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Based on record review, policy review, and staff interview, the facility failed to ensure that restraint orders were not written as a standing or PRN order for 1 (#1) of 4 patients whose medical records were reviewed for the use of restraints or seclusion. Findings include:

Patient #1 was admitted to the facility on 10/19/13 with a diagnosis of vomiting.

During review of the medical record on 10/21/13 at 2:00 p.m., "Hand restraints as needed" was documented as a physician's order on 10/19/13. The order did not contain a clinical reason for the restraint order, and was not written for a specific type of restraint.

On 10/22/13 at 12:30 p.m., documented within Policy Number N1350 Restraint of Patients, was the following statement, "A 'PRN' order for restraint application will not be accepted."

On 10/22/13 at 9:00 a.m., staff member B stated PRN restraint orders were not allowed in the hospital.

Based on record review, policy review, and staff interview, the facility failed to ensure that restraint orders were not written as a standing or PRN order for 1 (#1) of 4 patients whose medical records were reviewed for the use of restraints or seclusion. Findings include:

1. Patient #1 was admitted to the facility on 10/19/13. The patient was admitted with a diagnosis of vomiting.

During review of the medical record on 10/21/13 at 2:00 p.m., the following was documented on the patient care plan of 10/19/13; "Hand restraints as needed."

On 10/21/13 at 2:30 p.m., the surveyor was told by staff member F, a nurse, that a PRN restraint order would be documented on the care plan to inform staff of the order for the restraints.

During interview on 10/22/13 at 9:00 a.m., staff member B, QA manager, stated that PRN restraint orders are not allowed in the hospital.

On 10/22/13 at 12:30 p.m., the surveyor reviewed Policy Number N1350 Restraint of Patients, which revealed that "A 'PRN' order for restraint application will not be accepted."

Based on record review and policy review the facility failed to obtain a physician's order for the use of a restraint for 1 (#26) of 61 sampled patients. Findings include:

The following was documented on the Restraint of Patients policy, "...the use of restraint will be limited to clinically appropriate and adequately justified situations. Patient will be assessed for potential restraint use...Orders are obtained prior to application of restraints. A written order, based on the examination of the patient by a licensed independent practitioner, is entered into the patient's record within 24 hours of the initiation of the restraint." The medical record lacked a physician's order for the restraint.

On 10/23/13 at 10:00 a.m., patient #26 was admitted to the hospital on 8/14/12 with the admitting diagnosis of acute confusion. The patient was aggressive, agitated and documented on the restraint "violent" flow sheet a roll belt was applied on 8/15/12 at 6:40 a.m., by a staff nurse.

The roll belt, soft limb restraints and hand mitts restraint renewal orders were documented on 8/16/12, 8/17/12, 8/18/12, and 8/19/12. On 8/20/12 at 7:51 a.m., documented by a nurse on a restraint flow sheet, patient #26 was "up in a chair with the roll belt on." At 12:37 p.m., "four side rails were raised on his bed, and at 8:27 p.m. hand mitts were applied to the patient." On 8/21/12 at 8:52 a.m., documentation included that the "patient was agitated with the roll belt and at 14:12 up in chair with the roll belt on." The medical record lacked documentation of physician's orders for restraints on 8/20/12 and 8/21/12. The last renewal order for restraint was on 8/19/12 at 8:00 a.m., was for 24 hours. The medical record lacked documentation in the physician's progress notes, nursing notes, or assessments that the physician was aware of the continued use of the restraints.

Based on record review, policy review, and staff interview, the facility failed to ensure that orders for the use of restraints or seclusion were not written as a standing order, or as needed (PRN) for 1 (#1) of 4 patients whose medical records were reviewed for the use of restraints or seclusion. Findings include:

Patient #1 was admitted to the facility on 10/19/13 with a diagnosis of vomiting.

During review of the medical record on 10/21/13 at 2:00 p.m., the following was written in the physician's order of 10/19/13: "Hand restraints as needed."

On 10/21/13 at 2:30 p.m., the surveyor was told by staff member F, a nurse, that a PRN restraint order was common. "A PRN restraint order is a line of communication between the physician and nurse. There is restraint paperwork which would be filled out if the PRN order was put into place."

During an interview on 10/22/13 at 9:00 a.m., staff member B, QA manager, stated that PRN restraint orders were not allowed in the hospital.

On 10/22/13 at 12:30 p.m., the Policy Number N1350 Restraint of Patients, was reviewed by the surveyor. The policy revealed that "A 'PRN' order for restraint application will not be accepted."

Based on record review, policy review and staff interview, the hospital failed to assess 1 (#26) of 61 sampled patients after 24 hours for a "violent" patient restraint order. Findings include:

Patient #26 was admitted to the hospital on 8/14/12 with a diagnosis of acute confusion. On 10/23/13 at 10:30 a.m., the medical chart was reviewed by a surveyor. Documented within the medical record on 8/15/12 at 6:40 a.m. was that a roll belt had been initiated for a violent patient. The medical chart lacked documentation that a face-to-face re-evaluation by a LIP was completed within 24 hours after the initiation of the restraint.

The Restraint of Patients policy was reviewed by a surveyor. The policy revealed that an order for a restraint for behavioral management of violent patients must be written by an LIP with face-to-face evaluation completed with in one hour of the restraint initiation. The policy further revealed that the patient in restraints would be monitored and assessed every 15 minutes.

Staff member B stated on 10/23/13 at 1:30 p.m., that aggression was considered a "danger to self" but the chart lacked documentation of assessed behaviors which were harmful.

Based on record review and policy review, the facility failed to do a face-to-face evaluation with in one hour after initiation of a restraint for 1 (#26) of 61 sampled patients. Findings include:

Patient #26 was admitted to the hospital on 8/14/12 with a diagnosis of acute confusion. On 10/23/13 at 10:30 a.m., the medical chart was reviewed by a surveyor. Documented on 8/15/12 at 6:40 a.m., was that a roll belt had been initiated and the nurse classified the patient as violent. The medical record lacked a face-to-face evaluation by an LIP within one hour of initiating the restraint.

The Restraint of Patients policy, "when a restraint was used for the management of violent or self-destructive behavior, the face-to-face evaluation needs to be within one hour after the initiation of the restraint by a LIP."

Based on document review and staff interview, facility staff failed to ensure that all entries in the clinical records were complete and accurate for 2 (#s 3 and 5) of 61 sampled patients. Findings include:

1. Patient #3, a 54 year old male, was admitted to the facility on 10/17/13 with acute pancreatitis. Based on review of the clinical record on 10/21/13, beginning at 2:00 p.m., physician progress notes labeled Med(icine) dated 10/17/13, 10/18/13, 10/19/13, and surgical services physician progress notes dated 10/20/13 and 10/21/13 were incomplete. The progress notes were not authenticated with the time when the entries were made in the clinical record.

Staff member V, the Intermediate Care Area manager, verified the absence of information in the medical record.


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2. Patient #5, a 67-year-old female, was admitted to the facility on 10/16/13 for surgery related to ovarian cancer. A written order on 10/18/13 at 1340 (1:40 p.m.) was not signed by the physician. The facility form labeled "PHYSICIANS PROGRESS RECORD" had an incomplete date of xx/xx/13 and did not include a time. Staff memmber F, an RN, and confirmed these findings.

Based on document review and staff interviews, facility staff failed to ensure that physician orders were properly authenticated with the date, time, and signature of the ordering practitioner for 12 (#s 1, 3, 4, 5, 10, 11, 12, 14, 15, 17, 60, and 61) of 61 sampled patients. Findings include:

On 10/21/13 at 2:00 p.m., the Intermediate Care Area was observed. During the review of active clinical records, the surveyor noted the following:

1. Patient #3, a 54 year old male, was admitted to the facility on 10/17/13, with diagnoses of pancreatitis and a history of multiple rib fractures. The following orders did not include proper authentication with date, time, and physician signature;
-A physician order for admission and care written on 10/17/13, did not include the time when the order was written.
-Medication orders written on 10/18/13, did not include the time when the order was written.
-Ultrasound and laboratory testing orders and orders for open cholecystectomy written on 10/19/13, did not include the time the order was written.
-Orders dated 10/20/13 for nothing by mouth (NPO), operative consent, and pre-operative antibiotics, did not include the time the orders were written.
-Incentive spirometry and laboratory test orders dated 10/21/13, did not include the time the order was written.
-Post Anesthesia Care unit orders dated 10/21/13, did not include the time the order was written.
-Post operative care and medication orders dated 10/21/13, did not include the time the order was written.

2. Patient #4, a 62 year old male, was admitted to the facility on 10/18/13, with diagnoses of status post incision and drainage of septic joints and right olecranon bursae, and sepsis. The following orders did not include proper authentication with date, time, and physician signature;
-Admission orders written 10/18/13, lacked the time when the order was written.
-Venous Thromboembolism Prophylaxis preprinted orders dated 10/18/13, did not include the order time the order was written.
-Laboratory test orders dated 10/19/13, did not include the time when the order was written.
-A Pharmacy Vancomycin protocol order was written on 10/19/13 and did not include the time the order was written.
-Incentive Spirometry, laboratory orders, and physical therapy consultation orders were written on 10/19/13. These orders did not include the time the orders were written.
-Medication orders, laboratory orders, peripherally inserted central line orders, and occupational therapy orders written 10/20/13. These orders did not include the time the orders were written.
-Antibiotic change orders written 10/20/13, did not include the time the order was written.
-Dietary order, nothing by mouth status, and laboratory orders written on 10/21/13, did not include the time the orders were written.

During an interview with staff member V, the clinical manager of Intermediate Care on 10/21/13, at 2:30 p.m., staff member V verified that the identified orders did not have the order time documented.

3. Patient #60 was admitted to the facility on 10/18/13 following aortic valve replacement surgery. The following orders did not include proper authentication with date, time, and physician signature;
-Cardiac Surgery Immediate Post-Operative Orders dated 10/18/13, did not include the time the order was written.

During an interview with staff member V, the clinical manager covering the Intensive Care Unit on 10/22/13, at approximately 2:30 p.m., staff member V verified that the identified orders did not have the order time documented.


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4. Patient #5, a 67 year old female, was admitted to the facility on 10/16/13 for surgery related to ovarian cancer. On 10/21/13 at 2:00 p.m., a review of the clinical record for patient #5 revealed that a telephone order dated 10/18/13 at 0330 (3:30 a.m.) lacked a physician signature. A written order on 10/18/13 at 1340 (1:40 p.m.) also lacked physician signature. Additionally, the resuscitation order found in the clinical record lacked the time when the order was signed. Staff member F, an RN, confirmed these findings.

5. Patient #61, a 91 year old male, was admitted to the facility on 10/18/13 for decompensated congestive heart failure, peripheral edema, and urinary retention. On 10/22/13 at 7:45 a.m., a review of the clinical record for patient #61 revealed two verbal orders (one for a restraint and one for resuscitation) did not include the time and date of the physician signature. Staff member BB, an RN, reviewed these orders and confirmed they had neither documentation of a date nor was the time of the physician signature documented.

6. Patient #12, a 72 year old male, was admitted to the facility on 10/19/13 for pneumonia, chronic obstructive pulmonary disease, and neurogenic bladder. On 10/22/13 at 8:30 a.m., a review of the clinical record revealed that orders dated 10/19/13 and 10/20/13 lacked both the physician signature and the time the orders were signed. Staff member BB, an RN, confirmed the lack of information in the medical record.

7. Patient #11, a 54 year old female, was admitted to the facility on 10/11/13 for severe injury. On 10/22/13 at 9:00 a.m., a review of the clinical record revealed the physician orders dated 10/16/13 and 10/19/13 lacked the time the physician signed the order. Orders written by the RN on 10/15/13 lacked both a date time by the physician. The resuscitation order in the clinical record lacked both the date and time the physician signed the order. Staff member BB, an RN, confirmed the orders were incomplete.


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8. Patient #1 was admitted to the facility on 10/19/13 for vomiting. On 10/21/13 at 2:00 p.m., the medical record was reviewed by the surveyor. The following physician's orders did not include the required information.
-A resuscitation order lacked a time and date;
-admitting orders for 10/19/13 lacked a time; and
-the PRN restraint order lacked a date and time.

9. Patient #10 was admitted to the facility on 8/23/13 with appendicitis. The medical record was reviewed on 10/22/13 at 2:00 p.m. The following physician's orders were not complete:
-physician's orders for 8/23/13 lacked a time; and
-PACU orders lacked a date and time.

10. Patient #14 was admitted to the facility on 10/22/13 with a diagnosis of partial small bowel obstruction. The medical record was reviewed on 10/22/13 at 9:30 a.m. and revealed that the Physician's orders for Non-ICU Alcohol Withdrawal Orders and the Resuscitation Order lacked a date and time.

11. Patient #15 was admitted to the facility on 10/21/13 with a diagnosis of left knee replacement. On 10/22/13 at 9:30 a.m., the medical record was reviewed. The following physician's orders were incomplete:
-arthroplasty pre-op orders lacked a date or time;
-Anesthesia pre-op orders--a.m. admits lacked a physician's signature, date and time; and
-Physician's orders dated 10/22/13 lacked a time.

12. Patient #17 was admitted to the facility on 8/21/13 with the diagnosis of biliary dyskinesia. The medical record was reviewed on 10/22/13 at 2:15 p.m. The following physician's orders were incomplete:
-a resuscitation order lacked a date and time; and
-Physician's orders for 8/24/13 lacked a time.

Based on document review and staff interview, facility staff failed to complete informed consent forms for 5 (#s 2, 3, 15, 17, and 60) of 61 sampled patients. Findings include:

1. During the review of active clinical records on 10/21/13 at 2:00 p.m., in the Intermediate Care Area, the surveyor identified the following:

Patient #3, a 54-year-old male, was admitted to the facility on 10/17/13, with diagnoses of pancreatitis and a history of multiple rib fractures.
-The facility form labeled "Authorization for Surgery or Special Procedures" included the signature of the patient and a witness. The time that the signatures were obtained was not documented on the form. The physician did not document that he had explained the procedure to the patient prior to surgery.

During an interview with staff member V, the clinical manager of Intermediate Care on 10/21/13, at 2:30 p.m., verified that the identified consent form did not include the time the signature was written.

2. During the review of active clinical records, on 10/22/13 at 2:00 p.m., in the Intensive Care Unit the surveyor identified the following:

Patient #60 was admitted to the facility on 10/18/13 following an aortic valve replacement surgery.
-The facility form labeled "Authorization for Surgery or Special Procedures" included the signature of the patient and a witness. The time the signatures were obtained was not documented. The physician did not document that he had explained the procedure to the patient prior to surgery.

During an interview with staff member V, the clinical manager of Intermediate Care, on 10/22/13, at 2:30 p.m., verified that the identified consent form did not did not include the time the signature was written.


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3. Patient #2 was admitted to the hospital on 10/20/13, with a diagnosis of abdominal distention with ascites. The medical record was reviewed on 10/21/13 at 2:15 p.m. The Patient Informed Consent form did not include a date or a time as to when the physician signed the consent form.

4. Patient #15 was admitted to the hospital on 10/21/13, with a diagnosis of left knee joint replacement. The medical record was reviewed on 10/22/13 at 9:30 a.m. The Consent to Operation and the rendering of Other Medical Procedures lacked a time of consent.

5. Patient #17 was admitted to the facility on 8/21/13, with a diagnosis of biliary dyskinesia. The medical record was reviewed on 10/22/13 at 2:15 p.m. The Patient informed Consent/Refusal form lacked a date and time of the physician's signature.

Based on observations and staff interviews, facility staff failed to prevent the use of unusable or expired medications in 4 (IMC, ED, Surgery, and OB) of 12 observed patient care areas. Findings include:

1. During the review of the Intermediate Care Area (IMC) on 10/21/13 beginning at 2:00 p.m., the surveyor noted an open bottle of Nitroglycerine 0.4 mg sublingual tablets that contained 20 tablets. The bottle was not labeled with the date when the tablets were first opened.

Staff member V, the clinical manager of the IMC, verified the absence of a open date.

2. During the review of the Emergency Department (ED) on 10/22/13 beginning at 7:30 a.m., the surveyor located an open 16 oz. bottle of Qdryl solution (Diphenhydramine) with a manufacturer's expiration date of 6/2013.

Staff member W, the ED manager, confirmed the expiration date on the bottle at the time of discovery. She stated that the medication was one not normally stocked in the ED.

3. During the review of the Surgical Services storage area on 10/23/13 at approximately 10:30 a.m., the surveyor identified four 1500 ml. bags of 1.5% Peritoneal Dialysis Solution with a manufacturer's expiration date of July, 2013.

Staff member Z, the Surgical Services manager, verified the expiration date.


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4. During the review of the Obstetrics/Nursery (OB) medication refrigerator on 10/22/13 at 7:45 a.m., the surveyor noted a box of Synagis Palivizumab 50 mg/0.5 ml with a manufacturer's expiration date of July 2013. The box had a patient's name written on it.

Staff member G, the OB manager, said that the medication belonged to an OB clinic patient. She added that the OB clinic did not have a refrigerator and used the OB department refrigerator.

Based on observation, staff interview and policy review, the hospital failed to store, prepare, and serve food in a clean environment for 1 out of 1 kitchen. Findings include:

On 10/22/13 at 7:30 a.m., the initial tour of the kitchen was completed with staff member K, the dietary manager.

1. The refrigerator contained the following food items lacked open dates:
-one plastic container, which was not the original container, of jalapeno's;
-one plastic container of cranberries, which was not the original container;
-two Styrofoam containers of mayonnaise;
-a quart of whipping cream in it's original container; and
-two incompletely covered blocks of butter.
The floor under the shelving in the refrigerator had a build up of brown and black debris along the walls.

2. The refrigerator next to the serving line had left over partially cooked chicken and beef which were not covered or dated. Open bags of shrimp and cod fillets were not dated and were exposed to the air. Staff member K stated that these food items should have been thrown away. At this time staff member K stated that all food items which were opened were to be dated as to when the items were opened. Any food item which was removed from the original container needed to be labeled with what the item was and also to include a date. Policy NS 419 included that all foods stored in the coolers must be covered, labeled, and dated.

3. In the cooler where milk, eggs, fruit, and other fresh food products were stored, the condenser was leaking fluid. Stored upon a cart, under the condenser, was a 1/2 full container of liquid which had dripped from the condenser into the container. On the same cart were 15 fruit cups and 8 pudding cups with holes in the lids. The liquid was observed to drip from the condenser into the fruit and pudding cups. At this time the surveyor asked staff member K how long the condenser had leaked. Staff member K stated she did not know and began to throw away the fruit and pudding cups.

4. The floor of the freezer, which was next to the cooler where the condenser was leaking, was covered in thick white ice. Multiple boxes of food had a layer of ice on the outside of the box. Staff member K stated that the maintenance department was aware of this problem and was working on a solution.

5. During the initial tour, four male dietary workers with beards and mustaches, were observed working the in food prep areas without any type of hair restraint on their face. Multiple female workers also worked in the food prep areas and lacked a hair restraint. At this time staff member K directed the male and female workers to properly restrain their hair with nets.

Based on observations and staff interviews, the facility staff failed to prevent the use of expired or unusable patient care supplies in 8 (ICU, PACU, Endoscopy, Same Day Surgery, Surgical Services supply area, Cardiac Catheterization Lab, Respiratory Therapy, and Inpatient Rehabilitation) of 12 reviewed patient care areas. Findings include:

1. During observation of the Intensive Care Unit (ICU) on 10/22/13, beginning at 1:00 p.m., the surveyor observed the following outdated or unusable supplies:
-one Catecholamine blood test collection tube, in the medication refrigerator, with a manufacturer's expiration date of 3/5/13.

The expiration date of the blood collection tube was verified by staff member V.

2. During observation of the pediatric intubation cart in the Post Anesthesia Care Unit (PACU) on 10/23/13 at approximately 8:15 a.m., the surveyor noted a 5.0 french Hudson - Sheridan cuffed endotracheal tube with a manufacturer's expiration date of 9/2009.

The expiration date of the endotracheal tube was verified by staff member Z, the Surgical Services manager.

3. During observation of the Endoscopy area on 10/23/13, beginning at approximately 9:00 a.m., the surveyor observed seven Becton-Dickinson viral culture tubes with a manufacturer's expiration date of 5/14/13.

Staff member Z, the surgical Services manager, verified the expiration date.

4. During observation of the Same Day Surgery area on 10/23/13, beginning at approximately 9:30 a.m., the surveyor observed three Becton-Dickinson 10 ml. red top blood collection tubes with a manufacturer's expiration date of 4/2013.

Staff member Z, the surgical Services manager, verified the expiration date.

5. During observations of the Surgical Services storage areas on 10/23/13 beginning at approximately 10:15 a.m., the surveyor noted the following unusable/expired patient care supplies:

- six Aquamantys Epidural Vein sealers with the manufacturer's expiration dates of 11/23/12 (2) and 2/19/13.

-three 2000 ml. Sorbitol/Mannitol irrigation solution bags with a manufacturer's expiration date of 9/1/13.

-two Applied Medical Convertible Trochar system 11 cm. by 150 cm. sets with a manufacturer's expiration date of 6/24/13.

-five Encursion AEM Disposable Hook Scissors with a manufacturer's expiration date of 2/2013.

-one Cooper Surgical 5 mm. Pilot Guide with a manufacturer's expiration date of 7/2013.

-nine Bard 16 french Deaver T-tubes with a manufacturer's expiration date of 8/2013.

-six Bard 14 french Deaver T-tubes with a manufacturer's expiration date of 7/2013.

-two 4 oz. bottles of sterile lotion remover with a manufacturer's expiration date of 2/2012.

The expiration dates of the identified supplies were verified by staff member Z, the Surgical Services manager, at the time of the discovery. Staff member Z stated that members of the surgery staff were assigned to check for outdates monthly.

6. During observation of the Cardiac Catheterization and Electrophysiology Lab on 10/23/13 beginning at 1:00 p.m., the surveyors noted the following expired patient care supplies:
- one St. Jude Medical Cool Point tubing set with a manufacturer's expiration date of 6/2013.

-one Sterimed 6 french by 115 cm. Electrophysiology catheter with a manufacturer's expiration date of 4/2013.

-two Monoject Tuberculin syringes with a manufacturer's expiration date of 2/2013.

-one Povidone-Iodine 3 pak swabsticks with a manufacturer's expiration date of 3/2013.

The expiration dates of the identified supplies were verified by staff member AA, the Cardiac Cath Lab manager.


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7. On 10/22/13 at 2:00 p.m., an Accapella Pep Valve that had expired 1/2013 was found in the respiratory department. Staff member D, the Respiratory Manager, confirmed the product had expired.

8. On 10/23/13 at 7:45 a.m., an open I.V. Start Kit, was found in the supplies area of the Endoscopy Lab. Staff member Z, an RN and Manager of Surgical Services, confirmed the product was open and should have been disposed of.

9. On 10/23/13 at 9:30 a.m., in the supply room for the OR suites, 23 expired Medtronic Neurosurgical Patties & Strips, 19 with an expiration date of 9/2013 and 4 with an expiration date of 3/1/2012, were found. Staff member Z confirmed these products were expired and removed them.

10. On 10/23/13 at 1:45 p.m., 3 guide wire systems (300 cm), with an expiration date of 9/2013, were found in the supply area of the cardiac cath lab. Staff member AA, the cardiac cath lab manager, confirmed that these items were expired.



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11. During observations of the rehabilitation department storage area, beginning at 9:20 a.m. on 10/23/13, the surveyor noted the following expired patient care supplies:
-two female speci-cath unit with a manufacturer's expiration date of 8/20/13.
-two self-cath catheter extension tubes with a manufacturer's expiration date of 2/2012.
Staff member M, the inpatient rehabilitation manager, took the expired supplies and said "I will put these in the teaching drawer."

Based on observation and staff interview, the facility failed to provide care in a manner which would avoid sources and transmission of infection for 2 (#s 42 and one unidentified patient) of 61 sampled patients and one observed patient. Findings include:

On 10/22/13 at approximately 8:45 a.m., during observation of the med pass, staff member R, a nurse, put on gloves without washing her hands, opened two drawers with gloved hands looking for a gauze pad, located a gauze pad, opened it and applied Ambesol to the gauze pad. Staff member R applied the medication to patient #42's back teeth. Wearing the same gloves, staff member R put her gloved hand into the drawer to get another gauze pad, picked up the tube of Ambesol, applied some of the medication to the gauze pad and applied it to the patient's teeth. Wearing the same gloves, the staff member took a gauze pad out of the open drawer, picked up the tube of medicine with the gloved hand, applied it to the gauze pad and applied it again to the patient's teeth. The staff member then removed her gloves and washed her hands. The staff member did not remove her gloves and sanitize her hands when going from dirty to clean tasks.

On 10/22/13 at 11:25 a.m., during an interview with staff member Q, RN, Unit Manager, he stated that staff are expected to sanitize hands before putting gloves on and to sanitize hands and change gloves when going from dirty to clean areas.



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On 10/21/13 at 2:20 p.m., a nurse was observed on the medical floor to enter a patient room. The nurse retrieved gloves and placed them on her hands. She did not wash or sanitize her hands prior to placing the gloves on her hands.