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Based on observation, interview, and policy review, the facility failed to provide a safe environment for patients on the medical/surgical unit. The facility failed to ensure:
-Staff performed hand hygiene after glove removal during medication administration for one patient (#6) of two patients observed during medication administration;
- Staff performed hand hygiene after glove removal during incontinent (uncontrolled body discharge) care for one patient (#6) of one patient observed during incontinent care.
-Staff disinfected multi-use topical medications prior to placing in medication storage area used to store all patient medication on the medical/surgical unit for one patient (#7) of one observed with multi-use topical medication. Failure to follow infection control policies places all patients and staff at risk for infection. The facility census was nine.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene" dated 01/13, showed direction for facility staff to routinely decontaminate (cleanse) their hands with antimicrobial soap or alcohol-based gel in view of the patient when at all possible in the following circumstances:

INDICATIONS FOR HANDWASHING:
-After contact with all blood, body fluids, and secretions;
-After contact with any item/object that is likely to be contaminated with blood or body fluids;
-After taking care of an infected patient or one who is likely to be colonized (presence of a germ in or on you without disease);
-In between contact with patients;
-Immediately after removal of gloves.

INDICATIONS FOR ALCOHOL-BASED HAND RUB:
-In accordance with the CDC (Centers for Disease Control) guidelines, personnel may routinely decontaminate their hands with an alcohol-based hand rub instead of soap and water with the following exceptions:
-With potential exposure to spore forming organisms such as Clostridium Difficile (C-diff, an organism found in the colon, that can cause diarrhea, usually associated with antibiotic use).

2. Record review of the Centers for Disease Control and Prevention Guidelines titled, "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings" showed:
- Indirect contact transmission involves the transfer of an infectious agent through a contaminated intermediate object or person. In the absence of a point-source outbreak, it is difficult to determine how indirect transmission occurs. However, extensive evidence cited in the Guideline for Hand Hygiene in Health-Care Settings suggests that the contaminated hands of healthcare personnel are important contributors to indirect contact transmission. Examples of opportunities for indirect contact transmission include:
- Hands of healthcare personnel may transmit pathogens after touching an infected or colonized (inactive infection) body site on one patient or a contaminated inanimate object, if hand hygiene is not performed before touching another patient.
- Patient-care devices (e.g., electronic thermometers, glucose monitoring devices) may transmit pathogens if devices contaminated with blood or body fluids are shared between patients without cleaning and disinfecting between patients.
- Clothing, uniforms, laboratory coats, or isolation gowns used as personal protective equipment (PPE, isolation gowns, gloves and/or masks) may become contaminated with potential pathogens after care of a patient colonized or infected with an infectious agent, (such as Methicillin Resistant Staphylococcus Aureus, MRSA, a type of staph bacteria that is resistant to certain antibiotics (drugs used to treat bacteria).

3. Record review of Patient #6's medical record, showed patient had a positive culture for C-diff and isolation precautions of gowning and gloving were in place. Patient #6 was having frequent incontinent bowel movements.

4. Observation on 01/29/13 at 8:30 AM showed Staff F, Registered Nurse (RN) staff nurse administering oral (by mouth) and injectable (with a syringe and needle) medication to Patient #6. Staff F changed gloves after administering oral medication and again after administering injectable medication. Staff F failed to wash her hands after glove removal and re-application of gloves.

During an interview on 01/29/13 at 3:20 PM, Staff F stated that she should have washed her hands after removing her contaminated (soiled) gloves and putting on clean gloves.

5. Observation on 01/29/13 at 10:30 AM showed Staff O, RN, performing incontinent care (washing stool off patient) for Patient #6. Staff O washed stool off patient's buttocks. Staff O removed gloves containing stool and reapplied gloves. Staff O failed to wash her hands.

During an interview on 01/29/13 at 3:30 PM, Staff O stated that she should have washed her hands after removing her contaminated gloves and putting on a pair of clean gloves.

6. During an interview on 01/29/13 at 3:30 PM, Staff N, Infection Control Coordinator stated that the expectation is for staff to wash hands with soap and water when caring for patients with C-diff infection. Staff N also stated that staff is expected to wash their hands between glove changes.

7. Observation on 01/29/13 at 10:00 AM showed Staff F, RN administered topical multi-use medication to Patient #7's abdomen (stomach) and buttocks. Staff F placed multi-use medication bottles on bed of Patient #7. Staff F returned multi-use medication bottles to bin in medication room used for all patients on the medical/surgical unit. Staff F failed to disinfect (clean) multi-use medication bottles with disinfection wipe after leaving patient room prior to placing in unit medication room.

During an interview on 01/29/13 at 10:15 AM Staff F stated that she should have wiped off the medication bottles with bleach wipes prior to return to the medication room, because the bottles had touched the patient's bedding.

Based on interview and record review, the facility failed to establish a policy for the implementation of patient seclusion in its Senior Psychiatric Unit (SPU). This failure had the potential to negatively affect the safety of two (#2 and #3) of two patients who were placed in seclusion on the SPU and had the potential to affect all patients admitted to the facility. The SPU census was eight and the total facility census was nine.

Findings included:

1. Review of the SPU policy, "Seclusion Room" dated 06/12, showed this direction:
"Policy: The seclusion room is used for safety measures only when less restrictive measures have failed, not as a disciplinary measure. Use of seclusion denies a patient's rights and thus must be used carefully. Adverse effects from seclusion may include feeling assaulted and imprisoned from the experience.
"Procedure": Refer to the Hospital Administrative Manual and/or Safety Manual for further details on Restraint and Seclusion Policy."
No other policy on seclusion was provided by the facility.

2. Review of the Nursing - House Wide policy, "Restraint Use (All Ages)" reviewed and approved 01/12, showed no mention of the use of seclusion.

3. During an interview on 01/29/13 at 9:30 AM, Staff C, Director of Risk Management and Quality, stated that the Restraint Use policy did not include seclusion implementation because the facility did not use seclusion until the designated seclusion room was included in the SPU that opened in July 2012.

4. Review of the facility's Restraint Log showed that Patient #2 was placed in seclusion on 12/21/12 during his SPU admission of 12/14/12 to 12/21/12 and that Patient #3 was placed in seclusion on 01/01/13 during her SPU admission of 12/18/12 to 01/3/13.

5. During an interview on 01/30/13 at 9:45 AM, Staff P, SPU Manager, stated that Patient #2 and Patient #3 were placed in seclusion in the SPU seclusion room.

Based on interviews, facility record reviews, review of the Missouri State Hospital Regulations and the accepted standards of nursing care and scope of practice as defined by the Missouri State Board of Nursing Practice Act, the facility failed to ensure that medications were prepared and administered by qualified personnel according to scope and authority per state law for five (#1, #8, #10, #11, and #12) of five current patients on the geriatric psychiatric unit (the Unit). The facility census was nine.

Findings included:

1. Record review of the facility's policy titled, "Certified Nursing Assistant (CNA) Job Description", policy #05.06.13 dated 06/12, showed the following direction:
Summary of Major Functions:
-Performs duties under the supervision of the Clinical Nurse Manager, Charge Nurse or Staff Nurse;
-Performs various duties assisting nursing or clinical staff in the treatment and care of Geriatric-Psychiatric Unit patients.
Qualifications:
-Graduate from a state accredited certification program for nursing aides;
-Certified as a nursing aide in the State;
-Satisfactorily completed the facility competencies and competencies checklist.
Responsibilities of Patient Care- Under the direction of the Charge Nurse:
-Participates in planning and implementing daily activities for patients;
-Monitors the patients' attendance in program activities, interactions, and safety;
-Interacts therapeutically with patients and reports relevant patient information to the Registered Nurse (RN) for evaluation, intervention and documentation.
The policy/job description for the CNA does not include any activity related to the preparation and administration of medication.

2. Record review of the facility's policy titled, "Medication Administration" dated, reviewed and approved by the Chief Nursing Officer (CNO) on 01/12, showed medication may be administered to patients by members of the medical staff to whom appropriate privileges have been granted and patient care staff who have completed appropriate medication administration orientation and competency validation.

3. Review of the Missouri State Board of Nursing, Nursing Practice Act and Rules Statute 335.016.15 (c) definitions showed;
Professional Nursing, the performance for compensation of any act which requires substantial specialized education, judgment and skill based on knowledge and application of principles derived from the biological, physical, social and nursing sciences, including, but not limited to:
(a) Responsibility for the teaching of health care and the prevention of illness to the patient and his or her family;
(b) Assessment, nursing diagnosis, nursing care, and counsel of persons who are ill, injured or experiencing alterations in normal health processes;
(c) The administration of medication and treatments as prescribed by a person licensed by a state regulatory board to prescribe medications and treatments;
(d) The coordination and assistance in the delivery of a plan of health care with all members of a health team;
(e) The teaching and supervision of other persons in the performance of any of the foregoing.

4. Record review of the facility's Medical Staff Bylaws on 01/30/13 showed no content delegating the authority for the administration of medications to patients in the facility.

5. During an interview on 01/30/13 at 9:00 AM, Staff V, Medical Staff Coordinator confirmed that the Medical Staff Bylaws and/or Medical Staff Rules and Regulations did not contain information which provided authority, guidance, or approval of personnel who are authorized to administer medications in the facility.

6. During an interview on 01/29/13 at 10:30 AM, Staff M, Staff Nurse, in the Geriatric Psychiatry Unit, stated that Staff Q is a medication technician and that she gives medications including IM's (intramuscular injections/shots).

7. During an interview on 01/29/13 at 10:30 AM, Staff D, RN Charge Nurse, stated that Staff Q is a medication technician and that she administers medications to patients in the Unit.

8. During an interview on 01/29/13 at 4:30 PM, Staff B, RN Chief Nursing Officer (CNO) stated:
-Staff Q is a medication technician and holds the same position as a CNA
-Staff Q is the only CNA that passes medication
-Human Resources (HR) department made the determination authorizing Staff Q to administer medication in a hospital setting.
Staff B stated "I did not question HR's determination".

9. During an interview on 01/30/13 at 9:00 AM, Staff P, RN Geriatric Psychiatry Unit Director, stated that Staff Q is a Medication Tech and prepares and administers medications to patients. Staff P stated that the facility HR department informed her that Staff Q was qualified to administer medication in the facility and she didn't question the decision and determination.

10. Review of Patient #1's medication administration record dated 01/28/13 through 01/30/13 showed Staff Q, a medication technician, prepared and administered a total of sixteen doses of oral medications to Patient #1.

11. Review of Patient #8's medication administration record dated 01/28/13 through 01/30/13 showed Staff Q, prepared and administered a total of eleven doses of oral medications and two doses of topical medications to Patient #8.

12. Review of Patient #10's medication administration record dated 01/28/13 through 01/30/13 showed Staff Q, prepared and administer a total of sixteen doses of oral medication to Patient #10.

13. Review of Patient #11's medication administration record dated 01/28/13 through 01/30/13 showed Staff Q, prepared and administered a total of eleven doses of oral medications to Patient #11.

14. Review of Patient #12's medication administration record dated 01/28/13 through 01/30/13 showed Staff Q, prepared and administer a total of ten doses of oral medications and six doses of medication drops applied into the eyes of Patient #12.

15. Review of Staff Q's personnel record on 01/28/13 showed:
-Job classification of full-time CNA with no licensure or credentials to prepare or administer medications in the facility;
-No evidence of medical or nursing licensure, education, experience and/or authority to prepare and administer medications to Patients #1, #8, #10, #11, and #12;
-A signed letter from an individual representing verification by the Missouri State Department of Mental Health (DMH) Division of Developmental Disabilities (DD) Unit Consumer Health and Wellness, that verified that Staff Q was issued a certificate on 10/19/2011 as a Level 1 DD Medication Aide and was on the Developmental Disabilities Medication Aide Registry.