CMS-HCA-Florida-Putnam-Hospital

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

Based on observation, interview, resident record reviews, policy and procedure review, and CDC (Center for Disease Control and Prevention) guidelines, the facility failed to prevent the possible spread of infection by not removing possibly infected PPE (Personal Protective Equipment) before exiting rooms after patient care, failed to perform hand hygiene before and after patient contact, and failed to clean/sanitize shared equipment of face shields in 2 out of 2 patients (Patient # 3 and Patient #4) observed out of 7 total patients on the Coronavirus 2019 dedicated wing and that two staff orrectly wore face masks on the Progressive Care unit ( PCU) wing.

Findings:

An observation on 05/15/2020 at 8:40 an RN, staff N with mask below nose (Identified as the Nurse Manager for Unit 2).

During an interview on 05/15/2020 at 1:20 PM, with Unit Manager of second floor, states that the mask should be on her nose and mouth, she stated did not realize it was not covering her nose when walked out her office.

An observation on 05/15/2020 at 8:45 AM on the PCU unit, staff RN N, walking in the halls with only mouth covered and not her nose.

During an interview on 05/15/2020 at 1:10 PM, with RN on the PCU unit , staff N was asked how she is to use the face mask. This RN stated that it keeps slipping. (Was observed coming out of a room, where charting and then entered hall, mask not on). Staff N stated, the mask should be on her nose and mouth.

Review of a Universal Protection Framework for Social Distancing under house wide Strategies Social Distancing: Masking required in all clinical areas. Signage add to reinforce masks are always required in common areas and promote social distancing.

Review of Creating Safety for resumption of Routine Patient Care: Universal Protection Framework Development: Under infection Prevention: Universal Masking.

Review of the facility medical records for Patient #3 shows an [AGE]-year-old male admitted to the facility on [DATE] with fever, cough. progressive left foot pain and erythema (redness)with a past medical history of a recent bunionectomy (a surgical procedure that corrects a foot deformity near the big toe), Diabetes Mellitus, hypertension and arthritis.

Patient #3 had a Covid -19 test completed on 5/14/2020, the result was negative for COVID-19.

A review of the physician progress notes for Patient #3 dated 5/14/2020 was reviewed and read: Patient remains symptomatic with fever, if patient #3 health deteriorates, will retest for Covid -19.

At 8:30 AM on 5/15/2020 Staff C, a Registered Nurse (RN) was observed entering Patient #3's room (there was no isolation signage on the door) and placing on gloves, he did not sanitize his hands prior to putting his gloves on.

At 08:32 AM on 5/15/2020 Staff C, an RN was observed exiting Patient #3's room with his gloves still on, he proceeded to walk up the hallway to the medication room, entered the medication door code opening the medication room door and prior to the door shutting, was observed touching the keyboard on the facility automated medication dispensing machine,

At 8:34 AM Staff C, an RN was observed exiting the medication room with gloves still on. Staff C, RN removed gloves and walked back down the hallway, he did not sanitize his hands after glove removal.

At 08:35 AM on 5/15/2020 Staff C, an RN entered Patient #3 room without sanitizing his hands.

At 08:36 on 5/15/2020 Staff C, RN exited Patient #3 room without sanitizing his hands.

At 08:38 AM on 5/15/2020 Staff C, an RN reentered Patient #3 room without sanitizing his hands.

During an interview on 05/15/2020 at 08:34 AM, with Staff C, an RN stated, That patient (Patient #3) is not on any isolation beyond standard precautions.

During an interview on 5/15/2020 at 8:55 AM with Staff C, an RN he stated, I should not have had my gloves on when I went to the medication room, I did not sanitize my hands each time I went into Patient #3 room and I should have. I didn't sanitize my hands before I put on my gloves and should have. I was just in a hurry and forgot. I should have cleaned off my face shield after I went into Patient #4 room. I always clean my shield normally.

Patient # 4:

A review of the facility medical record for Patient #4 was completed, Patient #4 is a [AGE]-year-old male who was admitted to the facility on [DATE] with a history of generalized weakness with cough and fever. Past medical history of Diabetes Mellitus, Myelodysplastic syndrome (a condition that occurs when the blood forming cells in bone marrow become abnormal) and hypertension.

A review of the physician orders for patient #4 was completed for 5/14/2020: Covid-19 testing and Isolation precautions were ordered.

At 08:42 AM on 5/15/2020, Staff C, RN was observed entering Patient #4 room, an isolation room for suspected COVID 19, upon entering the room he placed on a gown, gloves and a face shield over his N 95 and facemask.

Staff C, RN exited Patient #4 room at 08:43 AM, he did not sanitize his hands after removing gown and gloves, he did not remove his face shield and did not sanitize his face shield after exiting the room and walking up the hall to the nurses station.

At 8:45 AM on 5/15/2020 Staff C, RN was observed entering Patient #4 room donning gown and gloves without sanitizing his hands before putting on gloves.

At 8:48 AM on 5/15/2020 Staff D, RN was observed entering Patient #4 room, putting on a gown and gloves, N 95 and Face shield, he did not sanitize his hands before putting on his PPE or gloves.

At 8:50 AM Staff D,RN exited Patient #4 room Staff D, RN removed his gown, gloves and face shield and went up to the nurses station, the staff did not sanitize his hands or his face shield after leaving Patient #4's room who is symptomatic and on isolation for Coronavirus 2019.

At 8:53 AM on 5/15/2019 Staff C, RN was observed exiting Patient #4 room, he removed his gown and gloves but did not remove or sanitize his face shield or hands. He proceeded to an equipment cart that was positioned 2 rooms away from Patient #4 room and removed his face shield placing it in a plastic bag. He did not sanitize his face shield prior to putting his face shield away.

During an interview on 5/15/2020 at 8:55 AM with Staff C, an RN he stated, I should not have had my gloves on when I went to the medication room, I did not sanitize my hands each time I went into Patient #3 room and I should have. I didn't sanitize my hands before I put on my gloves and should have. I was just in a hurry and forgot. I should have cleaned off my face shield after I went into Patient #4 room. I always clean my shield normally.

During as interview on 5/15/2020 at 1:40 PM with the Chief Nursing Officer she stated, It is my expectation that all staff wear the appropriate PPE at all times to protect themselves as well as our patients and ultimately our entire community. Staff have been educated since day one about the virus and our changes in process. All staff get yearly infection control training, this training includes the expectation for standard, contact, droplet and airborne precautions. Staff understand that they are to wear facemasks on duty. We see very few not adhering to that policy. Staff are expected to clean/sanitize their hands prior to donning PPE and after doffing it. Staff should wear gloves when leaving a room when they have been touching anything in the rooms. Staff should sanitize their face shields after exiting a presumptive Covid room.

During an interview on 5/15/2020 at 12:15PM with the Director of Infection prevention she stated, It is my expectation as the facility infection prevention nurse that all staff follow all isolation precautions, perform hand hygiene before and after any contact with patients or their environment, and that staff do not wear PPE in the hallways, removing all PPE and sanitizing their hands before leaving patient rooms. Face shields should be cleaned after leaving any suspected Covid-19 patients.

Review of the facilities policy The Transmission Based Precautions: Isolation Guidelines Policy # 91 was reviewed shows Purpose: Transmission based precautions are the second tier of basic infection prevention measures. Transmission based precautions are to be used in addition to standard precautions for patients who may be infected or colonized with certain infectious agents to prevent infection transmission. These guidelines serve to protect patients, healthcare workers and visitors without violating patients' rights to confidentiality.

Definitions:

1. Airborne Precautions will be used for patients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei ( small particle residue 3-5 microns in size of evaporated droplets containing microorganisms that remain suspended in the air and that can be dispersed widely by air currents within a room or over a long distance).

3. Contact precautions will be used for specific patients known or suspected to be infected with epidemiologically important microorganisms that can be transmitted by direct contact with the patient ( hand or skin to skin contact that occurs when performing patient care activities that requires touching patients dry skin) or indirect contact ( touching) with environmental surfaces or patient care items in the patients environment.

4. Contact plus precautions; will be used for specific patients known or suspected to be infected with epidemiologically important microorganisms in their stool that can be transmitted by direct contact with the patient ( Hand or skin to skin contact that occurs when performing patient care activities that require touching the patients dry skin) or indirect contact ( touching) with environmental surfaces or patient care items in the patients environment.

5. Droplet precautions will be used for patients known or suspected to be infected with microorganisms transmitted by droplets (Large particle droplets larger than 10 microns in size) that can be generated by the patient during coughing, sneezing, talking or during the performance of cough inducing procedures.

Policy:

1.Transmission based precautions will be implemented per CDC Guidelines for isolation precautions: preventing transmission of infectious agents in health care settings Appendix A (2007).

2. All persons, including but not limited to physicians, medical students, nurses, environmental services personnel, respiratory therapists, physical therapists and food service personnel are responsible for complying with isolating precautions and tactfully calling observed infractions to the attention of offenders.

3. Transmission bases precautions will be in place until the patient is found to be clear of an active infection.

Isolation Categories:

1.Airborne Precautions include:

a. Private room necessary for all patients in this category

c. Respiratory protection: a particulate respirator (N-95) will be worn.

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Based on interview and facility document review the facility failed to ensure that the Infection Disease Practitioner has received sufficient training in hospital related infection control.

Findings:

1. Review of the Infection Disease Practitioner employee file revealed that in the fall of 2013 she was transferred into the position of Infection Disease Practitioner. The file revealed that she is a Registered Nurse that has worked a a floor nurse at the facility since 11/22/2004. Review of her file did not reveal any past experience or qualifying education as a Infection Disease Practitioner.

2. Review of the education record for the Infection Disease Practitioner revealed that she attended a 3 day 20.5 contact hour continuing education program provided on October 6-8, 2013. by APIC, (Association for Professionals in Infection Control and Epidemiology), titled The Fundamentals of Infection Surveillance, Prevention and Control.

The education file revealed a 2 and + day, (March 3-5), program provided by University of Florida on Tuberculosis.

Again in March 2014 she received a Certificate, Tuberculin Skin Test Train-the-Trainer Course

Review of the education file revealed that on September, 2014 she received a certificate on Hazardous Waste in Medical Facilities Annual Training.

Review of the Infectious Disease Practitioner's education record did not reveal any other education in 2014 other that completing 2 courses towards a Master of Public Health..

3. Interview with the Chief Nursing Officer (CNO) revealed that she is the director supervisor of the Infection Disease Practitioner. When CNO was asked what education was planned for the Infection Disease Practitioner she stated that none is planned and that she is waiting to see what happens with the possible purchase of the hospital by Hospital Corporation of America, (HCA)

Review of the Job Evaluation performed by the CNO completed on 12/08/2014 did not reveal any plans or that the facility is planning to assistance the Infection Disease Practitioner in her development of role as the facility's Infection Disease Practitioner.

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

Based on observations, interviews and record review the facility failed to ensure that for the Intensive Care Unit, emergency room , Medical/Surgical Unit and the Surgical Suite followed acceptable infection control practices.

Findings:

1. On 01/05/2015 at 10:40 AM an observation of Patient #2 ' s IV (Intravenous) site revealed there was no label to show the date, time, or initials indicating who started the IV and when. The IV bag was Lactated Ringers labeled 1/4/2015 started at 1700 with a flow rate of 0 (zero). The date and time on the IV tubing was absent

Patient # 2 was interviewed on 01/05/2015 at 10:40 AM. She said she came in on Saturday 01/03/2015 and the IV was started that day.

Chart review showed the IV started on 01/03/2015 by EMS (Emergency Medical Services). On 01/03/2015 at 12:56 PM the nurse's note stated maintain field IV. Dressing intact. 20 gauge left antecubital space. Further review of the patient ' s chart showed the patient had a history of chronic Hepatitis C.

An interview with the Infectious Disease Practitioner on 01/06/2015 at 4:00 PM revealed the infection control information is covered in nursing orientation and instructs the staff to label all IV sites and tubing. Further interview with the Infectious Disease Practitioner revealed there is not a specific hospital policy for labeling IV ' s and IV tubing. She stated the hospital uses Lippincott as nursing references for IV ' s.

The DON faxed the Lippincott Procedures to the Area 3 office on 01/09/2015. The procedures state to label the IV with the type, gauge, and length of the catheter, date and time of insertion, and initials. It further states, during an emergency if an IV catheter is inserted, it should be replaced as soon as possible, within a maximum of 48 hours, to reduce the risk of vascular catheter associated infection. In the IV tubing change policy provided revealed: Label the administration set and solution container with the date and time.

2. On 01/05/2015 at 10:45 AM, during the endoscopy for Patient # 2, the Certified Registered Nurse Anesthetist (CRNA) was observed putting a bite block in the mouth of the patient. The CRNA touched the monitor with gloves, then syringe, held patient ' s chin. He took the gloves off at 10:54 AM. He charted, and then touched the monitor with no gloves. He put his gloves back on and touched the syringe. The biohazard container, which was approximately + full of material with noticeable blood on it, had a black and red bag sitting on top of it.

The CRNA was observed cleaning the anesthesia equipment at 11:30 AM on 01/05/2015. He used Super Sani wipes. He cleaned the anesthesia cart, anesthesia equipment, lines, and poles. He did not wipe the monitor clean.

An interview with the CRNA on 01/06/2015 at 12:05 PM revealed he did not wipe down the monitors. He said the personal red bag had his goggles and personal gear and his black bag has his reference manuals in it. He said he carries the bags in and out of the procedure rooms daily. He stores them on top of the hazardous waste container. Asked if he knew the hazardous materials container was clean, he responded, no.

Review of the patient ' s chart showed the patient had a history of chronic Hepatitis C.

Review of the policy Environmental Sanitation approved date: 08/2002, reviewed 01/2013 revealed:

Policy:

(4.) All blood/body fluids, and tissue specimens are placed in red plastic biohazard bags prior to transport or in containers that are impervious and contain an agent to solidify solutions, if being disposed.

(5.) At the end of a surgical procedure, the furniture, equipment, and floors are cleaned with a germicidal solution.

Conclusion of operative procedure:

d. All equipment and furniture used during a case is considered contaminated.

3. 01/05/2015 at 11:17 AM turnover cleaning was observed in the procedure room. The housekeeper wiped down the counters, keyboards, under keyboards, and sink. She wiped down the trash container after trash was taken out. The spray cleaner used was in a white plastic container labeled with dates only.

An interview with the housekeeper on 01/05/2015 at 11:25 AM revealed she could not remember the name of the cleaner in the bottle. She said she knew what it was but could not remember. She dated the bottle when it was put into the bottle for cleaning.

An interview with the Manager of Environmental Services on 01/06/2015 at 9:00 AM revealed the labels are available to label the bottles when the bottle is filled with the cleaner. The label is preprinted to be applied immediately when the bottle is filled. The manager stated she did not have a policy for labeling the bottles when the bottle is filled with the cleaner.

Review of the policy and procedure guideline for surgical services with effective date 08/2002, reviewed 01/2013 with policy description Environmental Sanitation revealed:

Procedure:

3. To disinfect surfaces and equipment not requiring sterilization use either:

a. EPA approved hospital grade, tuberculocidal solution, mixed as directed by manufacturer:

b. Ten percent (10%) bleach solution prepared with 24 hours of use.

4. On 01/05/2015 at 4:40 PM during a tour of the emergency department housekeeper B was observed cleaning an emergency department bay. She was putting trash in a red bag and closing it with gloved hands. She then closed a second red bag with same gloved hands. She then opened the cabinet and removed a clean sheet and made up the stretcher. She then proceeded to clean the counter.

An interview with housekeeper B on 01/05/2015 at 4:42 PM revealed she wears one pair of gloves while cleaning the entire room. She changes the gloves if they tear. She washes her hands or uses hand sanitizer when done.

Observation of the Express Care area of the ER revealed two patient recliners with torn arm rests and observation of the main ER waiting rooms revealed 12 chairs with seat cushion that either were torn or have separated for the base of the cushion

5. 01/05/2015 at 12:10 PM a, peripherally inserted central catheter (PICC) line insertion was conducted in room 205. The nurse stated the room was Contact Isolation for Methicillin-resistant Staphylococcus aureus (MRSA) in the sputum. The RN set up a sterile field. The RN put on gloves, hat, and mask. The RN applied the mask below the nose.

During the procedure the face mask noted below nose. The RN shifted the mask onto her nose. The patient was not wearing a mask, was confused, turning his head toward the sterile field and talking. A surgical hand scrub was performed by the RN. The sterile tray set up at 12:30 PM. The mask again noted below the nose. The sterile field was draped over the patient exposing the area for insertion. The area cleaned. The catheter was inserted. The area covered, secured.

An interview on 01/05/2015 at 12:45 PM with the RN revealed she inserts PICC lines daily and does PICC line dressing changes every 7 days. She does central line dressing changes. She said she did not realize the mask was slipping down. She has a problem with her glasses fogging up when she wears a mask if her nose is covered.

6. On 01/05/2015 at 4:10 PM a Patient Care Tech (PCT) was observed taking vital signs for two patients sharing one contact isolation room. The PCT failed to remove his gloves and perform hand hygiene when moving from one patient to the next. At 4:10 PM when asked why he did not change his gloves, the PCT responded he realized he did not change his gloves between patients and apologized.

7. 01/05/2015 at 4:30 PM during the tour room 184 was observed with a sign for contact and droplet isolation. The posted sign included instructions for eye shields to be worn for droplet isolation. Across the hall, the container with PPE (Personal Protective Equipment) supplies did not contain eye shields.

An interview with the DON (Director of Nursing) at 4:30 PM revealed if there are no eye shields available staff will have the family go to the nurses.

Observation of the signs posted did not direct the visitors to see nursing personnel for eye shields.

8. Observation on 01/05/2015 at 11:19 AM of the sub-sterile decontamination room in the Surgical Department revealed a 2ft x 2ft return vent located in the ceiling had a significant buildup of dust. The return vent is located over and near to the area cleaned instruments are assembled for sterilization. During an 11:25 AM interview with the Operating Room Director, he/she stated the housekeeping staff is to clean vents.

9. Observation of the spinal injection performed on patient #4 in her room on 01/05/2015 at 11:30 AM revealed that after the Anesthesiologist explained the procedure to the patient he sanitized using the hand sanitizer located outside of the bathroom door. He then returned to the patient and located the injection site. He removed the gloves, re-sanitized, and put on sterile gloves. The physician did not wash his hands at any time before performing the spinal injection. Interview with the Infectious Disease Practitioner on 01/06/2015 at 2:44 PM revealed that before performing a sterile procedure the Anesthesiologist should perform a complete hand wash and not just a hand sanitization.

10. Observation on 01/05/2015 at 1:40 PM of wound care provided by the Physical Therapist/Wound Care Therapist on patient #7 revealed that the Therapist removed wound dressing that covered two surgical drain tubes. The drain tubes exited the right side of abdomen and on a vertical plain were about 8 inches between each drain. The Therapist did not change her gloves between each drain wound dressing.

11. Review of the medical record for Patient #5 revealed:He was triaged in the emergency department on 12/02/2014. The hospital stay was from 12/2/12 to 12/11/14.The lab report dated 12/14/2014 showed Faxed acid fast bacillus (AFB) results to physician on 12/11/2014 at 1532 hours. On 12/25/2014 Patient #5 triage in the emergency department showed: Tuberculosis (TB) screening: being checked for TB Cultures sent from hospitalization for pneumonia.Cat scan of the abdomen showed Lung bases large 9 cm thick-walled cavitary lesion in the posterior periphery of the right lung lower lobe that presumably represents a lung abscess/cavitating pneumonia, cavitating/superinfected neoplasm, and/or fluid filled/superinfected bulla. On 12/26/2014 Patient #5 ' s triage in the emergency department showed Tuberculosis screening: Possible symptoms: being tested for it by MD.

Review of the EMS transfer form (to another hospital) showed the first vitals taken 12/26/2014 at 1705 hours. Past medical history: Chronic obstructive pulmonary disease, Cardiac (heart disease) and Gastroesophageal Reflux. There is no mention of TB.

The hospital transferred patient #5 to another hospital on [DATE]. Review of the receiving hospital's history and physical on 12/26/2014 showed the patient presented as a transfer due to right sided kidney stone. The patient arrived in the emergency department at 6:00 PM. A late entry 12/26/2014 at 9:33 PM revealed the health department called staff and informed them the patient was actively undergoing treatment for tuberculosis.

Review of the transferring hospital's policy on Mycobacterium Tuberculosis Exposure Control Plan 2014, 0, revealed A. Known/Suspected M. TB: 2. upon arrival to the hospital, any patient with known/suspected M. TB will be masked (surgical Mask and will remain masked until admission to an AFB Airborne isolation room (negative pressure).

On 01/06/2015 at 2:44 PM, the Infectious Disease Practitioner stated she could not locate a hospital policy for notification of transport personnel that were exposed to Tuberculosis (TB). She further stated she did not send written notice to the transport personnel that transported the patient with TB to the ED (emergency department) and from the Putnam Community Medical Center emergency department to another hospital.

Further interview with the Infectious Disease Practitioner revealed the patient was admitted on [DATE]. He had bronchial washings done on 12/08/2014 for AFB (acid fast bacillus). The patient had no isolation at any time. The hospital discharged him home on 12/11/14.

Further interview with the Infectious Disease Practitioner revealed the patient returned on 12/25/2014 and 12/26/2014 to the emergency room . During these visits, the patient was not placed in isolation. She said the patient length of time for exposure to the staff was short 2 & 1/2 hours on the second visit and the third trip about 9 hrs.

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

Based on review of the facility's Policies and Procedures, record review, and staff interviews revealed that the facility failed to provide care and services with supervision for 1 of 10 patients (Patient #1).

Findings:

1. Medical record review revealed that patient #1's mother that was 39 weeks and 3 days gestation, and in active labor, presented to the hospital labor and delivery (L&D) department on 08/28/2014 at 9:20 AM. The baby's mother stated that her membranes had ruptured the previous day at 3:00 AM, and she did not seek medical attention.

The baby's mother had been diagnosed on admission prolonged rupture of membranes at term, and she was started on Intravenous (IV) fluids and an external fetal monitor was placed. Intrauterine press catheter was placed along with a scalp electrode and internal monitors were applied. Patient #1 had a fetal heart rate of 140's and 150's. The uterine contractions were mild to moderate, and the patient (mother) was started on Pitocin. During the insertion of the pressure catheter, there was no fluid that could be seen, and when the applicator was removed, it was full of very thick meconium. Amnioinfusion (amnion is the innermost membrane that encloses the embryo) began with warm lactated ringers in order to decrease the thickness of the meconium and to improve anticipated variable decelerations with a patient with amniotic fluid, which according to the physicians (Obstetrician) progress notes was from rupture at least two or three days prior to admission.

2. Interview on 10/09/2014 at 9:45 AM in L&D with Charge Nurse, RN#B revealed that the nursing staff was extremely busy on the day that this mother in active labor arrived, and Charge Nurse #A was marked off the schedule, and at a classroom training, which left nursing staff short. The L&D Nursing Director left the L&D to go get RN#A to assist us and was gone for an hour.

Patient #1 was delivered vaginally at 5:02 PM, with an APGAR: score of 2, a Neonatal Code Blue was called, and resuscitation by the Obstetrician, nursing and Respiratory Therapist. Nursing staff failed to call Respiratory prior to the Code Blue.

3. Review of the hospital ' s Policy and Procedure titled Newborn Assessment and Danger Signs in Newborn dated effective 02/2008 revealed the following:

PURPOSE: Guidelines for nurses when assessing newborns. Nurses are to observe the newborn for danger signs. Notify the attending pediatrician when appropriate.

4. Record review of the Neonatal Code Blue Record dated 08/28/2014 revealed that there was no documentation that Respiratory therapy was present nor documentation of her role in the resuscitation. Nursing staff failed to have vital signs including heart rate documented. And further review of the Code Blue revealed Epinephrine 0.5 ml was administered at 5:05 PM. But there was no documentation of the person that administered the Epinephrine or the response to the medication.

Interview on 10/09/2014 at 9:30 AM of RN# B revealed that she had asked RT #1 to run the blood gases to the lab after they had been obtained by the physician from the cord, and that the RT felt that it was not a priority, and left to get the O2 Hood. By this time 30 minutes had lapsed and it was too late to obtain results from the lab for the blood gases.

5. Review of the hospital's Policy and Procedure titled Code Blue: Adult & Pediatric Respiratory and/or Cardiac arrest dated effective date of 01/03/2011 revealed the following:

Putnam Community Medical Center has a process in place to respond to an adult or child, regardless of age, in acute or impending cardiopulmonary arrest.

Pediatric Code Blue for a child less than [AGE] years old, is the term used to differentiate a pediatric code from an adult Code Blue . The purpose of calling a code is to identify the location of the cardiopulmonary arrest.

Documentation: A code blue flow sheet, located at the top of the crash cart, will be utilized for documentation of assessments and interventions implemented during a cardiopulmonary arrest. Licensed personnel are to document on the Code Blue Record.

6. Interview on 10/12/2014 at 3:30 PM with RN, Director of Labor and Delivery (L&D), revealed that she had been concerned with the presence of the thick meconium, prolonged ruptured membranes, and suspected early chorea amnionitis, and had ordered on [DATE] at 3:45 PM that the Operating Room (OR) be opened and prep for an imminent C-section to be performed for patient#1 prior to the vaginal delivery. She was told by the physician that he did not want the Pediatrician on call to take care of the newborn, and that she had gotten in a heated argument with the Obstetrician by refusing to call another Pediatric Care group (Azalea Health). Further interview with the Director of the L&D revealed that she did not administer the epinephrine (Epi), but did order the oxygen hood for patient #1 in the nursery after this birth during the Code Blue.

Interview on 10/09/2014 at 1:30 PM with patient #1's Obstetrician providing care and services on 08/28/2014 revealed that he did not order epinephrine, an oxygen hood, and that he had drawn the blood gases from patient #1 after delivery and asked nursing staff to ensure that they were taken to the lab to obtain results, which the blood gases were not. This Obstetrician noticed a liquid when he was suctioning using the meconium aspirator, and he stated he was told by RN#B that it was the Epinephrine that had been administered.

7. Review of the hospital 's Policy and Procedure titled Administrative Call (AOC) approved on 06/2014 revealed the following:

POLICY: An Administrative representative shall be available 24 hours per day, seven days a week to assist and support hospital staff during off business hours. Administrative call for outside regular administrative office hours will be rotated between the Chief Executive Officer (CEO), Chief Financial Officer (CFO), Chief Nursing Officer (CNO) and other directors as designated by the CEO. Immediate notification of the person on administrative call is required for: Any question of issue requiring administrative support.

Interview of the CNO on 10/09/2014 at 1:30 PM and record review revealed that the Director of Labor and Delivery or the Charge Nurse did not notify the Chief Nursing Officer (CNO) regarding any of these issues or concerns requiring Administrative support on 08/28/2014. The CNO or AOC was not informed of possible delivery of decompensated infant, and that the L&D Director had been told by the Obstetrician that he did not want the Pediatrician on call to take care of the newborn.

Patient #1 was transported to a Neonatal Hospital for a higher level of care on 08/28/2014 at 8:02 PM.

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

Based on medical record review, review of Policy and Procedures, and interview revealed that Respiratory Services and Nursing Services failed to document and describe assessments and patients response to medications and service for a Neonatal Code Blue for 1 of 10 (patient #1) patients reviewed.

Findings:

1. Medical record review revealed that a Neonatal Code Blue was called for respiratory arrest of a newborn, (patient #1) on 08/28/2014 at 5:02 PM. Review of the call list revealed that respiratory paged at 5:07 PM on 08/28/2014.

Record review of the Neonatal Code Blue Record dated 08/28/2014 revealed that there was no documentation that Respiratory therapy was present or documentation of her role in the resuscitation.

Nursing staff failed to have vital signs including heart rate documented. And further review of the Code Blue revealed Epinephrine 0.5 ml was administered at 5:05 PM. But there was no documentation of the person that administered the Epinephrine nor the response to the medication.

2. Review of the hospital's Policy and Procedure titled Code Blue: Adult & Pediatric Respiratory and/or Cardiac arrest dated effective date of 01/03/2011 revealed the following:

Putnam Community Medical Center has a process in place to respond to an adult or child, regardless of age, in acute or impending cardiopulmonary arrest.

Pediatric Code Blue for a child less than [AGE] years old, is the term used to differentiate a pediatric code from an adult Code Blue . The purpose of calling a code is to identify the location of the cardiopulmonary arrest.

Documentation: A code blue flow sheet, located at the top of the crash cart, will be utilized for documentation of assessments and interventions implemented during a cardiopulmonary arrest. Licensed personnel are to document on the Code Blue Record.

3. Interview with Respiratory Therapist #1 on 10/09/2014 at 3:20 PM revealed that she stated when she arrived at the Neonatal Code Blue the Labor and Delivery (L&D) Director asked her to get the Oxygen (O2) Hood, which is kept in the L&D but could not be found, so she had to go to the Respiratory Therapy Department next door across the hall to obtain a O2 Hood. She further stated that RN# B asked her to run the blood gases to the lab on her way to get the O2 Hood. She chose to go and get the O2 Hood without taking the blood gases to the lab. There was no documentation of RT #1 retrieving the O2 Hood, or failing to take the blood gases to the lab, or any of her presence or duties performed during her visit to the Nursery.

4. Interview of the CNO on 10/09/2014 at 1:30 PM and record review revealed that the Director of Labor and Delivery or the Charge Nurse did not notify the Chief Nursing Officer (CNO) regarding any of these issues or concerns requiring Administrative support on 08/28/2014. The CNO or AOC was not informed of possible delivery of decompensated infant, and that the L&D Director had been told by the Obstetrician that he did not want the Pediatrician on call to take care of the newborn.

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

Based on record review and interview revealed that respiratory services failed to follow the facility's Policy and Procedures and document in 1 of 10 (patient #1) patient records services provided in a Neonatal Code Blue Record.

Findings:

1. Medical record review revealed that a Neonatal Code Blue was called for respiratory arrest of a newborn, (patient #1) on 08/28/2014 at 5:02 PM. Review of the call list revealed that respiratory paged at 5:07 PM on 08/28/2014.

Record review of the Neonatal Code Blue Record dated 08/28/2014 revealed that there was not any documentation that Respiratory therapy was present or documentation of her role in the resuscitation. Respiratory Therapy and nursing staff failed to have vital signs including heart rate documented. And further review of the Code Blue revealed Epinephrine 0.5 ml was administered at 5:05 PM. But there was no documentation of the person that administered the Epinephrine or the response to the medication.

2. Review of the hospital's Policy and Procedure titled Code Blue: Adult & Pediatric Respiratory and/or Cardiac arrest dated effective date of 01/03/2011 revealed the following:

Putnam Community Medical Center has a process in place to respond to an adult or child, regardless of age, in acute or impending cardiopulmonary arrest.

Pediatric Code Blue for a child less than [AGE] years old, is the term used to differentiate a pediatric code from an adult Code Blue . The purpose of calling a code is to identify the location of the cardiopulmonary arrest.

Documentation: A code blue flow sheet, located at the top of the crash cart, will be utilized for documentation of assessments and interventions implemented during a cardiopulmonary arrest. Licensed personnel are to document on the Code Blue Record.

3. Interview on 10/09/2014 at 1:30 PM with patient #1's Obstetrician providing care and services on 08/28/2014 revealed that he did not order an oxygen hood, and that he had drawn the blood gases from patient #1 after delivery and asked nursing staff to ensure that they were taken to the lab to obtain results, which the blood gases were not.

4. Interview with Respiratory Therapist #1 on 10/09/2014 at 3:20 PM revealed that she stated when she arrived a the Neonatal Code Blue the Labor and Delivery (L&D) Director asked her to get the Oxygen (O2) Hood, which is kept in the L&D but could not be found, so she had to go to the Respiratory Therapy Department next door across the hall to obtain a O2 Hood. She further stated that RN# B asked her to run the blood gases to the lab on her way to get the O2 Hood. She chose to go and get the O2 Hood without taking the blood gases to the lab. There was no documentation of RT #1 retrieving the O2 Hood, or failing to take the blood gases to the lab, or any of her presence or duties performed during her visit to the Nursery.

5. Interview on 10/09/2014 at 9:30 AM of RN# B revealed that she had asked RT #1 to run the blood gases to the lab after they had been obtained by the physician from the cord, and that the RT felt that it was not a priority, and left to get the O2 Hood. By this time 30 minutes had lapsed and it was too late to obtain results from the lab for the blood gases.

Show Text of Violation

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

Based on record review and patient interviews the facility failed to ensure for one of five (#1) patients', plan of care was updated to reflect the care needs.

Findings

Review of the medical record for patient #1 revealed that the patient presented to the emergency room on 09/22/2011. The medical record revealed that the patient was admitted to the facility at 1239 (12:39 PM) and was assigned a room on the 2nd floor.

A nursing admission assessment was documented at 1441 (2:41 PM) that included a pain assessment. The pain assessment revealed that the patient was experiencing pain in her left foot at a level of 4 on a 0 to 5 scale with zero being no pain. The care plan revealed that the patient took Lortab at home to control the pain.

Review of the pain management care plan developed during the assessment revealed that for the rest of the admission that a 0 to 10 pain scale will be used to evaluate pain every 4 hours.

Review of the medical record revealed a physician admission order dated 09/22/2011 (not timed by the physician) which included Motrin 400 milligrams (mg) every 8 hours as needed (PRN) for moderate pain and Lortab 5/500 mg every 6 hours PRN for severe pain.

Review of the order revealed the unit clerk signed the order at 1400 (2:00 PM) and the nurse signed the order at 1430 (2:30 PM).

Review of the nursing assessments revealed that on 9/22/11 at 2100 (9:00 PM) the patient reported a pain level of 5 or moderate pain. On 09/23/2011 at 0450 (4:50 AM) the patient reported a pain level of 5 or moderate pain, the next 2 scheduled pain assessment was not completed, the pain level at 1650 (4:50 PM) reported as a pain level of 5 or moderate pain and again at 2000 (8:00 PM) the patient reported a pain level of 5 or moderate pain. Review of the record or 09/24/2011 revealed that the 0000 (midnight) pain assessment was not performed and at 0400 (4:00 AM) the patient reported a pain level of 5 or moderate pain the next 2 scheduled pain assessments were not documented, at 1429 (2:49 PM) the patient reported a pain level of 5 or moderate pain, the next pain assessment was missed and at 2345 (11:45 PM) the patient reported a pain level of 5 or moderate pain.

Review of the patient Medication Administration Record, (MAR) revealed that Motrin was never administered or offered to the patient and that Lortab was only provided on 2 times, on 09/22/2100 at 2100 (9:00 PM) and on 09/23 at 1050 (10:50 AM).

The medical record did not reveal why the pain medication was not provided as ordered or why the nursing failed to perform pain assessments as outlined in the Plan of Care. The medical record revealed that at the end of each nursing shift the nurse electronically attaches and signs the following statement.

2. Review of the medical record for patient #1 revealed an intravenous (IV) assessment dated [DATE] at 1530 (3:30 PM) that stated, IV Type/Location: #22 Left Antecubital, Date Inserted: 09/22/2011, Dressing Change Date: 09/26/201, IV Site WDP: Y, Site Condition: (Not Completed).

Review of the IV assessment dated [DATE] at 1621 (4:21 PM) revealed, IV Type/Location: #22 Left Antecubital, Date Inserted: 09/22/2011, Dressing Change Date: 09/26/201, IV Site WDP: Y, Site Condition: (Not Completed).

Review of the IV assessment dated [DATE] at 2030 revealed, IV Type/Location: #22 Left Antecubital, Date Inserted: 09/22/2011, Dressing Change Date: 09/26/201, IV Site WDP: Y, Site Condition: (Not Completed).

Review of the IV assessment dated [DATE] at 0000 revealed IV Type/Location: #22 Right Forearm, Date Inserted: 09/23/2011, Dressing Change Date: 09/26/201, IV Site WDP: Y, Site Condition: (Not Completed).

Review of the medical record, (Nursing notes or nursing assessment) for patient #1 did not reveal the reason for changing the IV from the left antecubital to the right forearm or that if the patient had experienced any events related to the IV.

Review of the patient's Plan of Care did not reveal any updates or references to the change in the IV location.

Review of the medical record revealed a physician order dated 09/22/2011 (not time the order was written) that stated, Cold Compress to Left Upper Extremity and an order for ultrasound of Right Lower Extremity and Left Upper Extremity to be done today. Review of the physician order revealed that Unit Clerk had signed off on the order the next day on 09/23/2010 at 1502 (3:02 PM) and the Nurse signed the order on 09/23/2011 at 1514.

Review of the medical record did not reveal that the patient had received cold compress therapy on 09/22/2011 and the MAR for 09/23-09/24 the therapy was only noted done without a time documented. The writing of done was in the same pen and writing as the nurse documenting on the second shift.

Review of the medical record did not reveal any nursing documentation as why the Cold Compress was ordered or any assessment of the patient's Left Upper Extremity. The medical record did not reveal any Care Plan changes to either the Pain or IV Care Plans.

Review of the medical record did not reveal a report from the Radiologist for the ultrasound of the Left Upper Extremity or any if the procedure was performed or not. Review of the medical record revealed a Physician Progress note dated 09/23/2011, no time noted by physician, revealed Left upper extremity S/P IV infiltrate.

3. Interview with patient #1 on 10/31/2011 at 8:45 AM revealed that following the dose of Vancomycin on 09/22/2011 at 1700 (5:00 PM) her arm swelled to 3 times its normal size and that the nursing staff did not provide the cold compress or pain medication until the next night.

4. The medical record revealed that at the end of each nursing shift the nurse electronically attaches and signs the following statement. BY SIGN OFF ON THIS INTERVENTION, THE NURSE VERIFIES THAT THE STANDARD OF CARE FOR PUTNAM COMMUNITY MEDICAL CENTER AND THE CARE AREA STATEMENTS HAVE BEEN ADDRESSED IN THE DOCUMENTATION SCREENS OR NOTES .

Show Text of Violation

Based on record review and patient interviews the facility failed to ensure for one of five patients (Patient #1), received medications as ordered by the physician.

Findings

1. Review of the medical record revealed a physician admission order dated 09/22/2011 (not timed by the physician) which included Vancomycin 1 gram intravenous (IV) every 12 hours. Vancomycin Trough before 3rd dose. Review of the order revealed the unit clerk signed the order at 1400 (2:00 PM) and the nurse signed the order at 1430 (2:30 PM).

Review of the medication administration record (MAR) revealed that at 1700 (5:00 PM) on 09/22/2011 the first dose Vancomycin was given to the patient. The medical record did not reveal any nursing notes related to the administration of the Vancomycin or the condition of the IV site following the administration of the Vancomycin. Review of the MAR for 09/23/2011 did not reveal that any Vancomycin was administered to the patient. Review of the MAR for 09/24/2011 did not reveal that any Vancomycin was administered to the patient.

Review of the nursing note dated 09/24/2011 at 0420 (4:20 AM) revealed under IV fluids, #1 fluid Vancomycin. No other comments related to Vancomycin were documented by nurse on 09/24/2011. The medical record revealed a physician order dated 09/24/2011 at 1124 (11:24 AM) revealed Please give Vancomycin at 1300 [1:00 PM] exact. Review of the MAR revealed that the 1300 dose was not given to the patient. Review of the MAR revealed that the next dose of Vancomycin was administered on 09/25/2011 at 1500 (3:00 PM). The Medical record revealed that all other scheduled doses were given as ordered. Review of the medical record did not reveal why the Vancomycin scheduled doses were not given and did not reveal that the physician was made aware that there were doses not administered as ordered.

2. Review of the medical record for patient #1 revealed that the patient presented to the emergency room on 09/22/2011. The medical record revealed that the patient was admitted to the facility at 1239 (12:39 PM) and was assigned a room on the 2nd floor.

A nursing admission assessment was documented at 1441 (2:41 PM) that included a pain assessment. The pain assessment revealed that the patient was experiencing pain in her left foot at a level of 4 on a 0 to 5 scale with zero being no pain. The care plan revealed that the patient took Lortab at home to control the pain.

Review of the pain management care plan developed during the assessment revealed that for the rest of the admission that a 0 to 10 pain scale will be used to evaluate pain every 4 hours.

Review of the medical record revealed a physician admission order dated 09/22/2011 (not timed by the physician) which included Motrin 400 milligrams (mg) every 8 hours as needed (PRN) for moderate pain and Lortab 5/500 mg every 6 hours PRN for severe pain.

Review of the order revealed the unit clerk signed the order at 1400 (2:00 PM) and the nurse signed the order at 1430 (2:30 PM).

Review of the nursing assessments revealed that on 9/22/11 at 2100 (9:00 PM) the patient reported a pain level of 5 or moderate pain. On 09/23/2011 at 0450 (4:50 AM) the patient reported a pain level of 5 or moderate pain, the next 2 scheduled pain assessment was not completed, the pain level at 1650 (4:50 PM) reported as a pain level of 5 or moderate pain and again at 2000 (8:00 PM) the patient reported a pain level of 5 or moderate pain. Review of the record or 09/24/2011 revealed that the 0000 (midnight) pain assessment was not performed and at 0400 (4:00 AM) the patient reported a pain level of 5 or moderate pain the next 2 scheduled pain assessments were not documented, at 1429 (2:49 PM) the patient reported a pain level of 5 or moderate pain, the next pain assessment was missed and at 2345 (11:45 PM) the patient reported a pain level of 5 or moderate pain.

Review of the patient Medication Administration Record, (MAR) revealed that Motrin was never administered or offered to the patient and that Lortab was only provided on 2 times, on 09/22/2100 at 2100 (9:00 PM) and on 09/23 at 1050 (10:50 AM).

The medical record did not reveal why the pain medication was not provided as ordered or why the nursing failed to perform pain assessments as outlined in the Plan of Care. The medical record revealed that at the end of each nursing shift the nurse electronically attaches and signs the following statement.

3. Interview on 10/31/2011 at 8:45 AM with patient #1 revealed that patient stated that They gave me the Vancomycin when they wanted to any when they gave it to me they gave it to fast. The patient also stated that she did not receive pain medication until the next day after why are swelled up.

Show Text of Violation

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

Based on record review and interview the facility failed for one of five patients (Patient #1), to ensure that the medical record contains nursing assessments that reflect changes in the patient's condition, completed diagnostic reports and patient care plans that reflect the patient's care needs.

Findings:

1. Review of the medical record for patient #1 revealed an intravenous (IV) assessment dated [DATE] at 1530 (3:30 PM) that stated, IV Type/Location: #22 Left Antecubital, Date Inserted: 09/22/2011, Dressing Change Date: 09/26/201, IV Site WDP: Y, Site Condition: (Not Completed).