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Based on record review and staff interview, the Hospital failed to ensure the intravenous (IV) medications, Heparin and saline flushes used to maintain patency of Intravenous (IV) Access Devices, were provided in accordance with the Hospital policy, for 2 Patients (#3 and #31), of a total sample of 31 Patients. Findings included:

1. Patient #3 was admitted from a community Hospital on 5/8/18 with a diagnosis of S/P (status post) bilateral knee surgery. Current medications at the time of survey included the antibiotics Vancomycin 1.5 g (grams) IV (intravenous), every 12 hours, and Zosyn 4.5 g IV every 8 hours IV

The Patient had a right basilic vein, double lumen PICC (Peripherally Inserted Central Catheter) for which IV antibiotics were infused.

Interview with the DON on 5/29/18 at 8:45 A.M., confirmed that the Hospital utilized the SASH (Saline-Administer medication-Saline-Heparin) Method for maintaining the patency of Venous Access Devices such as PICC (Peripherally Inserted Central Catheters) lines and Portacaths (Implanted Venous access devices).

Record review from 5/23/18 to 5/29/18, indicated that both normal saline and heparin flushes were ordered "PRN" (as needed) for line care and not at the time each antibiotic was administered.

Utilizing the SASH method, and the Patient receiving Vancomycin every 12 hours and Zosyn every 8 hours, the Patient's PICC line should have been flushed with the following:

Saline flushes before and after each medication administration for a total of 10 flushes per day, (One flush before and after each dose of Zosyn = 6 flushes, and one flush before and after each dose of Vancomycin = 4 flushes).
Heparin flushes after each dose of Zosyn = 3 Heparin flushes, and after each dose of Vancomycin = 2 Heparin flushes, for a total of 5 Heparin flushes per day.

Review of the MAR (Medication Administration Record) revealed that the PICC line was not flushed with Saline and/or Heparin, before and after each dose of antibiotic as noted below:

5/23/18, Saline flushes administered 5 times instead of 10 times, as required.
5/24/18, Saline flushes administered 6 times instead of 10 times, as required.
5/25/18, Saline flushes administered 5 times instead of 10 times as required.

5/23/18, Heparin flushes administered 4 times instead of the required 5 times.
5/24/18, Heparin flushes administered 3 times instead of the required 5 times.
5/25/18, Heparin flushes administered 1 time instead of the required 5 times.

The DON was interviewed on 5/29/18 at 8:45 A.M., regarding the inappropriate schedule of flushing the Patient's PICC line with Normal Saline and Heparin. She acknowledged that the Patient's PICC line had not been flushed as often as required by the SASH method, or in accordance with the Hospital Policy. The DON also said that the Normal Saline and Heparin flushes should have been scheduled with the administration of each different antibiotic and should not have been ordered PRN (as needed).

2. Patient #3 was admitted from a community Hospital on 5/2/18 with a diagnosis of glioblastoma, S/P scalp wound debridement, partial craniectomy and rotational flap with split thickness skin graft with wound infection and wound infection. The medications at the time of inpatient care included the antibiotics Ancef 2 g, IV every 8 hours.

The Patient had a right wall Port-A-Cath device for for which IV antibiotics were infused.

Interview with the Director of Nurses on 5/29/18 at 8:45 A.M., confirmed that the Hospital utilized the SASH method for maintaining the patency of a Port-A-Cath.

Record review from the time period of 5/2/18 to 5/11/18, indicated that both normal saline, 10 ml syringe flush for line care and heparin 5 ml syringe flush for line care as needed (PRN) were ordered and not at the time each antibiotic was administered.

Utilizing the SASH method, and the Patient receiving Ancef every 8 hours, the Patient's IV line should have been flushed with the following: Saline flushes before and after each medication administration of Ancef for a total of 6 flushes per day and 3 flushes of heparin after each dose of Ancef.

Review of the MAR indicated that the Port-A-Cath line was not flushed with Saline and/or Heparin, before and after each dose of antibiotic as noted below:

5/2/18, Saline flushes administered 1 times instead of 6 times, as required.
5/3/18, Saline flushes administered 3 times instead of 6 times, as required.
5/4/18, Saline flushes administered 3 times instead of 6 times as required.
5/5/18, Saline flushes administered 3 times instead of 6 times, as required.
5/6/18, Saline flushes administered 2 times instead of 6 times, as required.
5/7/18, Saline flushes administered 2 times instead of 6 times as required.
5/8/18, Saline flushes administered 1 times instead of 6 times, as required.
5/9/18, Saline flushes administered 2 times instead of 6 times, as required.
5/10/18, Saline flushes administered 2 times instead of 6 times as required.
5/11/18, Saline flushes administered 1 times instead of 6 times, as required.


5/2/18, Heparin flushes administered 2 times instead of the required 3 times.
5/3/18, Heparin flushes administered 2 times instead of the required 3 times.
5/4/18, Heparin flushes administered 1 times instead of the required 3 times.
5/5/18, Heparin flushes administered 0 times instead of the required 3 times.
5/6/18, Heparin flushes administered 1 times instead of the required 3 times.
5/7/18, Heparin flushes administered 1 times instead of the required 3 times.
5/8/18, Heparin flushes administered 1 times instead of the required 3 times.
5/9/18, Heparin flushes administered 0 times instead of the required 3 times.
5/10/18, Heparin flushes administered 1 times instead of the required 3 times.
5/11/18, Heparin flushes administered 1 times instead of the required 3 times.

The DON was interviewed on 5/29/18 at 8:45 A.M., regarding the inappropriate schedule of flushing the Patient's PICC line with Normal Saline and Heparin. She acknowledged that the Patient's PICC line had not been flushed as often as required by the SASH method, or in accordance with the Hospital Policy. The DON also said that the Normal Saline and Heparin flushes should have been scheduled with the administration of each different antibiotic and should not have been ordered PRN (as needed).

Based on observation, record review and interview, the hospital failed to monitor the nutritional status of one Patient (#15), in a total sample of 32 patients, after the Patient had significant weight loss and then continued to have weight changes. Findings include:

Patient #15, was admitted on 5/10/18, with a status post surgical CABG (Coronary Artery Bypass Graft), hypertension, and renal failure/

Record review indicated the Patient's weight was 138.4 pounds on admission.

On 5/14/18, the Dietician initial assessment indicated the Patient had an inadequate oral intake and was at risk for weight loss. The assessment indicated the diet was a regular, Potassium Restriction, 2 gram low sodium. The assessment indicated the Patient was started on Megace (an appetite stimulant) and received nutritional supplements three times per day (providing an additional calorie intake of 660 plus calories daily).

The Dietician assessment indicated she was going to change the supplement from Ensure to Nepro (a nutritional supplement designed for patients with renal failure) 4 ounces, three times per day. The assessment goal indicated the patient would consume 50 to 75% of meals and supplements and would maintain his/her pre-operative weight, +/-3 pounds, of 130 pounds (not the admission weight of 138.4 pounds as recorded on admission).

Review of the physician orders indicated the Ensure was discontinued on 5/14/18 and the Nepro supplement was not ordered.

Review of the clinical flow sheets for weights indicated the Patient had a significant weight loss of 18.5 pounds (13.7%) in two weeks. The flow sheet indicated the Patient's weight fluctuated and that during the first week the physician was adjusting medications to monitor for fluid needs. However, once the Patient's fluid needs were met (and the physician discontinued the diuretic medication), the Patient continue to show weight loss. The Patient's weight was recorded as 119.8 pounds on 5/24/18 and record review failed to indicate that additional nutritional re-assessments or interventions were implemented to stem the weight loss.

Patient #15 was observed on 5/22/18 and 5/24/18 during breakfast meal. The Nepro supplement was not observed on his/her tray during both observations. The Patient's appearance was thin and his clothing was loose and ill fitting. The sweatshirt sleeve hem was below the shoulder and hanging approximately 5 inches below the shoulder. The Patient's pants were belted and bunched.

During interview on 5/24/18 at 9:15 A.M., Patient #15 shared thier medical history with the Surveyor. Patient #15 said he/she was weighed earlier in the morning and was aware of his/her current weight of 119 pounds. Patient #15 said that she/he tends to be thin, but this was a significant weight change for him/her. The Patient said she/he was surprised by the weight loss and said she/he thought they were eating okay. The Patient said she/he had not received any supplements, but had when they were first admitted.

Interview with the Dietician on 5/24/18 at 11:00 A.M., indicated that she was unaware of the weight changes. She said that she was scheduled to see the Patient (today) and would have picked up the weight changes. The Dietician said that there was no formal consultation process for her to address changes in weight. She said that she usually picked up changes when she did her follow-ups and that based on Staff's judgement, the Staff will contact her to re-assess.

During the interview the Dietician was unaware of the weight policy for weight changes/loss and said that she somehow failed to order the Nepro supplements when she discontinued the Ensure Supplement. She said that the Nepro had approximately 220 calories per 4 oz. This indicated the Patient was not provided an additional 660 calories per day.

During interview with the Director of Nurses on 5/25/18 at 11:30 A.M., she said that the rehab staff obtain weights, the weights are entered into the clinical flow record and the staff entering the weight are alerted of a change, She said the communication and process of alerting staff once entered was not clearly delineated, and said her expectation would be that staff would act upon the change in weight and then re-assess the patient's nutritional care plan to achieve and improve a weight status.

Based on observation, staff interview and record review, the facility failed to ensure that proper hand hygiene and glove use were implemented during patient meal service for 2 of 2 observations, and failed to monitor and document, prior to each use, the concentration of the chemical sanitizer in the three compartment sink to reduce food borne pathogens for a high risk population and that infectious waste was stored in a safe manner.

Findings include:

1. The facility failed to ensure that proper hand hygiene and glove use were implemented during patient meal service for 2 of 2 observations.

On 5/22/18 at 11:45 A.M., the Surveyor observed Food Service employees conducting tray line service in the main kitchen. The Food Service employees were observed to be placing food and beverage items on patient food trays for the noon meal.

It was observed during this meal service that the cook would frequently leave the tray line and obtain food items from surrounding areas of the kitchen and contaminated his disposable gloves. The cook would then return to the tray line and resume service. The cook continued to use the same gloves throughout the meal service and never change them and/or wash his hands.

During this same meal the cook was also observed to be serving meatloaf that was pre-wrapped in clear wrap. The cook would remove the clear wrap from the meatloaf with the gloved hands and place it on a plate. It was observed that the meatloaf was moist with meat juices and the cook's disposable gloves became wet. The cook did not stop and change his gloves but continued to serve the meal with contaminated gloves touching plates and serving utensils.

On 5/24/18 at 11:50 A.M., the Surveyor observed a second noon meal service in the main kitchen. During the meal service, the cook was observed wearing disposal gloves while serving the meal. The cook retrieved a casserole dish from the steam table well, which was filled with a ground macaroni and tomato casserole, and covered in plastic wrap. The cook removed the plastic wrap and took the gloved hand and removed the ground macaroni from the casserole dish and placed it on a plate. Prior to this, the cook had been utilizing the gloved hand to serve food and frequently touching non food surfaces contaminating the gloved hand. The Surveyor immediate identified the observation to the facility Dietitian, who accompanied the Surveyor during the meal service.

Interview with the Food Service Director (Director) on 5/24/18 at 12:00 P.M. identified the observations to the Food Service Director. The Surveyor asked the Director if there had been any education provided to the staff about food handling practices especially during meal service. The Director said that there was a food safety in-service for the kitchen staff on 3/19/18 that addressed use of gloves and when to change them as well as hand washing practices. The Director did acknowledge the poor practice of the staff during the meal service and was planning an in-service "next week" to address the observations of the Surveyor.

2. The facility failed to monitor and document, prior to each use, the concentration of the chemical sanitizer in the three compartment sink, to reduce food borne pathogens with a high risk population.

During the initial kitchen tour on 5/22/18, the Surveyor and the Food Service Director (Director) observed a diet aide obtain the concentration of the sanitizer in the 3 compartment sink. The diet aide completed the task and identified that the concentration was adequate. The Surveyor ask the Director where the information was documented, and she showed the Surveyor the Sanitizer Solution Log for 5/2018. The log reflected that the staff checked the concentration once a day. The Surveyor asked the Director is the 3 compartment sink use only once a day, and she said no it is used after each meal service but they only check and record the concentration of the sanitizer once a day per the company policy. There was no documented evidence that when the staff use the 3 compartment sink to wash, rinse and sanitize pots and pans that the concentration of the sanitizer was adequate with each use.

3. The hospital failed to store infectious waste in a safe manner.

During a tour of the Outpatient unit on 5/24/18 at 4 :00 P.M., located at 1 Scobee Circle in Plymouth, Massachusetts, 4 containers of hazardous sharps and other infectious material was observed stored in an uncovered box in the dirty utility room. One of the containers top was dislodged and sharps were exposed at the bottom of the box. In addition, the entrance to the storage area did not have any biohazard signage. Patients were being treated directly outside this room in a large open area.

The director of the unit said he was not aware of the need for the sign identifying hazardous waste stored in the room or that the material should be stored in a covered container.





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