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Based on observation, interview, and record review, the hospital failed to recognize the use of hand mitts could be a restrictive device to patients' movement which had caused the hospital staff to use hand mitts on patients without assessing the need for it.

Findings:

On December 27, 2010 at 1:30 PM, observed a patient (Patient 3) on a regular floor, in bed with mitts (similar to boxing gloves) on both hands. He was resting calmly in bed. A sitter was at bedside to keep Patient 3 from pulling the tubes.

On December 27, 2010 at 2:20 PM, during an interview, the charge nurse (CN) 3 on the floor stated the use of hand mitts in this hospital is not considered as restraints. CN 3 tried to locate an assessment or plan of care regarding the hand mitts but without success. She explained: "The mitts were used for patients trying to pull lines, tubes, and not considered as restraints." She stated that was the reason there was no documentation found in his records.

On December 27, 2010 at 10:25 AM, CN 4 on the third and the forth floor was interviewed. She stated the hand mitts were not used as restraints in the hospital as they were told.

On December 29, 2010 at 10:45 AM, during an interview, the Nursing Quality Specialist (NQS) stated, "The mitts are not considered as physical restraints because they (patients) can touch their faces and wiggle or move their fingers." Concurrently, the hospital's policy on "Restraint Management" was reviewed with the NQS. The policy read in part, "...Likewise, if the mitts are so bulky that the patient's ability to use their hands is significantly reduced, this would be considered restraint." Asked if an assessment would be required, she stated, "Yes." At 11:45 AM, the NQS, after attempting to locate an assessment related to the need for hand mitts, stated she could not find any assessment.

Based on interview and record review, the hospital failed to ensure one of 24 sampled patients had a complete informed consent (Patient 10). Patient 10's consent for a surgical procedure was not dated and timed to ensure the informed consent was obtained prior to the surgical procedure.

Findings:

The clinical record for Patient 10 was reviewed on December 28, 2010 at 11:05 AM. On December 27, 2010 a physician's order was noted which indicated to obtain consent for a "Diagnostic laparoscopy appendectomy". The form used to document the informed consent was reviewed. The patient signed the informed consent acknowledging he received the information necessary to make an informed decision but it was not dated and not timed.

During an interview with Charge Nurse (CN) 1 to 5 North, on December 28, 2010 at 11:15 AM, she was notified the consent obtained by Patient 10 was not dated and not timed. No further information was provided.

The hospital's policy and procedure titled, "CONSENT/INFORMED CONSENT" revised August 2010, indicated in part, "Hospital Consent Form... Consent form must be completed and include the complete and correct name of the surgery... Prior to obtaining patient signature on form a licensed employee of the hospital must verify that the informed consent process has taken place... The patient's signature must be witnessed by a licensed employee who is to sign first initial, last name and title, along with date and time."



27011

Based on observation, interview and record review, the hospital failed to ensure all emergency crash carts had the medication content list posted on the outside of the carts. This failure had the potential to result in adverse consequences in the event of a medical emergency.

Findings:

1. During an observation with Charge Nurse (CN) 2 of the emergency department (ED), on December 27, 2010 at 10:05 AM, the three emergency crash carts were examined. Cart 1 and Cart 18 did not have the medication content list posted on the outside for easy referral. This was confirmed by CN 2 and the Interim ED Department Manager.

The hospital policy and procedure titled, "EMERGENCY CRASH CART PROCEDURE" revised on November 2010, indicated under the policy subheading, "... The emergency drug supply will remain inside the cart, sealed, at all times when not in use... The contents shall be listed according to attachment 1..."

According to the California Code of Regulation, Title 22, Section 70263(f)(2), "The emergency drug supply shall be stored in a clearly marked portable container which is sealed by the pharmacist in such a manner that a seal must be broken to gain access to the drugs. The contents of the container shall be listed on the outside cover and shall include the earliest expiration date of any drugs within."



25558

2. On December 27, 2010 at 10:17 AM, during a tour of the fifth floor with CN 4, observed the correctional unit did not have a content list of medications outside its emergency crash cart.

On December 27, 2010 at 10:45 AM, during a tour of the telemetry unit on the fourth floor with CN 5, the emergency crash cart was observed not to have a content list of medications posted.



27194

Based on observation, interview and record review, the hospital failed to ensure the ice machine located in the kitchen was cleaned and sanitized according to the manufacturer's recommendations and to prevent substance build up. This resulted in a brownish substance being wiped from the inside portion of the ice shoot.

Findings:

During a tour of the kitchen with Registered Dietician (RD) 1 and RD 2 on December 27, 2010 at 10:40 AM, the kitchen ice machine was examined. A paper towel was used to wipe the inside of the ice shoot. A brownish substance was noted on the paper towel after this was done. RD 1 stated, it was the water which caused this. She indicated the dietary staff performed a weekly cleaning of the ice machine but the sanitizing of the ice machine was done bi-monthly by Plant Operations.

During an interview with Director of Plant Operations (DOP), on December 28, 2010 at 8:50 AM, he stated the hospital has purchased a new product for sanitizing the ice machine and new "rags". (Director of Plant Operations) stated (Engineer in Plant Operations) did the cleaning and sanitizing of the kitchen ice machine.

During an interview with Engineer 1 of Plant Operations, on December 28, 2010 at 9 AM, he was asked the process for sanitizing. He stated and demonstrated, he wiped the outside, wiped the inside of the ice bin without removing the ice and wiped the outside of the ice shoot.

The manufacturer's recommendations provided by DOP for the ice machine was reviewed on December 28, 2010 at 9:50 AM. Under section 4 "Maintenance" the cleaning procedure indicated, "Ice machine cleaner is used to remove lime scale or other mineral deposits. It is not used to remove algae or slime. Refer to the "Sanitizing procedure" for removal of algae and slime." The cleaning procedure steps included, "1. Remove all ice from the dispenser...7. Clean the inside of the bin..." For the sanitizing procedure it indicated, "1. Follow steps 1 - 8 under "Cleaning Procedure."..."

During an interview with the DOP, on December 28, 2010 at 10:20 AM, he was informed Engineer 1 was not sanitizing the ice machine according to the manufacturer's recommendations and to ensure no build up of brownish substance. The ice was not being removed from the ice bin to ensure no sanitizing solution contaminated the ice and he was not cleaning the inside of the ice shoot. The DOP confirmed Engineer 1 was not reaching far enough up the ice shoot to thoroughly sanitize to prevent build up of substances. No further evidence was provided.



27157

The hospital failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases as evidenced by:

1. Failure to ensure that housekeepers received training and were competent to clean isolation rooms, clean the burn intensive care unit (ICU), and the hydrotherapy room and tub, which resulted in three of three patients in a four bed burn ICU developing Acinetobacter baumannii (gram negative bacteria), in their urine (Refer to A Tag 748, item 1).

2. Failure to ensure the contract staff wore gloves during hemodialysis (process used to remove body waste from a renal failure patient's blood), and that the hemodialysis was provided in a manner to reduce the risk of developing blood stream infections (Refer to A 748, item 2).

3. Failure to ensure the patients or their representatives were notified immediately or as soon a practicable after the patient tested positive for Methicillin Resistant Staphylococcus Aureus (MRSA) (Refer to A Tag 748, item 3).

4. Failure to ensure patients who were readmitted to the hospital within 30 days were screened for MRSA with 24 hours of admission (Refer to A Tag 748, item 4).

5. Failure to implement the hospital's approved surgical attire policy and procedure (refer to A Tag 748, item 5).

6. Failure to implement a timely policy and procedure for screening physicians and allied health professional (nurse practitioner, nurse midwife, and physician assistant), for mycobacterium tuberculosis (Refer to A Tag 748, item 6).

7. Failure to maintain a sanitary environment in its Burn Unit which had placed burn patients at risk for infectious diseases (Refer to A Tag 749).

8. Failure to meet reporting requirements when there was an outbreak that occurred in the Burn Unit (Refer to A Tag 749).

The cumulative effect of these systemic problems resulted in the hospitals placed all patients and staff at risk of exposure to and potentially contacting infections and communicable diseases.

Based on observation, interview, and document review, the hospital failed to develop and implement policies and procedures governing control of infections and communicable diseases.

Findings:

1. On December 27, 2010 at 11:20 AM, an initial tour of the burn unit (four bed intensive care unit) was conducted.

During the tour, Charge Nurse (CN) 6 was asked if the burn unit had an isolation room. CN 6 stated that Room 3106 was the isolation room. It was noted that Room 3106 was currently vacant. CN 6 was asked when Room 3106 was last used as an isolation room. CN 6 replied that about a month ago a patient with Acinetobacter baumannii (gram negative bacteria), was admitted in the room. CN 6 was then asked if any other patients in the burn unit were diagnosed with Acinetobacter baumannii. CN 6 replied yes, other patients had been diagnosed with the same bacteria.

On December 27, 2010 at 11:45 AM, Housekeeper (HK) 1 observed cleaning the hydrotherapy tub (patients are placed in a tub of warm water where burned tissue/skin are removed). HK 1 was asked to explain the process for cleaning the hydrotherapy tub. HK 1 stated that she used towels wet with Virex (hospital grade disinfectant). During the interview, HK 1 was observed using one towel to clean the surfaces of the hydrotherapy tub. It was noted that approximately 1-2 minutes after the Virex was applied to the surface HK 1 used another towel and dried the surface of the hydrotherapy tub. HK 1 was asked to explain how she was trained to perform her housekeeping duties. HK 1 stated that she trained herself.

On December 27, 2010 at 1:55 PM, a document titled, "Burn Daily census log", dated 11/22/10, was reviewed. Documentation on the daily census log showed that three patients (18, 19, and 20) were patients in the burn unit and that all three patients were in isolation.

On December 28, 2010 at 8 AM, a request was made to review the medical records for the three burn patients. The medical records were provided, reviewed, and the following was noted:

Patient 18 was admitted to the burn unit September 27, 2010 and discharged on December 9, 2010. Documentation in the laboratory section of the medical record showed that on November 25, 2010 (28 days after admission) Acinetobacter baumannii was identified in the patients' urine. Documentation on the laboratory report showed that the urine specimen was obtained as a clean catch specimen.

Patient 19 was admitted to the burn unit on November 15, 2010, and was discharged on November 26, 2010. Documentation in the laboratory section of the medical showed that on November 21, 2010 (11 days after admission) Acinetobacter baumannii was identified in the patients' urine. Documentation on the laboratory report showed that the urine specimen was obtained as a clean catch specimen.

Patient 20 was admitted to the burn unit on November 4, 2010, and discharged on November 30, 2010. Documentation in the laboratory section showed that on November 28, 2010 (24 days after admission) Acinetobacter baumannii was identified in the patients' urine. Documentation on the laboratory report showed that the urine specimen was collected from an indwelling urine catheter.

On December 28, 2010 at 10 AM, a second tour was conducted of the burn unit. During the tour, HK 2 was observed cleaning the hydrotherapy tub. HK 2, was observed using one Dispatch wipe to clean and disinfectant the surfaces. HK 2 was then asked to explain the process she used for cleaning the hydrotherapy room and tub. HK 2 stated that she used Dispatch wipes (hospital grade disinfectant containing bleach) to clean all surfaces in the hydrotherapy tub room.

On December 29, 2010 at 8:30 AM, the personnel files for HK 1 and HK 2 were reviewed and the following was noted:

HK 1 was hired March 8, 2010. A review of the orientation/competency section of the personnel file contained two documents titled, "Day 1 new hire" and "Day 2 and 3 new hire training" was noted. It was noted that the documents did not include isolation room cleaning or the cleaning of the hydrotherapy tub. Two additional documents titled, "ICU /CCU Quiz" and "Isolation Room Quiz" were noted. It was noted that X marks were written through both documents, and that the quiz questions were not answered.

HK 2 was hired January 12, 2010. A review of the orientation/competency section of the contained two documents titled, "Day 1 new hire" and "Day 2 and 3 new hire training" were noted. It was noted that the documents did not include isolation room cleaning or the cleaning of the hydrotherapy tub. It was also noted the personnel file did not contain the documents titled, "ICU/CCU Quiz" or "Isolation room Quiz."

On December 29, 2010 at 9:30 AM, an interview was conducted with the Director of Environmental Services (DES). DES was asked to verify what disinfectant housekeepers were to use when cleaning the hydrotherapy tub and patient rooms in the burn intensive care unit. DES stated that Virex was the hospital's disinfectant. DES was then asked to explain the process for orienting new housekeeping staff to the hospital's environmental cleaning process and determining staff competency. DES stated that each housekeeper was first given verbal instruction and was then signed off by their supervisor by direct observation. When asked about training and competency for specialized areas such as the burn ICU and isolation rooms, DES stated that the housekeepers were given verbal instruction, completed a written quiz, and then were signed off by their supervisor by direct observation. DES was asked to provide documentation showing that competency had been determined for HK 1 and HK 2 to clean patient rooms in the burn ICU, the hydrotherapy tub, and isolation rooms. After reviewing the two personnel files the DES confirmed that there was no evidence that showed competency was established and that the two housekeepers were knowledgeable about cleaning and disinfecting isolation room, the hydrotherapy tub, and patient rooms in the ICU unit.

On December 29, 2010 at 10 AM, the manufacturers' label for Virex was reviewed. Manufacturer directions on the label were that the surface was to be cleaned prior to use of the disinfectant. Additional directions were that the Virex was then to be applied to the surface, and that the surface was to remain wet with the disinfectant for 10 minutes in order for the surface to be disinfected.

On December 29, 2010 at 10:30 AM, an interview was conducted with the hospital's Infection Preventionist (IP) 1 to explain what steps were taken after the three patients in the four bed ICU burn unit developed hospital acquired Acinetobacter baumannii in their urine. IP 1 stated that the housekeepers working in the ICU burn unit received training on the proper way to clean the hydrotherapy tub. When asked for documentation showing that the housekeepers received training on how to clean the hydrotherapy tub, IP 1 stated that she had no documentation showing that the housekeepers were trained on cleaning the hydrotherapy tub. When asked what additional steps were taken to reduce the risk of other patients contacting hospital acquired Acinetobacter baumannii, IP 1 stated that other than reviewing the process for cleaning the hydrotherapy tub, nothing else was done to prevent future outbreaks of Acinetobacter baumannii.

On December 29, 2010 at 11 AM, an article published by Centers for Disease Control and Prevention (CDC), 11/24/10, titled, Acinetobacter in Healthcare Settings, documented that Acinetobacter is a group of bacteria commonly found in soil and water. While there are many types or "species" of Acinetobacter and all can cause human disease, Acinetobacter baumannii accounts for about 80% of reported infections. Outbreaks of Acinetobacter infections typically occur in intensive care units and healthcare settings housing very ill patients. Acinetobacter infections rarely occur outside of healthcare settings. Acinetobacter poses very little risk to healthy people. However, people who have weakened immune systems, chronic lung disease, or diabetes may be more susceptible to infections with Acinetobacter. Hospitalized patients, especially very ill patients on a ventilator, those with a prolonged hospital stay, those who have open wounds, or any person with invasive devices like urinary catheters are also at greater risk for Acinetobacter infection. Acinetobacter can be spread to susceptible persons by person-to-person contact or contact with contaminated surfaces. In the article CDC indicated that Acinetobacter can live on the skin and may survive in the environment for several days. Careful attention to infection control procedures, such as hand hygiene and environmental cleaning, can reduce the risk of transmission.

The hospital failed to ensure that housekeepers working in the intensive care unit received training and were competent to clean isolation rooms and the hydrotherapy tub when working in the ICU burn unit. Failure to train and ensure competency of the housekeeping staff placed patients and staff at risk of contacting infectious and communicable diseases.

2. On December 27, 2010 at 10:15 am, an initial tour was conducted of the hospital and the following was noted:

During the tour, Patient 21 was observed having hemodialysis (a process used to remove body waste from a renal failure patient's blood). It was noted the contract registered nurse (RN) 1 was not wearing gloves while assisting with the patient's hemodialysis treatment. It was also noted that the red connector going into the acid solution was not secured exposing the dialysis solution to air.

On December 27, 2010 at 1 PM, Patient 22 was observed having hemodialysis. It was noted that the contract RN was not wearing gloves while assisting with the patient's hemodialysis treatment. It was noted that the red connector going into the acid solution was not secured exposing the dialysis solution to air. It was noted that a sign was posted on the entrance door indicating that the patient was in contact precautions.

On December 29, 2010 at 10:30 AM, an interview was conducted with the hospital's Infection Preventionist. IP 1 was asked to provide a manufacturer insert from the hemodialysis tubing. The hemodialysis tubing insert was provided and reviewed. Directions in the manufacturers' insert were that the hemodialysis tubing was, "Ensure all connections are secure before use, and monitor for leaks regularly during patient use. Blood leaks can result if connections are not secure." Additional direction in the manufacturers' insert was, "Air entering the extracorporeal (outside the body) circuit during dialysis may result in serious patient injury or death." Under the priming section the manufacturer directed that, "To maintain sterility of the blood path, do not allow the open ends of the bloodlines to come in contact with non-sterile solutions or surfaces which may contaminate the blood path."

During a concurrent interview, IP 1 was asked about RNs wearing gloves during hemodialysis treatments? IP 1 stated that because of possible exposure to bloodborne pathogens (hepatitis B, hepatitis C, and the virus that causes AIDS), dialysis staff was to wear gloves at all time during the hemodialysis treatment.

Patients and hospital staff were at risk of exposure to bloodborne pathogens by contract RNs not wearing gloves during hemodialysis treatments and placed hemodialysis patients at risk of contacting blood stream infections by failing to ensure that hemodialysis treatments were provided in a closed system.

3. On December 28, 2010 beginning at 8 AM, the following medical records were reviewed and the following was noted:

a. Patient 18 was admitted to the burn unit September 27, 2010 and discharged on December 9, 2010. Documentation in the laboratory section of the medical record showed that on November 25, 2010 (28 days after admission) Methicillin Resistant Staphylococcus Aureus (MRSA) was identified in the patients' urine. A review of the physician progress notes contained no evidence that the physician had notified the patient or the patient's representative of the positive MRSA test.

b. Patient 23 was admitted to hospital on December 20, 2010 and was discharged on December 23, 2010. Documentation in the laboratory section of the medical record showed that a laboratory test dated December 23, 2010 9:26 am, was positive for MRSA. A review of the physician progress notes section of the medical record contained no evidence that the patient or the patient's representative was notified of the positive MRSA test.

On December 28, 2010 at 3 PM, a October 18, 2010 email message addressed to the medical staff was reviewed. Direction in the email message was that the attending physician was to inform the patient or the patient's representative immediately or as soon as practically possible if a patient test positive for MRSA. To assist physicians in complying, a sticker will be attached to the progress note section of the medical record to document the notification has occurred.

During an interview on December 29, 2010 at 10:30 AM, IP 1 confirmed that the medical records contained no documentation showing that the physician had notified the patient or the patient's representative of the positive MRSA tests.

Failure to notify the patient or their representative of a positive MRSA test placed all patients and their families at risk of exposure to and potentially contacting MRSA.

4. On December 28, 2010 at 3 PM, the medical records for Patient 24 who was originally admitted to the hospital on November 23, 2010 and discharged on December 16, 2010. Documentation in the medical record showed that the patient was readmitted to hospital on December 20, 2010. A review of the laboratory section for the second admission contained no evidence that the patient was screened for MRSA with 24 hours of the second readmission.

On December 29, 2010 at 10:30 AM, an interview was conducted with IP 1. When asked to clarify what the hospital's policy and procedure was for screening readmissions, IP 1 stated that it was hospital policy that all readmissions to the hospital within 30 days were to be screened for MRSA within 24 hours.

Failure to screen patients who are readmitted to the hospital for MRSA, places all patients and staff at risk of exposure and potentially contacting MRSA.

5. On December 27, 2010 at 9:45 AM, during the entrance conference, the Director of Accreditation and Special Projects and Infectious Disease Specialist stated that the hospital had revised their surgical attire policy and procedure, educated staff and had improved with their compliance. They stated that staff was required to wear disposable caps over the reusable caps when opening sterile supplies or during surgical procedures.

On December 27, 2010 at 10:30 AM, the following was observed in cardiac catherization laboratory: A physician was observed dictating a report at the work station down the hallway from the department entrance door. It was noted that the physician had pulled his surgical mask down under his chin. It was noted that the physician was wearing a reusable hair covering. It was also noted that one male staff member's tee shirt sleeves were visible hanging below the sleeves of his scrub top.

Concurrently, staff was observed opening sterile trays and equipment in the procedure room directly in front of the work station. It was noted that the two staff members were wearing reusable hair coverings that did not completely cover their head/hair and they did not have a disposable cap covering the reusable hair covering.

On December 27, 2010 at 10:35 AM, two staff was observed working in the last cardiac catherization procedure room (down the hallway to the right) was observed wearing reusable hair covering that was not covered by a disposable cap.

On December 27, 2010 at 11:50 AM, two staff wearing blue surgical attire was observed walking out of the main hospital entrance, going right, and walking down an alley. It was noted that one staff member wore a waist length warm up jacket, and reusable hair covering, covered by a disposable cap. The second staff member was not wearing a cover gown.

On December 27, 2010 at 1:20 PM, two staff members wearing blue surgical attire were observed leaving the main entrance of the hospital, walking to the right, and walking down an alley. It was noted that one staff member was wearing a full length cover gown. The second staff member was not wearing a cover gown.

On December 28, 2010 at 2:30 PM, a tour was conducted of the radiology interventional procedure room. It was noted that a surgical procedure was being performed. It was also noted that two staff present were wearing reusable hair covering that were not covered by disposable caps.

On December 28, 2010 at 3 PM, a tour was conducted of the surgical intensive care unit. During the tour a physician (identified by staff present at the time), was observed wearing a surgical mask that was pulled down under his chin.

On December 29, 2010 at 8 AM, the hospital's November 8, 2010 policy and procedure titled, "Appropriate surgical attire" was reviewed. One page one of the policy and procedure the direction was that the approved policy applied to: Surgery, Cath lab, Central Processing, Maternity Care Center, Interventional Radiology, and Endoscopy. On page two of the policy and procedure, under item B. 4., direction in the policy was that, Scrub clothing may be worn outside the surgical suite within the hospital. The wearing of a laboratory coat is optional. When leaving the suite, disposable jumpsuit and masks must be removed. Under item B.5., direction in the policy and procedure was that, "Scrub clothing is not allowed off campus. If scrub clothing is worn outside the policy, it must be removed and freshly laundered attire donned when returning to the surgical suite. Scrub clothing does not need to be changed if a cover gown was worn ..." Under item B.7., "Reusable head covers must be of densely woven material and laundered daily. They will be covered with disposable bouffant cap within areas designated as red line." Under item B.9., direction in the policy and procedure was that, "All masks must be removed prior to leaving the restricted areas."

On December 29, 2010 at 10 AM, an interview was conducted with the Director of Surgical Services (DSS). During the interview, a description was provided about the instances related to surgical attire that were observed over the past two days. DSS, stated that most of the breaches in the hospital surgical attire policy and procedure were committed by staff working in the cardiac catherization and radiology procedure rooms.

Failure to implement the hospital's surgical attire policy and procedure places all patients at risk of developing surgical site infections.

6. On December 27, 2010 at 3 PM, an interview was conducted with the Medical Staff Coordinator (MSC). MSC was asked to explain the progress on screening physicians and Allied Health Professionals (Nurse practitioner, Nurse midwife, and Physician Assistant) for Mycobacterium tuberculosis (TB). MSC stated that currently about 79 percent of the members of the medical staff and Allied Health Professional had been screened for TB. When asked for an explanation about the delay in current screening of the medical staff members and allied health professionals for TB? MSC stated that she first surveyed other hospitals in the area, in order to obtain copies of their TB screening. She stated that none of the local hospitals surveyed currently required annual screening of their medical staff and allied health professionals. MSC stated that the medical staff rules and regulations needed to be revised, which was done, and the revision was scheduled to be approved by the Governing Body next week. MSC stated that once approved by the governing Body, a letter dated 1/14/11, was to be issued notifying members of medical staff and allied health professionals that non compliance with the hospital's annual TB screening policy and procedure would result in suspension. When asked why the process had taken over four months to implement when an immediate jeopardy was declared in July 29, 2010 for lack of TB screening, MSC stated that it took a while to make revisions to the medical staff rules and regulations.

Failure to annually screen all direct healthcare workers places patients and staff at risk of being exposed to and potentially contacting TB.



21905

Based on observation, interview, and record review, the hospital failed to: 1) maintain a sanitary environment in its Burn Unit which had placed burn patients at risk for infectious diseases, and 2) meet reporting requirements when an outbreak occurred in the Burn Unit.

Findings:

1. On December 28, 2010 at 10:20 AM, accompanied by the charge nurse (CN) 6, the Burn Unit was toured. In the clean equipment room, observed street jackets were hung on an IV pole, a personal jacket placed on top of a medication cart, and several pairs of personal street shoes on the floor. A container of take-out food was found on top of fluid warmers. It contained something similar to a dried up sausage inside and three pieces of unfinished food. CN 6 stated no food should be in this room.

2. On December 27, 2010 at 4 PM, the infection control tracking logs in the Burn Unit was reviewed. The log for the period of November 15 to November 29, 2010 revealed that three patients (Patient 18, 19, and 20) were found to be infected with Acinetobacter. Patient 18, admitted to the hospital on September 27, 2010 was diagnosed to have Acinetobacter in his urine on November 25, 2010. Patient 19, admitted on November 15, 2010, was diagnosed on November 21, 2010 to have Acinetobacter in his urine. Patient 20, admitted on November 4, 2010 also had Acinetobacter in his urine on November 28, 2010. Patient 18, 19, and 20 were all housed in the Burn Unit during the two-week period, November 15 to 29, 2010.

On December 29, 2010 at 10:40 AM, during an interview, the Infectious Disease Specialist (IDS) was unable to provide further information regarding the reason why the outbreak was not reported to the local health department or the Department.

According to the Center for Disease Control (CDC) Healthcare-Associated Infections (HAIs) that Acinetobacter is a group of bacteria commonly found in soil and water. It accounted for about 80 percent of reported infections. Outbreaks of Acinetobacter infections typically occur in intensive care units and healthcare settings housing very ill patients. Acinetobacter infections rarely occur outside of healthcare settings. Acinetobacter can be spread to susceptible persons by person-to-person contact or contact with contaminated surfaces.

Based on interview and record review, the hospital failed to ensure History and Physical (H & P) was completed prior to procedures for two of five records reviewed (Patient 16 and 17). This had the potential to affect these patients' overall outcome associated with the procedure.

Findings:

On December 28, 2010 at 3 PM, with assistance from the Clinical Information System Coordinator (CISC), five patients' records were reviewed. These five patients had surgical procedures or endoscopic procedures completed in the past two weeks at the hospital. The following issues were identified:

1. Patient 16 had a procedure done in the Endoscopic Department at the hospital on December 20, 2010. The H & P for Patient 16 was blank.

2. Patient 17 had a procedure done in the Endoscopic Department at the hospital on December 15, 2010. The patient 's H & P had only allergies and vital signs (temperature, pulse, respiration, blood pressure and oxygen saturation) documented.

On December 28, 2010 at 5 PM, during an interview, the Director of Accreditation and Special Projects stated the pre-procedure H & P used in its Endoscopic Department was a short form and should have been completed prior to the procedure taking place.

On December 28, 2010 at 5:10 PM, the hospital's Policy on "Medical Records Content Policy" was reviewed. Under "OUTPATIENT SURGERY/INVASIVE PROCEDURES-SPECIAL CONSIDERATIONS" read in part, "An abbreviated history and physical can be utilized for all patients treated as outpatients and shall consisted of all the elements of the comprehensive history and physical, with a provision that the information may ... At a minimum, the written physical exam (dictated and transcribed or hand written) shall include:

? Medical history
? A review of the system
? Allergies
? Major complaints
? Reason for operative procedure
? Initial diagnosis."