HospitalInspections.org

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Based on observation, record review and interview in two (2) observations, the facility did not ensure that the patients' right to privacy was maintained.

These patient exposures during examinations / treatments and discussions with Health Care Professional about their health status / care denied the patients' right to privacy while receiving care in the facility.

Findings:

Observations in the facility's 3 West Unit during a tour between 9:55AM and 12:30PM on 06/06/16 identified the following:

In Room 362 Patient #5, an elderly female, was observed lying in bed with her gown untied at the neck. This allowed the gown to fall exposing the upper half of her chest. A male Environmental Service staff member was mopping the floor in the patient's room. This female patient was exposed to the male staff member as well as to anyone in the hallway.

With the door open and the curtain not pulled to provide privacy, Staff B (Resident) lifted Patient #5's gown and exposed her abdomen while he palpated her midsection. He also discussed the patient's health status / care with her. These actions were visible and audible to anyone in the hallway.

During an interview with Staff J on 06/06/16 during the tour, the staff member confirmed the findings.

Observations in the facility's 1 East Unit during a tour between 1:00PM and 4:00PM on 06/06/16 identified the following:

In Room 362 Patient #1 was in the bed next to the door. The other patient was in bed next to the window and had visitors. With the door open and the curtain not pulled to provide privacy, Staff E (Podiatrist) performed a dressing change on Patient #1's right great toe. He also discussed the patient's health status / care with him. These actions were visible to the visitors and to anyone in the hallway and audible to anyone in the room and the hallway.

During an interview with Staff K (Infection Prevention Quality Management) on 06/06/16 at the time of the observation, the staff member confirmed the finding.

The facility's Policy and Procedure titled "Patient Privacy" last revised 04/01/16 stated the following: "It is the policy of the organization to have every staff member ensure that each patient's right to privacy is upheld as well as demonstrate respect for a patient's modesty during every encounter. Employees are required to close doors and/or pull curtains when performing patient care or taking care of patient's personal needs. Employees will interview patients in private. If other patients are nearby, employees should try to maintain some distance between individuals when interviewing. They should speak in a low tone of voice and be discreet when others are present."
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Based on record review, interview and observation, the facility failed to ensure that staff complied with the facility's Infection Control Practices, including the use of Personal Protective Equipment (PPE), Isolation Precautions, Handwashing and appropriate surgical attire and procedures, to avoid potential sources of cross contamination which increases the risk for the spread of infection.

This pattern of ineffective Infection Control Precautions places patients at risk for potential facility acquired infections.

Findings:

See Tag A 748

See Tag A 749
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Based on document review and interview, the Infection Control Officer failed to implement the facility's Mandatory Annual Education Program which includes Infection Control and Prevention for all Physicians providing care in the facility.

This failure places all patients at risk for potential infections.

Findings:

Personnel Files for Staff D, a Voluntary Physician with Privileges at the facility, revealed an employment date of 04/05/05. The file lacked evidence of any Annual Facility Infection Control Inservice or Education after his Initial Orientation date, eleven (11) years ago.

Per interview with Staff M, Assistant Executive Director, on 06/07/16 at 9:40AM, the staff member stated that the Voluntary Doctors, those that are not on staff but are Credentialed to see patients at the facility, do not have any Annual Handwashing or Infection Control Inservice or Education.

Personnel Files for Staff E, a Podiatry Resident, revealed a start date of 06/03/16. The file lacked evidence of any facility Infection Control Inservice or Education.

This was confirmed with Staff N, Director of Medical Credentialing, on 06/07/16 at 11:57AM, who also stated "Medical, Orthopedic and Surgical Residents attend Hospital-Wide and System Orientation, but Podiatry Residents do not get a formal Orientation."

On 06/07/16 Staff M provided a list of Voluntary Physicians, one (1) in each Discipline, with their initial start dates. The list of Voluntary Physicians was comprised of ten (10) Physicians who were granted Privileges, and included:

A Gastroenterologist who was granted Privileges in 1999, seventeen (17) years ago, and has not received any Annual Facility Handwashing or Infection Control Inservice or Education since their Initial Orientation.

An Internal Medicine Physician who was granted Privileges in 1998, eighteen (18) years ago, and has not received any Annual Facility Handwashing or Infection Control Inservice or Education since their Initial Orientation.

A General Surgeon who was granted privileges in 1997, 19 years ago, and has not received any Annual Facility Handwashing or Infection Control Inservice or Training since their Initial Orientation.

During an interview with Staff M in the afternoon of 06/07/16, she also revealed that there are 152 "Voluntary" Physicians with Privileges at the facility who have not had any Annual Facility Handwashing or Infection Control Inservice or Education since their Initial Orientation.
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Based on observation, document review and interview, the facility failed to ensure that staff provided care in accordance with the acceptable standards of Infection Control Practices. This was evident in the observations of widespread breaches of Infection Control Practices including Isolation Precautions, use of Personal Protective Equipment (PPE), Handwashing, and Operating Room Procedures by Professional and Non-Professional staff members in various Units throughout the facility.

The pattern of ineffective Infection Control Precautions places all patients at risk for exposure to Infectious Diseases.

Findings:

Observations in the facility's 3 West Unit during a tour between 9:55AM and 12:30PM on 03/06/16 identified the following:

Patient #5 was on Contact Precautions for MDRO (Multi-Drug Resistant Organism) Gram Negative. The Contact Precaution Sign outside the patient's door documented "All Healthcare Personnel Must: Gown and glove for patient or environmental contact. Everyone must clean hands when entering and leaving room. Use patient dedicated or disposable equipment. Clean and disinfect shared equipment."

Staff A (Physician) was observed in the Isolation Room without a gown and gloves on examining the patient. Then Staff A exited the Isolation Room without disinfecting the stethoscope that laid around his neck and proceeded to the sink in the hallway to wash his hands. He performed hand hygiene less than the required fifteen to twenty (15-20) seconds.

During an interview with Staff A on 06/06/16 after he performed hand hygiene, the staff member stated "I examined the patient, auscultated her lungs," pointing to the stethoscope that was hung around his neck. He also stated "I was not aware the patient was on Isolation. I was in the room with a Nurse and she did not tell me." He stated that "I clean the stethoscope when the patient is on Isolation." He was not aware the stethoscope had to be disinfected between patient uses. He stated, this (requirement) must have just changed."

Staff A was instructed to disinfect the stethoscope and perform hand hygiene for the required time. Staff A disinfected the stethoscope and once again washed his hands for less than the required fifteen to twenty (15-20) seconds. Staff J (Director of Nursing Medical / Surgical Services) then instructed and insured that Staff A washed his hands the required time.

The facility's 2015 Mandatory Program on Safety, Quality and Infection Control and Prevention revealed that when performing hand hygiene "Use plenty of soap and apply with vigorous contact on all surfaces and between fingertips for 15 - 20 (fifteen to twenty) seconds."

Staff B (Resident) was observed examining Patient #5, on Contact Precautions, with his gown untied, exposing the Physician's clothes to the patient and environment.

During an interview with Staff J on 06/06/16 during the tour, the staff member confirmed the findings.

Staff C (Physical Therapist) was observed in Patient #5's Contact Precaution Room at the patient's bedside without appropriate PPE (Personnel Protective Equipment), gown and gloves.

During an interview with Staff C on 06/06/16, after she exited Patient #5's room, the staff member stated that "I did not need a gown and gloves (to enter the room). I ran in the room to answer the call bell."

During an interview with Staff K (Infection Prevention Quality Management) on 06/06/16 at 11:30AM, the staff member confirmed the finding and stated that "she (Physical Therapist) needed to wear a gown and gloves to enter the room to answer the call bell."

Patient #6 was on Contact Precautions for C. Difficile. The Contact Precaution Sign outside the patient's door documented "Everyone must: wash or use the alcohol based hand sanitizer when entering the patient's room. Wash hands with soap and water when leaving the room. Gown and glove at the door."

Staff D (Physician) was observed entering and exiting Patient #6's Contact Precaution Room without performing hand hygiene and donning and doffing the required PPE.

During an interview with Staff K on 06/06/16 after Staff D exited Patient #6's room, the staff member confirmed the finding and stated "I saw".

Observations in the facility's 1 East Unit during a tour between 1:00PM and 4:00PM on 06/06/16 identified the following:

Staff E (Podiatrist) was in Patient#1's room. This patient was diagnosed with Cellulitis of the Right Great Toe. Staff E was observed performing a dressing change on the patient's toe. Staff E removed the dressing from the patient's toe. Without removing his gloves, performing hand hygiene and donning gloves, the Podiatrist opened new supplies and placed a dressing on the toe.

During an interview with Staff K (Infection Prevention Quality Management) on 06/06/16 at the time of the observation, the staff member confirmed the finding.

Patient #12 was on Contact Precautions for MDRO (Multi-Drug Resistant Organism) Escherichia Coli. The Contact Precaution Sign outside the patient's door documented "All Healthcare Personnel Must: Gown and glove for patient or environmental contact. Everyone must clean hands when entering and leaving room. Use patient dedicated or disposable equipment. Clean and disinfect shared equipment."

Staff F (Transporter) and Staff G (Transporter) were observed in the Isolation Room with their gowns untied at the neck and waist. Their gowns were falling off and exposing their clothes as they had contact with the patient and environment.

Staff F, wearing his PPE, exited the Isolation Room and stood in the hallway. Next he returned to the Isolation Room, removed his PPE, and without performing hand hygiene exited the room.

Staff G removed his PPE and exited the Isolation Room without performing hand hygiene.

Staff Members F and G transported Patient #12, in his bed, to the Radiology Department.

Staff H (Radiology Technician) and Staff I (Student Radiology Technician) were wearing PPE. However, with their gowns untied, they assisted the patient from the bed to the x-ray table. Then Staff H removed his gloves, and without performing hand hygiene, donned gloves. Then, without removing his gown, he proceeded to the Computer Room, sat in the chair, and used the computer.

When the procedure was completed Staff Members H and I assisted the patient to the bed. When the patient was removed from the room, Staff Members H and I disinfected the room. Staff H and Staff I did not perform hand hygiene between gloves changes.

During an interview with Staff K (Infection Prevention Quality Management) on 06/06/16 at the time of the observations, the staff member confirmed the findings.

The facility' Policy and Procedure titled "Placing Patients on Precautions" last revised 11/12/15, stated the following: "Contact Precautions: "wear gloves when contact with the patient or environment is expected. Remove gloves before leaving the patient environment and perform hand hygiene. After hand hygiene hands should not touch potentially contaminated environmental surfaces or items in the patients' room. Wear a gown if close contact with the patient or environment is anticipated. If use of common equipment or items is unavailable than adequately clean and disinfect them before use for another patient. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Wash hands immediately after gloves are removed, between patient contacts and when otherwise indicated to avoid transfer of microorganisms to other patients or environments."

Observations in the facility's Surgical Unit during a tour between 9:00AM and 11:30PM on 06/07/16 identified the following:

Staff W (Orthopedic Surgeon) was observed performing a surgical hand scrub. Using the scrub brush he went back and forth between scrubbing his fingertips / hands to his upper arm. When he completed the procedure, with his scrub attire spotted with water from neck to waist, he entered the Operating Suite where he gowned and gloved for surgery.

During an interview with Staff X (Staff Educator Operating Room) on 06/09/16 at 1:15PM, the staff member stated that "What the Surgeon did, did not comply with Policy and Procedure. You start at the fingertips and work your way up. You should not go back and forth from fingertips to arm. He did not do it right. He probably did the three to five (3-5) minute scrub that he learned a long time ago. The only surgical scrub allowed to be performed here is the brush stroke count method. The Surgeon should have changed his (wet) scrubs."

The facility's Policy and Procedure titled "Surgical Hand Antisepsis" last revised 08/15/13 stated the following: "Members of the Surgical Team within the Operating Room ...... that will be donning a sterile gown and gloves should perform a surgical hand scrub. Permissible method for the first and subsequent scrub of the day, include a stroke count method....... Scrub attire should be changed if it becomes wet. Water on scrub attire may soak through and contaminate the sterile gown."

Staff P (Environmental Services) was observed disinfecting an Operating Room between patients. Without removing his gloves and performing hand hygiene he exited the room. He returned to the Operating Room with a bag of disinfecting wipes. Next he opened the bag of wipes and with his gloves having contact with the wipes, he placed them in a container.

During an interview with Staff P on 06/07/16 at the time of the observation, the staff member stated that "I should have changed my gloves before I left the room" and "I'm throwing the (disinfection) wipes out"

During an interview with Staff V (Nurse Manager of the Operating Room) on 06/07/16 at the time of the observation, the staff member confirmed the finding.

Observations in the facility's Operating Room (OR) Suite during a tour between 12:30-1:00PM on 06/07/16 identified the following:

In the semi-restricted hallway Staff O, Radiology Technician, was observed without his mustache covered.

In the semi-restricted hallway Staff P, Environmental Services, was observed without his goatee covered.

These observations were made in the presence of Staff V, Operating Room Nurse Manager, who confirmed that they should have their facial hair covered.

The facility' Policy and Procedure titled "Peri-Operative and Invasive Procedures with Implants: Surgical Attire, implemented 03/17/16, stated the following: "All hair should be covered, including beards and mustaches" in the Semi-Restricted Areas.

During observation of Staff Y (Nurse's Aide) at 2:55PM on 06/09/16, the staff member was observed emptying the urine in Patient #20's Foley into a container. Without removing her gloves, performing hand hygiene and donning gloves, she entered the patient's bathroom. She used the handle on the toilet to flush the urine down the toilet. Then she used the handles on the handwashing sink to turn the water on. She placed the container under the faucet and filled it with water. After using the handles on the handwashing sink to shut the water off she used the handle on the toilet to flush the water down the toilet. Then she removed her gloves and performed hand hygiene.

During observation of Staff Z (Registered Nurse ICU) at 3:10PM on 06/09/16, the staff member was observed emptying the urine in Patient #21's Foley into a container. Without removing her gloves, performing hand hygiene and donning gloves, with her gloved hands she moved a chair to the side, opened the door to the toilet and used the handle on the toilet to flush the urine down the toilet. Then she used the handles on the handwashing sink to turn the water on. She placed the container under the faucet and filled it with water. After using the handles on the handwashing sink to shut the water off she used the handle on the toilet to flush the water down the toilet. Then she removed her gloves and performed hand hygiene.

During interview of Staff AA (Vice President Infection Prevention) on 06/10/16 at 11:00AM the staff member acknowledged the breeches in Infection Control when the Nurse's Aide and Registered Nurse emptied the Foley bag.

During observation of Staff BB (Endoscope Technician) at 10:00AM on 06/10/16, the staff member was observed pre-cleaning an endoscope. During the pre-cleaning procedure Staff BB changed her gloves eight (8) times without performing hand hygiene. When she completed the procedure, she removed her gloves and without performing hand hygiene she used the door handle to open the door and exit the room with the endoscope. She entered another room were the Medivator machine (automatic reprocessing device) was present. She turned water valves and set the Medivator.

During an interview with Staff BB on 06/10/16 at the time of the observation, the staff member stated "I don't wash my hands, I can't get the gloves on"

During interview of Staff AA (Vice President Infection Prevention) on 06/10/16 at 10:00AM, the staff member confirmed the findings.

During observation of Staff CC (Registered Nurse) at 11:50AM on 06/09/16, the staff member did not disinfect the rubber septum of a single dose medication vial with alcohol prior to piercing.

During an interview with Staff J (Director of Nursing Medical / Surgical) on 06/10/16 at 10:00AM, the staff member acknowledged the finding.

The facility's Policy and Procedure titled "Medication Vial, Infusion, and Safe Injection Practice Guidelines" last revised 12/11/14 lacked guidance directing the Nursing Staff to disinfect the rubber septum of a single dose medication vial with alcohol prior to piercing.
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Based on observation and interview: a) in two (2) of three (3) staff observed, Nursing Services did not ensure that Emergency Department (ED) Staff were able to locate the defibrillator pads or access paddles for pediatric patients, and b) in two (2) of four (4) observations, Nursing Services did not ensure that Emergency Department (ED) Staff labeled patient Intravenous (IV) bags and tubing.

These failures place patients at risk for negative patient outcomes.

Findings pertinent to (a) above include:

During a tour of the ED at 10:12AM on 06/06/16, Staff R, a Registered Nurse, was observed unable to locate the pediatric defibrillator pads on the ED Code Cart when asked.

This was observed in the presence of Staff T, ED Medical Director, and Staff U, ED Nurse Manager.

During a tour of the ED at 10:18AM on 06/06/16, Staff S, a Registered Nurse, was observed unable to locate the pediatric defibrillator pads on the ED Code Cart when asked.

Staff S was also observed unable to remove the defibrillator paddles from the defibrillator, even though the release button was clearly marked.

This was observed in the presence of Staff T, ED Medical Director, and Staff U, ED Nurse Manager.

Per interview with Staff U at the time of the tour, all ED Nurses are Pediatric Advanced Life Saving and Trauma Certified.

This was confirmed with Staff T at the time of interview with Staff U.

Findings pertinent to (b) above include:

During a tour of the ED between 10:00AM and 11:00AM on 06/06/16, a patient in ED District 1, in Room 5 in Bed B, was observed with an IV bag of normal saline infusing without a patient label on the bag or the tubing.

This was acknowledged with Staff U at the time of the observation who confirmed the finding.

During a tour of the ED between 10:00AM and 11:00AM on 06/06/16, a patient in ED District 2, in Room 16 in Bed A, was observed with an IV bag of normal saline infusing without a patient label on the bag or the tubing.

This was acknowledged with Staff U at the time of the observation who confirmed the finding.

The facility's Policy and Procedure titled "IV Insertion (Peripheral) Adult", effective date 07/11/13, lacks instructions to label IV fluid bags and tubing to identify when they were initiated, but states IV tubing should be changed every ninety-six (96) hours.

Per interview with Staff U, ED Nurse Manager and Staff M, Assistant Executive Director of Quality Management, in the morning on 06/06/16, they acknowledged that it would be difficult for Nursing Staff to know when the IV bag and tubing was due to be changed without labels on them.