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A. Based on document review, observational tour, and interview, it was determined, for 1 of 5 Emergency Department (ED) rooms (room 21) entered, the Hospital failed to ensure biohazard material was properly disposed of. This potentially affected all patients entering room 21 of the ED on 9/8/15.

Findings include:

1. On 9/9/15 at approximately 2:05 PM, the policy SYS-017-039, titled "Cleaning Inpatient Rooms and Adjoining Clinical Areas", reviewed on 2/24/14, was reviewed. The policy required, "III. Definitions...7. Red biohazard plastic bags are to be used only for trash contaminated with blood... IV Procedure... E. Patient Room Discharge/Transfer Cleaning... 2. c) (5) Pick up trash and litter off floor..."

2. On 9/8/15 at 9:30 AM, an observational tour was conducted in the emergency department (ED). At 10:00 AM, a bandage with dried blood was on the floor in room 21.

3. On 9/8/15 at 10:05 AM, an interview was conducted with the patient (Pt. #6) and her husband in room 21. Pt. #6 and her husband stated the bandage was in the room when they came.


B. Based on document review, observational tour, and interview, it was determined, for 1 of 3 staff (E #1) performing site preparation for the insertion of an IV needle, in the Emergency Department (ED), the Hospital failed to ensure staff performed the skin preparation according to policy. This potentially affected all patients for whom E#1 inserted an IV.

Findings include:

1. On 9/9/15 at approximately 2:00 PM, the policy titled "IV Catheter Insertion", revised 4/3/15, was reviewed. The policy required, "Preparing the site... Clean the site with chlorhexidine using a back-and-forth scrubbing motion for at least 30 seconds to remove flora that would otherwise be introduced into the vascular system with the venipuncture. Then allow the antiseptic to dry."

2. On 9/8/15 at 9:30 AM, an observational tour was conducted in the ED. At 9:40 AM, a Registered Nurse (E #1), in ED room 22, applied chlorhexidine skin preparation before drawing blood and starting an intravenous solution. E #1 applied the prep for approximately 5 to 10 seconds and then wiped the antiseptic off, not allowing it to dry.

3. On 9/8/15 at 9:45 AM, an interview was conducted with the Director of Nursing (E #2). E #2 was notified of the above findings.


C. Based on document review, observational tour, and interview, it was determined, for 1 of 3 staff (E #1) in the ED performing invasive procedures, the Hospital failed to ensure staff performed hand hygiene, as per policy. This potentially affected all patients in the ED on 9/8/15.

Findings include:

1. On 9/8/15 at approximately 3:00 PM, the policy titled "Standard Precautions", with undocumented implementation date, was reviewed. The policy required, "A. Hand Hygiene Overview... 1. All health care workers (HCW) must comply with the appropriate hand washing practices to prevent transmitting an infection or contracting an infection... After removing gloves..."

2. On 9/8/15 at 9:30 AM, an observational tour was conducted in the ED. At 9:40 AM, a Registered Nurse (E #1), in ED room 22, applied a chlorhexidine skin preparation, drew blood, and started an intravenous solution. E #1 removed her gloves but did not disinfect her hands before labeling blood tubes, placing a blood pressure cuff on the patient, removing a nasal cannula from the clean supply cart and placing it on the patient.

3. On 9/8/15 at 9:45 AM, an interview was conducted with the Director of Nursing (E #2). E #2 was notified of the above findings.


D. Based on document review, observational tour, and interview, it was determined, for 1 of 1 (Pt. #5) patient in a contact isolation room in the Emergency Department (ED), the Hospital failed to ensure isolation precautions were maintained and followed. This potentially affected all patients entering the ED on 9/8/15.

Findings include:

1. On 9/8/15 at 9:55 AM, the Contact Precaution sign on ED room 3 was reviewed. The sign included, "Stop. Contact Precautions. If you have questions, please ask at Nurse Station. Visitors, Patients, Healthcare Workers, Everyone... Visitors are strongly encouraged to wear gloves and gowns..."

2. On 9/8/15 at 9:30 AM, an observational tour was conducted in the ED. At 9:55 AM, a female and child were in room 3 with Pt. #5, but were not wearing a gown or gloves.

3. The clinical record for Pt. #5 was reviewed on 9/8/15 and included that Pt. #5 was a 43-year-old female presenting to the ED on 9/8/15 for an abscess to the left breast. The record included that Pt. #5 was placed on contact precautions for a history of Methicillin Resistant Staphylococcus Aureus (MRSA) in 2009.

4. On 9/8/15 at 9:45 AM, an interview was conducted with the Director of Nursing (E #2). E #2 stated the patient had MRSA three years ago and the sign was hung by nursing for precaution. E#2 further stated the visitors should have been asked to wear gowns and gloves.


E. Based on document review, observational tour, and interview, it was determined, for 1 of 1 point of testing device (blood glucose) in the peri-operative area (OR), the Hospital failed to ensure a glucose testing device was cleaned after use.

Findings include:

1. On 9/9/15 at approximately 2:15 PM, the policy titled "Point of Care Testing", without origination date, was reviewed. The policy required, "Procedure... 8. Safety... Handheld or portable testing devices must be cleaned and disinfected after each patient use."

2. On 9/9/15 at approximately 2:15 PM, the policy titled, "Glucose POC - Nova StatStrip," last revised on 12/1/13 was reviewed. The policy required, "VII. Maintenance...C. Disinfecting the Meter: 1. The Nova StatStrip must be disinfected after every patient test..."

3. On 9/8/15 at 12:15 PM, an observational tour was conducted in the OR. At 12:55 PM, in the OR holding area, a blood glucose testing device contained a spot of blood.

4. On 9/8/15 at 1:00 PM, an interview was conducted with the Surgery Manager (E #3). E #3 stated the testing device should have been cleansed.


F. Based on document review, observational tour, and interview, it was determined, for 1 of 1 Surgical Technician (E #5) opening sterile supplies in the peri-operative area (Endoscopies room 3), the Hospital failed to ensure the sterile field was maintained.

Findings include:

1. On 9/9/15 at approximately 2:25 PM, the AORN "Guidelines for Perioperative Practice 2015 Edition" was reviewed. The Guidelines required, "Sterile Technique Recommendation VI. Items introduced to the sterile field should be opened, dispensed, and transferred by methods that maintain the sterility and integrity of the item and the sterile field... VI.b. Items should be delivered to the sterile field in a manner that prevents un-sterile objects or unscrubbed team members from leaning or reaching over the sterile field... Microorganisms are shed from the skin of perioperative personnel..."

2. On 9/8/15 at 12:15 PM, an observational tour was conducted in the OR. At 1:40 PM, a Surgical Scrub Technician (E #5) was placing sterile items on the sterile field on the back table. E #5, with uncovered hands and arms, extended her hands and arms over the sterile field, instead of flipping items or handing them to a scrubbed/ gowned person.

3. On 9/8/15 at 1:00 PM, an interview was conducted with the Surgery Manager (E #3). E #3 stated the OR follows AORN Guidelines and bare arms and hands should not be extended over a sterile field.