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Based on review of the Allied Staff credential file, Medical Staff Bylaws and interview, it was determined the Medical Staff failed to examine credentials for one of one healthcare professional for Medical Staff membership and make recommendations to the Governing Body. The failure to examine credentials of prospective members of the Medical Staff prevented the hospital from assuring Physician Assistant #1 was legally authorized to practice within the State and provide services within their authorized scope of practice. The failed practice had the potential to affect all patients admitted to the hospital. The findings follow:

A. Review of the Medical Staff Bylaws (Rules and Regulations of the Professional staff St. Vincent Infirmary Medical Center/ST. Vincent Doctors Hospital) Section II, Clinical Privileges, Section G, ALLIED HEALTH PROFESSIONAL PRIVILEGES on 11/30/12 at 1330 revealed "Any member of the PROFESSIONAL STAFF may be assisted by his/her employee in the professional practice of his/her speciality provided PRIVILEGES have been granted by the Credentials Committee, the Medical Executive Committee, and the BOARD of directors in accordance with the GUIDELINES, RULES, AND REGULATIONS FOR NON-HOSPITAL EMPLOYED INDIVIDUALS REQUESTING PRIVILEGES AS ALLIED HEALTH PROFESSIONALS."

B. Review of the credential file revealed Physician Assistant #1 was hired on 03/08/12 as a Physician Assistant; a Medical Assistant job description was signed on 11/21/12; the file lacked evidence of current licensure and there was no evidence Physician Assistant #1 was credentialed or granted privileges to practice in the facility.

C. Registered Nurse #1 confirmed in an interview the progress notes transcribed on 07/14/12 and 07/15/12 in the clinical record for Patient #1 were transcribed by Physician Assistant #1.

D. During an interview on 11/30/12 at 1350, the Chief Nursing Officer stated Physician Assistant #1 was not licensed as a Physician Assistant. The Regulatory Officer stated Physician Assistant #1 was not credentialed or granted privileges to practice at the hospital.

Based on observation and document review it was determined the facility failed to maintain the overall hospital environment in a clean and sanitary manner. Failure to maintain a clean and sanitary environment created the potential for the transmission of infection among patients and staff. The failed practice had the potential to all patients admitted to the facility. The findings were:

Tour of the Neurosurgery Unit was conducted on 11/28/12 from 0940-1115 with the Regulatory Officer. The following was observed and confirmed at the time of observation.

1. Patient Room #5001 unoccupied and identified as clean and ready for patient occupancy revealed the entrance door to the room contained multiple nicks exposing the porous wood underneath; the mattress contained frayed edges and tears in the surface compromising the integrity; the closet which was utilized for storage of 19 pillows and a tri-fold bedside fall mat contained an accumulation of dust, the bedside fall mat contained dirt and grime; the integrity was impaired in eight of the 19 pillows and four of the 19 pillows were soiled with a brown substance; approximately six inches of formica was missing from the closet exterior surface exposing the porous wood beneath; the bedside toilet contained an accumulation of rust; the telephone receiver contained an unknown greasy substance; and the base of an intravenous pole contained rust.

2. Patient Room #5002 unoccupied and identified as clean and ready for patient occupancy revealed the entrance door to the room contained multiple nicks exposing the porous wood; the mattress contained frayed edges and tears in the surface compromising the integrity; the closet which was utilized for the storage of 17 pillows and a tri-fold bedside fall mat contained an accumulation of dust; the bedside fall mat contained dirt and grime; of the 17 pillows, ten were observed to have breaks in the surface comprising the integrity; the toilet base contained a buildup of dirt and grime; the over bed light pull cord contained a dark brown substance that extended down the pull cord; two intravenous pole stored in the room contained rust on the base; the telephone and call light had an accumulation of a dark brown unknown substance; two chairs stored in the room were soiled.

3. Patient Room #5011 unoccupied and identified as clean and ready for patient occupancy contained a circulating fan with an accumulation of dirt on the fan blades; the mattress contained frayed edges and tears in the surface compromising the integrity; the bed side rails contained a buildup of dirt and grime; an intravenous pole stored in the room contained a rusty base; and the over bed light fixture and pull cord was stained with a dark brown unknown substance.

4. Patient Room #5014, #5015, #5017, #5020 and #5021 were occupied and identified by the Unit Manager as carpeted seizure rooms. Four (#5014, #5017, #5020 and #5021) of five carpeted seizure rooms contained multiple darken stains and black tar-type stains on the carpet. Room #5017 contained a circulating fan with an accumulation of dirt on the fan blades

5. Review of the housekeeping frequency schedule #13 shampoo carpets revealed top shampoo or heavy deep extraction as needed. The Director of Housekeeping confirmed the carpeted rooms contained multiple stains on the carpet and needed shampooing. The Director of Housekeeping could not confirm the last time the carpet was shampooed.

Based on observation, Infection Control Manual review and interviews, it was determined the facility failed to assure a clean and sanitary environment to prevent the spread of infection. Failure to maintain a clean and sanitary environment created the potential for the transmission of infection among patients and staff. The failed practice had the potential to all patients admitted to the facility. The findings were:

Tour of the Neurosurgery Unit was conducted on 11/28/12 from 0940-1115 with the Regulatory Officer. The following was observed and confirmed at the time of observation.

Review of the Infection Prevention Equipment Cleaning Guidelines policy revealed "Reusable equipment such as Thermometers, Blood Pressure Cuffs and pulse Oximeter Probes, Stethoscopes ... must be cleaned between each patient use".

Patient Care Technician #1 failed to clean the thermometer, blood pressure cuff and pulse Oximeter probe between use for three of three patients observed.

Patient Care Technician #2 failed to clean the thermometer between use for three of three patients observed.