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The Promise Hospital of Overland Park reported a census of 39 inpatients. Based on documentation review, staff interview, and policy review the facility failed to ensure their license staff (Staff W) had obtained a physician order for one of one medication. This deficient practice has the potential to place a patient at risk for harm.

Findings Include:

- Medical Record reviewed on 4/6/2017 at 8:30 AM revealed Staff W failed to obtain an order prior to applying Betadine to patient # 2's right heel. On 3/29/2017 Staff W documentated "1600- Betadine applied to eschar on right heel." The MAR (Medication Administration Record) and the Wound Care orders did not have evidence of having an order for Betadine.

Wound Care Nurse Staff KK interviewed on 4/6/2017 at 9:25 AM acknowledged the patient did not have an order for Staff W to apply Betadine to patient #2's right heal. Staff KK stated there was an order prior to patient #2's hospitalization but we failed to reorder the Betadine with the physician.

- Policy reviewed on 4/6/2017 revealed the facility failed to have a policy to ensure licensed staff obtains a medication order from the physician prior to administration.

The Promise Hospital of Overland Park reported a census of 39 inpatients. Based on staff interviews, and policy review staff failed to follow their work order processing policy and procedure reporting for one of one maintenance needs (Staff JJ). This deficient practice can place patients and employees at risk.

Findings Include:

Registered Nurse Clinic Charge Nurse Staff JJ interviewed by phone on 4/6/2017 at 9:00 AM indicated they were told last Wednesday, 3/29/2017 or Thursday 3/30/2017 by a nurse that they found ants in room 414. Staff JJ stated as they were told by the nurse of the ants, the maintenance employee was passing by and they stopped them to inform them of the ants. Staff JJ did state they are to write up a work order form when maintenance is needed but they did not.

Maintenance Staff T interviewed on 4/6/2017 at 9:10 AM indicated all staff are to fill out a work order form for any maintenance needs, it is in our policy. Staff T stated they do not remember if they were told regarding the ants as they were passing by the nurse. Staff T stated nurses know not to tell us problems as we are passing by because we are doing other work and without the order form the needs will be missed.

Policy titled "Work Order Process" reviewed on 4/6/2017 directed staff " ...As maintenance needs and repair work are identified as being needed, personnel shall notify the Plant Operations department of work needed via a Work Order system. Staff members will complete a work order and give to the Plant Operations department as needs are identified. Work orders submitted are reviewed each business day and assigned to the appropriate personnel for completion ..."

The Promise Hospital of Overland Park reported a census of 39 inpatients. Based on observations, staff interviews, and policy review the Hospital Infection Control Officer failed to ensure staff wore the proper attire for one of one observations (Staff FF), performed hand hygiene for two of two observations (Staff GG and HH), performed cleaning of equipment for one of one observations (Staff HH), changed gloves for two of two observations (Staff GG and HH), patient equipment and linens were not stored on the floor in 1 of 1 linen closet observed, staff failed to perform hand hygiene appropriately during 3 of 5 observations (Staff J, Staff D, and Staff H), staff and visitors failed to wear personal protective equipment (PPE) correctly for 2 of 5 observations (Staff J and Visitor JJ) and staff failed to disinfect dirty equipment during 2 of 2 observations (Staff H and Staff J). This deficient practice has the potential to expose all patients in the facility at risk of exposure to contamination of microorganisms.

Findings include:

- CNA Staff GG observed on 4/3/17 at 9:05 AM revealed Staff GG disposing their gown and gloves in the trash can prior to exiting patient # 27 room 418. Patient #27 was in contact precaution. Staff GG picked up the trash bag with no gloves on, exits the room heads to the soil utility room, places the trash in the bin and washes their hands at the hallway sink.

CNA Staff GG interviewed on 4/3/2017 at 9:06 AM acknowledged they did not perform hand hygiene and gloved prior to exiting the patient #27's room per the facility's policy.

- Policy titled "Hand Hygiene Policy" reviewed on 4/4/2017 directed staff "...indications for hand hygiene: ...Gloves should be changed and hand hygiene performed after using gloves for contaminated activities..."

- CNA (Certified Nurse Aide) Staff HH observed on 4/4/2017 at 7:30 AM revealed Staff HH in contact precaution room 409 performing blood sugar check on patient # 26. Staff HH reached into a plastic cup with several lancets with gloved hand, takes one out and performs blood sugar check. Staff HH disposed their gown and gloves, step out of the room without performing hand hygiene and applying new gloves. Staff HH placed the plastic cup on the ledge outside of patient's room. Staff HH reached for an alcohol swab only to disinfect the glucometer and strip bottle not the plastic cup and the ledge then proceeded to walk down the hallway to nurse's station.

Certified Nurse Aide Staff HH interviewed on 4/4/2017 at 7:40 AM acknowledged they probably should have cleaned the equipment with new gloves and before leaving room. Also, they should have performed hand hygiene after gloving and leaving the patient's room. Staff HH was not sure of the policy on cleaning equipment.

- Policy titled "Hand Hygiene Policy" reviewed on 4/4/2017 directed staff "...indications for hand hygiene: ...Gloves should be changed and hand hygiene performed after using gloves for contaminated activities..."

- Policy titled "Cleaning of Patient Care Equipment" reviewed on 4/4/2017 directed staff "...following patient use, equipment will be cleaned in the patient's room, or taken to the Dirty Utility Room for cleaning ..."


- Maintenance Staff FF observed on 4/4/2017 at 8:55 AM revealed Staff FF stepped into patient #2 room 410 touched the curtain pulling it to the left to give the patient privacy. Staff FF entered into a contact precaution room without gowning and gloving prior to entering the room per the facility policy.

Maintenance Staff HH interviewed at 8:55 AM acknowledged they should have had their gown and gloves on prior to entering patient # 2's room.

- Policy titled "Guidelines for Transmission-Based Precautions" reviewed on 4/4/2017 directed staff "...Wear gloves whenever touching patient's intact skin or surfaces and articles in close proximity to the patient. Don gloves upon entry into the room ..."


- Observation on 4/3/17 at 11:55 AM revealed a linen closet in the 500 hallway with patient equipment (appeared to be bed mattresses covers) and a white bag filled with linens on the floor.

Interview on 4/3/17 at 11:56 AM Staff E, Registered Nurse (RN) verified the equipment and bag on the floor and stated he/she is not sure exactly what the equipment is and why it is on the floor but that it is for patient use. The equipment and bag of linens were removed and the floor cleaned.

- Observation on 4/4/17 at 8:43 AM revealed Staff H Certified Nurse Assistant (CNA) emptying a colostomy for a patient #16 with Clostridium Difficile (C-Diff) (a bacteria that causes diarrhea and is highly contagious). Staff H emptied the stool into the toilet and the toilet did not completely flush. Staff H proceeded to use a plunger to unclog the toilet and placed the plunger back onto the bathroom floor failing to disinfect it.

Interview on 4/4/17 at 8:45 AM, Staff H CNA stated the toilet has problems flushing at times and that is why they keep the plunger handy to use if needed.

Interview on 4/4/17 at 4:30 PM with Administrative Staff A stated that is not to be the practice and will have it addressed.


- Observation on 4/4/17 at 10:32 AM revealed Staff J with a contracted services called MobileX to perform an ultrasound per physician orders for patient #14 on contact precautions (precautions for patients known or suspected to have a serious illness easily contacted by direct or indirect patient contact with items in the patient's environment). During the duration of performing the procedure (67 minutes) the isolation gown was not tied at the top and was lifted it up numerous times contaminating his/her personal clothing. Staff J touched the patient's soiled linens throughout the procedure. Approximately half way through the procedure the Staff J could not find the gel. Staff J pulled up everything from the bed, under the bed touching the floor twice with gloved hands and then found the gel under a towel on the patient's bedside table. Staff J removed the dirty gloves and applied new gloves failing to perform hand hygiene in between glove changes and used the bottle of gel that was touched with dirty gloves on the patient again. Upon completion of the procedure Staff J put the cord to the transducer (a device that convert variations in a physical quantity, such as pressure or brightness, into an electrical signal, or vice versa) into the travel equipment bag with dirty gloves on. Staff J then changes gloves and cleaned the remainder of the equipment with a disinfectant cloth.

Interview on 4/4/17 at 11:39AM, Staff J, MobileX contracted provider was asked if he/she is aware of the facilities policies in regards to hand hygiene and he/she did not comment concerning changing dirty gloves, re-cleaning the gel bottle prior to using it on the patient again and placing the transducer cord into his/her travel equipment bag with dirty gloves.

Interview on 4/4/17 at 11:43 AM Staff F, Infection Control Officer was made aware of the issues with contracted services MobileX Staff J. Staff F stated the agency will be contacted with follow up to contracted staff complying with facility policies and procedures.

- Policy and Procedure review on 4/4/17 for policy "Cleaning of Patient Care Equipment" states ...only clean equipment is stored in clean equipment area. Clean equipment will be covered with a clear plastic bag to ensure cleanliness ...following patient use, equipment will be cleaned in the patient's room, or taken to the Dirty Utility Room for cleaning ...cleaned equipment will be stored in the patient room or a designated clean area.


- Observation on 4/3/17 at 12:55 PM with patient # 10 on contact precautions. The patient was admitted about 5 weeks ago and her fiancé (Visitor JJ) was with the in the room. The fiancé failed to have a gown on in the contact precaution room and stated they did not have to wear one.

- Policy and Procedure review on 4/3/17 for policy "Guidelines for Transmission-Based Precautions" states ...Gowns: wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Don gown upon entry into the room or cubicle.

- Policy and Procedure review on 4/3/17 for policy "Management of Multi-Drug Resistant Organisms" states ...Patient/Family Education: The Infection Preventionist and Nursing staff shall educate patients and their families/caregivers about ways to care for infected persons ...isolation gowns and gloves are required by all visitors. Those not performing hands on care may wear porous isolation gowns (such as yellow gowns) while visiting.


- Observation on 4/3/17 at 1:34 PM, Staff D RN emptied the urine from the foley bag (a bag that holds the urine from a urinary catheter) for patient #12. Staff D upon returning from emptying the urine container failed to remove dirty gloves and proceeded to adjust the patient's bed side table, TV remote and call light.

Interview on 4/3/17 at 1:35 PM, Staff D RN verified the dirty gloves were not discarded and hand hygiene performed before donning clean gloves. Staff D stated he/she knows that they should have been change

- Observation on 4/4/17 at 7:35 AM, Staff H Certified Nurse Assistant (CNA) performed care to patient # 12. The stool was cleaned from the patient's bottom and the same dirty gloves were used to apply a new depends (adult diaper).

Interview on 4/4/17 at 8:07 AM, Staff H CNA stated he/she was not aware that gloves needed to be changed when going from a dirty procedure to a clean procedure.

- Policy and Procedure review on 4/4/17 for policy "Hand Hygiene Policy" states ...indications for hand hygiene: after contact with inanimate environmental sources likely to be contaminated, after contact with all patients' equipment and after removing gloves.