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Based on observation, interview and record review the facility failed to follow use of restraint guidelines by allowing restraint orders to be written as standing orders or as PRN orders for 1 (Patient ID # 33) of 4 sampled patients receiving dialysis.
Finding:
Observation by the Surveyor along with facility Quality Manager ID # (51) and employee ID # (98) at 11:00 AM on 6/22/212 in the dialysis renal unit revealed a left wrist restraint on patient ID # (33).
Record review at 10:30 AM on 6/22/2012 revealed physician order written:
6/20/2012- " May put restraint to left hand while in dialysis treatment. " TORB (Telephone order read back) Employee ID # (89)
6/08/2012 - " Apply wrist restraint on left wrist every dialysis. " TORB Employee ID # (89)
Interview by the surveyor in the renal unit at 11:00 AM on 6/22/12 with employee # (33) revealed a standing order for restraint was obtained from Dr. Daca for use during dialysis to keep patient ID # (33) from moving his dialysis access arm.
Interview by the surveyor in the renal unit the morning of 6/22/12 with the Quality Manager Employee ID # (51) stated " those orders are not acceptable. We can ' t have restraint PRN orders " .
Record review by the surveyor at 14:00 PM on 6/22/2012 in the administrative conference room of Kindred Healthcare policy titled " Use of Physical or Chemical Restraints " Policy Number H-PC 05-010, revised 06/2011. This policy applies to all restraint circumstances, emergency and non-emergency ... ... " 2. Telephone orders may only be used for the first episode of restraint based on nursing assessment. If a telephone order is needed the clinical justification and events leading to restraint use must be documented at the time the telephone order is countersigned. 3. Do not write a restraint order as a standing or PRN order. "

Based on observation, interview, and record review, the facility failed to ensure an RN adequately supervised and evaluated patient care for 9 of 38 sampled patients ( Patient # 23 ; 24, and 35 at Town & Country) and Patient # 3, # 33, 38 ( Sugar Land). The facility failed to ensure:

1. Daily weights were obtained per physician order for Patients # 23, 24 and 38.

2. Physician order for "pass" was not clarified , which contributed to a delay in insertion of a Peripherally Inserted Central Catheter (PICC) line for Paitent # 35.

3. Correct dialyzer per physician order was utilized for Patient # 3

4. Correct blood flow and dialysate per physician order was utilized for Patient # 33.

Findings include:

Intake # TX 00159352

Review of patient #23(T&C) medical record on 6/21/12 revealed there was physician ' s order for daily weight dated 5/31/12. This patient was not weighed on the following dates: 6/3/12, 6/5/12, 6/6/12, 6/7/12, 6/13/12, and 6/20/12. This patient ' s diagnoses include: Renal Insufficiency, Anemia, Diabetes High Blood Pressure, pre-albumin was low.


Review of patient #24(T&C) medical record on 6/21/12 revealed there was physician ' s order for daily weight dated 6/5/12. This patient was not weighed on the following dates: 6/6/12, 6/7/12, 6/8/12, and 6/10/12, and 6/11/12. This patient was on dialysis; and was last dialyzed on 6/20/12.

Review of patient #38(SL) medical record on 6/21/12 revealed there was physician ' s order for daily weight dated 5/2/12. This patient was not weighed on the following dates: 5/4/12, 5/6/12, 5/7/12, 5/14/12, 5/23/12, 5/29/12, 6/2/12, 6/3/12, 6/9/12, 6/11/12, 6/14/12, 6/16/12, 6/17/12, and 6/19/12, Review of dialysis treatment record for this patient on 6/22/12 revealed the following documented by the dialysis nurse:
" 6/9/12-no bed scale "
" 6/12/12-no bed scale "
" 6/14/12-no bed scale "
" 6/17/12-no bed scale "
" 6/19/12-no bed scale "
" 6/21/12-no bed scale "
This patient ' s diagnoses include: Renal Failure, GI Bleed, dialysis on Tuesdays, Thursdays, and Saturdays.

Facility policy titled: Height and Weight " revised 11/2010 reviewed on 6/22/12 revealed:
" It is facility policy to ensure that each patient ' s height and weight will be determined by the appropriate method and recorded within 24 hours of admission. " Subsequent weights will be taken at least weekly or per physician order " .

Interview with facility staff #71(T&C) on 6/21/12 at 11:50am revealed that patient were weighed by the night shift, there was no explanation provided as the reason why these patients were not weighed as ordered by the physician..

Interview with facility staff #71(SL) on 6/22/12 on unit one nurse ' s station at 2:40pm revealed " we are in the process of ordering new bed scales, the one we have are not accurate but he should been weighed " .

Interview with facility staff #50(SL) on 6/22/12 in the conference room at 2:50pm revealed she was not aware that the bed scale was broken, " but I am now and I am going to take care of it right now " . This staff added " we have rolling weight machine they use that to weigh the patients " .



23032

Patient # 35

" Denial of Pass to Attend Funeral "

Review of Complaint Intake # TX 00159352, received 04-17-12, revealed Patient # 35 was admitted to the facility on 03-20-12. According to the complaint narrative, Patient # 35 was denied permission by the hospital to attend the funeral of her long-time, live in boyfriend, despite the fact the physician wrote an order for a " pass " to attend the funeral.

Review of the clinical record of Patient # 35 revealed she was 79 years old and admitted to the facility on 03-20-12 for wound care and IV antibiotics for Left Toe Osteomyelitis. Patient # 35 ' s medical history included: Peripheral Vascular Disease, Diabetes Mellitus, Anemia, and Amyoptrophia.

Review of the physician orders for Patient # 35 revealed a physician order dated 3-22-12 (not timed) that read; " ...OK for pt to have pass on Sunday to attend friend ' s funeral ... " The order was noted by LVN # 95 on 03-23-12.

Interview on 06-21-12 at 11 a.m. with RN Manager # 74 she stated the facility does not issue " passes " due to patient safety concerns and this was explained to the patient and the family. RN Manager # 74 went on to say the nurse should have notified the physician and clarified the order.

Timeliness of Peripherally Inserted Central Catheter (PICC) Line Insertion:

Further review of Complaint Intake # TX 00159352 revealed an issue regarding a delay in insertion of a PICC Line ordered for Patient # 35.

Review of the physician orders for Patient # 35 revealed an order dated 03-22-12 (time: 0700) that read: " ...PICC Line Placement ... " Further review of the clinical record revealed consent was signed on 03-22-12 at Noon by Patient # 35 for a PICC Line insertion.

Interview with Interview on 06-21-12 at 11 a.m. with RN Manager # 74 she stated the PICC line should have been inserted on 03-22-12 immediately after the consent was signed. She went on to say on 03-23-12 during the " morning meeting " it was discovered the PICC line for Patient # 35 had not been inserted per the order of the previous day. RN Manager #74 said she spoke with the " PICC Line RN " # 95 who reported the patient wanted to " wait until after she went out on pass to attend the funeral. " The RN Manager # 74 said there was a delay in insertion of the PICC line and Nurse # 95 failed to report this to the charge nurse or physician. RN # 95 was counseled regarding this incident. The PICC line was inserted on 03-23-12 at Noon. Prior to this date, Patient # 35 had been receiving her (IV) antibiotics via a peripheral IV line.


30124


Patient ID # (3)
Observation of Patient ID # (3) on dialysis at 9:30 AM on 6/22/2012 revealed patient on Machine # K102 with a Reviclear dialyzer in use.
Interview with Employee ID # (98) on 06/22/12 at 9:40 AM she confirmed a Reviclear dialyzer was in use. Employee verified an F-160 dialyzer had been prescribed by physician. Employee ID # (98) further stated " We do not have any F-160 dialyzer, so we just use the Reviclear dialyzer. " When ask if the physician was notified of the incorrect dialyzer used Employee ID # (98) stated, " No, we do not notify the doctor, we just use the Reviclear, they are the same. "
Record review of Patient ID # (3) physician orders dated 6/19/2012 and 6/21/2012 revealed she prescribed an F-160 dialyzer to be used with each dialysis.
Record review of Patient ID# (3) dialysis treatment record for 6/22/2012 and 6/20/2012 documented F-160 dialyzer used when a Reviclear dialyzer was confirmed to be used by Employee # (98).

Patient ID # (33)
Observation of Patient ID # (33) on dialysis at 10:15 AM on 6/22/2012 revealed patient on Machine # K 101, Blood flow at 300 milliliters per minute, dialysate flow at 700 milliliters per minute and Reviclear dialyzer in use.
Interview with Employee ID # (98) at 10:20 AM on 06/22/12 she confirmed patient using a Reviclear dialyzer, blood flow at 300 and dialysate flow at 700 milliliters per minute. When asked why the blood flow and dialysate flow had not been set at the prescribed rate Employee Id # (98) stated " I don ' t know why, sometimes we have trouble with his needle sticks, a reviclear dialyzer was use because we do not have an F 160 dialyzer. " Employee ID # (98) stated physician had not been notified of not being able to obtain ordered blood flow or the dialyzer substitute.
Record review of Patient Id # (33) physician orders dated 6/21/2012 revealed she prescribed F-160 dialyzer, Blood flow- 600, dialysate flow 600. Dialysis orders dated 6/18/2012 prescribed F-160 dialyzer, Blood flow -350-400, dialysate 600.
Review of Patient Id # (33) hemodialysis treatment sheet dated 6/22/2012 and 6/20/2012 document F160 dialyzer used. Blood Flow rate documented at 300 milliliters per minute for both days. Dialysate flow rate documented at 700 milliliters per minute on 6/22/2012. Record review documented no issues with access or blood flow issues during treatment.

Based on observation, record review, and interview the facility ' s Food Service Directors (2 of 2 kitchens -SL/TC) failed to ensure that the following foods and utensils were stored in good sanitary manner:
1. Perishable foods (raw chicken) out dated and no date stored in the cooler
2. Kitchen utensils stored inside bins
3. Dirty glove found on the floor of the freezer

Findings include:

During the tour of dietary department (SL) on 6/20/12 at 9:40 am with staff #72, the following were found:
Ice scoop stored in the ice machine
One steam table pan of uncooked marinated chicken in the cooler dated 6/13/12
One steam table pan of uncooked marinated chicken in the cooler with no date

During the tour of dietary department (T&C) on 6/21/12 at 9:00 am with staff #s60 and 63, the following were found:
A dirty glove found on the floor in the freezer
Scoops stored in the rice bin, flour bin, and sugar bin
A long ladle spoon stored in the corn meal bin

Facility policy tilted " Food Storage, Policy # H-NS 04-005 " dated 10/11 reviewed on 6/21/12 revealed:
#d: " Raw meats, poultry and fish will be wrapped, dated and labeled "

Facility policy tilted " Food Preparation: Employee Sanitary Practices # H-NS 04-011 " dated 10/11 reviewed on 6/21/12 revealed:
#q: " Store ice scoops in clean, dry container and not in the ice bin "

Facility policy tilted " Safety and Sanitation: Space and Equipment Policy # H-NS 06-004 " dated 10/11 reviewed on 6/21/12 revealed:
#12: All kitchen utensils, pots and pans, dishware are stored in a sanitary manner to prevent contamination " .

Prince Food System Policy and Procedure adopted by the facility 1/12 tilted " Food Storage of Opened Items, Policy # FS3.4 reviewed on 6/21/12 revealed:
#6: " Potentially hazardous foods prepared on-site will be served, frozen or disposed of within three days " .

Interview with facility (SL) staff #61on 6/20/12 at 10:30am regarding the uncooked marinated chicken revealed that " it should have been used in three days " . Interview with the RD #56 2 of 2 (SL) on 6/22/12 at 1:00pm in the conference room revealed the policy does not have specified number of days but that the chicken should have been discarded and added that seven days was too long.

Interview with Director of Food Services #63 (T&C) on 6/21/12 at 11:35 am in the dietary department regarding the scoops found in the bins revealed "the city did not have any problem with them being inside the bins " .

Based on observation, interview, and record review the facility ' s infection control officer failed to effectively implement policies to control infections and communicable diseases at 2 of 2 hospital locations: The facility failed to ensure:

1. Biological indicators of the autoclave were properly documented.

2. Endoscopes were stored in accordance with professional standards,

3. Biohazard containers were not overly filled.

4. Staff RN # 1 utilized proper hand hygiene during provision of wound care to Patient # 91.

5. Glucometers were properly cleaned in between patient use.

6. Patient care supplies were stored in a manner to prevent infection in the Intensive Care Unit and Physical Therapy Department.

Findings include:

BIOLOGICAL INDICATORS

The Infection Control Officer failed to ensure that biological indicator tests of the Autoclave (Sugar Land location) were documented. The Sterilization records for 2012 failed to indicate if the results of the biological indicators were negative or positive.

Record review of the Sterilization records for the Steam Autoclave dated 2012 revealed staff were not noting if the biological indicator results were negative or positive.

The Infection Control Officer (ID# 60) acknowledged 6/20/12 at 11 a.m. the Sterilization records should reflect if the Biological Indicators were negative or positive.

Record review of an "Infection Control Committee" meeting minutes dated January 19, 2012 stated "Sterilization reports - No sterilization issues. Chemical and biological indicators are done to show evidence of sterilization....no issues..."

ENDOSCOPES

Observation 6/20/12 at 9:15 a.m. in Procedure Room #1 at the Sugar Land location revealed a cabinet for storing clean endoscopes. Two Endoscopes were noted inside the cabinet that were not hanging vertically. The scopes were too long for the cabinets height so the ends of the scopes were curved pointing upwards.

The Society of Gastroenterology Nurse and Associates recommends that stored Endoscopes hang vertically, but also the distal tip should hang freely."

The Infection Control Nurse (ID# 60) stated 6/20/12 at 11 a.m. that corporate personnel instructed the hospital staff to store the scopes bending in an upward position.

Record review of a policy titled "Endoscope Re-processing" dated 2/2012 revealed the policy failed to address the storing of Endoscopes.

BIOHAZARD CONTAINERS

Observation 6/21/12 at 9 a.m. during tour at the Town and Country hospital location revealed Biohazard containers filled above the "Fill-Line" as follows:
-Second floor Medical-Surgical Floor: Inside the soiled utility room were two biohazard containers on the floor filled above the "Fill-Line." Also in patient room 226 a Biohazard container mounted of the wall was filled above the "Fill-Line."
-Third floor Biohazard containers filled above the "Fill-Line" as follows: Rooms 326, 329 (IV tubing with blood inside the tubing observed sticking out of the top of the biohazard container) and room 330.

The Nurse Manager (ID# 74) acknowledged 6/21/12 at 9:30 a.m. that housekeeping staff are responsible for replacing the Biohazard containers before they reach above the "Fill-Line."


23032

HAND HYGIENE

Observation on 06-21-12 at 2:00 p.m revealed RN # 1 performed wound care to Patient # 91 ' s sacral wound ( Sugar Land location) . RN # 1 removed the soiled dressing to Patient # 91 ' s sacrum and then removed the contaminated gloves. RN # 1 failed to perform hand hygiene between glove changes. During the remainder of the procedure, RN # 1 changed her gloves an additional 2 times and failed to perform hand hygiene between those glove changes.

Interview on 06-221-12 at 2:40 p.m. with the ICU Coordinator # 92 stated " staff should use hand gel between glove changes; if visibly soiled or contaminated, then staff should wash hands with soap and water. "

Review of policy titled " Infection Prevention and Control Practices, revised 06/2011, read: " ...Hand Hygiene will be performed as follows ...J. After removal of gloves ... "


GLUCOMETERS:

Observation on 06-20-12 at 9:15 a.m. in the Intensive Care Unit (Suagr Land location)revealed a glucometer with several visible smudges on the surface of the machine.

Observation on 06-20-12 at 10:45 a.m. on the Medical Surgical I Unit (Sugar Land location) revealed a glucometer with 3 red-colored spots on the surface of the machine. Interview with the Nurse Manager # 53 at this same time, she said " The spots may be blood. The glucometers are to be cleaned with bleach wipes between each patient use. "

Review of the " ( ) Meter Operator ' s Guide " : read: " " When to clean meter: ...if dirt, blood, or lint is present. Clean the outside of the meter with a cloth dampened with a 10% bleach solution ... "

IMPROPER STORAGE OF PATIENT CARE SUPPLIES:

Intensive Care Unit:

Observation on 06-20-12 at 9:45 a.m. in the Intensive Care Unit (Sugar Land) revealed Patient # 2 lying in bed receiving oxygen via a tracheostomy collar. Further observation revealed an opened in-line suction catheter stuck inside a blue latx glove. Interview with Respiratory Therapist # 93 she stated: " we store them that way in case we need to use them later when the patient is reconnected to the ventilator. "

Interview on 06-20-12 at 10:55 a.m with the RT Director # 94, he stated: " In-line suction catheters when not in use, should be stored in a plastic bag with a draw string. "

Physical Therapy Department:

Observation on 06-23-12 at 1:15 p.m. in the storage room in the Physical Therapy (PT) Department (Sugar Land location) revealed an opened, uncovered box of 4 x 4 gauze and an opened cotton-tip swab applicator. These items were located on a shelf, along with several pieces of unused therapy equipment and other supplies. Interview at this same time with PT Technician # 90 he stated " staff uses the supplies on any patients who might scrape or cut themselves while in the therapy department. "