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Based on interview and record review the facility failed to follow its protocol titled, "Intravenous Insulin infusion Protocol," (undated), for one of 20 sampled patients (Patient 1), when Patient 1's Insulin Drip Flow Sheets, dated 4/28/22 and 4/29/22-4/30/22 were missing documentation or not documented at all. This placed Patient 1 at risk of not having his insulin documented or given per protocol possibly leading to medication errors.

Findings:

During a review of Patient 1's document titled, "Emergency Room-Outpatient Record," dated 4/27/22, indicated Patient 1 was admitted on 4/27/22 with a chief complaint of DKA (Diabetic Ketoacidosis- serious complication of diabetes (not enough insulin) that occur when your body produce high levels of blood acids called ketones).

During a review of Patient 1's document titled, "ED Note," dated 4/28/22, the ED Note indicated, " ... Chief Complaint: Vomiting History of Present Illness ... diabetic man who was told a month ago that he should go off all of his diabetes medicines. It is unclear exactly what the reasoning behind that but that is what his doctor told him to do so he complied and did not take any of his diabetes medicines for the last month he has been vomiting nonstop for the last day and a half so his wife finally brought him to the emergency room ... Past Medical History: ... HTN [hypertension- elevated blood pressure], Diabetes ... ED Course Patient is in fairly severe diabetic ketoacidosis (referral lists laboratory studies). The patient was put on an insulin drip and multiple supplements were given for his low pH [figure expressing the acidity or alkalinity of a solution] and his hypokalemia (low potassium level) once his insulin drip was started. Patient remained clinically well through most of the night ..."

During a review of Patient 1's document titled, "Intravenous Insulin Infusion Protocol," dated 4/27/22, at 12:15 p.m., indicated Patient 1 would be on Algorithm 3 meaning he could receive insulin 0-16 units total for his blood sugar readings done hourly. At 4 p.m. a new protocol form was filled in moving Patient 1 to Algorithm 4, meaning he could receive insulin 0-28 units. On 4/28/22 at 8 a.m. the protocol was changed to Algorithm 2, meaning he could receive insulin 0-12 units based on his blood sugar readings.

During a concurrent interview and record review on 5/3/22, at 2:29 p.m., Patient 1's Intravenous Insulin Infusion Protocols (IIP), Insulin Drip Flow Sheets (IFS), and Insulin orders were reviewed with Emergency Department Manager (EDM), the EDM confirmed the following issues:

-The IIP dated 4/29/22, at 9 p.m., had two separate orders on the form and per the EDM it made the order confusing. The EDM stated the expectation is that the doctor would use one form for each order change.

-The IFS dated 4/27/22-4/28/22 was missing the 4/28/22 4 a.m., 5 a.m., and 6 a.m. blood sugars; rates on the pump; notes and from 4/27/22 at 8 p.m. on there is only one initial per hour indicating that the rate changes were not reviewed with another nurse. The EDM stated the expectation is that the blood sugars will be written on this form along with the infusion rates and initialed by two nurses to confirm the rate changes.

-The IFS dated 4/29/22 at 10 p.m. was missing along with documentation at 11 p.m. and 4/30/22 from midnight to 6 a.m. The EDM stated she would need to investigate it. The EDM pulled up the patients' electronic health records and looked at the order details for Insulin Reg/NS (Insulin Regular in Normal Saline) IVPB (give intravenous piggyback) with start date 4/29/22 at 8:48 p.m. stop date 5/1/22 at 1:19 p.m., this order indicated the Administrations that were given to the patient are as follows:

-1. 4/29/22 at 10 p.m. blood sugar 340 none given
-2. 4/30/22 at 7:30 a.m. titrate to 4 units/hr
-3. 4/30/22 at 10:49 a.m. blood sugar 138 give 3 units/hr
-4. 4/30/22 at 11:30 a.m. blood sugar 132 give 3 units/hr
-5. 4/30/22 at 1:55 p.m. blood sugar 160 give 4 units/hr

The EDM stated she would speak with the nurse who had the patient and get clarification as to why the blood sugars and insulin changes were not documented in either the computer or on the IFS form for 4/29/22 from 11 p.m. to 6 a.m. on 4/30/22. The EDM stated she will need to do more education on insulin drips and what the expectation is currently there is no policy and procedure just the insulin protocols which do not state where to document blood sugars and rate changes.

During a concurrent interview and record review on 5/4/22, at 7 a.m. with Registered Nurse (RN) 1, Patient 1's Intravenous Insulin Infusion Protocols (IIP), Insulin Drip Flow Sheets (IFS), and Insulin orders for admission 4/27/22- 5/1/22 were reviewed. RN 1 stated he was the nurse for Patient 1 on the evenings of 4/27/22 and 4/29/22. RN 1 stated Patient 1 was on an insulin drip and as he was looking through the patient's paper chart, he noted he had forgotten to document the blood sugars and insulin rate changes for 4/28/22 the 4 a.m., 5 a.m., and 6 a.m. hourly checks. RN 1 then stated he was not able to locate the IFS form for the night of 4/29/22 to 4/30/22 and stated he had spoken with his EDM, and he had filled in a new form for those blood sugar and insulin changes. RN 1 stated he was trained to use the IFS forms for charting the patients' blood sugars and to have a second nurse sign off on all rate changes and believe he did check with another nurse for each change for Patient 1's insulin drip but confirmed the second nurses' initials were not on the IFS form. RN 1 stated it is very important to track and document insulin drip numbers hourly and rate changes for the safety of the patient.

During an interview on 5/4/22, at 2:13 p.m., with the Pharmacy Director (PD), the PD stated she had created the Insulin Drip Flow Sheet to go with the Intravenous Insulin Infusion Protocol. The PD stated it is easier for staff to hand off using the paper form then the computer, so the expectation is do document correctly on the Insulin Drip Flow Sheet.

During a review of a professional reference titled, "ISMP [Institute for Safe Medication Practices] List of High-Alert Medications in Acute Care Settings," dated 2018, retrieved from: https://www.ismp.org/sites/default/files/attachments/2018-08/highAlert2018-Acute-Final.pdf, indicated, "High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients. We hope you will use this list to determine which medications require special safeguards to reduce the risk of errors. This may include strategies such as standardizing the ordering, storage, preparation, and administration of these products; improving access to information about these drugs; limiting access to high alert medications; using auxiliary labels; employing clinical decision support and automated alerts; and using redundancies such as automated or independent double checks when necessary ... Classes/Categories of Medications ... insulin, subcutaneous (given under the skin) and IV [intravenous- through the vein] ... *All forms of insulin, subcutaneous and IV, are considered a class of high-alert medications ..."

Based on observation, interview, and record review the facility failed to follow infection control practices to prevent the spread of infection when:

1.The front desk staff member failed to screen three of three visitors coming into the hospital. This had the potential to spread infection through out the hospital.
2.One staff member failed to wash his hands after removing gloves. This had the potential to cause infection to Patient 1's central line site.
3.One staff member was seen to have approximately one-inch-long fake nails. This had the potential to cause injury and spread bacteria to patients.

Findings:

1.During an observation on 5/2/22, at 1:10 p.m., in the hospital main entrance lobby, front desk staff member (FR) 1 did not perform COVID-19 (Coronavirus disease 2019- a contagious disease often cause respiratory symptoms that can feel like a clod, flu, and pneumonia) signs and symptoms screening for three hospital visitors.

During an interview on 5/2/22, at 1:56 p.m., with FR 1, FR 1 stated she was assigned to perform COVID-19 signs and symptoms screening for all visitors, patients, and staff. FR 1 stated she should have perform COVID-19 signs and symptoms screening for hospital visitors, and she did not.

During an interview, on 5/2/22, at 1:56 p.m., with the Administrator (ADM), the ADM stated FR 1 should have screened all visitors coming into the hospital for COVID-19 signs and symptoms.

During an interview on 5/3/22, at 4:18 p.m., with the Infection Preventionist (IP), the IP stated FR 1 should have screened all visitors for COVID-19 signs and symptoms prior to entering the hospital to prevent the spread of COVID-19.

During a review of the facility's policy and procedure titled, "Visitors During Pandemic," dated 5/1/22, the P&P indicated, "Purpose & Scope: To prevent the transmission of influenza/COVID-19 to healthcare workers or other visitors and patients by monitoring and limiting visitors if necessary ... All visitors will be screened by Hospital staff member for signs and symptoms of influenza/Covid-19 before entry into the facility. Person who are symptomatic will not be permitted to enter the facility ... Visitors will be limited to persons who are necessary for patient's emotional well-being and care ... The facility will restrict visiting as necessary to protect residents and patients. The Facility will follow the latest guideline and update from Centers for Disease Control and Prevention (CDC), California Department of Public Health (CDPH) and Fresno County Public Health..."

2. During a concurrent observation and interview on 5/3/22, at 10:38 a.m., with the Day shift House Supervisor (DHS), the DHS was seen removing a central line from Patient 1's chest. The DHS cleaned his hands and placed on clean gloves, explained the procedure to the patient and began pulling down the dressing; after the dressing was removed he removed his gloves and placed a new pair of clean gloves on and began cutting the sutures that held the central line in place; then instructed the patient to take a deep breathe and breath out as he pulled the line out and covered it with a 2x2 (size of dressing). The DHS stated he had forgotten to clean his hand in-between removing his dirty gloves and putting on clean ones. The DHS stated the expectation was for him to clean his hands and then place clean gloves on. The DHS stated the risk to the patient is transfer of germs, possible infection.

During an interview on 5/4/22, at 3:33 p.m., with the Infection Preventionist (IP), the IP stated staff should follow the five moments of hand hygiene by WHO (world health organization), prior to gloving hand washing, gel and after removal.

During a review of the facility's policy and procedure titled, Hand Hygiene, dated 5/1/20, indicated, "Purpose: To provide guidelines for effective hand hygiene, n order to prevent the transmission of bacteria, germs and infections ... Policy: I. All staff will use the hand-hygiene techniques, as set forth in the following procedure ... g. After working on a contaminated body site and then moving to a clean body site on the same patient ... k. Always after removing gloves ..."

During a review of a professional reference titled, "My 5 Moments for Hand Hygiene," retrieved from https://www.who.int/campaigns/world-hand-hygiene-day, indicated, it "defines the key moments when health-care workers should perform hand hygiene ... before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching patient surroundings ..."

3.During a concurrent observation and interview on 5/3/22, at 11:07 a.m., with Registered Nurse (RN) 4, RN 4 was seen sitting at a computer in the Emergency Department with long acrylic nails (approximately 1 inch long). RN 4 stated she knew her nails were too long, and she was putting patients at risk of being scratched while she was transferring them and also put them at risk of transferring bacteria or germs from her nails to the patients.

During an interview on 5/3/22, at 11:15 a.m., with the DHS, the DHS stated the expectation for nails is that they are kept short and clean.

During an interview on 5/4/22, at 3:33 p.m., with the IP, the IP stated staff should not have long nails, they can harbor bacteria and germs and staff can transmit this to other patients, risk of infection to the patients. The IP stated long nails can also cause injury to patients.

During a review of the facility's policy and procedure titled, Hand Hygiene, dated 5/1/20, indicated, "Purpose: To provide guidelines for effective hand hygiene, n order to prevent the transmission of bacteria, germs and infections ... Procedure: I. Using antimicrobial soap and water or non-antimicrobial soap and water: ... c. Keep nails short (1/4 inch in length). Nail polish may be worn only if is kept well manicured; chipped polish must be removed. No nail jewelry, artificial nails, acrylics, overlays, gels, wraps, tips silk wraps, or extenders for any employee, who provides patient care ..."