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Based on interview and record review the facility's governing body failed to effectively provide oversight in the conduct of the facility when:
- A list of contracted services was incomplete and did not specify the scope of contractor responsibility. (A0085)
- The contracted clinical services were not included in the facility-wide Quality Assurance and Performance Improvement Plan. (A0084)
- The Quality Assurance and Performance Improvement Plan was not facility-wide. (A0084)

The severity and cumulative effect of these systemic practices resulted in the facility being out of compliance with 42 CFR 482:12 Condition of Participation: Governing Body and resulted in the facility's failure to ensure quality health care and safety.

Based on interview and record review the hospital's Governing Body failed to ensure that all contracted services were included in the Quality Assurance and Performance Improvement Program (QAPI). The facility also failed to ensure that QAPI data was analyzed, reported, and evaluated to improve the quality of services provided to patients. This had the potential to put all patients at risk for substandard quality care and compromise their health and safety. The facility census was 59.

Findings included:

1. Record review of the facility's document titled facilities "Plan for Provision of Care" reviewed 10/25/16, stated that the executive responsibility for the performance improvement program rests with the facility's Board of Trustees through the Board Quality Oversight Committee.

2. Record review of the list of contracted services provided by the facility showed the following contracted services that affected patient care:
-Arrhythmia Services
-PFT/EKG
-Lithotripsy
-Dialysis
-Radiologists
-Anatomic Pathology
-Psychiatric evaluations/consults
-Radiology telemedicine
-PET
-Sterotactic Breast Biopsy
-Emergency Department Physicians and Mid-level Providers
-Hospitalists and Mid-level Providers
-Transcriptions
-Travel Nurses
-Reference laboratory

During an interview on 06/02/17 at 2:45 PM, Staff B, Director of QAPI, stated that contracted clinical services were not included in the facility-wide QAPI program.

Based on interview and record review the facility failed to maintain a complete list of contracted services including the scope and nature of services. This had the potential to impact the safety and appropriate care of all patients. The facility census was 59.

Findings included:

1. Record review of the list of contracted services provided by Staff DDD, Director of Risk and Regulation, showed 24 contracted services of which eleven were clinical services. Additionally, a list of 17 contracted services was found in the facility document "Performance Improvement and Patient Safety Plan" reviewed 10/25/16 of which six were clinical contracted services.

The facility provided two different lists of contracted services, which did not match.

2. Record review of the facilities "Performance Improvement and Patient Safety Plan" showed the executive responsibility for the performance improvement program rested with the facilities Board of Trustees through the Board Quality Oversight Committee.

Based upon observation, interview, and policy review, the facility failed to safeguard the Protected Health Information (PHI, any information about health status, provision of health care, or payment for health care that can be linked to a specific individual) in three of three areas (Critical Care Unit, Medical-Surgical Unit and in Rehabilitation Services.) This failure had the potential to affect the confidentiality of for all patients in the facility. The facility census was 59.

Findings included:

1. Record review of the facility's policy titled, "Confidentiality Policy," revised 08/2004, showed the patient has a right, ethically and within the law, to personal privacy and confidentiality, to assume that all communications and all records pertaining to his or her care be confidentially treated and read only by individuals directly involved in his or her treatment or the monitoring of its quality.

2. Observation on 05/30/17 at 2:45 PM, in the Critical Care Unit (CCU), showed three computer monitors were left unattended in the hallway outside of the patient's rooms. The computer monitors faced the hallway where patient information (names, medications, diagnosis) was visible by staff and visitors, who were not involved in the patient's care.

During an interview on 05/30/17 at 3:10 PM, Staff FFF, CCU Registered Nurse (RN), stated that staff left the computer monitors on because they went in and out of the patient rooms during procedures and medication passes, otherwise they would have to log back into the computer every time they need to chart.

During an interview on 06/01/17 at 01:35 PM, Staff JJJJ, Chief Nursing Officer (CNO), stated that it was the expectation that computer monitors have privacy screens (screens placed over the computer screen that shield or protect viewing of patient information) or be turned so that they cannot be seen by others.

During an interview on 06/02/17 at 08:30 AM, Staff N, Director of Health Information Systems and Privacy Officer, stated that she was not sure if the CCU had privacy screens on the computer monitors, but it was the expectation that computer monitors have privacy screens or be turned so that they cannot be seen by others.

3. Observation on 05/31/17 at 10:45 AM showed a computer was left unattended on the Medical-Surgical Unit with a patient's protected information, for example, name of the patient and date of birth on the screen. The computer screen faced the nurse's station and hallway where the information could be visible and accessible to anyone walking by.

During an interview on 05/31/17 at 10:45 AM, Staff I, RN, Director of Medical-Surgical-Pediatric Unit, stated that staff are expected to minimize the computer screen if they leave the computer and it is still on.

4. Observation with concurrent interviews on 05/31/17 at 3:30 PM in Rehabilitation Services (physical therapy, occupational therapy and speech) area showed unsecured PHI behind the reception desk:
- There were 25 name bands placed upside down under (information unable to be seen by those that walked by the area) a calendar with a small portion sticking out. The bands showed the patient's name, date of birth, attending physician, gender, medical record number, and visit number.
- There was a schedule for the next day upside down on the desk with 25 patient names on the sheet of paper.
- There were seven patient orders with the patient's name, date of birth, social security number, address, phone number, insurance information, and a diagnosis.
- There were five patient registrations with information such as the patient's name, date of birth, phone number, insurance information, the physician, diagnosis, and appointment date and time.
- There were two fax sheets for internal pre-authorization with information that included the patient's name, date of birth, date of service, phone number, diagnosis, insurance information, and account number.
- Staff RR, Patient Access Specialist and Staff SS, Patient Access Specialist both stated that they left the PHI unsecured overnight and housekeeping came into the area to collect trash unsupervised.

During interviews on 05/31/17 at 3:55 PM, Staff QQ, Rehabilitation Supervisor, stated that she was not aware that PHI needed to be secured when housekeeping was in the department unsupervised.

During an interview on 06/01/17 at 1:30 PM, Staff N, Director of Health Information Systems and Privacy Officer, stated that she did not think unsecured PHI was an issue when housekeeping was in the department unsupervised because the staff signed a confidentiality agreement. She stated that she could not ensure PHI was not read, destroyed, or removed from the area without supervision or camera monitoring of the housekeeper.



18018




29117

Based on observation, interview, record review and policy review the facility failed to individualize the restraint care plan for two patients (#28 and #29) of two patients who had been restrained. This failure had the potential to cause poor nursing care outcomes for restrained patients. There were two patients in restraints at the time of the survey. The facility census was 59.

Findings included:

1. Record review of the facility's restraint policy titled, "Restrictive Practices," revised 12/2016 showed staff were to document restrictive practices (restraints) and revise the care plan in the computerized documentation system.

Record review of the facility's policy titled, "Plan of Care," (PoC), revised 10/2015 showed patients will have an individualized PoC based upon needs and problems. Through assessment and perception, the multidisciplinary care team designates certain possible solutions and approaches to assist patients to meet documented outcomes (goals).

2. Observation on 05/31/17 at 09:40 AM, in the Critical Care Unit (CCU) showed Patient #28 with soft restraints to the left and right wrist.

3. Record review and during an interview on 05/31/17 at 9:50 AM, Staff HHH, Registered Nurse (RN), stated that Patient #28 was in medical restraints (used for patient who are at risk for harming themselves by tampering with medical devices) to prevent him from pulling out the endotracheal tube (tube used during intubation that maintains an open airway and helps prevent suffocation). The medical record showed no restraint care plan for Patient #28, which was confirmed by Staff HHH.

4. Record review of the physician orders for Patient #29 showed an order for restraints on 05/30/17 at 4:00 PM.

During an interview on 5/31/17 at 8:35 AM, Patient #29's family member verified that the patient had been in restraints after she was admitted to the CCU.

During an interview and concurrent record review on 05/31/17 at 8:50 AM, Staff GGG, RN, stated that the patient
was in medical restraints when she was transferred from outpatient recovery to CCU. The medical record showed no restraint care plan for Patient #29, which was confirmed by Staff GGG.

Based on interviews, record reviews, the facility's Rules and Regulations, and review of the revised State Laws for Missouri, the facility failed to ensure restraints were ordered only by a physician, when the facility allowed a Nurse Practitioner (NP, falls under the scope of an Advance Practice Registered Nurse, APRN) to order medical restraints in the Critical Care Unit for one patient (#28) of two patient records reviewed. This failure had the potential to cause poor nursing care outcomes for restrained patients. There were two patients in restraints at the time of the survey. The facility census was 59.

Findings included:

1. Record review of an undated copy of the facility's "Rules and Regulations," showed the use of restraint or seclusion requires a physician's verbal or written time-limited order. The order will be obtained for each use of restraint or seclusion.

2. Record review of the facility's restraint policy titled, "Restrictive Practices," revised 12/2016, showed restraint orders:
- Must be time-limited with a start and end date and time;
- Required the signature of a Licensed Independent Provider (LIP, interchangeable with APRN and NP); and
- Must be renewed on a daily basis.

3. Observation on 05/31/17 at 09:40 AM, in the Critical Care Unit (CCU), showed Patient #28 had soft wrist restraints on the left and right wrists.

4. Record review of orders for Patient #28 showed restraints ordered on 05/28/17 at 4:00 AM, were ordered by Staff BB, NP.

During an interview on 5/31/17 at 9:50 AM, Staff HHH, CCU Registered Nurse (RN), verified that Patient #28's restraint orders were ordered by a NP.

5. Record review of nurse's notes dated 05/28/17 through 05/31/17 showed staff restrained Patient #28 on 05/28/17 at 4:14 AM and the patient remained in restraints on 05/31/17 at 7:15 AM.

During an interview on 5/31/17 at 10:20 AM, Staff GGG, RN, CCU stated that the written order for restraint can be given by an LIP.

During an interview on 5/31/17 at 10:30 AM, Staff VVV, RN Director of Two North and Pediatrics stated that written orders for restraint could be written by a NP and renewed every 24 hours, per facility policy.

6. Revised State law RSMo 630.175 permits an Advance Practice Registered Nurse (APRN), in a collaborative practice arrangement with the attending licensed physician, to order restraints or seclusion in psychiatric hospitals and dedicated psychiatric units of general acute care hospitals.

The facility allowed a NP to order restraints in the CCU.

Based on interviews, record reviews and policy review the facility failed to have systemic practices in place to ensure that:
- All facility departments and contracted services were included in the facility-wide Quality Assessment and Performance Improvement (QAPI) Program with data collection, analysis, monitoring and reporting to provide patients with quality care and safety (A-0273);
- Timely and effective measures were implemented to prevent reoccurrence of a medication error which had the potential to negatively affect the health outcome of one patient (#37), of two patient medication errors reviewed. (A-0286)
- The Governing Body had established an ongoing program for improved health outcomes to maintain quality improvement. (A-0309). The facility census was 59.

The severity and cumulative effect of these systemic practices resulted in the facility being out of compliance with 42 CFR 482.21: Condition of Participation: QAPI and resulted in the facility's failure to ensure quality health care and safety.

Based on interview and record review the facility failed to ensure the quality program incorporated quality indicators to collect data to track, trend, and analyze in order to measure the effectiveness and safety of services of patients for seven departments (Emergency, Operating Room [OR], Rehabilitation Services [Physical Therapy, Occupational Therapy, and Speech], Pharmacy, Oncology [study and treatment of tumors], Cardiac Catheterization Lab [Cardiac Cath], and Discharge Planning) of nine departments reviewed and 15 of 15 contracted services. This failure had the potential to put all patients at risk for sub-standard quality of health care and adverse outcomes. The facility census was 59.

Findings included:

1. Record review of the facility's document titled, "Plan for Provision of Care," reviewed 10/25/16, showed directives for facility staff that:
- Improvement opportunities are developed by departments and committees. Additional opportunities are identified by internal and external benchmark comparative data bases. All of these trends are analyzed and evaluated to identify potential improvement opportunities.
- The facility is committed to a planned, systematic, organizational-wide approach to accomplish performance improvement.
- The facility's objectives included opportunities for each department/service line to participate in performance improvement activities.

2. Record review of the monthly Quality and Patient Safety meeting minutes for 12 months, from 05/2016 thru 03/2017, and also 05/2017, showed no reports of individual facility department or contracted services for Quality Assessment Performance Improvement (QAPI.)

The Quality and Patient Safety Committee failed to incorporate any individual facility departments or contracted services QAPI into the hospital wide QAPI program.

During an interview on 06/01/17 at 1:45 PM, Staff B, Director of QAPI, stated that the Emergency Department, Operating Room, Rehabilitation Services, and Pharmacy failed to have quality indicators in which to collect data to track, trend, and analyze in order to measure the effectiveness and safety of services.

3. Record review of the facility's document titled, "Oncology Department Quality Improvement-Patient Satisfaction" showed no quality indicators were chosen in which to collect data to track, trend, and analyze in order to measure the effectiveness and safety of services.

4. Record review of Cardiac Catheterization Lab QAPI documents showed no quality indicators in which to collect data to track, trend, and analyze in order to measure the effectiveness and safety of services.

During an interview on 06/02/17 at 10:50 AM, Staff X, Registered Nurse (RN), Case Management Supervisor, stated that the Discharge Planning Department did not have any QAPI projects or indicators that the department was working on.

5. Record review of the list of contracted services provided by the facility showed the following contracted services that affected patient care:
-Arrhythmia Services
-PFT/EKG
-Lithotripsy
-Dialysis
-Radiologists
-Anatomic Pathology
-Psychiatric evaluations/consults
-Radiology telemedicine
-PET
-Sterotactic Breast Biopsy
-Emergency Department Physicians and Mid-level Providers
-Hospitalists and Mid-level Providers
-Transcriptions
-Travel Nurses
-Reference laboratory

During an interview on 06/02/17 at 2:45 PM, Staff B, Director of QAPI, stated that contracted clinical services were not included in the facility-wide QAPI program.












18018







27727

Based on interview and record review the Governing Body (GB) failed to ensure that the Quality Assessment and Performance Improvement (QAPI) Program had data that was collected, analyzed, reported, and evaluated to improve quality of care provided to patients. The GB also failed to ensure that contracted services were involved in the facility wide QAPI program in order to be evaluated to ensure quality of services provided to patients. The facility census was 59.

Findings included:

1. Record review of the facility's document titled, "Performance Improvement and Safety Plan, reviewed 10/25/16, showed that the executive responsibility for the performance improvement program rests with the GB.

During an interview on 06/01/17 at approximately 3:00 PM, Staff B, RN Director of QAPI, stated that the Quality and Patient Safety Committee minutes were sent for review by the Board Quality Oversight Committee, and then to the GB.

2. Record review of the monthly Quality and Patient Safety meeting minutes for 12 months, from 05/2016 thru 03/2017, and also 05/2017, showed no reports of individual facility department or contracted services for Quality Assessment Performance Improvement (QAPI) .

3. Record review of the monthly GB meeting minutes from 06/2016 thru 05/2017 showed no review of individual facility department or contracted services quality indicators in which to collect data to track, trend, and analyze in order to measure the effectiveness and safety of services.

During a telephone interview on 06/02/17 at 2:05 PM, Staff QQQ, GB member, stated that he was not aware that all the facility departments and contracted services were not involved in the facility wide QAPI program. He stated that QAPI was the responsibility of the GB, but the GB relied on staff to ensure the QAPI program was carried out appropriately.

Based on interview and record review the facility failed to ensure the education and training of two of two physicians was part of the credentialing process upon hire or when re-credentialing. This had the potential for physicians to provide care for patients without the proper training. The facility census was 59.

Findings Included:

1. Record review of the facility's undated "Medical Staff Bylaws" showed the credentialing process was to include evidence of skills in order to provide a type of service that the Board of Trustees has determined to be appropriate for the performance within the hospital and for which a need exits.

During an interview on 06/02/17 at 1:20 PM Staff KKK, Interim Medical Staff Coordinator, stated that physicians medical school transcripts were not required upon hire and proof of ongoing training was not required for re-credentialing.

2. Record review of two physician credentialing files showed no evidence of education or training records included in the credentialing process.

Based on interview, record review and policy review, the facility failed to have systemic practices in place to ensure one patient (#37) was adequately monitored by licensed nursing staff, which resulted in a medication error that could have negatively affected the patients outcome. After the medication error was reported, the facility also failed to take steps to prevent the medication error from reoccurring. The severity and cumulative effect of these systemic practices resulted in the facility being out of compliance with 42 CFR 482.23: Condition of Participation: Nursing Services.

Based on interview, record review and policy review, the facility failed to ensure nursing staff adequately monitored one patient (#37), of one patient reviewed who received Cardizem (brand name for the medication Diltiazem, used in treatment of chest pain, high blood pressure, and abnormal rhythms of the heart) by intravenous (IV, in the vein) infusion (administration, also referred to as drip). The medication was removed from an infusion pump (medical device that administers specific dosages of medication through a timed or dosed program) and the patient received a bolus (large amount) of the medication while he was transferred from the Emergency Department (ED) to the Progressive Care Unit (PCU) by unlicensed staff. The facility also failed to implement timely and effective measures to prevent reoccurrence of the medication error, which had the potential to cause injury or death to patients who received IV medications. The facility census was 59.

Findings included:

1. Record review of the facility's policy titled, "Event Reporting," dated 09/2016, showed that:
- Staff were to report any event or condition which may result, has resulted or could have resulted in an injury to a patient or visitor.
- Examples of events included medication errors.
- Department Directors were to communicate patient care problems with the appropriate professional committee.

2. Record review of the facility's policy titled, "Medication - Adverse Medication Events," dated 06/2012, showed that the purpose of the policy was to report adverse drug reactions, variances and drug incompatibilities to continually monitor appropriate medical care and communicate that to those responsible for that care. The policy also showed:
- Medication variances (also known as errors, anything that does not meet the six rights: patient, dose, drug, route, time and documentation of medication administration) were considered an Adverse Medication Event (AME).
- Individuals observing AMEs will fill out an AME form and send a copy of the form to Continuous Quality Improvement (CQI) and Pharmacy.
- Goals for the reporting program are to educate hospital professional staff concerning any type of AME, to improve patient care.
- Review of the incident should occur at the Pharmacy and Therapeutics (P&T) Committee and Quality and Patient Safety Committee.

3. Although requested, the facility failed to provide a policy which defined to the type of medication administration/infusions that required continuous monitoring by a licensed nurse, including when a patient receiving the medication was transported from one area of the hospital to another.

4. Record review of an event report dated 03/16/17 at 7:00 PM, showed that Patient #37 was transported from the ED to the PCU with an IV Cardizem infusion. The medication was not on an infusion pump, and the patient received a bolus of the medication while he was transported between the two departments. The patient's blood pressure was 90/54 (normal is less than 140/90 and greater than 120/80) when the patient arrived to the unit.

5. Record review of the medication reference used by clinical staff, showed Diltiazem, administered by continuous intravenous infusion had the potential for the following adverse effects (in-part):
- Asystole (heart stops beating);
- Bradyarrhythmia (abnormal heart rhythm slower than 60 heartbeats per minute);
- Dysrhythmias (abnormal heart rhythm);
- Congestive heart failure (heart doesn't pump blood as well as it should);
- Heart block (electrical impulses in the heart are blocked, which causes a heart rate so slow it cannot sustain life);
- Hypotension (low blood pressure);
- Heart attack; and
- Fainting.

6. Record review of Patient #37's medical record dated 03/16/17, showed the following:
- The patient, a 71 year old male with a history of cardiac (pertaining to the heart and blood vessels) disease, presented to the ED with chest pain that radiated (spread) to his back, and had trouble breathing.
- Diltiazem 5 milliliters (ml, unit of measure) per hour, IV, was ordered at 5:25 PM, and initiated at 5:41 PM.
- The patient was diagnosed with Atrial Fibrillation with rapid ventricular response (irregular heart rhythm, with a fast heart rate), rate (heartbeat) 160 beats per minute (bpm, normal is 60-100) and chest pain.
- At 6:41 PM, the patient's pulse (heartbeat) was 154 bpm without a documented blood pressure (blood pressure recorded at 5:45 PM was 103/58, low).
- The patient was admitted to the PCU, and arrived on the unit at 7:00 PM.
- At 7:35 PM, the patient's pulse was 98, with a blood pressure of 90/54 (lower).
- Critical notification documentation dated 03/16/17 at 7:47 PM, showed that Patient #37's physician was contacted and advised that the patient was transported to the PCU without an IV pump while on a "cardizem drip". The "IV tubing was open, pt (patient) got a bolus while transporting up to PCU".
- There was no documentation in the record that showed how much of the Diltiazem infusion was administered to the patient from the time it was started, until the time the patient arrived to the PCU.

7. Observation on 06/02/17 at approximately 2:30 PM, showed that it took approximately 40 steps to walk from the exit of the ED to the entrance of the PCU (this showed the minimum distance Patient #37 was moved while his cardiac medication free flowed [to infuse freely and without obstruction]) without an infusion pump, and without a licensed nurse to monitor the infusion and condition of the patient.

During an interview on 06/06/17 at 1:02 PM, Staff FFFF, PCU Registered Nurse (RN), stated that Patient #37 was transported to PCU by a (unknown) transporter (unlicensed personnel). Staff FFFF stated that when patients were on a cardiac infusion (such as Diltiazem), the patient was typically transported by an RN, on an infusion pump, and that he could not remember a time when he received a patient on the PCU with a cardiac infusion that was not transported by an RN and not on an infusion pump. Staff FFFF stated that he was unable to remember how much of the Diltiazem infusion had been administered when he received Patient #37, and assumed the patient's care. Staff FFFF stated that he completed an event report related to the incident, but could not remember if he completed an AME report.

During an interview on 06/06/17 at 1:20 PM, Staff EEEE, ED Nursing Director stated that:
- Staff ZZZ, RN and Staff AAAA, Transporter, were the staff involved in Patient #37's AME.
- She spoke with Staff ZZZ and Staff AAAA regarding the incident, but was unsure who had removed the Diltiazem from the infusion pump.
- She did not provide education to all ED staff related to the types of medication that required an infusion pump, or required monitoring by a licensed nurse during patient transport.
- There was no facility policy that stated what medication required the use of an infusion pump, or monitoring by a licensed nurse during patient transport.

During an interview on 06/02/17 at 3:26 PM, Staff XXX, Assistant ED Director, was unable to produce documentation that showed education was provided to ED staff (except for Staff ZZZ and Staff AAAA) related to the medication error made on Patient #37, to prevent reoccurrence of the medication error.

8. Record review of ED staff meeting minutes from the date of the event (03/16/17) to current, showed no evidence that the medication error related to Patient #37 was reviewed with staff, or that education was provided to staff related to the types of medications that required an infusion pump, or required monitoring by a licensed nurse while the medication infused during patient transport.

During an interview on 06/02/17 at 3:49 PM, Staff YYY, ED RN, stated that she was unaware of the medication error related to the Diltiazem infusion without a pump, and had not received education related to the type of medications that required the use of an infusion pump or that required continuous monitoring by a licensed nurse while the medication infused during patient transport from one area of the hospital to another.

During an interview on 06/02/17 at 3:50 PM, Staff III, Director of Pharmacy, stated that:
- He had not received an AME and was unaware of the medication error made on Patient #37;
- He would have included the medication error in his P&T committee meeting minutes;
- A pump was required for the infusion of cardiac drips (such as Diltiazem);
- Diltiazem can cause a drop in a patient's blood pressure, which can (negatively) affect the patient's overall condition.

9. Record review of P&T and Quality and Patient Safety Committee meeting minutes from the date of the event (03/16/17) to current, showed no evidence that the medication error related to Patient #37 was reviewed.

10. Record review of an email dated 06/07/17 at 2:46 PM, from Staff DDD, Director of Risk and Regulatory, confirmed that an AME for the event (which involved Patient #37) could not be found, and that the facility still did not have an approved policy related to what medications required the use of an infusion pump, or required continuous monitoring by a licensed nurse while the medication infused during patient transport from one area of the hospital to another.

The facility failed to ensure that a licensed nurse adequately monitored Patient #37 while he received Cardizem by IV infusion, which lead to a medication error when the patient received a bolus of the medication while he was transported from one area of the hospital to another After the medication error occurred, the facility failed to develop a policy which defined the names or types of medication administration/infusion that required constant supervision by a licensed nurse, and failed to educate patient care staff to ensure that the medication error did not occur again. The facility also failed to ensure that an AME was completed related to Patient #37's medication error, which prevented review by Pharmacy leadership, and prevented communication to the P&T and Quality and Patient Safety Committee for their review and intervention to prevent medication error reoccurrence.

Based on observation and interview, the facility failed to ensure the diet manual was accessible to all nursing staff. This deficient practice had the potential to permit inappropriate foods to be served to patients on therapeutic diets. The total facility census was 59.

Findings included:

1. Although requested, the facility failed to provide a policy related to the availability of the diet manual to staff.

2. During an interview on 06/02/17 at approximately 5:00 PM, Staff RRR, Dietetics Director, confirmed there was no policy related to the diet manual availability to all staff. Staff RRR added that nursing staff should know that the diet manual was available to all staff online, and that the location of the diet manual was reviewed during nursing orientation.

During an interview on 06/01/17 at 2:50 PM, Staff TTT, Registered Nurse (RN), Orthopedics, stated she was unable to locate the facility diet manual without contacting the dietician for guidance.

3. Observation and concurrent interview on 06/01/17 at 3:01 PM, showed Staff UUU, RN, Critical Care Unit, was unable to locate where the facility diet manual was maintained, and stated that she did not know where the diet manual was maintained without asking other staff for the location.

During an interview on 06/01/17 at 3:10 PM, Staff SSS, RN, Women's Health, and Staff F, Director of Women's Health, stated they did not know where the facility diet manual was maintained.

Based on observation and interview, the facility failed to install sprinkler heads in accordance with the National Fire Protection Association (NFPA) 13, Standards for the Installation of Sprinkler Systems. These deficient practices puts all patients, staff, and visitors at a higher risk of injury or death from a fire. The facility census was 59.

Findings included:

1. All smoke compartments of the building must have sprinkler heads of the same temperature rating. When sprinkler heads of different temperature ratings are mixed this could delay the activation of the sprinkler heads in the event of a fire.
Section 8.3.3.2 of NFPA 13 states: "Where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3

2. Observation on 06/05/17, during the facility tour, showed nine standard sprinkler heads and three quick response sprinkler heads mounted in the same smoke compartment, on the third floor stairwell.

Observation on 06/05/17, during the facility tour, showed six standard sprinkler heads and one quick response sprinkler head mounted in the same smoke compartment, on the second floor stairwell.

During an interview on 06/09/17, at 2:15 PM, the Director of Facilities Management, stated that the different sprinkler heads, in the same smoke compartments, were installed during previous remodels in the hospital.

3. All elevator hoistway pits that use a petroleum based hydraulic fluid (a combustible substance) must have a sprinkler not more than two feet above the floor of the pit. The accumulation of debris in the elevator hoistway pits could result in a fire. The presence of petroleum based hydraulic fluid could act as an accelerant when exposed to the fire.

Section 8.15.5.1* of NFPA 13 states: " Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.

* The sprinklers in the pit are intended to protect against fires caused by debris, which can accumulate over time. Ideally, the sprinklers should be located near the side of the pit below the elevator doors, where most debris accumulates. However, care should be taken that the sprinkler location does not interfere with the elevator toe guard, which extends below the face of the door opening.
ASME A17.1, Safety Code for Elevators and Escalators, allow the sprinklers within 2 ft (0.65 m) of the bottom of the pit to be exempted from the special arrangements of inhibiting waterflow until elevator recall has occurred.

4. Observation on 06/05/17, during the facility tour, showed six of nine elevator hoistway pits did not have sprinkler coverage. Observation showed all six elevators employ a hydraulic elevator lift mechanism that uses a petroleum-based hydraulic fluid, which is combustible.

During an interview on 06/09/17, at 2:05 PM, the Director of Facilities Management stated that the elevator hoistway pits did not have sprinkler coverage.

5. Elevator machine rooms must have sprinkler protection. The absence of sprinkler protection in elevator machine rooms could result in the delay of fire extinguishment in the building.

Section 8.15.5.3* of NFPA 13 states: "Automatic sprinklers in elevator machine rooms or at the tops of hoistways shall be of ordinary or intermediate temperature rating.

* ASME A17.1, Safety Code for Elevators and Escalators, requires the shutdown of power to the elevator upon or prior to the application of water in elevator machine rooms or hoistways. This shutdown can be accomplished by a detection system with sufficient sensitivity that operates prior to the activation of the sprinklers (see also NFPA 72, National Fire Alarm and Signaling Code). As an alternative, the system can be arranged using devices or sprinklers capable of effecting power shutdown immediately upon sprinkler activation, such as a waterflow switch without a time delay. This alternative arrangement is intended to interrupt power before significant sprinkler discharge.

6. Observation on 06/05/17, during the facility tour, showed six of six elevator machine rooms did not have sprinkler coverage.

During an interview on 06/09/17 at 2:05 PM, the Director of Facilities Management, stated that the elevator machine rooms did not have sprinkler coverage.

Based on observation, interview and policy review, the facility failed to ensure staff removed outdated/expired supplies and equipment in the Woman's Health Department, Cardiac Care Unit (CCU) and Progressive Care Unit (PCU) Step-down. The facility also failed to perform a daily User Test (a manual check on equipment that also has automatic self-test capability) for 14 defibrillators (an apparatus used to control heart fibrillation by application of an electric current to the chest wall or heart) as stated in policy and in the manufacturer's instructions, of 24 defibrillators reviewed for proper testing. These failed practices to keep outdated/expired equipment in the patient care areas and properly test defibrillators had the potential to cause ineffective or harmful products to be used for patient care. There were 24 defibrillators in the facility. The facility census was 59.

Findings included:

1. Record review of the facility's policy titled, "Shelf life of a Packaged Sterile Item is Event Related," dated 02/16, showed the directive for facility staff that when a manufacturer places an expiration date on a sterile item that the expiration date should be honored.

2. Observation with concurrent interview in the Women's Health Department on 05/30/17 at 2:35 PM showed:
- An isolation bag (covers intestines outside the body of the newborn) that expired 10/2016;
- An endotracheal tube (ET, a tube that is inserted through the mouth down into the windpipe, used to establish and maintain an open airway to assist with breathing) that expired 06/2014.
- A urinary catheter (a tube placed into the bladder to allow urine to drain) tray (equipment needed to insert a catheter) that expired 01/2016.
- Two intrauterine pressure catheters (catheters placed into the uterus and beside the baby that measure the strength and duration of contractions) which expired 06/2014 and 08/2014.
- Staff F, Director of Woman's Health and Nursery, confirmed the findings.

During an interview on 05/30/17 at 3:30 PM, Staff F stated that she directed staff to remove expired supplies monthly, but had not ensured this occurred. The removal of expired supplies was not documented.

3. Record review of the facility's policy titled, "Code Blue Equipment Box" (a locked box with airway emergency needs), dated 06/2017, showed the directive for staff to check the lock for integrity and if intact, record on the log. If broken, staff should check that the contents match the RT Equipment Box Contents list and restock and clean the box as needed and document on the log.

4. Observation on 05/30/17 at 3:40 PM of the Respiratory Therapy (RT) box in the Women's Health Department showed four tubes of water soluble lubricant. Two expired 01/2017 and two expired 02/2017. One ET tube expired 06/2016.

5. Record review of the RT Code Blue Equipment Checklist showed the last time staff opened the box was on 11/02/15.

6. Observation with concurrent interview on 05/31/17 at 10:00 AM in the (CCU) supply cabinet, showed three expired laryngeal mask airways (keeps a patient's airway open during anesthesia or unconsciousness). Two had expiration dates of 12/2016 and one had an expiration date of 3/2017. Staff VVV, RN, Director of Two North, verified the supplies were expired.

7. Observation on 05/30/17 at 3:25 PM in the PCU Stepdown, showed an expired yankauer (an oral suctioning tool) in the RT box with a date of 02/2016.

During an interview on 05/31/17 at 10:10 AM, Staff HH, Director of the Respiratory Department, stated that she expected the nightshift respiratory therapist to check the RT boxes for expired dates.

During an interview on 06/01/17 at 1:35 PM, Staff DDD, Infection Preventionist, stated that all supplies should have been rotated out and not used for patients.

8. Record review of facility's policy titled, "Code Blue," revised 02/2017, showed that the Team Lead or designee is to complete defibrillator (an apparatus used to control heart fibrillation by application of an electric current to the chest wall or heart) test daily according to procedure on the crash cart (cart with supplies and equipment used during emergency medical procedures.)

9. Record review of facility's crash cart procedure, titled, "Code Blue Cart Checklist," revised 01/2013, showed Defibrillator User Test (a manual check on equipment that also has automatic self-test capability) to be checked daily. Test included that the defibrillator was plugged into an electrical socket and tested unplugged.

10. Record review of the manufactures Monitor/Defibrillator Operating Instructions showed that the User Test should be performed as part of completing the daily Operator's Checklist (Code Blue Cart Checklist).

11. Record review of "Code Blue Cart Checklist" for all defibrillators in the facility for 05/2017 showed 14 of 24 defibrillators in noncompliance with the facility's policy and manufactures instructions.

During an interview on 06/02/17 at 12:50 PM, Staff IIII, Registered Nurse (RN), Clinical Educator, stated that the model of defibrillators that were not in compliance with the facility's policy and manufactures instructions only required the automatic self-test. Staff IIII, RN, stated that she did not have information to confirm that the defibrillators only required the automatic self-test.

12. Observation in the CCU and concurrent interview on 05/30/17 at 3:45 PM, showed the defibrillator had self-tested automatically at 3:00 AM. Staff FFF, RN, stated that the self-test passed and no further tests were performed.

13. Observation in the CCU and concurrent interview on 05/31/17 at 10:05 AM, showed the defibrillator had self-tested automatically at 3:00 AM and Staff GGG, RN, stated that the self-test passed and no further tests were performed.

14. Observation in the Emergency Department (ED) and concurrent interview on 06/02/17 at 10:20 AM, showed the defibrillator had self-tested automatically at 3:00 AM and Staff HHHH, RN, stated that the self-test passed and no further tests were performed. Staff HHHH showed the procedure for a manual User Test and stated that this would only be done if the self-test failed and did not include an unplugged User Test.






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Based on observation, interview, record review and policy review, the facility failed to:
- Maintain a sterile environment in the OR sterile processing room, which processes instruments used in all operating room (OR) suites, when they failed to terminally clean the area daily; left multiple paper products (particle shedding products that can cause contamination) hanging on the walls; and failed to remove the residue and lime in two large steam prevac sterilizers (equipment that destroys bacteria by bringing steam to a high temperature);
- Maintain a sterile environment in the OR decontamination sterile processing room when they failed to remove exposed insulation (particle shedding products that can cause contamination) around a pipe;
- Maintain sterilization when staff placed a contaminated stethoscope on one (#30) of one patient's chest in OR #4 during a surgical procedure;
- Maintain a sterile field when staff wore contaminated lanyards (a strap worn around the neck) with badges during a surgical procedure for one (#30) of one patient.
- Maintain a sterile environment in the Endoscopy sterile processing room when staff failed to terminally clean the area daily;
- Maintain the appropriate storage of four colonoscopes (an instrument used to examine the colon), four endoscopes (an instrument used to examine the inside of the body, usually the throat or the esophagus) and three bronchoscopes (an instrument used to examine the airways);
- Ensure that four laryngoscope blades (device that allows visualization of the vocal cords to allow for a tube to be placed into a patient's airway) on 2 South, four in the Women's Health Department and two in the Critical Care Unit (CCU) were sealed in individual packages, inside the Respiratory Therapy boxes (secured boxes with emergency airway supplies) located on the crash carts.
- Dispose of two unclean pediatric intravenous (IV) arm boards stored in a medication room drawer;
- Place tubing change stickers on tubing for IV medications for four patients (#7, #24, #25 and #3) of thirteen patients observed;
- Clean a stethoscope before and after entering Patient #10's contact isolation room;
-Perform hand hygiene when entering a patient's room, between touching a patient and the environment and between glove changes for four patients (#13, #26, #10 and #33) of four observed.
-Appropriately wear Personal Protection Equipment (gown) for one patient (#32) of two patients observed in isolation.
These failed practices had the potential to expose all patients, visitors and staff to cross contamination and increase the potential to spread infection. The facility census was 59.

The cumulative effect of these systemic failures resulted in the facility's non-compliance with 42 CFR 482.42 Conditions of Participation: Infection Control and resulted in the facility's failure to ensure safe infection control practices to prevent infections and communicable diseases.

Please refer to A-0749 for additional information.



36473

Based on observation, interview, record review and policy review, the facility failed to:
- Maintain a sterile environment in the OR sterile processing room, which processes instruments used in all operating room (OR) suites, when they failed to terminally clean the area daily; left multiple paper products (particle shedding products that can cause contamination) hanging on the walls; and failed to remove the residue and lime in two large steam prevac sterilizers (equipment that destroys bacteria by bringing steam to a high temperature);
- Maintain a sterile environment in the OR decontamination sterile processing room when they failed to remove exposed insulation (particle shedding products that can cause contamination) around a pipe;
- Maintain sterilization when staff placed a contaminated stethoscope on one of one patient's (#30) chest in OR #4 during a surgical procedure;
- Maintain a sterile field when staff wore contaminated name badges and a contaminated stethoscope during a surgical procedure for one (#30) of one patient;
- Maintain a sterile environment in the Endoscopy (Endo) sterile processing room when staff failed to terminally clean the area daily;
- Maintain the appropriate storage of four colonoscopes (an instrument used to examine the colon), four endoscopes (an instrument used to examine the inside of the body, usually the throat or the esophagus) and three bronchoscopes (an instrument used to examine the airways);
- Ensure that four laryngoscope blades (device that allows visualization of the vocal cords to allow for a tube to be placed into a patient's airway) on 2 South, four in the Women's Health Department and two in the Critical Care Unit (CCU) were sealed in individual packages, inside the Respiratory Therapy boxes (secured boxes with emergency airway supplies) located on the crash carts.
- Dispose of two of two unclean pediatric intravenous (IV) arm boards stored in a medication room drawer;
- Place tubing change stickers on tubing for six IV medications for four patients (#7, #24, #25 and #3) of thirteen patients observed;
- Clean a stethoscope before and after entering Patient #10's contact isolation room;
-Perform hand hygiene when entering a patient's room, between touching a patient and the environment and between glove changes for four patients (#13, #26, #10 and #33) of four observed.
-Appropriately wear Personal Protection Equipment (gown) for one patient (#32) of two patients observed in isolation.
These failed practices had the potential to expose all patients, visitors and staff to cross contamination and increase the potential to spread infection. The facility census was 59.

Findings included:

1. Record review of the Association of Operating Room Nurses (AORN) and the Association for the Advancement of Medical Instrumentation (AAMI) of the cleaning of sterile processing rooms showed that they recommend that they were to be terminally cleaned daily the same as the operating, delivery and invasive procedure rooms. AAMI also stated that the sterilizers water hardness can affect the purity of the steam used and can carry over excessive chemicals into the steam used for sterilization.

2. Record review of the facility's policy titled, "Cleaning of Operating Room Department," dated 11/2016, showed the directive for staff that OR and procedure rooms should be cleaned from top to bottom and clean to dirty; and terminal cleaning is any cleaning that is performed at the completion of surgical or procedural daily surgery schedules.

3. Record review of the manufacturer cleaning recommendations for the steam prevac sterilizers, showed that when mineral deposits formed (due to water hardness), the chamber should have been cleaned and descaled more often to maintain peak operating condition.

4. Observation on 05/31/17 at 9:35 AM in the OR sterile processing clean room, showed:
- The floors were unclean;
- Paper (partical shedding) products hung on the walls (temperature logs and a clip board with several papers in it);
- The inside bottom of the two large steam prevac sterilizers were covered with residue and lime; and
- The outside doors of the two large sterilizers were unclean.

During an interview on 05/31/17 at 3:15 PM, Staff LL, Plumber, stated that he cleaned the inside of the sterilizers quarterly and that he did not have a log.

5. Observation on 05/31/17 at 9:25 AM in the OR sterile processing decontamination room, showed:
- The floors were unclean;
- Paper temperature logs hung on the walls;
- The outside door of the washers were unclean; and
- Exposed insulation (particle shedding) around pipes to the left of the washers.

During an interview on 05/31/17 at 9:35 AM, Staff JJ, Lead Technician for sterile processing, stated that they had no cleaning log for the sterile processing rooms.

During an interview on 05/31/17 at 2:20 PM, Staff NN, Director of Environmental Services, stated that they never terminally cleaned the OR sterile processing rooms and that they followed AORN recommendations. Staff NN stated that there were no cleaning logs because they had thrown them away, because they were starting a new schedule the next day.

During an interview on 05/31/17 at 3:25 PM, Staff MM, Director of Perioperative Services, stated that she recognized they had cleaning issues in the OR sterile rooms and she had spoken to the Director of Facilities regarding the exposed insulation covering the pipes.

During an interview on 06/01/17 at 4:10 PM, Staff BBB, Director of Facilities, stated that he was unaware that the insulation around the pipes caused particle shedding.

During a telephone interview on 06/07/17 at 9:16 AM, Staff MM, Director of Perioperative Services, stated that their facility followed AORN and AAMI.

6. Record review of the facility's policy titled, "Aseptic Technique," dated 01/2017, showed that:
- The directive was for staff who participated in the care of patients in the OR should have followed aseptic technique guidelines;
- Any supply or instrument that was used during a surgical procedure, that did not require sterilization, should have been cleaned before and after each use with a high level disinfectant or sterilization; and
- AORN guidelines should have been followed.

7. Observation and concurrent interview on 06/01/17 at 11:00 AM in OR #4, during Patient #30's knee surgery, showed Staff WW, Circulating Nurse, wore a contaminated name badge and stated that she always wore her name badge since she wiped it off daily.

Observation on 06/01/17 at 11:00 AM in OR #4, during Patient #30's knee surgery, showed Staff XX, Certified Nurse Anesthetist (CRNA), wore a contaminated name badge that continued to touch the patient in the head when she leaned over to give him medication.

During an interview on 06/01/17 at 12:43 PM, Staff XX stated that she thought it was policy to wear a name badge during surgery.

Observation on 06/01/17 at 11:00 AM in OR #4, during Patient #30's knee surgery, showed Staff YY, Anesthesiologist listened to lung sounds with a contaminated stethoscope and wore a contaminated name badge that touched the patient when he leaned over to listen to lung sounds.

During an interview on 06/01/17 at 12:45 PM, Staff YY, stated that it was typical for him to wear his stethoscope and name badge during surgery, and that he cleaned them daily.

8. During an interview on 06/01/17 at 4:22 PM, Staff MM stated that they did not have a cleaning log for the Endoscopy sterile processing area and that Environmental Services would have it.

During an interview on 06/01/17 at 3:45 PM, Staff NN, Director of Environmental Services, stated that she was unaware that the Endoscopy sterile processing area had to be terminally cleaned.

9. Record review of the AORN, showed that all flexible scopes should have been enclosed in a cabinet with sufficient height, width, and depth which allowed them to hang vertically, without coiling and without touching the bottom of the cabinet.

10. Observation on 06/01/17 at 4:23 PM in Endoscopy room #1, showed two colonoscopes, two endoscopes and two bronchoscopes stored in an enclosed cabinet. All of the scopes were hung curved on hooks.

11. Observation on 06/01/17 at 4:25 PM in Endoscopy room #2, showed two colonoscopies, two endoscopes and one bronchoscope stored curved on hooks in an enclosed cabinet.

During an interview on 06/01/17 at 4:45 PM, Staff MM, Director of Perioperative Services, stated that she thought the scopes were hung straight enough and didn't realize that they had to be hung completely straight.

12. Record review of the facility's policy titled, "Code Blue Equipment Boxes," dated 06/2017, showed the directive that after sterile processing cleaned the laryngoscope blades, they were to remain in clean sleeves and placed into the RT box on the crash cart.

13. Observation with concurrent interview on 05/30/17 at 3:40 PM of the RT box in the Women's Health Department showed two curved and two straight laryngoscope blades that staff failed to ensure were covered in individually sealed packages. Staff F, Director of Woman's Health and Nursery, confirmed the findings.

14. Observation on 05/30/17 at 2:30 PM in the Critical Care Unit (CCU) showed two of three RT boxes contained laryngoscope blades which were not packaged in clean sleeves, as per policy.

During an interview on 05/30/17 at 2:45 PM, Staff WWW, Sterile Processing Technician, stated that she did not know if the laryngoscope blades were to be kept in clean sleeve packaging.

15. Observation on 05/30/17 at 2:55 PM on 2 South, of the RT box on the crash cart, showed two curved and two straight unpackaged laryngoscope blades.

During an interview on 05/31/17 at 10:10 AM, Staff HH, Director of Respiratory Services, stated that she periodically checked the RT boxes and that she expected the laryngoscopes to be packaged.

16. Observation on 05/30/17 at 3:45 PM, in the PCU Step-down (Progressive Care Unit) medication room, showed two unclean pediatric IV arm boards located in the second drawer to the left of the sink.

During an interview on 06/02/17 at 1:40 PM, Staff KKK, Charge Nurse for PCU Step-down, stated that the Certified Nurses Assistant's (CNA's) are responsible for stocking the drawers in the medication rooms.

17. Record review of the facility's policy titled, "Intravenous Therapy-Initiation and Maintenance," ((IV, needle placed into a vein to deliver fluids and medications) dated 02/2017, showed the directive for staff that when hanging preliminary solution or changing tubing place a change sticker on the tubing.

18. Observation on 05/31/17 at 9:50 AM showed that the intravenous tubing for Patient #7's IV did not contain a sticker/label with the date, time or initials of staff when they initiated it.

During an interview on 05/31/17 at 9:56 AM, Staff I, Registered Nurse (RN), Director of Medical-Surgical-Pediatrics Unit stated that staff is expected to put a sticker/label on IV tubing with the date, time and initials of staff that initiated the IV.

19. Observation on 05/31/17 at 4:15 PM in rooms of Patient #24 and Patient #25 showed neither had a change sticker on their IV tubing.

During an interview on 05/31/17 at 4:25 PM, Staff L, RN, stated that staff should have placed a change sticker placed on the tubing.

20. Observation on 05/30/17 at 3:15 PM, on PCU Step-down, in Patient #3's room, showed three IV tubings with no change sticker.

During an interview on 05/30/17 at 3:35 PM, Staff KK, RN, stated that she typically puts the change sticker labels on the IV tubing.

21. Record review of the facility policy titled "Hand-washing, Hand Hygiene and Nail Care" revised 10/15 showed:
-The purpose is to decrease the risk of transmission of infection by appropriate hand hygiene.
-Hand hygiene is generally considered the most important procedure for preventing healthcare associated infections.
-Decontaminate hands before and after direct patient care.
-Decontaminate hands after contact with a patient's intact skin.
-Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.
-Decontaminate hands after removing gloves.

Record review of the facility policy titled, "Gloves" reviewed 10/15 showed:
-The purpose is to promote appropriate use of gloves for patient and healthcare worker safety.
-Hands should be washed immediately after gloves are removed.
-After carrying out a procedure, do not wear gloves outside of the patient's room.

22. Observation on 05/30/17 at 3:50 PM in the Emergency Department (ED) showed Staff CC, RN, entered the room of Patient #13 and did not perform hand hygiene and applied gloves. She then left the room wearing the gloves and reentered the room wearing the same gloves. She repositioned the patients arm, checked the identifying arm band and administered an intravenous medication wearing the same gloves.

During an interview on 05/30/17 at 4:00 PM, Staff CC stated that she should have performed hand hygiene when she entered and should have removed the gloves when she left the room. She stated "I think I was nervous having someone watch. I had [infection control] training."

23. Observation on 05/31/17 at 8:40 AM in the CCU showed Staff UU, RN, entered the room of Patient #26 and applied gloves and connected a syringe to the nasogastric tube (NG, a tube placed in the nose, down the throat and into the stomach). She then removed her gloves and reapplied gloves without performing hand hygiene and administered medications. She then checked blood return on the peripherally inserted central catheter (PICC line, a tube placed into a vein which empties near the heart and is used to draw blood or administer medications or nutrition) disposed of the syringe in the sharps box and used the same gloves and prepared to administer IV lipids (liquid nutrition) by flushing the tubing and connecting the tubing to the PICC line.

During an interview on 05/31/17 at 9:15 AM, Staff UU confirmed that she had not performed hand hygiene between glove changes and should have removed her gloves and performed hand hygiene between administering medications through the NG and administering IV lipids.

24. Observation on 05/31/17 at 10:25 AM showed that on Patient #10's door was a sign posted that read Contact Isolation (used for infections, diseases or germs that are spread by touching the patient or items in the room) and directed staff to wear Personal Protective Equipment (PPE, gown, mask, and gloves) before entry into the patient's room. Staff K, RN, entered the room to perform a dressing change and Staff GGGG, Physician, entered to assess the patient. Staff K put on non-sterile gloves and removed the old dressing that had a large amount of bright red drainage. Staff K removed the non-sterile gloves and put on another pair of non-sterile gloves. Staff K did not perform hand hygiene after the removal or before putting on another pair of gloves. Staff K cleansed the wound, repacked it and placed a new dressing on the opened wound. Staff GGGG put on gloves and placed his own stethoscope onto the patient to listen to his heart, lungs and abdomen. Staff GGGG removed his gloves but did not perform hand hygiene and did not clean or disinfect his stethoscope before leaving the patient's isolation room. Staff GGGG, used his own stethoscope instead of one provided in the isolation room and did not clean or disinfect it before he left the patient's room.

During an interview on 05/31/17 at 10:33 AM, Staff I, RN, Director of Medical-Surgical-Pediatrics Unit stated that Staff GGGG did not perform hand hygiene or cleanse or disinfect his stethoscope upon leaving Patient #10's room.

During an interview on 05/31/17 at 10:35 AM, Staff K stated that staff is to perform hand hygiene before and after entry into a patient's room. Staff K stated that she did not think hand hygiene had to be done after glove removal.

25. Observation on 06/01/17 at 10:15 AM showed Staff PPP, RN, entered Patient #33's room to administer blood. Staff PPP put on gloves, started the blood and then removed her gloves. Staff PPP did not perform hand hygiene before she put on the gloves or after she removed them.

During an interview on 06/01/17 at 10:16 AM, Staff PPP, RN, stated that she should have performed hand hygiene before and after gloving.

26. Record review of the facility policy titled, "Multi-Drug Resistant Organisms" (MDRO revised 10/16 showed the purpose is to:
- Prevent the spread of healthcare or community acquired organisms or infections
in patient care areas.
- Prevent the exposure of patients, visitors and healthcare workers to communicable or infectious diseases.
- Provide a dedicated stethoscope and blood pressure cuff for patients in isolation precautions.

The policy did not address what the staff should wear when in a contact isolation room.

27. Observation on 06/01/17 at 12:15 PM in the PCU showed Staff DDDD, RN, in the Contact Isolation room of Patient #32. Her Personal Protection Equipment gown was hanging from her neck and was not tied in the back, which exposed her clothes to infectious organisms. These organisms could be spread to other patients.

During an interview on 06/01/17 at 12:20 PM, Staff DDDD, stated that she did not realize her gown was not tied and did not cover her uniform.

During an interview on 06/01/17 at 1:35 PM, Staff CCC, Infection Control Preventionist, stated that:
- Staff should be terminally cleaning the OR sterile processing rooms and the Endo sterile processing rooms;
- She was unaware that OR and Endo sterile processing rooms were not being terminally cleaning daily;
- Staff should not have paper products hanging in the sterile processing rooms;
- Staff should be removing insulation from the decontamination room;
- Staff should be following manufacturers guidelines for cleaning the sterilizers;
- She had not done a walk through in the sterile processing department since February and did not open the sterilizers;
- In surgery, staff should have a dedicated stethoscope for each OR and they should not have worn their badges without sterilizing them;
- She walked through surgical areas, but did not observe in surgery;
- She was unaware that the endoscopes were hung curled;
- The laryngoscopes should remain in peel pouches and if opened they should have gone back to sterile processing;
- The nursing staff should have disposed of the unclean pediatric arm boards;
- The nursing staff should have placed the change labels on all IV tubing;
- Staff should not bring stethoscopes into a Contact Isolation room;
- Staff should perform hand hygiene before entering a patients room and when leaving a room, after removing gloves, and change gloves and perform hand hygiene between touching the patient and surrounding environment.
- Staff should appropriately tie gowns to protect their clothes in a Contact Isolation room.







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