HospitalInspections.org

Based on observation, interview and record review, the facility failed to:

A. ensure staff kept a sanitary environment in the soiled utility room, patient rooms, nursing clean supply room/equipment rooms, isolation rooms, respiratory supply room, and hemodialysis supply room on 1 of 1 long term care unit.
The facility failed to ensure staff used proper infection control techniques during care of patients in isolation and patients at high risk for infections.
Refer to tag A0144 for additional information.

B. ensure 2 of 2 patients in restraints had complete assessments and physician orders to justify usage ( Patient #s' 3 and 10).
Refer to tag A0154 for additional information.


C. ensure antipsychotic medications were used as a standard treatment or dosage to treat a patient's condition. The facility failed to ensure antipsychotic medications were medically necessary. This deficient practice was found in 1 of 1 sampled patients (Patient #3).
Refer to tag A0160 for additional information.

Based on observation, interview and record review the facility failed to:

A. ensure 2 of 2 patients with a contagious infectious disease received a consistent assessment, timely collection of lab and provided isolation precautions as needed (Patient #s' 2 and 3).
Refer to tag A0395 for additional information.

B. to ensure antipsychotic medications were used and administered according to accepted standards of practice. The facility failed to ensure nursing staff documented reasons/behaviors to indicate administration and alternative for prn antipsychotic medication usage. They failed to ensure complete pain assessments. This deficient practice was found in 1 of 1 sampled patients (Patient #3).
Refer to tag A0405 for additional information.

Based on observation, interview and record review, the facility failed to:

ensure staff kept a sanitary environment in the soiled utility room, patient rooms, nursing clean supply room/equipment rooms, isolation rooms, respiratory supply room, and hemodialysis supply room on 1 of 1 long term care unit. The facility failed to ensure staff used proper infection control techniques during care of patients in isolation and patients at high risk for infections.
Refer to tag A0749 for additional information.

Based on observation, interview and record review, the facility failed to ensure a sanitary environment in the soiled utility room, patient rooms, nursing clean supply room/equipment rooms, isolation rooms, respiratory supply room, and hemodialysis supply room on 1 of 1 long term care unit.
The facility failed to ensure staff used proper infection control techniques during care of patients in isolation and patients at high risk for infections.
This deficient practice had the likelihood to cause harm to all patients on the unit.
Findings include:

During observation on 05/19/2015, after 8:30 a.m., the following was found:

Soiled utility room
The biohazard container was overflowing with bags of biohazard trash. The top on the container would not close.
A stainless steel rack used to hold food trays was found in the room without any trays on it. The rack was soiled with a buildup of dried substance.

Crash cart
A crash cart stored in the hallway had an open basket near the floor. An unbagged suction canister with tubing attached were in the open basket and were not covered. The suction tubing that was attached was draped down near the floor.

Respiratory supply room
Respiratory supplies were stored in a room on uncovered shelves. Patient equipment, paper files, and a shipping box were on top of the clean supplies. The patient use equipment on the shelves was not covered to indicate it was clean.

Central supply room
Clean and sterile supplies were stored on open shelves and were not covered. Some of the supplies had been taken from their original packets and thrown back on the shelves. Over half of the shelves in the room were approximately 3 inches from the floor. The supplies on the bottom shelf were not protected from dust or dirt. One of the shelves was pulled away from the wall and supplies were found on the floor. Underneath the bottom shelves were packets of supplies and buildup of dust on the floor.
A multi lumen central catheterization kit was found on the shelf which expired on 01/2014.
There was a medication cart in the room which had a buildup of dirt.
A supply transporting cart in the room had a sign on the top of it that read "PLEASE DO NOT USE THIS CART FOR SOILED LINEN OR TRASH AS THIS CART IS USED TO TRANSPORT FOOD AND STERILE SUPPLIES. IF YOU USE THIS CART PLEASE RETURN IT TO THE STOCKROOM". The clear tape that held the sign down was soiled and had turned brown. The top and bottom level of the cart was soiled with brown stains. There were screws on inside of the bottom level that had rusted making the cart unable to be sanitized.
An uncovered oxygen concentrator was found stored in the room with the supplies. The concentrator had a dried brown substance on it and still had an adapter connected to it. The concentrator was not clean.
According to the Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, page 75 revealed the following:
"Following the sterilization process, medical and surgical devices must be handled using aseptic technique in order to prevent contamination. Sterile supplies should be stored far enough from the floor (8 to 10 inches), the ceiling (5 inches unless near a sprinkler head [18 inches from sprinkler head]), and the outside walls (2 inches) to allow for adequate air circulation, ease of cleaning, and compliance with local fire codes (e.g., supplies must be at least 18 inches from sprinkler heads).

Patient rooms
Room # 306
The baseboards in the room had a buildup of dirt and dust. The door frame as you enter the room was cracked open and the wood underneath was exposed. The door could not be sanitized. The patient's bedside table was missing paint and had dried spills down the front of it. There was a used syringe of saline on the floor and the base of the intravenous pump had dried spills. The open trash can was full to the top. Inside the biohazard container was a used Foley Catheter bag with tubing attached.
There was an empty bag of Magnesium sulfate still hanging on the intravenous pole. There was no identifying information on the bag to indicate when it was prepared, supposed to be administered or when it expired.
Review of the clinical record of Patient #4 (housed in Room #306) revealed that she was an 80 year old female admitted on 04/24/2015, with diagnoses that included severe deconditioning and left femur fracture.
Review of the Medication administration record revealed that the Magnesium sulfate was administered to Patient #4 the day prior (05/19/2015) at 9:50 p.m.
Review of the nurse's notes revealed that Patient #4's Foley catheter was removed two days prior on 05/18/2015.
During an interview, Staff #3 reported nursing staff should remove supplies and biohazards from the patient's room after giving care.

Room #308
The door frame as you enter the room was cracked open and the wood underneath was exposed. The light colored floor tile underneath the sink had turned brown in color and the baseboards had a build-up of dirt.
Review of the clinical record on Patient #2 revealed that she was a 71 year old female admitted on 05/11/2015, with diagnoses that included acute kidney failure and hyperkalemia. Patient #2 was housed in Room #308 and was not on contact isolation.
Patient #2 was totally dependent and had a Flex seal (fecal containment) system in place and an indwelling Foley catheter. Patient #2's room had a foul odor. The Foley catheter was positioned underneath Patient #2's leg and the tubing was not looped at the port of entry to allow for free flow of urine into the collection bag. This put Patient #2 at risk for urinary tract infections.
Staff #6 donned gloves while in Patient #2's room and picked up soiled linen. Staff #6 had the linen in direct contact with her uniform. With the same soiled glove on Staff #6 touched items in the room and Patient #2's hand.
Review of the clinical record on Patient #2 revealed a physician's order dated 05/20/2015, which was checked off at 10:00 p.m. The order was for staff to obtain a stool specimen for Clostridium deficile (C.diff).
During an interview on 05/21/2015, at 12:30 p.m., Staff #3 reported that staff had not obtained a stool specimen and was doing so now.

Room #310
Review of the clinical record revealed that Patient #1 was a 54 year old male admitted on 05/19/2015, with a diagnosis of pneumonia. According to the initial nursing assessment, Patient #1 was being placed on contact isolation for the organism Pseudomonas (in the respiratory tract). Patient #1 was placed in room #310.
On 05/20/2015, PPE (Personal Protective Equipment) was stored in a hanging organizer on the outside of the door to Room #310 (leading to hallway). The white plastic covering over the bottom of the same door was broken and exposed the wood underneath. There was no way the door could be sanitized. The white covering was soiled and had turned brown and the tile floor as you enter the room was soiled with a brown build-up.
Housekeeper #8 donned PPE and took a bottle of cleanser, toilet bowl cleanser and a mop into Room #310 with her. Housekeeper #8 was observed to still have on her PPE and stuck her gloved hand out the door and cleaned part of the outside of the door and the door handle with a towel. Housekeeper #8 opened the door to the room and pulled the housekeeping cart closer to the door. She was noted to still have her PPE on. Housekeeper #8 placed the bottle of cleanser used in the room on top of her cart next to another container of cleanser. Housekeeper #8 exited the room later with gloves on and carrying two bags of soiled items. The cloth covering on the mop head used in the room was placed in a plastic bag on the outside of the room and the mop handle was placed on the cart without sanitizing first. After changing gloves Housekeeper #8 obtained another container of cleanser on top of her cart and wiped down the handle of the mop and the lower stainless steel portion of the mop. The lower stainless steel portion of the mop could not be sanitized because it was soiled with a buildup of black substance.
During an interview, Staff #9 and #10 (environmental administrative staff) reported the housekeeper was not supposed to come out of the room with her PPE on. The caddy was supposed to be taken into the room and after usage everything sanitized on it. They reported that sometimes the nursing staff was not putting isolation signs up and staff had to ask if the patient was in isolation. Staff #9 reported housekeeping staff work the unit from 8a.m.-5p.m., Monday -Friday. They will go to the unit to clean a room in emergency cases during the off hours.

Hemodialysis room
The floor in the room had a layer of dust and debris covering it. The baseboards had a buildup of dirt. There was a bath tub in the room which had a soiled towel draped over the side. A cabinet which houses cleaning supplies had one of the doors missing. The supplies were in close proximity to the floor and exposed to dirt and dust.
Eight 6.4 liters of NaturaLyte Liquid Bicarbonate Concentrate used for treatment of acute and chronic renal failure during hemodialysis was stored on a cart which was soiled with brown spills and stains.
Water sample testing equipment, solutions, strips, plastic containers, and a funnel were stored on the open shelf with a container which read "Tri-Station Waste." The shelf was covered with a layer of dust.
During an interview on 05/20/2015, Staff #2 reported the room had not been cleaned by housekeeping because it was not on their schedule and they did not have keys to the room.

Isolation Rooms
The floor in the ante room connected to isolation Room #313 and 314 had baseboards that were soiled with a build-up of dust and dirt. Two poles with attached baskets used for Dynamap (blood pressure equipment) were stored in the area. The equipment had areas of missing paint and rust and could not be sanitized.

Patient clean equipment storage room
There were intravenous poles, a hospital bed, box of pads, intravenous pump, patient controlled analgesic pumps, medication carts, television, and coffee canisters found in the storage room. Some of the patient care equipment was covered with a plastic bag and some was not. Three of the intravenous poles were covered with rust and were unable to be sanitized. A step stool that was soiled with dirt and two pallets used to store items on were in the room.
During an interview on 05/20/2015, Staff #7 confirmed the room was where they stored equipment after they sanitized it.
Staff #3 confirmed all the observations on the unit. Staff #3 reported all the equipment was supposed to be covered to indicate it was clean. The bed and box of supplies stored on the bed was used for training.

Review of environmental and infection control rounding sheets from December 2014 -March 2015 revealed no documentation of problems with supply rooms, equipment or hemodialysis room.

Review of facility policies revealed the following:
"SUBJECT: CLEANING OF PATIENT EQUIPMENT" dated 08/2013
Patient care equipment will be used in such a manner as to provide quality care with the least risk of infection. Standard precautions will be used at all times and Personal Protective Equipment will be worn whenever indicated.
Meticulous physical cleaning must precede disinfection. Items that have foreign material or oils present should be cleaned before applying the disinfecting agent ....

"SUBJECT: CONTACT PRECAUTIONS" dated 05/2013
Environment Measures
Staphylococci can survive desiccation for days to weeks. It has been documented that enterococci are capable of prolonged survival on hands, gloves, and environmental surfaces and spores of C.difficle may remain for weeks.
2. Daily room cleaning: Housekeeping personnel will wear gloves, and a protective overgown while cleaning room/s of patients with antimicrobial resistant infecting organism colonization/infection. The protective clothing, and all equipment will be removed and placed into the appropriate receptacle when cleaning is completed. Hands will be thoroughly washed after all cleaning and equipment removal has been accomplished.

Based on interview and record review, the facility failed to ensure 2 of 2 patients in restraints had complete assessments and physician orders to justify usage ( Patient #s' 3 and 10).
This deficient practice had the likelihood to cause harm in all patients in restraints.
Findings include:,

Review of the clinical record on Patient #3 revealed that she was a 76 year old female admitted on 01/21/2015. A physician physical examination dated 01/22/2015, revealed some of diagnoses of the admission were altered mental status, respiratory distress, hypertension and deep vein thrombosis.
Review of a "Restraint Order Form" dated 02/13/2015, revealed the physician signed and dated the restraint order, but failed to indicate what kind of restraint to use.
Review of the "Patient Monitor Form" dated 02/13/2015, revealed Patient #3 was placed in a wrist restraint.

Review of the "Restraint Order Form"dated 02/15/2015, revealed the medical necessity for restrain usage was not marked under the clinical justification section.
Review of the "Patient Monitor Form" dated 02/15/2015, revealed Patient #3 was placed in a wrist restraint.

Review of "Restraint Order Form" dated 02/18/2015, revealed the section under patient assessment which addressed actions or activities was left blank by nursing. This section was for the assessment of the behavior that impeded or prevented medical treatment and would justify the usage of restraints. The medical necessity section for restraint usage was not completed to indicate clinical justification for restraint usage.
Review of the "Patient Monitor Form" dated 02/18/2015, revealed Patient #3 was placed in a wrist restraints.

During an interview on 05/21/2015, after 8:29 a.m., Staff #2 confirmed the missing assessment and documentation on the restraint orders.

Review of an admission assessment revealed that Patient #10 was a 71 year old male, who was admitted on 03/19/2015, with diagnoses which included Atrial fibrillation, diabetes mellitus and bladder cancer. According to the assessment, Patient #10 had lower leg cellulitis and was on contact isolation for Methicillin Resistant Staphylococcus aureus (MRSA).
On 04/06/2015, at 7:30 a.m., there was a physician order written for "Restraints, prn"
Review of the next "Restraint Order Form" dated 04/06/2015, at 7:30 a.m., revealed an order for a soft limb and elbow restraint to the left upper (extremity).
According to the "Patient Monitor Form" starting on 04/06/2015, Patient #10 was in bilateral wrist restraints. There was no physician signed order for bilateral wrist restraints.
Review of the next "Restraint Order Form" dated 04/09/2015, revealed an order for a soft limb restraint to the right and left upper (extremities). The physician failed to complete the clinical justification section to show the restraint was necessary. The order was not signed, dated or timed by the physician.
Review of the next "Restraint Order Form" dated 04/10/2015, and 04/16/2015, revealed an order for a soft limb restraint to the right and left upper (extremities). The physician failed to complete the clinical justification section to show the restraint was necessary.
During an interview on 05/21/2015, after 11:00 a.m., Staff #3 confirmed the missing information.

Review of a facility policy named "RESTRAINTS" date 08/2013, revealed the following:
I. Purpose
To provide a structure for the use of restraint that protects and promotes each patient's rights, physical and psychological safety and promotes healing. To ensure restraint use only occurs when clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff or others.
III. Directive
F. Restraint will not be used as a means of coercion, discipline, convenience, or staff retaliation.
G. Restraint will be used only when less restrictive interventions are ineffective.
H. The least restrictive form of restraint will be used that protects the physical safety of the patient , staff or others.
I. Restraint will be discontinued at the earliest possible time, regardless of the scheduled expiration or the order.
J. Standing orders for restraint and orders for restraint on an as needed basis(PRN) are not permitted.
K. Restraint may be used to protect the physical safety of the nonviolent and non-self destructive patient.
M. Orders for patient restraint will be written on the Restraint Order Form.
N. The qualified RN will complete the Patient Assessment section of the Restraint Order Form including:
Mental Status
1. Patient Actions/Activity
2. Safety Factors
3. Medical Devices/Dressings
O. The qualified RN will complete the Clinical Justification section of the Restrain Order Form.
P. The physician /LIP(Licensed Independent Practitioner) will complete the Doctor's Order section of the Restraint Order Form by signing, dating and timing the order.
Q. Documentation of patient monitoring will be completed on the Restraint Monitoring Form by qualified nursing staff. An RN will assess and sign the Restraint Monitoring Assessment Form every shift.

Based on interview andrecord review, the facility failed to ensure antipsychotic medications were used as a standard treatment or dosage to treat a patient's condition. The facility failed to ensure antipsychotic medications were medically necessary for pateints.. This deficient practice was found in 1 of 1 sampled patients (Patient #3).
This deficient practice had the likelihood to cause harm in all patients on antipsychotic medications.
Findings include:

Review of the clinical record on Patient #3 revealed thatr she was a 76 year old female, admitted on 01/21/2015. A physician physical examination dated 01/22/2015, revealed some of diagnoses of the admission were altered mental status, respiratory distress, hypertension and deep vein thrombosis.
Review of physician orders revealed the following antipsychotic medication ordered:
02/08/2015, Haldol 2 milligrams (mg) intravenous push (IVP) every 6 hours as needed for anxiety/agitation;
02/12/2015, Seroquel 50 milligrams po night and every night, Seroquel 25 milligrams by mouth three times a day prn for anxiety;
02/21/2015, Increase Haldol 2 milligrams IM every 12 hours prn for agitation, Seroquel 50 mg every night;
02/21/2015, Xanax 0.25 mg po x 1 now ( no time of when it was written);
02/22/2015, Xanax 0.25 mg po three times a day prn for anxiety;
On 02/22/2015, Discontinue all sedative and hypnotics, Give Trazadone 50 mg by mouth every night.

Review of nurses notes revealed some of the following prn antipsychotic administrations:
02/07-08/2015
At 9:15 a.m., Haldol 2 mg IM was administered. There was no documentation of what alternative was tried first and the reason or behavior that warranted administration.
02/08-09/2015
At 9:00 a.m., Seroquel 25 mg was administered without documentation of the reason or the behavior at the time.
At 9:41 p.m., there was documentation that the patient was screaming, and yelling, claimed her head and neck was hurting. PRN meds given (see prn sheet). Review of the prn sheet revealed Morphine was administered for a pain level of 8 out of 10 at 9:41 p.m. and Seroquel 25 mg was administered at the same time for agitation.
At 4:10 a.m. , the patient was screaming and hollering, agitated and wanted to get out of bed. Prn Haldol given. There was no documentation of what alternative was tried prior to administering the medication. At 4:33 a.m., Patient #3 complained of a headache and prn Tylenol was given.

02/10-11/2015
At 8:16 p.m., Patient #3 night medications and Haldol 2mg IVP and Benadryl 25 mg given for itching. There was no documentation as to the reason the Haldol was administered nor alternative measures tried before giving the medication.
At 4:15a.m, Patient #3 was shouting out her head hurts, the nurse gave one 500 mg Tylenol and 2mg Haldol IVP. This medication was not documented on the prn sheet nor an alternative measures tried before administering the Haldol. There was no assessment of what the pain level was on the patient.

02/16-17/2015
At 3:45 a.m , Seroquel was administered and there was no documentation of the reason nor alternative measures tried prior to administration.
Review of physician orders dated 02/23/2015, revealed Patient #3 had an order to be put on 1:1 (supervision) for safety reasons.
Review of a "Hospital Summary" dated 01/21/2015-02/28/2015, revealed one of Patient #3's diagnoses was Dementia.
During an interview on 05/21/2015, after 8:30 a.m., Staff #2 confirmed the missing information. The medications were stopped because they were not helping. They discovered Patient #3 did better when the family was there or someone was in the room with her.


Drugs.com information showed
Elderly patients with dementia - related psychosis treated with antipsychotic drugs are at an increased risk of death. Haldol injection is not approved for the treatment of patients with dementia related psychosis.
Haldol injection in not approved for intravenous administration.

Review of a facility policy named "RESTRAINTS" dated 08/2013, revealed the following:
I.Purpose
To provide a structure for the use of restraint that protects and promotes each patient's rights, physical and psychological safety and promotes healing. To ensure restraint use only occurs when clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff or others.
II. Definitions:
The Joint Commission (TJC) refers to the Center for Medicare and Medicaid Services (CMS) definitions:
A.Restraint
2. A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement an is not a standard treatment or dosage for the patient's condition.
III.Directive
F. Restraint will not be used as a means of coercion, discipline, convenience, or staff retaliation.
G. Restraint will be used only when less restrictive interventions are ineffective.
H. The least restrictive form of retraint will be used that protects the physical safety of the patient , staff or others.
I.Restraint will be discontinued at the earliest possible time, regardless of the scheduled expiration or the order.
J.Standing orders for restrain and orders for restraint on an as needed basis(PRN) are not permitted.
K.Restraint may be used to protect the physical safety of the nonviolent and non-self destructive patient.
M. Orders for patient restraint will be written on the Restraint Order Form.
N.The qualified RN will complete the Patient Assessment section of the Restraint Order Form including:
Mental Status
1. Patient Actions/Activity
2. 2. Safety Factors
3. Medical Devices/Dressings
O. The qualified RN will complete the Clinical Justification section of the Restrain Order Form.
P. The physician /LIP(Licensed Independent Practitioner) will complete the Doctor's Order section of the Restraint Order Form by signing, dating and timing the order.
Q.Documentation of patient monitoring will be completed on the Restraint Monitoring Form by qualified nursing staff. An RN will assess and sign the Restraint Monitoring Assessment Form every shift.

Based on observation, interview and record review the facility failed to ensure 2 of 2 patients with a contagious infectious disease received a consistent assessment, timely collection of lab and provided isolation precautions as needed (Patient #s' 2 and 3).

This deficient practice had the likelihood to cause harm in all patients.
Findings include:
Review of the clinical record on Patient #3 revealed she was a 76 year old female admitted on 01/21/2015. A physician physical examination dated 01/22/2015 revealed some of diagnoses of the admission were altered mental status,respiratory distress, hypertension and deep vein thrombosis.
Review of intake and output records and nurses notes revealed the following:
01/22-24/2015, a total of 6 stools were documented during this timeframe.
1/25-26/2015, Patient #3 had no stools during this timeframe.
01/27/2015, 1 stool
01/28/2015, 3 stools
01/29/2015-02/01/2015, a total of 13 stools with 7 being on one shift. There was documentation in the nurses notes of Patient #3 having brown loose stools and Immodium being administered on 01/31/2015. Patient #3 was documented as being in isolation on 01/30-31/2015. There was no documentation of the isolation continuing into the next day.
02/02-05/2015, a total of 14 stools with 7 being on one shift. On 02/03/2015 at 8:00 a.m. there was documentation of the patient being in isolation. There was no documentation of isolation after this during this timeframe.
02/06-09/2015, a total of 3 stools during this timeframe. On 02/07/2015 from 8:00 a.m.-6:00 p.m., Patient #3 was in isolation. The next documentation of isolation precautions was 2 days later on 02/09/2015 from 8:00 a.m.-6:00 p.m..
02/10-13/2015, There was no documentation of bowel movements during this timeframe. On 02/11/2015 there was documentation of isolation precautions.
02/14-20/2015, 2 stools during this timeframe.
On 02/18/2015 and then again on 02/20/2015 there was documentation of isolation precautions in place.
Review of a physician order dated 02/20/2015 revealed an order for Stool for C-diff now.
Review of lab results dated 02/20/2015 revealed the C Difficile was positive and the results were called to nursing at 1:37 p.m.
There was no documentation what type of isolation the patient was on or physician orders to discontinue isolation on the patient at any time during the stay.
During an interview on 05/21/2015 after 11:00 a.m., Staff #3 confirmed the problems found.



During an observation on 05/20/2015 after 9:00 a.m., Patient #2 was totally dependent and had a Flex seal (fecal containment) system in place and an indwelling Foley catheter. Patient #2's room had a foul odor. Patient #2 was not in isolation.
Review of the clinical record on Patient #2 revealed she was a 71 year old female admitted on 05/11/2015 with diagnoses including acute kidney failure, hyperkalemia and status post exploratory laparotomy.
Review of intake and output records from 05/11-20/2015 revealed nursing staff failed to document a consistent assessment of the bowel status on Patient #2. There were 9 blanks out 20 opportunities for documentation for bowel status.
Review of the clinical record on Patient #2 revealed a physician's order dated 05/20/2015 which was checked off at 10:00 p.m. The order was for staff to obtain a stool specimen for Clostridium difficile (C.diff).
During an interview on 05/21/2015 after 11:00 a.m., Staff #3 confirmed the missing information.
During an interview on 05/21/2015 at 12:30 p.m., Staff #3 reported staff had not obtained a stool specimen yet and was doing so now. Staff #3 reported when they suspect C.diff infection they put the patient in isolation.

Review of facility policies revealed the following:

SUBJECT: CONTACT PRECAUTIONS" dated 05/2013
Environment Measures
Staphylococci can survive desiccation for days to weeks. It has been documented that enterococci area capable of prolonged survival on hands, gloves, and environmental surfaces and spores of C. difficile may remain for weeks.
SUBJECT:TRANSMISSION BASED PRECAUTIONS: INITIATING AND DISCONTINUING" dated 05/2013
PROCEDURE:
In addition to Standard Precautions, use Transmission-based Precautions for patients with documented or suspected infection or colonization with highly transmissible or epidemiologically-important pathogens for which additional precautions are needed to prevent transmission....

If the physician disagrees with the isolation initiated, the unit manager/charge nurse should notify the Infection Control Coordinator/DOPC (Director of Patient Care).
A Transmission -based Precaution Sign and an illustration of the correct method of donning and removing Personal Protective Equipment (PPE) will be provided for associate and visitors. Both door signs must be promptly affixed to the patient's room door. Record in the patient record the date precautions were initiated, time, reason for, and type of precautions in use. when isolation is discontinued, an order to discontinue Transmission-based Precautions should be placed in the chart. If an isolation cart is in use for storage or PPE, the isolation cart should be removed and returned for cleaning and/or storage.

"SUBJECT:ASSESSMENT OF THE PATIENT" dated 06/2013
A review of body systems and other patient data will be completed and documented at least every shift by RN/LVN/LPN. A nursing assessment will be completed and documented by a RN at least every 24 hours. Focused assessments will be completed and documented as patients' condition or needs warrant. Nursing assessment findings will be documented on the Nurses' Notes form.

Based on interview and review record the facility failed to ensure antipsychotic medications were used and administered according to accepted standards of practice. The facility failed to ensure nursing staff documented reasons/behaviors to indicate administration and alternative for prn antipsychotic medication usage. They failed to ensure complete pain assessments. This deficient practice was found in 1 of 1 sampled patients (Patient #3).
This deficient practice had the likelihood to cause harm in all patients on pain and psychotropic medications.
Findings include:

Review of the clinical record on Patient #3 revealed she was a 76 year old female admitted on 01/21/2015. A physician physical examination dated 01/22/2015 revealed some of diagnoses of the admission were altered mental status,respiratory distress, hypertension and deep vein thrombosis.
Review of physician orders revealed the following antipsychotic medication ordered:
02/08/2015, Haldol 2 milligrams (mg) intravenous push (IVP) every 6 hours as needed for anxiety/agitation;
02/12/2015 Seroquel 50 milligrams po night and every night, Seroquel 25 milligrams by mouth three times a day prn for anxiety;
02/21/2015 Increase Haldol 2 milligrams IM every 12 hours prn for agitation, Seroquel 50 mg every night;
02/21/2015 Xanax 0.25 mg po x 1 now ( no time of when it was written);
02/22/2015 Xanax 0.25 mg po three times a day prn for anxiety;
On 02/22/2015 Discontinue all sedative and hypnotics, Give Trazadone 50 mg by mouth every night.

Review of nurses notes revealed some of the following prn antipsychotic administrations:
02/07-08/2015
At 9:15 a.m., Haldol 2 mg IM was administered. There was no documentation of what alternative was tried first and the reason or behavior that warranted administration.
02/08-09/2015
At 9:00 a.m., Seroquel 25 mg was administered without documentation of the reason or the behavior at the time.
At 9:41 p.m., there was documentation the patient was screaming, and yelling, claimed her head and neck was hurting. PRN meds given (see prn sheet). Review of the prn sheet revealed Morphine was administered for a pain level of 8 out of 10 at 9:41 p.m. and Seroquel 25 mg was administered at the same time for agitation.
At 4:10 a.m. , the patient was screaming and hollering, agitated and wanted to get out of bed. Prn Haldol given. There was no documentation of what alternative was tried prior to administering the medication. At 4:33 a.m. Patient #3 complained of a headache and prn Tylenol was given.

02/10-11/2015
At 8:16 p.m., Patient #3 night medications and Haldol 2mg IVP and Benadryl 25 mg for itching given for itching. There was no documentation as to the reason the Haldol was administered nor alternative tried before giving the medication.
At 4:15a.m, Patient #3 was shouting out her head hurts, the nurse gave one 500 mg Tylenol and 2mg Haldol IVP. This medication was not documented on the prn sheet nor an alternative tried before administering the Haldol. There was no assessment of what the pain level was on the patient.

02/16-17/2015
At 3:45 a.m , Seroquel was administered and there was no documentation of the reason nor alternative tried prior to administration.
Review of physician orders dated 02/23/2015 revealed Patient #3 had an order to be put on 1:1 (supervision) for safety reasons.
Review of a "Hospital Summary" dated 01/21/2015-02/28/2015 revealed one of Patient #3s' diagnoses was Dementia.
During an interview on 05/21/2015 after 8:30 a.m., Staff #2 confirmed the missing information. The medications were stopped because they were not helping. They discovered Patient #3 did better when the family was there or someone was in the room with her.

According to Drugs.com
Elderly patients with dementia - related psychosis treated with antipsychotic drugs are at an increased risk of death. Haldol injection is not approved for the treatment of patients with dementia related psychosis.
Haldol injection in not approved for intravenous administration.

Review of a facility policy named "RESTRAINTS" date 08/2013 revealed the following:
I.Purpose
To provide a structure for the use of restraint that protects and promotes each patient's rights, physical and psychological safety and promotes healing. To ensure restraint use only occurs when clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff or others.
II. Definitions:
The Joint Commission (TJC) refers to the Center for Medicare and Medicaid Services (CMS) definitions:
A.Restraint
2. A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement an is not a standard treatment or dosage for the patient's condition.
III.Directive
F. Restraint will not be used as a means of coercion, discipline, convenience, or staff retaliation.
G. Restraint will be used only when less restrictive interventions are ineffective.
H. The least restrictive form of retraint will be used that protects the physical safety of the patient , staff or others.
I.Restraint will be discontinued at the earliest possible time, regardless of the scheduled expiration or the order.
J.Standing orders for restraint and orders for restraint on an as needed basis(PRN) are not permitted.
K.Restraint may be used to protect the physical safety of the nonviolent and non-self destructive patient.
M. Orders for patient restraint will be written on the Restraint Order Form.
N.The qualified RN will complete the Patient Assessment section of the Restraint Order Form including:
Mental Status
1. Patient Actions/Activity
2. 2. Safety Factors
3. Medical Devices/Dressings
O. The qualified RN will complete the Clinical Justification section of the Restraint Order Form.
P. The physician /LIP(Licensed Independent Practitioner) will complete the Doctor's Order section of the Restraint Order Form by signing, dating and timing the order.
Q.Documentation of patient monitoring will be completed on the Restraint Monitoring Form by qualified nursing staff. An RN will assess and sign the Restraint Monitoring Assessment Form every shift.

"SUBJECT:ASSESSMENT OF THE PATIENT" dated 06/2013
A review of body systems and other patient data will be completed and documented at least every shift by RN/LVN/LPN. A nursing assessment will be completed and documented by a RN at least every 24 hours. Focused assessments will be completed and documented as patients' condition or needs warrant. Nursing assessment findings will be documented on the Nurses' Notes form.

Based on observation, interview and record review, the facility failed to ensure a sanitary environment in the soiled utility room, patient rooms, nursing clean supply room/equipment rooms, isolation rooms, respiratory supply room, and hemodialysis supply room on 1 of 1 long term care unit. The facility failed to ensure staff used proper infection control techniques during care of patients in isolation and patients at high risk for infections.
This deficient practice had the likelihood to cause harm to all patients on the unit.
Findings include:

During observation on 05/19/2015, after 8:30 a.m., the following was found:

Soiled utility room
The biohazard container was overflowing with bags of biohazard trash. The top on the container would not close.
A stainless steel rack used to hold food trays was found in the room without any trays on it. The rack was soiled with a buildup of dried substance.

Crash cart
A crash cart stored in the hallway had an open basket near the floor. An unbagged suction canister with tubing attached were in the open basket and were not covered. The suction tubing that was attached was draped down near the floor.

Respiratory supply room
Respiratory supplies were stored in a room on uncovered shelves. Patient equipment, paper files, and a shipping box were on top of the clean supplies. The patient use equipment on the shelves was not covered to indicate it was clean.

Central supply room
Clean and sterile supplies were stored on open shelves and were not covered. Some of the supplies had been taken from their original packets and thrown back on the shelves. Over half of the shelves in the room were approximately 3 inches from the floor. The supplies on the bottom shelf were not protected from dust or dirt. One of the shelves was pulled away from the wall and supplies were found on the floor. Underneath the bottom shelves were packets of supplies and buildup of dust on the floor.
A multi lumen central catheterization kit was found on the shelf which expired on 01/2014.
There was a medication cart in the room which had a buildup of dirt.
A supply transporting cart in the room had a sign on the top of it that read "PLEASE DO NOT USE THIS CART FOR SOILED LINEN OR TRASH AS THIS CART IS USED TO TRANSPORT FOOD AND STERILE SUPPLIES. IF YOU USE THIS CART PLEASE RETURN IT TO THE STOCKROOM". The clear tape that held the sign down was soiled and had turned brown. The top and bottom level of the cart was soiled with brown stains. There were screws on inside of the bottom level that had rusted making the cart unable to be sanitized.
An uncovered oxygen concentrator was found stored in the room with the supplies. The concentrator had a dried brown substance on it and still had an adapter connected to it. The concentrator was not clean.
According to the Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, page 75 revealed the following:
"Following the sterilization process, medical and surgical devices must be handled using aseptic technique in order to prevent contamination. Sterile supplies should be stored far enough from the floor (8 to 10 inches), the ceiling (5 inches unless near a sprinkler head [18 inches from sprinkler head]), and the outside walls (2 inches) to allow for adequate air circulation, ease of cleaning, and compliance with local fire codes (e.g., supplies must be at least 18 inches from sprinkler heads).

Patient rooms
Room # 306
The baseboards in the room had a buildup of dirt and dust. The door frame as you enter the room was cracked open and the wood underneath was exposed. The door could not be sanitized. The patient's bedside table was missing paint and had dried spills down the front of it. There was a used syringe of saline on the floor and the base of the intravenous pump had dried spills. The open trash can was full to the top. Inside the biohazard container was a used Foley Catheter bag with tubing attached.
There was an empty bag of Magnesium sulfate still hanging on the intravenous pole. There was no identifying information on the bag to indicate when it was prepared, supposed to be administered or when it expired.
Review of the clinical record of Patient #4 (housed in Room #306) revealed she was an 80 year old female admitted on 04/24/2015 with diagnoses which included severe deconditioning and left femur fracture.
Review of the Medication administration record revealed the Magnesium sulfate was administered to Patient #4 the day prior (05/19/2015) at 9:50 p.m.
Review of the nurse's notes revealed Patient #4's Foley catheter was removed two days prior on 05/18/2015.
During an interview Staff #3 reported nursing staff should remove supplies and biohazards from the patient's room after giving care.

Room #308
The door frame as you enter the room was cracked open and the wood underneath was exposed. The light colored floor tile underneath the sink had turned brown in color and the baseboards had a build-up of dirt.
Review of the clinical record on Patient #2 revealed that she was a 71 year old female, admitted on 05/11/2015, with diagnoses that included acute kidney failure and hyperkalemia. Patient #2 was housed in Room #308 and was not on contact isolation.
Patient #2 was totally dependent and had a Flex seal (fecal containment) system in place and an indwelling Foley catheter. Patient #2's room had a foul odor. The Foley catheter was positioned underneath Patient #2's leg and the tubing was not looped at the port of entry to allow for free flow of urine into the collection bag. This put Patient #2 at risk for urinary tract infections.
Staff #6 donned gloves while in Patient #2's room and picked up soiled linen. Staff #6 had the linen in direct contact with her uniform. With the same soiled glove on Staff #6 touched items in the room and Patient #2's hand.
Review of the clinical record on Patient #2 revealed a physician's order dated 05/20/2015, which was checked off at 10:00 p.m. The order was for staff to obtain a stool specimen for Clostridium deficile (C.diff).
During an interview on 05/21/2015, at 12:30 p.m., Staff #3 reported staff had not obtained a stool specimen and was doing so now.

Room #310
Review of the clinical record revealedthat Patient #1 was a 54 year old male, admitted on 05/19/2015, with a diagnosis of pneumonia. According to the initial nursing assessment, Patient #1 was being placed on contact isolation for the organism Pseudomonas (in the respiratory tract). Patient #1 was placed in room #310.
On 05/20/2015, PPE (Personal Protective Equipment) was stored in a hanging organizer on the outside of the door to Room #310 (leading to hallway). The white plastic covering over the bottom of the same door was broken and exposed the wood underneath. There was no way the door could be sanitized. The white covering was soiled and had turned brown and the tile floor as you enter the room was soiled with a brown build-up.
Housekeeper #8 donned PPE and took a bottle of cleanser, toilet bowl cleanser and a mop into Room #310 with her. Housekeeper #8 was observed to still have on her PPE and stuck her gloved hand out the door and cleaned part of the outside of the door and the door handle with a towel. Housekeeper #8 opened the door to the room and pulled the housekeeping cart closer to the door. She was noted to still have her PPE on. Housekeeper #8 placed the bottle of cleanser used in the room on top of her cart next to another container of cleanser. Housekeeper #8 exited the room later with gloves on and carrying two bags of soiled items. The cloth covering on the mop head used in the room was placed in a plastic bag on the outside of the room and the mop handle was placed on the cart without sanitizing first. After changing gloves Housekeeper #8 obtained another container of cleanser on top of her cart and wiped down the handle of the mop and the lower stainless steel portion of the mop. The lower stainless steel portion of the mop could not be sanitized because it was soiled with a buildup of black substance.
During an interview Staff #9 and #10 (environmental administrative staff) reported the housekeeper was not supposed to come out of the room with her PPE on. The caddy was supposed to be taken into the room and after usage everything sanitized on it. They reported that sometimes the nursing staff was not putting isolation signs up and staff had to ask if the patient was in isolation. Staff #9 reported housekeeping staff work the unit from 8a.m.-5p.m., Monday -Friday. They will go to the unit to clean a room in emergency cases during the off hours.

Hemodialysis room
The floor in the room had a layer of dust and debris covering it. The baseboards had a buildup of dirt. There was a bath tub in the room which had a soiled towel draped over the side. A cabinet which houses cleaning supplies had one of the doors missing. The supplies were in close proximity to the floor and exposed to dirt and dust.
Eight 6.4 liters of NaturaLyte Liquid Bicarbonate Concentrate used for treatment of acute and chronic renal failure during hemodialysis was stored on a cart which was soiled with brown spills and stains.
Water sample testing equipment, solutions, strips, plastic containers, and a funnel were stored on the open shelf with a container which read "Tri-Station Waste." The shelf was covered with a layer of dust.
During an interview on 05/20/2015, Staff #2 reported the room had not been cleaned by housekeeping because it was not on their schedule and they did not have keys to the room.

Isolation Rooms
The floor in the ante room connected to isolation Room #313 and 314 had baseboards that were soiled with a build-up of dust and dirt. Two poles with attached baskets used for Dynamap (blood pressure equipment) were stored in the area. The equipment had areas of missing paint and rust and could not be sanitized.

Patient clean equipment storage room
There were intravenous poles, a hospital bed, box of pads, intravenous pump, patient controlled analgesic pumps, medication carts, television, and coffee canisters found in the storage room. Some of the patient care equipment was covered with a plastic bag and some was not. Three of the intravenous poles were covered with rust and were unable to be sanitized. A step stool that was soiled with dirt and two pallets used to store items on were in the room.
During an interview on 05/20/2015, Staff #7 confirmed the room was where they stored equipment after they sanitized it.
Staff #3 confirmed all the observations on the unit. Staff #3 reported all the equipment was supposed to be covered to indicate it was clean. The bed and box of supplies stored on the bed was used for training.

Review of environmental and infection control rounding sheets from December 2014 -March 2015 revealed no documentation of problems with supply rooms, equipment or hemodialysis room.

Review of facility policies revealed the following:
"SUBJECT: CLEANING OF PATIENT EQUIPMENT" dated 08/2013
Patient care equipment will be used in such a manner as to provide quality care with the least risk of infection. Standard precautions will be used at all times and Personal Protective Equipment will be worn whenever indicated.
Meticulous physical cleaning must precede disinfection. Items that have foreign material or oils present should be cleaned before applying the disinfecting agent ....

"SUBJECT: CONTACT PRECAUTIONS" dated 05/2013
Environment Measures
Staphylococci can survive desiccation for days to weeks. It has been documented that enterococci are capable of prolonged survival on hands, gloves, and environmental surfaces and spores of C.difficle may remain for weeks.
2. Daily room cleaning: Housekeeping personnel will wear gloves, and a protective overgown while cleaning room/s of patients with antimicrobial resistant infecting organism colonization/infection. The protective clothing, and all equipment will be removed and placed into the appropriate receptacle when cleaning is completed. Hands will be thoroughly washed after all cleaning and equipment removal has been accomplished.