other members of the medical team. The CEO stated, the medical record should have recommendations and a treatment plan as per the policies of the organization. The CEO stated, any communication with the doctor should be documented in the medical record. The CEO stated, the recommendations by the Wound Consult Team should be documented as it allows for other members of the medical team to see the plan of care. The CEO stated, documenting in the medical record allows for collaboration and communication amongst the whole medical team.

During a record review, the record titled, "Wound Care Nurse Job Description," dated 9/1/2015, indicated," ... The Wound Care Nurse is responsible for implementing, coordinating, monitoring managing the hospital wound care program. ... Implements wound care program to include patient care protocols, documentation tools ... Identifies patient's needs and communicates that need to the patient's physician. ... ".

During a record review, the facility's P&P titled, "Wound Care Team Policy," dated 8/2021, indicated, " ... Wound Care Program will be managed by a Wound Care Team acting in conjunction with an interdisciplinary team. Each discipline will have a vital role in wound management. Expected actions will include assessment, planning, implementation, documentation and re-assessment of care. ... C. The team will include representatives from each of the following disciplines. Responsibilities include: ... 1. Wound Care Team: ... d. Consult with physicians and initiate appropriate wound care protocols. ... h. Make recommendations for appropriate surfaces based on assessment ..."

Based on interview and record review the facility failed to electronically sign orders in accordance with hospital policy and procedure for one (Pt 10) of 21 sampled patients.

This failure had the potential for the medical team not having the most up to date information during the care of the patient.

Findings:

During a concurrent interview and record review, on 8/15/2024 at 10:31 a.m., with Staff Registered Nurse (RN 1), Patient 10's medical record was reviewed. Patient 10 had been admitted to the hospital on 7/15/2024 at 6:58 pm for intravenous (through the vein) antibiotics (medications used to treat infections) and management of a surgical wound of his left foot. Pt 10 had orders placed in the computer on 7/15/24 at 9:05 p.m. for Admelog (insulin medication to help with blood sugar levels) per hypoglycemic (low blood sugar) protocol 7/16/24 at 1:27 a.m., for foley (a tube inserted in the bladder to allow for drainage of urine) care every shift, and 7/15/24 @ 9:05 p.m. for glucagon (a medication for treating low blood sugars) 1 mg (milligram) as need for glucose (blood sugar) levels less than 55 mg/dL (milligrams per deciliter) (normal range is 70 to 100 mg/dL). All three orders were electronically signed by the provider on July 24, 2024, at 11:31 a.m., which is about 8 days after being entered into the computer.

During an interview on 8/16/24, at 9:55 a.m., with the Chief Medical Officer (CMO), the CMO stated, per hospital policy, telephone and verbal orders should be signed within 48 hours after the order was given and put into the computer. The CMO stated, the orders for Pt 10 were not signed until after eight days from when the orders were placed in the electronic medical record by the nurse and probably were not signed by the provider due to the provider being on leave. The CMO stated, it is expectation that another provider should have been assigned to review and sign the orders within 48 hours.

During a review facility's policy and procedure (P&P) titled, "Concurrent Audits of Medical Records", 4/1/2013, the P&P indicated, "... Medical Records should notify physicians promptly regarding unsigned orders to meet regulatory requirements. An unsigned order report shall be generated and printed daily. Orders unsigned within 48 hours of issuance shall be tracked and the physician shall be notified. ..."

Based on observation, and record review of facility policies and procedures (P&P) and interview with staff, it was determined that the facility failed to maintain drug storage areas in accordance with acceptable standards of practice when:

1. One normal saline (NS, 0.9% sodium chloride solution, a mixture of salt and water) 100 milliliters (ml, unit of measurement) IV (intravenous, into the vein) bag of was stored out of the manufacturer wrapper and undated;

2. a. One NS 1 liter (L, unit of measurement) IV bag was identified in a bin with three half-normal saline (1/2 NS, 0.45% sodium chloride solution, a mixture of salt and water) 1 L IV bags; and

b. Three NS 500 ml IV bags were identified in a bin labeled "D5W (dextrose 5% in water, a mixture of sugar and water) / 0.45% NS 1 L"; and

3. a. One NS 250 ml IV bag was found hanging and undated for Patient 12; and

b. One NS 100 ml IV bag was found hanging and undated for Patient 21.

These failures had the potential to result in administration of outdated or incorrect medications.

Findings:

1. During a tour of the facility's pharmacy on 8/13/24 at 10:42 a.m. with the Director of Pharmacy (DOP), one NS 100 ml IV bag was observed in a storage bin, out of the manufacturer's wrapper, undated and available for patient use.

During an interview on 8/13/24 at 10:58 a.m. with the DOP, the DOP stated, the NS 100 ml IV bag was good for 30 days when removed from outer packaging and should have been dated.

Review of the manufacturer instructions on the NS 100 ml IV bag's outer packaging, provided by the facility, indicated, "Do not remove unit from overwrap until ready for use. Use all units promptly when pouch is opened."

During a review of the facility's P&P titled, "Security of Medication Storage Areas," revised April 2024, the P&P indicated, "No product will be stored in a manner likely to cause it to become damaged, etc., or otherwise render it unusable."

2. During a tour of the facility's pharmacy on 8/13/24 at 10:45 a.m. with the DOP:

a. One NS 1 L IV bag was identified in a storage bin with three half-NS 1 L IV bags; and

b. Three NS 500 ml IV bags were identified in a storage bin labeled "D5W / 0.45% NS 1 L."

During an interview on 8/13/24 at 11 a.m. with the DOP, the DOP stated, it was important to store medications in properly labeled bins to avoid pulling the wrong medication.

Further review of the facility's P&P titled, "Security of Medication Storage Areas," revised April 2024, indicated, " ...Products should be stored in properly labeled areas, bins, etc. to promote ease in selecting products efficiently and without error."

3. a. During a concurrent observation and interview on 8/13/24 at 2 p.m. with the House Supervisor (HS 1), one undated NS 250 ml IV bag was identified hanging on a pole at bedside, for Patient 12. The HS 1 acknowledged the NS 250 ml IV bag was undated and stated, "[The bag] should be dated."

b. During a concurrent observation and interview on 8/13/24 at 2:30 p.m. in the Overflow Unit with LVN 1, one undated NS 100 ml IV bag was identified hanging on a pole at bedside, for Patient 21. LVN 1 acknowledged the NS 100 ml IV bag was undated and should have been dated.

During an interview on 8/15/24 at 3:41 p.m. with the DOP, he stated, the expectation was if the IV bag was in use, then it should have been dated with an expiration date.

Based on observation and interview, the facility failed to ensure a wound treatment cart containing a medication used to treat wounds was locked and secured to prevent unauthorized access to the medication.

This failure had the potential to result in access to the medication by unauthorized personnel.

Finding:

During a concurrent observation and interview on 8/13/24 at 2:22 p.m., with the Director of Pharmacy (DOP) and the Wound Care Supervisor (WCS), a wound treatment cart was identified unlocked and unattended in the hallway on the second floor. The wound treatment cart contained five SilvaSorb (medication used to treat wounds) 42.5 gram (g, unit of measurement) tubes. The Director of Pharmacy (DOP) stated, the expectation was for a cart containing medications to be locked and secured. The WCS acknowledged he forgot to lock the cart and stated, "I usually lock [the cart]."

During a review of the facility's policy and procedure (P&P) titled, "Security of Medication Storage Areas," revised April 2024, the P&P indicated, "All medication carts shall remain locked at all times when not attended. This shall include the time required for a nurse to enter a patient's room to administer medication."

Based on observation, interview, and record review, the hospital failed to ensure that all unusable or expired medications were segregated and not available for patient use in accordance with the manufacturer's recommendations, and hospital policies and procedures when:

1. A single dose 45 millimole (mmol-unit of measure) per 15 milliliter (ml- unit of measure) partially used and resealed injection vial of potassium phosphate injection (medication given in the vein used to treat low phosphorus in the blood) with an expiration date of 8/29/24, was available for patient use;

2. Five 5-ml oral tacrolimus (medication used to prevent organ transplant rejection) 1milligram (mg-unit of measure)/ml syringes with expiration dates 7/30/24 was not separated from four non-expired medications in a bin.

These failures had the potential to result in patient harm due to potentially subtherapeutic (ineffective) medications.

Findings:

1. During an observation on 8/13/24 at 10:48 a.m. with Director of Pharmacy (DOP) in the pharmacy, a 45 mmol/15ml partially used and resealed injection vial of potassium phosphate labeled "single dose" was observed stored on the pharmacy shelf, with an expiration date of 8/29/24, available for patient use.

During an interview on 8/13/24 at 11:00 a.m. with DOP acknowledged the potassium phosphate vial was a single dose vial and stated single dose meant one time use and once punctured, the contents of the vial could not be stored or reused. DOP stated repeated use could compromise the sterility of the medication.

During a review of Center for Disease Control and Prevention (CDC), a nationally recognized organization the protects the public's health, an article titled "Proper Use of Single-Dose and Multi-dose Vials, retrieved 8/22/24, from https://www.cdc.gov/injection-safety/media/pdfs/Injection-Safety-For-Healthcare-P.pdf, the article indicated, "A single-dose vial (SDV) is approved for use on a single patient for a single procedure or injection. SDV typically lack an antimicrobial preservative (used to prevent growth of bacteria). Do not save leftover medication from these vials. Harmful bacteria can grow and infect a patient."

2. During a concurrent observation and interview on 8/13/24 at 11:28 a.m. with DOP in the pharmacy, five 5 ml tacrolimus 1 mg/ml unit dose syringes for Patient (PT) 20 with an expiration date of 7/30/24 were observed stored and not separated from four non-expired 5 ml tacrolimus 1 mg/ml unit dose syringes in a bin, for the same patient. DOP acknowledged expired medications should be separated and discarded and stated it was important, so the expired medications are not accidentally administered to patients. DOP stated PT 20 was discharged on 7/5/24 and all nine tacrolimus 1mg/ml syringes should have been discarded and not stored.

During a review of the hospital's Policy and Procedure (P&P) titled, "Security of Medication", revised 4/24, the P&P indicated, "No expired or otherwise unusable drugs may be stored with active inventory. These drugs must be segregated in an area that would preclude their inadvertent use."

Based on interview and record review, the hospital failed to implement its policy and procedure (P&P) for destruction of controlled drugs (drugs tightly controlled by federal government with high potential for addiction and abuse) when licensed staff did not appropriately document the destruction of two diazepam (medication commonly used for anxiety) 10 milligram (mg- unit of measure) tablets and one morphine (medication used for pain) 2 mg per milliliter (ml- unit of measure) syringe.
These failures had the potential for drugs to disappear from the hospital without accountability and unauthorized use.
Findings:
During a concurrent interview and record review on 8/14/24 at 2:47 p.m., with Director of Pharmacy (DOP), the hospital's automated dispensing cabinet (ADC) discrepancy report for controlled drugs, dated 7/1/24 to 7/31/24, was reviewed. The report indicated that on 7/26/24 at 10:59 p.m., a discrepancy was documented at nursing station 1's ADC for one unaccounted morphine 2mg/ml syringe, and on 7/3/24 at 11:11 a.m., a discrepancy was documented at nursing station 4's ADC for two unaccounted diazepam 10 mg tablets. DOP acknowledged there was no documentation on the ADC report indicating that nursing staff returned or destroyed the unaccounted morphine and diazepam tablets. DOP explained that during pharmacy investigation on 8/1/24, nursing staff stated she accidentally pulled two morphine 2 mg/ml syringes instead of one for Patient (PT) 7, wasted the extra syringe at bedside with another nurse, but did not document the destruction of the controlled drug on the ADC. DOP acknowledged nursing staff did not record or document the destruction of the extra morphine 2mg/ml syringe or return the medication to pharmacy to be destroyed with a pharmacist, at the time of the incident on 7/26/24.
For the two unaccounted diazepam 10 mg tablets, DOP explained that during pharmacy investigation on 7/9/24, nursing staff stated she accidentally pulled seven diazepam 10 mg tablets instead of five for PT 8, wasted the two extra tablets with another nurse, but did not document the destruction of the controlled drug on the ADC. DOP acknowledged nursing staff did not record or document the destruction of the two diazepam 10 mg tablets or return the medication to the pharmacy to be destroyed with a pharmacist, at the time of the incident on 7/3/24.
During an interview on 8/15/24 at 3:43 p.m., with DOP, DOP stated nursing staff was expected to document destruction of any controlled drug on the ADC. DOP stated it was important to appropriately document wastage and destruction for controlled drugs to prevent potential diversion or theft.
During a review of the hospital's P&P titled, "Controlled Drug Distribution", revised 7/24, the P&P indicated, "Destruction of partial doses of controlled drugs must be done and recorded by two registered nurses. Destruction of other controlled drugs must be done according to federal law and in the presence of two pharmacists or pharmacist and registered nurse. The record of such destruction will be done on approved form or log."

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment to avoid sources transmission of infection when:

1. Staff did not clean and maintain the floors and drains to prevent contamination, in three of three sampled rooms (Hospital Supply, Medication Rooms and Soiled Utility room). Clean patient care supplies were found on shelves close to the contaminated floor, drains were found to have grey debris and missing caulking (a sealant used to fill in between cracks) and shelves were propped up using a roll of medical dressing gauze (a fabric used to cover patient wounds and keep them clean and protected from infection).

2. Staff did not ensure proper infection control practices were implemented during a wound care treatment for one of one sampled patient (Patient (Pt) 17).

These failures placed all patients and staff at risk for transmission of infections (an infectious agent is transferred from a reservoir to a susceptible host) and cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and increased the potential for hospital acquired infections and illnesses.

3. Nurses applied tape over and around the top and opening of the glucometer (a device for measuring the concentration of glucose in the blood) preventing the cleaning and disinfecting of two of two sampled Glucometers in accordance with the hospital's P&P titled "Equipment Cleaning -- [Brand Name of glucometer] Glucometers."

This failure had the potential to place patients and staff who access glucometers at risk for cross contamination.

Findings:

1. During a concurrent observation and interview, on 8/13/24, at 10:30 a.m., with the Director of Nursing (DON), and House Supervisor (HS) 2, on the third floor, in the clean storage room, next to the nurses' station, a shelf of a shelving units for medical supplies was noted to be less than two inches from the floor. The DON stated, a mop could not fit under the shelving unit to clean underneath. The DON stated, the floors should be swept and mopped daily and as needed, including under the shelving units. The DON stated, supplies could be cross contaminated from the debris on the floor and affect the hospitals infection control.

During a concurrent observation and interview, on 8/13/24, at 11:33 a.m., with the DON, and HS 1, on the second floor, in the Soiled Utility room, on the south hall, the two drains floor drains were observed to have grey debris and caulking that was black around the opening. The DON stated, the drains should have been cleaned on more than just a daily basis. The DON stated, the drains should have been cleaned and maintained to allow for easy cleaning as the missing caulking made it more difficult to clean.

During a concurrent observation and interview, on 8/13/24, at 2:25 p.m., with the DON, and the Quality Manager (QM) 1, on the first floor, in the clean storage room, on the south hall, the bottom shelf for medical supplies was observed not attached to one of the braces and was held up from the floor by a four-inch roll of medical gauze. The medical gauze had some yellowing around the edges. The DON stated, the shelf should have been fixed and not held up by medical supply gauze. The DON stated, this was unacceptable as the gauze would absorb the mop water as staff cleaned the floor and would be a source of possible infection and cross contamination to patients.


During a concurrent observation and interview, on 8/15/24, at 1:00 p.m., with the Chief Executive Officer, QM, the Infection Control Manager (IPM), the Director of Facility Operations (DFO), and the Director of Environmental Services (DEVS), the findings, and pictures of the first, second and third floor were reviewed.

a. Third floor, cleaning supply room, the shelf of a shelving units for medical supplies was noted to be less than 2 inches from the floor. The DEVS stated, the staff are unable to clean under the shelving unit if it is not high enough for a broom and mop to fit underneath. The IPM stated, cross contamination could occur if the room was not cleaned.

b. Second floor, in the Soiled Utility room, on the south hall, the two drains in the room on the floor. The DFO stated, the caulking around the drains should be replaced and the floor drains should be in a color that will allow staff to determine if they have been cleaned. The DEVS stated, the cleaning staff would not be able to notice the difference between clean and dirty based on what has been done so far. The IPM stated, the drains need to be addressed by maintenance as the drains do not appear clean, even after the staff have cleaned the drains.

c. First floor, in the clean storage room, on the south hall, the bottom shelf of a shelving unit for medical supplies. The DFO stated, the shelf was fixed when it was brought to his attention. The DFO stated, broken shelves should be reported so that staff can fix them. The IPM stated, the gauze would absorb water and allow for bacteria to grow. The IPM stated, this would be a cross contamination issue and put people in possible harm.

During a review of the facility's policy and procedure titled, "Environmental Services - Cleaning Schedule", effective date 3/2023, the policy indicated, " ... Facility will have quality control checks and inspections periodically using a daily, bi-monthly schedule for regular services Dust mopping, wet mopping, and vacuuming where needed. ... These areas of service will be provided, but not limited to on a regular basis, patient rooms, nurse's stations, dinning/activity rooms, core areas, utility rooms, ... and common areas. ... 22. Floor - polished ... The complete floor including all edges, comers and main floor spaces must have a uniform shine and be visibly clean with no blood and body substances, dust, dirt, debris, spillages or scuff marks. ... Furnishings and fixtures ... 28. Low surfaces ... All surfaces must be visibly clean with no blood and body substances, dust, dirt, debris, adhesive tape or spillages. ... "

During a review of facility's policy and procedure titled, "Infection Prevention and Control System," effective date 12/18/17, the policy indicated, " ... Hospital maintains an organized, hospital-wide program designed to systematically identify and reduce the risk of acquiring and transmitting infections among patients, visitors and health care workers ... EVS [Environmental Services] : ... Surveillance is conducted for compliance in which all components of room cleaning are conducted in randomized observation. Findings are used to identify opportunities for improvement ... Materials/Central Supply: ... Assists, supports, and complies with the policies and procedures that outline the appropriate cleaning, storage, disinfection, sterilization and disposal of equipment to reduce the risk of infections associated with reusable equipment, devices or supplies. ... Maintenance/ Plant Ops: ... Assist in environmental rounds and report any new renovations planned and/or in need of repair or under construction, to ensure a sanitary environment and to allow for evaluation of infection risk of patient population and staff. ... Infection Control: ... Surveillance activities: Environmental rounds ... Perform random and monthly EOC [environmental] rounds in conjunction with either Quality or EVS [environmental services] staff. "

During a review of the document titled, "Biofilms", undated, retrieved from https://www.cdc.gov/infection-control/hcp/environmental-control/appendix-c-water.html, the document indicated "Microorganisms have a tendency to associate with, and stick to surfaces ... These adherent organisms can initiate and develop biofilms (a thin layer of bacteria that adheres to the surface.)"

2. During an observation on 8/15/24 at 1:05 p.m. in Pt 17's room, Licensed Vocational Nurse (LVN) 4 introduced herself and briefly explained the procedure to the patient. Afterwards, LVN 4 performed hand hygiene and donned a new pair of gloves prior to placing the unopened wound care supplies on a clean bedside table. The wound care supplies included a Q-Tip, a roll of Kerlix (a bandage made up of woven gauze that is fluff dried), foam dressing, two normal saline packets, normal saline syringes clear cups for liquid, bordered gauze, and gauze pads. LVN 4 then elevated the patient's bed and turned the patient to the left side. LVN 4 opened a normal saline packet, placed gauze in the clear cups and put normal saline to saturate the gauze. LVN 4 removed the previous dressing and placed the used dressing in the trash bin by the bedside table. LVN 4 used the wet gauze from the clean cups to clean the inside of the wound from the inside of the wound to the outside. LVN 4 removed her gloves and placed them in the trash bin. LVN 4 put on new gloves and opened the roll of Kerlix and used two Normal Saline syringes to place on the Kerlix. LVN 4 removed a Q-Tip from its wrapping and used the Q-Tip to pack the wet Kerlix gauze into the wound. LVN 4 stated, she stopped packing the wound when packing met with resistance. LVN 4 removed her trauma shears from her scrub pants pocket and cut the excess roll that was not packed into the wound. LVN 4 returned the trauma shears to her scrub pants pocket. LVN 4 applied the foam dressing and dated the dressing. LVN 4 cleaned the bedside table, disposed of the supplies used, removed her gloves, and performed hand hygiene.

During an interview on 8/15/24, at 3:53 p.m., with LVN 4, LVN 4 stated, she should have used sterile scissors to cut the excess Kerlix gauze from the dressing and not her personal trauma sheers stored in her pants pocket.

During a review of Pt 17's "History and Physical" dated 7/3/24 at 10:57 p.m., the H&P (History and Physical) indicated, Pt 17 was admitted to the hospital on 7/1/24. The H&P indicated " ... Management of chronic medical problems, drain care, and wound care. ... history of T12 [thoracic vertebra number 12 -back bone] paraplegia [partial paralysis that usually includes the lower half of the body], secondary to motor vehicle accident in 2018, with nonhealing, chronic pressure ulcer on the right buttock for which he underwent debridement ..."

During an interview, on 8/16/2024 at 10:50 a.m., with the Wound Care Supervisor (WCS) and Chief Executive Officer (CEO), The WCS stated, LVN 7 should not have used trauma shears from her pocket to cut the gauze. The WCS stated, she should have used scissors that had been cleaned or single use scissors from a new package. The CEO stated, the nurses should use aseptic techniques when doing dressing changes including using clean scissors and not from their pockets.

During a review of the document titled, "Wound Care Nurse Job Description," dated 9/1/2015, the job description indicated," ... The Wound Care Nurse is responsible for implementing, coordinating, monitoring managing the hospital wound care program. ... Abides by all safety, infection control, and other guidelines as required. ... 3. Cleans equipment between patient usage. ... ".

During a review of the document titled, "CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings" retrieved from, https://www.cdc.gov/infection-control/hcp/core-practices/index.html dated 4/12/24, " ...standard precautions (basic level of infection control that is used in patient care) include: ...hand hygiene ...environmental cleaning and disinfection .. Reprocessing of reusable medical equipment between each patient or when soiled..."

3. During a concurrent observation and interview on 8/13/24 at 2:20 p.m. with Quality Manager (QM), on the First floor, at nurses' station 1 and 2, glucometer 1 and glucometer 2 were observed to have tape around the opening at the top of the machine where the blood is sampled. The QM validated tape was on glucometer 1 and glucometer 2. The QM stated, the tape should not be on the devices as it makes it hard to clean the equipment. The QM stated, the tape should not be on the device and started removing the tape immediately. The QM stated the device can not be cleaned as per the policies of cleaning equipment if tape covers the device. The QM stated cross contamination between patients could occur if the glucometers are not properly cleaned.

During a concurrent observation and interview on 8/15/24 at 1:00 p.m. with Infection Control (IP), QM and the Chief Executive Officer (CEO), on the First floor, at nurses station 1 and 2, glucometer 1 and glucometer 2 were observed. The pictures of glucometer 1 and glucometer 2 from 8/13/24 at 2:20 p.m. were shown to IP and the CEO. The QM validated tape was on glucometer 1 and glucometer 2. The IP stated tape should not be on the glucometers as the machines could not be properly cleaned. The IP stated the machines could have bacteria that breeds on the machines and could contaminate patients. The CEO stated the nurses should follow the policy for cleaning the machines and what is indicated in the manufacturer's guidelines for cleaning the devices. The CEO stated, the machines need to be clean to prevent harm to the patients.

During a record review, the facility's P&P titled, "Equipment Cleaning -- [Brand Name of glucometer] Glucometers," dated 4/2019, indicated, " ... To ensure that [Brand Name of Glucometer] are adequately cleaned and disinfected ... policy and procedure as well as manufacture's guidelines after use. ... Ensure all parts of the machine are wiped down ... ".

During a review of facility's Glucometer "Operators Manual (OM)", not dated, the OM indicated, " ... Cleaning and disinfecting the meter is important to prevent the spread of infectious diseases. Follow your facility's policies and procedures for infection control, which may require more frequent cleaning and disinfecting ... 1. For cleaning, wipe all outside surfaces of the meter thoroughly, taking care to avoid the strip port opening and the data port connector, until they are visibly clean. 2. Discard the wipes in used appropriate biohazard waste container. Disinfection of the meter should be accomplished after use with each patient. Disinfection is a process that destroys pathogens, such as viruses and other microorganisms on the meter surfaces. Disinfecting the meter helps ensure that no infection is passed on when the user or others come in contact with the meter, The meter should be cleaned prior to disinfection ... l. For disinfection, wipe all outside surfaces of the meter thoroughly, taking care to avoid the strip opening and the data port connector, until they are wet in order to pre-clean the meter, 2. After pre-cleaning, use a second wipe to disinfect the meter using the same process. 3. Allow the meter surfaces to remain wet for ONE FULL MINUTE. Allow the meter to air dry completely before use or before docking the meter. ... "