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Based on observations, interviews, record reviews and policy reviews the facility failed to have an infection control systemic practice in place. The facility failed to:
- Ensure isolation rooms were cleaned in a manner to prevent the spread of infection.
- Ensure terminal cleanings and high level dust removal was done in an appropriate manner.
- Ensure Personal Protective Equipment was worn appropriately.
- Perform hand hygiene (wash hands with soap and water or use hand sanitizer) before putting on gloves or between glove changes.
- Perform hand hygiene and change gloves after touching a contaminated inanimate object and prior to touching the patient's medications during medication administration.
- Properly glove when touching indwelling urinary catheter tubing and dependent drainage bag.
The severity and cumulative effect of these systemic practices resulted in the facility being out of compliance with 42 CFR 482.42 Condition of Participation: Infection Control.

Please see A749 for details.


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Based on observation, interview, record review and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards when they failed to:
- Ensure isolation (special precautions taken to prevent the spread of infection of patients known or suspected to have highly contagious diseases) rooms were cleaned in a manner to prevent the spread of infection during the terminal cleaning (deep cleaning process completed after a patient discharge, in preparation for a new patient, or at the end of the day in rooms where procedures are conducted) of two patients' (#49 and #65) isolation rooms of two isolation room terminal cleanings observed. The facility also failed to ensure that cubicle curtains, in isolation rooms, were changed after patients were discharged from the Pediatric Hematology/Oncology Outpatient Center (the diagnosis, treatment and prevention of blood diseases and cancer) for one patient (#52) of one patient observed.
- Ensure personal protective equipment (PPE, items such as gowns, gloves and masks worn to prevent the spread of infection) was worn and removed when appropriate by two staff (VV and AAA) of two staff observed who wore PPE.
- Ensure the two of two areas (Operating Room (OR) and the Pediatric Hematology/Oncology Outpatient Center) were cleaned in a manner to remove high level dust.
- Ensure staff wore gloves when performing invasive procedures for one patient (#4) of one patient observed.
- Ensure staff performed hand hygiene after touching inanimate (lifeless, such as tables) objects and between glove changes for four patients (#4, #37, #65 and #10) of four patients observed;
-Ensure personal protective equipment (gown) was tied at the waist when in a Contact Isolation room for one of one patient (#33) and that a head cover contained all hair when drawing blood cultures from a central line for one of one patient
(#34.)
These deficient practices had the potential to increase the risk of cross contamination and placed all patients, visitors, and staff at risk for infection. The facility census for St. Mary's was 287, and the facility census for Cardinal Glennon was 168.

Findings included:

1. Record review of the facility's undated policy titled, "Shine - Isolation Room - Discharge and Terminal Cleaning," showed the following direction for cleaning vacated (discharged) patient isolation rooms:
- Red plastic liners (biohazard plastic bags, used to contain patient items contaminated or dirty with organisms, such as bacteria or viruses, that pose a risk to health or the environment) should be used for bagging waste (trash), linen, utensils, mop heads and cleaning wipers;
- The floor should be mopped prior to placing clean linens on the bed; and
- The curtains should be removed from the room prior to staff removing PPE.

Record review of the facility's undated policy titled, "Isolation Guidelines," showed the following:
- Isolation precautions (measures to prevent infectious disease from spreading) are designed to prevent the spread of microorganisms to patients, personnel, and visitors.
- Contact isolation was designed to reduce the risk of microorganisms by direct or indirect contact with items in the patient's environment, and required the use of gown and gloves upon entry into the patient's room.
- Contact isolation rooms were to be terminally cleaned after patient discharge or transfer and cubical curtains were to be changed.
- Droplet isolation required the use of an isolation mask and gloves upon entry to a patient's room.
- When terminally cleaning a droplet isolation (measures to prevent infection disease from spreading though speaking, sneezing or coughing) room, staff should thoroughly clean all surfaces and change the cubicle (privacy) curtains.

2. Observation on 09/12/16 at 1:28 PM, showed Staff VV, Environmental Services (EVS), terminally clean discharged Patient #49's isolation room in the Pediatric Intensive Care Unit. During the observation:
- Red plastic liners were not used while Staff VV cleaned the room.
- Staff VV placed clean linens on the bed to prepare for the next patient while contaminated items remained in the isolation room, and prior to sweeping and mopping the floor.
- Staff VV failed to wear an isolation mask and gown while contaminated items remained in the room.
- Contaminated items included a bedside commode (used for toileting), a supply cart with multiple patient care items inside the cart, disposable curtains and trash.

Record review of Patient #49's Isolation precautions showed that the patient was on contact isolation for shingles (painful skin rash) and on droplet isolation for influenza (respiratory illness.)

During an interview on 09/12/16 at approximately 1:45 PM, Staff VV stated that:
- She had worked in her position for two months.
- She learned to clean isolation rooms by watching a video.
- She was unsure if she had completed a competency checklist specific to her position.
- She was not required to demonstrate that she was competent to clean isolation rooms during her orientation.
- She did not wear appropriate PPE in the room while placing sheets on the bed, because she felt the room was clean.
- She had not, and did not need to clean the adjoining hopper (water filled basin used to flush human waste) room or ante (area that separates an isolation room from a common area) room after the isolation patient was discharged.

3. Observation on 09/12/16 at 3:20 PM, showed that while Staff AAA, EVS, terminally cleaned discharged Patient #65's isolation room, she obtained clean linens and placed them in the room on a table. The isolation room had debris on one countertop (indicated it had not been wiped thoroughly) and significant dust (able to be rolled into a pea size ball) on top of the bathroom mirror (indicated the isolation room was not clean). Staff AAA failed to wear an isolation mask or gown in the room, which remained contaminated. Wearing gloves, Staff AAA removed trash from the room and placed it in a trash bin, which did not contain red plastic liners. Her gloves were then contaminated and still wearing the gloves she
pushed her EVS cart out of the room to the corner of the hall, and reached inside the cart to obtain supplies.

Record review of Patient #65's isolation precautions showed that the patient was on contact isolation for Respiratory Syncytial Virus (virus that affects the lungs and breathing passages in babies and small children) and droplet isolation for influenza.

During an interview on 09/13/16 at approximately 2:00 PM, Staff WW, Operations Manager, stated that:
- Red biohazard bags were only used for items saturated with blood or body fluid, and all other isolation trash was managed in the same manner as regular trash.
- The room should be completely wiped down and cleaned of contaminated items, then linen and trash removed from the room, then PPE removed, then obtain clean linens to make the bed and then dry mop (similar to sweeping) and wet mop the floor (differs from the facility policy).
- EVS staff should follow the "Training Class Outline for Isolation Room Discharge & Terminal Cleaning," and not the facility policy. The policy was formulated by the contracted EVS Company (all of EVS staff was employed by the contracted company.)
- The terminal cleaning procedure in the "Training Class Outline" differed from the facility policy.
- He was unaware if Staff VV had documented competency for her position.
- He had not observed Staff VV clean an isolation room before.
- Staff VV should have cleaned the adjoining hopper and anteroom as part of the terminal cleaning.
- Staff VV should have worn appropriate PPE until all contaminated items were removed from the room, and until the room and adjoining rooms were cleaned.

During an interview on 09/13/16 at 3:14 PM, Staff JJJ, Infection Preventionist, stated that the contracted EVS Company policy was approved for use in the hospital, and should be followed by EVS staff.

4. Observation on 09/13/16 at 11:00 AM, showed Patient #52 in isolation for contact precautions in the Pediatric Hematology/Oncology Outpatient Center. Inside the room was a non-disposable curtain.

Record review of Patient #52's isolation precautions showed that the patient was on contact isolation for Vancomycin-Resistant Enterococci (VRE, a type of bacteria called enterococci that have developed resistance to many antibiotics, especially vancomycin.)

During an interview on 09/13/16 at 10:35 AM, Staff EEE, Registered Nurse, (RN), Team Leader, (TL), stated that if a patient was in isolation that the staff would wipe down the room after the patient was discharged and that EVS would do a terminal clean at the end of the day. She stated that the curtains were not disposable and were changed every 90 days by EVS.

During an interview on 09/13/16 at 11:38 AM, Staff FFF, Chief Operating Officer COO, stated that he was unaware that the Pediatric Hematology/Oncology Outpatient Center did not have disposable curtains within the patient rooms.

Record review of facility document titled, "Curtains changed (90 Days)," showed the last date for curtain change in the Pediatric Hematology/Oncology Outpatient Center was 08/13/16. The form was signed by Staff WW, Operations Manager.

During an interview on 09/13/16 at 3:14 PM, Staff JJJ, Infection Preventionist, stated that she was aware that the curtains in the Pediatric Hematology/Oncology Outpatient Center were non-disposable but expected EVS to change the curtain within an isolation room after the patient was discharged from that room.

5. Record review of the facility's undated policy titled, "Surgical/Invasive Areas and Delivery Rooms - Terminal Cleaning at the end of each day," showed that EVS staff were to use a cloth dampened with disinfectant solution to clean fixtures at the end of each day after OR scheduled procedures were completed. The expectation was that all walls, furniture, fixtures, ledges and stainless steel surfaces would be clean.

6. Observation on 09/13/16 at approximately 11:00 AM of OR Suites five and eight, showed large amounts (able to be rolled into a ball the size of a nickel) of dust and debris on high level, horizontal surfaces near the proximity of the operating table. These observations were verified by Staff PPP, EVS and Staff CCC, OR Director.

During an interview on 09/13/16 at 11:38 AM, Staff WW, stated that he had not made observations of the terminal cleaning process in the OR, completed by EVS staff.

7. Observation on 09/13/16 at 11:15 AM, of the Pediatric Hematology/Oncology Outpatient Centers showed one blanket warmer, and 12 fire alarm boxes, with large amounts (able to be rolled into a ball the size of a dime) of dust and debris on high level, horizontal surfaces located in the hallways outside of patient rooms.

During an interview on 09/13/16 at 11:38 AM, Staff WW stated that he did morning rounds in the Pediatric Hematology/Oncology Outpatient Center and that his expectation was for EVS to do high level cleaning weekly.

8. Record review of the facility's policy titled, "Hand Hygiene," revised 03/2013, showed the following indications for hand hygiene:
- After handling patient equipment;
- After removing gloves; and
- Before performing any invasive procedure.

Record review of the facility's policy titled, "Standard Precautions," revised 04/2014, showed:
- All healthcare personnel will utilize appropriate barriers to protect themselves from possible exposure to bloodborne pathogens (infectious microorganisms in human blood that can cause disease in humans) and other potential infectious materials;
- Standard Precautions are on the principles that all blood, body fluids, secretions, excretions, non-intact skin and mucous membranes may contain transmissible infectious agents;
- Standard Precautions include a group of infection prevention practices that apply to all patients regardless of suspected or confirmed infection status.

9. Observation on 09/06/16 at 2:50 PM, showed Staff S, RN, in Patient #65's room on Two East where she repositioned the indwelling urinary catheter (a thin sterile tube inserted into the bladder to drain urine) tubing and touched the dependent drainage bag and then typed on the computer in the room. She was not wearing gloves nor did she perform hand hygiene before going to the computer.

During an interview on 09/06/16 at 3:00 PM, Staff S, stated that she did not touch the dependent drainage bag.

10. Observation on 09/06/16 at 3:20 PM, showed Staff J, RN, prepared to administer medications to Patient #4 in the Emergency Department, (ED). Staff J typed on the computer keyboard, administered medication intravenously (IV, within the vein) typed on the computer keyboard, and touched the bed controls to raise the head of the bed. Staff J did not wear gloves to administer the IV medication and she did not perform hand hygiene in between these tasks.

During an interview on 09/06/16 at 3:40 PM, Staff J stated that she was unsure of the process for glove use with IV medications and that she was to perform hand hygiene after glove use only if the gloves were dirty.

During an interview on 09/06/16 at 3:36 PM, Staff F, RN, ED Director, stated that her expectation was for staff to wear gloves when administering IV medications, perform hand hygiene in between glove changes and after touching inanimate objects like the computer keyboard.

11. Observation on 09/07/16 at 9:20 AM showed Staff W, RN, in Patient #10's room on Three West to administer medications. She performed hand hygiene and put on gloves. She administered the oral medications, then hung an IV antibiotic, administered a subcutaneous injection (SQ, a method of administering medication under the skin) to the patient. She then touched the indwelling urinary catheter dependent drainage bag. She did not change gloves or perform hand hygiene between any of these tasks.

During an interview on 09/07/16 at 9:40 AM, Staff W stated "I should have changed my gloves and washed my hands. I didn't think about that."

12. Observation on 09/07/16 at 10:00 AM, showed Staff X, Certified Wound Care Specialist, RN, in Patient #13's room on the Transitional Care Unit (TCU). She performed a dressing on an abdominal wound. Staff X, with gloved hands, moved the trash can closer to the patients bed, then removed her gloves and put on new ones without first performing hand hygiene. She then removed part of the soiled dressing and with the same gloves removed the cap from the sterile water bottle. Wearing the same gloves, she placed her hands on the patient's skin, while the patient began to remove the rest of the soiled dressing. Wearing the same gloves, she removed gauze from a package and picked up the sterile water and poured the water on the area to loosen the dressing. She removed her gloves and performed hand hygiene. She cleansed the wound with a gauze and used the same soiled gauze to clean the skin around the wound. She removed her gloves and did not perform hand hygiene.

During an interview on 09/07/16 at 10:40 AM, Staff X stated that she should have performed hand hygiene after each glove change and that she had moved the trash can with a Sani wipe (a germicidal disposable wipe).

13. Observation on 09/12/16 at 1:55 PM, showed Staff QQ, Respiratory Therapist, (RT), entered Patient #37's room on the Two South Pediatric Unit and prepared to administer high frequency chest wall oscillation (inflatable vest that is attached to a machine which mechanically performs chest physical therapy by vibrating at a high frequency to help loosen lung secretions). During the observation Staff QQ:
- Put on gloves and typed on the computer keyboard;
- Removed her gloves and applied new gloves without performing hand hygiene;
- Listened to the patients lungs then applied the vest;
- Suctioned the patient's mouth then removed her gloves;
- Typed on the computer keyboard then applied a new pair of gloves and adjusted the vest;
- Adjusted the patient's position in the bed;
- Removed gloves and reached into her pants pocket and answered her phone then replaced her phone inside her pants pocket;
- Performed hand hygiene and applied gloves;
- Suctioned patient's mouth then listened to patient's lungs; and
- Removed gloves and typed on the computer keyboard.
Staff QQ did not perform hand hygiene after glove removals or after touching inanimate objects and before patient contact. Staff QQ did not clean her phone prior to returning it to her pocket.

During an interview on 09/12/16 at 2:15 PM, Staff QQ stated that she felt she did not have any failures with her hand hygiene while she cared for Patient #37. She stated that she cleaned her phone at the end of her shift.

14. Record review of the facility policy titled, "Isolation Guidelines" revised 05/2014 showed:
-Contact Isolation is designed to reduce the risk of epidemiologically important microorganisms (infections, disease or germs) by direct or indirect contact with items in the patient's environment.
-All personnel are responsible for complying with and enforcing isolation precautions including appropriate usage of personal protective equipment (gown, gloves, mask and goggles and head covers).

15. Observation on 09/12/16 at 1:40 PM showed Staff GG, RN, entered Patient #33's contact isolation room on Four North to obtain blood cultures (blood that is obtained to test for bacteria) from a central line (a long thin flexible tube inserted into a large vein to give medication, fluids, nutrients or blood, over a long period of time. Staff GG's head cover did not contain all of her hair.

During an interview on 09/12/16 at 1:55 PM, Staff GG stated that the purpose of the head cover was to protect the sterile field from contamination from hair.

Staff GG failed to completely cover her hair, which led to the potential for hair to fall onto the sterile field.

16. Observation on 09/12/16 at 2:10 PM showed Staff H, Physician, entered the room of Patient #34's Contact Isolation room on Four North. Staff H did not tie the PPE gown at the waist.

During an interview on 09/12/16 at 2:25 PM, Staff H stated that not tying the gown was an oversight and that not tying it could possibly contaminate his clothes.

The possible contamination could then be transferred to anyone with whom he came into contact.











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