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Based on observation, interview, record review and nationally-recognized standards review, the hospital failed to perform fire-risk assessments for one current patient (#9) and five discharged patients (#4, #5, #6, #7 and #8) prior to surgical procedures. These failures placed all surgical patients and staff at an elevated fire-risk.The hospital census was five Acute Care Patients, three Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and two Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or to discharge the patient) patients for a total census of 10.

Findings Included:

1. Observation on 03/11/24 at 1:30 PM, in the Operating Room Suite, showed during Patient
#9's Esophagogastroduodenoscopy (EGD, a procedure that visualizes the oropharynx, esophagus, stomach and duodenum) with biopsies, the staff failed to perform a fire-risk assessment

2. During an interview on 03/12/24 at 3:45 PM, Staff A, Nurse Manager of Surgical Services, stated they were unaware of the need for fire-risk assessments and have no policy.

3.Review of Patient #4's medical record, dated 11/02/24 for a left knee arthroscopy (a procedure to view the joint) with excision, showed no fire-risk assessment was performed.

4.Review of Patient #5's medical record, dated 11/02/23 for a left carpal tunnel (irritation of the median nerve in the wrist) release and Guyon's canal (distal portion of the ulnar nerve) release, showed no fire-risk assessment was performed.

5.Review of Patient #6's medical record, dated 10/03/23 for a sebaceous cyst (a fluid filled, noncancerous lump beneath the skin) removal, showed no fire-risk assessment was performed.

6.Review of Patient #7's medical record, dated 02/22/24 for an EGD with biopsies and colonoscopy (an exam of the large intestine and rectum) with biopsies, showed no fire-risk assessment was performed.

7.Review of Patient #8's medical record, dated 11/27/23 for a colonoscopy, showed no fire-risk assessment was performed.

8. Review of the Association of PeriOperative Registered Nurses (AORN) "Guidelines for Fire Prevention Practices," dated 2023, showed the direction for staff to:
- Perform a fire-risk assessment as part of the preprocedural briefing process, to include ignition, fuel, and oxidizer sources present in the Operating Room (OR).
- Include cognitive aids (eg, algorithms, checklists).
- Collaborate on and implement interventions based on the fire-risk assessment.
- Document the fire-risk and the actions taken to address them.
- Prevent contact between fuel sources (eg, drapes, skin antisepsis agents) and ignition sources (eg, electrosurgical devices).
- Prevent pooling of flammable skin antiseptic agents under, on, or near the patient.
- Prevent the pooling of flammable antiseptic agents by:
*Placing sterile or clean towels near the surgical preparation site to absorb excess solution from pooling;
*Using sterile towels to absorb excess solution from the prepped site;
*Removing materials (eg, sterile or clean towels) that become wet with the skin preparation solution before draping;
*Moving flammable antiseptic soaked materials away from ignition sources and outside of the patient care vicinity (ie, at least 6 feet away);
*Allow the skin antiseptic agent to dry before applying surgical drapes and follow the manufacturer's IFU for dry time;
*Use a water-soluble gel for the patient's head and hair when performing procedures that involve the head of neck.; and
*Use moistened radiopaque sponges near oxidizer and ignition sources during airway procedures.

The operating room contains several elements of the fire triangle, including oxygen (oxidizer), lasers and electrosurgical devices (ignition sources), and alcohol-based skin antiseptics and surgical drapes (fuel). The perioperative team can help reduce the risk of fire by performing a fire-risk assessment and implementing interventions (eg, preventing contact between fuel sources and ignition sources) based on that assessment.

Based on policy review, review of the Missouri Food Code and nationally-recognized standards review, observation and interview, the hospital failed to ensure staff maintained a sanitary environment was preserved through maintenance and cleaning that would not harbor bacteria and transmit infections in the kitchen, surgical hallway and the Central Sterile areas. The facility also failed to ensure staff performed hand hygiene (washing hands with soap and water or use of appropriate hand sanitizer) when indicated, wore gloves when indicated, performed hand hygiene after glove removal, and performed hand hygiene before re-gloving during medication administration for four patients (#11, #12, #13, and #14) out of five medication administration observations made of staff administering medication to patients.
These failures had the potential to expose patients, visitors and staff to cross-contamination and increased the potential to spread infection. The hospital census was five Acute Care Patients, three Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients and two Observation (Observation - outpatient services provided to a patient while the patient's physician decides whether to admit the patient to Acute Care services or to discharge the patient) patients for a total census of 10.

Findings included:

Kitchen
1. Review of the facility's policy titled, "Infection Prevention and Control Program," last revised 10/2021, showed the direction for the infection control nurse to conduct surveillance within the organization and in consultation with other departments to include indications for obtaining microbiological cultures from patients and the environment as indicated.

2. Review of the Missouri Food Code for the Food Establishments of the State of Missouri, dated 06/03/13, chapter 6, showed surface characteristics of floors, walls and ceiling surfaces should be smooth, durable, and easily cleanable for areas where food establishment operations were conducted and nonabsorbent for areas subject to moisture such as food preparation areas, walk-in-refrigerators, washing areas, toilet rooms, mobile food establishment servicing areas, and areas subject to flushing or spray cleaning methods.

3. Observation on 03/13/24 at 9:30 AM, in the kitchen, showed:
- The wall next to the entrance had sticky tape and seven holes.
- A window with a large crack.
- Caulking around sink was cracked.
- Under the garbage disposal sink was two missing floor tiles with exposed glue.
- The steam table was unclean on the outside and inside the second warmer was discolored.
- One cart with four rusted (reddish-brown oxidation of metal that can harbor bacteria) wheels.
- On the right side of the stove was grease and discoloration up the wall to the ceiling.
- Inside the ice machine lid was unclean tape with paper and the right corner of the lid was broken with particle board exposed.
- A rusted vent above the dishwasher.
- The salad bar hinges were unclean.
- Two cracked and stained ceiling tiles in the dining area.

4. During an interview on 03/14/24 at 10:30 AM, Staff H, Manager of Food Services, stated they should have reported any repairs needed to maintenance and they followed the Missouri Food Code.

Surgical Services
5. Review of the Association for Professionals in Infection Control and Prevention (APIC), "Infection Preventionists Guide to the Operating Room," dated 2018, showed the operating room environment (surgical hallway and Central Sterile Areas) required surfaces that were smooth, cleanable, non-absorptive, and capable of withstanding cleaners and disinfectant solutions with no cracks and crevices where dirt can become trapped. Other materials (e.g., vinyl) can rip or wear in ways that create environmental reservoirs for microorganisms.

6. Observation on 03/12/24 at 9:00 AM, showed outside of the Operating Room, chipped paint around window frame and door frame.

7. Observation on 03/12/24 at 9:10 AM, showed inside the Central Sterile clean room, drywall damage with particle shedding.

8. Observation on 03/12/24 at 9:15 AM, showed inside the Endoscope Decontamination room, wall damage with particle shedding.

9. During an interview on 03/12/24 at 3:45 PM, Staff A, Nurse Manager of Surgical Services, stated they follow APIC National Standards and she hadn't put any work orders in.

10. During an interview on 03/13/24 at 11:30 AM, Staff G, Registered Nurse (RN), Infection Preventionist, stated they hadn't performed environmental rounds for approximately five years, they expected staff to report any maintenance issues to their managers and they round on the surgery and kitchen areas quarterly. They also stated they followed APIC.

Hand Hygiene and Gloving
11. Review of the facility's policy titled, "Handwashing Policy," dated 03/2022, in part showed staff directives:
Use alcohol-based hand sanitizer:
- Immediately before touching a patient.
- Before performing an aseptic task (i.e., placing an indwelling device) or handling invasive medical devices.
- Before moving from work on a soiled body site to a clean body site on the same patient.
- After touching a patient or the patient's immediate environment.
- Immediately after glove removal.
Wash with soap and water:
- When hands are visibly soiled.
- After known or suspected exposure to spores.
- After contact with blood, body fluids, or contaminated surfaces.
There are five key moments that define when a healthcare worker should perform hand hygiene: Before and after patient contact; before aseptic technique (process that is maintained free of germs or bacteria); after body fluid exposure risk; and after contact with patient surroundings.

12. Review of the facility's policy titled, "Standard Precautions," dated 03/19/21, in part showed staff directives:
- To provide guidelines for interactions between patients and healthcare providers to prevent the transmission of infections agents associated with healthcare delivery.
Standard Precautions include:
- Hand Hygiene
- Gloves:
- To be worn when touching blood, body fluids, secretions, excretions, mucous membranes, non-intact skin, and other contaminated items (i.e., equipment). Gloves do NOT take the place of hand hygiene. Hands are to be washed after removing gloves.
- Gloves should be changed between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms.
Safe Injection Practices:
- Use aseptic technique to avoid contamination of sterile injection equipment.
Care of the Environment:
- Surfaces that are likely to be contaminated with pathogens, including those that are in
close proximity to the patient (i.e., bed rails, over the bed tables) and frequently-touched surfaces in the patient care environment shall be cleaned and disinfected on a more frequent schedule compared to that for other surfaces.
- Multi-use electronic equipment, including those items that are used by patients, items used during delivery of patient care, and mobile devices that are moved in and out of patient rooms frequently shall be cleaned and disinfected on a daily basis.

13. Observation on 03/12/24 at 8:16 AM, showed Staff C, RN:
- Prepared medications to administer to Patient #11.
- Performed hand hygiene and gloved upon entry into the patient's room.
- Removed the barcode scanner from the computer workstation, touched/scanned the patient's identification (ID) band, and wearing the same gloves, Staff C scanned the five individual packaged medication's barcodes.
- After Staff C scanned each medication barcode, wearing the same gloves, Staff C removed each medication from the individual package, placed each medication into a plastic medication cup, and handed the plastic medication cup to the patient.
- Wearing the same gloves, Staff C removed a medication patch from the patient's back, discarded the old patch, and placed a new medication patch to the patient's lower back.
- Removed gloves, performed hand hygiene, re-gloved, cleansed the IV port with an alcohol pad, and administered medication per intravenous (IV - in a vein) push (IVP - to manually administer a dose of medication through a tube into a vein).
- Wearing the same gloves to administer the IVP medication, Staff C prepared subcutaneous (SQ - under the skin) medication to administer to the patient's lower abdomen. Wearing the same gloves, Staff C cleansed the patient's lower abdomen with an alcohol pad and administered the SQ medication to the patient's lower abdomen.
- After Staff C administered the SQ medication to the patient's lower abdomen, Staff C removed gloves, performed hand hygiene, re-gloved, scanned the patient's ID band, scanned the barcode on the IV antibiotic medication fluid bag, attached the IV antibiotic medication bag to the IV tubing, connected the IV antibiotic medication fluid bag tubing to the IV pump, programmed the IV pump to administer the antibiotic at the ordered rate, and touched the IV pump start function to administer the
medication.

14. Observation on 03/12/24 at 8:52 AM, showed Staff O, RN:
- Prepared medication to administer to Patient #12.
- Performed hand hygiene and gloved upon entry into the patient's room.
- Removed the barcode scanner from the computer workstation in the patient's room, touched/scanned the patient's ID band, and wearing the same gloves, Staff O scanned the four individual packaged medication's barcodes.
- Wearing the same gloves worn to scan the patient's ID band and medication barcodes, Staff O typed on the computer keyboard, then removed each medication from the individual package, placed each medication into a plastic medication cup, handed the plastic medication cup to the patient, and then removed an old medication patch and placed a new one on the patient.
- Removed gloves, performed hand hygiene, re-gloved, cleansed the patient's abdomen with an alcohol pad and administered SQ medication to the patient's lower abdomen.
- Wearing the same gloves to administer the SQ medication, Staff O turned off the IV pump, cleansed the IV port with an alcohol pad, and administered IVP medication.
- After Staff O administered the IVP medication, wearing the same gloves, Staff O turned on the IVP pump, programmed the pump, and restarted the IV infusion.
- Removed gloves and performed hand hygiene and exited the patient's room to retrieve requested pain medication from the pharmacy.
- Performed hand hygiene upon entry into the patient's room.
- Without gloves, Staff O removed the barcode scanner from the computer workstation in the patient's room and scanned the patient's ID band, typed on the computer keyboard, and scanned the barcode on the pain medication.
- Performed hand hygiene, gloved, cleansed the IV port with an alcohol pad and administered the IV pain medication.
- Wearing the same gloves worn to administer the IV pain medication , Staff O removed the old IV tubing and replaced the old tubing with new tubing.

15. Observation on 03/13/24 at 8:17 AM, showed Staff C, RN:
- Prepared medication to administer to Patient #13.
- Performed hand hygiene and gloved upon entry into the patient's room.
- Removed the barcode scanner from the computer workstation, touched/scanned the patient's ID band, and wearing the same gloves, Staff C scanned the seven individual packaged medication's barcodes.
- After Staff C scanned each medication's barcode, wearing the same gloves, Staff C removed each medication from the individual package, placed each medication into a plastic medication cup, and handed the plastic medication cup to the patient.
- Wearing the same gloves, Staff C cleansed the IV port with an alcohol pad and administered IVP medication.
- Wearing the same gloves, Staff C turned off the alarm on the IV pump.
- Twice Staff C removed gloves but failed to perform hand hygiene after each glove removal or before re-gloving.

16. Observation on 0313/24 at 8:40 AM, showed Staff C, RN:
- Prepared medication to administer to Patient #14.
- Performed hand hygiene and gloved upon entry into the patient's room.
- Removed the barcode scanner from the computer workstation, scanned the patient's ID band, and wearing the same gloves, Staff C scanned the four individual packaged medication's barcodes.
- After Staff C scanned each medication's barcode, wearing the same gloves, Staff C removed each medication from the individual package, placed each medication into a plastic medication cup, and handed the plastic medication cup to the patient.

17. During an interview on 03/13/24 at 9:12 A, Staff D, RN, Director of Patient Care Services, stated staff was expected to perform hand hygiene when indicated, wear gloves and change gloves when indicated, and to perform hand hygiene before gloving, after removal of gloves and before re-gloving. Staff D stated staff was expected to follow the facility's "Hand Hygiene" policy and procedure.

18. During an interview on 03/13/24 at 9:13 AM, Staff N, RN, stated:
- The facility provided infection control prevention during orientation and yearly.
- Staff are expected to perform hand hygiene anytime staff touch something, between patient care/tasks, and when going from one patient's body part to another part.
- Before staff put on gloves, after glove removal, and before re-gloving.
- After touching inanimate objects (barcode scanner, computer keyboard, mouse, bed rail, over-the bed table ...) in a patient's room.

19. During an interview on 03/13/24 at 11:37 AM, Staff G, RN, Infection Preventionist, stated staff are expected to perform hand hygiene:
- Upon entry/exit of patients' rooms.
- Before medication prep.
- Before gloving, after glove removal and before re-gloving.
- Anytime staff touch items in the patient's room, for example, computer keyboard, computer mouse, barcode scanner, side rails, and over-the-bed table.
- After staff use the barcode scanner to scan the patient's ID band and medication barcodes.
- Before staff remove medications from the individual packaging and place into the plastic medication cup.
- After staff remove old medication patches and before placing a new patch onto the patient.
- When going from one patient body part to another.
- After and before staff administer medications of different routes, for example, after administering SQ medications and before staff administer IVP medications or hang IV antibiotic medications.
Staff G stated staff was expected to follow the facility's infection control policy's related to hand hygiene and standard precautions.


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