HospitalInspections.org

I. Based on review of contracted services Y (CSY) policy, observation and staff interview, the hospital failed to ensure that the CSY (the service the hospital contracted with to provide dialysis services) staff maintained the pHoenix meter (a pHoenix meter is a handheld device used to ensure the accuracy of the dialysis machine conductivity and its ability to correctly mix the solutions used for dialysis treatments) calibration station by ensuring that the conductivity solutions and RO (Reverse Osmosis) water used for calibration and rinsing the meter are not available for use beyond the discard date.

Failure to ensure the conductivity solutions and RO (Reverse Osmosis) water used for calibration and rinsing of the Phoenix meter are within acceptable usage dates could result in staff utilizing a meter in which the manufacturer of the solution can no longer guarantee the accuracy of the solution potentially resulting in improper calibration of the pHoenix meter. An inaccurate pHoenix meter or improperly calibrated pHoenix meter could result in staff failing to determine if the dialysis machine is mixing the solutions correctly potentially resulting in a dialysate to be mixed outside of the safe acceptable conductivity ranges. The use of a dialysis machine for a patient's dialysis treatment when the dialysate does not fall within an acceptable conductivity range could potentially cause hemolysis, which could cause severe illness and or death to the dialysis patient.

The hospital reported an acute inpatient hemodialysis census of 7 at the time of the validation survey. Findings for observation of CSY's sole pHoenix meter calibration and rinse station include:

1. Review of the policy titled, "pHoenix Meter, pHoenix XL and Tri-Station Care and Maintenance", effective date 6/14/2017 included in part, " Scope Applies to all syringe-type meters and accessories...STATION MAINTENANCE DAILY Rinse and refill the water with fresh RO (reverse osmosis) water...AS NEEDED Replace your standard solutions; Conductivity solutions- 30 days after opening..."

2. Observation of the acute dialysis unit's sole pHoenix meter calibration station on 4/2/18 at 1:00 PM showed the following:

a. A bottle 1/2 full of clear liquid labeled "RO water". The bottle lacked information that indicated the date the bottle was filled with RO water.

b. A fluid filled conductivity solution bottle labeled in part, "100 mS (millisiemens)", included an opened date of 3/1/18 and expiration date of 4/1/18.

c. A fluid filled conductivity solution bottle labeled in part, "14 mS", included an opened date of 3/1/18 and expiration date of 4/1/18.

3. During an interview on 4/4/18 at 10:45 AM, CSY's Director of Operations and Program Manager acknowledged the findings and reported that the solutions and water used for maintaining the pHoenix meter should be maintained according to CSY's policy.

4. During a findings review on 4/4/18 beginning at 11:30 AM, the hospital's Chief Operating Officer acknowledged the findings.

II. Based on review of contracted services Y (CSY) policy, documents, dialysis treatment flowsheets, observation and staff interview, the hospital failed to ensure the CSY staff documented the results of the total chlorine tests at the actual time the critical water test was completed.

Failure to accurately document the actual time of the total chlorine test could result in failure of CSY's staff to identify an elevated total chlorine level in the water used for the patients' dialysis treatments in a timely manner consistent with required intervals of testing. This could result in staff waiting too long to conduct the tests and/or take the actions/steps needed for an elevated total chlorine test result to keep the patients safe. Elevated total chlorine in the water used for dialysis treatments could cause serious patient harm, patient illness, hemolysis (the rupture of red blood cells), and patient death.

The hospital reported an inpatient acute hemodialysis patient census of 7 at the time of the validation survey. Findings for observation of 1 of 1 CSY staff (CSY RN [Registered Nurse] AA) and 2 of 2 total chlorine logs (at station #2 and station #3) include:

1. Review of the policy titled, "Carbon Filtration Monitoring for Portable Water Systems for Inpatient Services", Effective Date 19-JUN 2013, included in part, "Purpose This document provides FMS guidelines for carbon filtration monitoring when using a portable reverse osmosis system (PRO) in the inpatient setting...Policy: Testing Locations and Frequency...IF...Inpatient Services Conventional Hemodialysis (HD) Then Test Chlorine...*Worker carbon filter: ...Prior to initiation of treatment and no less than every two hours...Documentation * Routine Total Chlorine Testing will be documented on form TCL-1..."

2. Review of the CSY document titled, "Portable Water Systems Total Chlorine Log Form: IP-PS-TCL1", for the portable RO (Reverse Osmosis) unit located at the acute dialysis treatment station #2 showed that CSY RN AA documented a total chlorine test was completed on the portable RO unit on 4/2/18 at 2:00 PM.

3. Review of the CSY document titled, "Portable Water Systems Total Chlorine Log Form: IP-PS-TCL1", for the portable RO unit located at the acute dialysis treatment station #3 showed that CSY RN AA documented a total chlorine test was completed on the portable RO unit on 4/2/18 at 2:00 PM.

4. Observation on 4/2/18 at 2:26 PM showed Patient #50 on dialysis at acute dialysis treatment station #2.

Observation on 4/2/18 at 2:28 PM showed Patient #47 on dialysis at acute dialysis treatment station #3.

Observation on 4/2/18 showed CSY RN AA completed a total chlorine test for the RO unit located at the acute dialysis treatment station #2 at 2:26 PM, 26 minutes later than the documented time indicated on the Portable Water Systems Total Chlorine Log for the RO located at station #2. Continued observation showed CSY RN AA completed a total chlorine test for the RO unit located at the acute dialysis treatment station #3 at 2:28 PM, 28 minutes later than the documented time indicated on the Portable Water Systems Total Chlorine Log for the RO unit located at Station #3.

5. During an interview on 4/2/18 at 2:26 PM, CSY RN AA reported running behind on getting the total chlorine tests completed.

6. During an interview on 4/4/18 at 10:45 AM, CSY's Director of Operations and Program Manager acknowledged the findings and reported all procedures and assessments in the acute dialysis unit should be documented with the actual time the procedure or assessment was completed.

7. During a findings review on 4/4/18 beginning at 11:30 AM, the hospital's Chief Operating Officer acknowledged the findings.

III. Based on review of Contracted Services Y (CSY) policies and procedures, observation, and staff interview, the hospital failed to ensure the contracted agency staff performed the total chlorine test in accordance with CSY policy and procedure.

Failure to ensure staff performed the total chlorine test in accordance with CSY policy and procedure could potentially result in inaccurate test results. Lack of accurate test results could potentially result in a test result within the acceptable limits while actually being outside the safe acceptable limits. If the dialysis staff obtained a total chlorine test result that appeared acceptable and the test result was actually outside the acceptable limits, the unsafe water could potentially be used for dialysis treatments. This could potentially result in patient harm, such as severe illness, hemolysis (the rupture of red blood cells), and/or patient death.

The hospital reported an inpatient acute dialysis census of 7 at the time of the validation survey. Findings for observation of 1 of 1 CSY staff (CSY RN [Registered Nurse] AA) during 2 of 2 total chlorine tests ( on 4/2/18 at 2:26 PM and 2:28 PM) include:

1. Review of the policy titled, "Carbon Filtration Monitoring for Portable Water Systems for Inpatient Services", Effective Date 19-JUN 2013, included in part, "Purpose This document provides FMS guidelines for carbon filtration monitoring when using a portable reverse osmosis system (PRO) in the inpatient setting...Policy: Testing Locations and Frequency...IF...Inpatient Services Conventional Hemodialysis (HD) Then Test Chlorine...*Worker carbon filter: ...Prior to initiation of treatment and no less than every two hours...Documentation * Routine Total Chlorine Testing will be documented on form TCL-1..."

2. Review of the facility procedure titled, "Total Chlorine Testing using the RPC Ultra Low Total Chlorine Test Strips", Effective Date, 10-JUN-2013, included in part, "...2. Prior to collecting the sample, rinse the clean, dry sample cup with the water to be tested. Collect a fresh 100 ml (milliliter) sample of water in a plastic sample cup:..4. Remove the strip and shake once, briskly, to remove excess water. 5. Wait 20 seconds for the test strip color to develop...6. After the 20 second wait period, immediately compare the strip color..."

3. Observation on 4/2/18 showed CSY RN AA used a RPC test strip and conducted a total chlorine test at 2:26 PM on a portable RO (Reverse Osmosis) unit located at station #2. Observation revealed CSY RN AA obtained a sample cup and failed to rinse the cup with the water to be tested prior to obtaining the 100 ml sample. CSY RN AA dipped the test strip into the sample cup for 60 seconds, removed the RPC test strip from the sample water, waited 10 seconds and compared the strip to the color indicator chart.

Observation on 4/2/18 showed CSY RN AA used a RPC test strip and conducted a total chlorine test at 2:28 PM on a portable RO (Reverse Osmosis) unit located at station #3. Observation revealed CSY RN AA obtained a sample cup and failed to rinse the cup with the water to be tested prior to obtaining the 100 ml sample. CSY RN AA dipped the test strip into the water sample, waited 14 seconds and then compared the strip to the color indicator chart.

CSY RN AA failed to rinse the sample cup with RO water prior to obtaining the sample and failed to wait 20 seconds after removing the test strip prior to reading the test result as indicated by CSY policy.

4. During an interview and policy review on 4/4/18 at 10:45 AM, CSY's Director of Operations and Program Manager acknowledged the findings and reported all staff should complete total chlorine test procedures according to facility policy and procedure.

5. During a findings review on 4/4/18 beginning at 11:30 AM, the hospital's Chief Operating Officer acknowledged the findings.

IV. Based on review of Contracted Services Y (CSY) policy, manufacturer's information, facility logs and staff interview, the hospital failed to ensure that Contracted Services Y (CSY) staff performed quality control testing procedures for the test strips used to check for residual chlorine in the dialysis machines following chemical disinfection.

Failure to perform quality control testing procedures for the test strips used to check for residual chlorine in the dialysis machines that have been chemically disinfected could potentially result in the risk of inaccurate test results and failure to take appropriate actions to keep patients safe which could result in patient harm and patients becoming severely ill, hemolysis (the rupture of red blood cells), and/or patient death from exposure to residual chlorine left in the dialysis machine following chemical disinfection.

The hospital reported an inpatient acute dialysis patient census of 7 at the time of the validation survey. Findings for 3 of 3 CSY staff interviews (CSY Director of Operation, CSY Program Manager, CSY RN [Registered Nurse] AA) that showed staff failed to ensure completion of quality control testing procedures on the residual chlorine test strips include:

1. Review of the policy titled, "Cleaning and Disinfection", effective date: 28-JAN-2015, included in part, "PURPOSE: The purpose of this policy is to provide guidelines to prevent the spread of infectious disease in accordance with appropriate regulations, and to maintain a clean, safe, and aesthetically pleasant environment for patients, staff, and visitors...Cleaning the Dialysis Machine...Internally disinfect the dialysis machine as outline below or per manufacturer's guidelines:...Bleach disinfect each week (at least every 7 days)..."

2. Review of the manufacturer's packaging insert titled, "WaterCheck RC For Residual Chlorine in Rinse Water", no date, included in part, "...Bleach (chlorine) solution is commonly used as cleaning agent to disinfect the dialysis machines and the supporting system. The cleaning agent is then rinsed off with deionized or RO water before the system is ready for the next patient. Any residual chlorine remained in the system may contaminate the patients' blood and cause hemolysis...Quality Control...Perform QC test on one bottle from each box of the same lot received. More frequent if required..."

3. Review of the facility log titled, "RECORD OF DAILY MACHINE DISINFECTION with HEAT CYCLE", no date, included sections where CSY staff were to record disinfection cycles, including bleach disinfection, of each of the 4 dialysis machines used by CSY staff for dialysis treatments. Closer review of the log showed that CSY staff performed a bleach disinfection procedure and residual chlorine check for each of the 4 dialysis machines on 2/19/18, 2/26/18, 3/5/18, 3/12/18, 3/19/18, and 3/26/18. Further review of the log sheets lacked documentation that reflected quality control testing was done on any of the test strips used to check for residual chlorine in each of the machines.

4. During an interview on 4/4/18 at 9:30 AM, CSY Director of Operations along with CSY Program Manager reported staff probably does not complete the quality control testing on the WaterCheck RC strips used to test residual chlorine. CSY Director of Operations reported the dialysis machine disinfection logs would not contain information related to the quality control procedures completed on newly opened boxes or bottles of test strips.

During an interview at 9:30 AM, CSY RN AA reported she completed the chemical disinfection of the machines weekly however, did not know there was a quality control testing procedure on the test strips used to test for residual chlorine. CSY RN AA acknowledged she has opened boxes of the test strips used but has never done a quality control test on the first bottle out of each box.

During an interview and review on 4/4/18 at 10:45 AM, CSY's Director of Operations and Program Manager acknowledged the findings.

5. During an interview and findings review on 4/4/18 beginning at 11:30 AM, the hospital Chief Operating Officer acknowledged the findings.

V. Based on review of Contracted Services Y (CSY) policy, dialysis flowsheets, RO (reverse osmosis) logs, observation, and staff interview, CSY staff did not document performance tests of the portable RO systems used in the acute dialysis unit prior to initiating patients' dialysis treatments.

Acute dialysis programs often use portable RO units to provide safe water for use in dialysis. In order to ensure the portable RO unit is functioning properly staff test and record the various performance measures on the RO system prior to initiating the dialysis treatments. Failure to document the RO performance tests could lead to staff using a portable RO unit that is not providing dialysis quality water. This could potentially endanger dialysis patients by exposing them to water that is not safe for use in dialysis potentially placing patients in harm's way.

The hospital reported an inpatient acute dialysis patient census of 7 at the time of the validation survey. Findings for review of 2 of 4 portable ROs (RO unit # 1326838 and RO unit # 1326946) units used for dialysis in the inpatient dialysis unit include:

1. Review of the policy titled, "Reverse Osmosis Machine", included in part, "The purpose of this document is to provide FMS Clinical and Technical Staff guidance on the use of a reverse osmosis (RO) system...Policy: Daily Water Testing. *Daily testing will be completed and documented before any patient treatments are initiated on every day treatments are to be performed..."

2. Review of the medical record for Patient #50 showed Patient #50 received a dialysis treatment in the acute dialysis unit on a dialysis machine connected to RO unit # 1326838 on 4/2/18 that began at 10:35 AM and ended at 2:37 PM.

Review of the medical record for Patient #47 showed Patient #47 received a dialysis treatment in the acute dialysis unit on a dialysis machine connected to RO unit # 1326946 on 4/2/18 that began at 10:43 AM and ended at 2:47 PM.

3. Review of the water RO logs for portable RO units # 1326946 and #1326838 at 1:30 PM on 4/2/18 lacked information that demonstrated CSY staff had recorded RO testing for the treatment day. CSY staff failed to document the performance data and RO testing prior to starting dialysis treatments for both Patient #47 and #50.

4. During an interview at 3:00 PM on 4/2/18, CSY RN (Registered Nurse) AA reported she completed the testing on the RO units but had not documented the results in the RO logbook. CSY RN AA reported the RO testing should be completed and documented prior to initiating any patient treatments.

During an interview on 4/4/18 at 10:45 AM, CSY Director of Operations and Program Manager acknowledged the findings.

5. During a findings review on 4/4/18 beginning at 11:30 AM, the hospital Chief Operating Officer acknowledged the findings.

I. Based on review of documents, observations and, interviews the hospital's administrative staff failed to implement a policy to educate and direct staff regarding the cleaning of surgical instruments.

Hospital administrative staff failed to implement policy to educate and direct sterile supply staff on the testing of machines used to clean surgical instruments.

The hospital's failure to implement policies to educate and direct staff related to the cleaning of surgical instruments and testing machines used to clean surgical instruments could potentially result in a life threatening infection from biohazardous surgical matter of one patient potentially being introduced to another surgical patient.

Observation in Sterile Supply on 4/4/2018 at 11:15AM revealed Steris instrument washer test strips ran through both washers had failed from 3/27/2018 to 4/4/2018.

Interview with Certified Instrument Tech P on 4/4/2018 at 11:15 AM revealed; Certified Instrument Tech P confirmed she lacked knowledge of the pass and fail process of the Steris instrument washer and the need to use the troubleshooting guide and rerun the process with a new test strip. When asked about pink being on the indicator strips, Certified Instrument Tech P responded with, " I thought if there was just a little they would pass, nobody has complained about anything being dirty".

Interview with Director of Sterile Supply on 4/4/2018 at 11:15 AM revealed: Director of Sterile Supply verified when a test strip has any pink on it the machine is to be adjusted by using the instructions and the load is to be rerun with a new test strip. Director of Sterile Supply reported some of the instruments cleaned in the washers that have failed testing since 3/27/2018 have been used in surgical procedures on other patients. There was no way to track what instruments have been cleaned since 3/27/2018 and what ones were used on patients. Director of Sterile Supply reported Sterile Supply runs approximately 30 loads of instruments per day with four racks in each washer.

Review of the Steris, Verify All Clean Test Washer Indicator instructions, dated 6/2014 revealed in part, "Introducing the Verify All Clean Test Washer Indicator ... After running a complete cycle, remove the device from the tray or basket and carefully remove the Verify All Clean Test Indicator from the holder, Inspect the indicator for evidence of soil by placing the plastic film against a white background. Compare the results against the samples below to determine the cause of action. If the indicator remains visible to the naked eye- the result is a Fail".

In the result samples there were four pictures of test strips, one had red, and it said unused; one was clear and it said Pass. The other two had pink on the indicator strips and they each gave instructions for the user:

A. Impingement Related Failure

1. Incorrect positioning of indicator

2. Blocked spray arms

3. Lack of water pressure

4. Overloading of rack

B. Chemistry Related Failure

1. Incorrect positioning of indicator

2. Enzyme and/or wash phase is too short

3. Temperature parameters are not correct

4. Chemistry injection rates are not correct

There was a number supplied in case of needing help from the manufacturer stating, "For further information, please contact Steris in the United States at 800-548-4873".

During an interview with Steris Technician from Steris Corporation on 4/4/2018 at 2:45PM revealed: STERIS Technician identified if the test strip turns pink there are four options to troubleshoot and make adjustments. The machine operator makes adjustments, then runs the machine again to see if the adjustment was successful. If the next test strip ran was also pink after adjustments are made, other adjustments on the list need attempted until a successful clear strip's obtained. Steris Technician reported the washer can sterilize most instruments, but was unable to do so if there is bio-surgical matter on the instruments.

During observation of an operative procedure in the Operating Room (OR) on 4/4/2018 from approximately 8:15 AM to 9:00 AM, Certified Registered Nurse Anesthetist (CRNA) K was observed drawing up medications from multiple medication vials, after cleaning off the top of each vial using 2 x 2 gauze pads soaked in a zephiran/alcohol (antiseptic) solution from a multi-patient use container, into labeled syringes. CRNA K was observed administering these medications to the patient through an intravenous line, wiping the injection port with a fresh 2 x 2 gauze pad each administration from the same multi-patient use container used during medication preparation. CRNA K was observed touching the patient and anesthesia equipment in the time surrounding the medication administration process and then observed returning to the multi-patient use container of 2 x 2 gauze pads without performing hand hygiene.

During observation of preparation for a second operative procedure on 4/4/2018 at approximately 9:15 AM CRNA K was observed dropping a cap to a medication vial on the OR floor. CRNA K picked up the cap from the floor, tossed it in the sharps container and proceeded to prepare medications for administration to the patient without performing hand hygiene.

During observations on 4/3/2018 at 8:30 AM, Registered Nurse (RN) H entered room 608 to administer Patient #1's morning medications. RN H removed 0.25 mg of Ativan (a medication to calm patients) from a vial. RN H removed his gloves and failed to perform hand hygiene (washing his hands or using alcohol based foam sanitizer to cleanse his hands). RN H placed new gloves on his hands.

During observations on 4/3/2018 at 8:50 AM, RN I entered room 672 to administer Patient #2's morning medications. When RN I entered Patient #2's room, RN I failed to perform hand hygiene (washing her hands or using alcohol based foam to cleanse her hands). RN I put gloves on while checking Patient #2's blood pressure. RN I took off her gloves and failed to perform hand hygiene before putting on new gloves. RN I then administered Patient #2's morning medications. Next, RN I administered intravenous (IV) medications to Patient #2. RN I removed her gloves after administering the medication and failed to perform hand hygiene prior to leaving Patient #2's room.

During observations on 4/3/2018 at 9:15 AM, RN J entered room 466 to administer Patient #3's morning medications. RN J performed hand hygiene (washing her hands or using alcohol based foam sanitizer to cleanse her hands) when she entered Patient #3's room. RN J put on gloves and went to administer Patient #3's medications. RN J realized she needed supplies from the cart in the room, and removed her gloves to get the supplies. RN J failed to perform hand hygiene before putting on new gloves. RN J then administered Patient #3's medications. RN J removed her gloves and failed to perform hand hygiene prior to leaving Patient #3's room.

The hospital staff's failure creates an atmosphere that promotes widespread potential infection risk as there are several areas of the hospital that hand hygiene are not being performed properly, health assessments of volunteers are not being completed in a timely manner the policy of the hospital dictates to ensure volunteers are not bringing in disease to vulnerable patients. Hand hygiene is lacking in several areas of the hospital, showing a lack of knowledge across the seperate disciplines of the hospital. Cleaning of surgical instruments is not being monitored according to manufacturer's instructions, staff has no policy to educate them of the proper technique to test the equipment used to wash surgical instruments. The potential for contracting a life threatening infectious disease is posed by not having appropriate hand hygiene, monitoring of health of volunteers and surgical equipment.

II. Based on review of facility documents and Contracted Services Y (contracted to perform acute dialysis services for dialysis patients) staff failed to:

a. sanitize hands before and after glove use in accordance with policy and procedure (Refer to A 749)

b. sanitize hands before and after computer keyboard use in accordance with policy and procedure (Refer to A 749)

c. wear gloves when touching the hemodialysis machine in accordance with policy and procedure (Refer to A 749)

d. sanitize hands and/or change gloves between dialysis patients in accordance with policy and procedure (Refer to A 749)

e. sanitize hands and change gloves between "dirty" and "clean procedures in accordance with policy and procedure (Refer to A 749)

f. disinfect all non-disposable equipment/supplies when removed from a dialysis station and before taking the equipment/supplies elsewhere in accordance with policy and procedure (Refer to A 749)

g. wear personal protective equipment in accordance with policy and procedure (Refer to A 749)

h. ensure visitors wore personal protective equipment when required in accordance with policy and procedure (Refer to A 749)

i. perform central venous catheter procedures in accordance with policies and procedures (Refer to A 749)

j. use acid concentrate solutions as single use in accordance with policy and procedure (Refer to A 749)

k. dispose of used solutions in the approved disposal area in accordance with policy and procedure (Refer to A 749)

l. clean blood spills in accordance with policy and procedure (Refer to A 749)

m. clean all equipment in the dialysis station in accordance with policy and procedure (Refer to A 749)

n. follow policy and procedure regarding having personal beverages within the dialysis treatment area (Refer to A 749)

I. Based on review of CSY, (Contracted Services Y) policies, procedures, observations, and staff interviews, the facility failed to ensure all staff followed and maintained infection control practices as outlined in the approved policies and procedures.

Failure to maintain and provide a sanitary environment in accordance with CSY's policies and procedures could potentially spread bloodstone pathogens, bacterial and/or viral contaminants resulting in cross-contamination to patients, healthcare personnel, and/or visitors. These practices could potentially cause severe illness and/or death.

The hospital reported 7 patients admitted to the hospital that required acute hemodialysis services at the time of the survey. Findings for 3 of 4 ( CSY RN [Registered Nurse] AA, CC, and CSY Area Technical Operation Manager) staff observations where staff did not follow approved infection control techniques and/or maintain a sanitary environment include:

1. CSY provided acute dialysis services at the hospital. Review of CSY policies and procedures showed the following:

a. Review of the policy titled "Hand Hygiene", with effective date of March 20, 2013, included in part, "...All staff, patients, patient care givers ...other indirect patient care staff must follow the same requirements for hand hygiene ...Hand hygiene includes either washing hands with soap and water or using a waterless alcohol-based antiseptic hand rub ...Hands will be ...washed with antimicrobial soap and water ...Decontaminated using alcohol based hand rub or by washing hands with antimicrobial soap and water ...Before and after direct contact with patients ...Entering and leaving the treatment area ...Before performing any invasive procedure ...Immediately after removing gloves ...After contact with body fluids ...After contact with inanimate objects ...When moving from a contaminated body site to a clean body site of the same patient ...gloves must be provided to patients when performing procedures which risk exposure to blood or body fluids ...family members ...hand hygiene must be performed ...Used items should not be ...drained in the handwashing sinks ...".

b. Review of the policy titled "Cleaning and Disinfection" with an issue and effective date of January 28, 2015, included in part, " ...Use clean hands without gloves on ...keyboards ...Hand hygiene is imperative after contact with Chairside computer devices and before contact with the patient ...".

c. Review of the policy titled "Visitors Policy" with an effective date of September 25, 2013, included in part, "...visitors are prohibited from entering the treatment area during the time treatments are initiated and terminated...Personal Protective Equipment will be provided if there is likelihood that the visitor may be exposed to bloodborne during the time that he/she is in the treatment area...".

d. Review of the policy titled "Post Treatment Fistula Needle Removal" with a revision date of January 28, 2015, included in part, "...Wash hands and don PPE. If the patient is able to hold pressure on the site, assist patient in gloving hand...Discard needle in the sharps container...".

e. Review of the policy titled "Use of Priming Buckets" with an effective date of July 17, 2017, included in part, "...At the completion of the patient treatment, remove the priming bucket...and dispose of the Normal Saline in the utility room hopper or dirty sink...".

f. Review of the policy titled "Cleaning and Disinfection of the Dialysis Station", with an effective date of July 17, 2017, included in part, "...The purpose of this policy is to provide guidelines to prevent the spread of infectious disease...and to maintain a clean, safe, and anesthetically pleasant environment for patients, staff, and visitors...The chair and dialysis equipment are used by multiple patients during a treatment day and it is critical that these items be thoroughly cleaned and disinfected between uses...the nature of dialysis treatments with frequent exposure to blood and body fluids, close proximity of patients and staff, and the immunocompromised status of dialysis patients make dialysis a high-risk area for spreading infectious disease...After use, all equipment and supplies must be considered as potentially blood contaminated, and should...handled with caution and wither disinfected or discarded..."Work Surface Cleaning and Disinfection w/out Visible Blood using Bleach Solutions"...All work surfaces shall be cleaned and disinfected with 1:100 bleach solution after completion of procedures...Work Surface Cleaning and Disinfection with Visible Blood < or equal to 10ml and Other Potentially Infectious Material using Bleach Solutions"...Use 1:100 bleach solution to clean surfaces with visible blood. After cleaning up all visible blood, use a new cloth with 1:100 bleach solution for a second cleaning of the surface...Externally disinfect the dialysis machine with 1:100 bleach solution after each dialysis treatment...Give special attention to cleaning control panels on the dialysis machines and other surfaces that are frequently touched and potentially contaminated...Hand hygiene is imperative after contact with the Chairside computer devices and before contact with the patient...Externally disinfect the dialysis machine including the keyboard...Non-disposable items such as...clipboard it should be made of plastic to allow for adequate disinfection between patients...".

g. Review of the policy titled "Needle Placement for Arteriovenous (AV) Fistula or AV Graft" with an effective date of January 28, 2015, included in part, "...Tape from singe use role: [roll] A barrier piece of tape must be placed between dialysis chair side table and the tape. Tape may then be hung off of the table. In order for tape to remain "clean"...".

h. Review of the policy titled "Concentrate Storage and Handling" with an effective date of January 31, 2018, included in part, "...Disposable concentrate containers (single gallon) may be used to perform a dialysis treatment...Disposable containers are single use and will not be used for multiple treatments. Residual concentrate at the end of a treatment will be discarded...Residual concentrate transfer into a disposable container is prohibited...Acid wands will be rinsed with RO...water, allowed to air dry when not in use and stored to prevent infiltration of dirt or other contaminants before use...".

i. Review of the policy titled "CENTRAL VASCULAR ACCESS DEVICE" with effective date of January 22, 2018, included in part, "...Dressing Changes...ii. Central venous access device dressing change...perform hand hygiene...put on a mask...perform hand hygiene, assemble the supplies on a sterile field...perform hand hygiene...put on gloves to comply with standard precautions...remove existing dressing...inspect the catheter for cracks, leakage, kinking or pinching...remove and discard your gloves...perform hand hygiene...put on sterile gloves...measure the external catheter length using a sterile tape measure to make sure the catheter hasn't migrated...clean the catheter insertion site with chlorhexidine using a back-and-forth motion to provide skin antisepsis...Apply a skin barrier solution according to the manufacturer's instructions to reduce the risk of medical adhesive-related skin injury...".

j. Review of the policy titled "Termination of Treatment Using a Central Venous Catheter and Optiflux Single Use Ebeam Dialyzer" with an effective date of January 28, 2015, included in part, "...Disconnect the arterial bloodline from the catheter limb...Using a new sterile alcohol pad, scrub threads of the luer lock (hub) vigorously using back and forth friction for 15 seconds - let dry and discard pad...immediately attach a 10ml saline filled syringe to the catheter limb...Repeat steps...Termination...Preparing Catheter for Patient Discharge...Open the arterial catheter limb clamp, and flush limb with saline, Close the catheter clamp...Remove empty saline syringe from a catheter limb...Apply a sterile cap on the end of the lumen maintaining aseptic technique. Tighten the end cap securely...Sterile caps prevent infection and provide protection between treatments...Repeat steps...".

k. Review of the policy titled "Personal Protective Equipment" with effective date of February 14, 2018, included in part, "...Personal protective equipment such as a full face shield or mask and protective eyewear with full side shield, fluid-resistant gowns and gloves will be worn to protect and prevent employees from blood or other potentially infectious materials to pass through to or reach the employee's skin, eyes, mouth, other mucous membranes...Prescription corrective eyewear is not considered appropriate eye protection...All personal protective equipment shall be removed prior to leaving the treatment area...Facemask's are single-use only and must be discarded after the task for which they were needed to complete. Practice hand hygiene after mask removal to prevent cross-contamination...Disposable gloves must be used: ...when holding access bleeding sites...when handling contaminated dialysis equipment and accessories...When touching...items or surfaces potentially contaminated...When touching any part of the dialysis machine or equipment at the dialysis station...Change gloves and practice hand hygiene between each patient and/or station to prevent cross-contamination...Remove gloves and wash hands after each patient contact, and after exposure to blood and body fluids...Hand hygiene must always be performed after glove removal...Avoid touching surfaces with gloved hands that will be touched with ungloved hands (for ex. patient charts and computers.)..."Requirements for the use of protective body clothing, such as fluid-resistant gowns...fluid-resistant gowns with long sleeves must be used for procedures in which exposure of the forearm to blood or other potentially infectious material...is anticipated to occur...".

2. Observations during the course of the validation survey of CSY staff performing dialysis procedures included the following:

a. Observation on 4/2/18 at 1:11 PM showed CSY RN AA typing on a computer keyboard at station #2. CSY RN AA removed a glove from a glove box, wrapped the glove around her index finger and pushed a button on the dialysis machine in station #4 without performing hand hygiene or donning gloves.

Observation on 4/2/18 at 1:14 PM showed CSY RN AA typing on the computer keyboard at station #4. Further observation showed CSY RN AA failed to perform hand hygiene and don gloves after typing on the keyboard and before touching the dialysis machine at station #4.

b. Observation on 4/2/18 at 1:20 PM showed CSY RN AA typing on a computer keyboard at station #2. CSY RN AA touched the acid concentrate container (a container that holds acid concentrate used during the dialysis treatment) located on the front ledge of the dialysis machine, and the bicarbonate bag (a disposable bag that held bicarbonate used for dialysis treatment, secured in a holder on the dialysis machine) without performing hand hygiene and donning gloves. Further observation showed CSY RN AA returned to type on the computer keyboard without performing hand hygiene. CSY RN AA then moved from the computer keyboard, and donned gloves without performing hand hygiene first.

Observation on 4/2/18 at 1:28 PM showed CSY RN AA in station #2 wearing gloves. CSY RN AA removed gloves, and went into the nurse's station without performing hand hygiene.

c. Observation on 4/2/18 at 1:37 PM showed CSY RN AA typing on a computer keyboard at station #4. CSY RN AA donned gloves without performing hand hygiene, repositioned a patient, removed gloves and resumed typing on the computer keyboard without performing hand hygiene. CSY RN AA then donned gloves without performing hand hygiene before she touched the dialysis machine and silenced a dialysis machine alarm.

d. Observation on 4/2/18 at 1:44 PM showed CSY RN AA at the nurse's station holding a clamp (used to clamp dialysis lines) without wearing gloves. CSY RN AA went to station #4, picked up the patient's dialysis blood lines, (lines used to hold patient's blood during the dialysis treatment) and secured the patient's blood lines to the patient's hospital gown without performing hand hygiene or wearing gloves.

Observation on 4/2/18 at 1:49 PM showed CSY RN AA standing next to the dialysis machine at station #4. The dialysis machine alarm went off, CSY RN AA donned gloves without performing hand hygiene, repositioned the patient, pushed a button on the dialysis machine to silence the alarm, removed gloves, and began typing on the computer keyboard without performing hand hygiene. The dialysis machine at station #4 alarmed again, CSY RN AA donned gloves without performing hand hygiene, touched the front of the dialysis machine, silenced the alarm, removed gloves, and entered station #2 without performing hand hygiene.

e. Observation on 4/2/18 at 2:04 PM showed CSY RN AA with gloves in her hands standing next to the nurse's station. CSY RN AA removed gloves, donned gloves without performing hand hygiene and silenced the dialysis machine (touched the front of the dialysis machine) alarm at station #4. CSY RN AA removed gloves and then donned new gloves without performing hand hygiene. CSY RN AA then repositioned the patient who was receiving dialysis at station #4.

f. Observation on 4/2/2018 at 2:38 PM showed CSY RN AA standing next to the patient's recliner at station #2. Without performing hand hygiene, CSY RN AA donned gloves and returned the patient's blood at the end of the dialysis treatment. CSY RN AA disconnected the bloodlines from the patient, obtained the patient's blood pressure, removed the blood pressure cuff from the patient's arm, and without removing gloves, sanitizing hands, and donning new gloves began performing the catheter care for the patient's CVC (central venous catheter). Wearing the same gloves, CSY RN AA went from station #2 to station #3 to silence a dialysis machine alarm and then removed the gloves and began to type on the computer keyboard without performing hand hygiene.

g. Observation on 4/2/2018 at 2:43 PM showed CSY RN AA without gloves marking containers located on dialysis machines at station #2 and #3. CSY RN AA then took the marker used to write on the containers and without disinfecting the marker returned it to the clean supply cart. Without sanitizing hands, CSY RN AA donned one glove to her right hand and went to station #4 to silence the dialysis machine alarm. CSY RN AA then removed the glove, and failed to perform hand hygiene.

h. Observation on 4/2/18 at 2:46 PM showed CSY RN AA left station #3 without sanitizing hands, went into the nurse's station, used the phone, and then entered the supply room. CSY RN AA donned a protective gown without securing all the closure snaps and entered a room used to disinfect items before taking those items back into dialysis stations ("dirty" area) and then returned to station #3 with a face shield with an attached mask in her ungloved hands. Still not wearing gloves, CSY RN AA donned the shield/mask, obtained a thermometer from the top of dialysis machine, obtained the patient's temperature and returned the thermometer to the top of dialysis machine. Continuing to not wear gloves, CSY RN AA removed 2 pre-filled normal saline syringes from the top of dialysis machine and placed the syringes next to the patient at station #3. CSY RN AA donned gloves without performing hand hygiene and then removed gloves and without sanitizing hands began typing on on the computer keyboard. At 2:48 PM, without sanitizing hands, CSY RN AA donned gloves and began returning the patient's blood at the end of the dialysis treatment. Observation showed a visitor sitting next to the patient at station #3. The visitor was not wearing any personal protective equipment to protect against any potential spattering or spurting of blood during the discontinuation process. CSY RN AA placed a protective barrier under the patient's CVC limbs, disconnected the bloodlines and laid the CVC limbs on the barrier without protecting the open catheter ports. CSY RN AA attached a pre-filled normal saline syringe to each of the CVC limbs without performing an alcohol scrub to the threads of the open ends of the catheter limbs.

i. Observation on 4/2/18 at approximately 3:00 PM showed CSY RN AA failed to perform hand hygiene after removing gloves while at station #3 and before donning gloves and repositioning the patient at station #4.

Observation on 4/2/18 at 3:11 PM showed CSY RN AA typing on the computer at the nurse's station. CSY RN AA did not sanitize hands and then went to type on the computer keyboard at station # 4. CSY RN AA then failed to sanitize hands after leaving station #4 and taking equipment logs from station #4 to place in a binder labeled "RO logs" at the nurse's station.

j. Observation on 4/2/18 at 3:18 PM showed CSY RN AA at station #4, returning the patient's blood at the end of the dialysis treatment. CSY RN AA disconnected the dialysis blood lines from the patients's vascular access and removed the acid concentrate container (used by the dialysis machine as one part of the dialysate required for dialysis) located on the dialysis machine, placed the container on the floor, and then moved it across the floor with her shoe until it reached the wall at station #4. Without changing gloves and without removing gloves and sanitizing hands, CSY RN AA removed a table located between station #3 and station #4, and placed it next to the patient's bedside at station #4. CSY RN AA, still without removing gloves sanitizing hands, and donning clean gloves, began tearing strips of tape and placing those torn strips onto the table.

Observation on 4/2/18 at 3:23 PM showed CSY RN AA standing next to the patient's bed in station #4. CSY RN AA had removed the vascular access needle from the patient's vascular access and placed the blood contaminated vascular access needle on top of the table located next to the patient's bed where RN AA had placed the strips of tape. CSY RN AA folded a 4x4 gauze, placed the gauze over the puncture site, then looked up and stated, "I know I'm not to put the needle there, but ...". CSY RN AA shrugged her shoulders then continued to secure the 4x4 gauze with tape. During this observation CSY RN AA's face shield did not cover or protect her eyes from potential spurting or spattering of blood.

Observation on 4/2/18 at 3:26 PM showed CSY RN AA removed the second vascular access needle and placed it on the bedside table next to the torn tape strips and the first blood contaminated needle. CSY RN AA placed gauze over the needle puncture site and asked the surveyor to retrieve supplies for her. After the surveyor explained they were unable to assist with patient care, CSY RN AA instructed the patient to hold the gauze over the second puncture site. The patient held the site without performing hand hygiene or use of disposable gloves (in accordance with the policy). CSY RN AA removed gloves and then without performing hand hygiene, retrieved additional supplies from the common supply cart (potentially contaminating those clean supplies). CSY RN AA returned to station #4, and without sanitizing hands, donned gloves, removed a blood saturated 4x4 gauze from the top vascular access site, applied a new folded 4x4 gauze over the puncture site and held pressure over the puncture site.

Observation on 4/2/18 at 3:36 PM showed CSY RN AA removed gloves, failed to sanitize hands, again went to the supply cart to obtain clean supplies (again potentially contaminating those supplies). CSY RN AA then donned gloves without performing hand hygiene, tore additional strips of tape and placed those strips directly on top of the bedside table. CSY RN AA did not place a barrier strip of tape under the torn tape in accordance with the policy. CSY RN AA removed gloves and failed to sanitize hands prior to obtaining additional 4x4 gauze from the common supply cart. CSY RN AA donned gloves without performing hand hygiene, removed the blood contaminated vascular access needles from the table located next to the patient's bed at station #4 and discarded the needles into a nearby sharps container. CSY RN AA removed gloves, did not sanitize hands, donned a single glove and went to a common cart supply cart and removed the protective cover with the gloved hand and removed an item from that clean supply cart. CSY RN AA went into another room and returned to station #4 where she cleaned 4 "quarter" sized blood spots on the floor using a wet cloth with her gloved hand. CSY RN AA failed to clean the floor a second time in accordance with the policy. CSY RN AA removed the single glove and donned new gloves, however failed to perform hand hygiene.

k. Observation on 4/2/18 at 3:45 PM showed CSY RN AA standing next to the dialysis recliner at station #2 holding a plastic clipboard. CSY RN AA went to station #4 holding the same clipboard without sanitizing hands or disinfecting the clipboard and had the patient at station #4 sign a piece of paper attached to the clipboard that CSY RN AA held. CSY RN AA then placed the plastic clipboard on a cloth covered chair located between station #2 and station #3, again not disinfecting the clipboard.

l. Observation on 4/2/18 at 3:49 PM showed CSY RN AA at station #4 wearing gloves. After touching the dialysis machine, CSY RN AA removed gloves, however, failed to perform hand hygiene.

m. Observation on 4/2/18 at 3:58 PM showed CSY RN AA disinfecting the dialysis machine at station #2. CSY RN AA did not disinfect the prime bucket (a container attached to the dialysis machine used to collect the normal saline when priming the dialyzer and blood lines pretreatment) interior or exterior surface. CSY RN AA did not disinfect the R. O. (reverse osmosis) machine ( used to prepare dialysis quality water), the front ledge of the dialysis machine, the connectors and hoses attached to the dialysis machine, the sharps container, the keyboard on the dialysis machine, and the back of the recliner. Continued observation showed CSY RN AA failed to lay the dialysis recliner flat to disinfect between the top and bottom crevice of the recliner. CSY RN AA removed gloves, failed to sanitize hands and then went into the clean supply room to obtain clean supplies, potentially contaminating those supplies.

n. Observation on 4/2/18 at 4:04 PM showed CSY RN AA wearing a partially closed protective gown, don gloves without sanitizing hands, remove the blood contaminated bloodlines, the acid concentrate (used to prepare dialysate during the dialysis treatment) container, and other disposable equipment used during dialysis from the dialysis machine. While carrying the "dirty" supplies through the dialysis treatment room, CSY RN AA reached into the "clean" linen cart with her "dirty" gloves and obtained linen from that cart, potentially contaminating the entire cart of clean linen.

o. Observation on 4/2/18 at 4:08 PM, showed CSY RN AA in the "cleaning" room. CSY RN AA reached into the bleach solution used to soak blood contaminated supplies and wetted a clean cloth in that bleach solution. At 4:10 PM, CSY RN AA used the cloth wetted in the bleach solution used to soak contaminated equipment to disinfect the dialysis equipment at station #3. CSY RN AA did not disinfect the prime bucket exterior or interior surfaces, the wire basket located on the left side of the dialysis machine, the front ledge of the dialysis machine, the R.O. machine, the sharps container, the back of the dialysis machine, or the computer keyboard.

p. Observation on 4/2/18 at 4:20 PM showed CSY RN AA at station #3 preparing the dialysis machine for the next patient. CSY RN AA removed gloves, did not perform hand hygiene, went to the nurse's station, obtained a clipboard, returned to station #3 and entered information into the dialysis machine. CSY RN AA then returned the clipboard to the nurse's station without disinfecting the clipboard. CSY RN AA then obtained 2 acid concentrate containers used for previous dialysis treatments and emptied the contents into a sink with a sign above it marked "clean sink" .

q. Observation on 4/2/2018 at 4:30 PM showed CSY RN AA wearing gloves, removed an acid concentrate container (that had not been disinfected after used during a dialysis treatment for a patient earlier that day) from a supply cart. CSY RN AA put the acid concentrate container on the front ledge of dialysis machine at station #2. RN AA removed gloves and donned new gloves without performing hand hygiene and went into the supply room and obtained 2 additional acid concentrate containers.

r. Observation on 4/3/18 at 8:07 AM showed CSY RN AA eating in the break room. After leaving the break room, CSY RN AA did not sanitize hands prior to entering the treatment area in accordance with the policy. At 8:17 AM, CSY RN AA returned to the break room and was observed eating, however, CSY RN AA did not sanitize hands after leaving the treatment area before entering the break room. At 8:25 AM CSY RN AA left the break room and entered the treatment area, again without sanitizing hands

s. Observation on 4/3/18 at 9:05 AM showed CSY RN CC at the nurse's station typing on the computer keyboard. CSY RN CC entered station #2 and used the computer keyboard without performing hand hygiene.

t. Observation on 4/3/18 at 9:06 AM showed CSY RN AA wearing gloves and a partially closed protective gown removing the CVC dressing for the patient at station #3. CSY RN AA removed gloves, failed to sanitize hands, and donned new gloves. CSY RN AA then opened a package labeled "chlorhexidine" ( a commonly used disinfectant during the care of a dialysis access CVC). CSY RN AA disinfected the exit site using a left to right half circle motion to clean around the top 1/2 of the patient's CVC exit site.

u. Observation on 4/3/18 at 9:10 AM showed CSY RN CC typing on the computer keyboard at station #2. CSY RN CC left station #2 to gather supplies for CSY RN AA without performing hand hygiene.

v. Observation on 4/3/218 at 9:15 AM showed CSY Area Technical Operation Manager entered the dialysis treatment area. CSY Area Technical Operation Manager went into the nurse's station, retrieved a pen, went to station #1, left station #1, and returned to the nurse's station with a binder. Observation did not show CSY Area Technical Operation Manager perform hand hygiene in any of those instances. CSY Area Technical Operation Manager rubbed his nose with the palm of his right hand, entered the nurse's station, and returned the pen. CSY Area Technical Operation Manager left the binder in station #1 and without sanitizing hands, left station #1 and went into the employee break room.

3. During observations on 4/2/18 all acid concentrate containers did not have expiration dates written on the outside of the container. During an interview on 4/2/18 at 1:30 PM , CSY RN AA reported the acid concentrate containers should have a date written on the outside of the container, however did not know if the open date, the expiration date or both were to be written on the container. CSY RN AA reported the solution in the acid concentrate containers expired 30 days after opened.

During an interview on 4/3/18 at 3:10 PM, CSY Regional Director (RD) reported each acid concentrate container was to be dated, however, did not know if the open date or expiration date was required. CSY RD reported the acid concentrate expired 28 days after opened. CSY RN CC acknowledged the acid concentrate expired 28 days after opening.

During an interview on 4/3/18 at 4:22 PM, CSY RN AA again reported not knowing which date should be written on the outside of the acid concentrate container, however, disagreed with CSY RD and CSY RN CC and reported the acid concentrate did not expire until 30 days after opening. CSY RN AA went on to report staff combined the acid concentrate solutions (topped off). CSY RN AA acknowledged the same concentration of acid solutions such as 2 potassium acid concentrates used for different patients were combined to prevent "running low". CSY RN AA acknowledged she had not disinfected the outside of the acid concentrate containers after removing the containers from the dialysis machine post dialysis and placing the containers on a supply cart with other containers.

Observation on 4/4/18 at 9:23 AM showed CSY RN BB had dated all acid concentrate containers in use with an "opened 4/4/18" and "expires 5/2/18".

During an interview on 4/4/18 at 9:23 AM, CSY RN BB reported the opened and expiration dates should be written on the outside of the acid concentrate containers. CSY RN BB reported the acid concentrate expired 28 days after opening.

4. During an interview on 4/4/18 at 9:30 AM, CSY RN CC acknowledged staff had been using the same 1:100 bleach solution to soak potentially blood contaminated reusable items and to disinfect the dialysis station post dialysis.

During an interview on 4/4/18 at 9:50 AM, CSY RD acknowledged the acid concentrate containers were single use and were not to be used for multiple patients.

During an interview on 4/4/18 at 10:00 AM, CSY RN CC, and CSY RD acknowledged the findings that all staff had not followed approved policies and procedures related to infection control techniques.

During an interview on 4/4/18 beginning at 11:30 AM, the hospital Chief Operating Officer acknowledged the findings.


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II. Based on review of Contracted Services Y (CSY) policy, observation and staff interview the hospital failed to ensure the CSY staff did not have personal beverages within the acute dialysis treatment unit according to CSY policy.

Failure to ensure CSY staff adhered to policy regarding personal beverages could lead to the potential transfer of pathogenic organisms from staff to patients and/or from patients to staff which could lead to infection and poor patient outcomes.

The hospital reported an inpatient acute dialysis census of 7 at the time of the validation survey. Findings for observation of 1 of 1 CSY staff (CSY RN [Registered Nurse] AA) include:

1. Review of the policy titled, "Eating and Drinking Policy", effective date: 25-SEP-2013, included in part, "PURPOSE The purpose of this policy is to guide FMS Inpatient Services Staff...FMS Inpatient Services Staff are prohibited from eating or drinking in the treatment area. The staff lounge or other designated room shall be used for meals/breaks..."

2. Observation on a tour of the inpatient unit on 4/2/18 at 1:00 PM showed Patient #50 on dialysis at station #2 and Patient #47 on dialysis at station #3. Further observation showed RN AA at the nurse's station of the treatment area with partially fluid filled enclosed drinking glass and an opened can of soda sitting the counter of the nurses' station. Further observation showed RN AA picked up both the drinking glass and soda can and moved both items into the employee break room.

3. During an interview on 4/2/18 at 3:00 PM, the surveyor asked if CSY nursing staff were allowed to eat or drink at the nurses' station. CSY RN AA reported staff are not allowed to have beverages at the nurses' station. CSY RN AA reported when the surveyors arrived, she moved her personal drinking glass and soda can into the employee break room because food and drink should not be present in the treatment area.

During an interview and policy review on 4/4/18 at 10:45 AM, CSY Director of Operations and Program Manager acknowledged the findings.

4. During a findings review on 4/4/18 beginning at 11:30 AM, the hospital COO (Chief Operating Officer) acknowledged the findings.


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III. Based on document review and staff interview the hospital administrative staff failed to ensure health exams were regularly completed as part of the system to identify and prevent transmission of infections and communicable diseases. The problem was identified for 4 of 5 volunteers selected for review (Staff B, C, D and E).

Failure to identify infections and communicable diseases among employees and volunteers could potentially result in the transmission of a communicable disease to patients.

Findings include:

Review of a hospital policy titled "Mercy Volunteer Health Requirements", dated 1/1/2016, revealed in part "... Volunteers must complete required health assessment forms and health assessments through Employee Health Department every four years ..."

Review of the health information for Staff B, Volunteer, revealed documented evidence of the most rec