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Based on observations, facility record reviews and interviews with staff, the governing body failed to ensure that policies and procedures in the hospital are implemented and maintained, to protect the safety of patients for one of ten departments in the facility.


The Findings Include:


Observation of Labor and Delivery on 4/8/14 at 12:30 PM revealed 1 of 3 Operating Rooms (OR) in use. The OR staff were seen wearing purple scrubs. The Labor and Delivery Registered Nurse (RN) revealed that scrubs are worn in from home, and they have to be purple. She stated the unit does not require the staff to change into hospital-provided scrubs in the OR.

Interview with the Surgical Techician on April 8, 2014, at 12:45 PM, while cleaning the OR, revealed she buys her own scrubs, launders them at home, and wears them into work.

Review of the facility's Policy for Surgical Dress Code revealed all persons entering the restricted area of the Surgical Suite must wear clean scrub attire as supplied by the hospital, or designated jump suites. The policy referenced the Association of Operating Room Nurses (AORN) recommended practices. The policy also revealed shoe covers are available as personal protective equipment, and may be worn by persons entering the Surgical Suite to prevent splattering of shoes with blood and/or body fluids. However, shoe covers are to be removed when leaving the Surgical Suite.

Review of the Recommended Practices for Surgical Attire from AORN Journal 2012 revealed that AORN is taking a stronger stance against home laundering of surgical attire. The practice rationale is that surgical attire and appropriate personal protective equipment in the semi-restricted and restricted areas of health care facilities promotes personnel safety and helps ensure cleanliness in the perioperative environment. Using a health care-accredited laundering facility is preferred because accredited facilities follow industry standards. Perioperative personnel should change into surgical attire in designated dressing areas to decrease the possibility of cross-contamination and to assist with traffic control, and should change back into street clothes if they need to leave the facility or travel between buildings, to prevent contaminating the surgical attire through contact with the external environment.

Interview with the Director of Nursing (DON) and the Quality Manager (QM) on April 14, 2014 at 12:30 PM, revealed that both the DON and QM were aware that the policy regarding hospital scrubs was that the hospital would provide scrubs, and that they were to be worn only in the Operating Rooms, laundered by a certified laundry, and not to be worn outside the operating rooms.

Despite this information, both the DON and the QM stated they were aware that the Operating Room in Obstetrics were not following hospital policies, and stated they have not corrected this issue for as long as three years.

An interview with the Director of Infection Control was conducted on 4/9/14 at 11:40 AM. She stated it is her understanding and expectation that all employees who work in surgery need to wear hospital-provided scrubs in the OR. That includes the Main OR, the Cardiovascular OR, and the Labor and Delivery OR. She revealed that audits would be done in the future, but she has not started them yet.

Based on observations, facility record reviews and interviews with staff, the facility failed to ensure that the Quality Assurance/Performance Improvement (QAPI) maintains an effective hospital-wide program for one of 10 departments reviewed (Obstetrics).


The Findings Include:


Observation of Labor and Delivery on 4/8/14 at 12:30 PM revealed 1 of 3 operating rooms (OR) in use. The OR staff were seen wearing purple scrubs. The labor and delivery RN revealed that scrubs are worn in from home, and they have to be purple. She stated the unit does not require the staff to change into hospital-provided scrubs in the OR. Interview with the Surgical Technician on 4/8/14 at 12:45 PM, while cleaning the OR revealed she buys her own scrubs, launders them at home, and wears them into work.


Review of the facility's Policy for Surgical Dress Code revealed all persons entering the restricted area of the Surgical Suite must wear clean scrub attire, as supplied by the hospital or designated jump suites. The policy referenced the Association of Operating Room Nurses (AORN) recommended practices. The policy also revealed shoe covers are available as personal protective equipment, and may be worn by persons entering the Surgical Suite to prevent splattering of shoes with blood and/or body fluids. However, shoe covers are to be removed when leaving the Surgical Suite.

Review of the Recommended Practices for Surgical Attire from AORN Journal 2012 revealed that AORN is taking a stronger stance against home laundering of surgical attire. The practice rationale is that surgical attire and appropriate personal protective equipment in the semi-restricted and restricted areas of health care facilities promotes personnel safety and helps ensure cleanliness in the perioperative environment. Using a health care-accredited laundering facility is preferred, because accredited facilities follow industry standards. Perioperative personnel should change into surgical attire in designated dressing areas to decrease the possibility of cross-contamination, to assist with traffic control, and should change back into street clothes if they need to leave the facility, or travel between buildings, to prevent contaminating the surgical attire through contact with the external environment.


Interview with the Director of Nursing (DON) and the Quality Manager (QM) on April 14, 2014 at 12:30 PM, revealed that both the DON and QM were aware that the policy regarding hospital scrubs was that the hospital would provide scrubs, and that they were to be worn only in the Operating Rooms, laundered by a certified laundry, and not to be worn outside the operating rooms. Despite this information, both the DON and the QM stated they were aware that the Operating Room in Obstetrics were not following hospital policies and stated they have not corrected this issue for as long as three years.



An interview with the Director of Infection Control was conducted on 4/9/14 at 11:40 AM. She stated it is her understanding and expectation that all employees who work in surgery need to wear hospital-provided scrubs in the OR. That includes the Main OR, the Cardiovascular OR, and the Labor and Delivery OR. She revealed that audits would be done in the future, but she has not started them yet.

Based on observations, interviews, and record reviews, the facility failed to prevent unauthorized usage and distribution of expired blood culture bottles on 1 of 14 units observed.

The Findings Include:

An observation of the Medical Surgical Intensive Care Unit (MSICU) Intravenous Supply Room on 4/8/2014 at 10:33 AM revealed 9 loose blood culture bottles ready for use with an expiration date of 2/28/2014.

An interview with the Director of the MSICU Unit revealed and confirmed the presence of the expired blood culture bottles in the IV Room. The Director of the MSICU stated that she was unsure why the expired bottles were there, and that all the supplies in the room were checked a week ago for valid expiration dates.

Interview with the Laboratory Director on 4/9/14 at 12:13 PM revealed blood is drawn by nurses or laboratory technicians in the Intensive Care Units. The Laboratory Director stated they do not like it, because it is hard to keep control of the expiration dates since they do not know where the nurses are keeping the blood culture bottles on the unit. On 4/9/14 at 12:44 PM, the Laboratory Director presented a policy for blood specimen collection with a protocol for Limiting Venipuncture attempts. The Laboratory Director stated that in microbiology, the practice is for staff to check expiration dates on specimens that they receive. The Laboratory Director stated that if they receive a specimen with an expiration date on the container, the specimen is discarded and re-drawn. She stated it was not written in the policy, but they can fix it right away, and write it into the policy.

Review of the Policy and Procedures for Specimen Collection revealed blood collection tubes and blood culture bottles are to be used within their expiration date and stored per manufacturer's instructions. Staff is to check expiration dates prior to use, and to discard any expired tubes and/or blood culture bottles into an approved sharps/biohazard waste container.

Based on observations, interviews, and facility policy and procedure reviews, the facility failed to ensure that infection control practices were maintained to prevent the cross contamination of patients and staff on 3 of 5 observed floors of the hospital.

The Findings Include:

1.) Observation of Labor and Delivery on 4/8/14 at 12:30 PM revealed 1 of 3 Operating Rooms (OR) in use. The OR staff were seen wearing purple scrubs. The Labor and Delivery RN revealed that scrubs are worn in from home, and they have to be purple. She stated the unit does not require the staff to change into hospital-provided scrubs in the OR. Interview with the surgical tech cleaning the OR stated she buys her own scrubs, launders them at home, and wears them into work.

An observation was made on 4/11/14 at 11:15 AM of a surgical staff member walking into the cafeteria while still wearing surgical shoe covers. The staff member confirmed he had been working in the OR.

Review of the facility's policy for Surgical Dress Code revealed all persons entering the restricted area of the Surgical Suite must wear clean scrub attire as supplied by the hospital, or designated jump suites. The policy referenced the Association of Operating Room Nurses (AORN) recommended practices. The policy also revealed shoe covers are available as personal protective equipment, and may be worn by persons entering the Surgical Suite to prevent splattering of shoes with blood and/or body fluids. However, shoe covers are to be removed when leaving the Surgical Suite.

Review of the Recommended Practices for Surgical Attire from AORN Journal 2012 revealed that AORN is taking a stronger stance against home laundering of surgical attire. The practice rationale is that surgical attire and appropriate personal protective equipment in the semi-restricted and restricted areas of health care facilities promotes personal safety and helps ensure cleanliness in the perioperative environment. Using a health care-accredited laundering facility is preferred, because accredited facilities follow industry standards. Perioperative personnel should change into surgical attire in designated dressing areas to decrease the possibility of cross-contamination and to assist with traffic control, and should change back into street clothes if they need to leave the facility or travel between buildings, to prevent contaminating the surgical attire through contact with the external environment.

An interview with the Director of Infection Control was conducted on 4/9/14 at 11:40 AM. She stated it is her understanding and expectation that all employees who work in surgery need to wear hospital-provided scrubs in the OR. That includes the main OR, the cardiovascular OR, and the labor and delivery OR. She revealed that audits would be done in the future, but she has not started them yet.

Interview with the Chief Nursing Officer (CNO) and Labor and Delivery Charge Nurse on 4/9/14 at 12:00 PM revealed there was a discussion that started about 3 years ago regarding the scrubs worn in the Labor and Delivery ORs. It was decided that it was more important that the scrubs be purple for infant safety, than wearing the hospital-provided blue scrubs that the rest of the surgical departments wear.

2.) On 4/10/14 at 10:30 AM, there was an observation of raw chicken in plastic bags being thawed in the kitchen sink. There was running water over the chicken, but it was sitting in a sink full of water and it was not draining. A food service employee who was wearing gloves and chopping green onions brought a grate over and placed it in the bottom of the sink while picking up the bags of chicken. There was some chicken that was falling out of the bag, and the employee put the chicken back in the bag and proceeded to return to chopping green onions. The food service employee did not remove his soiled gloves that had come into contact with the raw chicken, nor wash his hands. The General Manager of the kitchen confirmed the employee should have washed his hands prior to changing tasks.

Review of the food safety standards and requirements provided by the facility revealed hands must be washed after handling raw meat, poultry, seafood and produce, and between handling different types of food.

3.) A medication administration observation of a staff nurse on 4/9/14 at 2:00 PM revealed that she was medicating a patient with Phenergan 12.5 milligrams (mg) intravenously. She retrieved the medication from the Pyxis machine using Bio Identification. She knocked on the room door, entered the room, and donned gloves without washing her hands. The nurse identified the patient by asking the patient to verify her name, date of birth, and checking her ID band. The nurse then removed the medication from her right scrub top pocket with gloved hands. The nurse opened the in-room computer work station, and logged into the intra-facility system. The nurse then picked up the containers holding the empty syringes, went to the door and asked other staff to get her some normal saline syringes. The nurse waited at the patient's room door and took the normal saline syringes from the other staff member. She went to the in-room computer work station, logged into the system, scanned the patient's armband and the medication using the scanner. The nurse opened the Phenergan, withdrew 12.5 mg of medications, removed the needle, laid the open syringe on the work station surface, open the normal saline syringe, and expelled the air over the trash can. The nurse then approached the patient, wiped the needless port of the IV tubing with an alcohol pad, administered the medication over one and half minutes using the needless port, followed by the normal saline flush. The nurse exited the in-room computer system, removed her gloves, and exited the room.

An interview with the staff nurse on 4/8/14 at 2:15 PM revealed that she always dons new gloves when entering a patient's room. She states that she prefers to use gloves when using the in-room work stations, but she had not realized that she was supposed to change her gloves again before working with the patient. She assumed that changing her gloves when entering and leaving the room was good enough.

An interview with the Infection Control Nurse on 4/9/14 at 11:38 AM revealed that it is expected that staff nurses would wash their hands before donning gloves for Medpass, and to change gloves appropriately.