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Based on observations and staff interviews the compliance of infection control policies and procedures for: aseptic technique for procedures before surgery; promotion of hand washing hygiene among staff; and, techniques for cleaning and disinfecting environmental surfaces, were not being followed.

Findings include:

1) During the observation of Patient #28 in the Ambulatory Surgery Unit (ASU) on 9/12/14 at approximately 12:35 P.M., licensed nurse #6 (LN #6) was seen setting up the IV start kit on the overbed table next to the patient's bedside. There was no barrier placed on top of the table and LN #6 did not wipe down/sanitize the table prior to placing the contents of the IV (intravenous) start kit onto the table top. The supplies included an angiocatheter, a peeled opsite dressing ("ready to use"), tape, tourniquet, etc. LN #6 also placed the patient's binder chart on the right half of the table, next to the IV supplies. Strips of tape were also placed along the edge of the overbed table by LN #6.

LN #6 did not wash or sanitize her hands prior to the IV insertion to the patient's left hand, although LN #6 had touched the chart, IV supplies and the patient before donning her gloves. After inserting the IV, LN #6 used two pieces of tape to secure the IV site. However, she could not find the opsite so she removed her gloves and stepped out. Just outside of the room, LN #6 opened a drawer from a cart to get another IV kit. Once back in the room, she donned a new pair of gloves. She did not hand wash nor sanitize her hands before doing so, but proceeded to open the kit to take out the opsite and cover the IV site.

LN #6 was asked if the overbed table was a clean area as the supplies were placed directly onto the table without a barrier. LN #6 stated, "Yes," but also said, "the chart is not clean. I did clean the table before." It was explained to LN #6 that she had touched items/objects between patient contact without sanitizing her hands prior to donning clean gloves. LN #6 did not realize she did not hand wash or sanitize her hands 1) prior to starting the IV, 2) after removing her gloves to obtain a new kit and 3) prior to donning another pair of gloves. At approximately 1:35 P.M. in the post-anesthesia care unit (PACU), LN #6 approached surveyors and said, "I know what you mean now," and acknowledged she touched items/objects without sanitizing prior to donning clean gloves.

Review of the facility's policy, "Hand Hygiene" (Policy No. IC-006, rev. 6/2014) and discussion with the Infection Control Nurse (LN #2) on 9/15/14, she pointed out under "Procedure...All personnel and Medical Staff should perform a 15-20 second hand wash to decontaminate hands;...Between: a. Tasks or procedures on same patient..."



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2) On 09/10/2014 from 1:00 PM observed licensed nurses, (LN), administer medications to patients on the Medical/Surgical (MS), unit of the hospital.

Observed LN#3 sanitize her hands and go into the medication room to obtain Pt#9's antibiotic solution in an intravenous "piggy-back," (IVP), 50 ml bag. The IVP bag was placed directly onto Pt#9's overbed table, while LN#3 went to wash her hands at the pt's bathroom sink. After LN#3 washed her hands she donned clean gloves and went to the electronic medication administration record, (e-MAR), bedside computer to input the drug being given. To input pt. information LN#3 used the handheld scanner to scan Pt#9's wristband, and the keyboard to mark the drug being given. After using the e-MAR, LN#3 connected the IV line to the IVP bag and hung it onto the IV pole. After making adjustments to the IV lines and pump, LN#3 removed the gloves and washed her hands.

Informed LN#3 of hand hygiene observation, and LN#3 stated that she washed her hands before donning gloves and after completed task. Discussed with LN#3 clean gloves no longer considered clean after touching inanimate objects like the e-Mar, bed rail and pt wristband. Also inquired if the overbed table was sanitized before placing the IVP bag onto the surface, and LN#3 stated that overbed tables are usually sanitized with Sani-cloth once a day.

3) Went to Pt##12's room to observe LN#4 administer medications. LN#4 had clean gloves on using the e-Mar keyboard and scanner to input medications being administered. The medication tab(s) were individually packaged and placed inside a paper medicine cup that sat on top of the e-Mar keyboard. As LN#4 used the e-Mar keyboard, the paper med cup fell onto it's side and the packaged tab(s) fell onto the keyboard. LN#4 continued using the keyboard and placed a gloved finger into the med cup to hold it upright. After using the keyboard, LN#4 opened each packaged tab to drop it into the med cup and provided the tab(s) to Pt#12.

Informed LN#4 that observed that she used gloves to dispense the tab(s), and LN#4 stated that she uses gloves for most tasks to protect herself. Informed LN#4 that it was observed that she placed a gloved finger into the med cup and then placed tab(s) into cup to dispense to the pt. LN#4 stated that she didn't realize she did that and stated, "Thank-you for telling me." Then informed LN#4 that she touched inanimate objects with clean gloves on, so technically not clean anymore.

Later at the nurses station, LN#4 inquired of surveyor, how other facility's perform hand hygiene when using the e-Mar to document medication administration and dispensing medications at the same time. Provided examples of hand hygiene to LN#4, but advised that should be following hand hygiene policy and procedure that this facility adheres to.

The facility's, hand hygiene, policy no. IC-006, revised 06/2014, provides that,... "IV. Procedure; A. All personnel and Medical Staff should perform a 15-20 seconds hand wash to decontaminate hands:.. 3. After:.. e. Contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient."


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4) An environmental tour was conducted with the Facilities Supervisor on 9/12/14 at 1:55 P.M. During the tour it was observed on the second floor that the roaming vital sign caddy which included a blood pressure cuff was dirty. LN#5 stated the expectation was for staff to clean/wipe down the apparatus after each patient's use.

The Medical Equipment, Disinfection And Sterilization Guidelines Infection Control policy was reviewed. Under the heading, "Blood Pressure Cuffs (electronic roaming) service level responsibilities," an X mark was in front of, "After each patient & when visibly soiled; After each patient on Enhanced Standard or Contact Isolation Precautions; Daily & when visibly soiled; and Weekly & when visibly soiled." LN#5's expectation concurred with the hospital's policy.

Based on record review, staff interview and a review of the Medical Staff Rules and Regulations, the facility failed to ensure non-emergent surgical patients had an updated examination (history and physical), including any changes in the patient's condition, which was completed and documented before the surgery for 4 of 33 patients in the case sample.

Findings include:

Patient #30 underwent an elective colonoscopy at the facility's surgical OR suite on 9/12/14. The procedure started at 8:40 A.M. and ended at 9:05 A.M. (inclusive of anesthesia time). Patient #31 also underwent an elective colonoscopy on 9/12/14, that started at 9:14 A.M. and ended at 9:44 A.M. Patient #32 underwent an elective esophagogastroduodenoscopy (EGD) and colonoscopy on 9/11/14, that started at 10:53 A.M. and ended at 11:33 A.M. Patient #33 underwent an EGD on 9/11/14, that started at 10:53 A.M. and ended at 11:27 A.M. Physician #1 was the surgeon for these four patients.

On 9/15/14, record review for Patients #30, #31, #32 and #33 found Physician #1 did not complete and/or document the updated examinations, including any changes to the patients' condition before performing the surgical procedures. This was verified by the OR Nurse Manager (LN #1) on 9/15/14 at 1:25 P.M. during a concurrent chart review. LN #1 stated that Physician #1, "should have" completed the H&P update and this physician did not.

It was also found the physician did not document any vital signs on the Ambulatory Surgery Unit Physician Record within the physical examination portion. LN #1 stated, "He hasn't been putting the vital signs for all these. He does it for all of it. He comes in the same day of the procedure. We need the stamper H&P, vital signs. The nurses have their own vital signs. Okay, I see that."

In addition, the Medical Staff Rules and Regulations produced on 9/10/14, stated on p. 76, "g. The documented update on the history and physical must confirm that the necessity for the procedure is still present. The history and physical including all updates and assessments, must be included in the patient's medical record, except in emergency cases, prior to surgery."

Based on record review, staff interview and a review of the facility's policy and procedure, the facility failed to ensure the pre-anesthesia evaluation record was complete in documentation for 2 of 33 patients in the case sample.

Findings include:

On 9/15/14, a concurrent record review with LN #1 was done for Patients #32 and #33's surgical records. It was found that Physician #2 did not complete the pre-procedure vital signs entry on the Preanesthesia Evaluation record. The patients' procedures were on 9/12/14 and Physician #2 was the anesthesiologist for both cases. LN #1 said she would be educating the physician on this.

In addition, the pre-procedure vital signs at the time of the preanesthesia evaluation would have been the patients' documented baseline vitals signs. The baseline vitals as a reference point, holds comparative value and per the facility's policy, "The Anesthesia Record" (No. NRS-ANS-016), it noted the vital signs are to be documented immediately before the start of anesthesia. Yet, for Physician #1's cases, the pre-procedure vital signs were omitted and only the vital signs prior to the start of anesthesia were documented. Additional record reviews however, found that other anesthesiologists completed their pre-procedure vital signs in addition to documenting the vital signs prior to the start of anesthesia.