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A. Based on document review, observation, and interview, it was determined that for 1 of 1 Registered Nurse (RN) (E #5) who cannulized (inserted a catheter) a vein (Pt. #2) in the Emergency Department (ED), the Hospital failed to ensure that staff disinfected the cannulation site and allowed the site to dry within the time requirements per the disinfectant manufacturer.

Findings include:

1. On 7/2/18 at 2:20 PM, the Hospital's policy titled, "Intravenous / Intra-arterial Access Devices - Guidelines for Care" (revised January 2018), was reviewed. The policy required, "... 2.1 Skin antisepsis (insertion and site maintenance) Peripheral insertion: 2% Chlorhexidine gluconate (CHG) recommended..."

2. On 7/2/18 at 2:25 PM, the "ChloraPrep FREPP 1.5 ml Applicator" Manufacturer's Guidelines were reviewed. The Guidelines included, "... 2% chlorhexidine gluconate (CHG) and 70% isopropyl alcohol (IPA)... Apply... For dry sites (e.g. abdomen or arm): Use repeated back and forth strokes for 30 seconds... Dry: For dry surgical sites, allow the area to dry for approximately 30 seconds..."

3. On 7/2/18 at 9:45 AM, an observational tour was conducted in the ED. At 9:50 AM, in Room #6, a RN (E #5) disinfected Pt. #2's right arm to insert a peripheral venous catheter using a ChloraPrep (skin cleanser) applicator. E #5 swabbed Pt. #2's proposed cannulation site for 10 seconds, palpated the site, and swabbed the site again for another 4 seconds. E #5 inserted the catheter within 15 seconds after the disinfection, not permitting the ChloraPrep to dry.

4. On 7/2/18 at 2:25 PM, an interview was conducted with the Manager of Quality Assurance and Performance Improvement (E #11). E #11 stated that ChloraPrep should be applied for 30 seconds and let dry for 30 seconds.

B. Based on document review, observation, and interview, it was determined that for 1 of 3 Registered Nurses (RN) (E #4) in the Intensive Care Unit South (ICU-S) and 1 of 1 Surgeon (MD #1) in the Operating Room (OR), the Hospital failed to ensure that staff wore protective equipment/covering when caring for patients in isolation.

Findings include:

1. On 7/2/18 at 1:45 PM, the Hospital's policy titled, "Transmission Based Precautions" (revised February 2018), was reviewed. The policy required, "B. Transmission Based Precautions: 1. Contact Precautions (in addition to Standard Precautions) are used to reduce the risk of transmission by direct contact with the patient or by indirect contact with the patient's environment from resistant organisms such as MRSA [methicillin resistant staphylococcus aureus]... d. Wear a clean non-sterile impervious gown when having direct patient contact or contact with patient's environment and equipment..."

2. On 7/2/18 at 9:55 AM, an observational tour was conducted in the Intensive Care Unit South (ICU-S). At 10:00 AM, a RN (E #4) entered room #3 carrying a styrofoam cup, not wearing gloves or a gown. There was a Contact Precaution sign posted near the door of room #3. The sign included, "Contact Precautions: Gloves: Wear when entering the room... Gown: Wear if you anticipate contact with the patient or the environment..." E #4 spent approximately 5 minutes in room #3, adjusting intravenous solutions and lines. E #4 was not wearing a protective gown.

3. On 7/2/18 at 10:05 AM, an interview was conducted with E #4. E #4 stated that she did not know if room #3 was a contact isolation room. E #4 stated that Pt. #3 came during the night shift when the contact isolation sign was placed.

4. On 7/2/18 at 10:15 AM, an interview was conducted with the Manager of ICU (E #3). E #3 stated that E #4 was a registry nurse and should have worn a gown in the contact isolation room.

5. On 7/3/18 at 9:20 AM, an observational tour was conducted in the Main OR. In OR #4, a Patient (Pt. #10) was scheduled for an exploratory laparotomy (exploration of the abdomen). Pt. #10 was on contact isolation for MRSA. At 10:05 AM, the Surgeon (MD #1) entered the room without a cover gown and adjusted Pt. #10's position on the table and cut and clamped the jejunostomy tube (feeding tube). MD #1's scrubs were in contact with Pt. #1's bed sheets from the ICU.

6. On 7/3/18 at 10:25 AM, an interview was conducted with the OR Team Leader (E #17). E #17 stated that the Surgeon should have worn a cover gown when caring for the contact isolation patient.

C. Based on document review, observation, and interview, it was determined that for 1 of 3 Registered Nurses (RN-E #4) in the Intensive Care Unit South (ICU-S), 1 of 1 Surgical Assistant (E #15) in the Operating Room (OR), and 1 of 1 Registered Nurse (RN-E #16) in Same Day Surgery, the Hospital failed to ensure that staff changed gloves and disinfected their hands after coming in contact with potentially contaminated items.

Findings include:

1. On 7/3/18 at 1:35 PM, the Hospital's policy titled, "Hand Hygiene" (revised February 2018), was reviewed. The policy required, "C. Hand Hygiene before and after every patient/resident contact! Hand hygiene is required for the following... 2. After removing sterile or non-sterile gloves... 3. After handling contaminated material or waste..."

2. On 7/2/18 at 9:55 AM, an observational tour was conducted in the Intensive Care Unit South (ICU-S). At 10:00 AM, a RN (E #4) entered room #3 carrying a styrofoam cup, not wearing gloves. There was a Contact Precaution sign posted near the door of room #3. The sign included, "Contact Precautions: Gloves: Wear when entering the room..." E #4 spent approximately 5 minutes in room #3, adjusting intravenous solutions and lines. E #4 left room #3 without disinfecting her hands.

3. On 7/2/18 at 10:15 AM, an interview was conducted with the Manager of ICU (E #3). E #3 stated that E #4 should have worn gloves in the contact isolation room and should have disinfected her hands when leaving the room.

4. On 7/3/18 at 9:20 AM, an observational tour was conducted in the Main OR. In OR #4, a Patient (Pt. #10) was scheduled for an exploratory laparotomy (exploration of the abdomen). Pt. #10 was on contact isolation for MRSA (methicillin resistant staphylococcus aureus). At 10:00 AM, the Surgical Assistant (E #15), wearing gloves, removed a soiled binder from under Pt. #10. Without changing gloves, E #15 placed a paper covering across Pt. #15's arms. E #15 then removed a cut portion of Pt. #15's contaminated jejunostomy tube (feeding tube) and did not change gloves before securing Pt. #10's arms to the OR table. E #15 did not remove his gloves or disinfect his hands before leaving the room.

5. On 7/3/18 at 10:25 AM, an interview was conducted with the OR Team Leader (E #17). E #17 stated that the Surgical Assistant (E#15) should have changed his gloves and disinfected his hands after touching contaminated items.

6. On 7/3/18 at 10:45 AM, an observational tour was conducted in Same Day Surgery (SDS). At 11:00 AM, a Registry RN (E #16), in Procedure Room #228, with bare hands, was setting up the instruments and supplies on a Mayo Stand (surgical supply table) for Pt. #11's excision of a right arm lipoma (tumor of fat tissue). E #16 dropped a covered needle on the floor, picked it up, and placed it on another supply table. E #16 did not disinfect her hands and continued to place sterile supplies on the Mayo Stand.

7. On 7/3/18 at 11:25 AM, an interview was conducted with an SDS RN (E #19). E #19 stated that E #16 was a Registry Nurse and "we'll talk to her" about not disinfecting her hands.

D. Based on document review and interview, it was determined that for 1 of 4 months (April 2018) of dialysis reverse osmosis (purified water) cultures reviewed, the Hospital failed to ensure that cultures were performed every month. This potentially affected the safety of approximately 120 hemodialysis treatments each month.

Findings include:

1. On 7/3/18 at 2:25 PM, the Hospital's policy titled, "Hemodialysis SPS Care and Disinfection" (revised January 2018), was reviewed. The policy required, "E. Monthly Culturing of Dialysis and Reverse Osmosis [RO] Machines: Once a month a water sample is to be sent... for bacterial colony count... R.O. Culture results... 50 - 99 cfu/ml [culture forming unit/ml]... chemically disinfect..."

2. On 7/2/18 at 11:00 AM, the dialysis culture logs from March 2018 to June 2018 were reviewed. Every RO machine's culture in March and/or May exceeded 50 cfu/ml [action level]. The repeat cultures were 0 cfu/ml. However, there was no documentation that RO cultures were taken for machines (C, D, E, F, & H) in April 2018.

3. On 7/3/18 at approximately 1:00 PM, an interview was conducted with the Manager (E #3) of the Dialysis Unit. E #3 stated that RO cultures had been completed right at the end of March and beginning of May, so cultures in April were not done.