Every finding on record at Prairie Lakes Health Care System Inc.

Based on observation, interview, record review, and policy review, the provider failed to follow standard infection prevention practices while using reusable equipment for one of four sampled hospice patients (4) during a home visit. Findings include: --- 1. Observation on 4/16/25 at 9:30 a.m. of registered nurse (RN) G during a hospice home visit with patient 4 revealed:*She placed a disposable drape as a barrier on the floor in the bedroom in front of the patient's bed, then placed her nursing bag on the barrier.*She completed hand hygiene, opened the bag, and removed the following reusable equipment items: stethoscope, blood pressure cuff, thermometer, and oximeter, and set the equipment on the floor next to the bag without a barrier under that reusable equipment.*She then picked the equipment items up off the floor and used them on the patient to obtain his blood pressure, temperature, oxygen saturation, and to listen to his heart, lungs, and bowel sounds with the stethoscope.* She then laid the equipment items back on the floor without a barrier next to her bag which remained on the same drape barrier.*When her visit was completed, she cleaned those equipment items with a germicidal wipe before returning them to her bag.2. Interview on 4/16/25 at 10 a.m. with RN G regarding infection prevention during the hospice home visit with patient 4 revealed:*She had worked at the hospice agency for approximately two years.*She was trained on infection prevention and proper bag technique to maintain infection control during new hire orientation and received additional infection prevention training from the agency.*She agreed that laying reusable equipment from her bag on the floor without a barrier and then using it on the patient did not follow standard infection prevention practices. 3. Review of the provider’s undated and blank Home Health/Hospice RN Orientation Check List form revealed the following item was listed:*HOSPICE – Nurse Orientator”“____12. Nursing Bag Technique/Infection Control              a. Copy of policy.”4. Review of RN G’s training revealed:*Her hire date was 6/19/2023.*Her Home Health/Hospice RN Orientation Check List, dated as completed on 8/21/23, did not include the:“____12. Nursing Bag Technique/Infection Control              a. Copy of policy.” 5. Interview on 4/16/25 at 4:30 p.m. with director A and clinical coordinator B regarding infection prevention revealed:*Nurses received infection prevention and nursing bag technique/infection control training as part of their new hire orientation and ongoing during their employment with the agency.*The agency had a Home Health/Hospice RN Orientation Check List form that was completed and signed off by a preceptor/trainer during a nurse’s new hire orientation, and it included nursing bag technique/infection control.*The agency had a meeting scheduled on 4/24/25 and planned a training review of nursing bag technique/infection control.*They agreed that the reusable equipment placed on the floor without a barrier by RN G during the observed hospice home visit had not followed infection prevention standards and posed an infection risk to the patient.*Director A agreed RN G’s 8/21/23 dated Home Health/Hospice RN Orientation Check List form did not include the nursing bag technique/infection control training. 6. Review of the provider's 5/2024 Home Care Nursing Bag Technique Policy revealed:*”PURPOSE:1. To minimize the contamination of agency equipment and the spread of infectious diseases to patients and employees.*POLICY:1. Clinical personnel will comply with the basic principles of asepsis and bag technique in caring for patients and in the use of equipment.”“PROCEDURE:1.      Upon entrance to a patient’s home, the nursing bag is placed on a clean workspace. If cleanliness is an issue a barrier such as newspaper, unsterile drape, or paper towel or chux [disposable absorbent sheet] pad should be placed under the bag.”“3.    The inside of the bag is considered a clean area and contains unused or clean    equipment/supplies.”“5.     After handwashing, the nurse enters the bag and takes out all equipment that will be needed for the visit. Equipment is placed on a clean field with a clean field developed by an unsterile drape, paper towel, etc.”“8.    All reusable equipment is disinfected prior to returning item(s) to the bag. Each item shall be cleansed with a germicidal wipe according to the manufacturer’s recommendation. Equipment may include but is not limited to:                      1. Stethoscope, bell and diaphragm                      2. Blood Pressure cuff”                     “6. Oximeter”

Review of the provider's healthcare system February 2022 Disaster Alert Activation/Emergency Operations Plan revealed no mention of a hospice disaster plan in the following sections: *Incident Command System. *Staff assignments. *Job action sheets. *Staff recall procedures. *Patient unit-specific evacuation plans were only for critical care, maternal/child health, medical/surgical/pediatric, and the emergency department. *Appendix H Disaster Alert Department Emergency Operations Plans. Review of the provider's July 2020 Disaster Plan Home Health/Hospice (HH/hospice) revealed: *The purpose was to provide guidance to home health, hospice, and home connections in the event of an internal or external disaster or weather-related to safely serve patients in our region. *A patient roster would be printed daily to ensure a complete list of all patients served was readily available. *An individual EP plan would be completed on all patients on admission and assigned a priority level. -Level one patients were high priority whereas level 3 would be a low priority. *Paper documentation sheets were available for all discipline visits in the event of an electrical outage. *All staff were provided with a smartphone. *For threatening weather, the administrator would be notified by emergency management, the hospital, weather radio, or public radio that threatening weather was approaching. *All staff would be notified by the administrator or designee by an email that weather was approaching and to be alert of danger in each area. *Field staff should seek shelter. *Office staff or those located in the hospital should close all blinds in the immediate area upon the issue of a weather WATCH. The hospital staff should seek shelter in the hospital basement or an inner area away from windows. Interview on 5/19/22 at 9:00 a.m. with administrator A revealed: *Their service area covered seven counties. *Currently two hospice patients were level one. -Level one would be a patient that was a quadriplegic or required oxygen by a concentrator. *Each nurse was aware of what level their patients were categorized. *The priority list was printed weekly for all HH, hospice, and home connection patients. -Home connection patients received care through a contract with the Department of Human Services (DHS). -The list was maintained in a three-ring binder with level one first, followed by level two then level three categories. -The list was not separated by counties or areas where the patients lived in the seven counties. *On 5/12/22 a DHS patient's home had been damaged from the severe weather in Hamlin County. -The DHS patient did not have electricity and required oxygen. -The patient was transported to the hospital and then to a local motel where she would receive services. -The nurse had independently implemented safety and continuing care needs for the DHS client. *For severe weather, she would send a mass email out to the staff as all staff had a smart phone issued to them. *The expectation was for the nurses to check on their level one patients first to ensure safety, then to check on level two and then level three. *She had not sent out a mass email to the staff regarding the severe weather until the following morning on 5/13/22 as she had no electricity at her home. *The current policy did not address what procedures the staff were to conduct to ensure patient safety following inclement weather. *She agreed the policy was not all-inclusive by providing direction to the staff for patient safety. Based on observation, interview, and policy review, the provider failed to develop policies and procedures on what measures the staff were to implement after inclement (severe) weather or other emergency situations to ensure patient safety and if the patient's needs were being met. Findings include: 1. Observation and interview on 5/18/22 at 9:30 a.m. with patient 11's elderly caregiver during a home visit revealed: *There had been a violent wind/thunderstorm on 5/12/22. -Tornadoes had been reported in Hamlin County just south of their farm, their home was also located in Hamlin County. *A large grain bin was laying on the ground approximately thirty feet from their north facing dining room picture window. *The grain bin had been torn off the cement foundation and bent nearly in half during the storm. *One of two garage doors on the south side of the house had also sustained a vertical dent from top to bottom and was no longer functional. *The caregiver stated: -"It was pretty scary". -Their son had checked on them following the storm. Interview on 5/18/22 at 11:10 a.m. with registered nurse (RN) C revealed: *EP (emergency preparedness) was discussed monthly at the nurse's meetings. *If there had been a tornado or other natural disaster, they would meet at the office or await hospice director A's instruction. *She was unsure if there was a secondary meeting place. *Hospice director A would call them on the agency provided phones to give direction on what to do next. Interview on 5/19/22 at 10:00 a.m. with RN B regarding the 5/12/22 storm revealed she: *Was assigned to patient 11. *Had not recalled receiving a phone call, text, or email from hospice director A. *Had been surprised she had not received any direction from the agency office staff or from hospice director A. *Had expected to hear from someone within the agency when the storm hit. *Had not known: -How many high risk level patients she had. --Stated office staff could run a report on patient EP levels, but she had not known how to do that. -How to access the EP plan. *Had a routine visit with patient 11 the day after the storm and observed the damage mentioned above. -Had not called patient 11's home the day of the storm to check on their status. *Stated the hospice agency had recently had an EP meeting. -"We talked about EP but no 'black and white' on what to expect from staff during an emergency." *Had not called any of her assigned patients following the storm to check on their status. -"It [EP] could be better."