HospitalInspections.org

Based on review of medical records (MR), policy and procedure and staff interviews, it was determined staff failed to:

a) Perform and document ordered wound care.

b) Ensure laboratory tests were performed as ordered.

c) Perform and document daily weights as ordered.

d) Perform PICC (peripherally inserted central catheter) line care as per policy.

e) Confirm incomplete medication orders and apply medications to ordered sites.

f) Administer sliding scale insulin as ordered.

This had the potential to affect all patients served by this facility.

Findings include:

Refer to A 392 and A 405 for findings.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served by the hospital.

Findings include:

Refer to Life Safety Code violations for findings.

Based on observations, review of the Infection Control Tracking document, personnel files, facility policies and procedures and interviews, it was determined the facility failed to ensure the staff:

a) Followed and performed hand hygiene and gloving per the facility policy and procedure.

b) Followed the facility policy and procedure for cleaning of equipment (blood glucose monitor) after patient use.

c) Wore appropriate personal protective equipment (PPE) when performing tasks as directed per facility policy.

d) Were deemed competent to access and maintain a central intravascular catheter.

e) Followed the facility policy for Hepatitis B screening requirements and immunization.

This had the potential at affect all patients served by this facility and the staff.

Refer to A 749 for findings.

Based on review of medical records (MR), policy and procedure and staff interviews, it was determined staff failed to:

a) Perform and document ordered wound care.

b) Ensure laboratory tests were performed as ordered.

c) Perform and document daily weights as ordered.

d) Perform PICC (peripherally inserted central catheter) line care as per policy.

e) Administer medications and skin treatments as ordered by the MD (Medical Doctor).

This affected 12 of 20 records reviewed, which included MR # 14, 13, 15, 19, 17, 2, 28, 20, 23, 1, 24, and MR # 30, and had the potential to affect all patients treated at the facility.

Findings include:

Facility Policy and Procedure: Intravenous Therapy
Policy #: 614
Revision Date: 6/2014

Purpose: It is the purpose of this policy to provide guidelines for safe insertion, management of and administration of intravenous therapy as prescribed by the physician.

I. Types of Intravenous (IV) Catheter Devices

2. Central Catheters:

b. Non-tunneled catheters:

i. PICC

VIII. Central Venous Catheter Dressing Change Procedure.

6. Cleanse insertion site with Chloraprep Swabs using back and forth motion and allow solution to completely dry (cleanse area 10 cm (centimeters) (4 inches) in size around catheter insertion site). Assess catheter position for migration by verifying cm mark on exposed catheter.

8. Document in nursing progress notes.

Table 5:

PICC Catheters (Non-tunneled Catheters): Replace dressings at 24 hours after insertion for first dressing change and every 48 hours after first dressing change.

1. MR # 14 was admitted to the facility on 2/18/16 with diagnoses including Left Total Knee Arthroplasty (TKA) and History of Degenerative Joint Disease.

Review of physician's orders dated 2/18/16 at 10:51 AM included fasting Lipid Profile in the AM (morning), B12, Folate and Vitamin D levels.

Medical record review failed to include results for the 2/19/16 Lipid Profile,Vitamin D, B12 and Folate levels.

The above labs were not performed as ordered.

Review of the transferring acute care inpatient facility Patient Admission Report documentation included incisions-Aquacel dressing to knee-stay on till Mon (Monday) 2/23/16.

Review of the Daily Nursing Assessments dated 2/20/16 and 2/21/16 revealed a surgical incision/wound location to the Lt (left) knee/left TKA.

There was no documentation of the presence of the Aquacel dressing, the condition of the MR # 14's left knee dressing and if the dressing was dry and intact.

Review of physician's orders dated 2/23/16 at 8:51 AM revealed the following: Clean incision site with Carraklenz (wound cleanser), cover with 4x4's (gauze) and paper tape.

Review of the 2/23/16 11:05 AM Registered Nurse (RN) Narrative Comments/Additional Information revealed the following documentation: "Dressing change to (L) [left] knee incision. All staples intact. No drainage covered with 4x4 secured with tape."

There was no documentation the incision site was cleansed with Carraklenz as ordered.

In an interview conducted 2/25/16 at 1:45 PM, Employee Identifier (EI) # 15, Certified Registered Rehabilitation Nurse (CRRN) confirmed the above findings.

2. MR # 13 was admitted to the facility on 2/17/16 with diagnoses to include Right Nondisplaced Greater Trochanteric Fracture.

A review of a physician's order written on 2/17/16 at 7:15 PM revealed apply moisture barrier cream to buttocks every 12 hours and as needed (prn).

Review of the 2/20/16 Daily Nursing Assessment failed to include skin assessment documentation to reveal the presence or absence of intact skin integument and application of moisture barrier as ordered.

Review of Daily Nursing Assessment/Narrative Comments failed to reveal documentation moisture barrier cream was applied every 12 hours and prn on 2/18/16, 2/19/16, 2/20/16, 2/21/16, 2/22/16 and 2/23/16.

Review of the 2/23/16 Daily Nursing Assessment documentation revealed integument assessment included "buttocks red".

In an interview on 2/25/16 at 1:35 PM, EI # 5 confirmed staff failed to document moisture barrier cream application twice daily as ordered.

3. MR # 15 was admitted to the facility on 8/18/15 with diagnoses including Disuse Myopathy and Chronic Obstructive Pulmonary Disease.

Review of 8/18/15 Standing Physician's Orders revealed orders for daily weights.

Review of the medical record failed to include weights on 8/20/15 and 8/21/15.

In an interview on 2/25/16 at 1:00 PM with EI # 5, Certified Registered Rehabilitation Nurse (CRRN) confirmed staff failed to perform and document daily weights as ordered.

4. MR # 19 was admitted to the facility on 2/13/16 with diagnoses including Spinal Stenosis status post Lumbar Fusion.

Review of the 2/13/16 3:45 PM Standing Physician's Orders revealed orders for a dietary consult and daily weights.

Record review failed to include documentation of daily weights on 2/14/16 and 2/15/16.

In an interview on 2/25/16 at 2:09 PM with EI # 5 confirmed staff failed to perform and document daily weights as ordered.

5. MR # 17 was admitted to the facility on 1/11/16 with diagnoses including L2 (Lumbar Vertebrae # 2) Compression Fracture status post Fall and Severe Low Back Pain.

Review of the 1/11/16 Standing Physician's Orders included daily weights.

Record review failed to include documentation weights were performed on 1/13/16, 1/16/16 and 1/17/16.

In an interview on 2/25/16 at 2:20 PM with EI # 5 confirmed staff failed to perform and document daily weights as ordered.





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6. MR # 2 was admitted to the facility on 2/19/16 with diagnoses including Amputation to Partial Right Foot With MRSA (Methicillin-Resistant Staphylococcus Aureus).

Review of the Interdisciplinary Assessment dated 2/19/16 revealed the patient had a PICC line in the right upper extremity.

Review of the physician's order written on 2/20/16 at 2:05 AM revealed wound care orders to the Partial Amputation Right Foot with Sutures as follows:

1. Clean with Carraklenz daily.
2. Cover with dry dressing.

Review of the physician's order written 2/20/16 at 9:54 AM revealed an order for Clonidine 0.1 mg (milligram) every 4 hours as needed (PRN) for systolic blood pressure (SBP) over 170.

Review of the Vital Signs between 2/19/16 and 2/25/16 revealed the following:

2/21/16 - PM (no documentation of the time) SBP was 190
2/22/16 - 8:00 AM SBP was 181
2/23/16 - 8:00 AM SBP was 171
2/23/16 - PM (no documentation of the time) SBP was 181

The Vital Signs indicated the staff checked the patient's SBP 2 times a day. There was no documentation the staff checked the patient's SBP every 4 hours to assess need for Clonidine as ordered.

Review of the Medication Administration Record dated 2/19/16 to 2/23/16 revealed no documentation the staff administered the Clonidine for the SBP over 170.

Review of the Daily Nursing Assessments dated 2/19/16, 2/20/16, 2/21/16, 2/22/16, and 2/23/16 revealed no documentation the nursing staff changed the PICC line dressing or assessed the catheter position for migration according to the facility's policy.

Review of the Skilled Nurse documentation dated 2/20/16, 2/21/16 and 2/22/16 revealed no documentation the nursing staff performed wound care to the Partial Amputation Right Foot with Sutures as ordered.

An interview was conducted on 2/25/16 at 1:50 PM with EI # 6, Chief Nursing Officer, who verified the above findings.

7. MR # 28 was admitted to the facility on 2/22/16 with diagnoses including Disuse Myopathy.

Review of the physician's orders dated 2/22/16 at 6:30 PM revealed orders for a wound VAC (Vacuum Assisted Closure) to be changed Tuesday and Friday with 125 continuous negative pressure.

Review of the Physician's orders dated 2/23/16 at 7:20 AM revealed the following wound care orders:

1. Clean with Carraklenz BID (twice a day).
2. Apply Granulex and cover with dry dressing BID and PRN...
4. Notify wound care nurse.

Review of the Physician's orders dated 2/23/16 at 10:09 AM revealed orders for the nurse to cleanse the wound with Carraklenz on Monday, Wednesday and Friday and PRN if dressing soiled and cover with adhesive foam.

Review of the Physician's order dated 2/23/16 at 6:00 PM revealed an order for sterile water 500 ml (milliliters) for wound care.

Review of the Daily Nursing Assessment dated 2/22/16 revealed no documention the staff performed wound care.

Review of the Daily Nursing Assessment dated 2/23/16 at 4:55 PM and 2/24/16 at 9:00 PM revealed documentation the nurse changed the dressing to the left groin area with a wet/dry dressing. There was no documentation of a physician's order for the wet/dry dressing.

There was no documentation in the Daily Nursing Assessment dated 2/22/16, 2/23/16 and 2/24/16 of a wound description to include size or description of tissue.

An interview was conducted with EI # 6, Chief Nursing Officer on 2/25/16 at 2:20 PM. EI # 6 verified the above findings.

8. MR # 20 was admitted to the facility on 2/5/16 with diagnoses including Disuse Myopathy.

Review of the physician's orders dated 2/6/16 at 3:20 AM revealed orders for the nurse to provide incision care as follows:

1. Clean with Carraklenz daily.
2. Cover with dry dressing.

Review of the Daily Nursing Assessment dated 2/6/16 revealed no documentation the staff provided wound care.

Review of the Daily Skin Assessment dated 2/6/16 revealed documentation of an area to the right toes with sutures and minimal serosanguineous drainage. There was no documentation of a size or description of the surrounding tissue.

Review of the Skin Assessment dated 2/7/16 revealed no documentation the staff provided wound care.

Review of the Daily Skin Assessment dated 2/7/16 revealed a blank page.

Review of the Daily Nursing Assessment dated 2/9/16 revealed no documentation the staff provided wound care.

Review of the Daily Skin Assessment dated 2/9/16 revealed documentation of an area to the right toes with sutures. There was no documentation of a size or description of the surrounding tissue.

An interview was conducted with EI # 6 on 2/25/16 at 2:25 PM. EI # 6 verified the above findings.

9. MR # 23 was admitted to the facility on 12/3/15 with diagnoses including Anorexia with Sepsis Respiratory Failure.

Review of the Interdisciplinary Assessment dated 12/3/15 revealed the patient had a PICC line in the right upper extremity.

Review of the physician's order written on 12/4/15 at 11:00 AM revealed orders to weigh patient daily and PEG (percutaneous endoscopic gastrostomy) site care as follows:

1. Clean with Carraklenz daily.
2. Cover with dry dressing.

Review of the graft sheet revealed no documentation of a weight on 12/3/15 or 12/4/15.

Review of the Daily Nursing Assessments dated 12/3/15 to 12/10/15 revealed no documentation PEG site care was performed.

Further review of the Daily Nursing Assessments dated 12/3/15 to 12/10/15 revealed the only documented PICC line dressing change was on 12/9/15.

Review of the 12/9/15 Daily Nursing Assessment revealed the following documentation, "IV(Intravenous) dressing changed to triple lumen on R (right) AC (antecubital-fossa) (the inter elbow area). There was no documentation of what the nurse used to clean the area, the dressing applied or catheter position.

An interview was conducted with EI # 6 on 2/25/16 at 2:00 PM. EI # 6 verified the above findings.

10. MR #1 was admitted to the facility on 2/23/16 with diagnoses including Disuse Myopathy.

Review of the physician's orders dated 2/23/16 at 4:00 PM revealed orders for the nurse to provide incision care as follows:

1. Clean with Carraklenz daily.
2. Cover with dry dressing.

Review of the Interdisciplinary Assessment dated 2/23/16 revealed the patient had an abdominal incision with staples.

An observation of medication administration was conducted on 2/23/16 at 8:45 AM with EI # 13, Registered Nurse. EI # 13 administered Lovenox 40 mg (milligrams) subcutaneous in MR # 1 abdomen. When EI # 13 lifted the patient's shirt MR # 1 complained of tenderness at the incisional area. EI # 14, Occupational Therapist was also in the patient's room. EI # 14 asked EI # 13 if the incisional area could be covered and EI # 13 stated, "The orders are for the incisional area to be left open to air".

An interview was conducted on 2/24/16 at 9:30 AM with EI # 5, Certified Rehabilitation Registered Nurse. The surveyor asked if the abdominal wound should have been covered according to the orders and the response was, "Yes"



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11. MR # 24 was admitted to the facility on 2/11/16 with diagnoses including Left Above the Knee Amputation and Thoracic 9 Paralysis.

Review of the MR revealed wound care orders as follows:
Stage 2 sacral wounds:
1. Clean with Carraklenz BID (twice a day)
2. Apply Granulex then cover with moisture barrier cream BID and PRN...

Deep tissue injury / pressure ulcer right heel:
1. Clean with Carraklenz BID
2. Apply Granulex and cover with dry dressing BID and PRN...

Incision Care right AKA (above the knee amputation)
1. Clean with Carraklenz daily
2. Cover with dry dressing

Physician's Order dated 2/11/16: Medihoney apply to right heel daily with wound care.

Physician's Order dated 2/12/16:
Wound care daily to right dorsal foot:
Medihoney or therapeutic equivalent daily, cover with Xeroform every 24
hours.

Physician's Order dated 2/12/16: wound culture / gram stain, dorsum right foot.

Physician's Order dated 2/16/16: Hibiclens to right foot daily with wound care, cover with Vaseline gauze, wrap with Kerlix, change daily or sooner if soiled.

Physician's Order dated 2/17/16: Contact Isolation - multidrug resistant Pseudomonas colonizing foot wound.

Review the 24 hour nurse notes dated 2/12/16, 2/13/16, and 2/14/16 revealed no documentation the wound care was provided as ordered to the sacral wounds, the right dorsal wound and the right heel wound.

Review of the medication administration record dated 2/13/16 to 2/23/16 revealed an order for balsam Peru-castor oil topical 87 mg-788 mg/g(gram) twice a day for Granulex. There was no documentation as to where this was to be applied.

An interview was conducted on 2/25/16 at 1:45 AM with EI # 12, Regional Chief Nursing Officer, who verified the above findings.

12. MR # 30 was admitted to the facility on 1/30/16 with diagnoses including Cerebral Infarction.

Review of the physician's orders revealed wound care orders to stage 2 area to sacrum/buttocks as follows:
1. Clean with Carraklenz BID.
2. Apply Granulex then cover with moisture barrier cream BID and PRN...

Review of the 7 Day Medication Administration Record dated 2/3/16 to 2/9/16 revealed the following order: balsam Peru-castor oil-trypsin topical 87 mg-788 mg-0.12 mg/g top at 6 AM and 6 PM, replaces Proderm.
There is no documentation as to where to apply.

Review of the Interdisciplinary Daily Documentation (IDD) Daily Nursing Assessment notes and the Daily Skin Assessment notes dated 2/1/16, 2/2/16, 2/3/16, 2/4/16, 2/5/16, 2/6/16, 2/7/16, and 2/9/16 revealed no documentation of the ordered wound care being provided.

An interview was conducted with EI # 12, Regional Chief Nursing Officer, who verified the above findings.

Based on observation, medical record (MR) review and interviews, it was determined staff failed to:

a) Confirm incomplete medication orders and apply medications to ordered sites for 1 of 1 patient's with topical medications MR # 13.

b) Administer sliding scale insulin as ordered in 1 of 5 patient's requiring sliding scale insulin MR # 14.

This had the potential to affect all patients treated at the facility.

Findings include:

1. MR # 13 was admitted to the facility on 2/17/16 with diagnoses to include Right Nondisplaced Greater Trochanteric Fracture.

A review of a physician's order written on 2/23/16 at 11:26 AM revealed Voltaren gel to (B) bilateral knees QID (4 times a day) was ordered.

Review of the Medication Administration Record (MAR) revealed Diclofenac topical 1 % (Voltaren) 1 top (topical) four times daily to B knees QID. The MAR documentation did not include a dosage for the Voltaren gel.

Observations were made on 2/24/16 at 8:00 AM with Employee Identifier (EI) # 3, Registered Nurse who performed a medication pass. The surveyor observed the following:

The Voltaren gel was kept at the patient's bedside. There was no physician's order for Voltaren gel to be left at the bedside.

EI # 3 applied 1 % Voltaren to bilateral elbows as well as bilateral knees. The physician's order was to apply to bilateral knees. There was no order to apply Voltaren gel to bilateral elbows.

EI # 3 applied 2 grams of Voltaren to bilateral elbows and knees. The physician's order did not reveal the amount of Voltaren gel to be applied QID. The MAR order was not specific for the amount of Voltaren gel to apply.

In an interview on 2/24/16 at 8:20 AM following medication administration, the surveyor asked EI # 3 how he/she knew to apply 2 grams of Voltaren? EI # 3 replied he/she had always applied 2 grams, that was what he/she was taught.

At 9:10 AM on 2/24/16, EI # 3 reported to the surveyor she/he had spoken with the pharmacy department. Per EI # 3, pharmacy instructions revealed Voltaren was to be applied 2 grams to the elbows and 4 grams to the knees. The surveyor asked EI # 3 to obtain written information of the Voltaren dosing from pharmacy. No documentation was provided to the surveyor.

The 2/23/16 Voltaren order was not specific to the amount of Voltaren to be applied. Staff failed to document confirmation of an incomplete Voltaren order in the medical record. The MAR was transcribed with an incomplete Voltaren dosage. EI # 3 failed to confirm the Voltaren dosage prior to application. EI # 3 applied Voltaren to sites not ordered by the physician. There was no physician's order to leave Voltaren at the patient's bedside.

During an interview on 2/25/16 at 1:30 PM, EI # 5, Certified Rehabilitation Registered Nurse confirmed the findings above.

2. MR # 14 was admitted to the facility on 2/18/16 with diagnoses including Left Total Knee Arthroplasty (TKA) and History of Degenerative Joint Disease. Past medical history revealed Diabetes Mellitus Type II.

Review of the 2/18/16 4:00 PM Standing Physician's Orders included Perform Blood Sugar with Sliding Scale Insulin using Lakeshore Protocol.

Review of the MAR revealed Insulin Novalog 2-12 units subcutaneous as needed for the following blood sugar: 61-180-give nothing; 181-200-give 2 units; 201=250-give 4 units, 251-300-give 6 units; 301-350-give 8 units; 351-400-give 10 units; > 400-give 12 units and call medical doctor; normal range=79-120 milligram/deciliter (mg/dl).

In an interview with EI # 5 on 2/25/16 at 1:40 PM, EI # 5 reported blood glucose monitoring was to be performed daily at 7:00 AM, 11:00 AM, 4:00 PM and 9:00 PM.

Record review revealed the 2/20/16 4:00 PM blood glucose results were 221 mg/dl. There was no documentation 4 units of Novalog insulin was administered as ordered.

During the interview on 2/25/16 at 1:45 PM, EI # 5 verified staff failed to document sliding scale insulin administration on 2/20/16 at 4:00 PM.

Based on United States Health Public Food Code 2009 regulations, observations and interview, it was determined the hospital failed to ensure food was stored in a safe and sanitary manner.

This had the potential to negatively affect all patients.

Findings include:

United States Health Public Food Code 2009

3-501.17 Ready-to-Eat, Potentially Hazardous Food
(Time/Temperature Control for Safety Food),
Date Marking.
...commercially processed food open and hold cold
(B) Except as specified in (D) - (F) of this section, refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety...

(C) A refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) ingredient or a portion of a refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is subsequently combined with additional ingredients or portions of food shall retain the date marking of the earliest- prepared or first prepared ingredient.

(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include:...
(2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section;
(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section...

A tour of the Dietary Department was conducted on 2/23/16 at 10:30 AM. The surveyor observed the following in the refrigerator:

a. Multiple single serving plastic covered bowls of black bean salad on a tray without a label or date.

b. Opened green bean containers with no date opened.

c. Opened large containers of mixed vegetables with no date opened.

d. Multiple plastic wrapped bread products out of the original package without a label or date.

e. French fries out of the original package without a label or date.

f. Open package of Hot Dogs without a label or date. The hot dogs had ice inside the package and on the hot dogs.

g. Open package of chicken strips without a label or date. The chicken strips had ice inside the package and on the chicken strips.

h. Precooked eggs out of original package with no labeled or date.

Also during the tour of the Dietary Department on 2/23/16 at 11:00 AM, the surveyor observed the following in the cooking area freezer:

Numerous large metal cooking pans covered with aluminum foil and some had torn places in the aluminum foil. One metal pan was labeled 12/2015. There was no other label to identify what were in the large metal cooking pans.

An interview with Employee Identifier (EI) # 17, Contracted Dietary Worker and EI # 16, Contracted Dietary Manager at various areas of the tour on 2/23/16 from 10:30 to 11:00 AM, confirmed the above findings.

Based on observations, review of facility policy and procedure and interviews with facility staff it was determined the facility failed to ensure supplies were stored safely in the Outpatient Therapy (OPT) Department.

This had the potential to negatively affect all patients receiving services in the OPT Department.

Findings include:

Infection Control Policy and Procedure Manual
Revised/Reviewed: February 2014

Section 1- Infection Control Program

1.1 Purpose: The Infection Control Program (ICP) is designed to identify, control, and prevent hospital acquired infections. It provides guidelines for the practice of infection control. ... This document applies to all personnel ...

Section 3: Supplies and Equipment

...3.7. Supply Storage.

...3.7.2 ...Supplies are not stored ... in any way that may be deemed unsafe."

1. During observations of care in the OPT Department on 2/24/16 at 9:25 AM the surveyor observed an Ultrasound Gel bottle (8.5 ounces) with a piece of blue tape on the bottle labeled, "BioFreeze".

The surveyor asked Employee Identifier (EI) # 23, Senior Occupational Therapist (OT) what was in the bottle and when did it expire. There was no expiration date on the blue bottle labeled "BioFreeze". EI # 23 verified that it was "Biofreeze which came from this larger pump bottle and they had just put it in this bottle (Ultrasound Gel) to make it easier to use". EI # 23 then proceeded to pick up the large pump bottle of BioFreeze and stated, "it expires 7/2016, do I just need to put that date on there?"

An interview was conducted on 2/25/16 at 9:16 AM with EI # 7, Director of Therapy Operations, who stated the BioFreeze should be left in its original container.

Based on observations, review of the Infection Control Tracking document, personnel files, facility policies and procedures and interviews, it was determined the facility failed to ensure the staff:

a) Followed and performed hand hygiene and gloving per the facility policy and procedure.

b) Followed the facility policy and procedure for cleaning of equipment after patient use.

c) Wore appropriate personal protective equipment (PPE) when performing tasks as directed per facility policy.

d) Were deemed competent to access and maintain a central intravascular catheter.

e) Followed the facility policy for Hepatitis B screening requirements and immunization.

f) Changed dust mop heads.

This affected Medical Record (MR) # 25, #13, # 2, # 24, 8 unsampled patients, and Employee Identifiers (EI) # 25, 22, 24 (3 of 12 personnel records reviewed), and had the potential to negatively affect all patients and staff at this facility.

Findings include:

Facility Policy:Infection Control Policy and Procedure Manual
Revised/Reviewed: February 2014

Section 1- Infection Control Program

1.1 Purpose: The Infection Control Program (ICP) is designed to identify, control, and prevent hospital acquired infections. It provides guidelines for the practice of infection control. ... This document applies to all personnel ...

Section 2 - Patient Care Practices

...2.3 Handwashing: Handwashing is the single most effective method to prevent the spread of infection.

...2.3.5.1.1. Before and after performing routine patient care or direct patient, equipment, and environment contact.

...2.3.5.1.7. Before and after wear of gloves.

...

2.4. Standard Precautions.

2.4.1. Standard Precautions (SPs) apply to the handling of all blood, body fluids, secretions ... SPs are to be used with every patient, every time they receive care, inpatient or outpatient, regardless of their diagnosis or presumed infection status.

... 2.4.2.5. Gloves are changed and appropriate hand washing is accomplished after each patient contact and when moving from one body area to another with the same patient.

2.4.2.6. ... Hand washing is accomplished immediately after removing gloves.

...

Section 3: Supplies and Equipment
...3.3 Cleaning, Decontamination, and Disinfection
3.3.3. Disinfection is a process that kills or destroys nearly all disease producing microorganisms...

3.3.4.3. Virex-TB (tuberculosis), Sani-Cloths are available for cleaning and disinfecting patient care items and equipment (with the exception of Glucometers...which shall be cleaned with bleach wipes). Gloves will be worn when handling any disinfectant...

Section 5-Employee Health

...5.2 Periodic and Pre-employment Health Surveys and Examinations.

5.2.2 All personnel complete...and comply with the immunization and screening requirements... Department Managers are responsible for making sure all employees are processed through Employee Health for completing of in-processing health survey and immunization screening...

Table 5 A, Immunization & Screening Requirements:

Personnel Category-

Employees of LSH (Lakeshore Hospital)

Table 5B, Immunization Requirements

Hepatitis B (HBV)-Currently all high-risk personnel are recommended to receive the vaccination series.
-Applicable personnel are screened for a history of the completed HBV series and documented serologic evidence of immunity within 10 days of hire to Lakeshore Hospital
-Personnel recommended to have the Hepatitis Vaccine series will sign a declination letter if they do not wish to have the vaccine...

Section 6 - Isolation and Precautions

6.1. Fundamentals of Isolation Precautions. These fundamentals are infection control measures used to decrease the risk of transmission of microorganisms in the outpatient and inpatient environment.

...6.6. Contact Precautions. In addition to Standard Precautions, use Contact Precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by indirect contact with items in the patient's environment...

...6.6.2. Personal Protective Equipment (PPE). Gloves are required when entering the patient's room. Gown and gloves are required for all personnel and visitors when in close or direct contact with the patient, or used patient equipment (... bed rails, over bed table ...) or supplies."

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Facility Policy: Environmental Services General Housekeeping and Patient Room Cleaning
Revised/Reviewed: 1/2014

Policy: Healthsouth will utilize established Infection Control practices to safely maintain a clean and hygienic facility.

Procedure:

The following are general infection control guidelines for environmental cleaning. ...

1) All ES (Environmental Services) personnel will utilize standard precautions at all times for all patients.

...8. Mop heads are changed with each patient room.

How to Dust Mop a Room

1. Use a new dusting pad for each room.

...5. After you have completed mopping the room, remove the pad from the mop handle by:

...c. Lift the handle ... place into laundry bag.

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Facility Policy:Performing Patient Testing on the Accu-chek Inform II System

Procedure-Patient Testing

12. Press the power OFF button to turn off the ACCU-CHEK Inform II system.

13. Document the blood glucose result...

14. The meter should be cleaned according to manufacture's directions, using a Super Sani-Cloth Germicidal Disposable Wipes or Clorox Germicidal Wipes. Do not use any other cleaning or disinfecting solution..."


1. MR # 24 was admitted to the facility on 2/11/16 with diagnoses including Left Above the Knee Amputation and Thoracic 9 Paralysis.

Review of the MR revealed the following orders:

2/11/16: Deep tissue injury / pressure ulcer right heel:
1. Clean with Carraklenz BID (twice a day)
2. Apply Granulex and cover with dry dressing BID and PRN (as needed)...

2/11/16: Medihoney apply to right heel daily with wound care.

2/12/16: Wound care daily to right dorsal foot: Medihoney or therapeutic equivalent daily, cover with Xeroform every 24 hours.

2/12/16: Wound culture / gram stain dorsum right foot.

2/16/16: Hibiclens to right foot daily with wound care, cover with Vaseline gauze, wrap with Kerlix.

2/17/16: Contact Isolation - multidrug resistant Pseudomonas colonizing foot wound.

Surveyor observation of care was conducted on 2/24/16 at 9:45 AM with Employee Identifier (EI) # 11, Registered Nurse, to observe wound care and foley catheter change with MR # 24.

EI # 11 donned gown and gloves prior to entering the patient's room. EI # 11 began opening wound care supplies and placed on the overbed table without cleaning the surface and without a barrier. EI # 11 then removed a pair of scissors from his/her uniform pocket and placed on the overbed table without cleaning the scissors. EI # 11 cut the dressing on the patient's right foot using the scissors, removed the soiled dressing, exposing two wounds. EI # 11 discarded the soiled dressing in the patient's bedside trash can. EI # 11 removed the gloves and regloved without performing hand hygiene, cleaned the dorsal wound and the right heel without changing gloves between wounds. With the same gloves EI # 11 picked up the top to the Hibiclens bottle and replaced it, picked up the scissors and cut the Vaseline gauze, placed the Vaseline gauze on the dorsal wound, cut a second piece of Vaseline gauze and placed on the heel wound. EI # 11 removed the soiled gloves, donned clean gloves without performing hand hygiene, wrapped the right foot with Kerlix covering both wounds, cut the Kerlix wrap with the scissors without cleaning the scissors, and secured the dressing with tape, dated the dressing and removed the gloves. The surveyor did not observe the use of Medihoney as ordered during the wound care. All soiled supplies and gloves were discarded in the patient's bedside trash can which was lined with a regular clear can liner not a red biohazard bag.

During the same observation, EI # 11 donned gloves without performing hand hygiene, opened the foley catheter insertion tray on the overbed table without cleaning the table surface or a barrier, removed the sterile drape and placed on the patient's bed on top of the sheet. EI # 11 removed the gloves, donned the sterile gloves from the insertion tray, removed all supplies from the tray maintaining them on a clean field, prepared the betadine solution with cotton balls in the sterile tray, opened the foley catheter and inflated/deflated the catheter balloon and placed the tip in the lubricant. EI # 11 then realized he/she did not have the supplies needed to remove the old foley and had to leave the room to obtain a syringe. EI # 11 did not perform hand hygiene when leaving the isolation room. EI # 11 returned with a syringe and additional sterile gloves. He/she donned non-sterile gloves, deflated the balloon and removed the old catheter which was connected to a leg bag. EI # 11 took the used catheter and leg bag along with the patient's urinal into the adjacent bathroom, measured the urine in the urinal and discarded in the toilet. The used catheter and leg bag was discarded in the bedside trash. EI # 11 removed the gloves without performing hand hygiene, donned sterile gloves and proceeded with the foley catheter insertion by first cleansing the meatus with betadine soaked cotton balls then inserted the foley catheter, inflated the balloon and urine return was observed. EI # 11 did not have a drainage bag to connect the foley to and retrieved the urinal from the bedside without cleaning and placed the sterile foley catheter tube into the urinal to drain.

An interview was conducted on 2/25/16 at 1:45 PM with EI # 2, Regional Chief Nursing Officer, who verified the findings above were not in accordance with infection control policy/practices.

During a review of the infection control program on 2/25/16 at 10:25 AM with EI # 6 and EI # 10, Interim Infection Control, the aforementioned infection control findings were reviewed. EI # 6 and EI # 10 confirmed the staff were not following the facility's infection control policies and procedures.

2. An observation was conducted on 2/23/16 at 1:30 PM with EI # 18, Environmental Services (ES) Team Leader (TL) and EI # 19, ES Float Technician to clean and disinfect a patient's room post discharge. EI # 6, Chief Nursing Officer (CNO) was also present during this observation. The surveyor observed the following:

EI # 18 and # 19 changed gloves multiple times without performing hand hygiene between glove changes as directed per the facility policy.

EI # 19 was not wearing gloves while assisting with disinfecting the mattress with Virax 256 and the wheelchair with bleach cloths.

At 2:30 PM EI # 19 re-entered the room with an uncovered red dust mop. EI # 19 dusted the room the with mop, then proceeded to sit the mop in the hallway outside the door unbagged. The surveyor asked EI # 19 how often are mop heads changed post use? EI # 19, replied, "I change it out over 2-3 rooms." EI # 19 then carried the dust mop down the back hallway to the stairwell.

EI # 19 did not follow the facility policy for changing dust mop heads between each patient room cleaning and placing the dust mop in a laundry bag post use.

3. An observation was conducted by the surveyor on 2/24/16 at 7:45 AM with EI # 11, Registered Nurse (RN) to observe 8:00 AM medication administration to MR # 25.

Review of the Infection Control Tracking document submitted to the surveyors on 2/24/16 revealed MR # 25 was admitted on 2/9/16 and had a urine Culture and Sensitivity (C&S) on 2/11/16 which resulted in Vancomycin-Resistant Enterococci (VRE).

Prior to entering MR # 25's room the surveyor observed a sign which read, "Contact Isolation".

Upon entering MR # 25's room the surveyor observed EI # 20, Aide, standing directly at the MR# 25's bedside. EI # 20 was not wearing a gown as directed per the facility policy.

4. An observation was conducted by the surveyor on 2/24/16 at 8:00 AM with EI # 21, RN (Registered Nurse) to observe 8:00 AM medication administration to an unsampled patient. EI # 21 informed the surveyor that one (1) medication would have to be retrieved from the first floor medication room. EI # 21 proceeded to the backstair well with the unsampled patient's medication cup containing 4 oral medications and 1 injectable medication to the first (1st) floor medication room. EI # 21 entered the medication room and retrieved the unsampled patient's medication from the medication dispense system without performing hand hygiene.

An interview was conducted on 2/25/16 at 10:25 AM with EI # 6, who verified the aforementioned findings.

5. During observations of care in the outpatient therapy department on 2/24/16 at 8:45 AM, the surveyor observed EI # 22, Physical Therapist, performing massage therapy exercises to an unsampled patient's lower back. EI # 22 retrieved a jar of "Professional Massage Cream" from a cabinet then stuck his/her finger into the jar, obtained a small amount of cream then proceeded to massage it into the patient's back. EI # 22 then repeated this process again. EI # 22 stored the jar of Professional Massage Cream in the cabinet post use. EI # 22 was not wearing gloves and did not use an applicator to obtain the massage cream from the jar.

An interview was conducted on 2/24/16 at 10:40 AM with EI # 7, Director of Therapy Operations, who stated, "The staff should have used a tongue depressor ... or a clean glove - never re-entry because of contamination".



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6. During observations of care on 2/23/16 at 10:40 AM in the 'green gym', the surveyor made the following observations:

The surveyor observed an unsampled patient enter the treatment room and transfer from wheelchair (wc) to the treatment table. After the treatment was complete at 10:55 AM, EI # 14, Occupational Therapist (OT) cleaned the treatment table using Sani-Cloths disinfectant wipes.

EI # 14 was not wearing gloves while disinfecting the treatment table. EI # 14 did not perform hand hygiene after cleaning the treatment table

EI # 14 then retrieved the 'treatment plan' notebook, placed it on the clean treatment table and assisted another unsampled patient in a wheelchair to the side of the clean treatment table.

EI # 14 failed to perform hand hygiene prior to patient contact.

7. At 10:55 AM, EI # 15, Physical Therapist, while wearing gloves, was observed cleaning a walker with a wash cloth, then folded the walker and placed it in the treatment room corner. The surveyor asked EI # 15 what the walker was cleaned with ? EI # 15 reported to the surveyor Virex Tb was used to clean the walker.

EI # 15 then removed and discarded gloves. EI # 15 failed to perform hand hygiene after glove removal. With dirty hands, EI # 15 then retrieved a Sani Cloth wipe, cleaned a table top and discarded the Sani-wipe. EI # 15 then exited the treatment area.

EI # 15 was not wearing gloves while cleaning the table top (corner area). EI # 15 did not perform hand hygiene after equipment cleaning/disinfecting.

EI # 15 failed to perform hand hygiene after glove removal and did not wear gloves while disinfecting equipment.

8. During observations of care on 2/23/16 at 11:30 AM, EI # 2, Patient Care Technician was observed performing blood glucose testing using an ACCU-CHEK Inform II glucometer.

EI # 2 retrieved the ACCU-CHEK Inform II glucometer and case from the nursing station, entered an unsampled patient's room and obtained gloves from the glove box on the wall. EI # 2 placed the glucometer case on the bed, then donned gloves.

EI # 2 did not perform hand hygiene before donning gloves and before patient contact.

EI # 2 completed blood glucose testing using the ACCU-CHEK Inform II glucometer. EI # 2 removed the right glove and discarded the glove and lancet (sharp) into the sharps container. EI # 2 then opened the glucometer case and replaced the ACCU-CHEK glucometer into the case. EI # 2 then removed his/her left glove and used hand sanitizer.

EI # 2 entered the second unsampled patient's room, placed the ACCU-CHEK Inform II glucometer case on the bedside table. EI # 2 donned gloves but failed to perform hand hygiene before donning gloves.

EI # 2 performed blood glucose monitoring, discarded the lancet into the sharps container, removed the right glove, discarded the alcohol prep package, removed left glove and sanitized hands.

EI # 2 returned to the nursing station and placed the ACCU-CHEK Inform II glucometer onto the charging station.

EI # 2 failed to disinfect the ACCU-CHEK Inform II glucometer with bleach wipes between patient use.

9. On 2/24/16 at 7:55 AM, care observations during medication pass were completed with EI # 3, Registered Nurse (RN), and revealed the following:

EI # 3 entered MR # 13's room and performed hand hygiene and gloved. EI # 3 proceeded to complete vital signs and cleaned the temporal scan thermometer with an alcohol wipe.

EI # 3 then retrieved MR #13's chart from the wall bin, removed and discarded the gloves. EI # 3 did not perform hand hygiene after glove removal and EI # 3 failed to perform hand hygiene before inserting unclean hands into the clean glove box.

With gloves on, EI # 3 then administered 5 oral medications to MR # 13 and retrieved a box of Voltaren gel left at the bedside.

EI # 3 removed and discarded gloves, obtained clean gloves from the glove box. EI # 3 failed to perform hand hygiene after glove removal.

EI # 3 applied Voltaren gel to the measuring device, rubbed Voltaren gel on MR # 13's elbows. EI # 3 then removed and discarded gloves, obtained and donned clean gloves from the glove box, then applied Voltaren gel to MR # 13's knees.

EI # 3 failed to perform hand hygiene after glove removal and prior to inserting unclean hands into the clean glove supply.

During an interview with EI # 3 on 2/24/16 at 10:25 AM, EI # 3 confirmed she/he failed to follow facility policy for hand washing.




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10. An observation of a medication administration was conducted on 2/24/16 at 8:15 AM with EI # 13, RN. EI # 13 entered an unsampled patient's room. Donned gloves without hand hygiene, removed the gloves and went to the refreshment room to obtained a glass of ice water. EI # 13 returned to the patient's room, donned gloves, administered the oral medication, removed the gloves, and exited the room all without hand hygiene.

11. Another observation of a medication administration was conducted on 2/24/16 at 8:25 AM with EI # 13. EI # 13 entered the patient's room and the patient stated he/she had gone to the bathroom. EI # 13 donned gloves without hand hygiene, changed the patient's wet diaper, removed gloves, donned more gloves without hand hygiene, and administered the patient's medication. EI # 13 failed to perform hand hygiene before and after gloves.

12. MR # 2 was admitted to the facility on 2/19/16 with diagnoses including Amputation to Partial Right Foot With MRSA (Methicillin-Resistant Staphylococcus Aureus).

Review of the Interdisciplinary Assessment dated 2/19/16 revealed the patient had a PICC (peripherally inserted central catheter) line in the right upper extremity.

Review of the Medication Administration Record revealed EI # 24, RN administered Heparin and Vancomycin via the PICC line on 2/20/16 and 2/21/16.

Review of EI # 24 personnel record on 2/25/16 revealed no documentation of a competency for EI # 24 to access or maintain a central intravascular catheter.

An interview was conducted with EI # 6, Chief Nursing Officer on 2/25/16 at 11:00 AM. EI # 6 verified there was no documentation in the personnel record of competency to access or maintain of a central intravascular catheter.



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13. During observations of care on 2/23/16 at 11:00 AM to observe Employee Identifier (EI) # 1, Licensed Practical Nurse (LPN) perform a blood glucose with a Glucometer machine on an unsampled patient. EI # 1 removed his/her gloves and donned new gloves three times during the procedure without performing hand hygiene between glove changes as directed per the facility policy. After completing the procedure, EI # 1 then cleaned the glucometer with Virex TB. EI # 1 failed to follow the facility policy for cleaning the glucometer with bleach wipes post use.

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On 2/25/16 at 1:00 PM, review of personnel files revealed the following missing documentation for Hepatitis screening and immunization:

1. EI # 25, Registered Dietician, date of hire was 8/28/06. There was no documentation EI # 25 had been screened for Hepatitis B.

EI # 25 signed the document titled Hepatitis B Vaccine Employee Consent on 8/28/06. There was no documentation the facility administered the Hepatitis B vaccination series to EI # 25.

2. EI # 22, Physical Therapist, date of hire was 10/5/2015. There was no Hepatitis B screening documentation in the personnel file. There was no consent or declination for the Hepatitis B vaccination documented in EI # 22's personnel record.

Written questions were were submitted to staff on 2/25/16 at 1:14 PM.

At 2:37 PM on 2/25/16, EI # 27, Hospital Educator verified the above documentation was not in the personnel files and no additional documentation was submitted.

3. EI # 24, Registered Nurse, date of hire was 7/3/89. There was no documentation of Hepatitis B screening in the personnel file. There was no consent or declination for the Hepatitis B vaccination documented in EI # 24's personnel record.

An interview was conducted on 2/25/16 at 2:40 PM with EI # 27, who verified the above documention was not in personnel files and no additional documentation was submitted.

Review of facility policy, 2015 Utilization Review Dashboard, 4th Quarter 2015 Utilization Review Report, medical record (MR) and interview, it was determined the facility failed to evaluate rehabilitation inpatient readmissions for discharge planning effectiveness. This affected MR # 15 and had the potential to affect all patients admitted to the facility.

Policy: Utilization review Policy
Revised/Reviewed: 1/16

Purpose

"The Utilization Plan...is designed to ensure efficient and appropriate utilization of resources to meet individual patient's clinical needs and service expectations.

Objectives:

...To assist in the promotion of quality patient care through the review and evaluation of clinical practices, including service utilization, LOS (length of stay) management and acute care transfers....

II. Committee Functions and Responsibilities

A. The Committee functions shall include, but are not limited to:

3. Utilize peer review process to perform reviews
7. Review and analysis of acute care transfers and readmissions.

IX. Evaluation of Utilization Review Plan

B. Results of this analysis with pertinent information is reported through the utilization Review function to quality/performance improvement structure of the facility..."

Findings include:

MR # 15 was admitted to the facility 8/18/15 with diagnoses including Disuse Myopathy and Chronic Obstructive Pulmonary Disease.

Review of the Discharge Summary dated 9/3/15 revealed MR # 15's length of stay was 14 days and included a "hospital course complicated by multiple factors including confusion...consulted for evaluation for active depression...started on Wellbutrin (anti-depressant)...developed increased cough and shortness of breath...chest x-ray revealed bilateral lower lobe atelectasis. Sputum culture was positive...started on Levaquin (antibiotic)...able to participate in therapy and make significant gains..."

MR # 15 was discharged home on 9/1/15, home health services to follow.

Review of facility readmissions documentation within 30 days revealed MR # 15 was re-admitted to the facility on 9/24/15.

Review of the 9/24/15 Pre-screen Admission form revealed the following hospitalization history documentation: Previous acute inpatient admission 8/4/15 to 8/14/15, treated and transferred to Lakeshore Rehab (rehabilitation) hospital. Patient did well, was discharged home on 9/1/15. Patient was home approximately 2 hours and fell, returned to emergency department where he/she was found to have a fracture of right wrist, right elbow and right shoulder. Patient was casted and right upper extremity placed in an immobilizer. On 9/4/15 MR # 15 was admitted to named nursing home and more intensive rehabilitation was ordered. MR # 15 was then re-admitted to HealthSouth Rehab hospital on 9/24/15 for Orthopedic Aftercare.

An interview was conducted on 2/25/16 at 9:45 AM with Employee Identifier (EI) # 4, Director of Case Management.

During the interview, the surveyor asked EI # 4 how the facility evaluated the effectiveness of discharge planning services?

EI # 4 provided the surveyor with the facility 2015 Utilization Review Dashboard documentation and the 4th Quarter 2014 Utilization Review Report.

Review of the facility 4th Quarter 2014 Utilization Review Report did not include documentation of the facility readmission rate.

Review of the facility 2015 Utilization Review Dashboard documentation also failed to include facility readmission evaluation data. There was no documentation the facility tracked its readmissions, performed and evaluated analysis of its readmissions to assess discharge planning effectiveness.

During the interview on 2/25/16 at 12:35 PM, EI # 4 confirmed the above findings and reported no review of MR # 15's record for discharge planning effectiveness was performed.

Based on the review of the facility's policy and procedure, record review and interview with staff, it was determined the facility failed to ensure the staff followed the policy for Organ Donation including the Alabama Eye Bank (AEB) for 1 of 1 death record reviewed. This included Medical Record (MR) # 21 and had the potential to affect all deaths that occur in this facility.

Findings include:

Facility Policy and Procedure: Organ Donation
Procedure #: 686
Revised Date: 8/15

Purpose: This procedure is established with Federal, State, and JCAHO (Joint Commission on Accreditation of Healthcare Organizations) requirements of written protocols for the identification of potential organ, tissue, and eye donors. The protocol is designed to ensure that families of potential donors are informed of the option of donation and their option to decline. In cooperation with the Alabama Organ Center (AOC) and the Alabama Eye Bank (AEB), ...Hospital will participate with the Routine Referral Donation Program.

Procedure:

1. Determination of Suitability for Organ, Tissue, or Eye Donation

A. The nursing supervisor or designee will notify the AOC and AEB when a death occurs, (within 1 hour) or becomes imminent.

C. The AOC and AEB representative will evaluate each potential donor to determine suitability for donations.

D. A Routine Referral Donor Form will be completed with each referral by the nursing supervisor or designee upon consultation with the AOC and AEB representative.

E. The Routine Referral Donor Form will become a permanent document of the patient's medical record. The form will serve as documentation of organ, tissue, and eye donation candidacy or denial, and the family response to the request.

1. MR # 21 was admitted to the facility on 10/23/15 with diagnoses including Disuse Myopathy. MR # 21 expired on 10/24/15 at 4:47 AM.

Review of the Narrative Comments dated 10/24/15 revealed at 5:03 AM the Nursing Supervisor called AOC and the patient was not a candidate. The Nursing Supervisor called AEB and the staff at AEB want to speak to the family. There was no documentation of a follow up with AEB indicating if the patient was or was not a candidate for eye donation.

Further review of the medical record revealed no documention of a Routine Referral Donor Form being completed.

An interview was conducted on 2/25/16 at 1:35 PM with Employee Identifier # 6, Chief Nursing Officer, who verified the above findings.