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Based on observation, interviews, and document review, the facility failed to ensure the patients identification was verified prior to administration of medications in 1 of 3 medication administration observations. Additionally, the facility failed to ensure medications were secured and safely handled in 2 of 3 nurse servers in the Intensive Care Unit.
This failure created the potential for negative patient outcomes related to unsafe medication handling and administration.
FINDINGS:
POLICY
According to the policy, Medication Administration & Minimum Information Available for Medication Administration, when entering the room, identify the patient using two patient identifiers prior to giving the medication.
According to the policy, Identification of Patient, patients are identified utilizing their name and date of birth. Before any procedure is carried out, patient identification must be confirmed using the two-identifier system prior to conduction any healthcare procedures including administration of medications, transfusion of blood or blood products and obtaining blood or other specimens from the patient. Verbally and visually assess the patient to assure proper identification by asking the patients name and date of birth.
According to the policy, Medication Storage, all medications are secured by being stored in locked cupboards, devices, rooms or under constant surveillance by authorized person (persons authorized to administer medications per attached patient care standards; medication administration, CNAs, Rehab Aides, material distribution technicians).
1. The nursing staff failed to identify a patient, using two identifiers, before administering medication in accordance with the facility's policy.
a) On 01/24/17 at 12:50 p.m., Registered Nurse (RN) #5 brought in two medications to Patient #8's room and handed the medications to RN #4. RN #4 scanned the pre-transfusion oral medications, Tylenol and Benadryl, and then administered the two medications to the patient. The patient was awake, alert and answering questions appropriately. The patient then took the medications by mouth. RN #4 failed to verbally verify the patient prior to administration of medications. This was in contrast with the facility's Medication Administration and Patient Identification policies.
b) On 01/24/17 at 4:23 p.m., an interview was conducted with RN #4 who confirmed s/he did not verbally identify the patient with two identifiers before administration of medications to the patient. S/he stated verbal verification with a patient prior to administration of medications was expected of the RN and scanning the patient's armband did not replace the need for verbal verification of patients. S/he further stated verbal verification was needed to confirm the right patient was receiving the right medication in accordance with the 5 rights of medication administration.
c) On 01/26/17 at 11:45 a.m., an interview was conducted with the Chief Nursing Officer (CNO #17) who stated staff were expected to utilize the scanning system to verify patients. This contradicted the facility's patient verification policy.
2. The facility failed to secure medications, including insulin pens, in nurse servers that were kept in patient's rooms.
a) An observation of RN #3 was conducted 01/24/17 at 10:50 a.m. in the Intensive Care Unit (ICU). The RN opened multiple drawers containing patient care supplies, insulin pen lancets, and normal saline syringes, RN #3 opened the nurse server in patient room 316 multiple times throughout the observation without needing to disengage any locking mechanism. The nurse server was kept in the patient's room and on inspection of the top drawer of the nurse server, no access code or locking mechanism was needed for entry. Located in the top drawer of the nurse server was an insulin pen whose label identified a different patient's name than the one who was currently occupying the room. This was in in contrast with the facility's Medication Storage policy.
On further inspection of the ICU, 2 more nurse servers in 2 different patient's rooms (305 and 315), revealed neither were secured and easily accessed by simply opening the drawer. One of the nurse servers in room 315, contained multiple medications, including 2 different insulin pens and eye drops.
During the tour, the ICU Clinical Nurse Manager (Manager #18) stated nurse servers were located in every room and housekeeping, certified nurse aids, respiratory therapist and multiple other staff had access to the nurse server. S/he stated the nurse servers should be locked with insulin pens in the room for safety. Manager #18 stated s/he was unsure why the nurse servers were not currently locked.
b) An interview was conducted on 01/25/17 at 4:16 p.m. with RN #3 who verified an insulin pen for a different patient was kept in the top drawer of the unsecured nurse server in the room of the patient s/he was taking care of during the observation conducted on 01/24/17. S/he stated the unlocked nurse server was an oversight.

c) An interview was conducted on 01/25/17 at 4:30 p.m. with the Manager of the Cardiovascular Intensive Care Unit (Manager #14) who stated s/he was aware medications were kept in unsecured nurse servers in the patients' room and identified it was a patient safety concern due to family access to the medications. S/he stated there was a potential a family member could steal or administer the medication to the patient.

Furthermore, s/he stated s/he had requested new nurse servers from the facility in July of 2016 but was waiting on the approval from the facility and at this time was unsure where in the process his/her request was. Manager #14 stated s/he had not heard from management on the request.

d) An interview was conducted on 01/26/17 at 9:00 a.m., with the Pharmacy Manager (Manger #16) who stated medications should not be stored in the nurse server unsecured. Manager #16 stated unsecured medications were a safety concern. Patient family members and visitors could be unsupervised with the medications. Furthermore, Certified Nurse Assistants (CNAs) should not have access to patient medications.

e) An interview was conducted on 01/26/17 at 11:45 a.m. with CNO #17 who stated s/he was aware of the issue with the nurse servers not locking and they were placed in the budget. The CNO stated it was a safety risk if the nurse server didn't lock. CNO #17 stated it was not appropriate for medications to be left unsecured.

Based on observation, interviews, and document review, the facility failed to ensure the patient's identification was verified prior to administration of blood in 1 of 1 blood transfusion observations (Patient #8).
This failure created the potential for the wrong patient to receive the wrong blood.
FINDINGS:
POLICY
According to the policy, Blood Components-Administration, at the patient's bedside, ask the patient to state their name and date of birth. If the patient is not capable, confirm with a family member-if present (see patient care standard: Identification of Patients).
According to the policy, Identification of Patient, patients are identified utilizing their name and date of birth. Before any procedure is carried out, patient identification must be confirmed using the two-identifier system prior to conduction any healthcare procedures including administration of medications, transfusion of blood or blood products and obtaining blood or other specimens from the patient. Verbally and visually assess the patient to assure proper identification by asking the patients name and date of birth.
1. The nursing staff failed to identify a patient using two identifiers before performing a blood transfusion in accordance with the facility's policy.
a) During observation of a blood transfusion on 01/24/17 at 12:40 p.m., Registered Nurse (RN) #4 and RN #5 were both present at Patient #8's bedside. The patient was awake, alert and answering questions appropriately. RN #5 scanned the patient's armband and then scanned the blood product. S/he then administered the blood products to the patient. Neither RN #4 or RN #5 verbally verified the identity of the patient to ensure the right patient was receiving the blood. This was in contrast with the facility's Blood Components-Administration and Identification of Patients policy.
b) On 01/24/17 at 4:23 p.m., an interview was conducted with RN #4 who confirmed s/he did not verbally identify the patient with two identifiers before administration of the blood. S/he stated verbal verification with a patient prior to administration of blood was expected of the RN and scanning the patient's armband did not replace the need for verbal verification of patients. S/he further stated verbal verification was needed to confirm the right patient was receiving the right procedure. RN #4 stated his/her normal process was to verbally verify the patient's identity and s/he was unsure why s/he did not follow the process for Patient #8's blood transfusion.
c) On 01/24/17 at 4:34 p.m., an interview was conducted with RN #5 who confirmed s/he did not verbally identify the patient with two identifiers before administration of the blood. S/he stated verbal verification with a patient prior to administration of blood was expected of the RN to make sure the right blood gets to the right patient.
d) On 01/26/17 at 11:45 a.m. an interview was conducted with the Chief Nursing Officer (CNO #17) who had oversight of all nursing in the facility. CNO #17 stated 2 verbal patient identifiers were needed when administering blood products to patients.

Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.42, INFECTION CONTROL, was out of compliance.

A-0749 - Standard: The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. The facility failed to maintain appropriate infection control processes and follow infection control standards in multiple areas throughout the hospital, including: hand hygiene, integrity of patient care supplies, and cleaning/disinfection of surgical supplies. These failures created the potential for transmission of health care acquired infections to patients receiving care in the facility.

Based on observations, interviews and document review, the facility failed to maintain appropriate infection control processes and follow infection control standards in multiple areas throughout the hospital, including hand hygiene, integrity of patient care supplies, and cleaning/disinfection of surgical supplies.

These failures created the potential for transmission of health care acquired infections to patients receiving care in the facility.

FINDINGS:

POLICY

According to the policy, Hand Hygiene, hand hygiene is the single most important procedure for preventing transmission of infections and is performed before clean/aseptic procedures, after body lurid exposure risk, after glove removal, before and after contact with a patient or their surroundings, and between patients. Use an alcohol-based hand rub or wash hands with an antimicrobial soap and water for routinely decontaminating hands in the following clinical situations:

-Before having direct contact with patients.
-Before inserting peripheral vascular catheters, or other invasive devices that do not require a surgical procedure, or performing clean/aseptic procedures.
-After contact with inanimate objects (including medical equipment) or surroundings in the immediate vicinity of the patient.
-Immediately after removing gloves.
-Before and after dispensing medications.

Additionally, remove gloves after caring for a patient or when no longer in contact with items used by the patient.

According to the policy, Standard Precautions, all blood, body fluids, secretions, excretions, except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents.

According to the policy, Droplet Precautions, Droplet Precautions, in addition to standard precautions, are used for patients known or suspected to be infected with pathogens transmitted by respiratory droplets. PPE should be removed upon leaving the patient room.

According to the policy, Contact Precautions, remove PPE upon leaving the patient room.

REFERENCE

According to Steris Prolystica Enzymatic Cleaner manufacturer's instructions, dilute 1/8 to 1/2 fluid ounce per gallon (1 to 4 milliliters per liter) of cleaner to warm water.

1. The facility failed to ensure patient care staff performed hand hygiene and glove change according to established infection control guidelines.

a) Observations in hand hygiene were conducted on 01/23/17, 01/24/17, and 01/25/17. There were multiple breaches, in multiple areas of the facility during the 3 days of observations. As example,

i) On 01/23/17 at 5:15 p.m., an intravenous (IV) catheter insertion was observed in the Emergency Department (ED). Emergency Medical Technician (EMT) #1 entered Patient A's room with supplies for IV placement in hand and laid the supplies on a stand next to Patient A, no hand hygiene was done on entering the room. EMT #1 then put on gloves and touched several items in the room including the rolling chair, the bedrail and Electrocardiogram (EKG) cords attached to the patient along with the patient and patient gown. With the same contaminated gloves, the EMT inserted an IV catheter in Patient A's left antecubital vein and collected blood specimens.

After collecting the blood specimens, EMT #1 removed the bloody IV catheter and placed a 2x2 secured with tape on Patient A. EMT #1 placed the IV catheter on the stand with other IV supplies. S/he then used 2x2 gauze and self-adherent wrap (Coban) to control the bleeding from the IV site on Patient A. EMT #1 then cleaned up the IV supplies from the stand with gloves and discarded the supplies and gloves in the trash can.

EMT #1 went to the computer located in Patient A's room, printed stickers for Patient A's blood and with a ungloved hand labeled the patient's blood specimens. EMT #1 then placed on gloves, put Patient A's blood into a biohazard bag, walked out of room with the contaminated gloves, used the tubing system located in the hallway across from the patient's room and sent the blood. EMT #1 then used the contaminated gloves to grab additional IV supplies from a supply cart located outside of Patient A's room which contained clean patient supplies and returned to Patient A's room.

During the entire observation no hand hygiene was done. This was in contrast to policy.

ii) On 01/23/17 at 4:50 p.m., a medication pass was observed on the Surgical Unit. Registered Nurse (RN) #2 was observed entering Patient #1's room without performing hand hygiene. RN #2 touched the patients arm and bed. RN #2 then, with contaminated hands, administered an oral medication to the patient.

iii) On 01/24/17 at 12:35 p.m., a blood transfusion observation was conducted on the Telemetry unit. RN #4 entered Patient #8's room, donned gloves, then entered information in the computer on wheels, s/he then exited the room with removed gloves in his/her hand. No hand hygiene was performed when RN #4 entered and then exited the patient's room.

RN #5 who was also present for the blood transfusion was observed multiple times entering and exiting the room and putting on and removing gloves without hand hygiene being done all while patient care and a blood transfusion was performed. RN #5 entered the patients room with blood product in hand and grabbed gloves, no hand hygiene was done. RN #5 then inserted IV tubing into the blood bag, connected the tubing to the pump, programmed the pump and connected the tubing to the patient with the same contaminated gloves. RN #5 then was observed with the same gloves touching the computer on wheels located in the patient's room. RN #5 removed gloves and exited the room with no hand hygiene done.

During the same observation, Lab Tech # 28 entered Patient A's room without hand hygiene being done. Lab Tech #28 brought with him/her, an open basket on wheels containing patient care supplies including: a stack of 2x2's opened on top of the cart, blood specimen tubes, tourniquets and opened packages of Coban. Lab Tech #28 then put on gloves. Immediately after putting on gloves Lab Tech #28 dropped a black hair tie on the floor, picked the black hair band up from the floor, placed the hair tie in his/her shirt pocket, touched his/her hair, grabbed a beeper/pager from his/her pocket, returned it back to the pocket and then removed supplies from the basket. Lab Tech #28 then proceeded to perform venipuncture on Patient A's arm with the same contaminated gloves.

On 01/24/2017 4:23 p.m., and interview was conducted with RN #4. S/he confirmed that s/he did not perform hand hygiene as s/he should have during the Patient 8's blood transfusion. RN #4 stated hand hygiene should be done as soon as the RN walked into the room, when donning gloves for blood transfusions, or when hands were visibly soiled. S/he stated the importance of hand hygiene was for infection control.

On 01/24/17 at 4:34 p.m., an interview was conducted with RN #5. RN #5 stated hand hygiene should be done when entering or leaving a room, before putting on gloves or when hands were visibly soiled. S/he stated the importance of hand hygiene was for infection control. RN #5 stated as long as the RN washed hands prior to placing gloves on, no additional hand hygiene and glove change was required while in the patients room performing patient care, including handling of inanimate items, preparing and administering blood products. This was in contrast to the facility's hand hygiene policy.

iv) On 01/25/17 at 8:20 a.m., a surgical case tracer was conducted for Patient #10. In the pre-operative unit, RN #6 was observed inserting a peripheral IV catheter in Patient #10's right hand. After s/he placed the IV, RN #6 removed his/her gloves, then proceeded to label the IV fluids connected to the patient, placed wrist bands on the patient, stored the patient's belongings under the stretcher, and then performed a physical assessment. RN #6 then exited Patient #10's room without performing hand hygiene. S/he then entered the unit's medication room, discarded extra IV fluids and exited the medication room. Upon exiting the medication room, RN #6 performed hand hygiene.

At 8:45 a.m., Interventional Radiology Technician (Technician) #7 entered Patient #10's room without performing hand hygiene. Technician #7 donned gloves, removed saline syringes out of his/her pocket, then proceeded to inject radioactive medication into Patient #10's IV catheter. Technician #7 then removed his/her gloves, performed hand hygiene after patient care, and exited the room. Although, Technician #7 performed hand hygiene after patient care, s/he did not perform hand hygiene according to policy prior to administering the medication directly into the patient's vein.

At 9:10 a.m., Physician #8 entered Patient #10's room without hand hygiene being done and marked the patient's surgical site, throat area. Physician #8 explained the surgical process to the patient, reviewed the patient's chart which was located in the room, and then exited the room. Physician #8 did not perform hand hygiene when exiting the room.

From 8:10 a.m. to 9:10 a.m., 3 staff members involved in Patient #10's care, did not perform hand hygiene according to the facility's infection control guidelines.

v) On 01/25/17 at 8:50 a.m., an operating room (OR) turn-over was observed in room 6. During the observation, Surgical Aide #23 cleaned multiple objects, including the bed and OR lights with disinfectant and washcloth. Surgical Aide (SA) #23 cleaned the room with gloved hands and after disinfecting the inanimate objects and wearing the same contaminated gloves, s/he reached into a wall cabinet warmer for a washcloth and continued to clean the room. The wall cabinet warmer contained multiple wash cloths and blankets.

On 01/26/17 at 9:50 a.m., an interview was conducted with SA #23 who stated the warmer supplies could be used on multiple patients and confirmed s/he did not change gloves or perform hand hygiene prior to reaching into the warmer which contained clean supplies. SA #23 stated s/he realized his/her breach and was aware of the cross-contamination risk between patients.

b) On 01/26/17 at 10:26 a.m., an interview was conducted with the Interim Director of the Perioperative services (Director #11), the Interim OR Manager (Manager #27), the Central Sterile Processing Manager (Manager #12) and the Sterile Processing Coordinator (SPC #13).

Director #11 who was in charge of all personnel and care performed in the perioperative area stated training for infection control in the perioperative area was the job of the perioperative educator and the position had been vacant since November of 2016. S/he stated staff were expected to follow guidelines and expected staff to wash hands before and after patient care, after glove removal and if hands were visibly soiled. S/he stated perioperative leadership did not have discussions with the medical doctors on hand hygiene. Director #11 stated if leadership had concerns with infection control they would involve the Infection Prevention Manager.

Director #11 stated the perioperative department had no concerns in the last 6 months.

c) On 01/26/17 at 11:12 a.m., an interview was conducted with the Infection Prevention Manager (Manager #9) who stated the facility followed the Centers for Disease Control and Prevention (CDC) infection control guidelines for hand hygiene and staff were expected to follow the policy. S/he stated if staff did not follow the established infection control standards, the patients, employees, and visitors were at risk for infection.

After review of the multiple hand hygiene breaches, Manager #9 stated s/he and a part-time Infection Preventionist (IP) conducted hand hygiene audits. Manager #9 stated the observations were done outside of the inpatient rooms and staff were observed entering and exiting the inpatient rooms only.

Manager #9 stated s/he did not monitor hand hygiene and infection control compliance in the perioperative areas. Manager #9 stated infection control monitoring was up to the perioperative educator; however, s/he was available for consults if they had questions. Review of the Hand Hygiene Compliance by Care Site and Unit for January of 2017 revealed no evidence the perioperative units were monitored by the IPM for hand hygiene compliance.




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2. The facility did not ensure patient care supplies stored in nurse servers in the Intensive Care Unit (ICU) were handled in a way to prevent cross-contamination between patients.

a) During the tour of the Cardiovascular ICU and the ICU, the following infection control breaches were revealed:
i) A medication administration observation of RN #3 was conducted 01/24/17 at 10:50 a.m. in the ICU. During the medication preparation, RN #3 primed Patient #9's IV tubing with normal saline, while at the sink in the room. At the same time, RN #3 reached in the nurse server with the same gloved hands used to prepare the medication at the sink and removed an IV connector which was stored in the nurse server with other patient care supplies, including IV tubing, connectors, saline syringes, unpackaged 2x2 gauze, and IV catheter port caps. RN #3 then connected IV tubing to the patient with the same gloves, entered the nurse server for additional IV supplies, and then returned to the patient to flush the IV.
ii) On 01/24/17 at 11:30 a.m., 2 insulin pens and a tube of artificial tears were found on top of patient care supplies located in the top drawer in room 315's nurse server. One of the insulin pens was noted to have dried blood on the patient label adhered to the pen.
ICU Clinical Manager #18 was present during the observation and stated the nurse server supplies were only emptied if the patient was on isolation precautions.
iii) On 01/24/17 at 11:55 a.m., an inspection of the nurse server in room 305 revealed 3 scissors and 2 tweezers out of the packaging, located in the top drawer, near clean patient care supplies. An interview was conducted with RN #21 who was responsible for the patient in room 305. S/he stated if the patient was on isolation precautions, the supplies in the nurse server would be replaced. If the patient was not on isolation precautions, the supplies were considered clean.
The patient in room 305 was not in isolation precautions.
On 01/25/17 at 4:44 p.m., a second interview was conducted with RN #21 who stated the scissors and suture removal tweezers were for the patient's ostomy products and were used to trim the product to fit his/her ostomy. The tweezers were used for his/her jejunostomy (an opening of the skin of the abdomen) care.
S/he stated s/he would clean the supplies with alcohol and disinfectant wipes before returning the supplies back to the drawer. RN #21 stated s/he could not speak to other staff members' disinfection process.
b) On 01/25/17 at 4:16 p.m., an interview was conducted with RN #3 who stated to ensure patient care supplies stored in the nurse servers did not become contaminated, supplies should not be handled with contaminated gloves. RN #3 stated gloves and hand hygiene should be done before removing supplies from the drawer. S/he stated if this process was not followed, there would be a risk of cross-contamination to patients.

Although, RN #3 was aware of hand hygiene and glove change standards, s/he did not follow these standards during the observation conducted on 01/24/17.

c) On 01/25/17 at 4:30 p.m., an interview was conducted with Manager #14 who stated patient care supplies could be contaminated if patients' medications were stored in the top drawer near the clean supplies.
d) On 01/26/17 at 11:12 a.m., an interview was conducted with Manger #9 who stated there would be a concern for cross contamination between patients and s/he did not feel it was okay for contaminated gloves to be used to reach in the nurse servers for supplies. Furthermore, Manager #9 stated used patient supplies, including medications should not be stored near clean patient care supplies and this process was an infection control risk.
3. The facility failed to ensure OR staff discarded or replaced patient care supplies that were contaminated after falling on the OR floor while a patient was already in the room.

a) On 01/25/17 at 9:37 a.m., during a surgical case tracer for Patient #10, the patient's gel pad which was used for head support, fell on the floor prior to the surgery. Physician #8 was present in the OR while the patient was being prepped for surgery. Physician #8 picked up the gel pad from the floor, then placed the contaminated gel pad under the patient's head. Although, the OR room was cleaned prior to the patient's procedure, multiple OR staff walked in the room from other peri-operative areas, including the ORs.

Furthermore, while the patient was prepped, another OR staff member dropped a silver package on to the OR floor when EKG patches were removed from the 3rd drawer of the Anesthesia Machine. The OR staff member picked up the contaminated silver package and returned it to the blue bin located in the 3rd drawer next to the opened EKGs patches.

b) On 01/26/17 at 9:50 a.m., an interview was conducted with SA #23 and Surgical Tech #24. SA #23 stated s/he was responsible for ensuring the proper equipment was in the OR and room turnovers. SA #23 stated although, floors in the OR were disinfected during turnovers, the floors were still considered a "dirty" environment and items should not be picked up off floor then used on the patient.

c) On 01/26/17 at 10:26 a.m., an interview was conducted with Director #11, Manager #12, Manager #27, and SPC #13. Director #11 stated if infection control issues arose in the peri-operative area, audits would be conducted then. Director #11 stated there had been no concerns in the last six months with infection control and no audits or monitoring had been done. Director #11 stated the educator responsible for peri-operative infection control left the facility in November 2016 and the position was still open.

4. The facility failed to ensure endoscopy staff performed high level disinfection according to manufacturer's instructions when re-processing flexible endoscopes which were used for gastrointestinal procedures.

a) On 01/25/17 at 9:15 a.m., Employee #25 was observed performing High Level Disinfection (HLD) on a flexible endoscope used for a gastrointestinal procedure. According to the Enzyme Solutions manufacturer's instructions for the enzymatic detergent used by Employee #25 during the manual cleaning, instruments and equipment should be soaked a minimum of two (2) minutes or until organic material was removed. The flexible endoscope was not soaked for the minimum time required.

Review of the Olympus manufacturer's guidelines for reprocessing, revealed the enzymatic detergent manufacturer's recommendations should be followed.

b) On 01/26/17 at 7:22 a.m., an interview was conducted with Employee #25 who stated manufacturer's recommendations should be followed during HLD. Employee #25 stated the medical enzymes in the detergent was to kill germs. S/he stated typically s/he would soak the scope for 2 minutes and time the soak with the clock on the wall.

Employee #25 stated s/he did not soak the scope on 01/25/17 for the 2 minutes because s/he was being observed by surveyors. Employee #25 stated the same scope was re-processed in the automated endoscope reprocesser once s/he identified s/he had not soaked the scope for the 2 minutes required. Employee #25 then stated it was acceptable to repeat the process through the AER without repeating the soak time.

Employee #25 stated the 2 minute soak time was important to loosen any soils on the scope.

c) On 01/26/17 at 11:20 a.m., an interview was conducted with the Peri-anesthesia Clinical Nurse Manager (Manager #26) who stated flexible endoscope reprocessing was important to ensure protein bacteria would not be transferred to another patient. Manager #26 stated if the scope had to be reprocessed, the scope should be soaked for the 2 minutes prior to being placed in the AER.

Manager #26 further stated the repeated use of an AER without the 2 minute soak time was not acceptable and the scope manufacture had not indicated otherwise.

5. The facility failed to ensure patient care staff removed personal protective equipment (PPE) prior to leaving a patient isolation room.

a) On 01/24/17 at 12: 35 p.m., a tour of the 3rd floor Telemetry Unit was conducted with the Director of Quality and Safety (Director #20). During the tour, RN #5 was observed exiting patient isolation room 368. RN #5 was wearing PPE, including: an isolation gown, mask, and gloves. RN #5 removed the PPE outside of the patient's room, in the main hallway and discarded the PPE in a trash can located in the hallway outside of the patient's doorway. Multiple staff and visitors were present walking in the hallway. The signs posted outside of room 368 indicated the patient was on droplet precautions. During the observation, RN #5 stated the patient was on both contact and droplet precautions.

RN #5 did not discard the PPE worn in patient room 368 prior to leaving the patient environment. This was in contrast to the facility's Standard Precautions policy, Droplet Precautions policy and Contact Precautions policy.

b) On 01/24/17 at 4:34 p.m., an interview was conducted with RN #5 who stated removal of PPE outside of the room on the Telemetry floor was standard process for the entire floor. RN #5 stated the IPM was aware of this process.

c) On 01/26/17 at 11:12 a.m., an interview was conducted with Manager #9 who stated it was okay to remove PPE outside of patients' isolation rooms on the third floor and there were guidelines in place which spoke to this process. Manager #9 stated the linen carts and trash cans were stored outside of the room due to room size.

Manager #9 was unable to provide guidelines indicating PPE could be removed outside the patient's room prior to exit of survey.

When asked what the risk was if infection control practices were not followed, Manager #9 stated there would be a risk of infection to patients, staff, and visitors.

6. The facility failed to ensure Foley catheter bags were maintained in a manner to prevent cross-contamination from debris.

a) On 01/24/17 at 10:50 a.m., a tour of the CVICU and the ICU was conducted with the Director of Critical Care (Director #19). During the tour, Foley catheter bags, a thin sterile tube and collection system which was inserted in a patient's bladder to drain urine, was observed hanging on the outside of contaminated trash cans. The trash cans in patient rooms 307 and 316 contained debris.

During the tour, RN #3, who was responsible for the care of the patient in room 316, stated Foley catheter bags could be hung on trash cans in order to avoid dependent loops. RN #3 further stated this was how s/he was trained.

b) On 01/26/17 at 11:12 a.m., an interview was conducted IPM #9 who stated s/he was aware nursing staff were hanging Foley catheter bags on trash cans. IPM #9 stated this process was in place to avoid dependent loops in the tubing. However, s/he then stated the trash can was considered dirty and there could be a potential for patient infection. IPM #9 stated, prior to the survey, s/he did not consider this practice an infection risk.

7. Facility staff did not disinfect the rubber septum on IV medication vials prior to piercing.

a) On 01/24/17 at 10:55 a.m., an IV medication administration observation was conducted in the CVICU for Patient #9. RN #3 was observed reconstituting an IV antibiotic, Zosyn, with a 100 milliliter (ml) bag of Normal Saline (NS). RN #3 removed the plastic cap from the medication vial, and then connected the NS IV fluid bag to the vial with a connecting device, which pierced the rubber septum when connected. RN #3 did not disinfect the top of the vial. This was in contrast to facility policy.

RN #3 proceeded to administered the IV medication through the patient's IV access line.

During the observation, RN #3 stated s/he would only disinfect the top of the medication vial if the plastic cap was loose, otherwise it was not needed.

b) On 01/25/17 at 9:30 a.m., a case tracer was conducted to evaluate the overall care for Patient #10 during a surgical procedure. At 9:49 a.m., the Anesthesiologist (Physician #15) removed the plastic cap from 1 vial of Rocuronium, a paralytic, and then proceeded to pierce the top of the vial with a needle and a syringe. Physician #15 did not disinfect the top of the vial prior to drawing up the medication.

At 10:03 a.m., Physician #15 removed another IV medication from his/her medication cart. Physician #15 removed the plastic top of the IV vial, Decadron, pierced the top of the vial with a needle and a syringe, then proceeded to administer the IV medication through the patient's IV tubing. Physician #15 did not disinfect the top of the vial according to policy, before drawing up the medication.

c) On 01/25/17 at 3:34 p.m., an interview was conducted with Physician #15 who stated the rubber septum on top of IV medication vials did not have to be disinfected after the plastic cap was removed and prior to drawing up medications. Physician #15 stated s/he considered the top of the vial sterile if the plastic cap was in place. This was in contrast to the CDC guidelines.

d) On 01/26/17 at 9:00 a.m., an interview was conducted with the Pharmacy Manager (Manager #16) who stated although, the top of an IV medication vial was sterile if the cap was in place, there was no guarantee it remained sterile when the cap was removed. Manager #16 stated staff were expected to disinfect the top of the vial before insertion of a needle or connector. S/he then stated if the process was not followed there could be a risk of residue or some particulate matter remaining on the rubber septum.

e) On 01/26/17 at 11:12 a.m., an interview was conducted with the IPM who stated the facility follows the CDC guidelines for infection control. According to the CDC Safe Practices for Medical Injections, the rubber septum should be disinfected with alcohol prior to piercing it.

8. The facility staff who were responsible for the disinfection of surgical instruments failed to follow the manufacturer's instructions for use of enzymatic detergent in the pre-cleaning of surgical instruments.

a) On 01/25/17 at 10: 40 a.m., the Sterile Processing Technician (SPT #10) was observed pre-cleaning surgical instruments. The sink was filled with water between two marked lines. The SPT stated the first line indicated 3 gallons of water and the second line indicated 6 gallons of water. SPT #10 stated s/he believed the water in the sink was 4-5 gallons. SPT #10 stated s/he did not measure the water.

Furthermore, SPT #10 stated s/he was unsure of how many pumps of Enzymatic Detergent was used, then stated I think 4 or 5 pumps.

During the observation, Manager #12 stated staff were expected to use a ruler to measure the water, then once measure, staff were expected to use the chart indicating how much enzymatic detergent was needed. SPT #10 stated s/he did not use the ruler. Additionally, the measuring chart was only posted on the opposite side of the sink, out of view of SPT #10.

b) On 01/25/17 at 3:19 p.m., an interview was conducted with SPT #10 who stated the purpose of the pre-cleaning process was to remove any bioburden or debris from the surgical instruments. S/he stated the step was important to ensure blood or tissue did not harden, which allowed the instruments to be cleaned easily.

SPT #10 stated s/he was not aware of the manufacturer's recommendations for the enzymatic detergent dilution. S/he stated 1 pump of enzymatic detergent was used per gallon. However, s/he stated the detergent was not measured and did not know how much volume was in 1 pump. SPT #10 stated if the solution was too concentrated, it may not break down the bioburden. SPT #10 was unaware the effects of cleaning if too little of the enzymatic detergent was used.

This process contradicted the Steris Prolystica manufacturer's instructions.

c) On 01/26/17 at 10:26 a.m., an interview was conducted with Director #11, Manager #12, and SPC #13. SPC #13 stated the marked lines in the sink were there to make it simple for staff to measure the water. SPC #13 stated staff should follow the manufacturer's instructions for the enzymatic detergent.

Director #11 stated if infection control issues arose in the peri-operative area, including the Central Sterile Processing department, audits would be conducted then. Director #11 stated there had been no concerns in the last six months with infection control and no audits or monitoring had been done.