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Based on interview, record review and policy review the facility failed to ensure that one patient (#13) of one Medicare patient on the Mental Health Unit (MHU) received the Important Message From Medicare (IM) before discharge. This had the potential to affect all Medicare patients' on the MHU to make an informed decision regarding their discharge options. The facility census was 180 with 25 patients on the Mental Health Units.

Findings included:

1. Record review of the facility's policy titled, "An Important Message from Medicare," reviewed on 09/22/14, stated:
- "An important Message from Medicare must be provided to Medicare inpatients or representative within seven days of scheduled inpatient admission, within two calendar days of an unscheduled admission and again no sooner than two days of discharge.
- Follow-up copy of signed An Important Message from Medicare must be given no more than two days prior to discharge.
- Required for Medicare (Fee for Service Medicare or Managed Medicare) Acute Care and Mental Health Unit (MHU) inpatients.

2. During an interview on 12/01/14 at 3:50 PM, Patient #13 stated that she would be discharged the next day from the Mental Health Medical/Surgical Unit. Patient #13 stated that she had not received the IM in preparation for her discharge.

3. Record review of Patient #13's medical record did not show evidence that the IM had been given to the patient.

During concurrent interviews on 12/02/14 at 10:50 AM, Staff J, MHU Associate Team Leader; Staff K, Associate Administrator for Mental Health Services and Staff EE, Licensed Master of Social Work (LMSW), stated that the units had "been missing that piece" of the process and the MHU Medicare patients' had not received the IM as part of discharge planning.

Based on interview and policy review the facility failed to include written rationale for visitor restrictions in their policy for four areas (the intensive care unit [ICU], Level II nursery, Pediatrics [children], and the G.I. center [gastrointestinal procedures]) of seven areas identified with restrictions in the hospital. This could potentially result in a lack of understanding about when visitors could visit. The facility census was 180.

Findings included:

1. Record review of the facility's policy titled, "Visitor Guidelines," revised on 05/01/13, showed the following:
- Children under 12 are restricted and allowed only with Nurses/Physician approval in the ICU.
- The Critical Care doors are secured between the hours of 6:00 AM - 8:00 AM and 6:00 PM - 8:00 PM. Visitors are not encouraged.
- No one under the age of 12 will be allowed in the Level II nursery.
- No visitors under 16 years old except the patient's parent(s) may stay overnight, and infants and young children may be restricted as necessary in the Pediatric unit.
- Visitors are not allowed in the post procedure holding area until just prior to discharge in the G.I. center.

Facility staff failed to have written rationale for these restrictions in the policy.

2. During an interview on 12/02/14 at 10:50 AM in the ICU, the daughter of Patient #28 stated that when she left her mother's room at 4:45 AM she was told no visitors were allowed between 6:00 AM and 8:00 AM and she would need to wait in the visitor's waiting room until 8:00 AM. She was not aware of why visitors were restricted.

During an interview on 12/03/14 at 3:30 PM, Staff AA, Registered Nurse (RN), ICU Team Lead (TL), stated that:
- Her expectation was that the ICU caregivers (RNs) give patients and family members the ICU Visitors Guide pamphlet and explain to them the reason for restrictions on visiting hours was to maintain confidentiality of patient information due to bedside shift report (RN to RN patient report given at the bedside during change of shift and includes the patient) and patient assessments.
- The restrictions were loose guidelines and could be individualized.
- The ICU Visitors Guide pamphlet was old and needed to be updated to include the written rationale for visitor restrictions.

During an interview on 12/03/14 at 8:35 AM, Staff E, Advanced Practice Registered Nurse (APRN), TL for Women's and Children's Services stated that the Level II Nursery does not allow children under the age of 12 due to infection control reasons and the Pediatric Unit does not allow visitors under the age of 16 to spend the night with a pediatric patient unless the parent is under 16.

During an interview on 12/04/14 at 8:55 AM, Staff B, Regulatory Compliance, stated that she knew of the regulation requiring restriction rationale; however, did not realize their policy was not specific enough in certain areas.





















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Based on observation, interview, record review and policy review, the facility failed to provide nursing oversight and evaluation to contracted staff on the Dialysis (hemodialysis - the artificial process of eliminating waste and unwanted water from the blood when the kidneys can no longer perform the natural function) Unit. This failure put three patients (#8, #42 and #43) of three patients at risk during treatment by failing to follow professional standards of care and facility/contract policy. This had the potential to affect all dialysis patients seeking treatment to be at high risk for harm, complications or death. The facility census was 180 with three on the dialysis unit. The Dialysis Unit averages 4.5 patients daily and 136 patients monthly.

Findings included:

1. Record review of the contracted agreement titled, "Acute Services Agreement" dated 09/01/07 and renewed annually, stated the following: "The Company will be responsible for maintaining competent personnel, and will provide proof of competency to Hospital. Company and Staff performing Services on behalf of Company will meet safety and quality criteria based upon the Missouri Department of Health and other applicable regulatory agencies. Company will reasonably assist Hospital in obtaining all necessary regulatory approvals with respect to provision of Services in Hospital."

Record review of the published document by The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) NIH (National Institute of Health) Publication No. 14-4554 dated May 2014 and last updated July 23, 2014, "A vascular access is a hemodialysis patient's lifeline. A vascular access makes life-saving hemodialysis treatments possible. The access is a surgically created vein used to remove and return blood during hemodialysis. A vascular access lets large amounts of blood flow continuously during hemodialysis treatments to filter as much blood as possible per treatment. About a pint of blood flows through the machine every minute." This places patients at an extreme high risk of bleeding to death within seconds should the vascular access and tubing become dislodged during treatment.

Record review of the contracted policy titled, "ARTERIOVENOUS FISTULA (AVF) AND ARTERIOVENOUS GRAFT (AVG) VASCULAR ACCESS CARE," revised on 03/2014, showed the following: Cannulation (tube inserted into the vein) sites and blood tubing connections will be verified for accurate, patent and secure connections, and remain visible throughout the treatment.

2. During an interview on 12/04/14 at 10:20 AM, Staff K, RN, Associate Administrator for Mental Health Services, stated that the facility did not have a policy and/or procedure regarding vascular access sites.

3. Observation on 12/02/14 at 8:35 AM with Staff K, RN, Associate Administrator for Mental Health Services, showed three patients (#8, #42 and #43) receiving dialysis treatments on the unit. The unit was staffed with two contracted registered nurses (RN's) Staff NNN, Staff VVVV and Staff MMM, Licensed Practical Nurse (LPN), who provided direct patient care. The patients' vascular access sites were covered by bedding and not visible during the dialysis treatments.

During an interview on 12/02/14 at 8:55 AM, Staff K stated that she could not see the vascular access sites of the patients.

During an interview on 12/03/14 at 11:07 AM Staff NNN, RN, stated that she was a certified dialysis nurse for the contracted service. She stated that she didn't know that the vascular access site was to be uncovered and in view at all times during dialysis treatment. She stated she did not know if there was a policy and procedure.

During an interview on 12/04/14 at 8:34 AM, Staff QQQQ, Dialysis Administrator, stated that he visited the unit quarterly and by telephone weekly. He stated that he was not aware that it was required for the patients' vascular access sites to be visualized at all times during dialysis treatment.

Based on interview, policy and record review the facility failed to ensure policies for the Health Information Management Department (HIM) directed which staff had access to patient medical records. This deficient practice had the potential to permit unapproved or inappropriate persons to have access to medical records of an average daily census of 198. The facility census was 180.

Findings included:

1. Record review of the facilitys policy titled, "Health Information Services Scope of Service," revised on 12/04/13, did not specify who had access to patient medical records

2. During an interview on 12/02/14 at 2:35 PM, Staff FF, HIM Team Leader, stated that any unauthorized person would need a badge, medical record number and know the filing system to access a patient medical record.

During an interview on 12/02/14 at 3:00 PM, Staff A, Chief Nursing Officer (CNO), stated that there was not a policy stating who could have access to patient records but it was their practice to allow only HIM staff, Supervisors and Security access.

3. Record review of the facilitys undated document, "Reader Assignment," showed a list of employees who had access to the HIM. This list included maintenance who should not have access without supervision.

Based on observation, interview, record review and policy review, the facility failed to ensure that staff:
- Followed their policy for Hand Hygiene (to cleanse the hands with either soap and water or hand sanitizer) for 11 patients (#8, #20, #22, #24, #33, #40, #42, #43,#45, #53, and #56) out of 17 patients observed.
- Followed their policy for Catheterization (tube placed into the bladder to remove urine) Insertion, Removal and Care Of for one patient (#54 ) out of one patient observed that received catheter care.
- Followed their Oral Pharyngeal (pertaining to the mouth, nose and throat) Suctioning policy and used aseptic technique for one patient (#46) out of two patients observed during breathing treatments.
- Followed infection control measures when wearing PPE (Personal Protective Equipment) in the Dialysis Unit for three patients (#8, #42 and #43) out of four patients observed.
- Prevent possible cross contamination when food was placed in the Dietary walk-in cooler without covers and failed to prevent possible spoilage when opened items were placed in the Dietary refrigerator without dates of expiration.
- Removed mattresses with tears, tape, and adhesive residue that allowed for growth of bacteria from three areas (Operating Room [OR], Obstetric [OB] OR, and Post Anesthesia Care Unit [PACU]) out of five surgical areas observed for mattress integrity.
These failed practices increased the risk of infection and cross contamination and placed all patients and personnel at increased risk for hospital acquired infections (HAI) and contracting communicable diseases. The facility census was 180.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene," revised on 08/01/13, showed the following direction for staff:
- Handwashing with either a non-antimicrobial soap and water or an antimicrobial soap and water when hands are visibly dirty or contaminated with blood or other body fluids and before medication preparation.
- Hand antisepsis with an alcohol-based hand sanitizer when hands are not visibly soiled.
- Either handwashing with soap and water or hand antisepsis with alcohol-based hand sanitizer:
- Upon entering and leaving the patient's room: "Foam In, Foam Out".
- Before having direct contact with patients.
- After contact with patient's intact skin.
- After contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressings if hands are not visibly soiled.
- If moving from a contaminated body site to a clean body site during patient care.
- After contact with inanimate objects (such as urine measuring devices, bedpans, urinals and secretion collection apparatuses including medical equipment) in immediate vicinity of the patient.
- After contact with the patient's environment.
- After removing gloves.
- Remove gloves after caring for a patient.
- Do not wear the same pair of gloves for the care of more than one patient and do not wash gloves between uses with different patients.
- Change gloves during patient care when moving from a contaminated body site to a clean body site.
- Hand hygiene guidelines applied to, but not limited to those directly or indirectly caring for patients and includes caregivers, physicians, volunteers, licensed independent practitioners, ancillary personnel, home care and hospice, and all inpatient and outpatient clinics.

Record review of the Centers for Disease Control and Prevention (CDC) "Guideline for Hand Hygiene in Healthcare Settings" showed healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms (germs and bacteria that cause illness) to patients including:
- Before patient contact;
- After contact with blood, body fluids, or contaminated surfaces (even if gloves are worn);
- Before invasive procedures; and
- After removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings).

2. Observation on 12/02/14 at 8:20 AM showed Staff U, Registered Nurse (RN), administer an IV (intravenous, an apparatus used to administer a fluid or medication through a vein) push (a one time, rapid injection of medication into the blood stream ) medication to Patient #8. Following administration of the medication Staff U removed her gloves and typed the medication into the computer without first performing hand hygiene.

3. Observation on 12/02/14 at 8:40 AM showed Staff CC, RN, entered Patient #22's room to administer medication. Staff CC scanned the medication packets and the patient's armband, typed on the computer then put on gloves but did not perform hand hygiene before rubbing medication cream on the patient's arms and abdomen (stomach). She removed the gloves and put them in the trash but did not perform hand hygiene and put the medication back into the medication drawer on the medication cart.

4. Observation on 12/02/14 at 8:55 AM showed Staff DD, RN, entered Patient #24's room to administer medication. Staff DD performed hand hygiene then removed the medication packets from the medication drawer and scanned the medication packets. She opened the packets and dropped one of the medication pills on top of the computer table. She picked up the pill with her contaminated, ungloved fingers and put it in the medication cup and gave it to the patient.

During an interview on 12/02/14 at 9:00 AM, Staff DD, stated that she should have washed her hands and reordered another pill instead of the one she gave to the patient.

5. Observation with concurrent interview on 12/02/14 at 8:55 AM showed Staff LL, RN, touched Patient #33's hand to prep the IV site. Staff LL then put on gloves. Staff LL failed to perform hand hygiene after contact with the patient. Staff LL stated that she was unaware she failed to perform hand hygiene after patient contact and typically she would.

6. Observation on 12/02/14 at 10:30 AM, showed Staff OO Certified Surgical Technician (CST), Certified First Assist (CFA), cleaned surfaces in the operating room (OR) after Patient #56 had surgery and removed gloves and failed to perform hand hygiene. Staff OO then put on gloves and cleansed the outside of the OR lights and removed gloves. She failed to perform hand hygiene and picked up clean pillows to relocate them in the room.

During an interview on 12/02/14 at 10:45 AM, Staff OO stated that she failed to perform hand hygiene because she removed her gloves without touching her skin.

During an interview on 12/02/14 at 10:56 AM, Staff KK, Team Leader of OR, stated that he expected his staff to perform hand hygiene after removal of gloves.

7. Observation on 12/02/14 at 11:15 AM showed Staff DD entered Patient #40's room to perform a glucose test (A glucose meter [or glucometer] is a medical device for determining the approximate concentration of sugar in the blood). She picked up the scanner and scanned the patient's armband and typed on the computer. She put on gloves without performing hand hygiene, pricked the patient's finger and extracted enough blood for the test. She removed her gloves and put them in the trash and put her hand in her pocket to get a pen without performing hand hygiene.

During an interview on 12/02/14 at 11:32 AM, Staff K, RN, Associate Administrator for Mental Health Services, stated that she saw the nurse put on and take off her gloves without performing hand hygiene.

8. Observation on 12/02/14 at 10:55 AM showed Staff HH, RN, started an IV line, with gloves on, in Patient #20's right arm. Staff HH removed her gloves after the IV was placed, but failed to perform hand hygiene before placing clean gloves on to administer the medication.

9. Observation on 12/02/14 at approximately 2:15 PM showed Staff CCCC, RN, entered Patient #53's room to perform a surgical dressing change. Staff CCCC removed non-sterile gloves and did not perform hand hygiene after she removed the gloves and before she taped down the new dressing in place.

During an interview on 12/03/14 at approximately 9:00 AM, Staff CCCC stated that she did not perform hand hygiene after she removed gloves or before she taped down the clean dressing. Staff CCCC stated that the facility's policy and procedure directed staff to perform hand hygiene after gloves are removed. Staff CCCC stated that her thinking was that she was at the bedside and she would finish the dressing change by taping it in place and then use hand sanitizer after she had completed the task and before leaving the patient's room.

10. Observation in the bronchoscopy (procedure that allows a doctor to examine the inside of a person's airway and lungs) lab on 12/03/14 at 10:10 AM showed Staff X, RN, positioned Patient #45 on the procedure table, placed the patients arms at her sides and placed safety straps across her legs and chest. Staff X then proceeded to prepare and administer IV push medications without performing hand hygiene or putting on gloves and did not perform hand hygiene after administering the medications.

During an interview on 12/03/14 at 10:20 AM, Staff QQQ, Team Leader (TL), stated that the expectation was hand hygiene was to be performed before and after patient contact and gloves would be worn to administer IV Push medications.

During an interview on 12/03/14 at 3:17 PM, Staff HHHH, RN, Infection Prevention Specialist (IPS) and Staff IIII, RN, IPS stated that:
- The facility followed CDC guidelines for hand hygiene:
- They expected staff to follow the facility's Infection Control standards and policy and procedures.
- Gloves should be worn for administration of IV push medications.
- Hand hygiene should be performed before preparing and after administration of medications.
- Hand hygiene should be performed every time gloves were removed.

11. Record review of the facility's policy titled, "Catheterization: Intermittent/Indwelling/Urinary/Suprapubic Insertion, Removal, and Care of," reviewed on 08/25/14, directed facility staff to:
- Catheter Care:
- Perform hand hygiene and apply clean gloves.
- Explain procedure to patient.
- Maintain patients privacy.
- Cleanse urinary meatus (the entrance where the catheter enters the body) and length of catheter with warm, soapy cloth; from meatus moving away from the patient's body. Rinse and dry area.

12. Observation on 12/03/14 at 9:30 AM showed Staff JJJJ, RN, entered Patient #54's room to perform catheter care (cleansing the urinary meatus). Staff JJJJ washed the patient's labia (outer folds of skin) with a wash cloth with soap and cleaned down the catheter tubing. Staff JJJJ placed the used wash cloth with soap down on a towel on the bed. Staff JJJJ then used a wet wash cloth to cleanse the labia and down the catheter tubing. Staff JJJJ then picked up the same wash cloth with soap she had used to clean the patient's labia and washed the patient's meatus and cleaned down the catheter tubing from the meatus. Staff JJJJ did not use a different wash cloth with soap to wash the patient's meatus after she had washed the labia.

During an interview on 12/03/14 at 9:31 AM, Staff JJJJ stated that she used the same wash cloth with soap to cleanse the labia and the patient's meatus. Staff JJJJ stated that she used a different area on the wash cloth with soap to wash the patient's meatus.

During an interview on 12/03/14 at 3:17 PM, Staff HHHH, RN, IPS, stated that she would have to check with the educator to see how staff were instructed to perform catheter care.

During an interview on 12/04/14 at 11:35 AM, Staff A, RN, Chief Nursing Officer (CNO) stated that when staff provided catheter care, staff should use a different wash cloth with soap when cleansing a patient's labia and meatus. Staff A stated that she would expect staff to use a different wash cloth when cleansing different areas during catheter care and not use just one cloth with soap.

13. Record review of the facility's policy titled, "Suctioning: Oral Pharyngeal, Nasal Pharyngeal, (Adult or Pediatric)," dated 04/14, showed direction for staff using a tonsil tip (suction catheter used to clear secretions from the mouth) suction to change the catheter every 12 hours. If the tonsil tip becomes contaminated with contaminate objects other than oral secretions it is changed at that time. If the catheter becomes clogged or is withdrawn, clear with sterile water.

14. Observation of a breathing treatment on 12/03/14 at 11:00 AM on Patient #46 showed a suction tubing hanging on the wall with the suction tip covered with an opened package. Staff UUU, Respiratory Therapist (RT) removed the Oxygen tubing adjacent to the suction catheter and the package that covered the suction tip fell off and revealed the suction tip to be completely filled with a brown tinged mucous from tip to tip. Staff UUU removed the suction tubing and tip and placed them in the trash. During a concurrent interview Staff UUU stated that the suction tip should have been discarded in the biohazard container after it was used and not left hanging on the wall full of oral secretions.

During an interview on 12/03/14 at 11:15, Staff WWWW, Medical-Surgical, Telemetry Team Lead (TL), stated that the suction tip should have been cleaned by flushing with sterile water when used or thrown away and not left hanging in the room.

15. Record review of the facility's policy titled, "Isolation Guidelines," revised on 07/2012, showed the following direction to staff for PPE wear:
- PPE will be worn when the nature of the anticipated patient interaction indicates that contact with blood or body fluids may occur.
- PPEs will be removed and discarded upon leaving the patient room/cubicle or patient environment.
General principles of PPE use:
- Gloves: Do not wear the same pair of gloves for the care of more than one patient.
- Change gloves during patient care if the hands will move from a contaminated body-site to a clean body-site.
- Hand hygiene will be performed when gloves are removed.
Mask, Eye Protection, Face Shields:
- Wear a mask in combination with eye protection, or a face shield to protect mucous membranes of the eye, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions.
- Masks will be used only once and discarded.
- Masks are worn in such a way that both the nose and mouth are covered.
Gowns:
- Wear a gown for direct patient contact if the patient has uncontained secretions, excretions or during procedures and patient care activities that are likely to generate splashes or sprays of blood or body fluids.
- Remove gown and perform hand hygiene upon leaving the patient's environment.
- Do not reuse gowns, even for use with the same patient.

16. Observation on 12/03/14 at 8:35 AM showed Staff NNN, RN, performed direct patient care to two patients (#8 and #42) in the dialysis (hemodialysis is the artificial process of eliminating waste and unwanted water from the blood when the kidneys can no longer perform the natural function) unit. Both patients had already been attached to the dialysis machines and were in active hemodialysis treatment. Staff NNN had on a PPE (personal protective equipment) gown that snapped in the front and typed on a computer that stood between the two patients beds. Staff NNN moved freely between the patients without changing her gown and without performing hand hygiene. She would put on and take her off the gloves but did not perform hand hygiene between changes. She went over to Patient #8 and touched the patient's blood lines, then touched the dialysis machine. She removed her gloves, touched her nose, then washed her hands at the sink and hung the PPE gown on a hook at the opposite side of the room where the patient's beds were placed. Without wearing a PPE gown or gloves she went back between the patients' beds and typed on the computer. Staff MMM, Licensed Practical Nurse (LPN), put on a PPE gown and took ice chips to patient #42. She removed the PPE gown and hung it on a hook next to the contaminated gown of Staff NNN. Staff NNN did not put on a PPE gown but put one glove on her right hand and touched the blood lines of Patient #42. She took the glove off and placed it on the patient's bed side table. Staff NNN did not perform hand hygiene before or after the glove wear. Staff NNN walked across the room and put on the contaminated PPE gown she had previously worn and went to Patient #8. She put on gloves without performing hand hygiene and touched the blood lines of Patient #8 then touched the dialysis machine. She removed the gloves and typed on the computer in the middle of the patient beds. She walked to Patient #42 and touched the blood lines without performing hand hygiene or wearing gloves.

During an interview on 12/03/14 at 11:07 AM, Staff NNN, RN, stated that she was a Certified Dialysis Nurse. When asked about her contaminated gown and lack of hand hygiene she stated, "How do you expect me to take care of them if I can't touch the machine and then the patient? It is his machine!"

17. Observation on 12/03/14 at 8:35 AM showed Staff VVVV, RN, in an isolation area with Patient #43 to prepare for dialysis treatment. Staff VVVV prepared the patient and the machine and began the dialysis treatment but never put on a PPE mask (to protect her eyes, nose and mouth) even though there was a high risk of blood spatter or spurt during that time.

18. Record review of the facility's policy titled, "Food Safety," reviewed 03/21/14
directed staff to store opened food with a wrap or store in containers with a lid and to write expiration dates of food on foil, wrap or container lid.

19. Observation on 12/03/14 at 10:35 AM in the kitchen walk-in cooler showed five pans with green beans, corn, diced chicken, ground beef and fish with no covering.

During an interview on 12/03/14 at 10:45 AM, Staff VVV, Dietary staff, stated that he had placed the uncovered pans in the cooler for a few minutes while he was cleaning some equipment but they should have a cover.

20. Observation on 12/03/14 at 10:50 AM in a kitchen refrigerator showed two slices of cheese in plastic wrap, an opened quart of chocolate Ensure (a nutritional supplement), an open quart of ice cream milk, an open quart of half and half milk and a half pound of butter in plastic wrap which was not dated as to time of opening.

During an interview at 10:55 AM, Staff WWWW, Dietary Team Leader, stated that opened items should be dated.

21. Record review of the facility's policy titled, "Surgery, PACU, Surgery Center, OB Surgical Suites and Sterile Processing Department (SPD), revised on 05/2014, showed direction for facility staff to report any rips or tears in pads and mattresses to the OR Team Leader or Clinical Specialist.

22. Observation with concurrent interview on 12/02/14 at 11:30 AM in OR #5 showed the OR table with two tears on the underneath side of the head pad with two tears. One tear was approximately one inch long and one fourth inch wide. The second tear was approximately one fourth inch long. The facility failed to provide an OR pad on the OR table with a cleanable surface. Staff KK, Team Leader (TL) confirmed the tears were present.

23. Observation with concurrent interview on 12/02/14 at 12:15 PM in OB surgical suite #1 showed the underneath area of the OR pad on the head of the OR table and on the foot of the OR table each with an area approximately five inches long and two inches wide with an X in the center. Each of these areas was noted due to the tape and tape residue that made the outline of the area. The underneath of the middle OR pad showed a tear approximately an inch long and a fourth inch wide. The facility failed to provide an OR pad on the OR table with a cleanable surface. Staff KK confirmed the tape, tape residue, and tear were present.

During an interview on 12/02/14 at approximately 12:30 PM, Staff KK stated that there was not any quality monitoring in place to ensure all OR pads had a cleanable surface. Staff KK stated he expected his staff to visually inspect the table pads for tears, tape, and tape residue when the staff cleaned the pads.

24. Observation with concurrent interview on 12/02/14 at approximately 12:35 PM in OB surgical suite #2 showed the underneath area of the OR pad on the middle of the table with an area approximately five inches long and two inches wide with an X in the center. This area was noted due to the tape and tape residue that made the outline of the area. The facility failed to provide an OR pad on the OR table with a cleanable surface. Staff KK confirmed the presence of tape and tape residue.

During an interview on 12/02/14 at 12:45 PM Staff RR, OR Clinical Specialist, stated that he performed no quality monitoring to ensure OR table pads had a cleanable surface and he did not keep track of the pads that were torn or the pads he replaced that might show trends.

25. Observation with concurrent interview on 12/02/14 at 3:02 PM, in PACU bay #7 showed a cart with a pad on it. The underneath area of the pad had an approximately two inch in diameter area of tape and tape residue. The facility failed to provide a cart pad with a cleanable surface. Staff A, CNO, and Staff XXXX, TL PACU, both confirmed the presence of the tape and tape residue.




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