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Based on medical record review and interview, the facility failed to ensure a medication was administered as ordered for one patient (Patient #4) of 13 medical records reviewed.

Findings include:

1. The medical record review showed Patient #4 was admitted to the facility on 04/24/15 with a diagnosis including Congestive Heart Failure. On 05/04/15 at 8:10 AM, a physician ordered two units of packed red blood cells with 20 milligrams of Furosemide, a diuretic, intravenously before the first unit of blood and before the second unit of blood.

On 05/04/15 at approximately 1:30 PM, Staff E was observed infusing the first unit of blood to Patient #4. Staff E was not observed administering the ordered Furosemide prior to the infusion. The medical record for Patient #4 contained a Day Medication Administration Record form. The form did not show the Furosemide as being administered prior to the first unit of blood being administered to Patient #4. On 5/4/15 at 3:30 PM, Staff E was interviewed regarding the Furosemide not being documented as administered prior to the first unit of blood. Staff E confirmed the ordered Furosemide was not administered prior to the first unit of blood and Staff E confirmed he/she missed the order.

Based on interview, policy review and observation, the facility failed to ensure staff washed hands in accordance with the facility's policy for two (Staff D and Staff E) of two staff members observed washing their hands. The facility failed to ensure nursing staff followed the facility's policy when changing a central venous catheter dressing for one (Patient #4) of one central line dressing change observed.

Findings include:

1. Staff D was observed performing checking Patient #10's blood glucose level on 5/4/15 at 10:56 AM. At the completion of the procedure, Staff D was observed washing his/her hands for three seconds. On 5/4/15 at 11:00 AM, Staff D was observed washing his/her hands for two seconds after cleaning the blood glucose testing equipment which had been placed on Patient #10's bed and counter.

2. On 05/04/15 at 1:30 PM, Staff E was observed initiating a blood transfusion to Patient #4. Staff E was observed washing his/her hands for five seconds at 1:40 PM on 05/04/15, after initiating the blood transfusion.

The facility's Hand Hygiene (Handwashing) policy was reviewed. The policy stated when washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for no less than 15 seconds.

3. On 05/04/15 at 4:05 PM, Staff B, the facility's wound care nurse, was observed changing the dressing on Patient #4's central venous catheter. Staff B donned clean gloves, removed the old dressing and then donned sterile gloves on top of the dirtied gloves.

The facility's Sterile Vascular Access Dressing Change competency form was reviewed. The form stated to remove the old dressing, remove non-sterile gloves and apply sterile gloves from the dressing kit.

Staff A was interviewed on 05/05/15 at 2:27 PM and reported the facility's staff is expected to remove non-sterile gloves and wash their hands before donning sterile gloves.