Frankfort Regional Medical Center

Based on interview, record review, and review of the Kentucky Revised Statue 209.030, it was determined the facility failed to report an allegation of sexual abuse by a facility employee towards a patient to state agencies. This effected one (1) of ten (10) sampled patients (Patient # 1) for closed medical records reviewed.

The findings include:

Review of the Kentucky Revised Statue (KRS) 209.030 (2) revealed the following: Any person, including but not limited to, physician, law enforcement officer, nurse, social worker, cabinet personnel, coroner, medical examiner, alternate care facility employee, or caretaker, having reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation, shall report or cause reports to be made in accordance with the provisions of this chapter.

Review of KRS 209.0303(3), revealed the following: An oral or written report shall be made immediately to the cabinet upon knowledge of suspected abuse, neglect, or exploitation of an adult.

Interview on 12/12/16 at 10:23 AM, with Patient #1, revealed he/she informed facility staff on 10/09/16, that earlier in the day a Respiratory Therapist (RT) had repeatedly touched him/her and made sexual suggestive comments in the course of providing care. Patient #1 revealed, following discharge from the facility he/she contacted the RT's licensing board to see if the incident had been reported for investigation. Patient #1 further revealed, upon the advice of the Kentucky Respiratory Therapist Board, Patient #1 filed a complaint with the Cabinet for Health and Family Services (CHFS).

However, review of the complaint information from CHFS and the Department for Community Based Services (DCBS), revealed no documented evidence the facility had reported Patient #1's sexual abuse allegation to the state agencies. In addition, review of the facility's Accidents and Incidents Log revealed no documented evidence the alleged incident was reported by Patient #1.

Interview conducted on 12/13/16 at 9:16 AM, with the facility's Risk Manager, revealed Patient #1 did report an allegation of sexual abuse to facility staff. Further interview revealed actions taken by facility personnel included contacting the local police department, interviewing staff that were on duty on the day of the alleged incident, terminating the alleged perpetrator and notifying the alleged perpetrator's licensing board of the alleged incident. Per interview, the Risk Manager acknowledged the allegation of sexual abuse was not reported to either CHFS or DCBS for investigation. The Risk Manager further revealed the facility had not developed a policy to direct facility staff to report allegations of staff abuse of patients. Further interview with the Risk Manager, verified Patient #1's complaint/allegation of abuse was not listed on the Accident and Incidents Log. Per interview, the facility failed to list the complaint/allegation on the Log for follow up, and failed to report the abuse allegation to state agencies for investigation. The Risk Manager revealed, I am not aware of any other allegations of staff to patient abuse ever occurring. The Risk Manager further stated, she had been in her position at the facility since the early 1990's.

Interview on 12/13/16 at 9:42 AM, with the facility's Associate Chief Nursing Officer (ACNO) revealed the facility had contacted the RT's Licensing Board and notified them of the allegation because facility administration felt the RT's behavior was unprofessional. The ACNO further revealed facility administration did not realize they needed to report the allegation to CHFS or DCBS since the police had been contacted. The ACNO further acknowledged the facility should be following state and local laws regarding the reporting of suspected abuse allegations of facility staff to state agencies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure medication for pain was administered as per Physician's Orders for one (1) of twelve (12) patients (Patient #6).

The findings include:

Review of the facility's policy titled, Pain Management, number PC.082, revised May 2013, revealed pain would be assessed with patient report of pain (new or significant change in). The Policy stated it was the nurse's responsibility to safely and efficiently administer analgesic drugs and to offer pain medications or interventions frequently and/or as ordered rather than wait for a patient to ask for pain relief. Further review revealed pre-emptive management of pain was encouraged.

Review of the facility's policy titled, Patient Rights, number CSG:QS.004, effective date October 2014, revealed the patient had the right to receive individualized care which fostered the patient's comfort and dignity.

Record review revealed the facility admitted Patient #6 on 03/20/15, with diagnoses which included Dehydration, Insulin Dependent Diabetes Mellitus, Acute and Chronic Renal Failure, Coronary Artery Disease and Chronic Congestive Heart Failure.

Record review revealed, on 03/29/15 at 6:00 PM, Patient #6 was noted to be crying out in pain and was disimpacted (removal of stool from the rectum) with some relief noted. However, even though Patient #6 was crying out in pain and had Tylenol (a non-narcotic pain reliever) ordered every four (4) hours as needed for pain, there was no documented evidence the Tylenol was administered. Record review revealed no documented evidence the nurse attempted to administer the Tylenol on the evening of 03/29/15.

Continued review revealed Nurse's Notes dated 03/29/15, documented by RN #1, who was providing care for Patient #6 beginning at 3:00 PM, revealed a Note timed 7:47 PM, which stated the nurse had received an order from the Physician for Ibuprofen (a nonsteroidal pain reliever) every six (6) hours as needed for pain. Record review revealed the Ibuprofen order was verified by a Pharmacist and was ready to give at 8:06 PM. However, there was no documented evidence nurses attempted to administer the Ibuprofen after 8:06 PM, until at 9:05 PM, when RN #2, who had taken over Patient #6's care at 7:00 PM, an attempt to administer the Ibuprofen, was at that time. Per RN #2's 9:05 PM Note, Patient #6 was experiencing agonal (an abnormal gasping respiratory pattern) breathing and was non-responsive. Further record review revealed Patient #6 expired on [DATE] at 9:17 PM.

Interview with the Assistant Director of Pharmacy, Clinical Services Manager, on 04/28/15 at 12:10 PM, revealed Tylenol and Ibuprofen (all strengths) were stored on the floors in a dispensing machine format (Pyxis system) for point-of-use to prevent wait time for medication to be delivered from the Pharmacy. He revealed the nurse on 03/29/15, could have accessed medications as soon as the medication order had been verified by a Pharmacist. The Assistant Director stated the order for the Ibuprofen was verified by a Pharmacist at 8:06 PM, but it was not signed out to be given to Patient #6 until 9:10 PM on 03/29/15.

Interview with RN #2, on 04/29/15 at 8:35 AM, revealed she was Patient #6's nurse starting at 7:00 PM, on 03/29/15. She revealed she went in to assess Patient #6, shortly after coming to work on 03/29/15 because Patient #6's granddaughter had come to the nurse's station requesting assistance due to the patient having abdominal pain and shortness of breath. RN #2 stated she repositioned Patient #6 at that time, and gave him/her sips of water. Per interview, Patient #6 stated he/she felt better and wanted to go to sleep. She revealed RN #1 had reported to her she was putting an order for Ibuprofen in the computer, and RN #2 could wait to medicate Patient #6 with the Ibuprofen. Continued interview with RN #2 revealed the only reason she could give as to the approximately one (1) hour delay between verification of the Ibuprofen order and her attempt to give the Ibuprofen to Patient #6, was because she was busy with other patients. She stated Patient #6 had not expressed any additional pain also, and Nursing Technician (NT) #1 who put Patient #6 on a bedpan, had told her, Patient #6 was not in any distress.

Interview by telephone with RN #1, on 04/29/15 at 9:48 AM, revealed she could not remember why she did not give Patient #6 Tylenol after she cried out in pain on 03/29/15 at 6:00 PM. She revealed she should have given the Tylenol, and perhaps she did not realize it was ordered and that was why she called the Physician for the Ibuprofen order.

Interview by telephone with NT #1, on 04/29/15 at 3:49 PM, revealed she had taken care of Patient #6 starting at 7:00 PM on 03/29/15. She revealed at 8:30 PM on 03/29/15, Patient #6 expressed no pain, and she thought the patient needed a drink and needed to have a bowel movement. NT #1 further revealed around 9:00 PM, she put Patient #6 on a bedpan, and she was conversant and did not seem to be in distress.

Interview with the Clinical Manager (CM) of the 4th Floor, on 04/30/15 at 2:40 PM, revealed the only reason she could think of why RN #1 did not give Patient #6 the Tylenol on 03/29/15 at 6:00 PM, when the patient expressed pain, was because RN #1 thought the patient needed something stronger for pain. The CM revealed it would be difficult for her to say, not having been in the situation, if the Tylenol should or should not have been given. Per interview, it was her expectation patients pain would be treated as quickly and as effectively as possible, in conjunction with the Physician's Orders.

Interview with the Chief Nursing Officer (CNO), on 04/30/15 at 4:15 PM, revealed she could not comment on the specifics of Patient #6's episode because the disimpaction did diminish the pain. Per interview, however, her expectation was nurses to do everything possible, within nursing standards of care and Physician's orders, to relieve a patient's pain as quickly and effectively as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, and review of the facility's Job Description for the Nursing Technician (NT), it was determined the facility failed to ensure daily personal hygiene was performed for three (3) of twelve (12) sampled patients (Patients #3, #6, and #12).

The findings include:

Review of the facility's Job Description for a Nursing Technician, revised 06/24/14, revealed the Nursing Technician was to work under close direction of the Registered Nurse (RN). Per the Job Description, the Nursing Technician was responsible for patients daily hygiene needs and for providing safe, quality care to patients. Further review revealed the Nursing Technician's Job Description included documentation of the care performed.

1. Review of Patient #3's medical record revealed the facility admitted the patient on 01/08/15, with a diagnosis of Shortness of Air, and discharged him/her in stable condition on 01/17/15. Further review revealed no documented evidence Patient #3 was provided daily hygiene or refused daily hygiene for the following dates: 01/09/15, 01/11/15, 01/13/15, 01/14/15, 01/15/15 and 01/16/15.

2. Review of Patient #6's medical record revealed the facility admitted the patient on 03/20/15, with diagnoses which included Acute and Chronic Renal Failure, Coronary Artery Disease, Chronic Congestive Heart Failure, Insulin Dependent Diabetes Mellitus and Dehydration. Continued review revealed Patient #6 was noted to have expired on [DATE] at 9:17 PM. Further review revealed no documented evidence Patient #6 was provided daily hygiene or refused daily hygiene for the following dates: 03/24/15, 03/28/15 and 03/29/15.

3. Review of Patient #12's medical record revealed the facility admitted the patient on 04/25/15, with diagnoses which included Right Lower Extremity Cellulitis, Insulin Dependent Diabetes Mellitus and Chronic Kidney Disease. Further review revealed no documented evidence Patient #12 was provided daily hygiene or refused daily hygiene on 04/26/15 and 04/28/15.

Interview with NT #2, on 04/28/15 at 11:40 AM, revealed one (1) of her duties was to assist patients with personal hygiene and give bed baths if needed on a daily basis. She revealed there had been a log started after 04/01/15 for NT's to list what had been done for patients which included personal hygiene. Per NT #2, she was supposed to document when personal hygiene was performed for her patients by the amount of assistance the patient required. Further interview revealed she was also to document if the patient refused care and add an explanatory note.

Interview with the Clinical Manager (CM), on 04/30/15 at 2:40 PM, revealed her expectation was for every patient to receive an assisted bath everyday if they desired, and if they were independent to receive a towel and wash cloth to take a shower. She revealed she thought there was an issue of documentation of patient refusals, and not of a patient wanting a bath and not getting one. The CM stated she expected the NT's to document patient care or refusal of care because it was part of the facility's nursing standard of care for baths to be given daily unless the patient refused.

Interview with the Chief Nursing Officer (CNO), on 04/30/15 at 4:15 PM, revealed her expectation was for patients to be bathed daily or at least have the NT offer a bath, with the patient having the right to refuse a bath. Per interview, there should have been documentation if patients refused the bath or if the bath/shower had been given. She stated if there was a refusal of care by a patient, it needed to be further explained in a note. The CNO revealed all nurses, at orientation, were told it was a global nursing standard of care for daily personal hygiene, or bathing, pull to every area's work list.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, it was determined the facility failed to ensure Physician's Orders were followed for one (1) of twelve (12) patients (Patient #6).

The findings include:

Interview with the Chief Nursing Officer (CNO), on 04/30/15 at 4:15 PM, revealed the facility might have a facility policy on nurses following Physician's Orders; however, it could not be located. Per interview, following Physician's Orders was not included in the job description for the Registered Nurse (RN).

Review of Patient #6's medical record revealed the facility admitted the patient on 03/20/15, with diagnoses which included Chronic Congestive Heart Failure, Acute and Chronic Renal Failure, Coronary Artery Disease, Insulin Dependent Diabetes Mellitus and Dehydration. Record review revealed a Physician's Order, dated 03/20/15 at 1:33 AM, to notify the Physician for a systolic blood pressure (B/P) of less than 90 mmHg (millimeters of mercury-the units used to measure blood pressure).

Review of a Nurse's Note documented by RN #2, dated 03/29/15 at 7:05 PM, revealed she went to assess Patient #6, per the family's request, due to the patient having abdominal pain and shortness of breath. Continued review of the Note revealed the patient's blood pressure was 88/53, with no documented evidence of RN #2 having notified the Physician of the systolic B/P of less than 90 mmHg (88), as per the order dated 03/20/15. Review of the Nurse's Note dated 03/29/15 timed 7:30 PM, documented by RN #1, revealed no documented evidence the Physician was notified of the systolic B/P of 88 obtained by RN #2 noted at 7:05 PM. Review of the Nurse's Note dated 03/29/15 at 9:05 PM, documented by RN #2 revealed Patient #6 was in agonal (an abnormal gasping respiration pattern) breathing and was nonresponsive. Further record review revealed Patient #6 was noted to have expired on [DATE] at 9:17 PM.

Interview with RN #2, on 04/29/15 at 8:35 AM, revealed she did assess Patient #6 at around 7:00 PM, on 03/29/15, and found the patient's B/P to be 88/53. She stated the patient's B/P was a little low, but the family did not ask her to call the Physician. Per interview, Patient #6 was feeling better and wanted to go to sleep, and she felt the low B/P was volume related. She revealed however, Patient #6 was receiving intravenous fluids. Further interview revealed she knew RN #1 was expecting a call back from the patient's Physician, and she had told RN #1 about her assessment of the patient and about his/her low B/P.

Interview by telephone with RN #1, on 04/29/15 at 9:48 AM, revealed if she had spoken to the Physician on 03/29/15, it would have been about Patient #6 being impacted. Per interview, she could not remember what she had informed the Physician of that far back however.

Interview with the Clinical Manager (CM), on 04/30/15 at 2:40 PM, revealed Patient #6 had an order to notify the Physician if the systolic B/P was less than 90 mmHg; however, it would be difficult for her to say in this case what should have been done. The CM revealed it would be her expectation for Physician's Orders to be carried out by nursing personnel.

Continued interview with the CNO, on 04/30/15 at 4:15 PM, revealed if the Physician had parameters set to be notified about B/P reading, and a BP of 88/53 fell into the range for notification, the Physician should have been notified, as per the order. Per interview, the nurse should document the Physician notification in the patient's medical record. She revealed it was her expectation for nurses to follow Physician's Orders and thoroughly document all Physician notifications. The CNO stated the nurse, as a licensed professional, should know to follow a Physician's appropriately written order. Further interview revealed information on a specific order for notification would go to the patient work list which the nurse followed for the entire shift for providing patient care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, staff interview, and facility policy and procedures, the facility failed to ensure informed consents for surgical and/or invasive diagnostic procedures were dated and timed by the patient prior to the procedure as required for seven (7) sampled patients. Patients #1, #3, #4, #27, #28,

#38, and #39.

The findings include:

Review of the facility policy for informed consent (RI.009) with a revision date of 01/2011 revealed all informed consent forms were to be completed and signed when the patient was to undergo any procedure performed by a Licensed Independent Practitioner. In addition, the policy required the patient to sign, date, and time the consent form after expressing understanding of the risks, benefits, and alternatives of the procedure.

1. Record review for Patient #1 revealed the patient underwent a left knee Arthroscopy Meniscectomy possible Chondroplasty on 03/29/11. The consent form for surgical or invasive diagnostic procedures was not dated or timed by the patient as required.

2. Record review for Patient #3 revealed the patient had a Endoscopic Sinus surgery , septoplasty, turbinate surgery, and resection of concha on 03/29/11. The consent form for surgical or invasive diagnostic procedures was not dated or timed by the patient as required.

3. Record review for Patient #4 revealed the patient had a left knee Arthroscopy Menisectomy with possible chondroplasty on 03/29/11. The consent form for surgical or invasive diagnostic procedures was not dated or timed by the patient as required.

4. Record review for Patient #27 revealed the patient had a Cystoscopy Fulguration bladder biopsy on 03/24/11. The consent form for surgical or invasive diagnostic procedures was not dated or timed by the patient as required.

5. Record review for Patient #28 revealed the patient had a Tympanoplasty, left ear procedure on 03/30/11. The consent form for surgical or invasive diagnostic procedures was not dated or timed by the patient as required.

6. Record review for Patient #38 on 03/30/11 revealed an admission date of [DATE] with a diagnosis of Gastroesophageal Reflux and a proposed surgical procedure of a possible open laparoscopic exam. The surgical consent form did not reveal a date and time the patient had signed the consent. A witness had signed the surgical consent form on 03/15/11 at 11:30am and a registered nurse had signed the surgical consent form on 03/28/11 at 6:42am under the witness's name.

7. Record review for Patient #39 on 03/30/11 revealed an admission date of [DATE] with a diagnosis of a mass on the right kidney. The proposed surgical procedure for Patient #39 was a right renal exploration and a possible right nephrectomy (removal of the right kidney). The surgical consent form for this procedure was signed by Patient #39 but without a date and time of the patient's signature. The surgical consent form was signed by a witness on 03/17/11 at 2:00pm, signed again by a registered nurse on 03/28/11 at 1:00pm under the witness's signature and signed a third time by an untitled witness on 03/29/11 at 7:45am under the registered nurse's signature.

Interview with the Quality Improvement Director on 03/31/11 at approximately 1:00pm revealed the Informed Consent forms were recently changed. The new Informed Consent form did not have a section to prompt staff to include a date and time as the previous forms had. She stated it was an oversight that will be corrected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, staff interviews, and facility policy and procedures the facility failed to ensure their system for controlling infections were not implemented consistently. Observation of Operating Room #5 revealed the room had not been thoroughly cleaned between patients. A vacuum canister with body fluids identified by the facility as serosanguinous blood, was left from the previous procedure. Patient #31 was on the operating table being prepped for a left hip replacement procedure when the canister was observed. The facility failed to ensure a sterile field and surgical hand antisepsis was maintained during a surgical procedure for one patient.

In addition, multiple IV (Intravenous) tubing were not dated or timed upon use. A glucometer was not cleaned between patient use.

The findings include:

1. Review of the facility's policy for Operating Room cleaning (# Dec.542.042) with a revision date of 03/2011 revealed the scrub team or environmental service tech were to seal suction equipment/drainage system canisters & tubing and/or contained fluids and dispose in a designated Biohazard waste container after each case.

Observations on 03/30/11 at 9:45 am revealed Operating Room(OR) #5 was staffed and prepared for Patient #31's surgical procedure of a left hip replacement. Patient #31 was on the OR table. The vacuum suction canister (used to suction patient's blood during surgery) was available for use. The suction canister contained a serosanguinous substance identified by the OR manager as blood.

Interview on 03/30/11 at 9:49am with the Director of Surgical Services revealed the serosanguinous substance appeared to be blood from the previous patient. She ststed the suction canister should have been removed by the OR staff prior to the patient being brought into the OR.

2. Review of facility policy for Sterile Field, Establishing & Maintaining (# DIC.542.084) with a revision date of 08/2008 revealed, All individuals involved in surgical interventions have a responsibility to provide and maintain a safe environment. Adherence to aseptic practices aids in fulfilling this responsibility. Aseptic practices are implemented preoperatively, intraoperatively, and postoperatively to minimize wound contamination. 2. B. Sterile drapes should be handled as little as possible, rapid movement of draping materials creates air currents on which dust, lint, and other particles can migrate. 2. E. The surgical drape that establishes the sterile field should not be moved. Shifting or moving the sterile drape can compromise the sterility of the field. 6. E. revealed unscrubbed persons should face sterile fields on approach, should not walk between two sterile fields, and should be aware of the need for distance from the sterile field. Accidental contamination can be kept to a minimum by keeping sterile areas in view.

Review of the facility policy for Handwashing/Hand Antisepsis (#. IC.001) with a revision date of 12/2010 revealed staff were to decontaminate their hands before having direct contact with patients, prior to donning gloves, after contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressings; after removing gloves; after contact with patient's intact skin; on leaving a patient care area or after handling soiled articles or equipment from a patient care area.

Observations on 03/30/11 at 9:50am revealed the Circulating Nurse was preparing OR #5 for a surgical procedure. The nurse bent down to the floor at the end of the OR table to move the compression stocking motor and adjust the electrical cord on the floor with her ungloved hands. Observation revealed she did not wash or disinfect her hands after handling the equipment on the floor. The nurse then opened a gown and handed it to the scrub tech for the physician without washing or disinfecting her hands. The Circulating Nurse was then observed to plug in a cord to the electrical outlet and then pulled the zipper on the back of the physician's gown down with her bare hands that had not been disinfected. The Circulating Nurse then assisted the surgeon by holding Patient #31's left foot with her ungloved hands that had not been washed or sanitized. The nurse then moved some equipment and unplugged the compression machine. She then used her fingertips to straighten out the sterile drape as it was placed over the patient. She had not washed or sanitized her ungloved hands. The Circulating Nurse turned the OR lights on and picked up the tubing from the floor to attach to the suction machine. At 10:03am the nurse documented on the computer then answered another staff member's cell phone at 10:05am. The nurse then walked passed the sterile instrument table and as she returned to the other side of the room, she swiped the skirt of the sterile drape. The Circulating Nurse then obtained and opened an orthopedic drive with ungloved hands (that had not been washed or sanitized) for the surgeon. The nurse placed plastic waste items and wrappers into the large black trash bag, tied up and removed the full trash bag, and replaced with a new bag. The Circulating Nurse did not wear gloves, wash or disinfect her hands with an alcohol based hand wash during the above observations. The nurse was observed to wash her hands at 10:15am.

Interview on 03/30/11 at 11:58am with the Circulating Nurse revealed staff were to wash their hands when coming in and out of a room, when you remove gloves, before and after touching patients, and when they were soiled. She stated she should have washed her hands and she should have used gloves. She stated the floor was not a sterile area and was considered dirty. She stated she thought it was okay to hold the patient's foot with ungloved hands, but she should have washed her hands afterwards.

Interview on 03/30/11 at 4:20pm with the Director of Surgical Services revealed the Circulating Nurse should have washed her hands more frequently. She stated she did not see the nurse swipe the sterile drape and had no concerns with the technique displayed by the nurse during the surgical procedure.

3. Review of facility policy for Surgical Attire for operating room and obstetrics (OR & OB) # DPC.542.004 with a revision date of 08/2008, revealed all persons who enter the restricted areas of the surgical suite should wear surgical attire intended for use within the suite. The policy stated a clean uniform must be worn each day and changed when dirty or contaminated by blood or body fluids. All scrub team personnel must wear a sterile gown and the materials should minimize the passage of microorganisms and be resistant to the penetration of blood and other liquids.

Observation on 03/30/11 at 10:20am and 10:40am revealed the Anesthesiologist came into the room to check on the patient and was wearing a fleece jacket over his scrubs.

Interview on 03/30/11 at 11:45am with the Anesthesiologist revealed he kept his jacket in his locker and took it home to be washed about every two weeks. He stated he thought it was no different than staff wearing scrubs from home.

4. Review of facility policy on general intravascular therapy with a revision date 08/10 revealed IV tubing should be labeled with the date, time, and expiration date. Primary and secondary tubing should be changed every ninety-six (96) hours.

Observation of the facility's fourth (4th) floor medical-surgical patient rooms #407, 418, 419, 424, and 425 on 03/30/11 at 2:30pm revealed patient IV (intravenous) lines which were not dated and timed upon use. In addition, the IV tubing had no date/time the IV line would need to be changed, for infection control purposes.

Observation of the third floor on 03/29/11 at 11:00am revealed several IV tubing that were not dated upon use. Patient #5 's Normal Saline and Arythromycin IV tubing was not dated. Patient #9's Normal Saline and Arythromycin IV tubing was not dated. Patient #11's Levaquin IV tubing was not dated. Patient #38's Normal Saline and Arythromycin IV tubing was not dated.

Interview with the Nursing Manager of the third floor on 03/30/11 at 3:20pm revealed the IV tubing should be dated upon use. She indicated Spot checks were conducted to ensure compliance and quality assurance does a quarterly assessment.

Interview with RN #8 on 03/30/11 at 2:40pm revealed all patient IV lines should have a date and time when they were hung by the nursing staff. Interview with RN #7 on 03/30/11 at 2:45pm revealed she confirmed that all patient IV lines should be dated with a time when the IV was hung by the nursing staff.

5. Review of facility policy for equipment cleaning (patient care) dated 12/10 revealed each department shall be responsible for cleaning equipment after use in any patient care area and as needed. The procedure states the equipment needed: a) hospital approved germicidal disinfectant cleaner or pre-moistened wipes, b) cleaning cloths, c) gloves. Guidelines: a) remove obvious soiling, b) saturate a cloth with cleaning solution or spray the surface with the germicidal spray, c) wipe down equipment completely with saturated cloth, d) do not rinse, allow to air dry at least five minutes.

Observation on 03/29/11 at 11:55am revealed Registered Nurse (RN) #5 performed a fingerstick for a blood sugar reading for Patient #6 who was admitted on [DATE] with a diagnoses of Pneumonia and history of Diabetes. RN #5 removed the glucometer from the carrying case. The RN placed a strip in the glucometer, scanned the patient's identification band, cleansed the finger with alcohol and performed the fingerstick. A drop of blood was placed on the glucometer strip. After obtaining the reading, the strip was discarded and the glucometer was returned to the carrying case. RN #5 walked into the hallway and cleaned the glucometer with an alcohol wipe and returned the glucometer to the carrying case.

Observation on 03/29/11 at 11:20am revealed RN #6 performed a fingerstick on Patient #38, admitted with a history of Diabetes. The RN washed her hands and put on gloves. The glucometer was removed from the carrying case and a strip was inserted. The patient identification band was scanned and the RN proceeded to wipe the the patient's finger with alcohol. A fingerstick was performed and a blood sugar was obtained. The RN discarded the strip after obtaining the reading. The glucometer was placed into the carrying case. RN #6 gave insulin as ordered. The glucometer was returned to the area by the nurses station.

Interview with the Infection Control Nurse on 03/30/11 at 3:00pm revealed the expectation of staff is to clean the glucometer before it is returned to the carrying case. The nurse explained there is no specific policy for cleaning the glucometer but it is expected the staff would follow the equipment cleaning policy. The Infection Control Nurse states alcohol wipes can be used to clean the glucometer but sani wipes are preferred.

Interview with the RN #6 on 03/30/11 at 3:10pm revealed she/he was aware the glucometer should be cleaned before it is returned to the carrying case. The RN stated the carrying case is contaminated if the glucometer had not been sanitized. RN #6 stated alcohol wipes are readily available and sani wipes are in the hallway.

Review of the Quality Assurance minutes for January and February 2011 revealed infection control goals for 2011 were: improved hand hygiene, environment cleaning (including equipment), and improved surgical site infections.

Interview with the Infection Control Director on 03/31/11 at 1:30pm revealed staff receive training on infection control procedures during orientation, annually, with quarterly updates. Infection control policies and procedures are reviewed annually and as needed. The facility track and trend infections including IV lines (peripheral and central), MRSA rates per unit, C-diff, and others. The facility reports to NHSN (national health surveillance network), CMS (center for medicare and medicaid), and go by CDC (Center for Disease Control) guidelines.