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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to provide Medicare patients with a second notice regarding their right to appeal being discharged as required by federal regulations for 4 of 5 patients reviewed (Patients #1, #2, #3, #4).

This limits a patient's ability to contest their discharge and appeal to a Quality Improvement Organization for review of their case.

Reference: 42 CFR 405.1205 - Notifying beneficiaries of hospital discharge appeal rights.
(c) Follow up notification.
(1) The hospital must present a copy of the signed notice described in paragraph (b)(2) of this section to the beneficiary (or beneficiary's representative) prior to discharge. The notice should be given as far in advance of discharge as possible, but not more than 2 calendar days before discharge

Findings:

1. The hospital's policy and procedure entitled "Patient Access: Delivery of the Important Message from Medicare (Inform Patients of Their Right to Appeal Discharge)" (Effective date: 5/2014) under "Procedures" read in part as follows: "Second Notification. Second notification of the IM [Important Message] is provided by Case Management staff. As soon as discharge is known, but not to exceed two days, the patient or representative is provided a second notification of discharge appeal rights per the IM... 5. Documentation of the patient's receipt of the second notification is completed by the case management staff member in the medical record in the IP Case Management Doc Flow Sheet under Discharge Information."

2. Review of the records of five Medicare patients on who had been hospitalized between 10/8/2014 and 10/20/2014 revealed the following:

a. Review of the records of Patient #1 revealed that s/he had been admitted to the hospital on 10/8/2014 and discharged on 10/15/2014. The "Important Message From Medicare" information form had been signed by the patient on admission on 10/8/2014. There was no documentation in the patient's record that the patient had received second notification of their discharge rights within two days of discharge.

b. Similar findings were found in the records of Patients #2, #3, #4.

3. During an interview with Surveyor #5 on 10/23/2012 at 11:30 AM, the Administrative Director of Case Management (Staff Member #1) and the RN Case Manager Coordinator (Staff Member #2) confirmed the findings above.
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Based on observation, the facility failed to maintain the patient environment in such a manner as to provide a safe patient environment.

Failure to provide a safe patient care environment puts patients at risk for harm.

Findings:

1. On 10/21/2014 at 2:40 PM, Surveyor #4 noted that an electric stove in the psychiatric unit was able to be energized although staff had removed its knobs in an attempt to make turning on the stove more difficult.

2. On 10/21/2014 at 2:45 PM, Surveyor #4 noted that a bottle of Aloe Vesta Cleansing Foam had been left in the patient bath/restroom (located adjacent to the day room) where it could be ingested by patients.
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Based on observation and review of hospital policies and procedures, the hospital failed to ensure all hospital staff members followed its procedure for identification of patients prior to medication administration for 1 of 4 patients observed (Patient #9).

Failure to follow the hospital's patient identification policy places patients at risk for medication errors.

Findings:

1. The hospital's policy and procedures entitled "Verification: Identification and Verification of Patients" (Reviewed 12/31/2013) read in part as follows: "3. Verify the patient's identification prior to any specimen collection, point-of-care testing, medication administration . . . The identity of the patient is verified using two different identifiers (neither of them can be the patient's room) against two sources of information. a. Acceptable identifiers are: Patient's name; Date of birth; or an assigned identification number (medical record number or contact serial number)."

2. On 10/22/2014 at 11:10 AM in the intensive care unit, Surveyor #6 observed a respiratory therapist (Staff Member #8) perform a respiratory therapy treatment for Patient #9 using a nebulizer with the medication budesonide (a steroid). The respiratory therapist did not identify the patient using two identifiers nor check the patient's armband prior to administration of the medication.
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Based on record review and review of hospital policies and procedures, the hospital failed to ensure hospital staff members performed a "safety check" according to hospital policy before infusing a unit of red blood cells, as demonstrated by 1 of 2 patient records reviewed (Patient #7).

Failure to systematically identify the patient and the unit of blood before a blood transfusion can result in the patient experiencing a hemolytic transfusion reaction by infusing the wrong blood type or a miss-matched unit.

Findings:

1. The hospital's policy and procedure entitled, "Blood and Blood Component Administration: Adult" (Effective date: April 2014) read in part as follows: "Pre-Transfusion: Patient Preparation. Steps 1 through 12 are completed prior to retrieving the blood from the SMC Transfusion Service Lab ... 1. Verify order to transfuse. 2. Verify identification of the patient. Accurate identification consists of using two patient identifiers: (1) the patient's full name and (2) the patient's MRN. 3. Verify informed consent is completed ... Documentation... 3. Document on the Blood Transfusion Record under Doc Flowsheets in the EMR... The pre-transfusion safety checks with each unit of blood component ... " "

2. On 10/23/2014, Surveyor #3 reviewed the medical records of two patients who had received blood transfusion within the last 30 days. A review of Patient #7's record revealed the patient received two units of red blood cells on 10/11/2014. There was no documentation in the patient's medical record that a "safety check" had been performed prior to administration of the second unit of blood.
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Based on observation, interview, record review, and review of hospital policies and procedures, the hospital failed to ensure patient care staff members followed infection prevention procedures and provided a sanitary healthcare environment to minimize the risk of transmission of infections and communicable diseases.

Failure to do so places patients at risk for harm from infectious disease, including extended hospital stays, increased healthcare costs, and death.

Item #1 - Hand Hygiene

Findings:

1. The hospital's policy and procedure entitled "Hand Hygiene: Handwashing and Hand Antisepsis" (Effective 4/2/12) read in part as follows: "1. Hand Hygiene is mandatory for the following: a. Before and after patient contact... d. After removing gloves... After contact with objects and surfaces in the patient area." and "4. Hand antisepsis using alcohol gel hand rub: ...c. Rub hands together covering all surfaces of hands and fingers until hands are dry."

2. On 10/21/2014 through 10/23/2014, hospital surveyors observed the following:

a. On 10/21/2014 at 2:00 PM Surveyor #1 observed preparation and performance of a bone marrow biopsy procedure in Interventional Radiology. The physician (Staff Member #14) entered the room after sanitizing his/her hands by flapping them to dry them, rather than rubbing till dry as directed by hospital policy.

b. On 10/21/2014 at 2:50 PM in the intensive care unit, Surveyor #6 observed a registered nurse (Staff Member #10) providing care to Patient #10, who was under contact enteric precautions for a bacterial infection. The nurse repositioned the patient, touched a bed rail an ultrasound machine, and then removed his/her gloves. The nurse, with unprotected bare hands, continued to touch items (bedside table and ultrasound machine) within the patient's room for a period of greater than five minutes before washing his/her hands and donning new gloves.

c. On 10/22/2014 at 9:00 AM in the intensive care unit, Surveyor #6 observed a registered nurse (Staff Member #11) provide care to Patient #11 who was in contact enteric isolation precautions. The nurse administered an intravenous medication and repositioned the patient. S/he then touched his/her nose and forehead with contaminated gloved hands before performing hand hygiene and changing gloves.

d. On 10/22/2014 at 11:15 AM while observing a surgical procedure, Surveyor #1 observed a registered nurse (Staff Member #16) use hand sanitizer. The nurse rubbed his/her hands for only a few seconds, then waved them in the air to dry them, contrary to hospial policy and procedure for hand hygiene.

Following the procedure, the surgeon (Staff Member #17) lifted the contaminated lid of the trash can hamper with his/her hand rather than using the foot pedal and did not perform hand hygiene prior to returning to patient care.

e. On 10/22/2014 at 2:00 PM in the Wound Clinic, Surveyor #1 observed a dressing change. A registered nurse (Staff Member #18) used hand sanitizer, rubbed his/her hands for a few seconds, then waved them to dry them, contrary to hospital policy and procedure. S/he later removed gloves without performing hand hygiene, and retrieved patient care supplies from a cabinet, potentially contaminating the clean patient care items.

f. On 10/22/2014, at 10:30 AM, Surveyor #4 observed a member of the kitchen staff (Staff Member #23) place food on a service cart in preparation for setting up the self-service line in the cafeteria. While performing this task the staff member wiped his/her face with a gloved hand. Upon intervention the staff member performed required hand hygiene.

(Reference: Section 02310 Hands and arms - When to wash (2009 FDA Food Code 2-301.14)


Item #2 - Personal Protective Equipment

Findings:

1. The hospital's policy and procedure entitled "Room Turnover/Between Case Cleaning: Perioperative and Interventional services" (Effective 6/2014) read in part as follows: "Personal protective equipment (includes but is not limited to): Gloves, Surgical mask, Protective Eyewear."

On 10/21/2014 at 10:30 AM, Surveyor #2 observed a surgical aide (Staff Member #21) perform a between-case cleaning in operating room #3. The staff member failed to wear eyewear or a surgical mask during the procedure.

2. The hospital's policy and procedure entitled "Contact Enteric Precautions" (Effective 1/2013) read in part as follows: "12. While in a room: a. Go from "clean" to "dirty" activities... d. if gown becomes soiled, remove gown and gloves, perform hand hygiene and put on new gown and new pair of gloves... f. Ensure your gown is fully wrapped around you."

On 10/21/2014 at 11:00 AM in the emergency department, Surveyor #6 observed a housekeeper (Staff Member #9) enter Patient #10's room, where a "contact isolation and droplet precautions" placard had been posted. The housekeeper's personal protection equipment was not tied at the waist. The housekeeper's clothing was subject to possible contamination by items in the patient's room.

On 10/21/2014 at 2:50 PM in the intensive care unit, Surveyor #6 observed a registered nurse (Staff Member #10) in Patient #10's room, posted for droplet and contact enteric isolation precautions for a bacterial infection. The nurse removed his/her gown and gloves, then touched an ultrasound machine and bedside table before performing hand hygiene and donning gown and gloves. The nurse's uniform was subject to possible contamination by items in the patient's room.


Item #3 - Surgical Attire and Masks

Findings:

1. The hospital's policy and procedure entitled "Attire for Restricted and Semi-Restricted Procedure Areas" (Approved May 2012) read in part as follows: "Body Cover. All visitors and ancillary personnel entering the restricted or semi-restricted area don hospital laundered scrubs ... "Masks. Masks cover the mouth and nose and must be secured in a manner to prevent venting. Both strings of the mask must be tied ..."

2. On 10/21/2014 at 1:37 PM, Surveyor #3 observed Patient #8 during an obstetrical and gynecological surgical procedure in the obstetrical operating room. After the sterile instruments were opened, an anesthesia provider (Staff Member #3) was observed wearing a surgical mask. The mask was tied at the top and the bottom ties were untied and hanging down, leaving the mask unsecure.

After the delivery, a respiratory technician (Staff Member #7) entered the OR wearing a disposable paper jumpsuit. The jumpsuit was ripped in the lower pant leg. The technician received a page and opened his/her jumpsuit to retrieve the pager. The jumpsuit was opened exposing the street attire underneath. The technician proceeded to provide care to a new born infant.

3. During an interview with Surveyor #3 on 10/21/2014 at 3:00 PM, the mother-baby unit manager (Staff Member #5) and director (Staff Member #6) confirmed that these actions risked transmission of infectious disease.


Item #4 - Sterilization Procedures

Findings:

On 10/21/2014 at 11:15 AM, Surveyor #2 reviewed documentation of the results of biologic indicator tests performed on the hospital sterilizers. The surveyor observed the following discrepancies in document #8043 "Steam Biologic Record": On 10/20/2014 sterile processing staff members recorded elapsed times of less than one hour for the incubation time to results for biologic indicator tests. At the time of the observation, Surveyor #2 interviewed the Sterile Processing Manager (Staff Member #24) about the required incubation period for the department's biologic indicator tests. S/he indicated that the hospital used biologic indicators with a one-hour incubation time.

Item #5 - Cross Contamination

Findings:

1. On 10/21/2014 at 11:00 AM, Surveyor #1 observed a registered nurse (Staff Member #12) remove a portable computer from a patient room without sanitizing it. The nurse had moved between the computer and the patient and patient areas without performing hand hygiene, thus contaminating it. The Unit Manager (Staff Member #13) confirmed that it was policy to sanitize computers when removing them from patient rooms.

2. On 10/21/2014 at 2:15 PM Surveyor #3 observed the following during a surgical procedure in the obstetrical operation room: An overhead burned out light bulb was taken out and changed directly over the back sterile table, after the initial incision was made. The table contained sterile instruments.

An interview on 10/21/2014 at 3:00 PM with the mother-baby unit manager (Staff Member #5) and director (Staff Member #6) confirmed changing a light bulb during surgery was an infection transmission risk.

3. On 10/22/2014 at 3:40 PM Surveyor #2 observed a surgical aide (Staff Member #20) perform a terminal cleaning in OR #2. During the observation, Staff Member #20 made multiple trips to a cabinet to retrieve clean wiping cloths without removing his/her contaminated gloved and performing hand hygiene. This contaminated the clean items in the cabinet.

4. On 10/23/2014 at 12:10 PM, Surveyor #2 observed a member of the Environmental Services Staff (Staff Member #22) perform a "discharge cleaning" of a patient room. During the process the surveyor observed the following:

a. The surveyor observed Staff Member #22 clean a patient walker located in the room. During the cleaning process Staff Member #22 wiped down the walker from top to bottom, allowing the cloth to contact the floor; Staff Member #22 then wiped back up to the top of the walker with the contaminated cloth.

b. The surveyor observed Staff Member #22 put his/her hands on the floor while cleaning the casters on the patient bed and then touch clean parts of the bed with contaminated hands.

5. On 10/21/2014, at 10:00 AM, Surveyor #4 noted that medical supplies were located under sewer waste lines in the "Stores" area of the facility. The sewer waste lines were not fitted with drip pans to avert any leaks and/or condensation that might emanate from them, which risked contaminated of the clean supplies.

6. On 10/21/2014, at 3:47 PM, Surveyor #4 noted that a breast pump located in the clean storage room of the Childbirth Center was not tagged as being cleaned and ready for use as were other pieces of equipment being stored there. After the surveyor asked about the status of the breast pump (Was it clean or dirty?) it was removed from the clean storage room and taken to the dirty storage area for processing as no one was certain of its status.


Item #6 - Food Services

Findings:

1. On 10/21/2014, at 4:08 PM, Surveyor #4 noted that a refrigerator in the nourishment room of the Childbirth Center was outfitted with an alarm type thermometer. The temperature reading given by the thermometer at the time of the finding was 51.5 degrees Fahrenheit (F.). It was also noted by the surveyor that the alarm high - low settings were at -58 degrees F. and 158 degrees F. respectively. A log sheet posted on the refrigerator door indicated that the expected temperature range of the refrigerator was to be between 30 and 40 degrees F.

(Reference: Section 03525 Temperature and time control - Potentially hazardous food, hot and cold holding (2009 FDA Food Code 3-501.16)

2. On 10/22/2014, at 10:25 AM, Surveyor #4 used a thin stem digital thermometer to take the temperatures of both sliced tomatoes and cubed ham at the cook's line. Temperatures were recorded as being 44.5 degrees F. and 43.4 degrees F. for the respective items.

(Reference: Section 03525 Temperature and time control - Potentially hazardous food, hot and cold holding (2009 FDA Food Code 3-501.16)


3. On 10/22/2014, at 10:30 AM, Surveyor #4 noted that squeeze bottles containing liquids (e.g. oil and water) were located at the cook's line. These bottles were not labeled.

(Reference: Section 03309 Preventing food and ingredient contamination - Food storage containers, identified with common name of food (2009 FDA Food Code 3-302.12)

4. On 10/22/2014, at 11:00 AM, Surveyor #4 used a thin stem digital thermometer to take the temperatures of lettuce, a chicken Vietnamese sandwich and a spring roll that were in the cafeteria self-service line bedded in ice. Temperatures were recorded as being 54.4 degrees F. for the lettuce, 65 degrees F. for the chicken Vietnamese sandwich and 43.4 degrees F. for spring roll.

(Reference: Section 03525 Temperature and time control - Potentially hazardous food, hot and cold holding (2009 FDA Food Code 3-501.16)
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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that all patients were screened by a case manager for discharge planning needs as directed by hospital policy for 3 of 10 patients reviewed (Patients #1, #2, #5)

Failure to perform an initial assessment of the patient's needs on discharge risks discharging the patient to an inadequate and harmful living environment, which can result in hospital readmissions.

Findings:

1. The hospital's policy and procedure entitled "Case Management Assessment and Discharge/Transition Planning" (Revised 7/2013) read in part as follows: "Policy: ...Within 48 hours of admission, Case Management (CM) will screen all inpatients to determine which patients are at risk for adverse health consequences post-discharge if they lack discharge planning..."

2. On 10/22/2014 and 10/23/2014, Surveyor #5 reviewed the medical records of five patients who had been admitted and discharged from the hospital during October 2014. This review revealed that 3 of 10 records did not include evidence that a case manager had screened the patients to determine if the patient needed a discharge plan.
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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to reassess and update the patient's discharge plan as directed by hospital policy for 1 of 10 patients reviewed (Patient #6)

Failure to reassess the patient's discharge needs when the patient's health condition deteriorates risks discharging the patient to an inadequate and harmful living environment, which can result in hospital readmissions.

Findings:

1. The hospital's policy and procedure entitled "Case Management Assessment and Discharge/Transition Planning" (Revised 7/2013) read in part as follows:

"Procedure: ... 7. CM [Case Management] will reassess the patients as needed, noting any updates or significant changes to the initial discharge plan based on patient status changes and/or family involvement."

2. Review of the medical records of Patient #6 revealed the following:

Patient #6 was a 71 year-old male who had been admitted on 9/29/2014 for treatment of chronic respiratory failure. The patient's condition deteriorated and required intubation for mechanical ventilation on 10/20/2014. A physician's critical care progress note and ethics consultation dated 10/21/2014 indicated the patient could not make health care decisions and had no durable medical power of attorney. The ethics consult included a recommendation that read as follows: "Social work should speak with the son and document the efforts to find any other family members."

Review of the patient's record on 10/22/2014 revealed that a case manager had completed a discharge planning evaluation on 10/3/2014 with an update on 10/7/2014 indicating that preparations were underway to transfer the patient to a skilled nursing facility. There was no evidence that the the patient's discharge needs had been reassessed when the patient's condition deteriorated. There was no evidence that a case manager had communicated with the patient's son and tried to reach other members of the patient's family.
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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that anesthesia providers performed and documented a surgical post-anesthesia evaluation according to hospital policy for 2 of 6 patients reviewed (Patients #12, #13).

Failure to do so results in an incomplete record of care and risks unmet post-operative patient needs.

Findings:

1. The hospital's policy and procedure entitled "Anesthesia Services Policy" (Effective 12/2010) read in part as follows: "The post-anesthesia evaluation should be clearly documented and shall at a minimum document: e. pain... f. nausea and vomiting..."

2. On 10/23/2014, Surveyor #1 reviewed the medical records of patients who had surgical procedures with general anesthesia during the month of October 2014. The post-anesthesia evaluation in the records of Patients #12 and #13 did not include the patient's status in terms of pain, and nausea and vomiting Staff Member #19, a hospital computer applications analyst, confirmed this finding at the time of the review.
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Based on observation, interview, record review, and review of hospital policies and procedures, the hospital failed to ensure patient care staff members followed infection prevention procedures and provided a sanitary healthcare environment to minimize the risk of transmission of infections and communicable diseases.

Failure to do so places patients at risk for harm from infectious disease, including extended hospital stays, increased healthcare costs, and death.

Item #1 - Hand Hygiene

Findings:

1. The hospital's policy and procedure entitled "Hand Hygiene: Handwashing and Hand Antisepsis" (Effective 4/2/12) read in part as follows: "1. Hand Hygiene is mandatory for the following: a. Before and after patient contact... d. After removing gloves... After contact with objects and surfaces in the patient area." and "4. Hand antisepsis using alcohol gel hand rub: ...c. Rub hands together covering all surfaces of hands and fingers until hands are dry."

2. On 10/21/2014 through 10/23/2014, hospital surveyors observed the following:

a. On 10/21/2014 at 2:00 PM Surveyor #1 observed preparation and performance of a bone marrow biopsy procedure in Interventional Radiology. The physician (Staff Member #14) entered the room after sanitizing his/her hands by flapping them to dry them, rather than rubbing till dry as directed by hospital policy.

b. On 10/21/2014 at 2:50 PM in the intensive care unit, Surveyor #6 observed a registered nurse (Staff Member #10) providing care to Patient #10, who was under contact enteric precautions for a bacterial infection. The nurse repositioned the patient, touched a bed rail an ultrasound machine, and then removed his/her gloves. The nurse, with unprotected bare hands, continued to touch items (bedside table and ultrasound machine) within the patient's room for a period of greater than five minutes before washing his/her hands and donning new gloves.

c. On 10/22/2014 at 9:00 AM in the intensive care unit, Surveyor #6 observed a registered nurse (Staff Member #11) provide care to Patient #11 who was in contact enteric isolation precautions. The nurse administered an intravenous medication and repositioned the patient. S/he then touched his/her nose and forehead with contaminated gloved hands before performing hand hygiene and changing gloves.

d. On 10/22/2014 at 11:15 AM while observing a surgical procedure, Surveyor #1 observed a registered nurse (Staff Member #16) use hand sanitizer. The nurse rubbed his/her hands for only a few seconds, then waved them in the air to dry them, contrary to hospial policy and procedure for hand hygiene.

Following the procedure, the surgeon (Staff Member #17) lifted the contaminated lid of the trash can hamper with his/her hand rather than using the foot pedal and did not perform hand hygiene prior to returning to patient care.

e. On 10/22/2014 at 2:00 PM in the Wound Clinic, Surveyor #1 observed a dressing change. A registered nurse (Staff Member #18) used hand sanitizer, rubbed his/her hands for a few seconds, then waved them to dry them, contrary to hospital policy and procedure. S/he later removed gloves without performing hand hygiene, and retrieved patient care supplies from a cabinet, potentially contaminating the clean patient care items.

f. On 10/22/2014, at 10:30 AM, Surveyor #4 observed a member of the kitchen staff (Staff Member #23) place food on a service cart in preparation for setting up the self-service line in the cafeteria. While performing this task the staff member wiped his/her face with a gloved hand. Upon intervention the staff member performed required hand hygiene.

(Reference: Section 02310 Hands and arms - When to wash (2009 FDA Food Code 2-301.14)


Item #2 - Personal Protective Equipment

Findings:

1. The hospital's policy and procedure entitled "Room Turnover/Between Case Cleaning: Perioperative and Interventional services" (Effective 6/2014) read in part as follows: "Personal protective equipment (includes but is not limited to): Gloves, Surgical mask, Protective Eyewear."

On 10/21/2014 at 10:30 AM, Surveyor #2 observed a surgical aide (Staff Member #21) perform a between-case cleaning in operating room #3. The staff member failed to wear eyewear or a surgical mask during the procedure.

2. The hospital's policy and procedure entitled "Contact Enteric Precautions" (Effective 1/2013) read in part as follows: "12. While in a room: a. Go from "clean" to "dirty" activities... d. if gown becomes soiled, remove gown and gloves, perform hand hygiene and put on new gown and new pair of gloves... f. Ensure your gown is fully wrapped around you."

On 10/21/2014 at 11:00 AM in the emergency department, Surveyor #6 observed a housekeeper (Staff Member #9) enter Patient #10's room, where a "contact isolation and droplet precautions" placard had been posted. The housekeeper's personal protection equipment was not tied at the waist. The housekeeper's clothing was subject to possible contamination by items in the patient's room.

On 10/21/2014 at 2:50 PM in the intensive care unit, Surveyor #6 observed a registered nurse (Staff Member #10) in Patient #10's room, posted for droplet and contact enteric isolation precautions for a bacterial infection. The nurse removed his/her gown and gloves, then touched an ultrasound machine and bedside table before performing hand hygiene and donning gown and gloves. The nurse's uniform was subject to possible contamination by items in the patient's room.


Item #3 - Surgical Attire and Masks

Findings:

1. The hospital's policy and procedure entitled "Attire for Restricted and Semi-Restricted Procedure Areas" (Approved May 2012) read in part as follows: "Body Cover. All visitors and ancillary personnel entering the restricted or semi-restricted area don hospital laundered scrubs ... "Masks. Masks cover the mouth and nose and must be secured in a manner to prevent venting. Both strings of the mask must be tied ..."

2. On 10/21/2014 at 1:37 PM, Surveyor #3 observed Patient #8 during an obstetrical and gynecological surgical procedure in the obstetrical operating room. After the sterile instruments were opened, an anesthesia provider (Staff Member #3) was observed wearing a surgical mask. The mask was tied at the top and the bottom ties were untied and hanging down, leaving the mask unsecure.

After the delivery, a respiratory technician (Staff Member #7) entered the OR wearing a disposable paper jumpsuit. The jumpsuit was ripped in the lower pant leg. The technician received a page and opened his/her jumpsuit to retrieve the pager. The jumpsuit was opened exposing the street attire underneath. The technician proceeded to provide care to a new born infant.

3. During an interview with Surveyor #3 on 10/21/2014 at 3:00 PM, the mother-baby unit manager (Staff Member #5) and director (Staff Member #6) confirmed that these actions risked transmission of infectious disease.


Item #4 - Sterilization Procedures

Findings:

On 10/21/2014 at 11:15 AM, Surveyor #2 reviewed documentation of the results of biologic indicator tests performed on the hospital sterilizers. The surveyor observed the following discrepancies in document #8043 "Steam Biologic Record": On 10/20/2014 sterile processing staff members recorded elapsed times of less than one hour for the incubation time to results for biologic indicator tests. At the time of the observation, Surveyor #2 interviewed the Sterile Processing Manager (Staff Member #24) about the required incubation period for the department's biologic indicator tests. S/he indicated that the hospital used biologic indicators with a one-hour incubation time.

Item #5 - Cross Contamination

Findings:

1. On 10/21/2014 at 11:00 AM, Surveyor #1 observed a registered nurse (Staff Member #12) remove a portable computer from a patient room without sanitizing it. The nurse had moved between the computer and the patient and patient areas without performing hand hygiene, thus contaminating it. The Unit Manager (Staff Member #13) confirmed that it was policy to sanitize computers when removing them from patient rooms.

2. On 10/21/2014 at 2:15 PM Surveyor #3 o