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Based on interview and record review, the facility failed to follow its own Governing Body Bylaws by granting two physicians temporary privileges without governing body approval and failed to adopt Medical Staff Bylaws that gave only the governing body authority to grant medical staff privileges. These failures had the potential to affect all patients admitted to the facility. The facility census was 39.

Findings included:

1. Review of the facility's undated Board of Trustees Bylaws showed that the board shall appoint a medical staff and that the credentialing process may be expedited by a committee of at least two board members that may grant medical staff privileges before the next regular board meeting.

2. Review of the facility's Medical Staff Bylaws approved 09/24/12 showed that temporary privileges may be granted by the Chief Executive Officer (CEO) upon recommendation of the Chief of (Medical) Staff.

3. During an interview on 11/01/12 at approximately 2:00 PM, Staff C, CEO, stated that he had recently granted temporary privileges to two physicians as permitted in the Medical Staff Bylaws.

4. Review of a copy of a facility letter dated 08/30/12 and addressed to Staff LL, Physician, showed that the letter granted Staff LL temporary privileges. The letter was signed by the CEO and the Chief of Staff. The letter had no Board of Trustees signatures.

5. Review of a copy of a facility letter dated 10/10/12 and addressed to Staff MM, Physician, showed that the letter granted Staff MM temporary privileges. The letter was signed by the CEO and the Chief of Staff. The letter had no Board of Trustees signatures.

The failure to follow Governing Body Bylaws regarding Medical Staff appointments increased the potential for inadequate oversight by the Governing Body and thereby increased the potential for inadequate credentialing of medical staff.

Based on observation, interview, and record review, the facility failed to ensure that:
-Contact isolation precautions were followed for two patients (#26 and
#49) of two patients on isolation precautions;
-Hand hygiene was performed for seven patients (#6, #8, #26, #51, #52, #53 and #54) of seven patients observed;
-Two of three Operating Room (OR) table pads and three of five mattresses in pre-op/recovery area of the Cardiac Cath lab were maintained without tears to allow a cleanable surface.
-Trash receptacles in corridors were kept in covered containers; and
-Patient toilet rooms were maintained in good repair with easily cleanable surfaces;
These failures had the potential to affect all patients admitted to the facility by increasing their risk of infection. The facility census was 39.

Findings included:

1. Record review of the facility's policy titled, "Contact Precautions" dated 10/02, showed the following direction:
-Contact precautions are to be used for patients known or suspected to be infected, or colonized with epidemiologically important microorganisms. These microorganisms can be transmitted by direct contact with the patient, or through indirect contact with the patient's environment.
-In order to reduce the risk of transmission of microorganisms, contact precautions will be routinely practiced by all [facility] personnel whenever indicated. The following strategies for contact precautions as recommended by the Centers for Disease Control (CDC) will be adhered to in order to protect patients and personnel.
-Gloves must be worn when entering the room of a patient on contact precautions.
-Gloves are to be changed after having contact with infective material that may contain high concentrations of microorganisms.
-Gloves are to be removed before leaving the patient's environment.
-Perform hand hygiene immediately following glove removal.
-After performing hand hygiene, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room.
-Wear a gown when entering the room if it [is] anticipated that clothing will be soiled or have contact with the patient or the patient's environment.

Contact Precautions Signage states:
- Wear gloves when entering patient room.
- Wash hands with an antimicrobial agent immediately after glove removal.
- Wear gown when entering patient room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room.

2. Observation on 10/30/12 at 9:57 AM, showed Staff V, Physician, enter Patient #26's room. The room had a sign, which alerted staff of contact precautions. Staff V failed to wear gown and gloves in Patient #26's room.

During an interview on 10/30/12 at 10:15 AM, Staff V stated that he did not exam the patient's wound and he did not think that he needed to wear personal protective equipment (PPE which included a gown and gloves).

During an interview on 10/30/12 at 10:35 AM, Staff S, Registered Nurse (RN), stated that she told Staff V that as long as he did not touch Patient
#26, that he did not need to wear PPE.

Observation on 10/30/12 at approximately 4:20 PM showed Staff CC, Physician, enter Patient #26's room. Patient #26's room had a sign alerting staff of contact precautions. Staff CC failed to wear gown and gloves in Patient #26's room.

Observation on 10/30/12 at approximately 4:20 PM showed Staff S told Staff CC that as long as he did not touch anything in the room, he did not need to wear PPE.

3. During an interview on 10/30/12 at 4:30 PM, Staff S stated that the facility's policy was that an employee could enter a contact isolation room without PPE as long as nothing in the room was touched.

4. During an interview on 10/30/12 at approximately 4:45 PM, Staff AA, Physician and Chair of the Infection Control Committee, stated that everyone, including physicians, is to follow isolation precautions as posted on the door of patient rooms.

5. Record review of Patient #49's medical record showed the patient tested positive for Clostridium Difficile (C.diff - a difficult to treat and highly contagious infection) on 10/25/12.

Observation on 10/31/12 at 10:30 AM showed Patient #49's room was not identified as a contact isolation room. The following staff entered Patient #49's room without protective gloves or gowns:
-Staff F, Interim Director of the Senior Mental Health Unit, entered the patient's room and unlocked a closet door (touched door with bare hands and keys) and brushed up against the patient's walker (assists in walking) as she passed though the room;
-Staff JJ, Charge RN, entered and exited the patient's room with a rolling snack cart, which contained multiple snacks that are taken from patient room to patient room and other patient care areas;
-Staff KK, Licensed Clinical Social Worker (LCSW), began to enter the patient's room with a tub of candy before she was stopped by Staff I. Staff KK then took a piece of candy out of the tub and entered the patient's room, handing the candy to the patient and leaning on the bed where Staff KK's cloth lanyard (worn as and similar in appearance to a necklace - holds keys or displays a staff name badge) came into contact with the patient's bed sheets.

6. During an interview on 10/31/12 at 10:30 AM, Staff I, RN caring for Patient #49, stated that she was aware Patient #49 had C-diff but did not use a protective gown or gloves when she entered the patient's room or provided care to the patient.

7. During an interview on 10/31/12 at approximately 10:35 AM, Staff JJ stated that he was aware Patient #49 had C-diff but added that the patient had been on antibiotics for several days, "so she should be good" (indicating that she was no longer contagious).

8. During an interview on 10/31/12 at 11:00 AM, Staff FF, Infection Control Coordinator, stated the following:
-Patients with a diagnosis of C-diff are to be placed on contact isolation until three consecutive stool cultures (laboratory test) indicates that the patient is no longer positive for C-diff; [record review showed the patient had not had three negative stool cultures]
-Contact isolation includes the use of protective gloves and gown every time a staff member enters the patient's room;
-Contact isolation education is provided to all patient care staff when they are hired as well as annually;
-She was not made aware that Patient #49 was on contact isolation for C-diff or she would have ensured that specific measures were being followed by staff;
-When she is notified that a patient is on contact isolation with C-diff, she contacts housekeeping to inform them to perform specific cleaning steps to prevent additional contamination of the unit.

9. Record review of facility's policy titled, "Hand Hygiene" dated 03/2010, showed the following direction:
-Hand hygiene is considered the single most important procedure for preventing nosocomial infections (facility acquired).
-Indications for hand hygiene:
-Before and after contact with patients.
-After contact with inanimate environmental sources likely to be contaminated.
-After removing gloves.

10. Observation on 10/29/12 at 9:25 AM showed Staff U, Physician in Patient #8's room. Staff U left the patient room without performing hand hygiene.

11. During an interview on 10/29/12 at 9:45 AM, Staff U stated "You are right I am allergic to alcohol so I have to use soap and water, and no I did not use soap and water before I left the patient's room. I try to wash my hands before and after I see each patient."

12. Observation on 10/30/12 at approximately 4:25 PM showed Staff CC, Physician in Patient #26's room. Staff CC left the patient room without performing hand hygiene.

13. Observation on 10/29/12 at 9:35 AM, showed Staff I, Registered Nurse (RN), administered medication to Patient #6. She failed to perform hand hygiene after she:
-Lifted the lid of a trash can with her hand;
-Opened the staff break room door to exit, touched the door handle with her hand;
-Opened the Nurses Station door to exit, touched the door handle with her hand, before she administered the medications to the patient.

During an interview on 10/29/12 at 9:45 AM, Staff I stated that she realized that she didn't wash her hands after she touched the trash can lid and should have. Staff I added that she typically uses foaming hand sanitizer in the break room (requires touching two door handles after exit and before reaching the patient) before she administers patient medications.

14. Observation on 10/30/12 at 3:45 PM, showed Staff NN, Certified Nurse's Aide (CNA), in a patient dining area. She moved between Patients #51, #52, #53 and #54, and took vital signs (heart rate, blood pressure, etc.) but did not perform hand hygiene between patients.

During an interview on 10/30/12 at 4:00 PM, Staff NN stated that she washed her hands before she began taking patient vital signs, but did not wash her hands or use foaming hand sanitizer between patients, although she "probably should".

15. Record review of the facility's policy titled, "Operating Room Sanitation" dated 03/11, showed the following direction:
-The cleanliness of the operating room is maintained through consistent cleaning according to established routine.
-Patients will be provided with a safe, clean environment free from dust and organic debris.
-Preparation of the surgical suites will include a visual inspection of the room for cleanliness before the case carts, supplies and instrument sets are brought into the room.
-Areas outside the sterile field contaminated by organic debris will be cleaned as contamination occurs.
-Equipment and furniture used during the surgical procedure will be cleaned with tubercidal, hospital-grade chemical germicide.

Record review of the facility's undated policy titled, "Positioning in the OR" showed that positioning and transporting equipment should be inspected before use for functioning condition.

16. Observation on 10/30/12 from 2:45 PM to 3:45 PM showed pad on patient tables in OR rooms number two and three with torn covering on each table. Torn covers allow for moisture and body secretions to enter the pad and prevent complete cleaning of the table pad.

During an interview on 10/30/12 at 3:45 PM, Staff Z, RN Director of the Surgery Service, stated that pads needed to be replaced. Staff Z stated that it is the responsibility of the RN circulator in the rooms to check the integrity of the table pads.

17. Observation on 10/30/12 at 2:10 PM showed a mattress cushion in Holding Bay 4 of the Cardiac Catheter surgery suite with a split seam edge along the bottom front. Four other mattresses were examined and two of the remaining four had similar small spits at corners and seams that exposed tufts of the white cotton fiber backing, creating a potential repository for harboring bacteria and soils.

18. Observation on 10/29/12 at 9:35 AM showed an unattended 35 gallon capacity trash receptacle half full of trash without a lid or cover in the Suite-3480 SF corridor area between two procedure rooms labeled Procedure 1 and Procedure 2. No staff was in the area at the time.

19. Observation of the Senior Mental Health unit on 10/29/12 at 10:51 AM showed Room #109's bathroom in disrepair and poorly sealed surfaces-peeled cove base around the edge of the bathroom and next to the toilet. Several vinyl floor tiles in front of the toilet had buckled and separated (approximately one sixteenth of an inch separation) from each other to expose black adhesive between vinyl tiles. What appeared to be urine was between the cove base and wall and pooled on the floor around the toilet. A strong smell of urine permeated the air.

During interviews at the same date and time, Staffs AAA, Director of Safety and Support Services and BBB, Director of Plant Operations, stated that they had learned there was a male patient who habitually voided on the wall and floor instead of the toilet. Staff BBB said that, at the time of observation, no work order request had been submitted to reattach the cove base.











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