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1. Based on observation, facility policy review, and staff interview, the facility failed to store, prepare, and serve foods in a safe and sanitary manner in 1 of 1 kitchen and in 3 of 5 nutrition stations (3 East floor, 4th floor, and 5th floor). These practices placed patients and visitors at risk for contamination of food during preparation which can lead to foodborne illness.

Findings include.

Review of the policy "Sanitation Program" occurred on 05/15/13. This policy, revised 06/10/10, stated, ". . . The Food and Nutrition Services Department maintains a sanitation program. To maintain a clean, safe and effective environment of care and to prevent the transmission of disease-carrying organisms . . . Clean equipment, walls, floors and storage areas routinely on a scheduled basis with the appropriate sanitizing compounds . . . Generally, equipment and contact surfaces are cleaned and sanitized between use."

Observation of the main kitchen occurred on 05/15/13 at 1:00 p.m. with three nutrition services staff members (#18, #19, and #20) and showed the following:
*dried food debris on the internal and external components of a stand-up mixer sitting on the counter
*all counters in the kitchen grimy to the touch
*a bag of frozen corn and a box of breakfast cubes directly on the floor in the walk-in freezer
*the two evaporator fans in both the walk-in freezer and refrigerator with dust build up
*the hood above the main stove in the kitchen with dust build up
*sticky/grimy counters and cupboards on the grill line in the retail area of the cafeteria/kitchen, as well as a build up of grease on the hood above the grill
*dirty dishes washed and stored in the same room as clean dishes - observation showed dried food debris on the clean, drying dishes

During an interview on 05/15/13 at 1:00 p.m., an administrative nutrition services staff member (#18) confirmed the lack of cleanliness in the kitchen.

Observation of the nutrition stations on each nursing unit occurred on the morning of 05/15/13 and identified the following:
*3 East floor (Medical/Surgical Unit) - a scoop stored inside a container of Nutrisource Fiber supplement
*4th floor (Intermediate Intensive Care Unit) - a scoop stored inside a container of Nutrisource Fiber supplement
*5th floor (Medical/Surgical Unit) - a scoop stored inside a container of Nutrisource Fiber supplement, two blue ice packs labeled "Therapy" stored in the freezer amongst patient food, accumulated food particles adhered to all surfaces inside the microwave available for patient use

During an interview on the afternoon of 05/15/13, an administrative nurse (#9) stated staff should not store ice packs used on patients for therapy in the same freezer as patient food and confirmed staff should not store scoops inside supplement containers.

2. Based on observation, policy and procedure review, record review, review of professional literature, and staff interview, the Hospital failed to follow established professional standards of care relating to infection control practices for 3 of 4 inpatients (Patient #4, #5, and #16) observed receiving personal hygiene care and for 2 of 8 inpatients (Patient #6 and #43) observed receiving intravenous (IV) medications/treatments. Failure to follow infection control practices may allow transmission of organisms and pathogens throughout the patient's body/bloodstream, from staff to patients, one patient to another, to visitors, and from one environment to another.

Findings include:

Review of the policy "Isolation: Transmission-Based Precautions" occurred on 05/16/13. This policy, revised 03/22/11, stated, ". . . Contact Precautions are designed to reduce the risk of epidemiologically important microorganisms by direct or indirect contact . . . PROCEDURE . . . D. Gloves: Always wear gloves when entering the room. During the course of providing care for a patient, change gloves after having contact with infective material that may contain high concentrations of microorganisms. Wash hands after glove removal . . . H. Wash hands: Hands must be washed upon entering and leaving the room, and before and after glove usage utilizing soap and water or alcohol-based product . . . Soap and water is best practice in Clostridium difficile (c. diff.) isolation, followed by alcohol-based product if warranted. . . ."

Review of the policy "Handwashing" occurred on 05/16/13. This policy, revised 03/21/11, stated, ". . . ALL personnel must wash their hands: . . .
5. After removing gloves or other personal protective equipment
6. When contaminated with blood or other body fluids . . .
8. In between performance of routine procedures (handling urinals, bedpans, catheters, changing dressings, collecting specimens, etc.) . . .
D. Gloves are not to be used instead of handwashing. . . ."

Review of the policy "Handwashing/Scrubbing" occurred on 05/16/13. This policy, revised 07/19/10, stated, ". . . Alcohol-based hand foam
1. Dispense golf-ball sized amount of foam on hand.
2. Rub foam into hands, fingers and wrists until dry. . . ."

"Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011", a publication from the Centers of Disease Control, page 8 and 53 stated, ". . . Needleless Intravascular Catheter Systems. Recommendations . . . 4. Minimize contamination risk by scrubbing the access port with an appropriate antiseptic . . . and accessing the port only with sterile devices . . ."

- Review of Patient #4's medical record occurred on 05/15/13 and identified the hospital placed the patient on contact precautions due to a diagnosis of Clostridium difficile (a contagious bacteria spread by contact with an infected patient's stool).

Observation on 05/14/13 at 8:15 a.m. showed two patient care technicians (PCT) (equivalent to a certified nursing assistant) (#6 and #7) wearing gowns and gloves and giving Patient #4 a bed bath. A PCT (#7) removed the patient's brief, soiled with stool, performed perineal care, applied barrier cream to his buttocks, and placed a new brief. Without washing her hands and changing her gloves, the PCT (#7) lotioned the patient's back, put his supplies away, moved his phone, touched his bedside table and walker, and used a gait belt to transfer the patient from his bed to his chair. After transferring the patient to the chair, the PCT (#7) wet the patient's comb and handed it to him, handed him his handkerchief, cleaned his glasses and put them on his face, gave him the breakfast menu, and bagged the soiled linen and garbage. The PCT (#7) then removed her gown and gloves and washed her hands for the first time since completing perineal care.

- Observation on 05/14/13 at 9:05 a.m. showed a nurse (#8) entered Patient #5's room, sanitized her hands, donned gloves, and removed the dressing on the patient's right hip incision. Without performing hand hygiene, the nurse (#8) changed her gloves, applied a new dressing to the patient's hip incision, and then removed her gloves and sanitized her hands.



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- Review of Patient #16's active medical record occurred on 05/14/13 and identified contact precautions related to Methicillin Resistant Staphylococcus Aureus (MRSA).

Observation on 05/14/13 at 11:00 a.m. showed the nursing staff members (#4 and #5) donned gloves and entered Patient #16's room. A staff member (#4) performed perineal cares for the patient after a bowel movement while the other staff member (#5) helped position the patient. Observation showed the staff member's (#4) gloves soiled with stool and needed changing three times during perineal cares. The staff member (#4) failed to perform hand hygiene after she removed the soiled gloves and before donning clean gloves; and failed to perform hand hygiene after she completed perineal cares and before continuing with other cares for the patient.


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- Observation of patient care occurred on 05/13/13 at 5:00 p.m. with a staff nurse (#14). The nurse (#14) entered Patient #43's room and disconnected the PCA (patient controlled analgesia) line from Patient #43's vascular access device or IV hub (also called stopcock, IV injection port, or needleless vascular system; used for administration of medications and/or injection of IV solutions), used the PCA pump to flush fluid through the line, and re-connected the line to the IV hub. The nurse (#14) failed to cleanse the IV hub with an antiseptic (alcohol or iodophor, used to kill organisms/bacteria) before re-connecting the PCA line to the hub.

- Observation of patient care occurred on 05/14/13 at 10:50 a.m. and showed a staff nurse (#15) failed to cleanse Patient #6's IV hub with an antiseptic before connecting the IV line to the hub.

During an interview on 05/16/13 at 8:45 a.m., two infection prevention staff members (#16 and #17) stated staff must cleanse IV injection ports with alcohol before accessing the port and/or administering a medication through the port. The staff members (#16 and #17) stated staff must always remove gloves after contact with bodily fluids (urine, stool, mucus) and perform hand hygiene or hand washing prior to moving on to other tasks and stated staff must also perform hand hygiene or hand washing after removing gloves or in between glove changes.

Based on record review and staff interview, the Hospital failed to arrange the implementation of the discharge plan for 1 of 3 sampled emergency department (ED) patients (#33) discharged and referred to another facility for treatment. Failure to contact the receiving psychiatric care facility limited the Hospital's ability to ensure the continuity and quality of care.

Findings include:

Review of Patient #33's ED medical record occurred on 05/16/13. The patient presented to the ED on 03/08/13 at 9:18 p.m. with a family member complaining of suicidal ideation. The physician's notes, dated 03/09/13 at 12:06 a.m., stated ". . . Patient presents with suicidal ideation. Brought in by his daughter. Patient has had a history of PTSD [post-traumatic stress disorder] was in the military . . . Describes that he was worried that he might use a shotgun to kill himself. Patient never had any suicidal thoughts in the past. No homicidal thoughts, hallucinations. . . . Assessment: . . . Depression with anxiety . . . Suicidal risk, Plan: Acute psych [psychiatric] hospitalization [I] suspect patient may be able to go voluntarily. Patient is willingly and wanting only needing help and will [sic] like to try voluntary commitment for her [sic] review evaluation. Patient's daughter is here and agrees that she she'll [sic] make sure that he gets her [sic] safely. Arrangements being made for transfer. . . ."

Patient #33's nurse's notes, dated 03/09/13 at 12:27 a.m., stated "Pt. [Patient] has d/c [discharge] orders. . . . Reviewed information with pt. and family. . . . Pt. instructed to go directly to [psychiatric care facility]. Pt. family given directions on how to get there."

Patient #33's medical record lacked evidence of contact with the psychiatric care facility to arrange the discharge and post-hospital care.

During interview, on 05/16/13 at 1:40 p.m., an ED supervisory nursing staff member (#21) reported the Hospital discharged the patient from the ED and did not transfer the patient to the psychiatric care facility. This staff member (#21) reported the Hospital did not have a policy regarding contacting the receiving facility for discharges from the ED. This staff member (#21) also reported the Hospital staff should have contacted the psychiatric facility to arrange post-hospital care.

Based on record review and staff interview, the Hospital failed to complete post-anesthesia evaluations for 3 of 3 closed patient records (Patient #40, #41, and #42) reviewed who required a cesarean section. Failure to complete post-anesthesia evaluations no later than 48 hours after surgery or a procedure requiring anesthesia services has the potential for undetected complications related to anesthesia.

Findings include:

- Review of Patient #40's closed Hospital medical record occurred on 05/16/13 and identified a cesarean section with anesthesia on 02/13/13. The post-anesthesia evaluation failed to identify if Patient #40 experienced any complications from the anesthesia and a practitioner failed to sign and date the evaluation.

- Review of Patient #41's closed Hospital medical record occurred on 05/16/13 and identified a cesarean section with anesthesia on 04/24/13. The post-anesthesia evaluation failed to identify if Patient #41 experienced any complications from the anesthesia.

- Review of Patient #42's closed Hospital medical record occurred on 05/16/13 and identified a cesarean section with anesthesia on 11/06/12. The post-anesthesia evaluation failed to identify if Patient #42 experienced any complications from the anesthesia. A practitioner electronically signed and dated the evaluation on 12/17/02 (41 days after anesthesia).



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