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Based on observation, interview, and record review, the Director of Food and Dietetic Services did not ensure the following:
(A) 1 of 1 dietary cook (Personnel #21) performed appropriate hand hygiene after taking her gloves off, and
(B) storage of 3 of 3 opened food items (1 package of broccoli and 2 packages of French fries) in the refrigerator and freezer sections were dated.

Findings Included:

During a tour in the dietary department the following was observed:

(A) On 2/5/15 at 11:20 AM Personnel #21 was observed taking off her soiled gloves and went on to get a pack of bread buns. She then put on a new pair of clean gloves and took 2 hamburger meat patties from a refrigerator and cooked them on a grill. She was not observed performing appropriate hand hygiene after taking off her gloves and in between tasks.

On 2/5/15 at approximately 11:30 AM, Personnel #15 was informed of the above findings and was asked for a policy and procedure. Personnel #15 confirmed dietary staff must wash hands after taking off gloves and/or when proceeding to do another task.

Policy: Operational Standard "Plastic Gloves" reviewed 1/12/15 required "3. Gloves are worn on clean hands; hands are washed before putting on gloves."

(B) On 2/5/15 at approximately 11:38 AM, the surveyor conducted a tour in the department's walk-in refrigerator and freezer sections with Personnel #20 (Interim Director of the Dietary Department). The surveyor observed one opened package of broccoli that was not dated in the refrigerator and two opened packages of French fries not dated in the freezer. Personnel #20 confirmed these findings.

Based on observation, interview, and record review, the Infection Control Officer did not implement policies governing control of infections in that:
(A) 1 of 3 physicians (Physician #9) wore a mask around his neck outside the restrictive area;
(B) 3 of 6 health care providers (Physician #7, Personnel #17, and Personnel #18) in OR #3 did not wear surgical masks appropriately; and
(C) 2 of 2 physicians (Physician #7 and #8) did not perform appropriate hand hygiene after removing their soiled gloves in operating room (OR) #3.

Findings included:

(A) With Personnel #1 and #16 a surveyor followed a tracer patient (Patient #26) on 2/4/15. At 9:05 AM Patient #26 was in the preoperative unit in bay #1. Beside bay #1 was a work station where a gentleman wearing scrubs was observed to have a surgical mask around his neck. Personnel #1 and #16 were asked who the gentleman was. Both personnel replied "He probably is an anesthesiologist." Personnel #1 and #16 confirmed the gentleman was wearing a mask around his neck outside the restrictive area. At approximately 10:20 AM, Personnel #11 informed the surveyor that the gentleman wearing a mask around his neck in the preoperative unit was Physician #9.

(B) A surveyor followed a tracer patient (Patient #26) to OR #3 with Personnel #11 and #16 on 2/4/15 at 10:10 AM. The surveyor observed Physician #7 tied her surgical mask's bottom strings loosely that on side view her nose and mouth could be seen. Personnel #17 and #18 were in OR #3. Personnel #17's and Personnel #18's surgical masks' bottom strings were not tied.

(C) On 2/4/15 at approximately 10:25 AM Physician #8 was observed to put on a pair of clean gloves. He assisted in transferring Patient #26 to the OR bed and provided direct patient care. He subsequently removed his used gloves and put on a clean pair of gloves. He was not observed performing appropriate hand hygiene after he removed his gloves.

After Physician #7 completed Patient #26's surgical procedure, she removed her soiled gloves. She then put on a pair of clean gloves and assisted in Patient #26's transfer to a gurney. She was not observed performing appropriate hand hygiene after she removed her gloves.

On 2/4/15 at 10:50 AM Personnel #11 was informed of the above findings. She confirmed the findings.

Policy "Hand Hygiene" revised 6/2013 required "K. Decontaminate hands after removing gloves. Note: Gloves are not a substitute for hand hygiene."

Policy "Surgical Attire and PPE (Protective Personal Equipment) reviewed 6/2011 required "IV...3. Masks...Nose and mouth must be covered and completely secured...prevent venting at the sides...Refrain from allowing masks to dangle around the neck...6. Leaving Surgical Services, Remove mask...and dispose in appropriate trash receptacles...Never wear soiled surgical attire outside the department..."

Based on observation, interview, and record review, the Hospital's surgical services failed to ensure the achievement and maintenance of high standards of medical practice and patient care for 1 of 1 patient (Patient #26) in that an alcohol based preparation used in sanitizing Patient #26's surgical site prior to the procedure was performed in a manner that some of the alcohol based preparation came in contact with a sponge-like egg crate that was not impervious. The egg crate was already placed at the back of the patient for support prior to the sanitizing of the surgical site.

Findings Included:

A tracer patient (Patient #26) was followed by a surveyor in OR #3 in the presence of Personnel #11 and #16 on 2/4/15 at approximately 10:10 AM. Patient #26 was scheduled for an incisional biopsy of the right shoulder mass.

The patient was positioned laterally. A sponge-like egg crate which was not impervious was placed at the patient's back for support. A nurse (Personnel #5) sanitized the patient's surgical site with "ChloraPrep" as ordered. (ChloraPrep was a name brand preoperative skin preparation that contained 2% chlorahexidine gluconate and 70% isopropyl alcohol.)

The surveyor observed some of the ChloraPrep solution came in contact with the egg crate.
The "ChloraPrep Safety Solution Data Sheet" indicated the solution was highly flammable. During the surgical procedure the surgeon (Physician #7) used an electric cautery device. The pooling of the ChloraPrep solution in the egg crate and in conjunction with the use of an electro-surgical unit placed Patient #26 at risk for fire.

In an interview on 2/4/15 at approximately 11:00 AM, Personnel #11 was informed of the above findings. She confirmed and agreed with the findings.

Policy "Surgical Skin Preparation" reviewed 4/2014 required "IV...h) Prevent antiseptic agent pooling beneath patients..."