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During medical record review on 8/21/12 at approximately 1600 it was found in the medical record of patient #12 that this patient had a Foley catheter in place while in the observation area. With further medical record review of this patient there was no evidence that the patient had a physician ' s order for a catheter to be placed, when it was placed, who placed it and why it was being put in. There was no evidence of ongoing documentation of why the catheter was being continued. Staff W assisted this surveyor with this medical record review and confirmed the above information was not documented in the record.



29774

Based on observation, interview and record review the facility failed to document medical orders for nor indication for continued use of, urinary catheters for five (Patient #s 7, 8, 10,11 and 12) of five patients with a urinary catheter's records reviewed resulting in risk for acquisition of healthcare associated infections for patients with a urinary catheter. Findings include:

On 8/21/12 at 1100 during facility tour observed Patient #7 with a urinary catheter. Interview with Staff AL regarding electronic medical records order for the urinary catheter revealed that the catheter was inserted in the Emergency Department, however the order for insertion nor the the ongoing indication for continued use was absent. This was confirmed by Staff AL on 8/21/12 at 1105.

On 8/21/12 at 1150 during facility tour observed Patient #8 with a urinary catheter. Interview with Staff AK on 8/21/12 at 1150 regarding the presence of the order for and the indication for continued daily use of urinary catheter recorded in the medical record revealed that there was neither documented.

On 8/21/12 at 1600 during facility tour observed Patient #10 with a urinary catheter. Interview with Staff R regarding the presence of the order for and the indication for continued daily use of urinary catheter recorded in the medical record revealed that there was neither documented.

On 8/21/12 at 1615 during facility tour observed Patient #11 with a urinary catheter. Interview with Staff R regarding the presence of the order for and the indication for continued use of urinary catheter recorded in the medical record revealed that the patient had multiple pressure ulcers in the hip and scrotal areas that were receiving treatment. Staff R could not however find a medical order for insertion of the urinary catheter.

On 8/22/12 at approximately 1430 a review of facility policy titled "Foley Catheter Reduction" revised 6/09 revealed that "The physician order the placement of urinary catheters for patients who meet the inclusion criteria...patients will be evaluated daily for the continued need for the catheter...Physician orders for indwelling urinary catheter placement are entered into the computer order entry system...Each patient with an indwelling urinary catheter will be evaluated each day to determine if the Foley is needed. The physician will be notified during rounding or via telephone regarding any patient who no longer meets the inclusion criteria ...if patients no longer meet the criteria, the physician will be contacted to request removal of the catheter...".

Based on observation, interview and policy review, the facility failed to ensure that staff wash their hands after glove removal and before answering a telephone in a room labeled contact isolation (clostridium difficile) resulting in the risk for transmission of clostridium difficile to other patients housed on the unit and cared for by the same personnel. Findings include:

On 8/21/12 at approximately 1115 during facility tour, observed a nurse coming out of room 951 labeled contact isolation with their gown and gloves still on, reach into a scrub pocket with contaminated gloves and answer a ringing phone. The nurse then returned the phone to her pocket, removed her gown and gloves and proceeded down the hallway to perform hand hygiene in the Pyxis room (the only sink in the isolation room is in the patient's bathroom). This was confirmed by Staff AK and Staff B on 8/21/12 at 1115. Staff AK said "we have the option of performing hand hygiene either in the patient bathroom or in the sink in the Pyxis room". Staff B was asked on 8/21/12 at approximately 1115 whether answering a ringing phone with contaminated gloves in a contact isolation room is acceptable practice, to which she replied "no, it is not acceptable".

On 8/22/12 at approximately 1500 a review of facility policy titled "Isolation and Precaution Guidelines" revised 4/09 revealed that "Contact Precautions: ...single use gown and gloves must be worn on entering the room...Practice Standard Precautions for all other patient care activities.. Removal PPE When removing PPE, care must be taken to avoid self-contamination and potential exposure to infectious materials PPE should be removed in this order: remove gown, remove gloves, wash hands....".

On 8/21/12 at approximately 1120 observed Staff P perform cleaning of the bathroom in a contact isolation room. Observed Staff P clean the toilet and proceed to the light switches and sink area in the bathroom, without changing her gloves. Staff P was asked when she will remove her gloves and perform hand hygiene to which she replied "when I am finished with the room".

Based on observation and interview the facility failed to ensure that the infection control officer developed a system for identifying potential infections and communicable diseases of patients and personnel. Findings include:

During observations on 8/21/12 during the hours of 1030-1600 the following areas were observed with infection control concerns:
Pediatrics Nourishment Room:
1. Refrigerator had debris, stains, liquid spills and dried particles in drawers
2. Ice machine had white film in catch basin on the bottom
Antepartum Nourishment Room:
1. Ice machine had white film around dispenser rim and in the catch basin on the bottom
Women ' s and Children Nourishment Room:
1. Refrigerator had debris, stains, liquid spills and dried particles in drawers
2. Universal waste container in the dirty utility was overflowing
Post-Partum:
1. Room 336X didn ' t have high dusting completed when terminally cleaned, lights, equipment, window sill all had a significant amount of dust build up
2. Nourishment room refrigerator had debris, stains, liquid spills and dried particles in drawers
Labor and Delivery:
1. Room L17 didn ' t have high dusting completed when terminally cleaned, lights, equipment and window sill all had a significant amount of dust build up
2. Nourishment room refrigerator had debris, stains, liquid spills and dried particles in drawers
Observation Unit:
1. Nourishment room refrigerator had debris, stains, liquid spills and dried particles in drawers
2. Soiled utility room cluttered, dirty and floor extremely sticky
These findings were confirmed by Staff U, V, W and AJ at the time of the observation




29774

On 8/21/12 at approximately 1210 during facility tour found on 8-south a soiled food refrigerator with residual food stains and accumulated food debris. This was confirmed by Staff Q, who said that she thought that "food service was responsible for cleaning the food refrigerators".

On 8/21/12 at 1230 found on 8-north the ante room for 858 was cluttered with patient care supplies that overflowed the storage drawers and cabinet top. Staff Q was asked how housekeeping could clean with all the clutter, she agreed that the room was cluttered and replied, that "this room was over stocked and needs to be cleaned out".

On 8/21/12 at 1215 found the pantry refrigerator on 8-north was soiled with accumulated food stains and food crumbs. This was confirmed by Staff Q on 8/21/12 at 1215.

On 8/21/12 at approximately 1605 found in a patient ready room #752, dust accumulated in the vents next to the patient bed. This was confirmed by Staff R who indicated that "engineering will clean those twice a year". Additionally on the nurses WOWs (medication storage and electronic documentation carts) a taped medication dispensing cup topped with clean stacked medication cups was observed. Staff R was asked how often that area of the cart is cleaned and how one could remove a single medication dispensing cup without contaminating the stack, to which Staff R replied "I don't know, I never thought of that". On 8/21/12 at approximately 1615 in the ante room of an unoccupied isolation room (758) found the following: a biopsy tray with a manufacturers expiration date of 2/2012, PerFix epidural anesthesia tray with a manufacturers expiration date of 7/2011, and over accumulation of patient care supplies and used N-95 respirators. This was confirmed by Staff R who said, "this room needs some attention".

On 8/21/12 at 1645 found in room 628 an unoccupied isolation ante room clutter and storage around the hand hygiene sink within spray and splatter contamination. Additionally on 6 south found the following: in the soiled utility room accumulation of dust and debris on the floor, in the equipment storage room accumulation of dust and debris on the floors, in the pantry area, drawers that had visible soiling and accumulation of crumbs and debris and a refrigerator with accumulated food stains and food debris, and in the clean storage room, a brown stained ceiling tile, and floor storage of outside packing cardboard boxes of incontinence diapers. The above items were confirmed by Staff S on 8/21/12 at 1700.