HospitalInspections.org

A. Based on observation and staff interview, it was determined that in 2 of 2 units observed (Pediatric and Mother/Baby Unit) the Hospital failed to ensure safety of infant and pediatric patients relative to child abduction.

Findings include:

1. During a tour of the Pediatric Unit conducted on 2/22/10 between 9:15 AM and 10:15 AM, the following was observed:

*The visitor main entrance door to the unit, approximately 30 feet from the elevators, was not locked or monitored.

*A second entrance to the unit with double doors, utilized by Hospital staff, and located on the north hallway was open to the main corridor. The corridor connected the pediatric unit to other units on the 5th floor. The doors remained open and the entrance was not monitored for traffic flow in an out of the Pediatric Unit.

*An unlocked stairwell on the north hallway, was approximately 27 feet from the Pediatric Unit entrance. The stairwell leads to all floors including the the first floor exits.

*The unlocked and unmonitored doors to and from the unit provided an access/or exit for potential infant abduction.

*Patients in the unit on survey date 2/22/10, were from 4 months to 18 years of age, and were not required to wear an alarm bracelet while in the unit.

*The unit did not have a system in place for monitoring children 2 and under, for safety (child abduction).

2. The above findings were confirmed during an interview with the Pediatric Nurse Manager on 2/22/10 at 1:30 PM.

3. During the tour of the Mother/Baby Unit conducted on 2/23/10 between 10:05 and 11:20 AM. The following was observed:

*A hallway connecting the East Units to the Mother Baby Unit had doors that remained open and was accessible to the public and public access elevators. The elevators led to the first floor exits. The hallway was not monitored for traffic flow into and out of Mother/Baby Units.

*Newborns are not required to wear an alarm bracelet while in the unit.

*The Mother/Baby Unit did not have a system in place for monitoring the open corridor accessible to the public. The unmonitored hallway provided an access for potential infant abduction.

4. The security office of the Hospital was toured on 2/23/10 at 11:25 AM. The live feed from the Pediatric Unit, and Mother Baby Unit hallways and stairwell camera was not in view nor was it viewed continuously.

5. The above findings were confirmed with the Nurse Manager and the Associate Director of Nursing for the Medical Center, during interview on 2/23/10 at 11:30 AM.


B. Based on review of Hospital guidelines, observation, patient family interview, and staff interview it was determined that in 1 of 3 (Pt. #11) children under 2 years of age in the Pediatric Unit, the Hospital failed to ensure patients have their identification bands on their person at all times, and families are oriented to the unit safety program.

Findings include:

1. The policy titled, "Pediatric Safety and Security Program," was reviewed on 2/23/10 at 8:15 AM. The policy required, "Policy/guidelines...Patient must have an identification band on their person at all times....Education: Family members shall be given pediatric safety and security information outlining our safety program and defining their role in promoting the safety and security of their child. This information shall be reviewed with the family by the admitting nurse."

2. During the tour of the Pediatric Unit, conducted on 2/22/10 between 9:15 AM and 10:15 AM., Pt #11 was observed not wearing an ID band.

3. The grandmother of Pt. #14 was interviewed on 2/22/10 at 9:50 AM. Pt. #14 was a 2 year old male admitted on 2/20/09 with diagnosis of Upper Respiratory Infection. Pt. #14's grandmother stated that no one from the unit discussed the safety and security information which outlined the unit's safety and security program for their child.

4. The above findings were confirmed with the Nurse Manager during an interview on 2/22/10 at 10:00 AM.

A. Based on review of Hospital policy, clinical record review, and staff interview, it was determined, for 1 of 2 clinical records reviewed (Pt. #22) on the Adult Psychiatric Unit, the Hospital failed to ensure restraint orders were obtained with each restraint episode, as required by policy.

Findings include:

1. Hospital policy No. TX 1.07, titled: "Restraints and Seclusion," was reviewed on 2/22/10 at 3:40 PM. The policy required: "Procedure I. Physician Orders..."

2. On 2/22/10 between 9:40 AM and 11:40 AM and again at 2:00 PM, tours were conducted in the Adult Psychiatric North Unit. At 9:55 AM, Pt. #22's was in room 887, with both hands wrapped in bandages, to protect her feeding tube from being removed. Both Pt. #22's arms and legs were unrestrained. At 10:15 AM, Pt. #22 was assisted by 2 staff members while ambulating through the hall. In the afternoon, at 2:00 PM, Pt. #22 was in bed, with all 4 limbs in soft restraints.

3. On 2/22/10 at 10:30 AM, the clinical record of Pt. 22 was reviewed. Pt. #22 was a 42 year old female, admitted on 2/4/10, with diagnoses of Schizoaffective Disorder, Catatonia, and ETOH Abuse. On 2/8/10, Pt. #22 was transferred from the Neurological Surgical Unit to the Adult Psychiatric North Unit. A physician's order for nonviolent behavior restraint, dated 2/21/10 at 7:25 PM, required application of 4 soft limb holders for a maximum time of 24 hours and included: "1) Reapplication of restraint after removal (for reasons other than care provided) requires a new order..." Consecutive 2 hour restraint monitoring from 2/21/10 at 9:00 PM through 2/22/10 at 7:00 AM, indicated that Pt. #22's behavior was confused, uncooperative, kicking, biting, spitting, and pulling at tubes. Subsequent 2 hours restraint monitoring (at 9:00 AM and 11:00 AM) indicated that Pt. #22 was no longer in restraints. Progress notes dated 2/22/10 at 12:53 PM, indicated: "... Staff had to place mitts, also soft restraints back on Patient for aggressive behavior, non-redirectable at times..." Subsequent restraint orders were not found.

4. On 2/22/10 at 10:50 AM, an interview was conducted with the Patient Care Provider (E #17), caring one to one for Pt. #22 on 2/22/10. E #17 stated that she removed the restraints at approximately 8:00 AM and reapplied them at approximately 11:00 AM. E #17 stated that she was not aware that a new restraint order was required.

5. These findings were confirmed by the Quality and Safety Coordinator during an interview on 2/22/10 at approximately 2:10 PM.

A. Based on clinical record review, observation, patient interview, and staff interview, it was determined that in 7 of 10 (Pt. #s 4, 5, 10, 19, 26, 28, and 29) clinical records reviewed, the Hospital failed to ensure all physician orders were followed as written.

Findings include:

The following findings were identified in 2 of 2 (Pt. # 4 and #5 ) clinical records reviewed on the 5 East Rehab Unit:

1. The clinical record of Pt #4 was reviewed on survey date 2/22/10 at approximately 11:00 AM. Pt #4 was a 38 year old male admitted to the Facility on 2/18/10 with a diagnosis of Rehabilitation. The clinical record contained a physician's order dated 2/18/10, that required Pt #4 to use Anti-Embolism Stockings and remove every eight (8) hours for skin care and assessment. The clinical record lacked documentation that Pt #4 was using the Stockings as ordered.

2. The clinical record of Pt #5 was reviewed on survey date 2/22/10 at approximately 9:45 AM. Pt #5 was a 60 year old male admitted to the Facility on 2/12/10 with a diagnosis of Rehabilitation following Trauma. The clinical record of Pt #5 contained a physician's order requiring the use of Sequential Compression Device (SCD) to the right lower extremity while in bed. The clinical record lacked documentation that Pt #5 was using the SCD device as ordered.

3. On survey date 2/22/10 at approximately 10:45 AM a tour was conducted on the 5 East Rehabilitation Unit. During the tour it was observed that Pt #5 was in bed and not using the SCD device.

4. Pt #5 was interviewed on survey date 2/22/10 at approximately 10:45 AM. During the interview, Pt #5 stated that he does not use the SCD device.


The following findings were identified in 4 of 5 (Pt. #s 10, 26, 28, and 29) clinical records reviewed on the 7 East Medical Unit:

5. The clinical record of Pt #10 was reviewed on survey date 2/22/10 at approximately 1:00 PM. Pt #10 was a 24 year old male admitted on 2/15/10 with a diagnosis of Sickle Cell Pain Crisis. The clinical record contained a physician's order dated 2/15/10, that required Pt #10 to be weighed daily. The clinical record lacked documentation of a weight for 2/18, 2/19, and 2/20/10.

6. The clinical record of Pt #26 was reviewed on survey date 2/23/10 at approximately 10:00 AM. Pt #26 was a 32 year old male admitted on 2/19/10 with a diagnosis of Cellulitis Right Leg. The clinical record contained a physician's order dated 2/19/10, that required Pt #26 to be weighed daily. The clinical record lacked documentation of a weight for 2/20/10.

7. The clinical record of Pt #28 was reviewed on survey date 2/23/10 at approximately 9:00 AM. Pt #28 was a 54 year old female admitted on 2/10/10 with a diagnosis of Failure to Thrive. The clinical record contained a physician's order dated 2/10/10, that required Pt #28 to be weighed daily. The clinical record lacked documentation of a weight for 2/18, 2/19, and 2/20/10.

8. The clinical record of Pt #29 was reviewed on survey date 2/23/10 at approximately 9:00 AM. Pt #29 was admitted on 2/16/10 with diagnoses of Altered Mental Status and Respiratory Failure. The clinical record contained a physician's order dated 2/16/10, that required Pt #28 to be weighed daily. The clinical record lacked documentation of a weight for 2/19, 2/20, and 2/21/10.

A physician's order dated 2/16/10, required the measuring of Pt #29's intake and output every four (4) hours. The intake and output records dated 2/20, 2/21, and 2/22/10 lacked documented intake and output every four hours for Pt #29 as ordered.

9. The findings were verified by the Chief Nursing Officer during interviews on survey date 2/22/10 at 11:15 AM and 2:00 PM and 2/23/10 at approximately 10:00 AM.


This was found in 1 of 3 (Pt. #19) clinical records reviewed on 8 West Oncology:

10. The clinical record of Pt. #19 was reviewed on 2/22/10 at 2:30 PM. Pt. #19 was a 21 year old female admitted on 2/16/10 with the diagnosis of Sickle Cell Crisis. The Plan of Care printed on 2/22/10 indicated that Pt. #19 had Anti-Embolism Stockings ordered on 2/16/10 at 9:36 PM to be "Removed every 8 hours for Skin Care and Assessment". The "Nursing Care Provided" forms dated from 2/16/10 through 2/20/10 lacked documentation of the stockings ever being applied. The "Nursing Care Provided" form dated 2/21/10 at 9:00 AM, indicated that Pt. #19 did have the stockings applied (5 days after the order).

11. The Nurse (E#16) caring for Pt. #19 was interviewed on 2/22/10 at 2:45 PM. E#16 stated that Pt. #19 did not have anti - embolism stockings. E#16 went to Pt. #19's room, and returned to inform this surveyor that Pt. #19 did indeed have stockings, "they just aren't on".

12. The above findings were confirmed with the Associate Director of 8 West on 2/22/10 at 3:00 PM, during an interview.
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B. Based on review of Hospital policy, clinical record review, and staff interview, it was determined that in 1 of 2 (Pt #5) clinical records reviewed on the 5 East Rehabilitation Unit, the Hospital failed to ensure that all wound care was documented as required.

Findings include:

1. Hospital policy entitled, "Pressure Ulcer Prevention and Treatment," reviewed on survey date 2/23/10 at 8:15 AM required, "...Physical Assessment of the skin is not within defined limits and a pressure ulcer, stage I to IV, is over a prominence, the Pressure Ulcer Documentation for ulcers #1-6 is completed...6. Dressing type..."

2. The clinical record of Pt #5 was reviewed on survey date 2/22/10 at approximately 9:45 AM. Pt #5 was a 60 year old male admitted to the Facility on 2/12/10 with a diagnosis of Rehabilitation following Trauma. Clinical documentation indicated Pt #5 had a Stage II ulcer on his left lower extremity. The clinical record contained a physician order, dated 2/12/10, that required a dressing change to the left lower extremity two (2) times a day using Gauze, Kerlix, and Hydrogel Dressing. Nursing documentation dated 2/21/10 at 2:16 PM indicated the dressing to the left leg was done, without identifying the type of dressing used.

3. The findings were verified by the Chief Nursing Officer during interviews on survey date 2/22/10 at 11:15 AM.


C. Based on clinical record review, patient interview, and staff interview, it was determined that in 1 of 5 (Pt #27) clinical records reviewed on the 7 East Medical Unit, the Hospital failed to ensure all nursing procedures were performed in accordance with a physician order.

Findings include:

1. The clinical record of Pt #27 was reviewed on survey date 2/23/10 at approximately 9:00 AM. Pt #27 was a 44 year old male admitted to the Facility on 2/16/10 with diagnoses of Hip Pain and Diabetes Mellitus. The clinical record contained documentation that Pt #27 had a Stage III Left Foot Ulcer. The clinical record lacked a physician's order that indicated the type and frequency dressing to be used for Pt #27.

2. On survey date 2/23/10 at approximately 2:00 PM Pt #27 was interviewed. Pt #27 stated that every day the staff nurses changed his foot dressings with wet to dry dressings.

3. The Chief Nursing Officer confirmed the finding during an interview on survey date 2/23/10 at approximately 9:00 AM.


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D. Based on review of Hospital nutrition policy review, Hospital stated practice, observation and staff interview, it was determined that, for 1 of 2 refrigerators inspected, (refrigerator #1) the Hospital failed, to ensure refrigerated breast milk was correctly labeled and fortified supplements were not refrigerated beyond 24 hours.

Findings include:

1. The Hospital's nutritional supplementary feedings policy was reviewed on 2/22/10 at approximately 11:30 AM. The policy included "...formula to be used same day or discarded after 24 hours".

2. Hospital stated practice for fortified human milk labeling included having the person who adds a fortifier to human breast milk, label the container with the name of the fortifier, the initials of the nurse who added the fortifier, the date and time the fortifier was added to the milk.

3. On 2/21/10 at approximately 9:30 AM, the Neonatal Intensive Care Unit was toured. Refrigerator #1 had a container of Enfamil with a preparation date of 2/16/10 at 1:17 PM. The Enfamil preparation was refrigerated 4 days beyond the 24 hour requirement. Refrigerator #1 also contained (2) 100 cc containers of breast milk labeled with the patient's name, name of additive (Similac 27 Kcal/oz-powdered fortifier) and dated 2/21/10. The labels failed to contain the initials of the nurse who added the fortifier and the time the fortifier was added.

4. The above findings were confirmed by the Charge Nurse (E#15) during an interview on 2/21/10 at approximately 10:00 AM.

A. Based on review of Facility policy, observation, clinical record review, and staff interview, it was determined for 2 of 2 clinical records (Pts. #22 & 23) reviewed on the Adult Psychiatric Unit, that the Hospital failed to ensure that all patient care plans were directed toward the patient's specific needs and goals.

Findings include:

1. Hospital policy titled: "Patient Care Planning" was reviewed on 2/22/10 at 3:30 PM. The policy required: "The individualized care plan... [is] to identify the patient's care needs... lists the strategy for providing services to meet those needs... and documents the patient's progress in meeting the specified goals and objectives."

2. Adult Psychiatric policy titled: "Treatment Planning" was reviewed on 2/22/10 at 3:40 PM. The policy required: "Objective To provide guidelines for treatment planning in a regular and systematic way which addresses individuals changing needs in a timely way, and includes patient and treatment team in a partnership."

3. On 2/22/10 between 9:40 AM and 11:40 AM and again at 2:00 PM, tours were conducted in the Adult Psychiatric North Unit. At 9:55 AM, loud moaning was heard through the closed door of room 887. Pt. #22 was resisting staff cleaning after toileting. Pt. #22's hands were enclosed by large bandage mitts, to prevent her from removing a feeding tube. A security guard was assigned to prevent injury to Pt. #22 and staff. A one to one sitter was assigned to calm and assist Pt. #22 who was thrashing around in bed. At 10:15 AM, Pt. #22 was ambulating through the hall and was assisted by 2 staff members. At 2:00 PM, Pt. #22 was in bed, with all 4 limbs in soft restraints, and was quiet..."

4. On 2/22/10 at 10:30 AM, the clinical record of Pt. #22 was reviewed. Pt. #22 was a 42 year old female, admitted on 2/4/10, with diagnoses of Schizoaffective Disorder, Catatonia, and ETOH Abuse. On 2/8/10, Pt. #22 was transferred from the Neurological Surgical Unit to the Adult Psychiatric North Unit. Both the initial "Department of Psychiatry Inpatient Adult Multidisciplinary Treatment Plan" dated 2/9/10 and the weekly "Department of Psychiatry Inpatient Adult Multidisciplinary Weekly Review" dated 2/16/10, included 5 pre-printed goals: 1. Patient's Goal for Safety, 2. Patient's Treatment Participation, 3. Patient will demonstrate Functional Improvement, 4. Patient will participate in Education, and 5. Patient will Participate in Discharge Planning. The same care plan goals were used for every adult psychiatric patient.

Pt. #22 was not capable of participation in goals 4 and 5: Participation in Education and Participation in Discharge Planning. The Care Plan lacked inclusion of Pt. #22's specific goals/needs related to: nutrition, ambulation, anxiety, and restraints.

5. On 2/22/10 at 11:10 AM, the clinical record of Pt. 23 was reviewed. Pt. #23 was a 27 year old male, admitted on 11/9/09, with diagnoses of Schizophrenia, NMS, and Catatonia after ECT treatment. A Seclusion/Restraint Form dated 2/6/10, included documentation of an event for Pt. #23 for hitting a staff member resulting in being restrained for 1 1/2 hours. The weekly "Department of Psychiatry Inpatient Adult Multidisciplinary Weekly Review" dated 2/9/10, and 2/16/10, included the same 5 pre-printed goals described for Pt. #22. Pt. #23's Care Plan lacked inclusion of specific goals/needs related to striking staff and restraints.

6. An interview was conducted with the Quality & Safety Coordinator on 2/22/10 at 11:40 AM. The Coordinator confirmed the findings that the Adult Psychiatric Care Plans were not specific to patient's needs and goals.

A. Based on a letter of attestation and staff interview, it was determined that the Hospital failed to ensure completion of medical records with in 30 days of discharge.

Findings include:

1. An attestation letter dated 2/22/10 from the Health Information Management (HIM) Director, was presented on 2/22/10. The letter indicated that as of survey date 2/22/10 there were 199 clinical records incomplete greater that 30 days.

2. The finding was confirmed with the Health Information Management Director on 2/24/10 at 3:15 P.M.

A. Based on review of Facility policy, clinical record review, review of a lab report, and staff interview, it was determined that in 1 of 1 (Pt #29) clinical record reviewed of a patient with a nasal MRSA (Methicillin Resistant Staphylococcus Aureus) culture, the Facility failed to ensure all staff were informed in a timely manner of a positive report.

Findings include:

1. Facility policy entitled, "Documenting and Reporting Corrected, Critical Tests or Result/Value," reviewed on survey date 2/24/10 at 11:45 AM required, "...A Critical Result/Value must be telephoned to the care provider...immediately"

2. Facility policy entitled, "Critical Test Results Reporting," reviewed on survey date 2/24/10 at 11:45 AM required, "...Critical results will be communicated to the health care provider responsible to act upon test results via both verbal notification and via the electrical medical record."

3. The clinical record of Pt #29 was reviewed on survey date 2/23/10 at approximately 11:00 AM. Pt #29 was a 76 year old female admitted to the Facility on 2/16/10 to the Intensive Care Unit (ICU) with diagnoses of Altered Mental Status and Respiratory Failure and transferred to 7 East Medical on 2/19/10. The clinical record contained a physician's order dated 2/16/10 that required a MRSA (Methicillin Resistant Staphylococcus Aureus) culture. The clinical record contained a report that indicated the culture was obtained on 2/16/10 and sent to the lab. The report indicated that the East 7 Medical Unit was notified of the positive report on 2/23/10 (seven days after obtained) with the report of "Moderate Staphylococcus Aureus (MRSA) patient required contact isolation."

4. On survey date 2/23/10 the Facility's Lab presented a report of the steps taken to confirm the final report for Pt #29's MRSA culture. The report indicated that the preliminary report was positive on 2/19/10 for gram positive cocci, and that the lab indicated Pt #29 was a clinic patient (patient actually on East 7). The final report was dated 2/ 22/10 indicated a positive MRSA culture and not called to the East 7 Medical Unit until 2/23/10.

5. The findings were confirmed by the Point of Care Testing Quality Assurance and Laboratory Compliance Officer during an interview on survey date 2/24/10 at approximately 11:45 AM.

A. Based on review of Hospital policy, review of Food Temperature Monitoring log and staff interview, it was determined that in 8 of 25 days, food temperatures were not consistently taken and documented as required by policy.

Findings include:

1. The Hospital policy titled, "Steam Table Temperature Control Record," was reviewed on 2/24/10 at 12:00 PM. The policy required, "Hot food temperatures are physically taken and recorded per meal service."

2. The Food Temperature Monitoring Sheets from 1/28/10 to 2/22/10 were reviewed on 2/24/10 at 12:00 PM. The following dates lacked documentation of food temperatures:

*2/21/10-Lunch
*2/19/10-Dinner
*2/16/10-Dinner
*2/15/10-Dinner
*2/13/10-Breakfast.
*2/14/10-Dinner
*2/8/10-No temperatures were taken for any meal service.
*2/5/10-Breakfast and Lunch.

3. The above findings were conveyed to the Director of Food and Nutrition on 2/24/10 at 12:10 PM during an interview.

During a Complaint Survey conducted on 12/09/09 (Complaint 002768) the surveyors found that the Standard, A 710, Life Safety from Fire, was NOT MET.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint conducted on 02/22/2010 through 02/25/2010, the surveyors still find that the facility does not comply with the applicable provisions of athe 2000 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated 02/25/2010.

Complaint # 092768

A Complaint Follow Up Survey to the above
complaint was conducted on 02/22/10, in
conjunction with a Full Validation Survey
due to complaint. The complaint citations
have been updated and transferred to the Full
Validation Survey. The complaint survey
will be closed and the Plan of Correction for
outstanding citations from the complaint
survey will be tracked under the Full
Validation Survey due to complaint,
dated 02/25/10.

A. Based on observation and staff interview, it was determined, for 1 of 4 Operating Room Suites toured (Suite 2), that the Hospital failed to ensure all OR suite equipment was free of tape and tape residue.

1. A tour was conducted in OR Suite 2 on 2/23/10 between 6:05 AM and 6:50 AM. The following was found:

- Tape residue was found on the table, table arm rests, and blood pressure cuff tubing.

- Tape was found on the X-ray view box and IV pole.

- The Anesthesia cart handle was broken and attached with tape.


2. An interview was conducted with the Quality & Safety Coordinator during the tour on 2/23/10 at 6:25 AM. The Coordinator confirmed the findings.


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B. Based on observation and staff interview, it was determined that for 1 of 1 crash cart available on 8 West (Oncology), the Hospital failed to ensure that there was unobstructed access to the crash cart.

Findings include:

1. A tour of 8 West Oncology unit was conducted on 2/22/10 at 1:00 PM. The crash cart was located in the back corner of the nurses station with 2 chairs and an Electrocardiogram machine directly in front of the crash cart, obstructing access. All of these items would have to be moved prior to gaining access to the Crash cart, causing a delay in an emergency situation.

2. The above finding was confirmed with the Associate Director of 8 West on 2/22/2010 at 3:00 PM, during an interview.


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C. Based on review of Facility policy, observation and staff interview, it was determined that for 1 of 1 patient nourishment refrigerator on the 7 East Medical Unit, the Facility failed to ensure staff food items were not stored in patient refrigerators.

Findings include:

1. Facility policy entitled, "Temperature Monitoring of Refrigerators and Freezers Used for Patient Care," reviewed on survey date 2/23/10 at 9:10 AM required, "...Proper Storage Requirements:...Note: Staff food is never to be stored in any designated Patient Care Refrigerator or Freezer."

2. On survey date 2/22/10 at approximately 1:45 PM, a tour of the 7 East Medical Unit was conducted. During the tour the patients' nourishment refrigerator was checked. A plastic bag containing employee food and an opened unlabeled bottle of soda were found.

3. The findings were verified by the Chief Nursing Officer during an interview on survey date 2/22/10 at 2:00 PM.

A. Based on protocol review and staff interview, it was determined that, for 2 of 2 employees interviewed (E#s 18 and 19), the Hospital failed to ensure staff use the Hospital approved cleaning product for management of Clostridium Difficile.

Findings include:

1. On 2/24/10 at approximately 1:00PM, the Hospital's "Management Protocol for Clostridium difficile" (C-diff) was reviewed. The protocol included, " Room disinfection must be conducted per policy. The room must be thoroughly cleaned using a 10% sodium hypochlorite(bleach) solution, daily..."

2. On 2/24/10 at approximately 9:30AM unit 6 West was toured. The census was 23 and there were two patients on contact isolation to rule out C-diff. At approximately 10:10AM, housekeeper (E#18) was interviewed. E # 18 stated that Virex is used for cleaning all rooms. The housekeeper was unfamiliar with the use of bleach for cleaning those rooms of patients who were in isolation for C-diff. On 2/24/10 at approximately 10:30AM, the Assistant Manager of Facilities (E#19)was interviewed. The Manager stated Virex was approved as the cleaning agent for all rooms.

3. The above findings were discussed with the Infection Control Practitioner during an interview on 2/24/10 at approximately 11:30AM.


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B. Based on review of Facility policies, observation, clinical record review, and staff interview, it was determined that in 1 of 2 (Pt #29) clinical records reviewed of patients requiring isolation on the 7 East Medical Unit, the Facility failed to ensure proper isolation procedures were implemented as required.

Findings include:

1. Facility policy entitled, "Multi-Drug Resistant Organism (MDRO) Management Protocol," reviewed on survey date 2/24/10 at 8:30 AM required, "Purpose: To establish a protocol to reduce the potential for transmission of MDRO to patients, staff and visitors. In addition to Standard Precautions, Contact Precautions will be utilized for all patients suspected to be infected or colonized with an MDRO....Identification surveillance cultures (ASC) are required for all high risk patients (admission to an ICU...)"

2. On survey date 2/23/10 at approximately 9:00 AM the 7 East Medical Unit was toured. During the tour it was observed that Pt #29 was in room 723 without isolation precautions.

3. The clinical record of Pt #29 was reviewed on survey date 2/23/10 at approximately 11:00 AM. Pt #29 was a 76 year old female admitted to the Facility on 2/16/10 to the Intensive Care Unit (ICU) with diagnoses of Altered Mental Status and Respiratory Failure and transferred to 7 East Medical on 2/19/10. The clinical record contained a physician order dated 2/16/10 that required a MRSA (Methicillin Resistant Staphylococcus Aureus) culture. The clinical record lacked documentation that Pt #29 was placed on Contact Precautions as required.

4. The finding was confirmed by the Director of Nursing during an interview on survey date 2/23/10 at approximately 10:00 AM.


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This was found for 1 of 3 (Pt. #11) patients on the Pediatric Unit, identified as a patient requiring isolation:

Findings include:

5. The Hospital policy titled, "Rationale for Isolation Precautions, "Type and Duration of Isolation Precautions for selected Infections and Condition: Clostridium difficile (C-diff) C (contact)...duration of illness. Contact precautions: Gown, gloves.... required to enter room."

6. The Pediatric Unit was toured on 2/22/10 between 9:15 and 10:15 AM. Pt. #11 in room 591, was identified as an isolation patient prior to the tour, was not on isolation. No isolation precaution signage was observed, or isolation precaution equipment available at the door, and staff were observed providing direct care to Pt. #11 without using personal protective equipment, (gloves and gown).

7. The clinical record of Pt. #11 was reviewed on 2/22/10 at 10:20 AM. Pt. #11 was a 17 year old male admitted on 2/16/10, with diagnoses of status post Renal Transplant, immunosuppressed, Fever and Pneumonia. An Emergency Department physician's note dated 2/16/10 at 8:35 PM included a diagnosis of Fever and Bacterial Infection. The clinical record contained documentation dated 2/16/10 at 10:00 PM that indicated: "Admit to: Isolation Bed." On 2/20/10 at 11:49 AM, a physician ordered to "collect specimen for C-diff." As of survey date 2/22/10 at 10:00 AM, Pt. #11 was not on isolation precautions.

8. The above findings were confirmed with the Pediatric Nurse Manager during interview on 2/22/10 at 10:30 AM

A. Based on observation and staff interview, and stated practice, it was determined, for 1 of 1 (E #14), Anesthesiologist in OR Suite 2, that the Anesthesiologist failed to ensure that the intravenous (IV) tubing port was disinfected prior to medication administration.

Findings include:

1. A tour was conducted in OR Suite 2 on 2/23/10 between 6:05 AM and 6:50 AM. At 6:37 AM the Anesthesiologist (E #14) administered medication through the IV port without first disinfecting the port.

2. An interview was conducted with the Quality & Safety Coordinator during the tour on 2/23/10 at 6:38 AM. The Coordinator confirmed the findings.

3. The OR Manager stated on 2/23/10 at approximately 7:30 AM, that there is no policy for IV tubing disinfection. However, the Manager stated it is standard practice to disinfect the IV tubing port prior to administration of medications.

A. Based on review of Hospital policy, observation and staff interview it was determined for 3 of 3 Operating Room suites toured (OR suites # 1, # 2 and # 12), that the Hospital failed to ensure that surgical attire policies were followed.

Findings include:

1. The Hospital policy titled, "Infection Control in the Operating Room," was reviewed on 2/23/10 at 9:00 AM. The policy included "...7. Masks are to be properly fastened and of proper fit and wear mask during sterile setup. Masks are discarded at the end of each case. Masks are not to be worn dangling around the neck....8. Hair and facial hair...must be covered by caps...11. All personnel entering the OR suite to assist (scrubbed) directly in a procedure must have jewelry removed (rings, bracelets and earrings)....13. Clothing that can't be covered by surgical attire should not be worn due to bacterial shedding ".

2. A tour of OR suite # 1 was conducted on 2/23/10 from 6:00 AM until 7:00 AM. The following was observed:

- At approximately 6:40 AM, E#13 entered the OR suite holding a surgical mask over his face, with the top and bottom ties unsecured, while sterile packs were opened. E#13 was wearing a white undershirt beneath his surgical attire.

- At approximately 6:45 AM, E#12 entered the OR suite with approximately 3 inches of his hair exposed from the bottom of the surgical cap. E#12 was not wearing a surgical mask, while sterile packs were opened.


This occurred in OR Suite 2:

3. A tour was conducted in OR Suite 2 on 2/23/10 between 6:05 AM and 6:50 AM. Sterile instruments and supplies were open at 6:10 AM and the following was found:

- An Operating Room Technician's (E #2) hair was exposed 2 inches below the hair net.

- An Orthopedic Resident (E #3) wore a gold colored neck chain.

- An Orthopedic Surgeon (E # 6) entered holding the untied mask.

- An Orthopedic Surgeon (E #7) entered tieing the mask.

4. An interview was conducted with the Quality & Safety Coordinator during the tour on 2/23/10 at 6:40 AM. The Coordinator confirmed the findings.


This occurred in Surgi Center Holding:

5. A tour was conducted in the unrestricted Surgi Center Holding Area, on 2/23/10 between 7:10 AM and 7:20 AM. The following was found:

- 1 of 12 staff members wore a mask that should have been removed and discarded at the end of the surgical case.

- 1 of 12 staff members wore a dangling mask and retied it before returning to the OR.

- Two of 2 staff members carried masks in the back pocket.

6. An interview was conducted with the Quality & Safety Coordinator during the tour on 2/23/10 at 7:15 AM. The Coordinator confirmed the findings.
(19843)


This was found in OR Suite 12:

7. During observation of OR suite 12 between 6:00 AM and 7:00 AM the following was observed:

*The CRNA (E #8) was observed wearing a white shirt underneath the scrub gown.
*A Medical Student (E #9) and an Anesthesiologist, (E #10) had 1 inch of hair exposed to the back of the head.
*An RN (E #11) entered the suite, with surgical packs opened, holding on to a mask over her face.

8. The above findings were discussed with the Manager of the OR, during interview on 2/23/10 at 7:40 AM.
(19840)


07105


B. Based on policy review, observation and staff interview, it was determined that the Hospital failed to ensure staff in surgical attire who are in restricted OR areas do not co-mingle with persons in unrestricted areas who wear street clothes.

Findings include:

1. The Hospital's policy titled, "Infection Control In The Operating Room," was reviewed on 2/23/10 at approximately 10:30AM. The policy included, "Traffic Flow Patterns: All...personnel must be properly attired before being permitted entry into the operating room suite. All individuals who enter the ...restricted areas of the surgical suite should wear ...surgical attire..."

2. On 2/23/10 the operating room suite was toured from 6:30AM until 8:45AM . Staff obtain surgical scrubs in an unrestricted area designated by a red line inside the OR and across from the nurse's station. Staff in scrub attire were observed leaving an OR corridor (restricted area) and entered the unrestricted area where staff were in street clothes. Hence, staff in scrubs were co-mingling with staff who were in street clothes.

3. The above findings were confirmed by the Nurse Manager and Chief Nursing Officer during an interview on 2/23/10 at approximately 7:30AM.


This was found in the Surgi Center Holding:

4. A tour was conducted in unrestricted Surgi Center Holding area on 2/23/10 between 7:10 AM and 7:20 AM. Personnel and Patient's family members wore street clothing. Approximately 10 of 12 staff members wore scrubs without cover gowns and were entering from and returning to the semi-restricted OR corridor.

5. An interview was conducted with the Quality & Safety Coordinator during the tour on 2/23/10 at 7:15 AM. The Coordinator confirmed the findings.
(19843)


C. Based on policy review, observation and staff interview, it was determined that the Hospital failed to ensure for 1 of 3 OR (operating room ) corridors observed, staff do not enter the restricted area of the OR with outside bags.

Findings include:

1. On 2/23/10 at approximately 10:00AM, the Hospital's Infection Control policy for the operating room was reviewed. The policy included, " ...no outside bags/backpack are brought into the O.R. External bags may carry contaminants into the surgical suite".

2. On 2/23/10 at approximately 7:00AM, an unidentified person was observed walking down a corridor in the restricted area of the OR while carrying a large black bag.

3. The above finding was confirmed by the Chief Nursing Officer during an interview on 2/23/10 at approximately 7:10AM.