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Based on observation, interview, record review and policy review, the facility's Governing Body failed to effectively provide oversight in the conduct of the facility when:
- Patients were not provided information about their patient's rights for four patients (#4, #5, #12 and #30). (A-0117)
- Patients or the patient's representative were not provided an address or telephone number in order to lodge a grievance or complaint with the State Agency (SA) for two patients (#2 and #30). (A-0118)
- The grievance committee was not more than one person. (A-0119)
- The facility's policy time frames for the provision of a response for patient grievances was not followed for two patient grievances (#31 and #32 ). (A-0122)
- The facility did not provide a written notice of resolution with actions taken for one patient grievance (#31). (A-0123)
- All facility departments and contracted services were not included in the facility-wide Quality Assessment and Performance Improvement (QAPI) Program with data collection, analysis, monitoring and reporting to provide patients with quality care and safety. (A-0273)
- An ongoing program for improved health outcomes to maintain quality improvement with contracted services was not conducted. (A-0309)
- Infection control practices to prevent infections and communicable diseases was not safe. (A-749)
- Patient paper medical records weren't protected against unauthorized access (by individuals who were not providing care for those patients). (A-441)
The facility census was 21.

The severity and cumulative effect of these systemic practices resulted in the facility being out of compliance with 42 CFR 482.12 Condition of Participation: Governing Body and resulted in the facility's failure to ensure quality health care and safety.

The facility census was 21.

Based on interview, record review and policy review, the hospital's Governing Body failed to ensure that all contracted services were included in the Quality Assessment and Performance Improvement (QAPI) Program in order to measure the effectiveness and safety of services. This had the potential to put all patients at risk for substandard quality care and compromise their health and safety. The facility census was 21.

Findings included:

1. Record review of the facility's document titled "Quality Assessment/Performance Improvement Plan," reviewed 06/26/18, stated that the executive responsibility for the performance improvement program rests with the facility's Board of Trustees (also known as the Governing Body) through the Medical Staff.

Record review of the list of contracted services provided by the facility showed the following contracted services that affected patient care:
- Radiology Service;
- Laboratory Services;
- Pharmacist;
- After Hours Pharmacy Services;
- Anesthesiology Medical Director;
- ED Physicians;
- Orthopedic Services;
- EKG Interpretations;
- Stress Testing Supervision; and
- Sleep Lab.

During an interview on 09/25/18 at 3:00 PM, Staff J, Director of QAPI, stated that QAPI was not submitted by the contracted service as a separate entity to the facility-wide QAPI program.

The facility did not ensure that all contracted services were included in the facility-wide QAPI.

Based on observation, interview, record review and policy review, the facility failed to:
- Ensure patients were provided information about their patient's rights for four patients (#4, #5, #12 and #30). (A-0117)
- Ensure that two patients (#2 and #30) or the patient's representative were provided an address or telephone number in order to lodge a grievance or complaint with the State Agency (SA). (A-0118)
- Ensure that the Governing Body's (GB) responsibility to review and resolve grievances was delegated in writing to a grievance committee (more than one person). (A-0119)
- Ensure that the facility's policy time frames for the provision of a response for patient grievances was followed for two patients (#31 and #32). (A-0122)
- Ensure that the facility provided a written notice of resolution with actions taken for one patient grievance (#31). (A-0123).

The severity and cumulative effects of these systemic practices resulted in the overall non-compliance with CFR 482.13, Condition of Participation: Patient's Rights, which prevented patients from understanding their rights as a patient, including the right to formulate a grievance with a prompt, written response from the hospital, related to the grievance outcome and actions taken. This also prevented patients from obtaining contact information necessary to file a complaint or grievance with the SA.

The facility census was 21.

Based on interview and policy review, the facility failed to ensure that four current patients (#4, #5, #12 and #30) of 12 current patients reviewed for patient's rights, received information regarding their patient's rights. This failure had the potential to prevent all patients from understanding their rights as a patient. The facility census was 21.

Findings included:

1. Review of the facility's policy titled, "Patient Rights and Responsibilities," revised 09/2017, showed:
- The purpose was to ensure patients and their designated representative had been informed of their patient rights and responsibilities.
- Patients receiving any health care services at the facility shall be informed of these rights as well as their responsibilities.
- Each patient/designated representative was informed of their rights and responsibilities and was offered and/or provided a written copy of the hospital's Patient Rights and Responsibilities handout. Every effort was made to provide the information prior to providing or discontinuing care.

During an interview on 09/25/18 at 9:40 AM, in the Intensive Care Unit (ICU), Patient #4 stated that she hadn't received any information regarding her patient's rights.

During an interview on 09/25/18 at 10:00 AM, in the ICU, Patient #5 stated that she hadn't received any information regarding her patient's rights.

During an interview on 09/25/18 at 11:10 AM, Staff F, ICU Registered Nurse (RN) stated that the admitting department gave a copy of the Patient's Rights to patients upon their admission.

During an interview on 09/25/18 at 3:25 PM, on the Medical/Surgical unit, Patient #12 stated that he was transferred to this floor earlier today from the ICU unit. He and his wife denied that they had received information regarding his patient's rights.

During an interview on 09/25/18 at 11:40 AM, Staff G, Registration Clerk, stated that patients were asked if they wanted a copy of their rights on admission and that it wasn't automatically given to patients. Staff G also stated that patients were not given a patient handbook that contained their patient's rights.

There was no clear process of informing patients of their patient's rights.

During an interview on 09/25/18 at 1:55 PM in the ED, Patient #30, stated that she did not receive a copy of the Patient's Rights and did not know her rights.

During an interview on 09/25/18 at 9:25 AM, Staff MM, Emergency Department (ED) Patient Registaton, staff stated that the notification of Patient's Rights are included in the Consent to Treat form. She stated that she did not automatically provide a copy of the Patient's Rights to the patient. She stated that the patient is given a copy of their Patient's Rights if they request it.





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27727

Based on observation, interview, and policy review, the facility failed to ensure that two current patients (#2 and #30) of three patients reviewed, were provided an address or telephone number in order to lodge a grievance or complaint with the State Agency (SA). This had the potential to prevent patient's or their representative from filing a complaint or grievance with the SA. The facility census was 21.

Findings included:

1. Review of the facility policy titled, "Patient Complaint/Grievance Policy," dated 02/2018, stated that the patient or patient's representative receiving services at the hospital, and/or its affiliates, has the right to submit complaints/grievances and will be provided information as to how they may submit them. If a patient and/or patient's designated representative feel it is necessary to report their concern with the hospital regulatory body, they may contact the Missouri Department of Health and Senior Services Bureau of Health Service Regulation at (573) 751 6303 (8:00 a. a.m.. to 5:00 p.m., Monday - Friday). No hotline number was provided in order to lodge a complaint when the State Office was not open.

Observation of the main lobby of the facility, the Emergency Department (ED) and the multiple medical units of the facility showed no signage which informed patients or potential patients of the phone number or the address of the SA in order to lodge a complaint or grievance.

During an interview on 09/25/18 at 9:37 AM, in the Obstetric Unit, Patient #2 (a non-English speaking patient) stated (per video interpreter) that she did not receive information on how she could contact the SA if she had concerns related to her care and treatment from staff.

During an interview on 09/25/18 at 1:55 PM in the ED, Patient #30, stated that she did not receive a copy of the Patient's Rights and did not know her rights. She stated that she did not know how to contact the SA if she had a complaint/grievance.

During an interview on 10/02/18 at 8:11 AM, AM, Staff PP, Corporate Compliance/Privacy Officer, stated that all patients should be made aware of the way to file a complaint or grievance which is included in the Patient's Rights and Responsibilities handout.

As part of its notification of patient's rights, the hospital must provide the patient or the patient's representative a phone number and address for lodging a grievance with the SA. The hospital must inform the patient that he/she may lodge a grievance with the SA (the State Agency that has licensure survey responsibility for the hospital) directly, regardless of whether he/she has first used the hospital's grievance process.



18018

Based on interview and policy review the Governing Body (GB) failed to ensure their responsibility to review and resolve grievances was delegated in writing to a grievance committee (more than one person). This failure could potentially endanger all patients if complaints/grievances were not investigated for systemic problems that could lead to patient harm. The facility census was 21.

Findings included:

1. Review of the facility policy titled, "Patient Complaint/Grievance Policy," dated 01/2018, showed no designation of a Grievance Committee.

During a telephone interview on 10/02/18 at 8:11 AM, Staff PP, Corporate Compliance/Privacy Officer, stated that she was responsible for reviewing and responding to patient complaints/grievances. She stated that the facility bylaws did not delegate authority to her and there was no committee.

Based on interview, record review and policy review, the facility failed to follow the facility policy time frames for the provision of a response for patient grievances for two discharged patients (#31 and #32 ) of three patient grievances reviewed. This practice had the potential to affect all patients that filed a grievance, and caused the complainant to be unaware of the status of their grievance. The facility census was 21.

Findings included:

1. Review of the facility policy titled, "Patient Complaint/Grievance Policy," dated 02/2018 showed that:
- The Service Leader and/or Patient Advocate will review, investigate, and resolve patient and/or patients designated representatives's grievance within a reasonable time frame.
- If the grievance will not be resolved, or if the investigation is not or will not be complete, the Patient Advocate shall inform the patient and/or patients designated representative that the hospital is still working to resolve the grievance and the hospital will follow-up with a written response within a stated number of days.
- If complaints/grievances cannot be resolved in a reasonable time frame, then a written response will be sent within 10 business days.

Review of Patient #31's grievance dated 06/13/18 showed that the patient requested a letter for follow up. A letter from Staff PP, Corporate Compliance/Privacy Officer, was sent on 06/26/18 (13 days later). The letter was not sent within the 10 days prescribed by the facility policy.

Review of Patient #32's grievance dated 12/01/17 showed the 18 month old patient's grandmother contacted the facility by phone with complaints related to the care her grandson received in the Emergency Department. The typed investigation by unknown staff stated that the complainant wanted a follow up call. No written response was found.

During an interview on 10/02/18 at 8:11 AM, Staff PP, Corporate Compliance/Privacy Officer, stated that if she was unavailable for any reason, the letters to patients would be sent when she returned.

Based on record review and policy review, the facility failed to provide a written notice of resolution with actions taken for one discharged patient grievance (#31) of three patient grievances reviewed. This had the potential to affect all patients and/or patients' representatives who filed a grievance, by denying them information regarding the outcome of their grievance. The facility census was 21.

Findings included:

1. Review of the facility policy titled, "Patient Complaint/Grievance Policy" dated 02/2018, showed that whenever the patient or the patients representative requests their complaint be handled as a formal complaint or grievance or when the patient requests a response from the hospital, then the complaint is a grievance and all the requirements apply.

The policy did not outline the required steps taken on behalf of the patient to investigate the grievance, the results of the grievance process or the date of completion.

Review of Patient #31's grievance dated 06/13/18, showed that a grievance response letter from Staff PP, Corporate Compliance/Privacy Officer, was sent on 06/26/18. The letter did not contain the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process or the date of completion.

Based on interview and record review, the facility failed to ensure that staff were educated on first aid response (techniques used to address common emergencies that can occur from the use of restraint and seclusion) related to restrained patients (application of mechanical restraining devices or manual restraints which are used to limit the physical mobility of a patient) for five staff (H, N, AA, RR and SS ) personnel files of six staff personnel files reviewed. This failure had the potential for serious injury or death to any patients that required restraints in the facility. The facility census was 21.

Findings included:

1. Review of facility policies showed no policy for restraint first aid training.

Review of six personal records for Staff H, Patient Care Technician, Staff N, Registered Nurse in the Intensive Care Unit, Staff AA, Registered Nurse in the Behavioral Health Unit, Staff RR, Agency Registered Nurse and Staff SS, Certified Registered Nurse Anesthetists, showed no restraint first aid training.

During an interview on 09/27/18 at 9:30 AM, Staff X, Health Information Management Director, stated that the restraint training provided to staff did not include restraint first aid training.

Based on interview, record review and policy review, the facility failed to have systemic practices in place to ensure that all facility departments and contracted services were included in the facility-wide Quality Assessment and Performance Improvement (QAPI) Program with data collection, analysis, monitoring and reporting to provide patients with quality care and safety (A-0273). The facility also failed to ensure the Governing Body had established an ongoing program for improved health outcomes to maintain quality improvement. (A-0309).

The facility census was 21.

The severity and cumulative effect of these systemic practices resulted in the facility being out of compliance with 42 CFR 482.21 Condition of Participation: QAPI, and resulted in the facility's failure to ensure quality health care and safety.

Based on interview and record review, the facility failed to ensure the quality program incorporated quality indicators to collect data to track, trend, and analyze, in order to measure the effectiveness and safety of services to patients for four departments out of eight departments reviewed, and for 10 out of 10 contracted services reviewed. These failures had the potential to put all patients at risk for sub-standard quality of health care and adverse outcomes. The facility census was 21.

Findings included:

1. Review of the facility document titled, "Quality Assessment/Performance Improvement Plan (QAPI)," reviewed 06/26/18, showed:
- The overall objective of the QAPI plan is to increase the probability of positive patient outcomes and prevention of negative events by continually assessing and improving governance, managerial, clinical, and support mechanisms that directly or indirectly impact patient outcomes.
- Quality Assessment (QA) involves the development and implementation of data sources and the analysis of information generated from the data sources to determine opportunities for improvement.
- Performance Improvement (PI) is the goal of QA in that information collected, analyzed and acted upon in a positive manner should lead to reduction/elimination of problems and/or improvement of processes's and/or performance.
- Service leaders are responsible for developing and implementing data sources for ongoing problem identification, resolution and improvement.

Record review of the list of contracted services provided by Staff NN, Clinical Services Director, showed the following contracted services that affected patient care:
- Radiology Service;
- Laboratory Services;
- Pharmacist;
- After Hours Pharmacy Services;
- Anesthesiology Medical Director;
- ED Physicians;
- Orthopedic Services;
- EKG Interpretations;
- Stress Testing Supervision; and
- Sleep Lab.

During an interview on 09/25/18 at 3:00 PM, Staff J, QAPI Director, stated that QAPI was not submitted by the contracted service as a separate entity to the facility-wide QAPI program.

The facility did not ensure that all contracted services were included in the facility-wide QAPI.

2. During an interview on 09/26/18 at 2:25 PM, Staff TT, Respiratory Therapy (RT) Manager, stated that he was the RT Manager since May 2018 and was unsure what QAPI indicators the RT Department was tracking and trending. Staff TT stated that he would find out what the RT Department's QAPI indicators was and supply the information as soon as he found out.

Even though requested, at the time of exit on 09/28/18 at 4:00 PM, Staff TT had not provided what QAPI indicators the RT department was tracking and/or trending to improve patient care.

During an interview on 09/28/18 at 8:41 AM, Staff FF, Certified Registered Nurse Anesthesiologist (CRNA), Chief of Anesthesia Services, stated that anesthesia services did not have any QAPI indicators and/or projects the department was tracking or trending to improve patient care.

During an interview on 09/28/18 at 10:40 AM, Staff GG, Certified Central Sterile Technician Lead, stated that Central Sterile services did not have a QAPI indicator and/or project at this time.

During an interview on 09/28/18 at 1:58 PM, Staff II, Registered Nurse (RN), Care Coordinator and Staff JJ, RN, Care Coordinator, stated that the Swing Bed Program (a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Care) for the facility did not have any QAPI indicators at this time.


18018

Based on interview and record review, the facility's Governing Body failed to effectively provide oversight in the conduct of the facility when the contracted clinical services was not included in the facility-wide Quality Assessment and Performance Improvement (QAPI) Plan, and the QAPI Plan was not facility-wide. This had the potential to put all patients at risk for substandard quality care and compromise their health and safety. The facility census was 21.

Findings included:

1. Record review of the facility's document titled, "Plan for Provision of Care," reviewed 10/25/16, stated that the executive responsibility for the performance improvement program rests with the facility's Board of Trustees through the Board Quality Oversight Committee.

Record review of the list of contracted services provided by the facility showed the following contracted services that affected patient care:
- Radiology Service;
- Laboratory Services;
- Pharmacist;
- After Hours Pharmacy Services;
- Anesthesiology Medical Director;
- ED Physicians;
- Orthopedic Services;
- EKG Interpretations;
- Stress Testing Supervision; and
- Sleep Lab.

During an interview on 09/25/18 at 3:00 PM, Staff J, QAPI Director, stated that contracted clinical services were not included in the facility-wide QAPI program.

Based on observation, interview and record review, the facility failed to ensure patients' paper medical records were protected against unauthorized access (by individuals who were not providing care for those patients) when housekeeping, maintenance staff and radiology technicians were allowed to have access to the medical records department after hours, when the department was closed. This deficient practice had the potential for unauthorized individuals to access, review, and/or possibly alter the documented health information in patients' paper medical records located in the medical record department area. The facility census was 21.

Findings included:

1. Review of the facility document titled, "On-site Information Storage Facility," dated 11/2016, showed that administrative, technical and physical safeguards to protect the privacy of protected health information shall be developed and implemented by the hospital to ensure that unauthorized individuals cannot gain access to or alter patient records.

Observation and concurrent interview on 09/26/18 at 2:10 PM, in the Medical Records Department, showed approximately six double rows of patient's paper medical records that were stacked from the floor to the ceiling. Staff X, Health Information Management (HIM) Director stated that housekeeping, radiology, and maintenance staff had access to the department after hours.

During an interview on 09/26/18 at 2:20 PM, Staff W, HIM clerk, stated that if she had not completed the days scanning of patient records, she would turn the papers upside down on her desk to be completed the next day.

During an interview on 09/26/18 at 2:45, Staff X stated that there were thousands of patients' paper medical records in the stacks and there were probably 100 - 200 papers left on the clerk's desk to be scanned the next day.

Based on observation, interview, record review and review of the United States Pharmacopoeia (USP) Chapter 797 (requirements for mixing certain medications or substances), the facility failed to ensure that pharmacy staff followed the infection prevention standards for compounded sterile preparations (CSP, drugs or substances mixed without contamination) when they failed to:
- Ensure the Compounding Aseptic Containment Isolator (CACI, enclosed medical equipment used to mix medications or substances that are hazardous, and prevents contamination of the drug or substance during the mixing process) was in a Segregated Compounding Area (SCA, a separate area designated for mixing medications or substances) away from other drug preparation or storage areas.
- Remove all paper products and cardboard from the hazardous medication compounding area.
- Apply appropriate personal protective equipment (PPE, gloves, hair covering, shoe covers and gowns) before they prepared CSP's.
These failures had the potential to increase the risk of cross contamination with infection and increase the risk of harm to any patients who received compounded medications. The facility census was 21.

Findings included:

1. Review of the USP, Chapter 797, dated 2013, showed that:
- All hazardous drugs shall be prepared in a CACI that is placed in an area that is physically separated from other preparation areas.
- Particle shedding objects (wood and cardboard) were prohibited in the SCA, and gloves, hair covers, beard covers, gowns and shoe covers were required in the SCA.
- Compounding personnel selected and appropriately put on PPE.

Review of the facility document titled, "Function and Description of the ChemoShield," revised 2013, showed that:
- All hand washing and garbing procedures should be followed when using a CACI unless the manufacturer has specifically stated differently in their literature.
- Compounding procedures specific to hazardous medications and are in addition to work practices, and standard aseptic technique compounding procedures.
- Gowns: Personnel intending to prepare chemotherapy agents shall put on a disposable, coated, non-permeable gown and check for appropriate fit.

Review of facility document titled, "Sterile Products Compounding, Skills Assessment Checklist," showed that staff were trained on proper garb including that attire is donned from dirtiest to cleanest: shoe covers, head/facial, hair covers, face mask and to properly put on non-shedding gown.

Observation on 09/27/18 at 12:15 PM of the pharmacy department, showed an open doorway (without a door) that lead into a large room where the CACI was located. Approximately two feet in front of the CACI was a desk and chair. To the right of the CACI were multiple shelving units with two cardboard boxes. On the front of the CACI was a paper taped to the front glass with an empty magnetic clip type holder beside the paper.
There was no line of demarcation (place marked by a line of paint or tape, that separates one area from another) or physically separated area, for the CACI and the compounding of hazardous drugs.

During an interview on 09/27/18 at 12:15 PM, Staff KK, Pharmacy Director, stated that compounding personnel were trained on proper garbing but that they did not use any PPE other than double gloving when preparing chemotherapy (considered a hazardous drug).

During an interview on 09/27/18 at 12:40 PM, Staff LL, Pharmacist, stated that he did not use any PPE other than washing hands at sink, donning regular gloves then donning chemotherapy safe gloves.

Review of the facility's CACI manufacturer's guideline did not state that the CSP personnel did not need to garb when compounding hazardous medications.

Based on observation, interview, record review and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards when they failed to:
- Label and date intravenous (IV, within the vein) tubing and IV sites for six patients (#4, #5, #10, #11, #17, and #18).
- Wear gloves during IV medication administration for one patient (#23) of one patient observed during IV medication administration.
- Perform hand hygiene with glove use and after contact with inanimate (not alive, for example, computer keyboard, computer mouse, bed, etc.) objects in the patient environment for two patients (#16 and #17).
- Appropriately clean blood glucose (sugar) monitors after use for two patients (#9 and #16).
- Appropriately place a Personal Protective Equipment (PPE, such as gowns, gloves, and masks) supply cart in relation to PPE disposal bins.
- Change the privacy curtain after one patient (#19) observed in contact isolation (precautions for patients with documented or suspected infections or colonization with highly transmissible germs, for which additional precautions are needed to prevent transmission) was discharged.
- Ensure the floor in the dietary (kitchen) department was free of debris and of cleanable surface.
- Ensure the walk-in freezer operated appropriately.
- Ensure that all staffs' hair was contained under a surgical cap while in the Operating Room (OR) Suite.

The cumulative effects of these systemic failures resulted in the facility's non-compliance with 42 CFR 482.42 Condition of Participation: Infection Control and resulted in the facility's failure to ensure safe infection control practices to prevent infections and communicable diseases.

The facility census was 21.

Refer to A-0749 for additional information.

Based on observation, interview, record review and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards when they failed to:
- Label and date intravenous (IV, within the vein) tubing and sites for six current patients (#4, #5, #10, #11, #17, and #18) of six IV tubing/sites observed.
- Wear gloves during IV medication administration for one current patient (#23) of one current patient observed during IV medication administration.
- Perform hand hygiene with glove use, and after contact with inanimate (not alive, for example, computer keyboard, computer mouse, bed, etc.) objects in the patient environment for two patients (#16 and #17) of two patients observed for care with proper hand hygiene.
- Appropriately clean blood glucose (sugar) monitors after use for two current patients (#9 and #16) of three current patients observed.
- Appropriately place a Personal Protective Equipment (PPE, such as gowns, gloves, and masks) supply cart in relation to PPE disposal bins.
- Change the privacy curtain after one current patient (#19) of one current patient observed in contact isolation (precautions for patients with documented or suspected infections or colonization with highly transmissible germs, for which additional precautions are needed to prevent transmission) was discharged.
- Ensure the floor in the dietary (kitchen) department was free of debris and of cleanable surface.
- Ensure the walk-in freezer operated appropriately.
- Ensure that all staffs' hair was contained under a surgical cap while in the Operating Room (OR) Suite.
These failures had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The facility census was 21.

Findings included:

1. Review of the facility's undated policy titled, "Intravenous Therapy: Initiation Clinical Skills Quick Sheet," showed direction for staff to apply a label to the IV tubing that indicated when the tubing needed to be changed and to label the dressing with the date and time of application and the staff's initials.

Observations of the following patients on 09/25/18 and 09/26/18 showed no labels on their IV tubing with no staff initials or start dates on the IV insertion site for:
- Patient #4 admitted on 09/24/18;
- Patient #5 admitted on 09/23/18;
- Patient #10 admitted on 09/23/18;
- Patient #11 admitted on 09/23/18;
- Patient #17 admitted on 09/26/18; and
- Patient #18 admitted on 09/25/18.

The failure to label IV tubing placed the patient at increased risk for infection with prolonged use of the tubing by not identifying to staff when the tubing was to be changed and/or when the IV was initiated.

During an interview on 09/25/18 at 9:30 AM, Staff O, Registered Nurse (RN) stated that IV tubing should be labeled with the initiation on the tubing.

During an interview on 09/25/18, Staff I, RN, Infection Control Preventionist stated that she would expect all patients IV tubing to have a label and all insertion sites to be labeled with staff initials and date of initiation.

2. Review of the facility policy titled, "Standard Precautions for Employee Protection," archived 05/2018 showed that hand hygiene is to be done before putting on gloves, after removing gloves, and after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. Gloves are to be used to protect the hands of employees when there is a risk of exposure to blood, other potentially infectious materials, mucous membranes and non-intact skin.

Observation and concurrent interview on 09/26/18 at 9:20 AM in the Ambulatory Care Unit, showed Staff Z, RN, administered Ceftriaxone (an antibiotic) IV to Patient #23 and did not wear gloves. Staff Z stated that she was not aware of the policy that dictated the use of gloves with IV medication administration, but stated "I probably should have."

3. Review of the facility policy titled, "Infection Prevention in the Point of Care Testing (POCT, smaller laboratory devices within a patient care department that test blood or other fluids)," dated 11/2016 showed the purpose was to prevent the transmission of blood borne infections during the point of care testing, such as blood glucose (sugar within the blood, tested by a finger stick) monitoring. POCT devices were to be cleaned and disinfected after every use.

Observation and concurrent interview on 09/25/18 at 11:40 AM, showed Staff H, Patient Care Technician (Tech) prepared to perform a blood glucose check to Patient #9. Staff H placed the blood glucose monitor onto the unclean bedside table beside papers, the patient's cellular phone and urinal (plastic container used to hold urine). Staff H stated that she should have cleaned the bedside table prior to placing the testing machine on it.

4. Observation and concurrent interview on 09/25/18 at 4:05 PM showed Staff M, Tech prepared to perform a blood glucose check on Patient #16. Staff M placed a bath towel on the patient's bed covers then placed her supplies on top of the towel. Staff M failed to perform hand hygiene prior to putting on gloves. Staff M stated that she should have cleaned a surface for the blood glucose monitor and that she should have cleaned her hands prior to putting on gloves.

Observation on 09/26/18 at 9:15 AM showed Staff O, RN prepared to perform blood glucose testing and draw blood for testing on Patient #17 in the Intensive Care Unit (ICU). Staff O completed the following tasks:
-Placed supplies (including the blood glucose testing monitor) on top of the patient's bed covers.
-Removed gloves, after obtaining blood sample, then touched the patient's bed linens, typed on the bedside computer keyboard, scanned the patient's armband, typed on the computer keyboard, labeled the blood tubes then performed hand hygiene.
- Failed to clean and disinfect the glucose testing monitor before she placed it in the charging station.

During an interview on 09/26/18 at 9:35 AM, Staff O stated that it was her usual process to place her supplies onto the patient's bed covers, it was the facility's policy to perform hand hygiene before and after glove use and she didn't realize she had not done hand hygiene after glove removal or that she hadn't cleaned the monitor after she used it.

5. Review of the facility's policy titled, "Transmission-Based Precautions (Isolation Precautions)," revised 05/2018 showed the following:
- The purpose was for transmission-based precautions to be used in addition to standard precautions for patients with documented or suspected infections or colonization with highly transmissible (contagious) germs, for which additional precautions are needed to prevent transmission.
- Transmission based precautions included contact precautions.
- PPE shall be removed and hand hygiene performed before leaving the patient care environment.

Observation and concurrent interview on 09/26/18 at 9:45 AM, in the ICU, showed a PPE supply cart outside of Patient #19's contact isolation room. The supply cart was positioned next to the PPE trash bins. Staff D, ICU Director, exited the patient's room, removed her PPE gown and gloves, and placed them into the trash bin. Staff D stated that Staff I, Infection Preventionist, was aware of the placement of the bins and was okay with it.

6. Observation on 09/26/18 at 10:10 AM showed Staff Q, Environmental Services (EVS), in Patient #19's room after she had been discharged. Staff Q failed to remove the privacy curtain from the room as part of the terminal cleaning process.

Review of Patient #19's medical record showed that she was placed in isolation for a history of Methicillin Resistant Staphylococcus Aureus (MRSA, a highly contagious and difficult to treat infection).

During an interview on 09/26/18 at 12:05 PM, Staff Q, EVS stated that he never removed the privacy curtains from isolation rooms after the patient was discharged unless he was instructed to do so by the nursing staff.

During an interview on 09/26/18 at 11:40 PM Staff I, Infection Preventionist (IP), stated that she expected PPE supply carts for isolation rooms to be placed on the opposite of the door opening from the disposal bins. She also stated that all privacy curtains should be removed from isolation rooms during the terminal clean and replaced with clean ones.

7. Observation and concurrent interview on 09/26/18 at 11:30 AM of the kitchen showed a white broken floor tile with a missing piece approximately the size of a dinner plate that was black in color. Staff I, stated that she was aware of the floor issue and that the facility had applied for a grant to help with the repair.

8. Observation on 09/26/18 at 11:10 AM of the kitchen walk-in freezer, showed formed ice on two non-blowing fans located just below the ceiling and formed ice on the insulated pipes next to the fans. The ice formation was the size of a softball on all three areas. Water droplets were visible and falling from the ceiling. Multiple cardboard boxes had visible wet areas on the top of the boxes that were located on the top shelf.

During an interview on 09/26/18 at 11:20 AM, Staff R, Dietary Supervisor stated that the fans in the walk-in freezer were not operating at this time because the freezer was in the defrosting phase that it went through every day. She stated that they had been having the ice formation and water droplet issues most of the summer because of the high humidity.

During an interview on 09/28/18 at 1:30 PM Staff CC, Maintenance, stated that:
- The facility had dealt with the humidity problem in the kitchen for most of the summer.
- They had installed plastic strips at the doorway in an attempt to help keep in the cold air with frequent opening of the door but that they continued to have ice that formed on the fans and the pipe insulation.
- The defrosting phase occurred once every 24 hours.
- He thought that the defrosting phase occurred during the nighttime hours.

The facility failed to recognize the defrosting phase occurred during the morning hours in between breakfast and noon meal preparation. During this time there was frequent access into the freezer that resulted in an increase in humidity and warm air inside the freezer. This had the potential to affect the integrity of the food storage boxes, as well as possible contamination of food, with the boxes becoming wet due to the increased humidity while the compressor was in the defrosting phase.

9. Review of the facility's policy titled, "Infection Prevention During Surgical Procedures," dated 01/2017, directed staff that surgical attire will be worn in restricted and semi-restricted areas by all personnel and visitors that include: Surgical caps/hoods covering head and facial hair.

Observation on 09/27/18 at 10:00 AM inside an OR Suite where a surgical procedure was being performed, showed four staff that did not have all of their hair contained under the surgical cap.

During an interview on 09/27/18 at 2:48 PM, Staff EE, RN, OR Nursing Director, stated that she expected all OR staffs' hair to be contained up under the surgical cap when in the OR.






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Based on observation and interview, the facility failed to ensure that the Operating Room (OR) had a tracheotomy (set of instruments used to create a surgical opening into the trachea [windpipe] for the passage of oxygen in an emergency situation) set readily available in the OR suite. This had the potential to affect the safety of all patients that underwent a surgical procedure in the facility's OR. The facility census was 21.

Findings included:

1. Observation on 09/27/18 at 11:45 AM, showed the OR Suite did not have a tracheotomy kit.

During an interview on 09/27/18 at 11:45 AM, Staff FF, Certified Nursing Anesthetist (CRNA), Chief of Anesthesia, stated that the facility did not have a tracheotomy kit available in the OR suite.