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Based on observation, interview, and record review, the facility failed to ensure patient privacy:
-By allowing video monitor surveillance of patients' before, during, and after surgery;
-By allowing visibility of a surveillance monitor to others who were not involved in the patient's care;
-While providing foley catheter care for one of two patients (#34); and
-The facility failed to communicate two of two patients' (Patients #CG8 and #CG31) condition/symptoms in a private setting so as not to allow others to overhear the conversations.

The facility census for the main campus of SSM St. Mary's Richmond Heights was 256 and for the Cardinal Glennon (CG) campus was 138.

Findings included:

1. Observation on 04/18/12 at 9:20 AM, of Operating Room (OR) #1 showed a camera which was mounted opposite the foot end of the surgical table, where the ceiling met the wall. The camera lens was directed at the surgical table.

During an interview on 04/18/12 at 9:20 AM, Staff CGT, Surgical Services Director stated that cameras were located in each of the 10 surgical rooms and ran continuously. The video monitoring included when the patinet's gown was removed, when the patient was scrubbed, prepped, and draped for surgery, during the surgical procedure, and after the surgical procedure, when the patient's drape was removed and the patient was cleaned, dressings were applied, and the patient was re-gowned. Staff CGT added that the surveillance monitor was located at the OR nurses desk, that monitoring was not recorded, and was used to improve throughput (measurement of time taken to move a patient through the OR process) in the OR. Staff CGT explained that whoever was observing the monitor would know when the patient was prepped, so the surgeon could be paged to start surgery, or when the surgery was done, so housekeeping could be notified to clean the room.

Observation on 04/18/12 at 1:47 PM showed a surveillance monitor located at the nurses desk inside the OR department. The 17 inch monitor showed four by four inch live video feeds of each of the 10 operating rooms, which were directed at the patients' undergoing surgery. The video feeds were able to be increased individually to the full size of the screen, and were visible to anyone who walked behind or to the side of the desk, which included staff who were not involved in the patient's care, or others, such as housekeeping.

Observation on 04/19/12 at approximately 1:00 PM showed a sliding door at the front entrance of the facility, which contained the following information, written in approximately two inch, white, block lettering:
"Please be aware you may be subject to video monitoring and recording while visiting this facility".

During an interview on 04/18/12 at 3:00 PM, Staff CGAA, Risk Management Director, stated that patients' were notified they may be monitored on cameras when they enter the building because of signage located on the front of the building. When Staff CGAA was asked if he felt patients and their family members understood this signage included monitoring during surgical procedures when the patient was completely undressed and operated on, Staff CGAA replied, "I understand what you're saying".

During an interview and concurrent record review on 04/19/12 at 11:42 AM, Staff CGE, Risk Management, stated that when patient's or their representative sign admission paperwork, they were consenting to video monitoring in all areas of the hospital, including the operating rooms during surgery. Review of the "Conditions of Admission Agreement" (admission paperwork) showed the following:
"The Facility reserves the right to implement policies for purposes of promoting the safety and security of the Hospital, its patients, visitors, employees and medical/professional staff. Consistent with the Facility's security policies, I understand and agree that the Facility may engage in electronic surveillance in public areas, patient rooms or other treatment areas, and that I may be photographed, videotaped, audio taped or have digital or other images of me recorded from time to time while in the Facility. I understand that these images and/or other recordings will be accessed and stored in a secure manner that will protect my privacy to the greatest extent possible and that they will be maintained and stored in accordance with Facility policies."

During a telephone interview on 04/26/12 at 10:50 AM, Staff CGAA, Risk Management Director verified there were no policies regarding video surveillance for the facility.
Record review of current Patients' #CG24's surgical consent dated 04/04/12 and current Patient #CG22's surgical consent dated 02/20/12, showed that the patient representatives checked marked they "did not consent to the taking of any photographs or audiovisual recordings in the course of the operation for the purpose of advancing medical education", on the surgical consent.

During an interview on 04/19/12 at 12:35 PM, Patient #CG30's family member stated that she was present during the patient's admission process and present during the consent for surgical treatment, but was not aware of video surveillance during Patient #CG30's surgical procedure, which occurred on 04/18/12.

During an interview on 04/18/12 at 9:20 AM, Staff CGT stated that the OR cameras can be turned off, but remain on and that all patients' were monitored at all times in the OR.

During an interview 04/19/12 at 11:42 AM, Staff CGE stated that when a patient or patient representatives indicated they "did not consent to the taking of any photographs or audiovisual recordings in the course of the operation for the purpose of advancing medical education", the patients were still video monitored because the video monitoring was not recorded or used for "advancing medical education", as stated on the surgical consent.

2. Review of a facility policy titled, "Notice of Privacy Practices," dated 04/14/03, showed patients have the right to request the hospital communicate their medical matters in a certain way.

Review of a facility policy titled, "Privacy Safeguards," dated 04/14/03, showed oral communication with patients by nursing staff and/or physicians should be completed in a quiet manner away from the flow of other patients, visitors and staff.

Review of a facility policy titled, "Patient Rights and Responsibilities," revised 04/09, showed the patients have a right to privacy, and confidentiality.

Observation on 04/19/12, at approximately 8:30 AM, showed a physician standing outside the doorway of Patient CG#8's room. The patient was on contact isolation, as indicated by a sign on the doorframe. The patient's nurse was inside the room, gowned and gloved appropriately. The physician questioned the nurse about the patient's condition from outside the room. This conversation between the physician and nurse could be heard in the hallway whereby the surveyor was standing, and possible passers by.

Observation on 04/19/12, at approximately 9:42 AM, showed a physician standing outside the doorway of Patient CG#31's room. The patient was on contact isolation, as indicated by a sign on the doorframe. The patient's nurse was inside the room, gowned and gloved appropriately. The physician questioned the nurse about the patient's condition from outside the room. This conversation between the physician and nurse could be heard in the hallway whereby the surveyor was standing, and possible passers by.

3. Observation on 04/18/12 at 9:30 AM showed Staff H, Registered Nurse, entered the room of Patient #34 to perform foley catheter (a tube which inserted into the bladder to drain urine) care (the washing of the genitals and catheter tubing). Staff H failed to completely close the privacy curtain between the two patients who shared the room. Dietary staff entered the room and placed a food tray on the bedside table of Patient #34 while the patient was exposed for the catheter care.

During an interview on 04/18/12 at 10:00 AM Staff II, Assistant Director of Nursing, stated that the privacy curtain should always be pulled by the nurse when giving foley catheter care.



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4. Observation on 04/18/12 at 9:30 AM showed Staff H, Registered Nurse, entered the room of Patient #34 to perform foley catheter (a tube which inserted into the bladder to drain urine) care (the washing of the genitals and catheter tubing). Staff H failed to completely close the privacy curtain between the two patients who shared the room. Dietary staff entered the room and placed a food tray on the bedside table of patient #34 while the patient was exposed for the catheter care.


27727

Based on policy review, observations and staff interview, the facility failed to ensure the confidentiality of patients' medical records were safeguarded and protected from the possibility of unauthorized persons reviewing them. The facility census for the main campus of SSM St. Mary's Richmond Heights was 256 and for the Cardinal Glennon (CG) campus was 138.

Findings included:

1. Record review of the facility's policy titled "Security of the Medical Record," revised date 10/11 showed the following direction:
-The Health Information Management (HIM) Department is responsible for ensuring the confidentiality and security of any medical record for patients treated at an SSM Health Care Facility.

2. During reviewing the HIM Department on 04/18/12 between 9:20 AM and 2:30 PM, Staff SSM X, Director of HIM, stated that the security staff had keys that accessed the department. She stated that HIM staff forgot their keys from time to time and Security Staff used their keys to let them into the Department.

3. Observation on 04/18/12 at 1:40 PM showed patients' medical records on shelves to be completed, scanned and or reviewed.

Record review of the patients' personal information contained in the records included the following:
-Name, address, phone number
-Social security number, date of birth and age
-Diagnoses
-Order for treatment
-Insurance information

Based on observation, interview, and policy review the facility failed to ensure medications were kept locked and secured to prevent access by unauthorized persons in the operating room (OR). The facility census for the main campus of SSM St. Mary's Richmond Heights was 256 and for the Cardinal Glennon (CG) campus was 138.

Findings included:

1. Record review of the facility's policy titled "Pharmaceuticals: Storage, Handling, Security and Returns " revised on 07/11, showed that anesthesiology carts located in the operating room or any other anesthesia location will (be) kept locked when unattended. The anesthesia provider is responsible for locking the cart.

2. Observation on 04/18/12 at 10:10 AM of OR #5, showed an unlocked anesthesia cart which was left unattended while the room was cleaned by housekeeping. The cart contained numerous medications such as antibiotics, intravenous (IV-in the vein) fluids, paralytics (medications that prevent voluntary movement, and anesthesia agents (medications used to induce sleep during surgery). On top of the anesthesia cart was an unlocked bin which contained an anesthesia narcotic box. Inside the box were multiple vials of narcotics (pain medications that are high risk for abuse and misuse), benzodiazepines (medications that cause slowing of the brain activity), and opiate analgesics (potent pain relievers), as well as other medications that were high risk for recreational abuse or misuse.

During an interview on 04/18/12 at 10:15 AM, Staff CGW, Anesthesiologist, stated that he leaves the anesthesia cart and narcotic box unlocked and unsupervised between surgical cases.

3. Observation on 04/18/12 at 10:27 AM of OR #7, showed Staff CGX, Anesthesia Resident, leaving the room. When he exited the room, Staff CGZ, Anesthesia Assistant Student, asked Staff CGX if he had remembered to lock the anesthesia cart. Staff CGX then turned around, re-entered the room, and locked the unsecured and unsupervised anesthesia cart.

During an interview on 04/18/12 at 10:30 AM, Staff CGY, OR attending, stated that the anesthesia narcotic box for OR #7 was kept inside the anesthesia cart (which had been unlocked and unsecured) because staff were unable to find the key to the lockable bin on top of the anesthesia cart where the narcotics should be secured.

Based on observation, interview and record review the facility failed to:
-Provide safe, sanitary supply storage by maintaining usable supplies with current dates and intact packaging in two (#1 and #5) of two operating rooms (OR) on the main campus;
-Maintain equipment including two of two supply carts (endoscopy [endo] cart and emergency heart cart) in OR corridor on the main campus;
-Remove outdated supplies in the OR anesthesia cart and in the medication room on the second floor at Cardinal Glennon, to prevent use of expired supplies on patients;
-Maintain clean operating room environments in two (#1 and #5) of two OR's and one of two Cesarean-Section (C-Section) rooms during room observation on the main campus;
-Clean food and supply storage equipment at the Cardinal Glennon campus; and
-Clean Dietary department floors at the Cardinal Glennon campus.

The facility census for the main campus of SSM St. Mary's Richmond Heights was 256 and for the Cardinal Glennon (CG) campus was 138.

Findings included:

1. Record review of the facility's policy titled, "OR Room Sanitation - Before, During, and After a Case" on 04/18/12, with review date of 10/2011, showed the following direction:
- All horizontal surfaces (i.e., furniture, surgical lights, equipment) should be damp dusted before the first scheduled surgical procedure of the day.
- Anesthesia is responsible for management of their supplies and equipment
- Operating Room equipment, lights, horizontal surfaces and furniture are cleaned with a hospital approved disinfectant at the end of each surgical procedure.

Record review of the facility's policy titled, "Expiration Supply Audit and Removal" on 04/18/12, dated February 2012, showed the following direction:
- Inventory control personnel must check all storeroom supplies for out-dated and expired items monthly. Inventory personnel must check all OR suites (outer supply shelf), Packs, and suture carts for out-dated materials and expired items monthly.
- Out-dated items must be removed at the time they are found.
- Anesthesia supply Techs must check their assigned area/supplies for out-dates and expired items monthly. Anesthesia Techs must check all OR suite drug carts, Anesth.(Anesthesia) Fluid supply shelf (OR Suite), supply workroom, and all fluid warmers for out-dated materials and expired items monthly.
- Out-dated items must be removed at the time they are found.
- Resource specialist/nursing staff/inventory control personnel must check their respective area's supplies for out-dates and expired supplies
- This inspection to include, the OR suites, center core (area designated as sterile in the center of OR suite - where sterile supplies are stored), and special team areas of their service.

Record review on 04/18/12 of the facility's policy titled, "Expired and Other Unusable Medications" with a date of February, 2012, showed the following direction:
- Medications are removed from the medication storage areas if they are:
a. Expired (outdated).

2. Observation of OR #1 on the main campus, on 04/16/12 at 4:00 PM showed:
Anesthesia cart:
- Five packaged connectors with an expiration (exp) date of 2010-04
- One Endo-tracheal tube #8 - package open (package states sterile unless package is open)
- #14 Intravenous needle (IV) - exp date 12/2011
- #16 IV needle - exp date 02/12
- #22 IV needle - exp date 02/12
- Forane (a liquid anesthetic) 250 milliliter (ml) - exp date 12/2011
Room supplies:
- Two blue top lab tubes - exp date 03/2012
- Blood warmer on an IV pole - exp engineering tag of 10/11
- OR table pad with sticky adhesive residue on the pillow portion of pad

During an interview on 04/16/12 at 4:15 PM, Staff C, anesthesia supply tech, stated that he was "shocked" at the outdated supplies, especially the connectors, with an expiration date of two years past.

During an interview on 04/16/12 at 4:20 PM, Staff B, Director of Surgical Services, verified the out-dated supplies. Staff B stated OR table pad would be cleaned of adhesive and/or pad would be replaced if non-cleanable.

Observation on 04/18/12 at 9:25 AM of Operating Room (OR) #1's anesthesia cart at Cardinal Glennon showed the following blood tubes (used during blood draws for specimen testing):
-Two blue tops, Lot #0063910, expired 09/11;
-Two purple tops, Lot #B090905, expired 02/11;
-One purple top, Lot #B031005, expired 09/11;
-Three green tops, Lot #B011001, expired 07/11;
-One green top, Lot #B050902, expired 11/10;
-One green top, Lot #B100906, expired 04/11.

During an interview on 04/18/12 at 9:25 AM, Staff CG-U, Anesthesiologist, confirmed the supplies were expired and stated that it was the responsibility of the Anesthesia Technician to check for and remove outdated items in the anesthesia carts on a daily basis.

Observation of the endo cart in the OR inner corridor at the main campus, on 04/17/12 at 9:45 AM showed:
- Two packaged items (Vaseline gauze and nasal forceps) with stains on the outside of the package
- Six endoscopy cytology brushes - exp date - 02/2012

During observation Staff B stated that the integrity of the package was compromised with the stains.

Observation of OR #5 at the main campus, on 04/17/12 at 10:30 AM showed OR table pad with sticky adhesive residue on the head portion of the OR table pad.

During observation on 04/17/12 at 10:30 AM, Staff C, Anesthesia tech stated that tape is an old process.

During observation on 04/17/12 at 10:30 AM, Staff B stated that we are educating staff on cleaning. Staff R, OR staff, during same interview, stated that if tape can't be cleaned off the pad, the pad will be replaced.

Observation on 04/17/12 at 10:40 AM of emergency heart cart on the main campus showed:
- One package of peanuts (sponges) - exp date 03/2012
- One package tubing connector - exp date 01/31/12
- One package tubing connector - exp date 04/30/2011

During an interview at the time of the observation, Staff C, Anesthesia Tech, stated that he did not know who was responsible for checking the cart.

Observation on 04/17/12 at 11:00 AM in C-Section room #1 on the main campus showed:
- Visible dust on tubing connecting Oxygen, Nitrous Oxide (laughing gas) and Air to the anesthesia machine (gases used when patient is placed in semi-conscious condition for surgery)
- Visible dust on electrical cords on the cautery machine (provides cautery to cut with and/or prevent bleeding by burning tissue with high amounts of heat, produced by electrical currents during surgical procedures)

During an interview on 04/17/12 at 11:15 AM, Staff L, Regulatory Compliance Officer, stated that dust measured approximately 1/8 inch in thickness.

Observation on 04/17/12 at 11:25 AM of anesthesia cart in C-Section room #1 on the main campus, showed a syringe flush of normal saline (salt solution) with an expiration date of 02/2012.

During an interview on 04/17/12 at 11:30 AM, Staff M, Certified Registered Nurse Anesthetist, stated that she did not know why syringe was attached to the package (package for sterile IV insertion -- package is usable/not expired).

Observation on 04/17/12 at approximately 10:45 AM of the second floor medication room showed seven Chloraprep solutions (used to cleanse skin before a procedure), Lot #36416, expired 02/12, and one Gastroccult solution (used as a developer to determine the presence of blood in a patient's stool), Lot #1028, expired 10/11.

During an interview on 04/17/12 at approximately 10:45 AM, Staff CG-I, second floor team leader, confirmed that the supplies were expired and stated that the second floor staff were responsible for ensuring outdated items were removed from use on a daily basis.

3. Observation on 04/17/12 at 11:14 AM in the bakery area of the Cardinal Glennon campus kitchen showed staff stored the following foods unrefrigerated on shelving:
-An opened, partial container of sesame sauce with a manufacturer's label to "refrigerate after opening".
-An opened, partial container of teriyaki sauce with a manufacturer's label to "refrigerate after opening".

During an interview on 04/17/12 at 11:14 AM Staff CG-K, Dietary Team Leader confirmed staff should not store the opened, partial containers of sesame sauce and teriyaki sauce unrefrigerated on shelving in the bakery.

4. Record review of the United States Department of Health and Human Services (USDHSS), Public Health Service (PHS), Food and Drug Administration (FDA), 2005 Food Code, Chapter 4-601.11 (c) showed direction for non food contact surfaces of equipment to be kept free of an accumulation of dust, dirt, food residue and other debris.

Record review of the facility's policy titled "Sanitation Program" dated 02/12 showed direction for the Dietary Team Leader to monitor sanitizing schedules and monitor the cleaning of equipment, walls, floors and storage areas.

Observation on 04/17/12 at 11:12 AM in the dry food storeroom of the Cardinal Glennon campus kitchen showed staff stored multiple canned foods on three heavily soiled can racks with the rims of the cans in direct contact with a layer of black powdery unknown debris.

During an interview on 04/17/12 at 11:12 AM Staff CG-K confirmed the can rack was soiled and should be cleaned as directed on the department cleaning schedule.

Observation on 04/18/12 at 12:06 PM showed Dietary staff prepared patient meal trays on a tray assembly line positioned under a large circular (approximately five foot diameter) air vent with two to three inch strands of dust and debris hanging off the metal flanges.

During an interview on 04/18/12 at 12:06 PM Staff CG-BB Director of Dietary said the Dietary department did not clean the air vent because the department did not have a ladder high enough to reach it and the staff would probably have to call maintenance staff.

5. Record review of the USDHSS, PHS, FDA, 2005 Food Code, Chapter 6-501.12 (A) showed direction for physical facilities of food service establishments to be cleaned as often as necessary to keep them clean.

Observation on 04/17/12 at 11:00 AM on the loading dock of the Cardinal Glennon building showed a shared elevator with a heavily soiled floor, used to transport all food deliveries (cases of produce, dairy products, breads, frozen and dry foods) up one floor to the kitchen area.

During an interview on 04/17/12 at 11:00 AM Staff CG-MM, Receiving Clerk stated the following:
-He had been "yelling for about a month" for staff to clean the elevator.
-No one had responded and cleaned the floor of the elevator.
-He had alerted his supervisor.
-The environmental services (EVS) staff was probably the staff who were supposed to clean the area.

Observation on 04/17/12 at 11:10 AM in the beverage storeroom of the Cardinal Glennon kitchen showed staff failed to sweep and mop the floor littered with scrap papers and unknown debris.

Observation on 04/17/12 at 11:15 AM in the facility walk-in vegetable refrigerator showed staff failed to sweep and mop the floor soiled to food debris and unknown soil.

During an interview on 04/17/12 at 11:10 AM Staff CG-K Dietary Team Leader confirmed the Dietary department floors should be swept and mopped daily.






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29047

Based on observation, interview and record review the facility failed to ensure the following were compliant with standard procedures for infection control:
- The contracted Hemodialysis (a medical procedure for patients who have temporarily or permanently lost kidney function due to renal (kidney) failure) Department did not wear PPE (personal protective equipment to prevent contamination e.g. gown, gloves, mask), use hand hygiene, gowns or glove use as recommended and had several infection control environmental issues;
-The Infection Control Nurse and Dietary service staff at the Cardinal Glennon campus failed to establish and maintain appropriate food handling practices to protect against cross contamination of foods; and
-The Cardinal Glennon Neonatal Intensive Care Unit failed to ensure medical records were protected from contamination and possible transmission of infectious diseases when the medical records were placed in patient rooms who were on contact isolation (measures taken by facilities to isolate and prevent the spread of infection).

This had the potential to affect all patients receiving dialysis and all patients in the facility.

The facility census for the main campus of SSM St. Mary's Richmond Heights was 256 and for the Cardinal Glennon (CG) campus was 138.

Findings included:

1. Record review of the facility policy titled, "Infection Control in the Hospital Dialysis Setting" revised 03/2011, gave the following direction:
- The Centers for Disease Control (CDC) Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients (Dialysis Precautions) will be followed when caring for all patients. -DaVita dialysis teammates (DaVita is the contracted service that provides dialysis to patients for the facility) will follow hospital mandated policies for infection control;
- Teammates will thoroughly wipe down all nondisposable items and equipment such as . . . the dialysis delivery systems with an appropriate disinfectant after every treatment;
- Hand hygiene is to be performed upon entering the hospital dialysis setting, prior to gloving, after removal of gloves, between patients even if the contact is casual;
- Teammates will wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station, and will remove gloves and wash hands or perform hand hygiene between each patient or station;
- Gloves should be worn when: Touching the blood lines, dialyzer or dialysis delivery system during or after a dialysis treatment;
- Appropriate PPE (personal protective equipment) will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces;

2. Observation on 04/18/12 at 2:40 PM in the Hemodialysis Department showed two patient's (#46 and #47) receiving dialysis. Staff CC, Registered Nurse (RN) was at the bedside of Patient #47 and had not donned PPE or gloves while providing care. Six different Dialysate (a chemical bath used in dialysis to draw fluids and toxins out of the bloodstream and supply electrolytes and other chemicals to the bloodstream) jugs were sitting the floor in front of the dialysis machine. Staff CC donned gloves without performing hand hygiene to draw a blood sample from Patient #47. After obtaining the blood sample Staff CC removed the gloves but did not perform hand hygiene. Staff CC then went over to check the dialysis machine for Patient #46 but did not perform hand hygiene in between patient care or donn gloves.

Behind the dialysis machines for Patient #46 and #47 were several feet of tubing lying on the floor containing water connected from the dialysis machine to the water source. The tubing was not clean and provided pathogens (something such as bacteria or a virus that can cause disease or infection) a pathway to the dialysis machine and possibly the patient(s) receiving dialysis. The storage area for the Dialysate located in the common patient area approximately five feet from the patients was dirty and had rings of crusty material on it.

The water room that stores the chemicals used in dialysis had a large puddle of standing water that contained a black substance.

During an interview on 04/19/12 at 8:45 AM Staff A, Chief Nursing Officer, stated that she accepted responsibility for the infection control problems in the dialysis department.

During an interview on 04/19/12 at 10:20 AM Staff EE, Acute Facility Administration, stated he did know there was a problem with the tubing being on the floor but it had all been secured above the floor level.

During an interview on 04/19/12 at 10:00 AM, Staff Z, Infection Control Officer, stated that she made rounds on the dialysis department nine to twelve times a year to observe for infection control issues but did not document her findings.

During an interview on 04/19/12 at 10:20 AM, Staff Z, Infection Control Officer and Staff FF, Infection Control Physician, stated that Staff Z does periodic rounding in all facility departments. Staff Z then stated, "I don't have a rounding tool".

3. Record review of the facility's document titled, "Procedure Review and Annual Skills Assessment" dated 11/19/11 showed Staff CC, RN, had passed the annual skills compentency review for infection control in the hospital setting and hand washing.

Record review of the facility's document titled, "Dialysis Quarterly Scorecard" dated the 4th Quarter of 2011did not address infection control issues.

4. Record review of the United States Department of Health and Human Services (USDHSS), Public Health Service (PHS), Food and Drug Administration (FDA), 2005 Food Code, Chapter 3-304.12 (A) showed direction for in-use utensils to be stored in the foods with their handles above the top of the food and the container.

Record review of the facility's policy titled "Food Storage" dated 02/12 showed direction for facility Dietary staff to store bulk food scoops in a separate holder apart from the food in a bulk bin.

Observation on 04/17/12 at 11:14 AM in the bakery area of the Cardinal Glennon kitchen showed the following:
-A metal scoop on the surface of sugar in a bulk bin.
-A flour covered metal bowl on the surface of flour in a bulk bin.
-A metal bowl on the surface of corn meal in a bulk bin.

During an interview on 04/17/12 at 11:14 AM Staff CG-K Dietary Team Leader stated the scoop and the metal bowls should not be stored in the bulk food bins.

5. Record review of the USDHSS, PHS, FDA, 2005 Food Code, Chapter 2-402.11 showed direction for food employees to wear effective hair restraints.

Record review of the facility's policy titled, "Appearance" dated 02/12 showed direction for staff to cover their hair with a hairnet or hat.

Observation on 04/18/12 at 10:44 AM showed Staff CG-CC, Dietary department secretary walked through the kitchen without wearing a hair restraint.

Observation on 04/18/12 at 10:44 AM showed Staff CG-K Dietary Team Leader in the Dietary department with a black cloth cap that did not effectively cover all hair (multiple strands of hair extended from underneath the cap).

6. Record review of the USDHSS, PHS, FDA, 2005 Food Code, Chapter 2-302.11 showed direction for food employees to not wear fingernail polish.

Record review of the facility's policy titled, "Appearance" dated 02/12 showed direction for staff to restrict nail products.

Observation on 04/18/12 at 12:06 PM showed Staff CG-II, Diet Aide worn blue nail polish while preparing noon meal trays for patients.

During an interview on 04/18/12 at 11:14 AM Staff CG-BB Director of Dietary confirmed Staff CG-II was wearing nail polish that was against department policy and would sent Staff CG-II off duty to remove the nail polish.

7. Record review of the USDHSS, PHS, FDA, 2005 Food Code Chapter 2-301.14 showed direction for food employees to clean their hands before engaging in food preparation, working with exposed food, clean equipment and utensils; after touching bare human body parts; after handling soiled equipment or utensils; before donning gloves and after engaging in other activities that contaminate the hands.

Record review of the facility's policy titled "Hand Hygiene" dated 01/11 showed direction for staff to wash hands after removing gloves.

Observation on 04/18/12 at 10:59 AM in the facility kitchen showed Staff DD, with gloved hands, prepared cold foods, touched her face then, failed to remove soiled gloves, perform hand hygiene and re-glove.

Observation on 04/18/12 from 11:55 AM through 12:20 PM showed the following:
-Staff GG, Diet Aide gloved without hand hygiene then, placed foods on patient meal trays.
-Staff GG, with gloved hands, answered a telephone call, then without removing soiled gloves and performing hand hygiene, hung the telephone from his belt and continued to place foods on patient meal trays.
-Staff II, Diet Aide, with gloved hands, answered a telephone call, then without removing soiled gloves and performing hand hygiene, placed the phone in her pocket and continued to place foods on patient meal trays.

During an interview on 04/19/12 at 12:36 PM Staff CG-YY, the Infection Control Nurse confirmed the following:
-She would expect Dietary staff to perform hand hygiene before gloving and after removing soiled gloves.
-She would expect Dietary staff to perform hand hygiene after using telephones and before handling foods.

8. Record review of the facility's infection control policies did not indicate a process for staff to follow to prevent disease transmission or contamiation of medical records.
Observation on 04/19/12 at 10:55 AM showed Staff CG-G, Neonatal Intensive Care Unit (NICU) Director entered Patient #CG-34's room after gowning and gloving, to retrieve the patient's medical record. The sign outside of the room indicated the patient was on contact isolation. Staff CG-G removed the potentially contaminated paper medical record, took it to a copier, made copies of the medical record, and returned the papers to the patient's room.

During an interview on 04/19/12 at approximately 10:55 AM, Staff CG-G stated that paper medical records were kept within all patient rooms, even if they were on contact isolation.

During an interview on 04/19/12 at 11:15 AM, Staff CG-G stated that Patient # CG-34 was on contact isolation for Methicillin Resistant Staph Aureus (MRSA - difficult to treat infection). Staff CG-G stated that MRSA and Vancomycin Resistant Enterococci (VRE - difficult to treat infection) "aren't a big thing" and that patients' with VRE don't remain on the hospital unit for long lengths of time. Staff CG-G added that paper records are kept inside the patient's room for verification of consents and time outs (process to ensure correct procedure is done on correct patient).

During an interview on 04/19/12 at approximately 10:55 AM, Staff CG-F, NICU Team Leader stated that 12 patients' in the NICU were on contact isolation for MRSA or VRE, out of a total of 46 patients. Staff CG-F added that once a contact isolation patient is discharged, the paper medical record was removed from the patient's isolation room, placed in a file folder, and placed in a basket at the front desk in the unit. Staff CG-F added that the paperwork was then picked up and taken to the medical records department for filing.

During an interview on 04/19/12 at 11:25 AM, Staff CG-O, Intensive Care Director stated that she didn't know of any other departments in the facility that kept medical records in patient rooms who were on isolation, and that consent verification and the time out process could be done without bringing the paper record into the patient's isolation room.
















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29047

Based on observation, record review, and review of nationally recognized standards, the facility failed to monitor the temperature and humidity levels in the Operating Room (OR) on the Cardinal Glennon campus, The facility census for the main campus of SSM St. Mary's Richmond Heights was 256 and for the Cardinal Glennon (CG) campus was 138.

Findings included:

1. Review of the AORN (Association of Perioperative Registered Nurses) Perioperative Standards and Recommended Practices, dated May 2009, Recommendation V showed:
-V.b. Low humidity increases the risk of electrostatic charges, which pose a fire hazard in an oxygen-enriched environment or when flammable agents are in use and increases the potential for dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored or procedures are performed.
-V.b.2 Humidity should be monitored and recorded daily using a log format or documentation provided by the heating, ventilation and air conditioning (HVAC) system.
-V.c. Temperature should be monitored and recorded daily using a log format or documentation provided by the HVAC system.

Record review of the facility's policy titled "Infection Control: Maintenance Department" revised 01/09, showed that temperature control and relative humidity are monitored by the Facilities Department and maintained according to the guidelines established by the Missouri Department of Health and Senior Services Hospital Regulations.

Record review of the Department of Health and Senior Services Hospital Regulations, which was provided by the facility as their policy for Operating Room Temperature and Humidity guidelines, showed that the operating room temperature should be maintained between 68 and 76 degrees Fahrenheit (F) and humidity should be maintained between 50 and 60 percent (%).

During an interview on 04/19/12 at approximately 8:35 AM, Staff CGZZ, facility mechanic stated that:
-A computer system in the Facility's Department monitors and digitally records the temperature and humidity of the OR 24 hours a day, seven days a week;
-Although the facility follows the "Department of Health" regulations for temperature and humidity ranges, the facility may alter the temperature and humidity of the OR based on the patient's size or type of procedure;
-OR temperatures may run as low as 55 or as high as 85 degrees F;
-Current humidity of OR #1 was 41%, but neither the OR Director or staff had been notified of the out-of-range humidity, nor had the humidity been adjusted to bring the humidity back into the expected range.
-"If we kept the humidity between 50% and 60%, we would be hearing from the OR staff about how warm it was";
-Increased humidity can be associated with mold growth and excessive moisture in the OR;
-Decreased humidity can create a spark or fire risk;

2. Record review of the OR temperature and humidity trends showed the following humidity levels:
-From 04/08/12 to 04/18/12, OR #1's humidity ranged between 25% (low) and 55%;
-From 04/08/12 to 04/18/12, OR #2's humidity ranged between 28% (low) and 54%;
-From 04/08/12 to 04/18/12, OR #3's humidity ranged between 32% (low) and 57%;
-From 04/08/12 to 04/18/12, OR #4's humidity ranged between 33% (low) and 60%;
-From 04/08/12 to 04/18/12, OR #5's humidity ranged between 31% (low) and 49% (low);
-From 04/08/12 to 04/18/12, OR #6's humidity ranged between 25% (low) and 47% (low);
-From 04/08/12 to 04/18/12, OR #7's humidity ranged between 29% (low) and 50%;
-From 04/08/12 to 04/18/12, OR #8's humidity ranged between 23% (low) and 57%;
-From 04/08/12 to 04/18/12, OR #9's humidity ranged between 31% (low) and 55%;
-From 04/08/12 to 04/18/12, OR #10's humidity ranged between 29% (low) and 56%;

During an interview on 04/19/12 at 9:17 AM, Staff CGT, Surgical Services Director stated that the Facility's OR temperature and humidity monitoring system has the ability to signal her pager when the OR temperature or humidity falls outside normal parameters, but the paging mechanism had not been enabled. Staff CGT added that she is not able to monitor the OR's humidity without contacting the Facility's Department and that she was rarely, if ever, contacted by the Facility's Department that the OR temperature or humidity was outside of the normal ranges.