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Based on observation, interview and policy review, the hospital failed to:
- Identify and follow isolation precautions (techniques used to prevent the spread of highly contagious or high-risk infections) for six (#1, #2, #3, #4, #5 and #10) of seven isolation patients observed;
- Perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) when providing care for two patients (#2 and #8) of two patients observed;
- Label intravenous (IV, in the vein) dressings with the initiation date and IV tubing with the initiation date and time for seven patients (#1, #6, #8, #9, #11, #12 and #13) of seven patients; observed;
- Discard expired food and label food with an expiration date in the kitchen;
- Ensure staff consumed food in a designated area;
- Ensure refrigerators, freezers and microwaves were clean in three of five units observed; and
- Properly store soiled linen.

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.42 Condition of Participation (CoP): Infection Prevention and Control and Antibiotic Stewardship.

Please refer to A-0749.

Based on observation, interview and policy review, the hospital failed to:
- Identify and follow isolation precautions (techniques used to prevent the spread of highly contagious or high-risk infections) for six (#1, #2, #3, #4, #5 and #10) of seven isolation patients observed;
- Perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) when providing care for two patients (#2 and #8) of two patients observed;
- Label intravenous (IV, in the vein) dressings with the initiation date and IV tubing with the initiation date and time for seven patients (#1, #6, #8, #9, #11, #12 and #13) of seven patients observed;
- Discard expired food and label food with an expiration date in the kitchen;
- Ensure staff consumed food in a designated area;
- Ensure refrigerators, freezers and microwaves were clean in three of five units observed; and
- Properly store soiled linen.

Review of the hospital's policy titled, "Isolation Precautions (techniques used to prevent the spread of highly contagious or high-risk infections)," reviewed 05/21/25, showed:
- It is the responsibility of the provider, nurse and/or the Infection Preventionist to document/initiate the appropriate isolation (to separate those known or suspected to be contagious).
- All personnel are responsible for complying with and enforcing isolation precautions including
appropriate usage of personal protective equipment (PPE, such as gloves, gowns, goggles and masks).
- Patients with a previous history of resistant microorganism (organisms, such as bacteria, too small for the naked eye) or actively infected with multi-drug-resistant organism (MDRO; bacteria resistant to many antibiotics) will be placed on the appropriate category of transmission-based precautions unless cleared by Infection Prevention.
- Patient care processes should include measures to protect the patient from infection or colonization (the presence of bacteria on a body surface but not having any active illness or symptoms).
- PPE will be donned and doffed per Center for Disease Control and Prevention (CDC) guidelines.
- Instruct patient/family on the patient's specific category of isolation, isolation precautions related to specific category of isolation and the expectation of adherence to isolation guidelines by patient, family and visitors. Document education in the electronic health record (EHR).
- Contact (precautions used to minimize the risk of infection spreading through touching an infected person or contaminated object) plus precautions are designed for patients with diarrhea with an unknown/infectious etiology (cause) or known/suspected clostridium difficile (C-diff, a bacterium in the gastrointestinal tract that causes severe diarrhea, fever, nausea, and abdominal pain) infection.
- Transportation of patients on Contact Plus precautions requires the patient to don a clean gown and perform hand hygiene prior to transportation.

Review of Patient #1's medical record dated 08/22/25, showed on 08/22/25 at 5:08 PM, a nasal swab culture (a test to identify bacteria that may cause) showed positive for Methicillin-Resistant Staphylococcus aureus (MRSA, highly contagious bacteria, that causes infections in different parts of the body and is resistant to many common antibiotics).

Observation with concurrent interview on 08/25/25 at 1:40 PM, showed Patient #1's door did not have isolation signage or PPE available. He stated that he had a wound to his right thigh. He was not aware he was on isolation and had been hospitalized for three days.

Review of Patient #2's medical record dated 08/22/25, showed on 08/23/25 at 9:34 AM, a nasal swab culture showed positive for MRSA.

Observation on 08/25/25 at 2:05 PM, showed Patient #2's door did not have isolation signage or PPE available.

During an interview on 08/25/25 at 2:05 PM, Staff B, Registered Nurse (RN), stated that she did not know what kind of isolation Patient #2 was on. She agreed there was no door signage or PPE available.

Review of Patient #3's medical record dated 08/21/25, showed on 08/23/25 at 1:47 AM, a urine culture showed positive for Klebsiella pneumoniae (a type of bacteria that causes respiratory, urinary and wound infections) and extended spectrum beta-lactamase (ESBL, highly contagious bacteria, that causes infections in different parts of the body and is resistant to many common antibiotics).

Observation on 08/25/25 at 2:10 PM, showed Patient #3's door did not have isolation signage on the door.

Review of patient #4's medical record dated 08/18/25, showed on 08/19/25 at 8:37 PM, a nasal swab culture showed positive for MRSA.

Observation on 08/25/25 at 2:30 PM, showed Patient #4's door did not have isolation signage or PPE available.

Review of Patient #5's medical record dated 08/19/25, showed on 08/22/25 at 2:55 PM, an order was written for a C-diff culture. The specimen was not collected at the time of survey.

Observation on 08/25/25 at 2:33 PM, showed Patient #5's door did not have isolation signage or PPE available. Patient #5 was transferred for a computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan, the transport staff were not aware Patient #5 was on isolation.

During an interview on 08/25/25 at 2:34 PM, Staff D, RN, stated that staff should have worn PPE when caring for Patient #5, she did not know what kind of isolation Patient #5 was on.

Observation on 08/25/25 at 4:00 PM, showed Patient #10's door did not have PPE available.

During an interview on 08/26/25 at 11:00 AM, Staff Q, RN and concurrent medical record review of Patient #10's medical record dated 08/14/25, showed the patient was placed in isolation because he had a history of MDRO infections. Staff Q stated that any patient with a history of MDRO infections were permanently flagged in the medical record and automatically placed in contact isolation for each admission. She was aware the patient was on isolation and did not know why the PPE was not available.

During an interview on 08/27/25 at 1:00 PM, Staff BB, Chief Nursing Officer (CNO), stated that she expected appropriate signage and PPE supplies on the doors of isolation patients. She was surprised by the failure to provide signage, PPE and patient education. She expected staff to follow the hospital's isolation precautions policy.

During an interview on 08/27/25 at 10:40 AM, Staff W, Infection Preventionist, Staff X, Infection Prevention Regional Director and Staff Y, Infection Prevention System Director, stated that the process for identifying patient isolation was through their EHR. A patient was flagged for isolation if he/she had a history of a resistant bacteria and/or the laboratory created the notice in the EHR once a culture result was positive. The patient was expected to remain on isolation until the infection preventionist was able to review the patients EHR, if it was determined the isolation was not necessary the infection preventionist removed the flag from the EHR and notified the nurse to discontinue the isolation. Once a patient was identified for isolation the nurse placed the appropriate signage and PPE on the patient's door. When a patient on isolation was transferred outside of their room, the staff were to don PPE prior to room entry, clean the contact surfaces on the bed, assist the patient to perform hand hygiene and donning a clean gown. The staff were then to remove their PPE prior to exiting the room with the patient. The receiving department was expected to review the EHR for potential isolation precautions prior to the patient's arrival. They were surprised to know the survey team identified this opportunity for improvement. Their audits showed an 85 to 88 percent compliance for isolation identification and care over the previous two months.

During an interview on 08/25/25 at 1:55 PM, Staff A, Three West Manager, stated that isolation identification and compliance was one of the items she was working on as a manager. Staff A was not aware of the policy expectations for transferring patients on isolation to other units/departments.

Review of the hospital's policy titled, "Hand Hygiene," revised 07/24/24, showed SSM Health follows the Centers for Disease Control and Prevention (CDC) and the World Health Organization's (WHO) "Five Moments for Hand Hygiene" process:
- lmmediately before touching the patient and upon arrival to patient care area (Moment one);
- Before a clean/aseptic procedure (Moment two);
- After body fluid exposure risk (Moment three);
- After touching a patient (Moment four); and
- After touching a patient's surroundings (Moment five).
- Contact with patient objects (linens, equipment, furniture, etc.) is associated with hand contamination, even without having touched the patient.

Observation on 08/25/25 at 2:05 PM, on Three West, showed Staff A, Three West Manager, did not perform hand hygiene prior to entering Patient #2's room.

Observation on 08/25/25 at 2:08 PM, on Three West, showed Staff B, RN, did not perform hand hygiene prior to donning gloves or entering Patient #2's room.

Observation on 08/25/25 at 3:50 PM, on Two West, showed Staff Q, RN, disconnected the IV tubing from Patient #8, placed her dirty gloved hand into her pocket, answered the phone and failed to perform hand hygiene and glove change prior to reconnecting the IV tubing.

During an interview on 08/27/25 at 1:00 PM, Staff BB, CNO, stated that she expected staff to follow the policy for hand hygiene. The hospital followed the WHO guidelines for hand hygiene expectations.

During an interview on 08/27/25 at 10:40 AM, Staff W, Infection Preventionist, Staff X, Infection Prevention Regional Director and Staff Y, Infection Prevention System Director, stated that they expected staff to follow the World Health Organization's (WHO) five moments of hand hygiene. That expectation included staff performing hand hygiene prior to donning gloves and entering a patient's room.

Review of the hospital's policy titled, "Peripheral Intravenous Catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream), Management and Removal," revised 11/19/24, directed staff to label the IV dressing with the date the dressing is applied and label the IV tubing upon initiation with the date and time.

Observation on 08/25/25 at 1:40 PM, on Three West, showed Patient #1's IV dressing was not labeled with the initiation date and the IV tubing was not labeled with the initiation date and time.

Observation on 08/25/25 at 2:35 PM, on Five West, showed Patient #6's IV dressing was not labeled with the initiation date and the IV tubing was not labeled with the initiation date and time.

Observation on 08/25/25 at 3:50 PM, on Two West, showed Patient #8's IV dressing was not labeled with the initiation date and the IV tubing was not labeled with the initiation date and time.

Observation on 08/25/25 at 4:15 PM, on Two West, showed Patient #9's IV dressing was not labeled with the initiation date.

Observation on 08/26/25 at 9:30 AM, on Two West, showed Patient #11's IV dressing was not labeled with the initiation date and the IV tubing was not labeled with the initiation date and time.

Observation on 08/26/25 at 9:45 AM, on Two West, showed Patient #12's IV dressing was not labeled with the initiation date and the IV tubing was not labeled with the initiation date and time.

Observation on 08/26/25 at 9:50 AM, on Two West, showed Patient #13's IV dressing was not labeled with the initiation date and the IV tubing was not labeled with the initiation date and time.

During an interview on 08/27/25 at 1:00 PM, Staff BB, CNO, stated that she had been in the CNO role for two weeks and was not aware of the inconsistencies with IV dressing and tubing labeling. She expected staff to follow the policy for the labeling of IV dressings and tubing.

During an interview on 08/27/25 at 10:40 AM, Staff W, Infection Preventionist, Staff X, Infection Prevention Regional Director and Staff Y, Infection Prevention System Director, stated that they expected staff to follow the IV policy for labeling IV dressings and tubing. IV sites and tubing were to be labeled with date and start time. The IV policy was owned and developed by the evidence-based nursing practice committee.

Review of the hospital's policy titled, "Food Safety Product Labeling and Dating Guidelines," revised 02/08/23, showed:
- Ready to eat, time/temperature control for safety (TCS) food prepared in a food establishment and held longer than the subsequent meal period must be marked to indicate the date or day by which the food is to be consumed or discarded;
- Once a Non-TCS food has a documented use by date, policy requires the product to be consumed or discarded by that date; and
- All managers and food employees need to be trained and understand the operation's date marking policy and the dating/labeling system they use.

Observation with concurrent interview, on 08/26/25 at 12:52 PM, in the kitchen, showed:
- Expired Teriyaki Marinade in the kitchen;
- Thyme leaves with an unreadable expiration date;
- Expired cooked noodles in the walk-in cooler;
- Expired half and half cream;
- Open fries in the freezer with no label; and
- Open pasta in dry storage with no label.
Staff CC stated that the expired items should have been discarded, and the open items should have a use by date.

During an interview on 08/27/25 at 10:40 AM, Staff W, Infection Preventionist, Staff X, Infection Prevention Regional Director and Staff Y, Infection Prevention System Director, stated that they expected all food to be labeled with expiration dates and all expired food was discarded. There was a contracted service responsible for maintaining the expiration dates of food in the kitchen. Audits were performed quarterly to assess for compliance. They were not surprised the surveyors identified expired food in the kitchen. The system had identified an opportunity for improvement and had begun a pilot program for regulatory meetings and more frequent and focused audits at other hospitals in the region.

Review of the undated Occupational Safety and Health Administration (OSHA) guideline showed eating and drinking in work areas where blood or other potentially infectious materials may contaminate work surfaces, or the food itself is prohibited.

Although requested, the hospital failed to provide a policy on designated staff break areas.

Observation with concurrent interview on 08/26/25 at 1:32 PM, in the Family Birth Center, showed Staff Z, Scrub Technician, eating at the nurses' station. Staff Z stated that she was not supposed to eat at the nurses' station.

During an interview on 08/27/25 at 1:00 PM, Staff BB, CNO, stated that she hoped staff had time for a 30-minute meal break and wanted staff to use a designated area.

During an interview on 08/26/25 at 1:40 PM, Staff T, Family Birth Center Manager, stated that it did meet her expectations for staff to eat at the nurses' station if there was a "potential case" in the unit. Staff T stated that there were no "expected cases" in the unit at that time.

During an interview on 08/27/25 at 10:40 AM, Staff W, Infection Preventionist, Staff X, Infection Prevention Regional Director and Staff Y, Infection Prevention System Director, stated that they expected staff to follow the OSHA guidelines for staff meal breaks. The expectation was for no staff food or drink to be stored or consumed in clinical areas. Each unit had designated areas for food storage and consumption. It did not meet their expectations for a nurse manager to state that it was acceptable to consume food in the nurses' station based on the busyness of the unit.

Although requested, the hospital failed to provide a policy in regard to the cleaning of patient nourishment areas.

Observation on 08/25/25 at 2:40 PM, in the Five West Patient Nourishment Room, showed a refrigerator with visible spilled and dried food on the base and a freezer with visible drips of spilled popsicle on the base.

Observation on 08/26/25 at 12:45 PM, in the Three West Patient Nourishment Room, showed a dirty freezer with visible drips of spilled popsicle on the base.

Observation on 08/26/25 at 1:00 PM and 1:15 PM, in the Emergency Department (ED) Patient Nourishment Areas, showed two microwaves with drips of dried food on the inside tops, sides, backs and bases.

During an interview on 08/27/25 at 1:00 PM, Staff BB, CNO, stated that she expected refrigerators, freezers and microwaves were clean. She believed the food and nutrition department may be responsible for the cleaning of those items.

During an interview on 08/27/25 at 10:40 AM, Staff W, Infection Preventionist, Staff X, Infection Prevention Regional Director and Staff Y, Infection Prevention System Director, stated that they expected all refrigerators, freezers and microwaves to be clean and free of food spillage.

During an interview on 08/27/25 at 2:06 PM, Staff FF, Environmental Services (EVS) Director, stated that the cleaning of refrigerators and freezers was a shared responsibility between the food service and nursing staff. EVS cleaned microwaves weekly on Wednesdays.

Review of the undated OSHA guideline prohibited putting soiled or contaminated linens on the floor, requiring them to be bagged and containerized to prevent contamination and infection spread.

Although requested, the hospital failed to provide a policy on the storage and handling of dirty linens.

During a concurrent observation and interview on 8/26/25 at 12:20 PM, in the Dirty Linen Storage Area, showed approximately 20 bags of dirty linen on the floor. Staff DD, EVS Director, stated that too many bags of dirty linen were placed down the laundry chute which caused the linen cart to break and overflow dirty linen bags on the floor. The dirty linen should not be on the floor.


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