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Based on medical record review and interview the hospital failed to include the order, and indication for urinary catheter insertion for 1 of 7 (# 14) patients that had a Foley catheter.

Findings include

On 06/20/12 at 9:40 AM, Surveyor #22198, RN Educator CC and RNS AA reviewed the medical record for Patient #14.

Patient #14 entered the Emergency Department (ED) on 06/18/2012, and then became unresponsive. The ED initiated a code and resuscitated Patient #14. After the code, Patient #14 was admitted in-patient to the ICU on a ventilator, with a femoral central line and a urinary catheter.

RN Educator CC and RNS AA confirmed to Surveyor #22198, there was no order found on Patient #14's medical record for a urinary catheter, and there was no indication for placement or reassessment for continued use.

Based on observation, staff interview, policies and standards of practice (SOP) review the ICP failed to ensure 5 of 5 areas (Hand Hygiene/PPE, Artificial Nails, Sterile Processing/Decontamination, Computer Key Board Cleaning and Respiratory Equipment and Single Use Items) had fully implemented infection control policies and procedures or had comprehensive policies and procedures that were updated and met current applicable SOP for IC.

Findings include:

Hand Hygiene/PPE

On 6/20/12 at 9:30 AM, Surveyor 29963 reviewed facility policy titled, Surveillance, Prevention and Control of Infection, Tab 6, Subject Laboratory, Policy # 6500_19010, dated 3/3/12, under II.J.5. "Handwashing or use of alcohol-based sanitizer must be done before and after patient contact."

On 6/20/12 at 9:30 AM, Surveyor 29963 reviewed facility policy titled, Organizational: Infection Prevention and Control, Standard Precautions, Policy # 50_06210, dated 3/3/12, under II. B. Gloves are worn 1. Whenever employees anticipate hand contact with blood, or body fluids. 2. When performing vascular access procedures. 3. When handling or touching contaminated items or surfaces. 4. Single use disposable gloves should be disposed of after use and not used as a substitute for washing hands. Gloves must be changed between tasks and hands decontaminated. 7. Gloves should be used as an adjunct to, not a substitute for, hand hygiene." II. 5.a. Gowning technique: Donning gown- tie waist strings."

On 6/18/12 at 10:00 AM, Surveyor 29963 reviewed facility policy titled, Hand Hygiene/Surgical Hand Antisepsis, Policy # 183, effective 10/10, under III. B. "The Aurora Health Care hand hygiene program complies with the CDC hand hygiene...". III. E. "For any given patient, cares shall start at the cleanest site and progress to the dirtiest site. When going from a dirty site to a clean site, hand hygiene will be performed between sites." III. G. 2. c. "Hand rub (Alcohol based waterless hand sanitizer) before and after patient contact. After contact with a patient's intact skin." g. "if moving from a contaminated body site to a clean body site during patient care." h. "after removing gloves." i. "after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient."

On 6/18/12 at 11:15 AM, Surveyor 29963 observed OT I in Pt. #3's room. OT I was wearing a gown and gloves as indicated by C Diff precautions posted outside the door. The gown was only tied around the neck, the body of the gown was left open exposing clothing while providing cares to pt. #3. OT I was then observed to remove gown and gloves, gel hands and exit room without washing hands. OT I reentered room without donning gown and gloves or completing hand hygiene. After entering isolation room with a rolling chair for pt. #3, OT I then donned gown and gloves. Sign hanging on door indicates gowns must be worn when entering the room and before leaving the room, Hand hygiene needs to be performed.

The above findings were confirmed with CNO A and RNM K at the completion of the observation.

On 6/18/12 at 2:05 PM, Surveyor 29963 observed LT L drawing blood form Pt. # 5. LT L entered pt. # 5's room with a tote filled with supplies to draw blood. LT L washed hands and gathered supplies from the tote and placed on bed of pt. LT L then put on gloves. LT L assessed and scrubbed hand of Pt. #5. LT L then went over to tote and grabbed supplies with contaminated gloved hand out of tote and dropped packaged item on the floor. LT L picked up item from the floor and placed in the corner of the tote. LT L then grabbed another item from tote and took to bedside. LT L then proceeded to draw blood with contaminated gloves, label tubes,and place them in a plastic bag on top of the supplies in the tote. LT L then removed gloves, washed hands and carried tote out of the room.

The above findings were confirmed with CNO A at the completion of the observation.

On 6/19/12 at 8:35 AM, Surveyor 29963 observed RN R providing oral medications to Pt. # 9. RN R entered room, washed hands and reviewed medication orders on the computer to administer medications to Pt. # 9. RN R attempted to obtain a B/P prior to medication administration but B/P cuff was not working. RN R then left the room without the benefit of hand hygiene. RN R reentered room with a blood pressure machine without benefit of hand hygiene and attached B/P cuff to Pt. # 9.

The above findings were confirmed with CNO A and RNM K at the completion of the observation.

On 6/19/12 at 11:43 AM, Surveyor 29963 observed RN T complete a dressing change to Pt. # 12's wound on buttocks. RN T donned a gown, gloves and mask. Pt. # 12 is on contact isolation due to MRSA in wound. RN T unhooked tubing attached to a wound VAC. Removed gloves and re-gloved to remove dressing on buttocks without the benefit of hand hygiene. RN T then removed intact dressing to buttocks, removed gloves and applied hand gel. RN T then removed rest of intact dressing, applied saline to assist with loosening of dressing and then removed gloves. RN T then opened the packages containing a scissors and dressings without the benefit of hand washing. RN T re-gloved and measured the wound tunnel with left hand index finger by inserting gloved hand into the tunnel, removed gloves and applied clean gloves without the benefit of hand hygiene.

On 6/19/12 at 12:30 PM, Surveyor 29963 observed RN T complete a dressing change on Pt. #13's wound right foot. RN T entered room, washed hands and put on gloves. RN T removed the intact dressing, removed gloves and opened the packages containing the clean dressings without the benefit of hand hygiene.

The above findings were confirmed with staff CC and RN T at completion of treatment.

Artificial Nails

On 6/18/12 at 10:00 AM, Surveyor 29963 reviewed facility policy titled, Hand Hygiene/Surgical Hand Antisepsis, Policy # 183, effective 10/10, under J. 1. "Artificial fingernails or extenders must not be worn when providing direct patient care."

On 6/18/12 at 2:05 PM, Surveyor 29963 observed LT L drawing blood form Pt. # 5. LT L noted to have an artificial overlay applied to finger nails. LT L confirmed the use of artificial nails to Surveyor 29963 in an interview.

The above findings were confirmed with CNO A on 6/20 12 at 2:00 PM.

On 06/19/12 at 10:00 AM during the tour of the Sterile Processing department Surveyor #22198 along with Director of Quality E and Surgical Director D confirmed the following observations:

Common surgical brushes (wire brushes and plastic bristled brushes) were worn and bent.

Sterile Processing/Decontamination

The Sterile Processing staff M was using pipe cleaners, without review of MFRs recommendations for appropriate cleaning devices to be used to ensure equipment is not damaged and would be cleaned appropriately.

Surgical Director D confirmed to Surveyor #22198, the hospital had no policy on common brushes used for the decontamination and cleaning of surgical equipment.

Computer Key Board Cleaning

On 06/19/12 during the OR tour and observation from 8:35 AM to 9:40 AM Surveyor #22198 watched the opening and clean up of a surgical case in OR #2.

During the transition of the break down and room cleaning from one surgical case to the next at 9:40 AM in OR #2 the 2 plastic computer (Pyxis and circulators) covers were not cleaned between cases.

Anesthesia had a laptop that was not covered. The laptop was turned on and open. This laptop was not cleaned between cases.

Patient Care Manager II removed the disposable plastic computer key board covers to validate the plastic cover had debris in the crevasses of the plastic covering.

Patient Care Manager II and RN G did not know how often the plastic key board covers were changed out.

In the OB C-section operating room a laptop computer with no covering was on the anesthesia cart.

Patient Care Manager II and RN G confirmed that the anesthesia laptop computers remained in the OR suite.

The stickers on the laptop were darkened and Patient Care Manager II and RN G did not know how often this laptop on the anesthesia cart was cleaned or how it was cleaned.

On 06/18/12 EVS Manager C confirmed to Surveyor #22198, between cases the plastic covers on the computers key boards are cleaned.

However, EVS Manager C confirmed, as Manager, C was not certain who was cleaning the laptops or how they were being cleaned.

A policy for changing the plastic computer covers was not obtained during this on-site survey.

Patient Care/Patient care Equipment

On 06/20/12 at 9:30 AM, after two observations of RT Z bagging used respiratory equipment to later be reused over a one week period, CNO A, Patient Care Manager II Director of Quality E and ICP F provided Surveyor #22198 with the most current policy entitled " Surveillance, Prevention and Control Infection TAB 1, Subject: Pulmonary Services " #c 3800_19010 dated 03/15/012, 3 pages long. Under Section F, A, II E and F confirmed the current policy failed to include the cleaning of respiratory equipment between use.

On 06/20/12 at 9:40 AM an oral hygiene observation for Patient #14 identified the following:

After oral care for Patient #14, RT Z then went to the ventilator where a bag hung taped to the handle of the ventilator and removed a Yankauer suction tip, took a suction hose that was laying over the top of the suction canister and suction wall apparatus and put them together, turned on the suction equipment and suctioned Patient #14's mouth.

When the tasks were complete, RT Z in reverse order removed the Yankauer suction tip from the tubing and put it back into the plastic bag taped to the ventilator handle, then wrapped the suction tubing back over the suction canister and apparatus.

The suction canister was 1/3 full of a dark fluid.

RT Z was leaving the room after the task was completed and Surveyor 22198 asked RT Z about the suction canisters and the suction tip.

RT Z confirmed to Surveyor #22198 that the used Yankauer suction tip and suction tubing is replaced weekly like the other RT equipment, and the suction canister would be emptied when it got gross or it was full.

On 06/20/12 at 12:20 PM CNO provided Surveyor #22198 with Page 672 of the hospital's Respiratory SOP (no additional information provided (name of SOP book or date of publishing) stated: #7. "Rinse catheter with water in a cup or basin until connection tubing is cleared of secretions." Also noted at the end of this segment on page 672 under rationale "clean suction tubing enhances delivery of set suction pressure. Prevents skin break down" "Reduce transmission of microorganisms".

On 06/20/12 at 12:20 PM CNO A provided Surveyor #22198 with the Yankauer Suction tip package that noted, "Single use". There was no policy for re-using single use items, and the hospital would be contacting the MFR.







29963

Based on observation, staff interviews, records, policies and SOPs reviews the ICP failed to maintain a comprehensive IC system for reporting, investigating and controlling infections for 8 of 9 services (Pain Clinic, OR, OB, L&D, Medical/Surgical, ICU Therapy and Laboratory).

Findings include:

On 06/18/12 at 8:30 AM during the Entrance conference for this survey the facility CNO A identified 9 total patient care areas and services, Pain Clinic, OR, OB, L&D, Medical/Surgical, ICU Therapy, Laboratory and Outpatient Services.

8 of 9 hospital services had findings in infection prevention and control related to hand hygiene, PPE, Medication, Patient Care/Patient Care Equipment and Environment.

Hand Hygiene:
Per Surveyor #22198

Surveyors were provided the most current Infection Control 22 page policy on 06/18/12 at 10:00 AM. " Infection prevention and Control Policy Manual: Organizational: Infection Prevention and Control " Policy #50_06210 dated 03/13/2012.

Page #2 notes under section B 4: " Singles use disposable gloves should be disposed of after use and not used as a substitute for hand washing. Gloves must be changed between tasks and hands decontaminated. (System Policy #183: Hand Hygiene/Surgical Antisepsis.) Remove gloves if soiled or torn; decontaminate hands and apply new gloves.

On 06/19/12 from 8:35 AM to 9:40 AM Surveyor #22198 made the following sterile surgical procedure observations:

Surveyor made five (5) observations of CRNA O removing and re-donning single use gloves between clean and dirty tasks. However, CRNA O failed to perform hand hygiene between each task and glove change.

RN Circulator FF was assisting OR staff with room clean up preparing for Patient #6 case completion. RN Circulator FF removed one glove and without hand hygiene picked up the ace wrap dressing for Patient #6 and handed it off for use.

Surveyor #22198 observed Surgical Technician (ST) GG and student ST HH removing gloves between clean and dirty tasks without hand hygiene.

Present during this observation were Surgical Director D and Director of Quality E, who confirmed donning gloves is not a substitute for hand hygiene..

Personal Protective Equipment (PPE):

Per Surveyor #22198

Surveyors were provided the most current Infection Control 22 page policy on 06/18/12 at 10:00 AM. " Infection prevention and Control Policy Manual: Organizational: Infection Prevention and Control " Policy #50_06210 dated 03/13/2012.

Page #3 section D Gowns and Protective Apparel 5 a. numbers 3 and 4 state: " Overlap back of gown with opening to the back so uniform is completely covered " . " Tie waste string " .

On 06/19/12 at 9:02 AM during an observation in OR #2 CRNA Q entered during a left knee arthroscopy to consult with CRNA O. CRNA Q failed to tie the mask. Surgical Director D. confirmed this observation. Also present was Director of Quality E.

On 06/19/12 at 10:00 AM during an observation of cleaning dirty surgical equipment and interview, Sterile Processing Technician M failed to tie the waste portion of the back of M ' s gown.

Medications:
On 06/20/12 at the exit conference (1:00 PM) ICP F confirmed to Surveyor #22198, that the previous standards of practice from Perry and Potter 7th edition 2010 and their current policy #50_06210 dated 03/13/2012 provided on 06/18/12 at 10:00 AM for Infection Control practices failed to include the current CDC Safe Injection Practice, that requires the cleaning of new medication vials' rubber septum prior to piercing it to obtain the medication content.



On 06/19/12 at 9:40 AM CRNA O drew up medication (propofol and lidocaine) into a syringe from new vials without cleaning the rubber septum first.

On 06/20/12 at 11:15 AM during the observation of a pain injection into the spinal space, RN Y opened up two vials of medication (xylocaine and kenolog) without first cleaning the septum. RN Y allowed the physician working on a sterile field to draw the 2 medications.

On 06/20/12 at 12:20 PM during an interview with Patient Care Manager II, Director of Quality E, Chief Nursing Officer A and ICP F told Surveyor #22198 that the hospital follows Perry and Potter 7th addition " Clinical Nursing Skills and Techniques " from 2010, that considers a vial sterile if newly opened .

However, ICP F confirmed to Surveyor #22198 at exit conference 06/20/12 at 1:05 PM, that as a part of the system wide hospital ' s initiative for " safe injection " practices, rolled out this year, the hospital does not allow any vials to be used without first cleaning the septum.

On 06/18/12 during a tour of the OB department Surveyor #22198 found an expired medication " Calcium Gluconate 10% 10 milliliter (ml) " in a locked drawer.

Patient Care Manager II and Director of CNO A confirmed it is the hospital ' s protocol to maintain medication within the computerized medication dispensing system (Pyxis) for safety and quality assurance.

The medication had expired in May 2012.

RN G confirmed to Surveyor #22198, that the Pyxis medication outdates are maintained by pharmacy.
RN G confirmed to Surveyor #22198, that the pharmacy would not be aware of medication kept in a drawer however, had the potential to be used on a patient.


Environment:
OR
On 06/19/12 from 8:35 AM to 9:40 AM Surveyor #22198 made these observations during a sterile surgical procedure:

Surgical Director D helped OR staff during the transfer of Patient #6 from a cart to the surgical table.

A blue plastic IV bag extender dropped on the floor.

Surgical Director D picked up the blue plastic extender off the floor, and placed it on counter/work surface where sterile supplies, dressings and the circulators paper work for this case were sitting.

Surveyor #22198 asked Surgical Director D why D did not throw the plastic hanger away. Surgical Director D told Surveyor #22198, that D considered the floor clean.

RN Circulator FF looking for an IV extender to lower the IV solution bag to allow the antibiotics to flow took the blue plastic IV bag extender dropped on the floor earlier by Surgical Director D. Surgical Director D stopped RN Circulator FF from using the extender.

Surgical Director D confirmed to Surveyor #22198, D should have tossed the extender, and acknowledged D understood the potential for cross contamination.

On 06/18/12 at 11:05 AM, ICP F provided Surveyor #22198 table defining the " ventilation requirements for areas affecting patient care in hospitals and outpatient facilities " from an APIC tool kit that states:
? " Sterile storage " :
? " Air movement relationship to adjacent area: Out "
? " Minimum total AC/Hr: 4 "
? " Relative Humidity: 70 (max) "

On 06/19/12 at 9:55 AM in the common corridor/hallway in the OR Surveyor #22198 observed surgical equipment and supplies stored on both sides of the corridor on racks open to the air co-mingled with clean equipment, lead aprons, cleaning supplies and the cleaning mop bucket that is used to mop the OR floors.

Surgical Director D told Surveyor #22198 that Joint Commission had just surveyed the hospital in February this year and told the hospital the storage of sterile equipment in a high traffic common corridor was acceptable.

Also noted and confirmed by D, that this corridor was the main corridor for all surgical traffic flow for both patients and staff.

On 06/19/12 at 11:15 AM review of the surgical sterile supply storage in common corridors with Surgical Director D, Director of Quality E and ICP F. ICP F and Surgical Director D acknowledged, sterile supplies and equipment required " a room " that meets the sterile environment requirements set by professional standards of practice that included maintenance of room temperature, humidity and air exchanges as well as limited/minimal traffic flow.

OB/L&D
On 06/18/12 Surveyor #22198 along with Patient Care Manager II and Director of Quality E toured and interview in the OB and L&D from 9:00 AM through 9:30 AM.

On 06/18/12 at 9:10 AM Surveyor#22198 along with Patient Care Manager II noted in 2 OB suites the bathrooms there were grout gaps (unsealed surface) that had the potential to harbor organisms because it was not a cleanable surface.

Cloth covered furniture was observed by Surveyor #22198 along with OB RN G, CNO A and Patient Care Manager II in the patient rooms of the OB and L&D units.

In L&D room #2, the cloth chair had a large lateral tear that extended ? of the length on the chair head rest.

On 06/18/12 Surveyor #22198 asked EVS Manager C " how cloth furniture was cleaned in a hospital setting? "

EVS Manager C confirmed to Surveyor #22198 it is not possible to completely clean cloth covered furniture to meet Infection Control SOP for cleaning in a healthcare setting. ICP F confirmed cloth furniture is not the SOP in a healthcare setting because the surface is not washable.

ICU
On 06/18/12 at 11:15 AM ICP F provided Surveyor #22198 with the APIC Table2 for "Ventilation Requirements for Areas Affecting Patient Care in Hospitals and Outpatient Facilities" stated the following:
Patient Corridors:
? Minimum total AC/Hr: 2

Medication and Clean workroom/clean holding room:
? Air movement relationship to adjacent area: Out
? Minimum total AC/Hr: 4

Critical and Intensive Care Units:
? Minimum air changes (AC) of outdoor air/hr: 2
? Minimum total AC/Hr: 6
? Recirculation by means of room units: No
? Relative Humidity (%): 30-60
? Design temperature (degrees F/C): 70-75 (21-24)

On 06/18/12 at 10:00 AM during a tour of the ICU surveyor noted the door to the clean supply room was propped open to a common hallway.

Patient Care Manager II told Surveyor #22198, that the hospital allowed the ICU department to prop open the clean supply door because the clean supply room was behind the nurse's station and the department was a closed department.

Surveyor #22198 confirmed with Patient Care Manager II the nurse's station was not an enclosed area and both the clean supply room and nurses station were open to a common hallway used by patients, visitors and staff.

On 06/20/12 at 9:50 AM Surveyor #22198 and Director of Quality observed the enclosed ICU unit had their unit door propped open to a main hospital common use corridor.

Patient Care Manager II told Surveyor #22198, that a room in the ICU was re-allocated for Respiratory clean and sterile equipment and storage.

The respiratory therapy supply room was carpeted throughout. Equipment was found on the floor and when picked up dust particles were seen in the air by Surveyor #22198. Patient Care Manager II who picked up the items off the floor in this newly designated storage room confirmed the findings.

Patient Care Manager II confirmed II was not aware if the Plant Operation Manager or hospital ICP were involved in the re-allocation of this new clean/sterile supply room for respiratory therapy.

On 06/18/12 at 11:05 AM in an interview ICP F confirmed to Surveyor #22198, that APIC has a defined requirement for ventilation, temperature and humidity for defined hospital spaces.

ICP F confirmed the ICU would not be able to maintain the ventilation/environmental specific requirement when propping open doors.

ICP F confirmed carpeting is not allowed in clean and sterile storage areas and was not aware of the newly allocated respiratory storage room.

On 06/20/12 at 9:40 AM an oral hygiene observation for Patient #14 identified the following:

While gloved RT Z, after swabbing Patient #14's mouth, went to the sink in Patient #14's room and using the same gloves used during oral care, turned on faucet, wet the swab and returned to Patient #14's bedside and re-inserted the swab into Patient #14's mouth and continued care. RTZ placed the used oral hygiene swab on the cart next to Patient #14's bed. RN Supervisor AA confirmed the cart where RT Z placed the used oral swab was a clean and sterile supply cart.

On 06/18/12 at 9:30 AM Surveyor#22198 along with OB RN G and Patient Care Manager II prepared to tour in the OB c-section suite however were required to don appropriate attire to enter a surgical area. When Surveyor #22198 entered the OR dressing room, observed the bathroom door was propped open to the dressing room and a bicycle was in the bathroom. OB RN G confirmed the bicycle belonged to G, and it was not hospital policy to bring a bicycle into the OB C-section area.

On 06/18/12 at 10:15 AM during a review of findings, CNO A and Patient Care Manager II confirmed to Surveyor #22198, that a bathroom door should not be propped open to the OR dressing room, and it is not hospital policy to allow staff to bring their bicycles into the hospital for storage.

Patient care Equipment/Supplies:
OR
On 06/19/12 at 9:40 AM in OR #2, equipment labeled " aquamantys " was in the suite from 08:35 AM through a sterile knee arthroscopy case (Patient # 6). At 9:40 AM OR suite #2 was cleaned and being prepared for the next case. The aquamantys remained un-cleaned and had dust and debris in the levers.

In OR Suite #2, two (2) containers of Cavi wipes for cleaning the OR suite between cases were open to air from 8:35 AM until 9:40 AM during an observation. When Surveyor left OR suite #2 one (1) container remained open to the air.

Surgical Director D confirmed to Surveyor #22198, the aquamantys equipment in the sterile OR was not clean. Surgical Director D confirmed to Surveyor #22198, surgical equipment requires cleaning at the start of each day, and between surgical cases.

On 06/19/12 at 9:40 AM in OR #2, the main OR light boom over the surgical table in OR was taped with surgical tape. At the same observation, a container had a paper sign taped on the top entitled "Co-mingled plastic."

On 06/19/12 at 9:40 AM in OR #2 the Bear Hugger (patient warming equipment) was dark and discolored in a circular pattern and had dark debris attached where taped had previously been placed.

Surgical Director D confirmed to Surveyor #22198, that paper and tape were porous and would not be a washable surface. Surgical Director D confirmed to Surveyor surgical tape should not be used to repair surgical equipment.

On 06/19/12 at 11:15 AM Surveyor reviewed surgical findings with Surgical Director D, Director of Quality E and ICP F. ICP F confirmed the disinfectant wipes (Cavi wipes) are to suppose to be sealed before and after use, or the pre-soaked disinfectant wipes dry out and are ineffective.

ICP F acknowledged paper signs were not wipeable surfaces, tape is not a cleanable surface, and these findings did not meet current accepted Infection Control standards of practice.

On 06/19/12 during the OR tour and observation from 8:35 AM to 9:40 AM Surveyor #22198 watched the opening and clean up of a surgical case in OR #2.

During the transition of the break down and room cleaning from one surgical case to the next at 9:40 AM in OR #2 the 2 plastic computer (Pyxis and circulators) covers were not cleaned between cases.

Anesthesia had a laptop that was not covered. The laptop was turned on and open. This laptop was not cleaned between cases.

On 06/19/12 at 10:00 AM during the tour of the Sterile Processing department Surveyor #22198 along with Director of Quality E and Surgical Director D confirmed the following observations:

Common surgical brushes (wire brushes and plastic bristled brushes) were worn and bent. The Sterile Processing staff M was using pipe cleaners, without review of manufacturer's recommendations for appropriate cleaning devices to be used to ensure equipment is not damaged and would be cleaned appropriately.

Surgical Director D confirmed the hospital had no policy on common brushes used for the decontamination and cleaning of surgical equipment.

Enzymatic cleaner labeled "Valsure" was used to manually clean dirty surgical instruments. Sterile Processing Technician M told Surveyor #22198 M manually dispensed the enzymatic cleaner into a sink compartment and filled the sink with water.

When Surveyor #22198 asked about the measuring process to ensure the enzymatic instrument cleaner was used per MFRs, M responded saying, it was a couple of pumps measuring was not required, and water measuring was not necessary since less water meant more chemical, and would be better to have a higher chemical concentration than a lower one.

Surveyor asked Sterile Processing Technician M if the enzymatic cleaner came with instructions and M read the automated dispensing instructions. Surveyor noted the manual dispensing process as follows: " Dilute 1 fluid ounce per gallon of warm water (8 milliliter (ml) per 1 liter). Activity increases as the water temperature increases. Soak minimum of 2-5 minutes. Soak time may be longer with dried on proteinaceous materials, or increase dilution to 2 fluid ounces per gallon of water (16 ml to 1 liter) to increase cleaning performance. Do not exceed 140 degrees F (60 degrees C).

Director of Quality E and Surgical Director D confirmed, that the MFR need to be followed.

OB
On 06/18/12 at 9:30 AM Surveyor#22198 observed 4 expired culture swabs during the tour in the OB c-section suite. Three (3) culture tubes expired in 2011 and 1 expired in 2010. Also present were OB RN G and Patient Care Manager II

The c-section room was clean and ready for a c-section noted by equipment and sterile supplies in the room.

Two pieces of cautery equipment housed on the same cart, had their front legs screwed onto the cart, which made it difficult for cleaning. Dust and debris noted under both pieces of cautery equipment.

A portable computer on wheels in the OB department and computers in C-section room had plastic covering their key boards for cleaning. Surveyor #22198 observed white debris between the concave key mold structures of the plastic. Patient Care Manager II removed the disposable plastic computer key board covers to validate the plastic cover had debris in the crevasses of the plastic covering. Patient Care Manager II and RN G did not know how often the plastic key board covers were changed out.

In the OB C-section operating room a laptop computer with no covering was on the anesthesia cart. Patient Care Manager II and RN G confirmed that the anesthesia lap top computers remained in the OR suite.

The stickers on the laptop were darkened and Patient Care Manager II and RN G did not know how often this laptop on the anesthesia cart was cleaned or how it was cleaned. On 06/18/12 EVS Manager C confirmed to Surveyor #22198, between cases the plastic covers on the computers key boards are cleaned. EVS Manager C confirmed, as Manager, C was not certain who was cleaning the lap tops or how they were being cleaned.

Policies for changing the plastic computer covers, or for cleaning uncovered laptop computers in a sterile environment, were not obtained during this on-site survey.

Medical Surgical

The American National Standards Institute (ANSI)/ International Safety Equipment Association (ISEA) ANSI/ISEA Z358.1-2009 standard:
" Maintenance - A plumbed eye wash station shall be activated weekly to verify proper operation " .

Eye washing station observation on tours conducted on 06/19/12 at 3:20 PM on the 2 West Medical and 2 West Surgical units and on 06/18/12 at 9:00 AM on the OB unit 3 eye wash stations connected to plumbing were observed to have white encrusting around the eye wash faucet head.

For the eye wash station on Medical 2 West the white debris encrusted the orifices of the water dispensing holes of the eye wash sprayer head.

The 2012 Medical 2 West maintenance log indicated:
March's weekly maintenance log was missing 3 of 4 weeks for inspection and flushing. April's weekly maintenance log was missing 3 of 4 weeks for inspection and flushing. May's weekly maintenance log was missing 2 of 4 weeks for inspection and flushing.
As of June 19th the date of the last observation (observation the beginning of week 3) weeks 1 and 2 (2 of 2) were missing for inspection and flushing.

Director of Quality E and CNO A confirmed the presence of foreign particles could result in further injury to the eye and debris would reduce or restrict the flow of the flushing fluid by obstructing nozzles.

ICU
Surveyor #22198 along with Patient Care Manager II and CNO A found during a tour and observation on 3rd floor OB and ICU between 9:00 AM and 10:10 AM, 2 Ice Machines that were on a cleaning schedule had white crusty, flaky material around the ice dispensing spout and in the catch tray below.

A pill crushing bowl and pummel in the ICU medication room had porous interior that made it a non-cleanable surface. White residue was noted on the bowl and pummel stick.

On 06/20/12 at 9:30 AM, CNO A, Patient Care Manager II Director of Quality E and ICP F provided Surveyor #22198 with the most current policy entitled " Surveillance, Prevention and Control Infection TAB 1, Subject: Pulmonary Services " dated 03/15/012 3 pages under Section F, failed to include the cleaning of respiratory equipment between use.

ICP F confirmed to Surveyor #22198 that MFR and IC SOP require cleaning and drying respiratory equipment between use.

On 06/20/12 at 9:20 AM during an observation on a respiratory therapy of " Duoneb " for Patient #11, Surveyor #22198 noted at the end of treatment RT Z emptied the medication chamber by dumping the remaining fluid into a waste receptacle, closing the chamber and placing the nebulizer equipment into a bag hung over the Oxygen (O2) valve.

RT Z confirmed to Surveyor #22198 that nebulizer equipment is changed out weekly, and there is no cleaning in between treatment.

The same respiratory therapy treatment and equipment storage observation occurred during an observation on Patient #14 on 06/20/12 at 9:50 AM.

On 06/20/12 at 9:50 AM an oral hygiene observation for Patient #14 identified the following:

After oral care for Patient #14, RT Z then went to the ventilator where a bag hung taped to the handle of the ventilator and removed a Yankauer suction tip, took a suction hose that was laying over the top of the suction canister and suction wall apparatus and put them together and turned on the suction equipment and suctioned Patient #14's mouth.

When the tasks were complete, RT Z in reverse order removed the Yankauer suction tip from the tubing and put it back into the plastic bag taped to the ventilator handle, then wrapped the suction tubing back over the suction canister and apparatus.

The suction canister was 1/3 full of a dark fluid.

RT Z was leaving the room after the task was completed and Surveyor 22198 asked RTZ about the suction canisters and the suction tip.

RT Z confirmed to Surveyor #22198 that the used Yankauer suction tip is replaced weekly like the other RT equipment, and the suction canister would be emptied when it got gross or it was full.

On 06/20/12 at 12:20 PM CNO provided Surveyor #22198 with the Yankauer Suction tip package that noted, " Single use " .


29963


Hand Hygiene

On 6/20/12 at 9:30 AM, Surveyor 29963 reviewed facility policy titled, Surveillance, Prevention and Control of Infection, Tab 6, Subject Laboratory, Policy # 6500_19010, dated 3/3/12, under II.J.5. "Handwashing or use of alcohol-based sanitizer must be done before and after patient contact."

On 6/20/12 at 9:30 AM, Surveyor 29963 reviewed facility policy titled, Organizational: Infection Prevention and Control, Standard Precautions, Policy # 50_06210, dated 3/3/12, under II. B. Gloves are worn 1. Whenever employees anticipate hand contact with blood, or body fluids. 2. When performing vascular access procedures. 3. When handling or touching contaminated items or surfaces. 4. Single use disposable gloves should be disposed of after use and not used as a substitute for washing hands. Gloves must be changed between tasks and hands decontaminated. 7. Gloves should be used as an adjunct to, not a substitute for, hand hygiene." II. 5.a. Gowning technique: Donning gown- tie waist strings."

On 6/18/12 at 10:00 AM, Surveyor 29963 reviewed facility policy titled, Hand Hygiene/Surgical Hand Antisepsis, Policy # 183, effective 10/10, under III. B. "The Aurora Health Care hand hygiene program complies with the CDC hand hygiene...". III. E. "For any given patient, cares shall start at the cleanest site and progress to the dirtiest site. When going from a dirty site to a clean site, hand hygiene will be performed between sites." III. G. 2. c. "Hand rub (Alcohol based waterless hand sanitizer) before and after patient contact. After contact with a patient's intact skin." g. "if moving from a contaminated body site to a clean body site during patient care." h. "after removing gloves." i. "after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient."


On 6/18/12 at 11:15 AM, Surveyor 29963 observed OT I in Pt. #3's room. OT I was wearing a gown and gloves as indicated by C Diff precautions posted outside the door. The gown was only tied around the neck, the body of the gown was left open exposing clothing while providing cares to pt. #3. OT I was then observed to remove gown and gloves, gel hands and exit room without washing hands. OT I reentered room without donning gown and gloves or completing hand hygiene. After entering isolation room with a rolling chair for pt. #3, OT I then donned gown and gloves.

The above findings were confirmed with CNO A and RNM K at the completion of the observation.

On 6/18/12 at 2:05 PM, Surveyor 29963 observed LT L drawing blood form Pt. # 5. LT L entered pt. #5's room with a tote filled with supplies to draw blood. LT L washed hands and gathered supplies from the tote and placed on bed of pt. LT L then put on gloves. LT L assessed and scrubbed hand of Pt. #5. LT L then went over to tote and grabbed supplies with contaminated gloved hand out of tote and dropped packaged item on the floor. LT L picked up item from the floor and placed in the corner of the tote. LT L then grabbed another item from tote and took to bedside. LT L then proceeded to draw blood with contaminated gloves, label tubes,and place them in a plastic bag on top of the supplies in the tote. LT L then removed gloves, washed hands and carried tote out of the room.

The above findings were confirmed with CNO A at the completion of the observation.

On 6/19/12 at 8:35 AM, Surveyor 29963 observed RN R providing oral medications to Pt. # 9. RN R entered room, washed hands and reviewed medication orders on the computer to administer medications to Pt. # 9. RN R attempted to obtain a B/P prior to medication administration but B/P cuff was not working. RN R then left the room without the benefit of hand hygiene. RN R reentered room with a blood pressure machine without benefit of hand hygiene and attached B/P cuff to Pt. # 9.

The above findings were confirmed with CNO A and RNM K at the completion of the observation.

On 6/19/12 at 11:43 AM, Surveyor 29963 observed RN T complete a dressing change to Pt. #12's wound on buttocks. RN T donned a gown, gloves and mask. Pt. #12 is on contact isolation due to MRSA in wound. RN T unhooked tubing attached to a wound VAC. Removed gloves and re-gloved to remove dressing on buttocks without the benefit of hand hygiene. RN T then removed intact dressing to buttocks, removed gloves and applied hand gel. RN T then removed rest of intact dressing, applied saline to assist with loosening of dressing and then removed gloves. RN T then opened the packages containing a scissors and dressings without the benefit of hand washing, re-gloved and measured the wound tunnel with left hand index finger by inserting gloved hand into the tunnel, removed gloves and applied clean gloves without the benefit of hand hygiene.

On 6/19/12 at 12:30 PM, Surveyor 29963 observed RN T complete a dressing change on Pt. #13's right foot wound. RN T entered room, washed hands and put on gloves. RN T removed the intact dressing, removed gloves and opened the packages containing the clean dressings without the benefit of hand hygiene.

The above findings were confirmed with staff CC and RN T at completion of treatment.

Medication Administration

On 6/18/12 at 2:30 PM, Surveyor 29963 observed RN U administer IV medication to Pt. # 10. RN U entered room, washed hands, and prepared medications. RN U applied alcohol to septum of vial, used syringe to draw out medication. RN U then inserted syringe into IV tubing and injected IV Zofran without the benefit of wearing gloves.

The above findings were confirmed with CNS EE at completion of medication administration.

On 6/19/12 at 8:35 AM, Surveyor 29963 observed RN R administer IV medication to Pt. # 9. RN R applied alcohol pad to IV port and administered saline through the IV without the benefit of wearing gloves.

The above findings were confirmed with CNO A and RNM K at the completion of the observation.

On 6/19/12 at 8:50 AM, Surveyor 29963 observed RN W administer IV medication to Pt. # 11. RN W removed medication from the Pyxis machine in the medication room in ICU, entered pt. room, and used hand gel. RN W then used a syringe to draw up the medication, rechecked medication on the computer at patient's bedside. Identification was checked and IV Ativan was given through IV without the benefit of using hand gel.

The above findings were confirmed with CNO A at the completion of medication administration.

On 6/19/12 at 9:55 AM, Surveyor 29963 interviewed CNO A who stated they follow the CDC recommendations and guidelines for safe injections.

On 6/19/12 at 8:50 AM, Surveyor 29963 observed RN V prepare oral medications for pt. # 10. RN V entered room without performing hand hygiene and verified medication to be given with orders in the computer. RN V checked her medications, placed the medication in individual packaging into the plastic medication cup. RN V then took medications cup to pt. #10. RN V then performed hand hygiene, as RN V opened the pill packages, and placed the pills into the same medication cup used to hold the medication, which is now contaminated. RN V offered Pt. # 10 (does not verbalize) a drink of milk from a straw. Pt. # 10 started to cough and proceeded to spit up thick phlegm. RN V decided to hold medication due to coughing and placed cup with opened medication into locked drawer in pt. # 10's room.

The above findings were confirmed by CNO A at the completion of the observation.

Patient Care and Patient Care Equipment

On 6/19/12 at 10:30 AM, Surveyor 29963 observed RT S complete a nebulizer treatment with Pt. # 8. RT S removed the nebulizer mask from pt. #8's face and immediately placed the mask in a plastic bag hanging on the wall by the oxygen hook-up without cleaning or rinsing the equipment.

On 6/19/12 at 10:45 AM, Surveyor 29963 observed RT S complete a nebulizer treatment with Pt. #7. Pt. #7 admitted to hospital with diagnosis of pneumonia. RT S removed the nebulizer mask from pt. #7's face and immediately placed the mask in a plastic bag hanging on the wall by the oxygen hook-up without cleaning or rinsing the equipment.

On 6/19/12 at 10:45 AM, Surveyor 29963 observed RT S used a stethoscope which was hanging around her neck to assess lung sounds of pt. #7 and then placed back around RT S's neck. The stethoscope remained around her neck while the contaminated diaphragm of the stethoscope rubbed on her uniform top. RT S used the stethoscope again to reassess lungs of Pt. #7 and prior to leaving the room, RT S did clean the diaphragm of the stethoscope with an alcohol wipe.

These findings were confirmed with CNO A on 6/20/12 at 11:00 AM.

On 6/20/12 at 9:10 AM, Surveyor 29963 observed CNA BB perform catheter care on Pt. # 15. CNA BB used a basin filled with water at bedside to complete peri care. Once bathing was complete CNA BB poured water down sink in Pt. #15's bathroom, potentially contaminating the sink with the water used to complete cares.

These findings were confirmed with CNO A and RNM K at the completion of the observation.

On 6/18/12 at 11:40 AM, Surveyor 29963 noted during a tour of Medical/Surgical unit that on door of room 254 hung a sign that stated "Contact precautions." The instructions on the sign states before leaving this room: remove gloves, remove gown, hand sanitize or wash hands. Per medical record review on 6/19/12 at 9:45 AM of Pt. #2 revealed diagnosis to rule out C-Diff. Precautions in this room need to require hand washing with soap and water.

These finding were confirmed with CNO A, RNM K, and RNS AA on 6/19/12 at 9:45 AM.

On 6/18/12 at 11:15 AM, Surveyor 29