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Based on record review and interview, the facility failed to have appropriate policies and qualified dietary assessments and reassessments for one of one patients (#86) reviewed for enteral (fed with nutrients directly into the stomach by a tube) feedings. This would apply to all patients receiving enteral and / or parenteral (fed by nutrients directly into the veins) nutrition. The facility census was 406.
1. Review of the Missouri Statute: 324.200. 1. Sections 324.200 to 324.225 shall be known and may be cited as the "Dietitian Practice Act", showed a definition of "Medical Nutrition Therapy" to be "nutritional diagnostic, therapy, and counseling services which are furnished by a registered dietitian ..." . Also, the Dietitian Practice Act describes the Registered Licensed Dietitian as;
"a person who is licensed pursuant to the provisions of sections
324.200 to 324.225 to engage in the practice of dietetics or medical nutrition therapy" ; and
"(a) Has completed a minimum of a baccalaureate degree granted by a United States
regionally accredited college or university or foreign equivalent;
(b) Completed the academic requirements of a didactic program in dietetics, as approved
by CADE;
(c) Successfully completed the registration examination for dietitians; and
(d) Accrued seventy-five hours of approved continuing professional units every five
years; as determined by the committee on dietetic registration."

During an email interview on 03/10/11, the Chairperson of the Committee on Dietitian Practice in the State of Missouri (The Committee responsible for the application and interpretation of the Dietitian Practice Act) interpreted the practice of Medical Nutrition Therapy for the State of Missouri in the reply, "..that nutritional assessment and reassessment of a hospital patient is medical nutrition therapy and is the role of the RD {Registered Dietitian}and not a RN {Registered Nurse}, or Pharmacist." The Committee Chairperson stated the law of the State of Missouri is a higher requirement than the practice or policy of a facility.
2. Review of facility policy for nutrition assessment and reassessment, "Nutrition Care Plan" showed the role of the dietitian is "using information from the nutrition assessment, helps the physician identify situations that might warrant further consideration, alerts the physician to subroutine responses or potential adverse events evaluates the effectiveness and modifies the nutrition therapy plan within a defined scope of practice."
The policy failed to state that Medical Nutrition Therapy is the exclusive responsibility of the Registered Licensed Dietitian.
2. Record review of current Patient #86, showed he/she was admitted on 2/14/11 with prostate cancer, diabetes, hypertension (high blood pressure) and a history of craniotomy (brain surgery) and stroke. Patient #86 was receiving nutritional support per tube feeding of Jevity 1.2 at 80cc (cubic centimeters) per hour. The Medical Nutritional Therapy assessment was provided by a registered, licensed dietitian on 02/16/11. Follow up Medical Nutrition Therapy Assessments were provided on 2/20/11 by Staff BE, a Pharmacist and on 03/01/11 by Staff BF, a Registered Nurse.

3. Review of the Personnel Credentials for the pharmacist and the nurse, who were on the Metabolic Support Team (a team of health care professionals who share the work of supporting patients who receive nutrition by tube feedings or parenteral nutrition by vein feedings.) showed both were certified by the National Board of Nutrition Support Certification, through the Association for Parenteral and Enteral Support, a special study organization. The testing for the nursing and pharmacist disciplines are "discipline specific" and do not presume to qualify a nurse or pharmacist as a dietitian. Each professional discipline is to provide the service of nutritional support from the basis of their specific discipline. Review of the sponsoring organization, "American Society for Parenteral and Enteral Nutrition" (A.S.P.E.N) web reference showed the role of the dietitian to be:
-conduct individualized nutriton screening and assessment;
-develop and implement a nutrition care plan;
-monitor the patient's response to the nutrition care delivered;
-and develop a transitional feeding care plan or termination of nutrition support as appropriate.
The reference for the role of the nurse showed:
-directing patient care including intravenous access;
-education of patients and caregivers;
-and participation in research activities.
Per this sponsoring organization and the references above, the role of the dietitian and the role of the nurse or the pharmacist are not interchangeable. Only the Registered Licensed Dietitian is qualified to provide the service of Medical Nutrition Therapy for patient nutritional assessments and re-assessments.

4. During interview on 03/04/11 at 12:50 PM, Staff YY, Lead Clinical Dietitian stated that the routine for patients receiving Metabolic Support (nutritional intake by tube or intravenous (direct to vein) routes) is for the RDLD (Registered Licensed Dietitian) to do the initial Medical Nutrition Therapy Assessment; and that other members of the Metabolic Support Team could provide the follow-up Nutritional Assessment(s), as by the facility policy. This policy and practice is not congruent with the Dietitian Practice Act in the State of Missouri for the role and practice of Registered Licensed Dieticians.

Based on document review the facility failed to adopt Medical Staff Bylaws which give only the facility Governing Body the authority to grant medical staff privileges. This deficient practice affects all patients in the facility. The facility census was 406.

Findings included:

Review of the Medical Staff Bylaws, on 03/03/11, showed the following information:

ARTICLE 5
F. TEMPORARY PRIVILEGES FOR PATIENT CARE NEED
Temporary Privileges as set forth above may only be granted by the CEO or his/her designee on recommendation of the following:
1. Department Chair
2. VPMA
3. Credentials
4. Medical Staff President or his/her designee

Based on policy review and record review the facility failed to ensure one patient (#67) who filed a grievance, received a timely response to the grievance. Three grievances were reviewed. The facility census was 406.

Findings included:

1. Record review of the facility's policy titled, "Patient/Family Concern/Grievance" dated 03/20/09, showed direction that if an investigation has not been completed within seven business days a letter will be mailed to the person filing the grievance explaining the delay and give an approximate resolution timeframe. This step will give the investigator time to thoroughly review the grievance, prepare an appropriate action plan and contact the initiator with the resolution. The grievance is to be resolved within 25 days.

2. Record review of a patient grievance showed the following:
-The facility received a grievance from Patient #67 on 12/13/10.
-The facility initially contacted the patient on 12/24/10 by phone and the patient requested a follow up contact at a later date.
-Patient #67 again contacted the facility on 12/27/10 asking for a resolution to his/her compliant.
-The patient contacted the facility again on 01/04/11 asking for a follow-up.
-The facility spoke with Patient #67 on 01/17/11.
-The facility sent a letter to the patient on 01/31/11 regarding final resolution of the grievance.

The facility resolved the grievance with Patient #67, 50 days after receipt of the complaint.

Based on policy review and record review the facility failed to provide written notice to patients or their representatives explaining the delay in resolving a grievance and an approximate resolution timeframe for two patients (#67 and #68) and the facility failed to provide a written response including the name of the facility contact person, the steps taken to resolve the grievance, the resolution and the date of completion for two patients
(#67 and #68). Three grievance files were reviewed. The facility census was 406.

Findings included:

1. Record review of the facility's policy titled, "Patient/Family Concern/Grievance" dated 03/20/09, showed direction that if an investigation has not been completed within seven business days a letter will be mailed to the person filing the grievance explaining the delay and give an approximate resolution timeframe. This step will give the investigator time to thoroughly review the grievance, prepare an appropriate action plan and contact the initiator with the resolution. The grievance is to be resolved within 25 days. All issues meeting the grievance criteria will require a written response to the initiator regarding the investigation steps including, the name of investigator and contact information, the resolution, and how to appeal the resolution.

2. Record review showed a grievance from Patient #67 received by the facility on 12/13/10. The facility initially contacted the patient on 12/24/10 by phone and the patient requested a follow up contact at a later date.

The facility failed to send a letter to Patient #67 within seven business days explaining the delay and giving the patient an approximate resolution timeframe per their facility policy.

Further review of the grievance filed by Patient #67 showed the facility sent a letter to the patient on 01/31/11. The letter thanked the patient for bringing his/her concerns to their attention, apologized to the patient and informed the patient the facility reviewed his/her concerns with nursing staff. The letter directed the patient that if he/she needs further assistance to call and speak with the charge nurse. A facility number was included in the letter.

The facility response sent to the patient does not address investigation steps including the name of the investigator, the resolution, and how to appeal the resolution.

3. Record review showed a grievance from Patient #68 received by the facility on 10/06/10. A letter to Patient #68 dated 10/08/10 stated that the facility was investigating his/her concerns and the facility would be in touch.

The letter failed to explain the delay and failed to give the patient an approximate resolution timeframe per their facility policy.

Further review of the grievance filed by Patient #68 showed an entry dated 10/08/10 at 2:52 PM, that the grievance was resolved.
The grievance file does not contain a written response to the patient addressing the resolution of the grievance.

Based on policy review and interview, the facility failed to ensure each patient and/or patient's representative in the Emergency Department (ED) are offered the opportunity to establish an advance directive or to determine if the patient had an established advance directive. The facility had two ED's, (North and South) that together averaged greater than 6,000 patient visits per month. The facility census was 406.

Findings included:

1. Record review of the facility's policy R1.8 titled "Advanced Directives- Including Living Wills and Durable Power of Attorney for Health Care Decisions",revised 5/08, showed the following direction:
-Written information concerning the individual's right under federal and state law will be provided to Cox Health patients at the time of entry into the system.
-This information will include information about the right to formulate advanced directives.
-In the outpatient setting patients will be given literature and phone numbers and website information to access available community forums to assist them.

2. During an interview on 03/03/11 at 10:25 AM, Staff SS, ED Director, stated that the staff does not ask patients or their representatives if they have an advanced directive. Staff SS stated that the physician would ask the patient or their representative if the patient condition indicated the need for that information.

3. During an interview on 03/03/11 at 10:28 AM, Staff R, ED registrar, stated that ED registration staff does not ask patients about advanced directives. Staff RR stated that information is gathered if patient is admitted to inpatient status by inpatient admission registrars.



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4. During an interview on 03/02/11 at 2:10 PM, Staff JJ, Patient Care Manager of the North ED, stated that he/she could not locate the area in the electronic medical record to indicate if patients in the ED have an advance directive. Staff JJ stated that the registration clerk asks patients if they have an advance directive.

5. During an interview on 03/02/11 at 2:25 PM, Staff KK, Assistant Registration Supervisor for the North ED, "We don't ask about advance directives."

Based on observation, interview and record review the facility failed to ensure staff followed physician's orders for two patients (#5 and #6) of two patients reviewed on the Three West unit. The total census on Three West, at the time of the survey, was 26. The facility census was 406.
Findings Included:
1. Review of a facility policy titled, "Admission of a Patient," revised 06/09, showed direction for medications, treatments, etc. to be executed after orders are obtained from the physician.
2. Review of Patient #6's History and Physical (H&P), dated 02/17/11, showed the patient was admitted on 02/17/11, with a diagnosis of shortness of breath.
Review of Physician's Orders, dated 02/27/11, timed 2:50 PM, showed orders for staff to keep the patient's left arm elevated.
During an interview and observation on 03/01/11 at 9:02 AM, Patient #6 stated he/she had suffered a blood clot in his/her left arm. The left inner arm, near the elbow was reddened and swollen. The patient's left arm was not elevated.
During an interview on 03/01/11 at 9:50 AM, Staff BD, Registered Nurse (RN), caring for Patient #6 that day, stated he/she received report from the off-going nurse at the beginning of his/her shift (7:00 AM) by reviewing the orders for Patient #6 via the computer. However, Staff BD stated that he/she was not aware of the physician order to elevate the patient's left arm. Staff failed to thoroughly review Patient #6 physician's orders, and follow them.
Observation on 03/01/11 at 10:24 AM, showed Patient #6's left arm was still not elevated by facility staff.
3. Review of Patient #5's Skin Care Nursing Plan, dated 02/25/11, showed a signed physician's order to treat a pressure sore on the patient's coccyx (tail bone). The physician order for pressure sore treatment included, cleansing with a wound cleanser, apply a cream called Silvadene, then cover with a dampened dressing (dampened with normal saline).
Observation on 03/01/11 at 10:00 AM, showed Staff E RN, cleansed the coccyx pressure sore with a wound cleanser, applied the Silvadene, applied a dry gauze pad and taped it in place. Staff E failed to cover with a dampened dressing as per physician order.
Staff F RN, nurse manager of the unit, confirmed the above physician order and Staff E's failure to follow it.

Based upon observation and interview, the facility failed to assure safety and confidentiality for medical records that were designated for shredding disposal at the North Campus and at the Walnut Lawn Campus, The facility failed to ensure paper patient medical records stored in the outpatient rehabilitation unit, and in the outpatient Radiology-Oncology unit were secured from unauthorized access. The facility census was 406.

Findings included:

1. Review of facility policy, "Data Destruction (paper and film)", effective 11/15/10, stated, "Persons who are in possession of confidential data in paper format shall ensure that the paper is placed into locked storage bins to be picked up for confidential shredding."
2. Observation on 03/01/11 at 1:30 PM, at the North Campus showed shred bins stored in-between the hospital buildings in a caged area with chain link fencing. The main gate was open to the Lynn Street exit. All 22 shred bins, filled with patient medical records, and confidential pages, were accessible to the public. This area did not have continuous surveillance and was not locked, allowing public access.
During interview on 03/01/11 at 1:30 PM with Staff AK, Director of Medical Records, acknowledged the above observation and confirmed the findings.
3. Observation on 08/02/11 at 10:30 AM, at the Walnut Lawn Campus, showed shred bins stored in a shed building behind the hospital. One of the four shred bins, filled with patient medical records, and confidential pages, was found with a broken lock. The maintenance employees routinely work in this building, and have access to the shred bins, but they do not have authorized access to patient medical records.
During interview on 08/02/11 at 10:30 with Staff AK, acknowledged the above observation and confirmed the findings.
(For both of these interviews with Staff AK - what was the date and time of each of these interviews? It needs to be included.)



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4. Observation of the outpatient rehabilitation unit on the North campus on 03/02/11 at 2:30 PM, showed an office with a door at each end of the office. Located in the office are three under the counter file cabinets containing approximately 38 outpatient medical records.

5. During an interview on 03/02/11 at 2:35 PM, Staff LL, Director of Outpatient Rehabilitation Therapy, stated that the two office doors are locked at night when the rehab staff goes home. Staff LL stated that the housekeeping department has access to the office containing the outpatient medical records when the rehab staff goes home.

Staff LL stated that the file cabinets containing the outpatient medical records are not locked at the end of each day. Staff LL stated that the file cabinets have locks but he/she has no keys to the locks.


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6. Observation and interview on the outpatient Radiology-Oncology unit on 03/02/11 at 10:40 AM, showed ten patients' medical records (in entirety) in a bin accessible to anyone passing by. Staff EE, Unit Manager, stated that these records are always kept in this location. Staff EE stated that the records were not locked after hours. Staff EE stated housekeeping staff had free, unsupervised access to this area by use of a key to the door.

Based on observation, interview and policy review the facility failed to ensure their policies regarding unauthorized staff and access to medications is specific in who the authorized staff are and why they would be authorized to have the freedom to access patient's medications. Staff without the need to have access to medications were found to have access to multiple medications in four medication rooms, on four separate units (Eight East and West, Five West, and the inpatient orthopedic unit). The facility census was 406.

Findings Included:

1. Review of a facility policy titled, "Medication Management," revised 02/11 showed the following:

- Medications and biological will be stored so that only authorized personnel have access. Authorized personnel are those required to access locked areas to complete their job related tasks.
- All drugs and biologicals must be secure. Generally, all drugs should be kept in a locked room or container. If the container is mobile or readily portable, when not in use, it must be stored in a locked room, monitored location, or secured location that will ensure the security of the drugs.
2. Observation and interview on 02/28/11 at 12:53 PM, showed a push button, coded door to the medication room on Eight West. Staff O, Registered Nurse (RN), unit manager, stated that all licensed nurses, patient care assistants (PCAs-same as a certified nurse assistant-not within their scope of practice to handle medications) and central supply technicians have free, unmonitored access to the medication room. Staff O also stated housekeeping staff is allowed to enter via the licensed personnel; however, they are not monitored while in the medication room. Further observation showed the following:
- In plastic, open bins on the counter in the medication room:
Respiratory drugs, Spiriva x 4 capsules, a Flovent, Ventolin, and Advair inhalers, and Fluticasone nasal spray (all these medications are used to improve breathing ability).
- In patient labeled, large envelopes on the counter in the medication room:
Calcium Carbonate 500 milligrams (mg) (an antacid) x 3
Lisinopril 10 mg (for high blood pressure) x 2
Vitamin D 400 IU x 40
Melatonin 3 mg (used to treat insomnia) x 6
Theragran M (vitamin)
Metoprolol 25 mg x 5 (for high blood pressure)
Cyanocobalamin 250 micrograms (mcg) x 5 (vitamin B)
Lovenox injectable 40 mg (blood thinner)
Acetaminophen 650 mg oral solution x 4 (used to treat pain or fever)
Senna syrup (laxative) 10 milliliters (ml)
Nexium 40 mg (anti-ulcer)
Tamsulosin 0.4 mg (muscle relaxant)
Citalopram 40 mg (anti-depressant)
Effexor 37.5 (anti-depressant) x 4
Lipitor 80 mg (cholesterol reducing drug)
- In an open plastic bin on the refrigerator in the medication room:
Insulin-Humalog 100 Unit (U) pens x 2 (used in diabetes to lower blood sugar)
Heparin 5 mg (blood thinner)
Baby aspirin 81 mg
Amlodipine besylate 5 mg (a cardiac drug)
Coreg 25 mg x 2 (for high blood pressure)
Lasix injectable 10 mg/ml (a diuretic)
Calcium Carbonate 500 mg
Lovenox 40 mg injectable
Baclofen 10 mg (muscle relaxant)
Depakote 500 mg (used for seizures or convulsions)
Theragran M
Claritin 10 mg (allergy medicine)
Cipro 250 mg (antibiotic)
Peridex 250 mg (mouth rinse)
Acyclovir injectable 500 mg/10 ml (150 mls) (use to treat herpes)
Cipro 400 mg
Metronidazole 500 mg (antibiotic)
Cipro 200 mg
- In the refrigerator in the medication room:
Ceftriaxone 40 mg/ml (50 mls) (antibiotic)
Piperacillin 3.375 grams (22.5 mls) x 2 (antibiotic)
Cefazolin 100 mg/ml (10 mls) x 3 (antibiotic)
Gabapentin 50 mg/ml (8 mls) (antibiotic)
Famotidine 2 mg/ml (10 mls) (antiulcer)
Vancomycin 1000 mg/10 mls (250 mls)
Heparin 25,000 U/250 ml
Alteplase 2 mg/2 ml (2 mls) (blood thinner)
Teriparatide 250 mcg/ml (3 mls) (used for osteoporosis)
3. Observation and interview on 03/01/11 at 2:01 PM, showed a push button, coded door to the medication room on Eight East. Staff O, Registered Nurse (RN), unit manager, stated that PCAs have free, unmonitored access to the medication room. Further observation showed the following:
- In an open plastic bin on the refrigerator in the medication room:
Humalog insulin 75/25 (60 U)
Humalog insulin pens (100 U) x 2
Fluticasone nasal spray
Carvedilol 12.5 mg. x 2 (for high blood pressure)
Allopurinol 100 mg (used for gout)
- In the refrigerator in the medication room:
Latanoprost 0.005 ophthalmic (2.5 mls)
Vancomycin intravenous (IV) solution 1000 mg/250 ml of normal saline (NS)
Vancomycin IC 1750 mg/500 ml NS
Clindamycin 900 mg/100 ml NS (antibiotic)
Cefazolin 100 mg (10 mls) x 3
Famotidine 2 mg
Flu vaccine
Piperacillin 3.375 grams x 3
Bieta 20 mcg pen (used to treat high blood sugar)
4. Observation and interview on 03/02/11 at 8:53 AM, showed a push button, coded door to the medication room on Five West. Staff AZ, RN charge nurse, stated that all licensed nurses, PCAs, central supply technicians and housekeeping staff have free, unmonitored access to the medication room via the code to the door. Staff AZ also stated, they are not monitored while in the medication room. Further observation showed the following:
- In patient labeled large envelopes on the counter in the medication room:
Nexium 40 mg
Diovan 80 mg x 2 (for high blood pressure)
Metoprolol 50 mg SR x 3
Metoclopromide 10 mg (used for nausea and vomiting)
Cozaar 50 mg (used for high blood pressure)
Hydrochlorthiazide 12.5 mg (a diuretic)
Amlodipine Besylate 50 mg x 2
- On the counter in the medication room:
Calcium Carbonate with Vitamin D 500 mg x 2
Cyanocobalamin 250 mcg x 4
Ferrous Sulfate 325 mg (iron supplement)
Lisinopril 5 mg
Doxazosin 2 mg (for high blood pressure)
Nexium 40 mg x 3
Simvastatin 20 mg (used to treat high cholesterol)
Fish Oil x 2
Humalog 100 U x 2
Ferrous Gluconate 324 mg x 3 (iron supplement)
Aspirin 81 mg
Multivitamin
Lipitor 80 mg
Allopurinol 300 mg
Cozaar 100 mg
Metformin Hcl 500 mg x 3 (used for high blood sugar)
Elavil 75 mg (antidepressant)
Megace 10 ml/400 mg x 2 (used to stimulate appetite)
Lovenox 30 mg injectable
Avelox 400 mg/250 ml (IV solution) (an anti-infective)
Potassium Chloride 20 millequivalents (mEq) (1000 ml) (potassium replacement)
Heparin 25,000 U/250 ml
Vancomycin 1000 mg/10 ml (250 mls)
Vancomycin 1500 mg/15 ml (250 mls) x 2
Cefepime 1 gram/10 mls
Promethazine 25 mg (50 mls) (an antinausea)
Promethizine 25 mg suppositories x 6
Promethizine 50 mg suppositories x 6
Cefazolin 100 mg/ml (10 mls)
Sodium Bacarbonate 1 mEq/ml (100 mls) x 2
Alteplase 2 mg x 2
5. Observation and interview on 03/02/11 at 1:23 PM, showed a door to the medication room on the inpatient orthopedic unit that responded/opened to staffs' name badge by scanning. Staff DD, RN Unit Manager, stated that all PCAs, have free, unmonitored access to the medication room via the scanning mechanism on the door. Staff DD also stated, the PCAs come into the medication room to retrieve the bladder scanner, and they are not monitored while in the medication room. Further observation showed the following:
- In the refrigerator in the medication room:
Lantus Solostar insulin 100 U x 3
Humalog insulin 100 U x 5
Flu vaccine 5 ml x 3
Cefazolin 100 mg/ml (20 mls)
Fluvanix 0.5 ml x 3
Ventolin inhaler
Spiriva capsules x 3 with inhaler device

Based on observation, interview, and policy review the facility failed to follow standards of practice for infection prevention by not removing gloves after performing tasks for one patient (#7) of three patients observed in the Pediatric Intensive Care Unit (PICU), and for not disinfecting equipment when removed from an isolation room. The facility also failed to ensure one randomly observed physician (Staff AY) washed his/her hands prior to caring for one patient (#5) of two patients observed for care on the Three West unit. The facility census was 406.

Findings Included:

1. Record review of the facility's policy titled, "Isolation Precautions" revised 12/08, showed the following direction:
-Change gloves between tasks and procedures on the same patient.
-Remove gloves promptly after use and clean hands immediately to avoid transfer of microorganisms.

Record review of facility's policy titled, "Isolation Discharge Cleaning Procedure" revised 10/01/10, showed no policy or procedure for disinfecting and removing equipment from occupied isolation rooms.

2. Observation on 02/28/11 at 3:40 PM, showed Staff G, Registered Nurse (RN), Nurse Manager of PICU, pulled a computer on wheels from a contact isolation room and rolled it through the PICU before cleaning it with a hospital approved disinfectant wipe.

During an interview on 02/28/11 at 3:50 PM, Staff G stated that he/she wanted to remove the computer on wheels as far away from the nurse caring for the patient in contact isolation because he/she may have an asthma attack from smelling the disinfectant wipe.

3. Observation on 03/01/11 at 9:35 AM, showed Staff H, RN failed to change gloves, and wash or sanitize hands while caring for Contact Isolation Patient #7 following:
- Mouth care (scrubbing patients lips, tongue, and teeth with mouthwash solution);
-providing the patient with small sips of water;
-removing the drain sponge on his/her tracheostomy (opening through neck with tube inserted to help patient breath) site;
-replacing the drain sponge on his/her tracheostomy site;
-removing a dirty dressing from a pressure sore;
-Staff H then placed sterile gloves over same non-sterile gloves to replace a sterile 4x4 dressing over the pressure sore securing the 4x4 with fishnet dressing (elastic tube dressing to hold dressings in place without using tape).
-picking up the dirty dressings off the bed sheet, from the tracheostomy and pressure ulcer, to throw them into the trash;
-Staff H then proceeded to prepare medications and administered a subcutaneous injection (injection in the fatty tissue of the abdomen) and liquid medication through the Percutaneous Endoscopy Gastrotomy (PEG tube [tube placed through stomach for feedings]).





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4. Review of a facility procedure titled, "Clostridium Difficile (C. diff)," dated 08/01/08, showed direction for staff to wash hands with soap and water. Alcohol-based hand disinfectants do not kill C. diff spores, therefore handwashing is required.

Review of a facility policy titled, "Hand Hygiene, revised 10/09, showed direction for staff to clean their hands before and after each patient contact.

5. Review of Patient #5's admission face sheet dated 02/16/11 showed the patient was admitted on that date with a diagnosis of respiratory distress.

Observation and interviews on 03/01/11 at 10:00 AM, showed Staff AY, Physician, put a plastic isolation gown on over his/her head, and gloves on prior to entering Patient #5's room. Staff AY failed to tie the isolation gown, allowing the ties to drag the floor/ground. Staff AY failed to wash his/her hands prior to gloving and having contact with Patient #5. Staff E, RN stated Patient #5 was in contact isolation because of C. Diff (a contagious bacteria in the bowel) and Vancomycin Resistant Enterococcus (VRE-a bacteria resistant to antibiotics). Staff FF, RN, Assistant Unit Manager, stated he/she also observed the physician enter Patient #5's room without sanitizing/washing his/her hands.

Based on interview and policy review, the facility failed to provide education for all pertinent patient care personnel at the North Campus for the reporting of Organ Procurement following the death of a patient. The facility census was 406.
Finding included:
1. Review of the facility policy, "Organ & Tissue Donation", 1988, Revised 6/09/10, showed, " When a patient is facing imminent death by " clinical brain death " criteria, Mid-America Transplant Services will be notified by the designated requestor or a nurse in the critical care area who is caring for the patient .... "
2. During and interview on 03/03/11, at 9:30 AM, Staff BA, North Campus Emergency Room nurse, stated that the process after the death of a patient would include " filling out the paper work", if the family would desire donation of anatomical gifts. There would be nothing else.
3. During an interview on 3/03/11, at 9:30 AM, Staff BD, a Registered Nurse, stated that if there is no donation of organs, the body of a deceased patient might stay a while for the family needs, and then may be sent directly to a funeral home within 5 minutes or so, once the family has left. Staff BD failed to respond with the knowledge that a call needed to be made to the Organ Procurement Organization for the purpose of reporting every patient death.
4. During an interview on 3/03/11 at 1:30 PM, Staff AB, Chaplain, stated that the chaplains generally take care of the needs of the Organ Procurement Program by making the call to the Organ Procurement Organization, for documentation purposes of the call and to have a conversation with the family. However, in "very rare occasions" a nurse may have to provide the Organ Procurement call. Staff AB also stated that general training for staff nurses had been planned, but had to be canceled; and agreed that the staff nurses at the North Campus had less experience with the processes for Organ Procurement. The nursing staff at the North Campus had no other training for the process or program of Organ Procurement.