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Based on observation, interview and record review the facility failed to provide four Patients (#7, #8, #9, #10) of 23 Patients on the acute Behavior Health Unit and four Patients (#12, #13, #63, #64) of 10 Patients on the Gero Psych Unit a written copy of their Patient's Rights before receiving medical care. The facility also failed to post the correct telephone number for the Department of Health and Senior Services in order to file a complaint regarding care for all posted in the hospital. The facility census was 125.
Findings included:
1. Record review on 10/26/2010 of four open medical records for acute Behavior Health Unit (Patients #7, #8, #9, #10) revealed no signed statement from the Patients regarding receiving notice of the Patient's Rights before receiving medical care. Patients who failed to recieve this information would not be informed of their Patients Rights and could potentially make poor decisions regarding their medical choices.
2. During an interview on 10/26/2010 at 10:35 AM Staff K, RN (Registered Nurse), Nurse Manager stated that there was no signed paper in the charts for Patients in the Behavior Health Unit because they do not sign anything acknowledging they have received their Patient's Rights. It was also stated that they haven't had any Patient's Rights Handbooks on that Unit for "about a year". The Nurse Manager stated the Patients are informed of their Patients' Rights verbally by the Social Worker.
3. Observation on 10/26/2010 at 8:15 AM revealed a poster stating Patient's rights in the main lobby waiting area of the facility. The telephone number listed to telephone a complaint to the Department of Health and Senior Services was (573)751-6451, a disconnected telephone number.
4. Observation on 10/26/2010 at 9:00 AM revealed a poster stating Patient's rights in the main hallway opposite the nurses' station in a covered glass box on the acute Behavior Health Unit. The telephone number listed to telephone a complaint to the Department of Health and Senior Services was (573)751-6451, a disconnected telephone number. The correct number to use in calling in a complaint to the Department of Health and Senior Services is (573)751-6303. This could potentially effect all Patients on the Behavior Health Unit at any given time and delay or prevent a complaint from being reported.


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5. Record review of four open medical records for Patients #12, #13, #63 and #64 showed no "check" (indicating completion) of the box titled Patient's Rights, the Initial Psychiatric Nursing Assessment completed on the day of admission.

6. During an interview on 10/26/10 at 9:30 AM Registered Nurse (RN) ZZZ stated she verbally gave the patient their rights on admission but confirmed the box for documenting the patient had been given their rights was not checked.

Based on observation and interview, the facility failed to ensure the privacy of patients by displaying patient names on computer monitors, which could easily be viewed by the public. This affected all patients in the Emergency Department (ED). The facility census was 125.

Findings included:

Observation on 10/27/10 at 3:30 PM showed a series of work stations for ED staff. At least four work stations were situated on countertops surrounding the nursing stations. The computer monitors on these work stations faced toward patient rooms, allowing ED staff to walk up to the workstation and easily view cardiac rhythms and other information pertinent to caring for that patient. Patient names were prominently displayed, and visitors were allowed to stand within inches of the monitors.

During an interview on 10/27/10 at 3:35 PM, Staff FP-G, Emergency Department Manager, said the names were displayed for the convenience of staff so that any patient displaying an abnormal rhythm would be easily identifiable. Staff FP-G agreed that displaying full names failed to provide confidentiality for patients.

Based on observation and interview the facility failed to provide a safe setting by allowing shower knobs and door hinges in all 20 rooms that do not meet the requirements for patients at suicidal risk for 23 of 23 patients in the acute Behavior Health Unit. The facility also failed to provide a safe setting by not locking a Sharps box containing used syringes and disposable razors and allowing plastic bags to be accessible to patients. The facility failed to conduct or implement mock code blue (medical emergency, especially in a hospital, when a patient's heart stops beating or his or her lungs stop functioning) exercises and to train all Registered Nurses in the use of an automated external defibrillators (AEDs) (life saving device that can help people survive cardiac arrest by sending electrical shocks to the heart). The facility census was 125 and the acute Behavior Health Unit was 23.
Findings included:
1. Observation on 10/25/2010 of rooms 304-326 and 301-319 revealed shower on/off/temperature knobs that project out of the wall in a straight line making it possible to use a hanging device. The door hinges on all of the rooms revealed a regular door hinge rather a hinge that would impede the ability to attach a lace, cord, or line such as a piano hinge.
2. Observation on 10/25/2010 at 3:25 PM of the dirty linen area revealed a large bio-hazard box (protective container) containing used syringes and used disposable razors.
3. During an interview on 10/25/2010 at 3:25 PM it was stated by RN, Staff I, Nurse Manager, that the bio-hazard box should be locked because the Patients in the acute Behavioral Health Unit uses this room to shave.
4. Observation on 10/26/2010 at 10:15 AM revealed the same bio-hazard box in the dirty linen room to be unlocked still containing the used syringes and the used disposable razors.
5. During an interview on 10/26/2010 at 10:15 AM it was stated by RN, Staff K, Nurse Manager that the bio-hazard box should be locked and was a safety issue for the patients.
6. Observation on 10/25/2010 at 3:10 PM revealed Charge Nurses Staff F and G, Registered Nurses, could not demonstrate the use of the defibrillator located on the crash cart in the nurses' station. These two nurses were in charge of all the day staff on the acute Behavior Health Unit.
7. During an interview on 10/26/2010 at 3:00 PM with RN, Staff T, Nurse Educator, stated that the facility does not implement mock codes (code blue exercises).
8. During an interview on 10/28/2010 at 9:10 AM with RN, Staff K, Nurse Manager stated that mock codes are not implemented in the facility.
9. Observation on 10/25/2010 at 3:20 PM showed a housekeeper with a cleaning cart entering the clean linen area and using the cart to hold the door open while they retrieved supplies. The back side of the cart remained out in the hall and had plastic bags available to patients and was unattended.
Staff K, RN (registered nurse), Nurse Manager witnessed this behavior and agreed that this practice was unsafe for the patients as only paper trash liners are used in the acute Behavior Health unit for safety concerns.
10. Observations on 10/26/2010 and 10/27/2010 showed the exact same practice with two different housekeepers and the plastic bags were exposed and unattended in the hallway. Plastic bags are a concern for patients on suicidal precautions.
Staff K, RN, Nurse Manager, spoke with the housekeeper and explained why they could not leave the bags unattended and should not have the plastic bags in the acute Behavior Health unit. The housekeeper became angry and left the unit.

Based on interview and record review the facility failed to notify the Missouri State Board of Nursing to report a substantiated incident of abuse after their investigation for one Registered Nurse (RN), Staff TT, RN of two incidents reviewed. The facility census was 125 and the acute Behavior Health Unit was 23. This applied to all patients on the Behavior Health Unit.
Findings included:
1. Record review of the Summary of Investigation dated 08/03/2010 revealed RN, Staff TT, Charge Nurse, observed the abuse of Patient #1 by a Staff RR on 08/01/2010. The record also revealed that Staff TT, RN was subsequently terminated from employment on Thursday, 08/05/2010 for failure to report the witnessed abuse to the facility administration.
2. During an interview on 10/28/2010 at 9:25 AM with Staff C, RN, Director of Nursing stated that the RN, Charge Nurse, Staff TT, a mandated reporter, had not been reported to the Missouri State Board of Nursing for failure to report a witness of abuse.
3. Record review of the Administration Policy and Procedure for Abuse/Neglect identified as Policy: 8311-72 states, in part:
PROCEDURE
4. When there is reasonable cause to suspect that a patient has been or may be subjected to abuse or neglect by a person, or corporation legally or contractually responsible for the patient's care, or by any employee of St. Alexius Hospital, the identifier will immediately report their findings to the patient's Charge Nurse, Social Worker, attending physicians, or any administrative staff:
? The Charge Nurse will notify the Social Worker, Case Manager, attending Physician and Department Manager/Shift Manager immediately.
Failure to report an act of abuse/neglect could potentially allow the alleged perpetrator(s) to abuse/neglect other Patients and create an unsafe atmosphere for all patients on the Behavior Health Unit.

Based on medication pass observation, facility policy review and interview, facility staff failed to follow facility policy with regard to administering medication via Intravenous (a line directly into a vein) push (IVP) for one (Patient #37) of one patient observed receiving medication via IVP, placing patient at risk for drug reaction when medication is not administered per accepted guidelines and failed to follow facility policy with regard to labeling of medication for 2 (Patient #34 and #37) of 2 patients with medication removed from original drug package, placing patient at risk to receive a wrong medication. The census at the time of the survey was 125 patients.

Findings include:

1. Review of the facility medication guideline Mosby Intravenous Medications Handbook on 10/27/10 states in part:
RATE OF ADMINISTRATION
IV injection: Each 200 milligram (mg) or fraction thereof over 2 minutes - for Torsemide - a medication used for treatment of edema (fluid retention).

Observation of medication administration to Patient #37 on 10/27/10 at 09:50 AM, showed Staff SA EE, Registered Nurse (RN) administer IVP Torsemide 200 mg in 1 minute.

During interview with Staff SA EE, RN after the medication administration, SA EE, RN said, "I gave it in 1 minute. I think I looked it up 2 weeks ago, thought it said 1 minute."

2. Review of facility policy on 10/27/10, Policy: 6211-173 states in part:
PROCEDURE
1. Labeling occurs when any medication or solution is transferred from the original packaging to another container, such as syringes, medicine cups, or basins. Labels should include the following information.
A. name of the drug or solution
B. Strength
C. Expiration date (if not used within 24 hours)
D. Expiration time (when expiration occurs in less than 24 hours.

3. During observation of medication administration to Patient #37 on 10/27/10 at 09:50 AM, showed Staff SA EE, RN place Torsemide injectable medication into a syringe. Staff SA EE, RN also withdrew Heparin (prevents blood from clotting-thins blood) solution into a syringe. Staff SA EE, RN failed to place a label on either syringe. Medication in each syringe was a clear liquid. Staff SA EE, RN administered medication without drug labels.

During interview with Staff SA EE, RN after the medication administration, SA EE, RN said "I had more than 1 syringe; I should have labeled the syringes, I usually do."

4. During observation of medication administration to Patient #34 on 10/27/10 at 08:50 AM, a red tablet was observed in a medication cup. Staff SA CC, RN said "I already set-up my medication". Staff SA CC, RN failed to label the medication cup. Staff SA CC, RN identified the red pill as a multi-dose vitamin after administration.

Based upon observation and interview, the facility failed to prevent unauthorized access to components of patient medical records. This affected all patients receiving services from the Laboratory and Mammography Departments. The facility census was 125.

Findings included:

1. Observation during a tour of the Radiology Department on 10/27/10 at 9:30 AM showed a room within the Mammography Department where patient information, including x-rays, was kept. The door to this room was standing open, and the outer door to the Mammography Department was unlocked. The Radiology Technician was in a room with a patient, allowing direct access to unsecured medical information for anyone entering the area.

During an interview on 10/27/10 at 9:35 AM, Staff FP-N, Radiology Director, said that medical information contained within the unsecured room represented past test results and x-ray films of patients scheduled for tests and were utilized as reference materials. Staff FP-N said that the materials were taken into the room at the beginning of the day and were returned to the Radiology records room at the end of the day. Staff FP-N said the door to the room had a self-locking mechanism and was normally kept shut.

2. Observation during a tour of the Laboratory Department on 10/27/10 at 9:40 AM showed an anteroom where ambulatory patients came to have blood drawn. Laboratory staff worked in a room adjacent to this area, but an employee was not assigned to the anteroom. Three stacks containing approximately 1000 printed laboratory test results were identified on a countertop within this anteroom, which allowed unauthorized access to medical information.

During an interview on 10/27/10 at 9:45 AM, Staff FP-H, Director of Laboratory, said that Laboratory staff are usually working near the door between the Laboratory and anteroom, and that staff were able to tell when patients or staff were in the anteroom. However, Laboratory employees were observed standing at the workstation nearest the door to the anteroom for a cumulated timespan of five minutes during the 20 minute tour of the Laboratory.

Based on record review and staff interview, the facility failed to date, time and authenticate entries for five (Patients #35, 40, 41, 50 and 61) of sixty-two inpatients medical records reviewed. The inpatients' census was 125 patients.

Findings Included:

Record review of the "St Alexius Medical Staff Rules and Regulations, Appendix B," revision date January 13, 2008, showed the document did not address the need for all entries to be legible, complete, dated, timed and authenticated.

1. Patient #35 was admitted on 10/25/10 with diagnoses of increased INR (International normalized ration - system used to report the results of blood clotting tests). The Physician prepared the History and Physical (H&P) on 10/25/10 and signed it, but failed to time and date the authentication.

Staff prepared a Wound Observation Record on 10/25/10, but failed to indicate a time of preparation on the report.

2. Patient #40 was admitted on 10/20/10 with diagnoses of hypertension, diabetes mellitus, abdominal pain and nausea. The Physician prepared the H&P on 10/21/10, but failed to note the time of preparation. He/she signed it, but failed to time and date the authentication.

The Physician prepared a Consultation Report on 10/21/10, but failed to note the time of preparation. He/she signed it, but failed to time and date the authentication.

The Physician prepared a Venous Thromboembolism Prophylaxis Assessment and Physician Orders Report, but failed to note the date and time of preparation.

The Physician prepared a Progress Note on 10/23/10, but failed to indicate time on the report.

3. Patient #41 was admitted on 10/18/10 with diagnoses of hypertension, schizophrenia, depression and mental retardation. The Physician prepared the H&P on 10/18/10, but failed to note the time of preparation. He/she signed it, but failed to time and date the authentication.

4. Patient #50 was admitted on 10/4/10 with diagnoses of diabetes, chronic renal failure with dialysis, anxiety, vomiting, morbid obese, depression and abcess (s) with foul smell. The Physician prepared a Consultation Report on 10/25/10, but failed to note the time of preparation.

The Physician prepared an Operative Report on 10/19/10, but failed to indicate the time on the report.

5. Patient #61 was admitted on 10/18/10 with diagnoses of colon cancer, dementia, severe dysarthria, vomiting and mental retardation. The Physician prepared the H&P on 10/19/10, but failed to note the time of preparation.

During interview on 12/27/10 at 2:15 PM, Staff SA #E stated he/she did not realize once the Physician signed a report, he/she also needed to sign and date the report again to authenticate the record.

6) Record review of the patient #50's medical record showed Staff failed to time nutrition orders for the following days: 10/08, 10/09, 10/11, and 10/14/10.

During an interview on 12/27/10 at 2:15 PM, Staff SA #E stated he/she thought facility's staff did well with dating and timing entries, but felt there needed to be more work done.













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Based on record review, interview and facility Medical Staff Rules & Regulations, the facility failed to ensure the staff followed the facility's policy when Physicians did not authenticate telephone and/or verbal orders within 48 hours for three (Patient #12, #13, #57) of ten patients reviewed. The facility also failed to date and time orders for one (Patient #50) of sixty-two inpatients reviewed. The facility census was 125.

Findings included:

1. Record review of Appendix B Medical Staff Rules & Regulations Revision date January 13, 2008 showed in part the following information:

B. 22 VERBAL ORDERS

1) Verbal Orders are to be cosigned by the ordering practitioner within 48 hours or by other practitioners involved in the patient's care.

An interview on 10/27/10 at 10:09 AM CNO E stated the physicians have 48 hours according to policy to sign verbal and telephone orders.

2. Record review of Patient #12's Physician's telephone order for Medication Reconciliation dated 10/21/10 at 11:20 PM showed no authentication by the physician of signature, date and time.

Record review of the Physician's Order written on 10/23/10 and 10/26/10 showed no time when authenticated.

Record review of Patient #13's Physician's telephone orders for admission orders for straight cath and lab dated 10/22/10 at 12:45 PM showed no authentication by the physician of signature, date and time.

Record review of Patient #57's Physician's telephone order dated 10/20/10 at 6:00 PM showed no authentication by the physician of signature, date and time.

Record review of the Physician's telephone order for medications dated 10/21/10 at 12:25 PM showed no authentication by the physician of signature, date and time.

Record review of the Physician's telephone order dated 10/21/10 at 1:50 PM for medicatins showed no authentication by the physician of signature, date and time.

Record review of the Physician's telephone order dated 10/25/10 at 6:40 AM to leave Naso gastric tube (NG ) out showed no authentication by the physician of date and time.

Record review of the Physician's telephone order dated 10/25/no year at 11:30 AM showed no authentication by the physician of signature, date and time.

Record review of the Physician's telephone order dated 10/25/no year at 11:30 AM for medications, diet, lab work, IV fluids showed no authentication by the physician of signature, date and time.

Record review of the Physician's telephone order dated 10/25/10 at 12:00 PM for clarification of order of 10/25/no year at 11:30 AM showed no authentication by the physician of signature, date and time.

An interview on 10/27/10 at 10:09 AM CNO E stated the physicians have 48 hours according to policy to sign verbal and telephone orders.

Based on policy review and interview, the facility failed to ensure that admixing of intravenous solutions containing high-risk medications was performed under the supervision of a pharmacist, subjecting patients to potentially receiving the wrong dose as well as risk of infection due to non-sterile conditions during admixture. This failure affected all patients receiving services within the Cardiac Catheterization Laboratory in the Radiology Department. The facility census was 125.

Findings included:

1. Review of facility Pharmacy policy titled, "Infection Control of IV Admixtures," not dated, gave the following direction (in part):
Aseptic Preparation: All admixtures will be prepared in Laminar Flow Hood or Biologically Safety Cabinet using aseptic technique.
Checking: A pharmacist performs final check on all IV admixtures.

Review of facility Pharmacy policy titled, "High Risk/High Alert Medications," revised 10/10, gave the following direction (in part):
- High-risk medications are those medications that carry a higher than average potential for causing severe or permanent harm to the patient if an error should occur. These medications include those identified by the Institute of Safe Medication Practices; insulin, opiates and narcotics, injectable potassium chloride, sodium chloride solutions greater than 0.9 percent and anticoagulation therapy.
- Medications that have been designated high risk require a double check prior to dispensing by the pharmacy.
- The double-check will be performed by two pharmacists or a pharmacist and technician/intern in the event that two pharmacists are not available. In those rare situations where two pharmacy personnel are not available, the double-check will be performed by a pharmacist and a nurse.

However, review of the facility Radiology policy titled, "Cardiac Cath/Special Procedure Lab," last revised 12/07, gave the following direction (in part):
Fluid Preparation: The 1000 ml. Flush will be heparinized with 1500 units of heparin in a sterile manner, and labeled with the time and date of preparation and nurse preparing the fluid.

2. During an interview on 10/27/10 at 9:15 AM, Staff SA-P, Clinical Leader in the Cardiac Catheterization Lab, said intravenous solutions are kept as floor stock in the Catheterization Lab and are mixed with heparin by nursing staff just prior to a procedure requiring the solution. The fluids are mixed in the procedure room. A laminar hood is not used, but a second nurse is used to verify the amount of heparin added to the solution.

3. During an interview on 10/27/10 at 2:45 PM, Staff FP-O, Pharmacy Director, said it was facility policy for intravenous fluids to be stored and issued from the Central Supply due to lack of space within the Pharmacy. Staff FP-O said he/she had not been inside Central Supply and did not know how the items were stored, but that Central Supply issued solutions as requested to replace floor stock. Staff FP-O said that the Pharmacy requisitions intravenous solutions from the Central Supply when they need more solutions, and stated he/she was unaware that staff in Radiology were mixing heparin solutions for intravenous use. According to Staff FP-O, all intravenous solutions were to be mixed by the Pharmacy, and he/she was unaware that there were hospital policies/procedures that conflicted with the Pharmacy's policy.

Based on facility policy review and interview, the facility failed to ensure medications were kept in a locked, secured area to prevent unauthorized access. This had the potential to affect all patients. The facility census was 125.

Findings included:

Review of the facility policy titled, "Medication Procurement and Storage," last revised 5/06 gave the following direction (in part):
Storage: Medication rooms on patient care units used for storage of floor stock medications will remain locked. Access is limited to licensed nursing personnel only.
Inspection: All drug storage areas within the hospital will be inspected monthly by the Pharmaceutical Services Department. A report of inspection will be maintained by the Pharmaceutical Services Department. Reports of discrepancies will be shared with the supervising professional of the unit involved.

Review of the facility policy titled, "Outdated Medications," established 3/80 gave the following direction (in part):
- Every drug storage area within the pharmacy and throughout the hospital including code carts and emergency boxes will be inspected monthly by pharmacy personnel.

During an interview on 10/27/10 at 9:15 AM, Staff SA-P, Clinical Leader in the Cardiac Catheterization Lab, said intravenous solutions and prefilled syringes of normal saline kept as floor stock for use during procedures are replaced by Central Supply rather than the Pharmacy.

During an interview on 10/27/10 at 2:45 PM, Staff FP-O, Pharmacy Director, said it was facility policy for intravenous fluids to be stored and issued from the Central Supply due to lack of space within the Pharmacy. Staff FP-O said he/she had not been inside Central Supply and did not know how the items were stored, but that Central Supply was not included in the areas for monthly inspection by the Pharmacy.

Based on observation, interview and facility policy review, the facility failed to ensure multi-dose vials were discarded twenty-eight days after opening, placing patients at risk for receiving unusable drugs. Facility does an average of 220 surgical cases a month. Facility census was 125.
Findings included:
1. Review of the facility policy on 10/27/10 titled "Expiration of Medications in the Patient Care Areas" directed staff in part to:
MULTIDOSE
Multidose vials will be discarded when they are empty or 28 days after opened, whichever comes first providing that there is no obvious contamination and that normal precautions have been taken.

During observation of anesthesia cart in room #4 on 10/27/10 at 2:40 PM, a multidose vial of Labetalol Hydrochloride (medication used to treat elevated blood pressure) was labeled 10/?. Label was not legible.

During an interview at the time of the medication label observation, Director of Surgical Services Staff SA FFF confirmed the lack of legibility of the medication vial label. Staff SA FFF disposed of the medication.

Based on record review and staff interview, the facility failed to demonstrate it had a system in place to ensure it met the nutritional needs for three (Patients #39, 40, and 50) of sixty-two inpatients based on their Physician's order for nutritional supplementation. The inpatient census was 125 patients.

Findings Included:

1. Patient #39 was admitted on 10/25/10 with diagnosis of Insulin Dependent Diabetes Mellitus, Hypertension, and a left great toe blackened and sore from a bump. The Physician wrote orders on 10/26/10 at 8:20 AM for the patient to receive Juven nutritional supplement at 10:00 AM and 2:00 PM. Patient also had orders to receive an HS (bedtime) snack. Interview on 10/27/10 at 11:20 AM, Staff #DDD (Registered Dietitian) stated Nursing Staff usually document patients' consumption or refusal of snacks on the MAR (Medication Administration Record).

Record review of the patient's MAR record showed the patient did not receive snacks as ordered on 10/26/10, but received a 10:00 AM supplement on 10/27/10, but no supplement at 2:00 PM and no bedtime snack. Staff failed to document reasons for no supplement and snack given.

2. Patient #40 was admitted on 10/20/10 with diagnosis of hypertension, diabetes mellitus, abdominal pain and nausea. The Physician wrote orders on 10/22/10 at 1:05 PM for the patient to receive Juven nutritional supplement at 10:00 AM and 2:00 PM. Patient also had orders to receive an HS (bedtime) snack.

Record review revealed the patient did not receive bedtime snack on 10/24/10.

3. Patient #50 was admitted on 10/4/10 with diagnosis of diabetes, chronic renal failure with dialysis, anxiety, vomiting, morbid obesity, depression and abcess(es) with foul smell. The Physician ordered Juven nutritional supplement at 10:00 AM and 2:00 PM and Glucerna nutritional supplement shake with lunch and dinner meals. A review of the patient's MAR indicated nursing staff failed to provide nutritional supplements and shakes to the patient on the following days and times:

10/05/10 - No supplement and no Glucerna Shake documented as offered, consumed or refused.
10/11/10 - No 2:00 PM snack documented as offered, consumed or refused.
10/17/10 - No 10:00 AM snack documented as offered, consumed or refused.

During interview on 10/27/10 at 11:28 AM, Staff SA #EEE looked for the information in the record and stated he/she could not find documentation for all times snacks and supplements should have been given. Staff provided records with snacks and supplements documented some times as ordered, but other times the documents did not indicate whether staff offered the snacks and patients consumed or refused them.

Based on observation, interview and facility policy review, the facility failed to follow facility standards of practice for isolations precautions for 3 Patients (#38, #58, and 59) of 3 patients observed on contact isolation precautions, failed to follow hand hygiene policy for 1 Patient (#38) of 1 patient receiving a Glucometer reading, failed to follow linen and equipment precautions for suicidal risk patient's on the acute Behavior Health unit for 23 of 23 patients, and failed to provide a sanitary environment to avoid the possible transmission of infections and communicable diseases by allowing staff to prepare and serve foods with bushy mustache and no beard restraint for 125 of 125 current census patients (Patients #1-125) and staff at the St Alexius Hospital. . The facility census was 125 on the first day of survey.

Findings included:

1. Review of facility policy IC 8040-23 Transmission Precautions directs states in part:

PURPOSE: Isolation precautions are designed to prevent the spread of infectious agents among patients, personnel, and visitors. Precautions are divided into two categories: Standard Precautions for general care and Transmission-Based Isolation Precautions used for specific diseases/conditions/organisms of epidemiological significance.

Contact Precautions
Are used in addition to standard Precautions for patients known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the patient or indirect contact with the environmental surfaces or patient-care equipment. This applies to a variety Multi Drug Resistant Organisms (MDRO) such as MRSA, VRE, C. difficile, Resistant Gram Negative rods. A patient who grossly soils his environment may also be on contact isolation.
b. All persons entering the room should wear gloves.
c. If significant patient and/or environmental contact are anticipated, an isolation gown should be worn upon entry into the room
d. Ensure that after gown and glove removal, and Handwashing that hands and clothing do not contact potentially contaminated environmental surfaces.
e. Patient-care equipment - If items must be shared, the items must be adequately cleaned and disinfected prior to use on another patient
Specific guideline:
b. All persons entering the room should wear gloves.
(3) Wash hands immediately after removal of gloves.
c. If significant patient and/or environmental contact are anticipated, an isolation gown should be worn upon entry into the room. Examples include making the bed, assisting with bathing, or assisting with other physical procedures.
Review of IC 8040-22 Standard Precautions
1. Hand Hygiene - This is the single most important means of preventing the spread of infection. Hands that are not visibly soiled (or likely contaminated with spores) may be sanitized with alcohol hand rubs. Alternatively, hands should be washed with an antimicrobial soap. A 15 to 20 second scrubbing is recommended.
a. Hands must be sanitized/washed before and after all patient and specimen contact and as soon as possible after being soiled or potentially contaminated.
b. Hands must be sanitized immediately when gloves and any other personal protective equipment are removed.
Gowns/Aprons
a. Gowns or aprons are worn to protect skin and prevent soiling of clothing during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions.
c. Select a gown that is appropriate for the activity.
12. Patient Chart
a. The chart should not be allowed to come into contact with infective material or objects that may be contaminated with fluid or infective material.
DONNING PPE
GOWN
*Fully cover torso from neck to knees, arms to end of wrist, and wrap around the back
*Fasten in back at neck and waist
2. During observation of nursing care on 10/27/10 at 9:00 AM Staff SA EE, registered nurse (RN) was observed going into Patient #38's room. Patient #38 is on contact precaution for MRSA of a foot wound. Patient #38 was scheduled that day for an above the knee amputation of the left leg.
Staff SA EE, RN was observed entering Patient #38's room without gown and/or gloves
three times on 10/27/10 during 9:00 AM to 10:00 AM.
Staff SA EE, RN was observed entering Patient #38's room with a Glucometer machine (a machine used to determine patient's blood sugar level - by obtaining a drop of the patient's blood). Staff SA EE, RN removed the Glucometer machine from the room and failed to clean with the Sani wipe disinfection cloth.
3. During observation of transport care on 10/27/10 at approximately 9:30 AM for Patient #38 Staff SA OO, transportation tech, was observed in the hallway with isolation gown on his/her person. The isolation gown did not cover Staff SA OO's, transportation tech's torso, Staff SA OO, transportation tech, did not have gown tied at the waist nor was the gown tied at the shoulders. Staff SA OO, transportation tech, took Patient #38's patient record and placed it on Patient #38's bed.
During interview with Staff SA EE, RN, after observation of care for Patient #38, Staff SA EE, RN, said "when a patient is on contact precautions you need to wear a gown and glove when you care for the patient." Staff SA EE, RN, confirmed (s)he did not tie the gown at the shoulders and waist, but should have. Staff SA EE, RN, confirmed that the transporter staff had not tied the gown.


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4. Observations on 10/25/2010 at 9:15 AM and 10/26/2010 at 2:45 PM showed the housekeeper on the Behavior Health Unit with a cleaning cart entering the clean linen area with a dirty mop and bucket in tow. Observation shows the housekeeper person performs this activity to hold the door open while they retrieve supplies.
Staff K, RN (registered nurse), Nurse Manager witnessed this behavior and agreed that the practice was exposing the clean linen items to possible infectious organisms.
5. Observation on 10/25/2010 at 3:25 PM showed a mattress in one of two seclusion rooms located on the female side of the Behavior Health Unit that had tears and missing covering exposing the underneath pad that had compromised the integrity of the mattress cover allowing possible infectious organisms to remain even after cleaning. The mattress covering had spots and other residue that was visible while standing over the mattress.
During an interview with Staff I, RN, Nurse Manager, it was stated that the mattress was not clean and should be replaced due to the room needing to be available at all times in case a patient would need to occupy the room.
6. Observation on 10/26/2010 at 10:15 AM showed the same mattress in the same seclusion room that was still soiled and had not been replaced.
During an interview with Staff K, RN, Nurse Manager, it was stated that the wrong mattress had been replaced. The mattress in the second seclusion room had been replaced but the mattress that was soiled and damaged was still in service.


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7. Observation on 10/28/10 at 10:30 AM Registered Nurse (RN) KK entered the room of Patient #58 with a gown not tied at the waist and the gown did not cover his/her clothing and proceeded to give care to the patient. The patient was in Contact Isolation (CI) [safety procedures that prevent certain germs from spreading] for suspected Cat scratch fever (an infectious bacterial disease).

8. Observation, on 10/28/10 at 11:00 AM, revealed RN LL entered Patient # 59's room wearing a gown that was not tied at the waist and did not cover his/her clothing. He/she untied the patient's bilateral wrist restraints and performed range of motion on the patient's arms and repositioned the patient and retied the restraints. This patient was in CI (contact isolation) with Methicillin Resistant Staph Aureus (MRSA) (a bacterial infection resistant to some antibiotics).

9. During an interview on 10/28/10 at 11:30 AM Director of Nursing C stated the gowns are more like aprons and even a skinny person wouldn't be covered.

Regarding the Food Service Infection Control:
10. A review of the US Department of Health and Human Services Public Health Service - Food and Drug Administration (FDA) 1997 Food Code guidelines, under Chapter 2, "Management and Personnel," Section 2-4, "HYGIENIC PRACTICES," Subpart 2-402, "Hair Restraints," and 2-402.11, "Effectiveness," stated the following:
(A) Except as provided in ?(B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.
(B) This section does not apply to food employees such as counter staff who only serve beverages and wrapped or packaged foods, hostesses, and wait staff if they present a minimal risk of contaminating exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.
11. During tour in the Food and Nutrition Department on 10/27/10 between 9:50 AM and 11:45 AM, observation revealed Staff SA #WW wore a bushy mustache about one-half inch long that was not covered. Staff SA #WW's responsibilities included preparing foods and placing hot foods on patients' plates for consumption. Staff did not wear facial hair restraint during meal service on 10/27/10.
12. During interview with Staff SA #UU (Certified Dietary Manager) on 10/28/10 at 11:25 AM, Staff stated he/she knew about the FDA Food Code guidelines regarding facial hair and the need to wear a beard restraint, but they did not have any. He/she also stated the facility did not have a policy regarding facial hair and beard restraint.

Based on observation, interview and policy review the facility failed to provide a safe environment for all patients by ensuring staff maintain supplies that are usable with current dates and intact packaging in the operating room (OR) supply room, airway cart in the OR holding area, and in 2 (Anesthesia cart room #4 and gastro intestinal (GI) anesthesia cart) of 2 Anesthesia carts reviewed. This places all patients at risk who receive a surgical procedure, average monthly surgery cases is 220. Facility census was 125.

Findings include:

1. Review of the facility policy titled Central Service Department:

Policy/Procedure 6251-10-IC states in part:
Items that have been sterilized through Central Service (CS) are considered sterile unless the package has been opened, damaged or it is suspected that the integrity has been compromised. All items, whether Hospital packaged and sterilized or Manufacture packaged and sterilized must be rotated. Supplies which are dispensed through Central Service will be checked by Central Service once a week. If items will expire, within that week, Central Service will pull those items and return them to Central Service. Central Service will replace the item with one that is not ready to expire.

Policy/Procedure 6251-10-IC states in part:
SHELF LIFE OF WRAPPERS AND PACKAGING MATERIALS
Peel - Pack Pouches:
Heat Sealed -----Contents are sterile unless damaged, opened or compromised.

Policy/Procedure 6251-10-IC states in part:
PACKAGING MATERIAL, SHELF LIFE AND ROTATION OF SUPPLIES
Rotation of Supplies:
1. Supplies are placed on the shelf, so expiration dates are clearly visible.
2. New supplies are placed on the left side of a shelf. Older supplies are moved to the right side of the shelf. Supplies are dispensed from the right hand side moving to the left side.
6. When stocking bins, new supplies are placed in the back. Older supplies are moved to the front. This allows easier access for older supplies.

Policy/Procedure 6251-29-IC states in part:
EXPIRED DISPOSABLE or SINGLE PATIENT USE ITEMS:
PROCEDURE Central Service Personnel will:
1. Remove the item from inventory. This includes the Nursing Division's stock and Central Services stock.

During a phone interview on 11/5/10 at 11:30 AM Staff SA FFF, Director of Surgical Services said that the OR does not have a separate policy for checking for outdates of supplies. Staff SA FFF said they follow CS policies.

2. Observation of the OR suite showed the following on 10/27/10 beginning at 2:40 PM:
*airway cart In the OR holding area showed a 10 milliliter (ml) syringe with expiration (exp) date 12/21/2008. Staff SA FFF OR manager verified the exp date on the syringe at this time.

*Observation of anesthesia cart in OR room #4 revealed:
Open package (pkg) Endo Tracheal (ET) tube (a tube placed to provide airway during anesthesia) #6 - pkg states sterile unless opened or damaged.
2 - ET tubes #7 - open pkgs
2 - 14 gauge (ga) Intravenous (IV) needles - exp date 05/2010
1 - 16 ga IV needle - exp date 06/2010
Staff SA FFF confirms dates of exp supplies during tour.

*Observation of OR sterile supply room revealed the following:
12 - Penrose drains size 1" - exp date 09/2010
28 Fr-5cc Foley catheter (a tube placed in the bladder to drain urine) - exp date 06/2010

During interview Staff SA FFF said when nurses restock shelves they are supposed to check for outdates when placing weekly supplies on the shelves.

*Observation of GI anesthesia cart on 10/27/10 at 3:40 PM revealed:
Open #6 ET tube
Open #9 ET tube
Staff SA FFF confirmed the open pkgs and disposed of the open ET tubes.

Based on record review and staff interview, the facility failed to provide a qualified therapist with necessary knowledge, experience and capabilities to properly supervise and administer rehabilitation services to patients receiving the services. The facility's census was 125 patients.
Findings Included:
During the tour of the Rehabilitation Department and interview on 10/27/10 between 4:15 PM and 4:45 PM, Staff SA #MM (Director of Rehabilitation Services and Respiratory Services) stated he/she was the Rehabilitation Department's Director. Staff SA #MM stated the hospital had a rehabilitation director who was a rehabilitation therapist, but that changed when administration merged staff at Forest Park and St Alexius Hospital campuses. Staff stated administration chose him/her to become the director of rehabilitation services because he/she has a Registered Nurse (RN) degree in addition to his/her credentials as a Respiratory Therapist.

Interview revealed Staff SA #MM did not have training as a Physical Therapist, Occupational Therapist or Speech Pathologist. Staff SA #MM stated he/she received rehabilitation in-service when vendors come and provide in-service education.

During interview on 10/28/10 at 10:15 AM, Staff SA #D (Human Resource Director) concurred the facility once had a Physical Therapist or Occupational Therapist as Director of Rehabilitation, but once the facility merger with Forest Park Hospital 04/10, that therapist left and Staff SA #MM became the Director of the department.

Staff SA #D presented a copy of the job description for Director of Respiratory Services and stated the facility did not have a current job description for Director of Rehabilitation Services. The policy did not contain a number or reference number, but the director signed it on 05/04/2010. He/she indicated the facility did not have an updated job description to reflect the current position and he/she needed to work on a current rehabilitation director's job description.

Record review of the job description presented reflected all duties and responsibilities for the respiratory department director and none for the rehabilitation department director. A review of the director's continued education for the past year indicated Staff #MM did not have continued education training in rehabilitation services listed.