HospitalInspections.org

Based on observation, record review, interview and policy review the hospital failed to:
- Ensure staff removed expired supplies from patient care areas on one Intensive Care Unit (ICU, a unit where critically ill patients are cared for) of five ICUs reviewed. (A-0144)
- Ensure staff followed hospital policy for crash cart (mobile cart which contains emergency medical supplies and medication) checks for three out of five ICU crash cart logs reviewed. (A-0144)
- Follow their policy when they placed one patient (#23) in restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) when he attempted to get out of bed. (A-0161)
- Develop care plans to include the use of restraints for three patients (#61, #66, and #67) out of three patients reviewed with restraints. (A-0166)
- Ensure restraints were ordered by a physician or other licensed practitioner (LP) responsible for the care of the patient for three patients (#26, #61 and #66) of eight restraint patients reviewed. (A-0168)
- Ensure orders for restraints were not written as standing orders for four patients (#26, #61, #66 and #67) of eight patients with restraints reviewed. (A-0169)
- Ensure appropriate monitoring and nursing documentation during the use of restraints for two patients (#66 and #67) of eight restraint patients reviewed. (A-0175)
- Ensure staff had training and met requirements to perform a one-hour face-to-face evaluation for one patient (#26) of eight patients with restraints reviewed. (A-0178)

These failures resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights.

Please refer to A-0144, A-0161, A-0166, A-0168, A-0169, A-0175 and A-0178

Based on observation, interview, record review, and policy review, the hospital failed to ensure that staff removed expired supplies from patient care areas and staff followed hospital policy for crash cart (mobile cart which contains emergency medical supplies and medication) checks for three out of five Intensive Care Unit (ICU, a unit where critically ill patients are cared for) crash cart logs reviewed.

Observation on 06/03/24 at 3:22 PM, on the Cardiac ICU (CICU), of a procedure cart showed the following:
- Three expired arterial line (thin, flexible tube placed into an artery) pressure monitoring kits; one that expired on 08/08/19, one that expired on 08/26/21, and one that expired on 06/21/23.
- One sterile (completely clean and free from germs) solution applicator that expired on 02/2024.
- One hemodialysis (dialysis, process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions) catheter that expired on 05/17/24.
- Two central line/central venous catheter (long, thin, flexible tube placed in a large vein and the end of the tube sits in a large blood vessel near to or in part of their heart, allowing multiple fluids to be given and blood to be drawn) monitoring catheters that expired on 03/23/24.
- Four thoracic catheters (a catheter that is for effective drainage after thoracic [middle portion of the spine] surgery), one that expired on 01/04/19 and three that expired on 03/10/19.
- One spring wire guide (a support for vascular access device [a flexible, sterile plastic tube inserted into a blood vessel to allow blood to be drawn from or medication to be delivered into a patient's bloodstream] needs) that expired on 01/31/22.
- One deluxe chest tube tray that expired on 04/30/21.

During an interview on 06/03/24 at 3:53 PM, Staff H, Registered Nurse (RN) CICU Manager, stated that the procedure cart had always been on the unit. It was not assigned to anyone to be checked for expiration dates. The cart was not used a lot. She had no idea the items found were expired.

Review of the hospital's document titled, "Rapid Response - Crash Cart Maintenance and Exchange - Policy," dated 01/09/23, showed daily unit nurse responsibilities included ensuring the emergency crash cart is sealed and locked, and then documented on the checklist.

Review of the hospital's document titled, "Crash Cart Verification Sheet," dated 04/2024, showed one of two crash carts in the ICU at Capitol Region Medical Center (CRMC) was not checked on 04/07/24, and both crash carts in the ICU were not checked on 04/10/24; 04/13/24; 04/15/24; 04/16/24; 04/17/24; and 04/18/24.

Review of the hospital's document titled, "Crash Cart Verification Sheet," dated 06/2024, showed both crash carts in the ICU at CRMC were not checked on 06/03/24; 06/06/24; 06/07/24; and 06/08/24.

Review of the hospital's document titled, "PICU - Crash Cart Log March to June 2024," dated 06/12/24, showed that the Pediatric ICU crash cart at University Hospital was not checked on 03/02/24; 03/16/24; 04/21/24; and 05/24/24.



41474




39354

Based on interview, record review, and policy review, the hospital failed to follow their policy when they placed one patient (#23) in restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) when he attempted to get out of bed.

Review of the hospital's policy titled, "Patient Safety - Nonviolent Behavior Restraint - Policy," dated 01/17/24, showed the objectives of the policy are to outline appropriate process for use of restraints for patients with non-violent behaviors in recognition of the rights of patients to be free from restraints that are not medically necessary or restraints that are imposed as a means of coercion, discipline, convenience, or retaliation.

Review of Patient #23's medical record showed he was a 50-year-old male admitted on 04/21/24. On 05/21/24, he was in cloth tied four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others). The behavior requiring non-violent restraint was listed as attempting to get out of bed, and documentation showed he was in restraints for attempting to get out of bed from 8:00 AM to 12:00 PM. The physician order for restraints listed the reason for restraints was tampering with medical devices.

During an interview on 06/06/24 at 1:40 PM, Staff JJJ, Surgical Specialties Registered Nurse (RN), stated that Patient #23 was a Traumatic Brain Injury (TBI, an injury in how the brain works) patient, who was oriented only to his name. He was in a sitter room and would try exiting out of the bed. He was in restraints for tampering with medical devices. When Staff JJJ cared for patients in restraints, her practice was to try to document a reason more specific to why they were in restraints. She documented the reason Patient #23 was in restraints was he was trying to get out of bed. He tried exiting forcefully out of the bottom of the bed. Staff tried turns and distractions, but nothing worked. Restraints were not to be used as an intervention for high fall risk patients.

During an interview on 06/06/24 at 1:45 PM, Staff KKK, Manager of Surgical Specialties and Surgical Intensive Care Unit (Intensive Care Unit (ICU, a unit where critically ill patients are cared for), stated that Patient #23 would throw the lower half of his body out of bed. He did have a sitter and was not able to be redirected. It became a safety issue when Patient #23 started kicking at the sitter. As Patient #23 improved, they removed his restraints. Restraints were not to be used as a fall prevention intervention.

During an interview on 06/13/24 at 9:40 AM, Staff WWWWW, Chief Nursing Officer (CNO), stated that it would not be appropriate to place patients in restraints to keep them from getting out of bed.

Based on interview, record review, and policy review, the hospital failed to develop care plans to include the use of restraints for three patients (#61, #66, and #67) out of three patients reviewed with restraints. This had the potential to affect the care of all patients in restraints.

Findings included:

Review of the hospital's policy titled, "Restraint Use (All Ages)," dated 02/03/21, showed there was no requirement for nursing to document a written modification to the patient's plan of care regarding the use of restraints.

Review of the hospital's policy titled, "Patient Safety - Nonviolent Behavior Restraint - Policy," dated 01/17/24, showed the patient's plan of care shall be updated to reflect the use of a restraint. The nurse will update the plan of care to reflect the trigger in patient behavior that requires restraint, the intervention taken, goal of removing the restraint and steps taken to prevent use of further restraint.

Review of Patient #61's medical record showed he was in restraints from 12:00 PM on 06/07/24 through 8:47 AM on 06/10/24. There was no restraint plan of care within his record.

Review of Patient #66's medical record showed he was in restraints from 8:00 PM on 05/13/24 through 4:00 PM on 05/23/24. There was no restraint plan of care within his record.

Review of Patient #67's medical records showed she was in restraints from 12:00 PM on 06/07/24 through 10:00 AM on 06/11/24. There was no restraint plan of care within her record.

During an interview on 06/11/24 at 4:25 PM, Staff QQQQ, Director of Inpatient Nursing at Capitol Region Medical Center (CRMC), stated that there should have been plans of care for restraints for patients in restraints.

During an interview on 06/11/24 at 4:15 PM, Staff OOOO, Director of Quality and Patient Safety at Capitol Region Medical Center, stated that plans of care for restraints were an "area of improvement," and it made sense to have them.

During an interview on 06/13/24 at 9:40 AM, Staff WWWWW, Chief Nursing Officer (CNO), stated that she would expect care plans for restraints at all hospitals in the system would be completed per University of Missouri Health Care policy.

Based on interview, record review and policy review, the hospital failed to ensure restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) were ordered by a physician or other licensed practitioner (LP) responsible for the care of the patient for three patients (#26, #61 and #66) of eight restraint patients reviewed.

Findings included:

Review of the hospital's policy titled, "Patient Safety-Violent Behavior Restraint and Seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) Policy," dated 01/17/24, showed the following:
- A LP was any individual permitted by State law and organization policy to order restraints and seclusion for patients independently within the scope of the individual's license and consistent with the individually granted clinical privileges.
- An order must be obtained from an LP before a restraint is applied.
- If the emergency application of a restrain is required, a Registered Nurse (RN) may apply, or delegate application to permissible professionals, the restraint and then shall request an order (written or verbal) immediately.
- The patient's attending physician shall be notified as soon as possible if the attending physician does not initiate the order.

Review of the hospital's policy titled, "Restraint Use (All Ages)," dated 02/03/21, showed a Physician, an Advance Practice Registered Nurse (APRN), or Physician Assistant may determine whether restraints are necessary for and order restraints for non-violent care or for violent reasons. The RN must have a provider order before applying restraints, except in life threatening situations which requires obtaining a physician order immediately after application. Orders for restraint will be renewed every calendar day.

Review of Patient #26's medical record, dated 06/03/24, showed the following:
- He was a 33-year-old male who presented to the Emergency Department (ED) for altered mental status (mental functioning ranging from slight confusion to coma).
- On 06/03/24 at 2:59 PM, Staff NN, RN, entered a standing order to initiate four point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) per Staff MM, Physician, with a beginning time of 12:50 PM and an ending time of 4:50 PM.
- Patient #26 was in restraints beginning at 12:50 PM and he remained in restraints until 3:35 PM.
- The standing order to initiate four-point restraints was not signed by Staff MM, Physician, until 06/08/24.

During an interview on 06/04/24 at 3:30 PM, Staff A, Risk and Regulatory Director, stated that a nurse did put in the order for the restraint and the physician did not sign it until much later.

Review of Patient #61's medical record showed the following:
- He was a 69-year-old male admitted to Capitol Region Medical Center (CRMC) on 06/05/24.
- He was in cloth tied restraints for both arms from 12:00 PM on 06/07/24 through 06/10/24 at 8:47 AM.
- He had no restraint orders on 06/07/24.

Review of Patient #66's medical record showed the following:
- He was a 69-year-old male admitted to CRMC on 05/13/24.
- He was in restraints from 08:00 PM on 05/13/24 through 4:00 PM on 05/23/24.
- He had no order for restraint on 05/13/24; 05/15/24; or 05/16/24

During an interview on 06/11/24 at 4:00 PM, Staff HHHHH, Chief Nursing Officer (CNO) of CRMC, stated that she expected staff to assess the patient for the appropriate type of restraints and behaviors and to reach out to the provider for a new order. Patients should not be in restraints without an active order.

During an interview on 06/13/24 at 9:40 AM, Staff WWWWW, CNO of University of Missouri Health Care, stated that there should be a physician order for each restraint episode and the order should not be a standing order.




46856

Based on interview, record review and policy review, the hospital failed to ensure orders for restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) were not written as standing orders for four patients (#26, #61, #66 and #67) of eight patients with restraints reviewed.

Findings included:

Review of the hospital's policy titled, "Patient Safety-Violent Behavior Restraint and Seclusion Policy," dated 01/17/24, showed the following:
- A Licensed Provider (LP) was any individual permitted by State law and organization policy to order restraints and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) for patients independently within the scope of the individual's license and consistent with the individually granted clinical privileges.
- An order must be obtained from an LP before a restraint is applied.
- If the emergency application of a restraint is required, a Registered Nurse (RN) may apply, or delegate application to permissible professionals, the restraint and then shall request an order (written or verbal) immediately.
- The patient's attending physician shall be notified as soon as possible if the attending physician does not initiate the order.
- An as needed order (PRN) for restraints was not allowed.

Review of the hospital's policy titled, "Restraint Use (All Ages)," dated 02/03/21, showed the following:
- A Physician, an Advance Practice Registered Nurse (APRN), or Physician Assistant (PA, a type of mid-level health care that can serve as a principal healthcare provider) may determine whether restraints are necessary for and order restraints for non-violent care or for violent reasons.
- The RN must have a provider order before applying restraints, except in life threatening situations which requires obtaining a physician order immediately after application.
- PRN orders will not be permitted.

Review of Patient #26's medical record, dated 06/03/24, showed the following:
- He was a 33-year-old male who presented to the Emergency Department (ED) for altered mental status (mental functioning ranging from slight confusion to coma).
- On 06/03/024 at 2:59 PM, Staff NN, RN, entered a protocol/standing order to initiate four-point restraints (medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others) per Staff MM, Physician, with a beginning time of 12:50 PM and an ending time of 4:50 PM.
- The standing order to initiate four-point restraints was not signed by Staff MM, Physician, until 06/08/24.

During an interview of 06/04/24 at 3:30 PM, Staff A, Director of Risk and Regulations, stated that restraints were never to be placed as standing orders. The standing order for restraints was a one off, and the nurse had put the order on the wrong form.

Review of Patient #61's medical record showed the following:
- He was a 69-year-old male admitted to Capitol Region Medical Center (CRMC) on 06/05/24.
- He was in cloth tied restraints for both arms from 12:00 PM on 06/07/24 through 8:47 AM on 06/10/24.
- He had restraint orders for 06/08/24 at 12:40 AM and 06/09/24 at 11:36 PM. Both orders were listed as per protocol/standing order.

Review of Patient #66's medical record showed the following:
- He was a 69-year-old male admitted to CRMC on 05/13/24.
- He was in restraints from 08:00 PM on 05/13/24 through 4:00 PM on 05/23/24.
- He had restraint orders on 05/14/24; 05/17/24; 05/18/24; 05/19/24; 05/20/24; 05/21/24; and 05/22/24. Four (05/17/24; 05/19/24; 05/21/24; and 05/22/24) out of seven restraint orders were listed as per protocol/standing order.

Review of Patient #67's medical record showed the following:
- She was a 62-year-old female admitted to CRMC on 05/30/24.
- She was in cloth tied restraints for both arms from 4:30 PM on 06/07/24 through 10:00 AM on 06/11/24.
- She had restraint orders for 06/07/24; 06/08/24; 06/09/24; and 06/10/24. Three (06/08/24; 06/09/24; and 06/10/24) out of four restraint orders were listed as per protocol/standing order.

During an interview on 06/11/24 at 4:00 PM, Staff HHHHH, Chief Nursing Officer (CNO) of CRMC, stated that she expected staff to be familiar with the hospital's restraint policy. Protocols and standing orders were not to be used for restraints.

During an interview on 06/11/24 at 4:25 PM, Staff QQQQ, Director of Inpatient Nursing at CRMC, stated that they did not have protocols or standing orders for restraints. Restraint orders were not to be a "just in case" order.

During an interview on 06/13/24 at 9:40 AM, Staff WWWWW, CNO of University of Missouri Health Care, stated that restraints were never to be placed as standing orders.


46856

Based on interview, record review, and policy review, the hospital failed to ensure appropriate monitoring and nursing documentation during the use of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) for two current patients (#66 and #67) of eight restraint patients reviewed. This failure created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety.

Findings included:

Review of the hospital's policy titled, "Patient Safety - Nonviolent Behavior Restraint - Policy," dated 01/17/24, showed the nurse is to observe and document on the patient at least every two hours. These observations are necessary to assess for the continued safety, well-being, comfort and dignity of the patient. Assess vital signs (measurements of the body's most basic functions), level of distress and agitation, mental status, cognitive functioning, hydration, elimination needs, circulation, skin integrity (refers to skin health, to be free of wounds or irritation), movement, and sensation, and offer an appropriate range of motion, hydration, toileting, and other relevant care as indicated by the patient's needs.

Review of the hospital's policy titled, "Restraint Use (All Ages)," dated 02/03/21, showed patients will be monitored at least every two hours for hydration, nutrition, elimination, skin condition, range of motion, circulation, and clinical condition. Nursing documentation for non-violent restraints included: type of restraint applied; date and time restraint applied; patient's condition warranting restraint use; assessment every two hours; family and patient education regarding the need for restraints; interventions attempted for reducing use of restraint or seclusion of least restrictive restraint; signs of injury; and date and time of restraint removal.

Review of Patient #66's medical record showed the following:
- He was a 69-year-old male admitted to Capital Regional Medical Center (CRMC) on 05/13/24.
- He was in restraints during his hospitalization.
- On 05/13/24, there were no nursing restraint assessments documented for five hours (missing restraint assessments at 4:00PM and 6:00 PM).
- On 05/15/24, there were no nursing restraint assessments documented for seven hours (missing restraint assessments at 2:00 AM, 4:00 AM, and 6:00 AM).
- On 05/16/24, there were no nursing restraint assessments documented for 11 hours (missing restraint assessments at 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, and 6:00 PM).
- On 05/21/24, there were no nursing restraint assessments documented at 10:00 AM and 2:00 PM.
- On 05/23/24, there was no nursing restraint assessment documented at 2:00 AM.

Review of Patient #67's medical record showed the following:
- She was a 62-year-old female admitted to CRMC on 05/30/24.
- She was in restraints during her hospitalization.
- On 06/08/24, there was no nursing restraint assessment documented at 6:00 PM.
- On 06/09/24, there was no nursing restraint assessment documented at 6:00 PM.

During an interview on 06/11/24 at 4:00 PM, Staff HHHHH, Chief Nursing Officer (CNO) of CRMC, stated that she expected staff to be familiar with the hospital's restraint policy. Staff were to follow policy on the frequency of assessments, monitoring, and documenting on restraints.

During an interview on 06/11/24 at 4:15 PM, Staff OOOO, Director of Quality and Patient Safety at CRMC, stated that the hospital had room for improvement and better documentation with restraints. Patients needed to be assessed every two hours at minimum.

During an interview on 06/11/24 at 4:25 PM, Staff QQQQ, Director of Inpatient Nursing at CRMC, stated that non-violent restraints were to be documented on every two hours or per policy. Elements included in the documentation were skin checks, range of motion, hydration and elimination needs, and assessing if the patient needed the restraint. She did not expect there to be gaps in nursing documentation.

Based on interview, record review and policy review, the hospital failed to ensure staff had training and met requirements to perform a one-hour face-to-face evaluation for one patient (#26) of eight patients with restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) reviewed.

Findings included:

Review of the hospital's policy titled, "Patient Safety-Violent Behavior Restraint and Seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) Policy," dated 01/17/24, showed that an order must be obtained from a licensed professional (LP) before a restraint is applied. An LP was defined as any individual permitted by state law and organization policy to order restraints and seclusion for patients independently within the scope of the individual's license and consistent with the individually granted clinical privileges. The LP must see and evaluate the patient within one hour of initial restraint/seclusion application.

Review of the hospital's personnel records on 06/12/24 at 9:00 AM, showed that Staff KK, Registered Nurse (RN), did not receive training to perform a one-hour face-to-face assessment following the application of restraints.

Review of Patient #26's medical record, dated 06/03/24, showed the following:
- He was a 33-year-old male who presented to the Emergency Department (ED) for altered mental status (mental functioning ranging from slight confusion to coma).
- On 06/03/24 at 2:59 PM, Staff NN, RN, entered a standing order to initiate four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) per Staff MM, Physician, with a beginning time of 12:50 PM and an ending time of 4:50 PM.
- On 06/03/24 at 1:01 PM, Staff XXXXX, ED Physician, documented an ED note but did not complete the one-hour face-to-face evaluation.
- On 06/03/24 at 2:59 PM, Staff KK, RN, documented a one-hour face-to-face assessment had been completed at 12:50 PM.
- Patient #26 was in restraints beginning at 12:50 PM and he remained in restraints until 3:35 PM.

During an interview on 06/12/24 at 9:00 AM, Staff SSSSS, Director of Human Resources, stated that RNs did not receive training to complete a one-hour face-to-face assessment and typically LPs performed those assessments. One-hour face-to-face assessment training could be unit based, but she did not have those records.

During an interview on 06/13/24 at 9:25 AM, Staff A, Director of Risk and Regulatory, stated that Staff KK, RN, did not meet training requirements to complete a one-hour face-to-face and he did not know why RNs were completing the assessments.

During an interview on 06/13/24 at 9:40 AM, Staff WWWWW, Chief Nursing Officer (CNO), stated that Physicians should complete the one-hour face-to-face assessment on patients in restraints.

Based on observation, interview, record review and policy review, the hospital failed to ensure licensed staff adhered to policies and procedures of the hospital when staff did not follow the hospital's infection prevention policy while providing care to seven current patients (#7, #13, #14, #17, #27, #31 and #60) at three of the four hospitals that made up the system where patient care was observed.

These practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation: Nursing Services.

Please refer to A-0395

Based on observation, interview and policy review, the hospital failed to ensure licensed staff adhered to policies and procedures of the hospital when staff did not follow the hospital's infection prevention policy while providing care to seven current patients (#7, #13, #14, #17, #27, #31 and #60) at three of the four hospitals that made up the system where patient care was observed.

Findings included:

Review of the hospital's policy titled, "Infection Prevention and Control Program- 2024 Infection Control Manual," dated 11/20/23, showed the following:
- The infection Control Manual functions as the definitive policy and guideline reference for all facilities, settings and health care personnel at University Of Missouri Health Care.
- Standard precautions (also known as universal precautions, avoiding contact with patients' bodily fluids by means of wearing gloves, goggles and face shields) were used for all patient care and included frequent hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer), clean and disinfect patient care equipment and environmental surfaces.
- Hand hygiene was to be performed before and after any patient contact, prior to applying gloves and after glove use and after touching beds or bedside objects (patient equipment, computers, handrails, nightstands, phone, etc.).
- Gloves shall be worn as an additional measure, not as a substitute for hand hygiene.
- Wear non-sterile, disposable, single-use gloves for direct contact with patient's mucous membranes (membrane that lines various cavities [mouth, nose, etc.] in the body and covers the surface of internal organs), blood, body fluids, moist body substances and non-intact skin.
- Wear gloves for handling potentially infectious materials or in contact with contaminated items and or surfaces.
- Federal law requires that gloves must be worn for all intravascular (relating to or containing blood vessels) procedures such as blood draw or intravenous (IV, in the vein) start.
- Critical items are defined as items which enter sterile tissue or vascular system (vessels that carry blood and lymph [fluid that removes waste products] through the body) and must be sterile.
- If any patient care item is touched with unclean hands or contaminated gloves, then it should be disinfected as soon as possible.

Review of the hospital's policy titled, "Infection Control Guidelines," dated 01/24/23, showed infection control practices are critical to reduce the transmission of infections from one person to another, such as from a healthcare worker to a patient or vice versa. It is best practice to "foam in" upon entering the treatment area before touching patients and then to "foam out" upon completion of treating the patient.

Observation on 06/04/24 at 10:00 AM, on the Medical Intensive Care Unit (MICU, a unit where critically ill patients are care for) three, showed Staff SS, Registered Nurse (RN), walked into Patient #31's room with a mobile wound cart that contained new wound dressing supplies, a clip board and papers that listed other wound patients she had to see, and failed to perform hand hygiene. Staff SS put single use nonsterile gloves on and cleaned stool from the patient's bottom and thighs. She then removed a soiled dressing from a wound on the patient's back, picked up a phone and ruler from the wound cart, measured the patient's wound and photographed it, without changing her gloves or performing hand hygiene. She then set the phone and ruler on the patient's incontinence pad where it stayed until she used it to photograph a second open area on the patient's right buttocks. After she photographed the second wound, she placed the phone and ruler on her mobile wound cart. She did not clean the phone used to photograph the wounds prior to placing it on her mobile wound cart. Patient #31 was turned and a third wound was assessed and the dressing was changed. Staff SS did not perform hand hygiene during the entire visit until she was ready to leave the room. She did not clean her phone that was on the patient's dirty bed pad and had been handled with dirty gloves until just before she exited the patient's room.

During an interview on 06/05/24, Staff SS, RN, stated that she only needed to perform hand hygiene after entering a patient room and just before exiting the room. Supplies and her phone should not be placed on patients' personal items and then placed onto the wound cart because she did take the cart into other patient rooms.

During an interview on 06/05/24 at 1:55 PM, Staff XX, Clinical Manager for Nursing Support Services, stated that hand hygiene was to be performed upon entering a patient's room, after touching a patient or equipment, before touching a patient, and between glove changes. Contaminated equipment and items should not be placed on the wound carts. The carts had clean supplies and were taken into several different patient rooms. There was a potential for infection to be spread to each room the cart was taken into.

Observation on 06/03/24 at 3:53 PM, in the Emergency Department (ED), showed Staff TTTTT, X-ray (test that creates pictures of the structures inside the body-particularly bones) Technician walked into Patient #7's room with gloved hands and failed to remove her dirty gloves, perform hand hygiene and don new gloves before providing care. When finished, Staff TTTTT, walked out of the room with the same gloved hands, failed to clean the x-ray machine or perform hand hygiene and pushed the machine into a trauma room where there was another patient.

During an interview on 06/12/24 at 10:50 AM, Staff TTTTT, X-ray Technician, stated that she was to perform hand hygiene before she entered the patient's room and put on gloves, and after she removed her gloves and exited the room. The x-ray machine was normally cleaned in the hall prior to entering another patient's room, but the hallway was too crowded that day.

Observation on 06/03/24 at 3:56 PM, in the ED, showed Staff QQ, RN, failed to perform hand hygiene, don gloves or clean Patient #7's IV port with an alcohol swab before she flushed the line. She again failed to perform hand hygiene after she provided care.

During an interview on 06/03/24 at 4:00 PM, Staff I, ED Service Line Specialist (Educator), stated that the process was to perform hand hygiene before placing gloves on and after removal. Gloves were not to have been placed on outside a patient's room and before performing hand hygiene. The x-ray technician was to have removed her gloves prior to leaving a patient's room and performed hand hygiene. He stated that he expected that the nurse performed hand hygiene, put on gloves and then used an alcohol swab before she flushed an IV.

Observation on 06/04/24 at 10:50 AM, at the Missouri Orthopedic Institute (MOI), Staff T, RN, failed to perform hand hygiene and change gloves after touching the computer and before removal of a drain from Patient #13's left knee. She then used the computer with the same gloves and took the drain out of the patient's room without placing it in a biohazard bag. Staff T never performed hand hygiene before she left the patient's room.

During an interview on 06/04/24 at 11:05 AM, Staff T, RN, stated that she should have removed her gloves and performed hand hygiene after touching the computer and before removing the patient's drain. She added that she did not realize that she needed a biohazard bag to take the drain out of the patient's room.

During an interview on 06/13/24 at 10:00 AM, Staff WWWWW, Chief Nursing Officer (CNO), stated that it was not appropriate to have worn gloves from the hallway into a patient's room prior to performing hand hygiene. She expected hand hygiene was performed before and after gloves were worn. She expected the nurse to perform hand hygiene, wear gloves and clean an IV port with alcohol prior to the administration of anything into an IV line.

Observation on 06/04/24 at 9:25 AM, on MICU three, showed Staff V, ICU RN, failed to perform hand hygiene between glove changes while performing tracheostomy (an opening created in the neck in order to place a tube into a person's windpipe that allows air to enter the lungs) care on Patient #14.

Observation on 06/04/24 at 10:15 AM, on MICU five, showed Staff X, ICU RN, discontinued a blood transfusion on Patient #17. Staff X did not wear gloves or place the used blood tubing in a biohazard bag prior to taking it out of Patient #17's room.

Observation on 06/05/24 at 9:00 AM, on the Cardiology floor, showed Staff NN, RN, failed to perform hand hygiene before putting on gloves. She moved two urinals off Patient #27's bedside table to a chair, and did not change her gloves or perform hand hygiene prior to opening eight oral medication packages, dumping them in a pill cup, and handing the pill cup and a water cup to the patient, then administered subcutaneous insulin in the patient's arm. Staff NN then changed her gloves, did not perform hand hygiene, and administered an inhaler medication to the patient.

During an interview on 06/05/24 at 10:05 AM, Staff NN, RN, stated that hand hygiene was performed on entrance and exit from a patient's room. She should have changed her gloves after moving the patient's urinals off the bedside table.

Observation on 06/06/24 at 9:10 AM, on MICU three, showed Staff ZZ, RN, assisting with a dressing change on Patient #31. At the end of the dressing change, Staff ZZ removed Patient #31's old pad from underneath her back/buttocks, then boosted the patient up in bed and adjusted the patient's head and pillow, all with the same gloves on and no hand hygiene.

Observation on 06/10/24 at 11:40 AM, on the ICU at Capitol Region Medical Center (CRMC), showed Staff TTTT, RN, discontinued a blood transfusion on Patient #60. Staff TTTT placed the used blood tubing on Patient #60's bedside table, then placed it in a biohazard bag prior to taking it out of Patient #60's room. She did not clean the bedside table after removing the used blood tubing.

During an interview on 06/10/24 at 12:00 PM, Staff TTTT, RN stated that she should have cleaned the patient's bedside table after putting the used blood tubing on it.



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