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Based on clinical record review and interview, it was determined the facility failed to ensure an Important Message from Medicare was provided to seven (#3, #4, #6, #8, #11, #12, and #14) of eight (#3, #4, #6-#8, #11, #12, and #14) Medicare inpatients within 48 hours of admission to the facility. The failed practice created the potential for patients to be uninformed of their rights and could affect any Medicare patient admitted to the facility. Findings follow.

A. Review of clinical records revealed Patient #3, #4, #6, #8, #11, #12, and #14 were not provided with an Important Message from Medicare within 48 hours of admission.
B. During an interview on 01/22/15 at 1445, the Regulatory Officer confirmed the Important Message from Medicare was not provided to the patient within 48 hours of admission.

Based on clinical record review and interview, it was determined the facility failed to ensure percentage of meal intake was documented at every meal for four (#4, and #6-#8) of eight (#1-#8) inpatients. The failed practice did not allow the dietitian knowledge of the patients food intake and diet tolerance, and created the potential to affect any patient in the facility. Findings follow.

A. Review of clinical records revealed the following:
1) Patient #4-from 01/20/15 through 01/22/15, intake percentage was not documented for 4 of 5 meals
2) Patient #6-from 01/18/15 through 01/22/15, intake percentage was not documented for 8 of 11 meals
3) Patient #7-from 1/17/15 through 01/22/15, intake percentage was not documented for 5 of 10 meals
4) Patient #8-from 01/20/15 through 01/22/15, intake percentage was not documented for 4 of 7 meals
B. During the time of clinical record review on 01/22/15 from 1010-1025, Registered Nurse #1 confirmed the meal percentages were not documented.

Based on observation and interview, it was determined one of one Respiratory Therapist (#1) observed, failed to change her gloves after touching a contaminated surface (trash can) and before delivering the breathing treatment for a patient on contact isolation. Failure to change gloves after touching a contaminated surface did not assure cross contamination to the patient did not occur and was likely to affect all patients admitted to the facility. Findings follow:

A. On observation, accompanied by the Vice President of Patient Care on 01/21/15 at 1008, Respiratory Therapist (RT) #1 donned a gown and gloves and entered Room #18 in the Medical Intensive Care Unit to perform a ventilator check and breathing treatment for Patient #16 who was on Contact Isolation precautions. RT #1 typed information into the computer and prepared medication for a breathing treatment. At 1012, she picked up a trash can (dirty) from the right side of the patient's bed and moved it to the left side of the bed. She then proceeded to perform a ventilator check and breathing treatment (clean) to the patient. She did not change her gloves after touching the trash can and prior to conducting the ventilator check and breathing treatment.
B. Findings identified as A were verified during interview with the Vice President of Patient Care at the time of observation.


Based on observation and interview, it was determined one of one Registered Nurse (#2) observed, failed to assure blood glucose test strips were not contamination from touching additional strips when removing one from the test strip canister. Failure to assure blood glucose test strips were free of contamination did not assure uncontaminated test strips were available for patient care. The failed practice was likely to affect all patients undergoing glucose testing in the facility. Findings follow:

A. On observation, accompanied by the Vice President of Patient Care on 01/21/15 at 1030, Registered Nurse (RN) #2, donned examination gloves, entered Room #6 in the Medical Intensive Care Unit and placed a blood glucometer onto a computer station. She then typed information into the computer and scanned the patient's arm band. Next, she opened a canister of blood glucose test strips, put her index finger into the canister and removed a test strip, contaminating the remaining strips. She closed the canister, placed it back in the glucose testing supply holder and proceeded to test the patient's blood.
B. Findings identified as A were verified during interview with the Vice President of Patient Care at the time of observation.


Based on observation, review of policies and procedures, review of Isolation Rooms Scheduled Maintenance, review of Station Census and interview, it was determined the facility failed to monitor one of one (Room #9) occupied negative pressure isolation room on a daily basis. Failure to monitor an occupied negative pressure isolation room on a daily basis did not assure the room remained negative pressure throughout the duration of the patient's isolation. The failed practice was likely to affect all patients, staff and visitors who were in close proximity to the negative pressure isolation room. Findings follow:

A. On observation, accompanied by the Vice President of Patient Care on 01/21/15 at 1050, in the Medical Intensive Care Unit (MICU), a sign was posted on the door of Room #9 which indicated the patient was on Airborne Isolation precautions. When asked, Registered Nurse #6 explained the patient's diagnosis was tuberculosis.
B. During interview with Registered Nurse #6 on 01/21/15 at 1050 when asked if Room #9 was monitored for negative pressure, he explained maintenance personnel monitored the room.
C. During interview on 01/22/15 at 1310 with the Lead HVAC (Heating, Ventilating and Air Conditioning) Technician when asked if the MICU Isolation Rooms had been monitored for negative pressure, he stated "yes" and presented documentation titled, "Isolation Rooms Scheduled Maintenance" for January 2014 with evidence the room had been monitored on 01/28/(14). There was no evidence daily monitoring had been conducted. When asked how often the room was monitored, he stated "monthly".
D. Review of Station Census ICU (Intensive Care Unit) Medical ICU presented by the Regulatory Officer on 01/21/15 at 0945 revealed Room #9 was occupied by Patient #9 admitted 01/03/15 with a LOS (length of stay) of 18 days.
E. Review of policy, "Infection Prevention: Standard and Isolation Precautions" presented by the Regulatory Officer on 01/22/15 at 0830 revealed, "Engineering Controls must be monitored daily when in use. Engineering should check air control changes and negative pressure daily while in use for airborne precautions."


Based on observation, review of policies and procedures and interview, it was determined one of one (#4) physician failed to undergo fit testing prior to examining a patient on Airborne Isolation precautions. Failure to undergo fit testing did not assure a proper fit of protective equipment (N-95 respirator mask) to reduce the risk of exposure to airborne isolates. The failed practice was likely to affect all persons required to wear N-95 respirator masks in the facility. Findings follow:

A. On observation, accompanied by the Vice President of Patient Care on 01/21/15 at 1050, in the Medical Intensive Care Unit, Physician #4, wearing a blue cup type mask, was observed using a stethoscope to listen to Patient #9's chest. A sign posted on the door of the patient's room indicated Airborne Isolation Precautions. At the time of observation, Registered Nurse (RN) #6 explained Patient #9 had a diagnosis of tuberculosis.
B. Review of policy, "Infection Prevention: Standard and Isolation Precautions" presented by the Regulatory Officer on 01/22/14 at 0830, revealed "Airborne Precautions: This isolation category requires employee use of an N-95 respiratory mask upon entering the patient's room."
C. During interview with the Infection Preventionist on 01/22/15 at 1340, he described N-95 respirator masks as being duckbilled and yellow-orange in color. When asked if the facility had any blue colored N-95 masks, he stated, "there may have been some ordered." When asked who undergoes fit testing, the Infection Preventionist stated, "all personnel who work with isolation patients have to be fit tested or they cannot work in the area."
D. On 01/22/15 at 1443, after requesting the fit test documentation for Physician #4, the Regulatory Officer stated, "he's a new doctor and we don't have a fit test record for him."


Based on observation and interview, it was determined one of one Registered Nurse (#4) observed, failed to perform hand hygiene prior to Foley catheter placement in a surgical patient. Failure to perform hand hygiene prior to Foley catheter placement did not assure hands were disinfected prior to performing a task requiring hand antisepsis. The failed practice was likely to affect all patients undergoing Foley catheter placement in the facility. Findings follow:

A. On observation, accompanied by the Vice President of Patient Care on 01/21/15 at 1320 in Operating Room #35, Registered Nurse (RN) #4 had on purple colored exam gloves. RN #4 pulled back the blanket on the surgical patient, exposing the lower half of the patient's body. RN #4 then removed the purple colored gloves without performing hand hygiene afterward. She then opened a Foley kit and placed the kit onto the legs of the patient. She removed the sterile gloves from the kit and donned them and then proceeded to perform Foley catheter placement. She did not perform hand hygiene prior to donning the sterile gloves and placing the Foley catheter.
B. Findings listed as A were verified during interview with the Vice President of Patient Care at the time of observation.


Based on observation and interview, it was determined staff did not remove Ioban (disposable product which leaves a sticky residue) or tape between patient use for one of one Mizuhosi Spine table observed. Failure to assure adhesive products containing sticky residue were removed from the table's components prior to disinfecting did not assure the table was sanitized between patient use. The failed practice was likely to affect all patients undergoing surgical procedures in the facility. Findings follow:

A. On observation, accompanied by the Vice President of Patient Care on 01/21/15 at 1345, Registered Nurse #5 cleaned the Mizuhosi Spine table with disinfectant wipes during room turnover. The Mizuhosi Spine table had six black upholstered pads used to position a patient for spine procedures. The pads were covered with Ioban as identified by Registered Nurse #5. Ioban was a disposable adhesive product which had a sticky residue and could not be disinfected. On the frame of the table was white tape which had a sticky residue and could not be disinfected.
B. Findings listed as A were verified during interview with the Vice President of Patient Care at the time of observation.


Based on observation and interview, it was determined the facility failed to assure cross contamination did not occur from using a bottom-to-top process to clean one of one (Room #28) Operating Room observed. Failure to assure cross contamination did not occur while cleaning operating rooms did not assure equipment was free of contaminants and was likely to affect all patients undergoing surgery in the facility. Findings follow:

A. On observation, accompanied by the Vice President of Patient Care on 01/21/15 at 1345 during room turnover, Registered Nurse (RN) #5 picked a black mat up off the floor (bottom) next to the Mizuhosi Spine table in Operating Room #28, wiped both sides of the mat with a disinfectant wipe, and then laid the mat back down on the floor next to blood droplets on the floor. He then wiped the frame (top) of the Mizuhosi Spine table with the same wipe, contaminating the frame by cleaning it with the wipe used to clean the mat (bottom).
B. Findings listed as A were verified during interview with the Vice President of Patient Care at the time of observation.


Based on observation, review of Kimberly-Clark Manufacturer's Directions for Use and interview, it was determined the facility failed to assure wrapped sterile instrument pans were not stacked in one (Operating Room Sterile Core) of two (Operating Room Sterile Core and Central Sterilization Department) areas. Failure to assure wrapped sterile instrument pans were not stacked did not assure the sterility was not compromised from crushing. The failed practice was likely to affect all patients undergoing surgery in the facility. Findings follow:

A. On observation, accompanied by Registered Nurse #3, on 01/21/15 at 1300, there was greater than 30 pans of wrapped sterile instruments stacked on wire shelves located in the Operating Room Sterile Core and available for patient use.
B. Review of Kimberly-Clark Manufacturer's Directions for Use, revealed "Caution: Do not stack trays. Stacking trays can result in damage to the wrap caused by undue pressure from the weight."
C. During interview with the Supervisor of Central Sterile on 01/22/15 at 1040, she explained wrapped sterile instruments should never be stacked.


Based on observation and interview, it was determined the facility failed to assure contaminated surgical instruments were covered for transport in one of one (Room #28) Operating Room observed. Failure to cover contaminated instruments did not assure cross contamination did not occur from instruments coming in contact with supplies or staff during transport to the decontamination area in Central Sterilization. The failed practice was likely to affect all persons working in the Operating Room and Central Sterilization. Findings follow:

A. On observation, accompanied by the Vice President of Patient Care on 01/21/15 at 1335, in Operating Room #28, a metal cart containing bloody instruments used on a spine procedure was not covered and was taken out of the room by Surgical Technician #2. Observation at the time revealed the instrument cart was pushed down a back hallway. When asked where the instruments would be taken, Registered Nurse #5 explained the cart would be taken to the dumbwaiter which delivered dirty instruments to Central Sterilization for reprocessing.
B. Findings listed as A were verified during interview with the Vice President of Patient Care at the time of observation.


Based on observation, review of policies and procedures and interview, it was determined the facility failed to assure four of four (Physician #3, Certified Registered Nurse Anesthetist #1, Surgical Technician #1, and Registered Nurse #3) staff followed facility policy to cover all hair while in a restricted area (Operating Room #35). Failure to cover all hair while in a restricted area did not assure contamination from falling hair/ hair pathogens from coming in contact with sterile supplies. The failed practice was likely to affect all surgical patients in the facility. Findings follow:

A. On observation, accompanied by the Vice President of Patient Care on 01/21/15 at 1300, Registered Nurse (RN) #3 and Surgical Technician (ST) #1 were in Operating Room (OR) #35 preparing for a surgical procedure. There was an open sterile field containing sterile instruments and supplies set up on a back table. Both RN #3 and ST #1 wore skull caps which did not completely cover their hair, leaving 3-4 inches of hair exposed on the backs of their heads. At 1303, Certified Registered Nurse Anesthetist (CRNA) #1 entered OR #35 wearing a skull cap which did not completely cover his hair, leaving 2-3 inches of hair exposed on the back of his head. At 1335, Physician #3 entered OR #35 wearing a skull cap which did not completely cover his hair, leaving 2-3 inches of hair exposed on the back of his head.
B. Review of policy, "Perioperative: Surgical Attire" presented by the Regulatory Officer on 01/22/15 at 0830, revealed, "Low-lint surgical head cover (preferably bouffant and hood style "cap") is to be worn to cover all head and facial hair including side burns when in the semi-restricted and restricted areas of the operating room."
C. Findings listed as A were verified during interview with the Vice President of Patient Care at the time of observation.


Based on observation and interview, it was determined two of two (Radiology Technologist #1 and Certified Registered Nurse Anesthetist #1) staff failed to disinfect medication vials after opening and before withdrawing the medication from the vials. Failure to disinfect medication vials after opening did not assure contamination did not occur from touching the rubber septum when removing the protective cap and before withdrawing the medication. The failed practice was likely to affect all patients requiring injectable medication in the facility. Findings follow:

A. On observation, accompanied by the Vice President of Patient Care on 01/21/15 at 1306, Certified Registered Nurse Anesthetist #1 removed the protective cap off a vial of Invance 1 gr (gram) and spiked (sticking a "spike" type device/needle into a vial) it to add NaCl (normal saline), reconstituting the Invance. He did not disinfect the rubber septum prior to inserting the spike.
B. Findings listed as A were verified during interview with the Vice President of Patient Care at the time of observation.
C. On observation, accompanied by Registered Nurse #1 on 01/22/15 at 1355, Radiology Technologist #1 removed the plastic caps from vials of Isovue, Sodium Bicarbonate, Lidocaine and Kenalog in preparation for a facet injection procedure in Special Procedures Room #4. Radiology Technologist #1 did not disinfect the rubber septums of any of the medications prior to Radiology Technologist #2 withdrawing the contents of the vials using separate syringes and needles for each vial.
D. Findings listed as C were verified during interview with Registered Nurse #1 at the time of observation.


Based on observation and interview, it was determined one of one Radiology Technologist (#1) observed, failed to assure a sterile skin preparation (prep) device (Duraprep) was not contaminated by walking from one room to the next and back while holding the skin prep device. Failure to assure a skin prep device was not contaminated prior to use did not assure the sterility of the prep device was not compromised. The failed practice was likely to affect all patients undergoing special radiologic procedures in the facility. Findings follow:

A. On observation, accompanied by Registered Nurse #1 on 01/22/15 at 1350 in Special Procedures Room #4, Radiology Technologist #1 opened a package containing a sterile Duraprep skin prep device. While carrying the device (exposed/unprotected) in her left hand, she walked into the Computer Control Room, used her right hand to type information into a computer, then walked back into Special Procedures Room #4 and, using the same prep device, prepped the back of a patient lying prone on the table beneath a C-Arm fluoroscopy machine.
B. Findings listed as A were verified during interview with Registered Nurse #1 at the time of observation.


Based on observation and interview, it was determined one of one Physician (#1) observed failed to assure cross contamination did not occur by not removing his gown worn in Angiography Room #2 for a procedure (contaminated) and entering the Computer Control Room (clean); and did not perform hand hygiene after removing gloves and prior to donning sterile gloves. Failure to assure cross contamination did not occur from wearing contaminated garments into a clean area did not protect staff from coming in contact with contaminants; and failure to perform hand hygiene after removing gloves and prior to donning sterile gloves did not assure hands were disinfected prior to performing a task requiring hand antisepsis. The failed practices were likely to affect all staff working in the Radiology Department. Findings follow:

A. On observation, accompanied by Registered Nurse #1 on 01/22/15 at 1415, Physician #1 was wearing a sterile gown and gloves and performing an angiographic procedure in Angiography Room #2. At 1420, Physician #1 walked out of Angiography Room #2 wearing the sterile gown (contaminated) and gloves (contaminated) and entered the Computer Control Room (clean). He stood with his hands tucked under his arms and looked at a computer monitor. He then removed his gloves and sat down at the computer still wearing his gown. At 1425, Physician #1 walked back into Angiography Room #2 and donned new gloves without performing hand hygiene.
B. Findings listed as A were verified during interview with Registered Nurse #1 at the time of observation.