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Based on observation, interview, record review and recognized standards of practice, the hospital failed to ensure patients were provided care in a safe setting in 22 of 22 patient rooms when the hospital failed to provide an environment aimed at preventing looping and hanging hazards. The facility census was 183.

Findings included:

1. Recognized standards of practice for a psychiatric facility include:

The Veteran's Health Administration (VHA) National Center for Patient Safety formed a national committee that developed The Environment of Care Checklist for the purpose of reducing environmental factors that contribute to inpatient suicides, suicide attempts, and other self-injurious behaviors. This initiative is consistent with the Joint Commission patient safety goals as well as the current literature on prevention of suicidal behaviors (Suicide Prevention Strategies: A systematic review, Journal of the American Medical Association, [JAMA], 2005, v 294, 2064 -2074).

The Joint Commission (TJC) is a United States-based not-for-profit organization. The Joint Commission accredits over 19,000 health care organizations and programs in the United States. This hospital is accredited and deemed by TJC.

JAMA, published continuously since 1883, is an international peer-reviewed general medical journal published 48 times per year. JAMA is the most widely circulated medical journal in the world.

The VHA, TJC and JAMA have all established accepted standards of practice for psychiatric inpatient facilities in the United States.

The VHA committee developed the Mental Health Environment of Care Checklist (MHEOCC) with the goal to prospectively identify and eliminate environmental risks for inpatient suicide and suicide attempts. Anchor points had the greatest risk-level classification and were the most common hazard for hanging.

2. Record review of the facility's policy titled, "Precaution and Observation levels" revised 06/11 stated:
Policy: All patients have observation levels assigned to them upon admission and are monitored at a minimum of every 15 minutes during their entire hospitalization. All patients admitted to Behavioral Health services have been deemed unsafe in some manner and are required to be placed within a locked facility.
Procedure: The levels of observation for patients are ordered by the attending psychiatrist. The following observation levels are used in Behavioral Health Services:
- 15 minute observation rounds documentation
- Within-Line-of Sight at all times
- Within-arm-length-reach at all times
PROCESS: Physician orders specify precautions that are used to identify the inherent risk of the specific patient.
- Suicide Precautions

3. Record review of the Patient List dated 09/20/11 submitted by Staff RR, Registered Nurse (RN), Team Leader for the Adult Unit showed 24 of 26 patients on the adult unit were on suicide precautions. All patients admitted to the Wentzville facility have been deemed unsafe in some manner and are required to be placed within the locked facility.

4. Observation of 2nd Floor Adult Unit with a census of 26 inpatients (24 inpatients on suicide precautions) on 09/20/11 at 4:04 PM and on 9/21/11 at 8:30 AM showed 22 patient rooms (Rooms 2200 through 2210 and 2101 through 2113). Each patient room contained a conventional nightstand approximately 3 feet tall that was easily moved and could be used to stand on to attach looping over the doors.

Each room contained the following beds:
- Room 2201 had two electric high/low (beds that could be raised and lowered - raised to approximately two feet and with the rails up a height of approximately three feet could be attained) beds and an attached electric cord in varying lengths (three to eight feet) that were not secured;
- Room 2202 had two beds, each with 4 moveable side rails providing both height and looping mechanisms;
- Room 2203 had one high/low electric bed with cord and two moveable side rails;
- Room 2204 had one bed with two moveable side rails;
- Room 2205 had one bed with two moveable side rails;
- Room 2206 had one bed with four moveable side rails;
- Room 2207 had one bed with four moveable side rails;
- Room 2208 had one electric bed with a 6 foot cord and two moveable side rails;
- Room 2009 had one electric bed with a 6 foot cord and two moveable side rails;
- Room 2010 had one electric bed with a 6 foot cord and two moveable side rails;
- Room 2101 had two beds; one with four moveable side rails and one with two moveable side rails;
- Room 2102 had one electric bed with a 3 foot cord and two moveable side rails; and
- Rooms 2103 through 2113; each room contained one bed with four moveable rails.

Beds with side rails and long cords provide looping and hanging hazard areas.

During an interview on 09/21/11 at 8:30 AM, Staff KK, RN, Executive Director of Nursing, stated that the facility had brought in a specialist in behavior health environment and he/she told them there were no psychiatric-safe beds on the market, so they [the facility] had no plan to change the beds but had discussed it. Staff KK also stated that the cords on the electric beds should have been secured with plastic ties to minimize the cord length to 6 inches or less.


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During an interview on 09/21/11 at 11:41 AM Staff KK stated that the rails were only one part of the safety issues of these beds. He/she stated that I don't see taking off the rails would solve anything because there are significant other problems; such as the holes in the deck [of the beds]; the head boards and foot boards and the heights of the beds. Staff KK stated that holes in the deck (under the mattress) of the beds can provide an anchor point to attach looping mechanisms.

Based on observation, interview, record review, and policy review, the facility failed to:
- Adhere to approved infection control practices and facility policy regarding contact isolation precautions and wearing of personal protective equipment (PPE) for four (#18, #8, #17, #4) of six patients observed on contact isolation. Failure to follow contact isolation precautions potentially results in cross contamination of infectious organisms and could impact all patients.
- Ensure staff performed hand hygiene as appropriate for seven (#17, #4, #18, #1, #5, #9, and #13) of 21 patients' procedures observed. Failure to perform hand hygiene potentially results in cross contamination of infectious organisms and could impact all patients.
- Ensure staff followed policy and checked for sterility of sterile instruments during one of one sterile instrument packs opened. Failure to check the sterility could result in non-sterile instruments being used in surgical cases.
- Ensure staff keep a test strip log, ensure test strips were not expired, ensure solution was not expired, and rinse equipment appropriately when using OPS Plus (solution used for high level disinfection of some instruments) in the Family Birthplace unit. Failure to follow policy and manufacturer's guidelines could result in equipment not being disinfected appropriately.
- Ensure medications and supplies were not expired or used in the Family Birthplace unit and the Orthopedic Unit. Failure to follow policy and manufacturer's guidelines could impact patient care by not having the desired results.
- Adhere to facility policy regarding maintenance of indwelling urinary catheters (a sterile tube inserted into the bladder to drain urine) for one (#18) of two patients observed for indwelling urinary catheter care. Failure to correctly perform indwelling urinary catheter care could result in a urinary tract infection.
- Maintain the integrity of a mattress on one of one bassinet's observed in the nursery. Failure to maintain the mattress integrity prevented appropriate cleaning of the mattress.
- Administer medications without contamination for one (#11) of eight patients observed during medication administration. Failure to maintain cleanliness and avoid contamination could result in the patient acquiring an infection.
- Maintain an air vent free of dust in one of one operating room observed where Caesarean sections (C-section - surgical procedure to deliver babies) were performed. Failure to maintain a clean environment could result in patients acquiring an infection.
- Maintain clean portable fans in use by two (#19 and #8) of two patients observed with portable fans. Failure to maintain cleanliness of portable fans could result in dust blowing on patients.
The facility census was 183.

Findings included:

1. Record review of the facility's policy titled "Infection Control Policies/Isolation Precautions" revised on 03/09 showed the following direction:
Standard Precautions:
- All linen is handled in a manner that prevents contamination of clothing and avoids transfer of microorganisms to other patients and environment.
Contact Precautions:
- Wear gloves upon entering the patient room and for all direct and indirect contact with the patient and contaminated items.
- Hands should be washed with an antimicrobial agent or waterless antiseptic agent.
- Wear a gown upon entering the room, since the nature of the interaction with the patient cannot always be predicted.
Education-Patient Teaching:
- The primary nurse will provide initial patient/family education as to the potential for spread of disease.

Record review of the facility's policy titled "Infection Control Policy/Care of the Patient with Multi-Drug Resistant Organisms" revised on 05/08 showed the following direction:
- Gloves are worn upon entry into the patients' room.
- Remove gloves and wash hands upon leaving.
- Visitors will be asked to don the same apparel required for staff.

Record review of the facility's policy titled, "Hand Hygiene" revised 01/11 showed the following direction:
- Hand hygiene: Before and after each patient contact.
- Hand hygiene: After handling patient equipment.
- Hand hygiene: After removing gloves.
- Hand hygiene: Before and after contact with wounds, whether surgical, traumatic or associated with an invasive device.
- Remove gloves and wash hands after caring for the patient.

Record review of the Centers for Disease Control 2007 (most recent) guidelines for "Preventing Transmission of Infectious Agents in Healthcare Settings" showed that alcohol does not kill Clostridium difficile also known as C. diff (a spore forming bacterium that causes severe diarrhea and other intestinal disease) spores and that the use of soap and water is more efficacious (effective) than alcohol-based hand rubs.

2. Observation on 09/20/11 at 9:45 AM showed Staff GG, Sitter, in Patient #18's room with a gown on but no gloves. A sign at the patient's doorway showed that the patient was on contact isolation and instructed anyone who entered to wear a protective gown and gloves.

During an interview at that time, Staff GG stated he/she would wear gloves if needed to help the patient but would not wear them all the time when in the room.

During an interview on 09/20/11 at 1:45 PM, Staff S, RN, Infection Control Coordinator, stated that he/she expected sitters to wear a gown and gloves in the room if a patient is on isolation precautions.

3. Review of Patient #8's medical record showed the patient was on contact isolation for MRSA.

Observation on 09/20/11 at approximately 11:30 AM showed Staff W, Clinical Partner (assistant to nurses), entered Patient #8's room to check the patient's blood sugar. A sign at the patient's doorway showed that the patient was on contact isolation and instructed anyone who entered to wear a protective gown and gloves. Staff W wore a protective gown but did not tie his/her protective gown at the neck or waist, exposing his/her clothing. (The protective gown is to be tied to provide maximum protection from microorganisms.) After completing the blood sugar test, Staff W removed his/her protective gown and gloves then walked back across the patient's room to the bathroom, saw that the sink was in use by dialysis (machine used to filter the blood when the kidneys do not function) equipment then walked back to the doorway to use the antiseptic hand foam.

Observation on 09/20/11 at approximately 11:40 AM showed Staff X, Laboratory Technician, entered Patient #8's room to draw blood. While at the patient's bedside, Staff X reached under his/her protective gown while wearing a contaminated glove to retrieve an ink pen and used the ink pen at the patient's bedside. Staff X left the patient's bedside two times while wearing the protective gown and gloves and reached outside the patient's room to retrieve items off of a cart. Staff X performed hand hygiene while holding the potentially contaminated ink pen and then carried the ink pen out of the patient's room without wiping it off.

During an interview on 09/20/11 at 1:30 PM, Staff S stated that the expectation was to tie the protective gown at both the neck and waist. Staff S stated that staff members should not wear the protective gown and gloves, leave the patient's bedside and retrieve items from outside of the patient's room.

4. Observation on 09/19/11 at 2:34 PM showed a code blue (a hospital code used to indicate a patient requiring immediate resuscitation) announced for Patient #17. A contact isolation sign was on the patient's door to alert staff and visitors that special precautions should be used before entering or exiting the room. Review of the medical record showed Patient #17 was on contact isolation for C. diff. A hospital visitor appeared in the hall directly opposite Patient #17's door. The hospital visitor was visiting Patient #16 in a different room who was on contact isolation precautions requiring Personal Protective Equipment (PPE) - (the use of a protective gown, gloves and/or mask to protect the patient, visitor, public and staff from contracting or spreading a known infectious organism). During an earlier interview on 09/19/11 at 1:58 PM, Staff LL, RN, stated that the visitor for Patient #16 had refused to wear PPE even though Patient #16 was diagnosed to have MRSA and did not use hand hygiene as requested.

Observation on 09/19/11 at 2:42 PM showed Patient #17's spouse leave the patient's room with PPE equipment on and hugged the visitor of Patient #16 and remained in the hall outside the contact isolation room (with no PPE on). Patient #16's visitor went into Patient #17's room and did not put on PPE equipment.

Observations on 09/19/11 at 2:50 PM showed Staff NN, Phlebotomist (person responsible to draw blood for laboratory testing or transfusion), enter Patient #17's room but did not put on PPE equipment and did not wash hands but put on gloves. Staff NN exited Patient #17's room and removed gloves but did not wash his/her hands with soap and water as required by CDC guidelines to remove C-diff spores.

During an interview on 09/19/11 at 3:00 PM, Staff NN stated he/she was, "just handing them some collection tubes". (C-diff spores are extremely mobile and airborne and can be transported on clothing and hands which is why PPE and soap and water hand washing are required.)

Observation on 09/19/11 at 2:53 PM showed Staff OO, Anesthesia, enter Patient #17's room and put on PPE equipment but did not tie the gown in back. (PPE is designed to cover all the clothing of the person wearing it and if not worn properly contaminates the clothing that will be worn out of the room and spreading the C-diff spores to other areas and spreading the infection.)

5. Observation on 09/20/11 at 9:45 AM showed Staff I, RN, and Staff J, Licensed Practical Nurse (LPN) provided indwelling urinary catheter care to Patient #4 who had a diagnosis of MRSA and was in Contact Isolation. Staff I donned a gown which did not cover approximately six inches of his/her body from the neck down and did not cover approximately eight inches in the back from neck to hemline. Staff J, after cleaning the perineum, placed the dirty wash cloths on the bedside night stand and the wash cloths then fell on the floor. After providing urinary catheter care, Staff J placed his/her hand on the bedside rail and picked up supplies and then emptied the patient's water pitcher. Staff I did not perform hand hygiene between the tasks.

During an interview on 09/20/11 at 1:55 PM Staff S stated that the expectation would be for staff to bring the dirty utility bag over by the patient's bed during urinary catheter care and put the dirty wash cloths in it. Staff S also stated staff should not put dirty wash cloths on the bedside table.

6. Observation on 09/20/11 at 9:50 AM showed Staff EE, Dietary Staff, entered Patient #18's room with gloves on and delivered a meal tray. A sign at the patient's doorway showed that the patient was on contact isolation and instructed anyone who entered to wear a protective gown and gloves. Staff EE left the room and took off his/her gloves and did not perform hand hygiene.

During an interview on 09/20/11 at 1:45 PM, Staff S stated that he/she expected anyone, to include dietary staff, to perform hand hygiene after removing gloves.

7. Observation on 09/19/11 at 3:05 PM showed Staff K, Patient Liaison, (an employee of the hospital who gives non technical support to the patients in the Emergency room) entered Room #7 of the Emergency Department without performing hand hygiene. Staff K left the room without performing hand hygiene and returned to the room, placed a blanket on the patient and exited the room. No hand hygiene was performed between these tasks.

During an interview on 09/19/11 at 3:06 PM Staff H, Director of the Emergency Department, stated that Patient Liaisons were employees who would receive infection control training for the "limited scope they have". Staff H stated all employees should perform hand hygiene.

8. Observation on 09/19/11 at 3:07 PM showed Staff JJ, RN wore gloves to draw blood from a vein access of the patient in Room #8. Staff JJ wearing the same gloves opened the cabinet doors and retrieved a label and placed it on the dressing for the vein access. Staff JJ removed his/her gloves and without performing hand hygiene listened to the patient's lung sounds and heart sounds and picked up the blood specimen tubes and carried them out of the room.

During an interview on 09/19/11 at 3:15 PM Staff H stated staff should remove their gloves after drawing blood and perform hand hygiene before touching anything else in the room.

9. Observation on 09/19/11 at 1:27 PM showed Staff L, RN, Director of Family Birthplace and Medical/Oncology, entered Patient #5's room to ask permission for the surveyor to interview the patient. Staff L entered the room, closed the door and was in the room for approximately 10-15 seconds and then exited the room. Surveyor entered the room and asked Staff L where the antiseptic hand foam was in order to perform hand hygiene. Staff L stated that he/she did not know where the hand foam was located. Staff M, RN, Team Leader on Family Birthplace showed Staff L the hand foam was located behind the privacy curtain (where it was not visible without moving the privacy curtain).

During an interview on 09/20/11 at 1:30 PM, Staff S stated that he/she expected staff to to perform hand hygiene when going in a patient's room and when leaving a patient's room. Staff S stated that even if the patient was not touched, he/she would still expect staff to perform hand hygiene.

10. Observation on 09/20/11 at 10:10 AM showed Staff PP, RN, Staff Nurse, inserted a PICC (peripherally inserted central catheter inserted in a vein, and then advanced through increasingly larger veins to administer medication and fluid) line into Patient #9. A PICC insertion is a sterile procedure, as explained by the nurse as a standard for the procedure, and a sterile field (a specified area [such as within a tray or on a sterile towel] that is considered free of infectious organisms) must be maintained throughout the procedure. At 10:45 AM Staff PP put on a sterile gown but did not fasten it in back. At 11:04 AM Staff PP removed sterile gloves and without performing hand hygiene, donned another pair of sterile gloves to continue the procedure.

During an interview on 09/20/11 at 11:30 AM, Staff Y, RN, Director for Critical Care Nursing, stated that Staff PP should have fasten the sterile gown that is required to maintain a sterile environment and did not perform hand hygiene between glove changes which is a CDC guideline for infection control.

11. Observation on 09/20/11 at 8:30 AM showed Staff CC, RN, entered Patient #13's room to administer medications. Staff CC donned gloves then removed the right glove to open liquid medications and pour into cup. Staff CC put the same glove back on the right hand rather than getting a clean glove and did not perform hand hygiene between the glove change, which is required by CDC guidelines.

12. Record review of the facility's policy titled, "Preparation of an Operating Room for a Surgical Procedure" updated 06/10 showed the following information:
- Verify the expiration date, package integrity and the chemical process indicator when opening each package of sterile supplies/instruments onto the sterile field.

13. Record review of the Centers for Disease Control and Prevention (CDC) document titled, "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008," showed the following direction:
- The sterilization procedure should be monitored routinely by using chemical indicators to evaluate the sterilizing conditions and indirectly the microbiologic status of the processed items.
- Chemical indicators indicate that the item has been exposed to the sterilization process.
- A chemical indicator also should be placed on the inside of each pack to verify sterilant penetration.
- Chemical indicators usually are either heat-or chemical-sensitive inks that change color when one or more sterilization parameters.

14. Observation on 09/19/11 at 1:45 PM showed Staff N, RN, Family Birthplace opened a pack of sterile instruments.

During an interview on 09/19/11 at 1:45 PM, Staff N stated that when he/she opened a pack of sterile instruments he/she looked at the date stamp on the outside of the pack and looked at instruments to make sure they were clean. After several prompting's, Staff N stated that he/she does not look at the chemical indicator (placed inside a pack to show if sterilization of pack was effective).

During an interview on 09/20/11 at 1:30 PM, Staff S stated that he/she expected staff members to check the chemical indicator to check for sterility of instruments.

Review of Staff N's personnel file showed no training specific to checking sterility of supplies.

During an interview on 09/21/11 at 11:10 AM, Staff II, Director of Education, stated that no specific training was found for Staff N opening sterile packs and checking sterility.

15. Record review of the facility's policy titled, "Guidelines for High Level Disinfection of Semi-Critical Device/Equipment with Ortho-Phthalaldehyde (OPA) Solution" revised 01/11 showed the following direction:
- Test the OPA solution prior to each use with appropriate test strips.
- Rinse each item thoroughly with copious amounts of potable water.
- Repeat rinsing process twice for a total of three rinses using clean water for each rinse.
- Discard OPA solution after 14 days.
- Date the test strips bottle after opening.
- Test strips are only good for 90 days after opening the bottle.
- OPA Solution Log Sheet included test date, load/tray, date solution expires, date test strips expire, results, tested by (initials).

16. Observation on 09/19/11 at 1:55 PM in the Family Birthplace dirty equipment room showed a facility policy titled, "Infection Control Policy Guidelines for High Level Disinfection of Semi-Critical Device/Equipment with Cidex OPA Solution," dated 08/06, on the shelf next to the OPA Plus. That policy was different than the policy provided later titled, "Guidelines for High Level Disinfection of Semi-Critical Device/Equipment with Ortho-Phthalaldehyde (OPA) Solution," dated 01/11. The Family Birthplace unit maintained an outdated policy for staff reference. However, both policies gave direction for staff to rinse a total of three times, not one time for three minutes as stated in the interview to follow. Further observation showed one open bottle of OPA Plus test strips. The bottle had been opened and a hand written note stated it expired on 05/10/11. The Family Birthplace unit staff provided a log of when the test strips were used with the last date of 03/23/11. The hand-written log did not include all of the elements required by the new policy. A small plastic container was on the shelf that contained OPA Plus for soaking and disinfecting instruments. A piece of tape on the top of the container showed the solution was good until 09/06/11. The date of 09/06/11 did not correlate with the last date the test strips were used of 03/23/11.

During an interview on 09/19/11 at 1:55 PM, Staff O, Scrub Tech in the Family Birthplace, stated that when the OPA Plus was used, the instruments were then rinsed with hot water for three minutes (different from policy that stated to rinse a total of three times)..

17. Record review of the facility's policy titled "Infection Control Policies Central Distribution Department" revised 05/07 showed the following direction:
- Items are shelved on a first in first out method.
- As items are shelved, existing items are checked for expiration dates.
- Minimum sterile stock is maintained and par leveled (minimum number of item to keep on hand) on the using units to better insure that expiration dates are checked.
- All disposable outdated supplies shall be brought back to Central Distribution for disposal or donation as appropriate.

Record review of the facility's policy titled "Expired, Defective and Recalled Drugs" reviewed 01/09 showed the following direction:
- Drugs in nursing areas that reach or exceed their stated expiration date shall be returned to the Pharmacy.

Record review of the facility's policy titled "Medication Labeling and Verification" revised 08/11 showed the following direction:
- All medications will be consistently identified and labeled in order to reduce the risks involved with the administration of medications.
- Medication or solution labels will included the following:
Medication name;
Strength of medication;
Initials of person labeling;
Expiration date when not used within 24 hours;
Expiration time when expiration occurs in less than 24 hours.
- Any medications found unlabeled will be discarded immediately.

18. Observation on 09/19/11 from approximately 2:15 PM to 2:35 PM in the Operating Room where C-sections were performed showed a mobile cart used by anesthesia for holding medications and supplies. On top of the anesthesia cart was a filled syringe marked "Neosynephrine" (medication to prolong anesthesia), dated 09/18 or 09/08 (unable to determine) and no initials. Two endotracheal tubes (ET tubes - sterile tubes placed in the airway for delivering breaths and oxygen) were on top of the cart with the packages open and ET tubes set up for use. Both ET tube packages showed, "Sterile unless package has been opened or damaged." One Yankauer (sterile tool used for suctioning) was hanging from the cart, with the package open and Yankauer connected to suction tubing. The Yankauer package showed, "Do not use if package is opened or damaged." Four empty syringes were on top of the cart and not in original manufacturer packaging. Two empty syringes were in the second drawer of the cart and not in original manufacturer packaging. Also the second drawer of the cart contained the following expired medications:
- Succinylcholine (muscle relaxant) 200 milligram (mg) bottle. A sticker affixed to the bottle showed an expiration date of 08/30/11.
- Succinylcholine 200 mg bottle. A sticker affixed to the bottle showed an expiration date of 08/19/09.
- Glycopyrrolate (reduces production of stomach acid) 1 mg / 5 milliliters (ml), open bottle not dated when opened.

During an interview on 09/19/11 at approximately 2:15 PM, Staff M, RN, Team Leader, stated that the last C-section was on 09/16/11. (Date of last surgery does not correlate with either possible dates on the syringe of Neosynephrine).

During an interview on 09/19/11 at 2:25 PM, Staff P, Medical Doctor (MD), Anesthesiologist, stated that the syringe of Neosynephrine should not have been there and could not explain why the date did not correlate with the last C-section date. Staff P stated that the syringes out of the manufacturer's packaging should have been thrown away at the end of the last surgical procedure. Staff P confirmed the expiration dates on the medications listed above. Staff P stated that anesthesia staff were responsible for the anesthesia cart.

During an interview on 09/20/11 at 1:30 PM, Staff S, RN, Infection Control, stated that the opened syringes should have been thrown away. During a later interview on 09/21/11 at 11:52 AM, Staff S stated that sterile supplies opened for a case and not used should be thrown away.

19. Observation on 09/19/11 at 2:40 PM of the anesthesia supply room located in the Family Birthplace unit showed a spray bottle of Cavicide (used for cleaning surfaces). The expiration date was 05/2002.

During an interview on 09/19/11 at 2:40 PM, Staff M confirmed the Cavicide was expired.

20. Observation on 09/20/11 at 9:30 AM on 4C, orthopedic unit, showed a mobile cart with supplies used for applying a cast. The following items were expired:
- Tegaderm dressing (a sterile, transparent dressing), three packages, expired 02/03;
- Tegaderm dressing, four packages, expired 02/07;
- Tegaderm dressing, two packages, expired 08/07;
- Povidone Iodine (sterile solution used for cleaning the skin), opened, expired 03/06;
- Povidone Iodine swab sticks, four packages, expired 04/10;
- Isopropyl alcohol, one bottle, opened, expired 12/09;
- Isopropyl alcohol, one bottle, expired 10/10;
- Petrolatum dressing (sterile, non-stick dressing), expired 05/11;
- Petrolatum dressing, expired 05/10;
- Antimicrobial drain sponges (sterile dressing that contains medication to treat infection), expired 03/10;
- Sterile cotton tipped applicators, eight packages, expired 11/07;
- Steri-strips (sterile tape-like strips used to close a laceration or incision), numerous packs, expired 04/07.

During an interview on 09/20/11 at 9:40 AM, Staff T, RN, Administrative Director of Nursing Operations, stated that he/she wasn't sure who was responsible for checking the cast cart for outdates and "apparently that's an issue."

21. Record review of the facility's undated policy titled "Indwelling Urinary Catheter: Assessment of Need, Insertion and Maintenance", provided by Staff A, Regulatory Coordinator on 09/20/11, showed the following direction:
- Female patients: Wipe from the perineum (the area between the female genitalia and anus in a female) to the rectum using separate sections of the washcloth with each wipe;
- Clean the first four inches of the exposed catheter in a circular motion, starting closest to the patient and work your way out along the catheter.
(A urinary catheter is a tube placed in the bladder to drain and collect urine from the bladder).

22. Observation on 09/20/11 at 11:15 AM showed Staff HH, Clinical Partner, performed indwelling urinary catheter care to Patient #18. Staff HH cleaned the catheter tubing, but did not clean the perineum.

During an interview on 09/20/11 at 11:30 AM Staff FF, RN, Team Leader, stated staff should clean the perineum when performing catheter care.

During an interview on 09/20/11 at 1:45 PM, Staff S stated that he/she expected staff to clean the perineum and tubing when performing urinary catheter care.

23. Observation on 09/19/11 at 2:50 PM in the nursery showed a bassinet mattress with six to seven rips in the mattress. The rips were less than one inch in length and exposed the inner core of the mattress. These rips prevented thorough cleaning of the mattress.

During an interview on 09/19/11 at 2:50 PM, Staff L stated that the mattress should not have rips because it could not be cleaned.

During an interview on 09/20/11 at 1:30 PM, Staff S stated that a mattress should be checked for rips every time it is cleaned. During a later interview on 09/21/11 at 11:52 AM, Staff S stated that the facility did not have a policy covering rips in mattresses.

24. Observation on 09/19/11 at 1:48 PM showed Staff BB, RN, entered Patient #11's room to administer medications. Staff BB dropped the syringe on the floor, picked it up and administered medications with the contaminated syringe.

25. Record review of the facility's policy titled "Surgical/Invasive Areas and Delivery Rooms - Terminal Cleaning at the end of each day" dated 2010 showed the following direction:
- Spot wash walls and wall vents with germicidal solution.

Record review of the facility's policy titled Surgical/Invasive Areas and Delivery Rooms - Weekly Cycle Cleaning dated 2010 showed the following direction:
- Damp wipe the air vents with a wall washer (cleaning tool used to wipe walls) dipped in germicidal solution.

26. Observation on 09/19/11 at approximately 2:10 PM in the Operating Room where Caesarean sections (C-section - surgical procedure to deliver babies) were performed showed an air vent covered with dust.

During an interview on 09/19/11 at approximately 2:10 PM Staff L, RN, Director of Family Birthplace, stated that the air vent was dusty and it should have been cleaned.

27. Record review of the facility's policy titled "Infection Control Policy/Equipment Cleaning/Disinfection" revised on 05/08 showed the following direction:
- Fans, etc,
- All items must be cleaned prior to any disinfection;
- Cleaning is the actual mechanical removal of debris and fluids;
- Each item must be completely disassembled in order to assure adequate cleaning.

28. Observation on 09/20/11 at 11:00 AM showed a portable fan at Patient #19's bedside. The fan blades and fan cover were covered with dust.

29. Observation on 09/20/11 at approximately 12:00 noon showed a portable fan at Patient #8's bedside. The fan blades and fan cover were covered with dust.

During an interview on 09/20/11 at 1:30 PM, Staff S stated that the fan should have been visually inspected for dust, cleaned and inspected after every patient.


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