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1235 E CHEROKEE

SPRINGFIELD, MO 65804

INFECTION PREVENTION CONTROL ABX STEWARDSHIP

Tag No.: A0747

INFECTION CONTROL PROGRAM

Tag No.: A0749

Based on observation, interview and policy review, the hospital failed to ensure they followed infection prevention policies when staff failed to:
- Perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) when administering medications, entering or exiting and patient room and touching inanimate objects for 13 patients (#5, #8, #12, #13, #14, #15, #24, #30, #32, #33, #34, #35 and #39) out of 39 patients observed;
- Prepare a clean work surface prior to administration of medications or patient procedures for 11 patients (#5, #12, #13, #15, #16, #17, #18, #19, #20, #25, and #36) of 14 patients observed;
- Appropriately don and doff personal protective equipment (PPE, such as gloves, gown, goggles and mask) for two patients (#24 and #25) of eight patients observed;
- Properly clean the glucometer (device used to check blood glucose [sugar that circulates in the blood and when too high or too low can be detrimental to a person's health]) after patient use for two patients (#10 and #11) of two patients observed; and
- Properly date food items that were located in the kitchen refrigerator, kitchen freezer and the dry goods area.

These failures had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The hospital census was 355.

Findings included:

Review of the hospital's policy titled, "Infection Prevention (IP) Hand Hygiene," dated 12/20/22, directed staff to perform hand hygiene:
- Before and after touching the patient;
- Prior to donning gloves, before touching the patient or the patient environment;
- Immediately after removing gloves;
- After contact with inanimate surfaces and objects (including medical equipment) in the immediate vicinity of the patient; and
- With soap and water after caring for a patient in Enteric (related to or occurring within the intestines) Contact Precautions (precautions used to minimize the risk of infection spreading through touching an infected person or contaminated object).

Review of the hospital's policy titled, "IP Standard Precautions and Use of Protective Barriers," dated 04/13/21, directed staff to:
- Perform hand hygiene immediately prior to donning and immediately after removal of gloves;
- Wear gloves when touching blood, body fluids, secretions, excretions, mucous membranes, non-intact skin or other potentially infectious material (OPIM); and
- Remove gloves after use, before touching non-contaminated items and surfaces.

Review of the hospital's undated document titled, "Medication Administration Scenarios," directed staff to:
- Enter patient care area, set medications and supplies on a clean surface if needed, and perform hand hygiene prior to contact with patient zone;
- Wear gloves if anticipated contact with blood or bodily fluid;
- Perform hand hygiene anytime gloves are removed; and
- Perform hand hygiene if they touch their hair, glasses or anything on their person.

Observation on 08/29/23 at 09:00 AM, showed that Staff X, Registered Nurse (RN), reached into her pockets to retrieve medication and failed to perform hand hygiene prior to administering the medication to Patient #12.

Observation on 08/29/23 at 09:15 AM, showed that Staff X, RN, reached into her pockets to retrieve medication and failed to perform hand hygiene prior to administering the medication to Patient #13.

Observation on 08/29/23 at 09:30 AM, showed that Staff Y, RN, reached into her pockets to retrieve medication and failed to perform hand hygiene prior to administering the medication to Patient #14.

Observation on 08/29/23 at 9:34 AM, showed that Staff OO, RN, failed to perform hand hygiene before she put gloves on for medication administration for Patient #5.

Observation on 08/29/23 at 09:37 AM, showed that Staff AA, RN, dropped vials of blood onto the floor, picked them up, and laid them on the bedside table. Staff AA, failed to perform hand hygiene or change gloves before continuing to provide care for Patient #15.

Observation on 08/29/23 at 10:13 AM, showed that Staff RR, RN, removed a key from her pocket to retrieve medication from a locked drawer on the Workstation on Wheels (WOW). She then placed the key back into her pocket and touched the patient to scan her identification bracelet. She again reached into her pocket and removed the key to access the cart for a second medication. She did not change her gloves or perform hand hygiene before administering medications to Patient #8.

Observation on 08/29/23 at 12:10 PM, showed that Staff YY, Medical Doctor (MD), failed to perform hand hygiene prior to entering and upon exiting Patient #24's room. Patient #24 was on isolation precautions for Clostridioides difficile (C-diff; a bacteria that causes diarrhea and inflammation of the colon).

Observation on 08/30/23 at 09:10 AM, showed that Staff III, RN, removed a blood product administration bag, failed to wear gloves when handling the bag, and failed to perform hand hygiene immediately following placing the administration bag into the biohazardous waste in Patient #32's room.

Observation on 08/30/23 at 9:50 AM, showed that Staff OOO, RN, failed to perform hand hygiene before entering Patient #35's room.

Observation on 08/30/23 at 9:55 AM, showed that Staff YYY, RN, failed to perform hand hygiene before he entered Patient #30's room.

Observation on 08/30/23 at 10:00 AM, showed that Staff LLL, Student Nurse, failed to perform hand hygiene when she exited Patient 33's room to access the medication box on the wall and then re-entered the room.

Observation on 08/30/23 at 10:10 AM, showed that Staff MMM, MD, exited Patient #34's room with gloves on and walked to nurse's station, without removing the gloves or performing hand hygiene.

Observation and concurrent interview on 08/30/23 at 10:30 AM, showed that Staff WWW, RN, failed to perform hand hygiene upon entering and exiting Patient #39's room. She stated she was supposed to perform hand hygiene before entering a room and she had been educated on hand hygiene. She stated "I am not normally on this floor and I just forgot."

During an interview on 08/30/23 at 10:30 AM, Staff VVV, RN Supervisor, stated that it was the expectation that all employees perform hand hygiene. All staff received training on hand hygiene prior to working on the floor and then yearly. She stated that she had the "Five Moments of Hand Hygiene" posted in various places on the floor as a reminder to staff.

During an interview on 08/29/23 at 12:15 PM, Staff J, Infection Preventionist, stated that all staff received yearly training on handwashing and that the expectation was for them to follow all guidelines and policies of the hospital.

During an interview on 08/30/23, at 11:50 AM, Staff QQQ, Infection Prevention Manager, stated that hand hygiene was expected when entering and exiting a patient room as well as before and immediately after glove use. If the nurse touched anything on her/his person hand hygiene would need to be performed. Nurse's pockets were considered dirty. If a nurse was performing a task where gloves were not initially required but then they performed a task where they could come in contact with blood, blood products or bodily fluids that gloves would need to be worn. "As many precautions that staff could take to protect the patient and the staff they should take it."

During an interview on 08/30/23, at 1:00 PM, Staff E, Chief Nursing Officer (CNO), stated that hand hygiene was expected to be performed before entering and when exiting a room, between touching anything dirty and then going back to the patient and if the staff touched anything outside the patient zone. Staff reaching into their pockets and then going to perform patient care would require hand hygiene in between.

Although requested, the hospital failed to provide a policy that pertained to cleaning of surfaces or use of a barrier before care was provided to a patient.

Observation on 08/29/23 at 09:00 AM, showed that Staff X, RN, failed to clean the bedside table or place a barrier down prior to the placement of medications for administration for Patient #12.

Observation on 08/29/23 at 09:15 AM, showed that Staff X, RN, failed to clean the bedside table or place a barrier down prior to the placement of medications for administration for Patient #13.

Observation on 08/29/23 at 9:34 AM, showed that Staff OO, RN, failed to clean the nightstand or place a barrier down prior to the placement of medications for administration for Patient #5.

Observation on 08/29/23 at 09:37 AM, showed that Staff AA, RN, failed to clean the bedside table or place a barrier down prior to initiating a peripheral IV for Patient #15.

Observation on 08/29/23 at 10:00 AM, showed that Staff DD, RN, failed to place a barrier down on Patient #16's bed prior to laying medications down.

Observation on 08/29/23 at 10:10 AM, showed that Staff FF, RN, failed to clean the bedside table or place a barrier down prior to placing supplies for a blood transfusion for Patient #17.

Observation on 08/29/23 at 10:15 AM, showed that Staff GG, RN, failed to clean the bedside table or place a barrier down prior to initiating a peripheral IV for Patient #18.

Observation on 08/29/23 at 10:25 AM, showed that Staff GG, RN, failed to clean the bedside table or place a barrier down prior placing supplies and medications for Patient #19.

Observation on 08/29/23 at 11:15 AM, showed that Staff VV, RN, failed to clean the bedside table or place a barrier down prior to laying supplies down while using a glucometer for Patient #20.

Observation on 08/29/23 at 12:05 PM, showed that Staff ZZ, RN, failed to clean the bedside table or place a barrier down prior to placing medications for Patient #25.

Observation on 08/30/23 at 10:35 AM, showed that staff UU, RN, failed to clean the nightstand or place a barrier down prior to placing medications for Patient #36.

During an interview on 08/30/23, at 9:40 AM, Staff OO, RN, stated that did not think she had to clean the bedside table prior to use as this was in the patient zone.

During an interview on 08/30/23, at 11:50 AM, Staff QQQ, Infection Prevention Manager, stated that bedside tables/patient work areas should be cleaned with a disinfectant wipe or bleach prior to use and if the surface could not be cleaned then a barrier should be placed down.

During an interview on 08/30/23, at 1:00 PM, Staff E, CNO, stated that staff should clean bedside tables or use a barrier on the patient's bed prior to placing any medication or supplies.

Review of the hospital's policy titled, "Personal Protective Equipment," dated 04/13/21, directed staff to:
- Secure the isolation gown to provide appropriate coverage.
- Perform hand hygiene prior to donning and after removing PPE.
- Remove PPE prior to leaving the patient's room or care area.
- Avoid reaching into pockets for supplies as PPE was contaminated by the patient and the patient's environment.

Review of the hospital's policy titled, "IP Enteric Contact Precautions," dated 10/19/19, directed staff to:
- Wear an isolation gown and gloves before entering the patient room.
- Perform hand hygiene before donning PPE.
- Upon exiting the patient room, remove the gown and gloves, and perform hand hygiene with soap and water.

Observation on 08/29/23 at 12:10 PM, showed that Staff YY, MD, did not don any PPE prior to entering the room of Patient #24 who was on enteric isolation for C-Diff.

Observation on 08/30/23 at 10:10 AM, showed that Staff OOO, RN, failed to properly tie her isolation gown prior to entering the room to provide care for Patient #35.

During a concurrent observation and interview on 08/30/23 at 10:10 AM, Staff NNN, RN, was performing care in a contact isolation room for Patient #35 and did not tie the isolation gown. She stated that she was aware of the policy that all PPE gowns should be tied but that she "never thought about tying the gown."

During an interview on 08/29/23 at 12:15 PM, Staff J, Infection Preventionist, stated that all staff receive yearly training on PPE and handwashing. It was the expectation that all guidelines and policies of the hospital be followed and that all staff wear PPE while in an isolation room.

During an interview on 08/30/23, at 1:00 PM, Staff E, CNO, stated that all staff were required to wear PPE in isolation rooms when they crossed the threshold, which was considered the doorway. PPE was to be properly tied when entering an isolation room. All employees received training upon hire and yearly that included these practices.

Review of the hospital's undated document titled, "Vital Signs and Glucometer Use Scenarios," directed staff to clean the glucometer with the appropriate disinfectant wipes and wait for the appropriate contact time.

Observation on 08/29/23 at 11:12 AM, showed that Staff UU, RN, failed to properly disinfect the glucometer after use on Patient #10.

Observation on 08/29/23 at 11:18 AM, showed that Staff UU, RN, failed to properly disinfect the glucometer after use on Patient #11.

During an interview on 08/29/23, at 11:20 AM, Staff UU, RN, stated that the process for cleaning the glucometer was after patient use and that she should have cleaned it prior to leaving the patient's room.

During an interview on 08/30/23, at 11:50 AM, Staff QQQ, Infection Prevention Manager, stated that the glucometer should be cleaned after use and prior to leaving the patient's room.

During an interview on 08/30/23, at 1:00 PM, Staff E, CNO, stated that the glucometer should be cleaned prior to the machine leaving the patient's room.

Review of the hospital's policy titled, "Food Storage," dated 08/2023, showed that:
- All food was to be stored at a minimum of six inches off the floor.
- All open food items were to be tightly wrapped and dated.
- All products were to be kept no longer than the printed manufacturers expiration or best by date.
- All products were to be dated after the original package was opened.
- All dry goods and freezer items were to be discarded at the end of 12 months after it was received, if there was not recommended best by date or expiration date.
- All refrigerated, ready to eat items, had a max shelf life of seven days, which included the day it was opened.
- After any sauce, dressing, condiment, base or similar items were opened they should be discarded within 30 days, unless the manufacturer's instructions specified otherwise.
- Whole produce was typically good for three to 14 days and that a visual inspection should be made before items were processed for service.
- Processed produce was good for seven days, unless otherwise specified from the manufacturer.

Observation on 08/29/23 at 3:30 PM, in the dry goods storage room, showed the following:
- A container with chopped nuts, with plastic over the top, was not labeled with any dates;
- Four large boxes of bananas stacked on top of each other directly on the floor in the dry goods storage area and not labeled with a received date;
- 10 large spice containers not labeled with an opened date or an expiration date;
- 21 small spice containers not labeled with an opened date or an expiration date;
- An opened bag of nuts not labeled with an opened date or an expiration date;
- Two opened bags of rice not labeled with opened date or an expiration date;
- An opened bag of egg noodles not labeled with an opened date or an expiration date;
- Five containers of pancake mix not labeled with a received date or an expiration date;
- Eight packages of gravy mix not labeled with a received date or an expiration date;
- Eight packages of cheddar cheese sauce not labeled with a received date or an expiration date;
- 12 containers of sea salt not labeled with a received date or an expiration date;
- 16 boxes of gravy mix not labeled with a received date or an expiration date;
- Approximately 50 individual packages of cheddar crackers not labeled with a received date or expiration date;
- Approximately 50 containers of mayonnaise not labeled with a received date or an expiration date;
- 52 packages of bullion not labeled with a received date or an expiration date;
- Approximately 75 packages of pudding not labeled with a received date or an expiration date;
- Approximately 250 packages of gelatin not labeled with a received date or an expiration date; and
- Approximately 1000 individual packets of jam not labeled with a received date or an expiration date.

Observation on 08/29/23 at 4:00 PM, in the freezer showed that no items had been labeled with a received date.

Observation on 08/29/23 at 4:00 PM, in the refrigerator showed:
- Two open containers of pickle relish with use by dates of 07/17/23 and 08/10/23;
- One open container of bacon bits, dated as opened 08/20/23 and use by date of 08/27/23;
- Four half gallon containers of heavy whipping cream with an expiration date of 08/25/23;
- Two gallons of soy milk with an expiration date of 08/24/23;
- 17 trays of baked desserts, dated as opened on 08/28/23, but no use by date labeled;
- Three boxes of tomatoes not labeled with a received date;
- One box of cucumbers not labeled with a received date;
- One box of zucchini not labeled with a received date;
- One box of carrots not labeled with a received date;
- Two containers of banana peppers not labeled with a received date or an expiration date;
- Nine mayonnaise containers not labeled with a received date or an expiration date; and
- 15 salad dressing containers not labeled with a received date or an expiration date.

During an interview on 08/29/23, at 4:15 PM, Staff PPP, Supervisor of Dietary, stated that all items that were opened should be labeled with the date the product was opened and an expiration date. He stated that all staff were aware of the procedure. He stated that when new products were received they were placed behind the current inventory. He stated that staff would check for outdated or expired products when they were putting new product away. He stated that he also performed a monthly inventory to check all products.

During an interview on 08/29/23, at 4:15 PM, Staff DDD, Dietary Manager, stated that all items in the kitchen were to be dated with either a received date, or an opened date, and with a use by or an expiration date. Dietary staff checked the refrigerators frequently for expired items. The freezer and dry goods were checked for expired items when new shipments came in. Fresh meats were kept for seven days after being defrosted. Produce, if not cut up, did not get a use by date and that it was assessed visually, "if it looks useable we use it." If a new truck came and fresh produce was still on shelves from the truck before the older items would be labeled as "use first". He stated that it was "safe to say that no items in the freezer had a received date marked on them."

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HospitalInspections.org

MERCY HOSPITAL SPRINGFIELD

INFECTION PREVENTION CONTROL ABX STEWARDSHIP

INFECTION CONTROL PROGRAM