HospitalInspections.org

Based on observation, interview, and policy review, the facility failed to provide privacy for patients who were monitored by video surveillance during surgical procedures in the Operating Room (OR), when a video monitor was not protected from the view of visitors and non-surgical staff in the Surgical Services Department. This failed practice had the potential to limit the promotion and protection of each patient's right to privacy. The facility census was 187.

Findings included:

1. Record review of the facility policy titled, "Photographing, Video Monitoring, Audio Monitoring/Recording, and/or Other Imaging of Patients, Visitors, Workforce Members, Non-employee Dependent Healthcare Professionals, Members of the Medical Staff, and Other Privileged Practitioners," dated 12/01/14, showed that the facility must have procedures in place to address how cameras and video monitors are stored, and designated appropriate personnel with access to the devices.

2. Observation and concurrent interview on 11/09/16 at 8:15 AM, in the Surgical Services Department nurses station, showed an unsecured video monitor (similar to a small television, with a screen that transmits images from video cameras located in the operating rooms) which was viewable by anyone standing in the nurses' station. The monitor showed continuous video monitoring of eleven operating rooms. Seven of the operating rooms showed patients in various stages of surgical procedures. There were 10 staff in the vicinity of, and able to view the monitor, including Staff SSS, Maintenance. The patient in room six, when prepped and draped for his surgical procedure, was exposed and revealed his chest on the video monitor, and was visible to all staff in the nurses station. Staff YYY, Register Nurse (RN), stated that cameras and monitors were not turned off during any stage of the patient's preparation (patients were disrobed and positioned) for, during or after (patients were redressed) surgical procedures.

During a telephone interview on 11/15/16 at 8:30 AM, Staff CCCC, RN, Director of Surgical Services, stated that the personnel who had access to the Surgical Services Department nurses ' station (where the monitor was visible) included:
-Hospital Environmental Services (EVS);
-Venders (non-employees who come from outside the hospital to sell/provide supplies to the hospital);
-Orthopedic Representatives;
-Sterile Processing Department;
-Administration;
-Medical records staff;
-Supply staff;
-Facility staff;
-Maintenance staff;
-Respiratory staff;
-Preoperative staff; and
-Postoperative staff.





37921

Based on interview, record review and staff guidance review, the facility failed to develop an individualized, pertinent care plan, with updates specific to assessed care needs for six of fifteen current patients' (#19, #24, #27, #25, #1, #10) and one of two discharged patients' (#60) care plans reviewed. This had the potential to affect all patients admitted as care was not planned. The facility census was 187.

Findings included:

1. Even though requested, the facility could not provide a policy related to care planning.

2. Record review of the facility's undated "Patient Plan of Care Review Quick Reference Card," (a guide to nursing staff) showed the following:
- Complete the patient assessment.
- Identified areas of shift assessment within normal limits are automatically added to a computerized care plan.
- Review the care plan each shift.
- Prioritize and re-sequence problems.
- Update problem status (active, complete, or incomplete).
- Top two problems must have goals.
- Goals and interventions can be free texted (added by staff by typing in).

3. Observation of Patient #19 on 11/07/16 at 1:36 PM in the Intensive Care Unit (ICU) showed the patient to have soft wrist restraints on both wrists.

Record review of Patient #19's History and Physical (H&P) dated 11/04/16 showed the patient was admitted to the ICU on 11/02/16 with a diagnosis of unresponsiveness and respiratory failure (not enough oxygen passes from the lungs into the blood). The patient was intubated (the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs).

Record review of the patient's care plan initiated on 11/02/16 showed a problem of Impaired Respiratory, patient's breathing pattern will be maintained/improved. No interventions were listed. The care plan also showed a problem of Restraint Free and without injury. Patient will meet the criteria for release of restraints and will be free of injury related to restraint episode. There were no interventions listed.

Staff failed to individualize the care plan specific to the patient's needs and to update the care plan as needed.

4. Record review of Patient #24's H&P dated 11/05/16 showed the patient, 84 years old and lived alone, was admitted to the Progressive Care Unit (PCU, a unit for patients not quite ready for the main medical/surgical unit, also called a step-down unit) on 11/05/16 with diagnoses of severe Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease that makes it hard to breathe) and chronic respiratory failure.

Record review of the patient's care plan initiated 11/05/16 showed no problem or interventions for discharge planning.

Staff failed to develop, individualize and update the care plan specific to the patient's needs.

5. Record review of Patient #27's H&P dated 11/03/16 showed the patient was admitted to the PCU on 11/03/16 with a diagnosis of generalized weakness, dry cough, sore throat and shortness of breath. Patient had pneumonia and was being treated with Rocephin and Zithromax (antibiotics).

Record review of the patient's care plan initiated on 11/03/16 showed a problem for Impaired Respiratory - Breathing Pattern. There was no intervention for administering antibiotics for her pneumonia and no updating of the care plan.

Staff failed to individualize and update the care plan specific to the patient's needs.

6. Record review of Patient #25's H&P dated 10/31/16 showed the patient was admitted to PCU on 11/01/16 with a diagnosis of left arm weakness and numbness and urinary tract infection.

Record review of Patient #25's care plan initiated on 10/31/16 showed a problem for Impaired Genitourinary (relating to the genital and urinary organs). There was no intervention for physician ordered antibiotic therapy to treat the urinary tract infection.

Staff failed to individualize and update the care plan specific to the patient's needs.

7. Record review of current Patient #1's H&P dated 11/05/16, showed the patient was admitted to the Sixth floor (Medical/Surgical) on that date with a diagnosis of diabetes (a condition whereby the body does not produce enough of a chemical called insulin to keep the level of sugar in the blood at an acceptable level, causing problems with overall breakdown of nutrients).

Record review of the patient's blood sugar levels from 11/05/16 through 11/07/16 showed high levels ranging from 105 milligrams per deciliter (mg/dl) to 216 mg/dl (normal = 70-99 mg/dl).

Record review of insulin orders from admission through 11/07/16 showed two types of insulin administered on a consistent basis.

Record review of the patient's care plan dated 11/05/16, showed a problem of Altered Blood Sugar, with a goal that blood sugar will be maintained within ordered parameters. The care plan had only one intervention which was "Blood Glucose Monitor."

Staff failed to individualize this care plan with interventions specific to the patient's needs.

8. Record review of current Patient #10's H&P dated 11/07/16, showed the patient was admitted to the Three East floor (Medical/Telemetry) on 11/06/16 with a diagnosis of suspected sepsis (a systemic infection).

Record review of the patient's medication orders showed two different antibiotics (Rocephin and Vancomycin) had been administered since admission.

Record review of the patient's care plan dated 11/07/16, showed staff failed to identify infection as a problem with a goal and interventions.

During an interview on 11/08/16, at approximately 11:10 AM, Staff R, Registered Nurse in charge, confirmed that staff failed to identify the problem of infection for Patient #10.

9. Record review of discharged Patient #60's H&P dated 09/16/16, showed that the patient was was admitted to the PCU on that date having breathing difficulty after surgery. The patient also had diabetes with a blood sugar level of 322.

Record review of the patient's care plan dated 09/07/16 (most likely carried over from the surgical admission) showed a problem of Altered Blood Sugar, with a goal that Blood sugar will be maintained within ordered parameters. The care plan had only one intervention which was "Blood Glucose (sugar, which is converted into energy in the body) Monitor."

Staff failed to individualize this care plan with interventions specific to the patient's needs.





27727

Based on observation, interview and record review, the facility failed to ensure that staff followed their policies and the infection prevention standards for The United States Pharmacopeia (USP) for compound sterile processing when they failed to:
- Remove jewelry before entering the buffer area (a room that is kept sterile at all times used to compound (mix) medications);
- Remove broom and dust pan from the buffer area;
- Remove paper calendar and paper schedule (particle shedding products which can cause contamination) from the buffer area; and
- Clean the buffer area on three days even though multiple medications were compounded on these days.
These deficient practices had the potential to increase the risk of cross contamination and placed all patients that received compounded medications at risk for infection. The facility census was 187.

Findings Included:

1. Record review of the facility policy titled, "Sterile Admixture," dated 06/2000, showed that aseptic (method used to prevent contamination) technique is used when compounding sterile admixtures and prepared in a separate room (buffer area). Work areas (buffer area) are to be kept uncluttered and only necessary items are placed in the work area in order not to breach aseptic technique.

2. Record review of the USP, Chapter 797, dated 2013, showed that before entering the buffer area, all outer garments to include makeup and jewelry are to be removed, floors are to be cleaned daily with documented cleaning records, unnecessary items removed and all paper products are to be removed.

3. Observation with concurrent interview on 11/08/16 at 9:20 AM in the buffer area, showed Staff U, Pharmacy Technician, wearing a necklace while compounding sterile admixtures. Staff U stated that she always wore her necklace.

Observation on 11/08/16 at 9:20 AM in the buffer area, showed the following:
- Broom and dustpan;
- Paper calendar and paper schedule; and
- Dust in the floor corners.

During an interview on 11/08/16 at 9:40 AM, Staff U, stated that she never knew they couldn't have paper in the buffer area and that Environmental service is in charge of cleaning the floors.

4. Record review of the Environmental services room cleaning record for 10/24/16 showed that the buffer area was not cleaned.

Record review of the medication compounding log for 10/24/16 showed that the following medications were compounded:
- 20 Antibiotics;
- 6 Cardiac drugs;
- 5 Antifungal medications:
- 4 Oxytocin, (a hormone used to strengthen contractions during childbirth);
- 3 Pain medications;
- 2 Steroids; and
- 1 Anesthetic.

5. Record review of the Environmental services room cleaning record for 10/10/16 showed that the buffer area was not cleaned.

Record review of the medication compounding log for 10/10/16 showed that the following medications were compounded:
- 30 Antibiotics;
- 14 Cardiac drugs;
- 2 Antifungal medications;
- 19 Oxytocin;
- 7 Pain medications;
- 5 Steroids;
- 3 Anesthetic; and
- 4 Anticonvulsant.

6. Record review of the Environmental services room cleaning record for 08/06/16, showed that the buffer area was not cleaned.
Record review of the medication compounding log for 08/06/16 showed that the following medications were compounded:
- 36 Antibiotics;
- 11 Cardiac drugs;
- 8 Antifungal medications;
- 4 Oxytocin;
- 4 Steroids;
- 1 Anesthetic; and
- 1 Anticonvulsant.

During an interview on 11/08/16 at 9:50 AM, Staff V, Director of Pharmacy, stated that he agreed that Staff U's jewelry should have been removed and that he was unaware that there was paper in the buffer area. He also stated that Environmental services was in charge of cleaning the floors.

During an interview on 11/08/16 at 1:25 PM, Staff WW, Director of Environmental Services, stated that the housekeepers should not have left the broom and mop in the buffer room and that the floors were cleaned daily, but they were worn.

Based on observation, interview and policy review the facility failed to ensure medications were secure for two crash carts (a set of trays/drawers/shelves on wheels used in dispensing emergency medications/equipment in emergency situations to potentially save someone's life) of 10 crash carts observed and for two insulin vials left unattended in two patient rooms (#3, #4). This failure had the potential to allow unauthorized access of medications by personnel, visitors and patients. The facility census was 187.

Findings included:

1. Record review of the facility policy titled, "Medication Security," revised 10/2015, showed:
- Purpose was to ensure that the medications were secured at all times throughout the facility.
- All drugs stored in the hospital shall be accessible only to authorized personnel.
- All drugs, except those intended for crash cart use, will be stored in Automated Dispensing Cabinets, lockable containers, or in a secure (restricted) area.

2. Observation and concurrent interview on 11/07/16 at 1:45 PM on the Fifth floor showed the crash cart with drawers closed and plastic break-away locks in place to prevent access. The top drawer was pulled slightly forward and it was able to be opened far enough to reach inside and retrieve items. The plastic tags remained intact. Staff E, Vice President of Quality, verified the ability to retrieve items inside the drawers and stated that the plastic break-away locks were to prevent this from occurring and stated that the drawers should tightly close to maintain security of the medications inside while the drawer/cart was locked.

Observation and concurrent interview on 11/07/16 at 3.25 PM on the Fifth floor showed the crash cart with new plastic security tags that had been inserted into the smaller hole for a tighter closure. The top drawer was pulled slightly forward and the ability to insert fingers and touch the items inside remained. Staff E stated that pharmacy had replaced the plastic break-away lock and had inserted them into the smaller holes for a tighter closure after the issue that was discovered earlier in the day.

3. Observation and concurrent interview on 11/08/16 at 8:55 AM of the Operating Room, Room of one crash cart, showed that when secured with a padlock (metal key or combination lock) and plastic breakaway lock, the medication drawer was able to be pulled open and allowed access to drugs stored in the cart. Etomidate (an intravenous, in the vein, medication which caused sedation or anesthesia, an artificially induced lack of sensitivity to pain, which is administered prior to surgery) was removed from the cart while the padlock and plastic break-away lock remained intact. Staff CCCC, Surgical Services Director, stated that the drawer should be secured and that drugs stored in the crash cart should not be accessible while the cart was locked.

4. Observation with concurrent interview on 11/07/16 at 1:27 PM, on the Fourth floor (orthopedic trauma) in Patient #3's room, showed that Staff L, Registered Nurse (RN), left an open insulin vial on the computer. Staff L stated that he missed it and that they are left out sometimes.
5. Observation on 11/07/16 at 1:50 PM, on the Fourth floor, in Patient #4's room, showed that Staff K, RN, left an open insulin vial on the computer.

During an interview on 11/07/16 at 2:50 PM, Staff K, RN, stated that the insulin vials should not be left in the patient rooms; they should be in the medication room.

During an interview on 11/07/16 at 3:11 PM, Staff O, Fourth Floor Manager, stated that she expected nurses to take the insulin out of the patient's room and place them back in the patient's drawer in the medication room.









29047




36473

Based on observation, interview, policy review and review of the United States Department of Health and Human Services Food Code (USDA Food Code), the facility's Director of Dietary failed to ensure that the dietary policies were followed by the dietary staff, for refrigerated and frozen food storage, hand hygiene of the front line staff and cleaning of the kitchen equipment. These failures had the potential for food borne illness for all patients, staff and visitors who ate foods prepared in the dietary kitchen. The facility census was 187.

Findings included:

1. Record review of the "USDA Food Code," updated on 09/09/16, stated that a food shall be discarded if the food is not consumed before the expiration date and if it is in a container or package which does not bear a date.

2. Record review of the facility's policy titled, "Food Handling Guidelines," showed that they follow the food safety program "Hazard Analysis Critical Control Point (HACCP), which showed that ready-to-eat foods that have been prepared onsite or commercially prepared and opened must be labeled with date to be consumed.

3. Record review of facility's policy titled, "Food Handling Guidelines, "dated 01/2015, showed that food is handled using the HACCP process in accordance with the regulatory guidelines.

Record review of the facility's policy titled, "Food And Supply Storage Procedures," dated 01/2015, showed that refrigerated and frozen foods past the "use-by" or "sell by" date should be discarded and unused opened products should be covered, labeled and dated.

4. Observation on 11/08/16 at 1:55 PM in the patient's freezer showed:
- Two bags of beef trim with expiration dates of 08/03/16;
- One bag of beef trim with an expiration date of 10/04/16;
- Three bags of beef trim with expiration dates of 03/04/16;
- One bag of beef trim with no label;
- One package of beef rib eye with an expiration date of 03/14/16; and
- Two bags of shrimp with expiration dates of 09/08/16.

5. Observation on 11/08/16 at 2:05 PM in the kitchen's main freezer showed one bag of haddock fish open to air with no label or date and one container of chopped garlic opened with no label or date.

During an interview on 11/08/16 at 2:20 PM, Staff TT, Executive Chef, stated that he assigned a cook two times per week to check expiration dates, rotate and apply the appropriate dates. He stated that it is his responsibility and that he goes by the USDA Food Code.

During an interview on 11/09/16 at 9:55 AM, Staff UU, Dietary Manager stated that she expected Staff TT, Executive Chef, to walk through all of the refrigerators and freezers daily to check for expiration dates.
6. Record review of the facility's policy titled, "Food Handling Guidelines," dated 01/2015, showed that single use disposable gloves are worn when preparing foods that will not be cooked again or while serving food. Gloves are to be placed over clean hands and are to be changed when soiled.

7. Observation with concurrent interview on 11/09/16 at 11:05 AM in the kitchen, showed that Staff MMM, Dietary Coordinator, without wearing gloves, touched the inside of the food plate lids. Staff MMM stated that she only used gloves when she touched "ready to eat" foods.

Observation with concurrent interview on 11/09/16 at 11:10 AM in the kitchen, showed that Staff LLL, Food Service Coordinator, without wearing gloves, touched the food on a patient's food plate. Staff LLL stated that she didn't realize that she touched anything.

During an interview on 11/09/16 at 12:05 PM, Staff UU, Dietary Manager, stated that she expected hand hygiene to be done if they had touched any food.

8. Record review of Staff YY's, Executive Chef's, kitchen cleaning checklist, showed no items that addressed the cleaning of the oven tops.

9. Observation on 11/09/16 at 11:22 AM in the kitchen, showed grease and dust on the top of one three drawer oven and two small ovens.

During an interview on 11/09/16 at 12:05 PM, Staff UU, Dietary Manager, stated that she expected Staff TT, Executive Chef, to oversee the cleaning of the ovens.

Based on observation, interview and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards when they failed to:
- Ensure one staff (FFF) of two on the Peripherally Inserted Catheter (PICC, a catheter or tube placed in a vein in the upper arm and threaded up into a large vein that leads into the patient's heart) Team followed policy and procedure for inserting a PICC.
- Follow hand hygiene (cleaning of hands) standards to prevent contamination or transmission of germs prior to putting on Personal Protective Equipment, (PPE, items such as gowns, gloves and masks worn to prevent the spread of infection) and prior to care provided to eight patients (#9, #19, #61, #26, #64, #62, #38 and #37) of 18 patient care observed for hand hygiene.
- Appropriately wear gowns in Contact Isolation rooms for one patient (#22) of three patients in Contact Isolation.
- Ensure that Operating Room (OR) equipment had clean, wipeable surfaces, when 15 of 23 carts utilized during the set up of sterile fields (to maintain an area free of contaminants) were rusted.
- Cleanse medication vial's rubber stopper (allows for passage of needles without the loss of medication) with alcohol before staff withdrew medications from vials for administration to two patients (#55 and #61) of six patients observed who received injectable medications.
- Follow the facility policy and standards, to thoroughly cleanse a female catheter (a tube placed into the bladder to remove urine) insertion site and surrounding tissue for one (#64) of two patients observed with catheter care.
- Ensure a crash cart (a set of trays/drawers/shelves on wheels used in dispensing emergency medications/equipment in emergency situations to potentially save someone's life) was free of dust and debris for one of 10 crash carts observed.
These deficient practices had the potential to increase the risk of contamination or cross contamination (to transfer germs from one person or object, to another) and placed all patients, visitors, and staff at risk for infection. The facility performs approximately 520 surgical procedures per month. The facility census was 187.

The cumulative effect 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 disease.

Please see A749 for further details.










29047

Based on observation, interview and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards when they failed to:
- Ensure one staff (FFF) of two on the Peripherally Inserted Central Catheter (PICC line, a soft flexible tube placed in a vein in the upper arm and threaded up into a large vein near the heart) Team followed policy and procedure for inserting a PICC line.
- Follow hand hygiene (cleaning of hands) standards to prevent contamination or transmission of germs prior to putting on Personal Protective Equipment, (PPE, items such as gowns, gloves and masks worn to prevent the spread of infection) and prior to care provided to eight patients (#9, #19, #61, #26, #64, #62, #38 and #37) of 18 observations for hand hygiene.
- Appropriately wear gowns in Contact Isolation rooms for one patient (#22) of three patients in Contact Isolation.
- Ensure that Operating Room (OR) equipment had clean, wipeable surfaces, when 15 of 23 carts utilized during the set up of sterile fields (to maintain an area free of contaminants) were rusted.
- Cleanse medication vial's rubber stopper (allows for passage of needles without the loss of medication) with alcohol before staff withdrew medications from vials for administration to two patients (#55 and #61) of six patients observed who received injectable medications.
- Follow the facility policy and standards, to thoroughly cleanse a female catheter (a tube placed into the bladder to remove urine) insertion site and surrounding tissue for one (#64) of two patients observed with catheter care.
- Ensure a crash cart (a set of trays/drawers/shelves on wheels used in dispensing emergency medications/equipment in emergency situations to potentially save someone's life) was free of dust and debris for one of 10 crash carts observed.
These deficient practices had the potential to increase the risk of contamination or cross contamination (to transfer germs from one person or object, to another) and placed all patients, visitors, and staff at risk for infection. The facility performs approximately 520 surgical procedures per month. The facility census was 187.

Findings included:

1. Record review of the facility policy titled, "Insertion of a PICC/Midline catheter by a Vascular Access (VA, individuals specially trained to insert intravenous, or in the vein, medical devices)," revised 08/2013 showed that after sterile central line kit was opened staff were to put on sterile gown and sterile gloves. The policy did not instruct the VA staff to double glove.

2. Observation on 11/09/16 at 9:35 AM, on the Fourth floor, showed Staff FFF, VA, Registered Nurse, (RN), prepared to insert a PICC for Patient #39. Staff FFF assembled the PICC sterile insertion kit on the bedside table. Staff FFF double gloved by putting on a pair of clean gloves underneath the sterile gloves. After the PICC insertion was completed Staff FFF removed his left, bloody, sterile glove and with his clean gloved hand he applied the end cap to the PICC line and cleaned up the supplies.

Staff FFF failed to follow policy when he touched the end cap with a non-sterile glove.

During an interview on 11/09/16 at 10:15 AM, Staff FFF, VA, RN stated that it was "his process" to double glove because he didn't want to get blood all over the sterile drape and he didn't want the patient to see his bloody gloves after the insertion was complete. He stated that he only used the clean gloved hand to apply the end cap to the line.

3. Record review of the facility's policy titled, "Hand Hygiene," dated 08/09/16, showed that hand hygiene should be performed:
- Before and after direct contact with patients;
- After contact with a patient's intact or non-intact skin;
- After contact with body fluids or excretions;
- If moving from a contaminated body site to a clean body site during patient care;
- After contact with inanimate objects (equipment and surfaces that may be contaminated with germs) in the immediate vicinity of the patient; and
- After removing gloves.

4. Observation on 11/07/16 at 1:40 PM, on the Fifth floor, showed Staff A, RN, at the doorway of Patient #9's isolation (special precautions taken to prevent the spread of infection of patients known or suspected to have highly contagious diseases) room. Staff A put on his PPE gown and then put on clean gloves without first performing hand hygiene. Staff A left the patient's room after patient care was provided.

Observation on 11/07/16 at 1:50 PM, on the Fifth floor, showed Staff A, RN put on PPE gown and gloves again without first performing hand hygiene prior to going back into Patient #9's isolation room.

During an interview on 11/07/16 at 2:05 PM, Staff A stated that he did not perform hand hygiene prior to putting on gloves when he prepared to enter Patient #9's room. He stated that he was unsure of the facility policy regarding hand hygiene and glove use.

5. Observation on 11/07/16 at 1:36 PM in the Intensive Care Unit (ICU) showed Staff BB, RN, put on gloves without performing hand hygiene. He then assessed Patient #19's eyes with a flash light, felt the patient's feet for pulses, performed mouth care, moved the Intravenous (IV, through the vein) pump, performed mouth care again and documented on paper. He then removed his gloves and did not perform hand hygiene. He then picked up the patient's right arm, moved the IV lines, placed his hand on the patient's bed and then adjusted the IV pump settings. The RN did not change gloves and perform hand hygiene between the tasks.

During an interview on 11/07/16 at 2:15 PM, Staff BB stated that he should have changed gloves and performed hand hygiene between procedures on the patient.

6. Observation on 11/07/16 at 2:51 PM in the Emergency Department (ED) showed Staff WWW prepared to administer medication to Patient #61. After Staff WWW performed hand hygiene and put on gloves, she touched various inanimate objects in the patient's room before she administered the medication to the patient.

During an interview on 11/07/16 at 2:59 PM, Staff XXX, ED Director, stated that the inanimate objects in a patient's room were considered clean, and therefore did not contaminate Staff WWW's gloves before she administered the medication (this differs from the facility policy).

7. Observation on 11/08/16 at 10:06 AM in the Progressive Care Unit (PCU) showed Staff LL, RN, entered the room of Patient #26. The RN removed a soiled dressing from the patient's toe and cleansed the toe. She then applied a clean dressing to the toe without changing gloves and performing hand hygiene.

During an interview on 11/08/16 at 10:20 AM, Staff LL stated that she considered the cleansing of the wound as part of the clean dressing and not the dirty and therefore would not need to change gloves and perform hand hygiene.

8. Observation on 11/08/16 at 11:00 AM on the Fourth floor, showed Staff II, Wound Nurse, wearing gloves, removed an outer dressing and a negative-pressure wound therapy vacuum (a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wound) from the abdominal wound of Patient #64. She placed a clean dressing in the wound wearing the same soiled gloves. She then removed her gloves and put on another pair of gloves without performing hand hygiene.

During an interview on 11/08/16 at 11:20 AM, Staff II stated that she would have to look at the facility policy on hand hygiene to confirm that hand hygiene was to be done between glove changes.

9. Observation on 11/09/16 at 9:30 AM showed Staff OOO, RN, administered medications through a tube feeding to Patient #62. Staff OOO, changed her gloves three times between patient tasks but did not perform hand hygiene between glove changes.

During an interview on 11/09/16 at 9:45 AM, Staff OOO stated that she should have washed her hands between the glove changes.

10. Observation in the Wound Clinic on 11/09/16 at 10:14 AM, showed Staff DDD, RN, failed to perform hand hygiene between glove changes, after touching the computer, cabinets, and supplies, and before he applied a numbing ointment (Lidocaine) to Patient #38's abdomen.

During an interview on 11/09/16 at 10:25 AM, Staff DDD stated that he should have performed hand hygiene between glove changes, but that it slipped his mind.

11. Observation in the Wound Clinic on 11/09/16 at 9:42 AM, showed Staff CCC, RN, failed to perform hand hygiene between glove changes, after touching the computer, her glasses, the counter, cabinets, and supplies, and before she applied Lidocaine to Patient #37's open wounds on both feet.

During an interview on 11/09/16 at 10:17 AM, Staff CCC stated that there was no hand sanitizer foam in the clinic examination rooms, it was outside the doorway.

During an interview on 11/09/16 at 10:20 AM, Staff EEE, Program Director of the Wound Clinic, stated that it would be a good idea to have the hand sanitizer foam in the examination rooms.

During an interview on 11/14/16 at 4:04 PM, Staff QQQ, Infection Preventionist, stated that:
- Patient rooms in specific departments where various staff move in and out of rooms, such as the ED, were not considered to have clean surface areas.
- Staff would need to complete hand hygiene and re-glove if they touched inanimate objects in the patients room, prior to the administration of medication.
- Her expectation was for staff not to double glove in any situation.
- Hand hygiene surveillance had not occurred in the Wound Clinic for at least one year and four months.

12. Record review of the facility policy, titled "Isolations Precautions" effective date 04/2016, showed:
- Isolation Precautions are developed to reduce/prevent the risk of transmission of communicable and other infectious diseases between patients and between patients and health care workers.
- A gown must be worn to protect skin, and to prevent soiling clothing during either procedure or patient care activities that are expected to generate splashes or sprays of blood, body fluids, secretions, or excretions.
- Wear a gown (a clean, nonsterile gown is adequate) when entering the room.
- Ensure that clothing does not contact potentially contaminated surfaces to avoid transfer of microorganisms to other patients or environments.

13. Observation on 11/07/16 at 3:40 PM showed Staff FFF, RN and Staff GG, Occupational Therapist (OT), in the Contact Isolation room of Patient #22. Staff GG's PPE gown was not tied at the neck and was hanging from her shoulders exposing her clothes to contamination.

During an interview on 11/07/16 at 3:55 PM Staff GG stated that she should have tied her gown.

During an interview on 11/07/16 at 4:00 PM Staff FFF, RN, stated that they had just extubated the patient (removed a tube from the patient's airway) and she did not notice that the OT's gown was not tied and was exposing her clothes.

14. Observation on 11/08/16 at 9:10 AM, during OR Surgical Suite five sterile field (area set up by staff that contains instruments, dressings and other medical equipment, which remains germ free and used during surgical procedures) set-up, the cart which contained packaged surgical instruments and equipment was found to have 12 areas of rust on the lowest shelf, which measured approximately two inches by one inch, which was confirmed by Staff CCCC, Surgical Services Director.

During an interview on 1/14/16 at 1:30 PM, Staff CCCC stated that 15 out of 23 carts used in OR Surgical Suites contained rust.

During an interview on 11/14/16 at 4:04 PM, Staff E, Quality and Risk Management, stated all staff were responsible for ensuring the equipment was maintained, and that any OR staff member could have completed a work order (written or electronic request for maintenance) to ensure the equipment was maintained and rust free.

15. Even though requested, the facility failed to provide a policy related to clean, wipeable surfaces in the OR.

16. Observation on 11/07/16 at 2:51 PM in the ED, showed Staff WWW, RN, failed to cleanse a medication vial's rubber stopper with an alcohol swab, when she passed a needle through the vial's rubber stopper and withdrew the medication for administration to Patient #61.

17. Observation on 11/08/16 at 10:35 AM in the Post Anesthesia Care Unit, showed Staff ZZZ, RN, failed to cleanse a medication vial's rubber stopper with alcohol when she passed a needle through the vial's rubber stopper and withdrew the medication for administration to Patient #55.

During an interview on 11/14/16 at 4:04 PM, Staff QQQ, Infection Preventionist, stated that staff should cleanse the rubber stopper of all medication vials with an alcohol swab, before medication is withdrawn from the vial for administration.

18. Even though requested, the facility failed to provide a policy related to the cleansing of medication vial's rubber stoppers.

19. Record review of the facility's guidance to staff on Perineal care of the female patient, revised 11/11/16, showed the following:
- Help the patient to a lying (face up) position.
- Ask the patient to bend her knees and spread her legs.
- Separate the patient's labia (lip-shaped folds of the female reproductive area) with one hand and clean the urethral meatus (opening that leads to the bladder) with the cloth using gentle downward strokes.
- Clean from front to back to prevent intestinal organism from contaminating the urethra.

20. Observation on 11/08/16 at 9:35 AM, showed the following:
- Patient #64 sat in a chair.
- Staff GGGG left Patient #64 in the chair, cleansed around the tubing as far as she could see (the patient's closed legs, in the sitting position, caused poor access and visualization), dried the tubing and left the room.
- Staff GGGG failed to thoroughly cleanse the actual insertion site, and the tissue surrounding the tubing.

21. Even though requested, the facility could not provide a policy regarding catheter care.

22. Observation on 11/08/16 at 10:45 AM, on the Labor and Delivery unit, showed large amounts (able to be rolled into a ball the size of a nickel) of dust and debris on the top of the crash cart including on the portable suction machine and packaged supplies.






27727




12450































32280

Based on observation, interview, record review and review of the Association of PeriOperative Registered Nurses (AORN) guidelines, the facility failed to ensure that Sterile Processing Department (SPD, where contaminated surgical equipment and instruments are cleaned) staff followed manufactures guidelines for enzymatic cleaner (cleaning agent) concentration when soaking contaminated surgical instruments, prior to sterilization (process that eliminates viruses and bacteria). This had the potential to lead to high levels of bioburden (the number of bacteria living on a surface that has not been sterilized) remaining on the surgical instruments, which could lead to contamination, infection, or surface breakdown of the instrument. The facility processes approximately 2000 pans of instruments per month in the SPD. The facility census was 187.

Findings included:

1. Even though requested, the facility failed to provide a policy related to the procedure used to soak contaminated surgical instruments in the SPD.

2. Review of the AORN "Guideline for Cleaning and Care of Surgical Instruments," dated 2015, showed the cleaning product manufacturer's written instructions for use should be followed for concentration and dilution.

3. Review of the enzymatic cleaner manufacturer directions showed that the cleaner should be dispensed at 1/40 - 1/10 ounces (oz, unit of measure - 1/40 oz equals slightly less than 1/4 teaspoon, and 1/10 oz equals slightly over 1/2 teaspoon) per gallon (gal, unit /of measure) of water, depending on water quality and application.

During an interview on 11/08/16 at approximately 2:30 PM, Staff DDDD, SPD Technician, stated that instead of using the enzymatic cleaner's electronic dispenser (when tap water was turned on, a premeasured amount of cleaner would be dispensed along with the water) in the instrument soak sink (stainless steel sink with marked water fill line, used to soak dirty instruments and equipment), he used plastic tubs and placed three pumps (depressed the pump by hand to dispense) of the cleaner in the smaller tub, and four pumps of the cleaner in the larger tub, when he added water to soak the dirty instruments.

During an interview on 11/15/16 at approximately 11:15 AM, Staff E, Quality and Risk Management, stated facility staff tested the process used by Staff DDDD and found the following:
- One pump of the cleaner, along with two gallons of water in the smaller plastic tub equaled three-fourths oz of concentration per gal;
- Two pumps of the cleaner, along with four gallons of water in the larger plastic tub also equaled three-fourths oz of concentration per gal;
- Staff DDDD stated that he used one pump of the cleaner in the small plastic tub, and three pumps of cleaner in the large plastic tub (differed from interview with surveyor); and
- The amount of cleaner dispensed per pump could vary between users and the pressure applied to the pump.