The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

BAYHEALTH HOSPITAL, KENT CAMPUS 640 S STATE STREET DOVER, DE 19901 July 19, 2012
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation, policy review and staff interview, it was determined that operating room staff failed to follow the facility's policy for medication administration during 1 of 1 surgical patient (Patient #6) tracer observations. Findings include:

The hospital policy entitled "Administration of Medications On and Off the Sterile Field" stated, "All medications both on and off the sterile field that are not immediately administered must be labeled even if there is only one medication being used...Labeling occurs when any medication or solution is transferred from the original packaging to another container...Labels must include drug name, strength, quantity..."

A. Patient #6
On 7/17/12 at 11:30 AM, an undated 20 milliliter syringe filled with white liquid, labeled "Propofol (used for procedural sedation and analgesia) 0900 mg/ml (milligrams per milliliter)" was observed on the top of the anesthesia cart.

When asked about the dose of the Propofol, certified registered nurse anesthetist (CRNA) A stated that the 0900 on the label was the time (9:00 AM) that the medication was drawn up in the syringe, not the medication dose.

CRNA A was interviewed on 7/17/12 at 12:45 PM, and confirmed that she did not label the syringe with a dose because Propofol only came in one dose.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
I. Based on observation, policy review, job description review and staff interview, it was determined that for 4 of 12 patient observations (Patient #'s 1, 4, 6 and 9), staff failed to follow the hospital's policy for infection control. Findings include:

The hospital job description entitled "Manager, Infection Control" stated, "...responsible for ongoing oversight and continuous improvement of the...Medical Center Infection Control program of surveillance, prevention, and clinical response regarding infectious disease exposures and hazards...Ensure ongoing compliance with...CMS requirements...Ensures for all areas of responsibility that employees are aware of...policies and procedures and that corrective action is taken to achieve fair, timely and consistent enforcement..."

The Infection Control Department policy entitled "Hand Hygiene" stated, "...Use of gloves during procedures does not eliminate the need for hand hygiene before glove application and following glove removal...Hand hygiene is required...Before, between and after contact with patients...After touching any source that is likely to be contaminated with pathogens...after touching any secretions such as...respiratory secretions even if gloves were worn...Before preparing and accessing medication station..."

A. Patient #1 - Intermediate Care Unit
The following was observed during a respiratory therapy treatment (aerosol) provided by respiratory therapist (RT) A on 7/19/12 at 9:15 AM:

- Washed hands
- Donned gloves
- With gloved hands:

- Placed gloved hand in uniform pocket
- Accessed and retrieved nebulizer equipment
- Placed medication in nebulizer reservoir chamber
- Handed nebulizer to patient
- Auscultated (listened with stethoscope) Patient #1's lungs
- Completed respiratory assessment and placed stethoscope around neck
- At completion of treatment, disconnected equipment, discarded any remaining liquid from nebulizer cup and stored using "AeroEclipse" manufacturer's guidelines for cleaning
- Removed gloves
- Documented treatment on paper form
- Performed hand hygiene

RT A failed to perform hand hygiene and/or change gloves:

- After touching inanimate objects
- Before patient contact
- After removing gloves

During an interview on 7/19/12 at 10:20 AM, the findings of the respiratory therapy observation were discussed with Infection Prevention Manager A. Infection Prevention Manager A confirmed that RT A failed to follow the hospital's hand hygiene policy.
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B. Patient #4 - Medical-Surgical Unit
The following was observed during care provided by certified nursing assistant (CNA) #1 on 7/17/12 at 10:31 AM:

- Removed gown and gloves
- Performed hand hygiene
- Donned gloves
- Wiped equipment with cleansing cloth
- Removed and discarded gloves
- Entered information into computer

CNA #1 failed to perform hand hygiene:
- After removing gloves

During an interview with Director of Accreditation A, Infection Prevention Manager A, Infection Prevention Coordinator A and Infection Preventionist A on 7/18/12 at 3:05 PM, it was confirmed that CNA #1 failed to follow the hospital's hand hygiene policy.
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C. Patient #6 - Surgical patient: Medical and nursing staff were observed providing care to Patient #6 from the operating room through discharge. Observation revealed that staff failed to follow the hospital's infection control policy for hand hygiene at the following times:

1. Operating Room
The following was observed during care provided by Certified Registered Nurse Anesthetist (CRNA) A on 7/17/12 between 11:30 AM and 12:30 PM:

- Removed gloves
- Picked up the medical record that had fallen on the floor
- Touched anesthesia equipment
- Moved intravenous (IV) pole
- Opened a bag of IV medication and attached to the IV tubing
- Donned new gloves
- Touched anesthesia equipment
- Discarded supplies
- Touched IV tubing
- Touched anesthesia equipment
- Wrote in the medical record
- Opened a second bag of IV medication and attached to the IV tubing
- Touched anesthesia equipment
- Opened the drawer of the anesthesia cart
- Attached a syringe to the IV tubing
- Touched overhead light
- Administered medications
- Wrote in chart
- Removed gloves
- Opened anesthesia cart and took out supplies
- Donned new gloves
- Removed clear adhesive from both eye areas of patient
- Removed arm straps
- Removed airway
- Removed left glove
- Donned new left glove
- Wasted medication
- Removed gloves

CRNA A failed to perform hand hygiene:
- Before application of gloves
- After removing gloves
- After touching sources likely to be contaminated with pathogens
- After touching secretions (airway removal)

2. Operating Room
The following was observed during care provided by Registered Nurse (RN) First Assistant A on 7/17/12 between 12:16 PM and 12:30 PM:

- Removed sterile gown and gloves
- Donned new gloves
- Touched patient

RN First Assistant A failed to perform hand hygiene:
- After removing gloves

3. Post-Anesthesia Care Unit (PACU)
The following was observed during care provided by RN A on 7/17/12 between 12:50 PM and 1:15 PM:

- Walked from patient area to medication dispensing machine
- Retrieved and prepared Dilaudid (a narcotic pain reliever)
- Administered Dilaudid
- Entered information into computer
- Removed the nasal cannula that delivered oxygen to the patient
- Wrote on papers and entered information into computer
- Performed aromatherapy for patient complaint of nausea
- Wrote on papers and entered information into computer
- Walked from patient area to medication dispensing machine
- Retrieved and prepared Zofran (medication used to treat nausea)
- Administered Zofran
- Wrote on papers and entered information into computer
- Closed privacy curtain
- Touched patient
- Assessed left breast surgical dressing/site
- Opened curtain
- Entered information into computer
- Touched patient's shoulders
- Gave patient a cup of ice chips
- Touched patient's stretcher

RN A failed to perform hand hygiene:
- Before and after patient contact
- After touching any source likely to be contaminated with pathogens
- Before preparing medication
- Before accessing medication station

During an interview with Director of Accreditation A, Infection Prevention Manager A, Infection Prevention Coordinator A and Infection Preventionist A on 7/18/12 at 3:05 PM, it was confirmed that CRNA A, RN First Assistant A and RN A failed to follow the hospital's hand hygiene policy.
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D. Patient #9 - Labor and Delivery Unit
The following was observed during care (epidural block/anesthesia for pain) provided by Anesthesiologist A on 7/18/12 at 2:10 PM:

- Performed hand hygiene
- Palpated patient's back/spinal area
- Opened package and prepared sterile field
- Donned sterile gloves
- Inserted epidural
- Applied Tegaderm (adhesive dressing)
- Removed gloves
- Applied tape to area
- Donned new gloves
- Wiped back with gauze
- Removed gloves
- Applied more tape to back area
- Moved supplies
- Donned new gloves

Anesthesiologist A failed to perform hand hygiene:
- After patient contact
- Before donning gloves
- After removing gloves

During an interview with Director of Accreditation A, Infection Prevention Manager A, Infection Prevention Coordinator A and Infection Preventionist A on 7/18/12 at 3:05 PM, it was confirmed that Anesthesiologist A failed to follow the hospital's hand hygiene policy.

II. Based on observation, policy review and staff interview, it was determined that staff failed to disinfect 1 of 1 medication vials at the time of access. Findings include:

The Elkin, Perry and Potter "Nursing Interventions & Clinical Skills" 5th Edition utilized by the nursing staff to direct care stated, "...Prepare vial containing a solution ...Remove cap covering top of unused vial to expose sterile rubber seal ...Firmly and briskly wipe surface of rubber seal with alcohol swab and allow it to dry..."

A. Patient #6
The following was observed during the postoperative care provided by RN A on 7/17/12 at 1:03 PM:

- Removed the cap of an unused medication vial
- Opened packaging of new needle and syringe
- Accessed vial with the needle and syringe

RN A failed to:
- Cleanse the medication vial access diaphragm with alcohol prior to the insertion of the needle

During an interview with Director of Accreditation A, Infection Prevention Manager A, Infection Prevention Coordinator A and Infection Preventionist A on 7/18/12 at 3:05 PM, it was confirmed that RN A failed to follow hospital policy.

III. Based on observation, policy review and staff interview, it was determined that staff failed to date 1 of 8 medication vials at the time of initial opening. Findings include:

The hospital policy entitled "Infection Control Guidelines for Pharmacy" stated, "...Multi-dose vials will be discarded 28 days after opening the vial..."

A. The following was observed during a tour of the Medical-Surgical Unit 4A with Risk Specialist A, Nurse Manager A and Clinical Nurse Specialist A on 7/17/12 at 10:43 AM:

- One (1) opened unlabeled multi-dose vial of Humalog (insulin) 100 units/milliliter

During an interview with Director of Accreditation A, Infection Prevention Manager A, Infection Prevention Coordinator A and Infection Preventionist A on 7/18/12 at 3:05 PM, it was confirmed that staff failed to label the vial, according to hospital policy, with the date the vial was opened and/or the date the vial was to be discarded.

IV. Based on observation, policy review and staff interview, it was determined that 3 of 7 staff (CNA #'s 1 and 2 and Wound Care Nurse A) providing care to patients identified as requiring contact precautions, failed to adhere to the hospital's Infection Prevention Department Isolation Guidelines. Findings include:

The hospital policy entitled "Isolation Guidelines" stated, "...Contact Precautions...Precautions must be used by all persons entering the room...Remove gloves before leaving the room, wash hands with an antimicrobial soap and make sure hands do not touch potentially contaminated environmental surfaces or items...Remove the gown before leaving the patients room. After removal of the gown, make sure clothing does not come in contact with environmental surfaces in order to prevent contamination with microorganisms...Exhibit A...Gown...Fully cover torso from neck to knees, arms to end of wrist, and wrap around the back...Fasten in back at neck and waist..."

A. During observations of care with Risk Specialist A, Nurse Manager A and Clinical Nurse Specialist A on 7/17/12 between 10:31 AM and 10:55 AM, staff failed to adhere to the Infection Prevention Department Isolation Guidelines at the following times:

10:31 AM - CNA #1 entered a patient room requiring contact precautions without tying the isolation gown at the waist as per hospital policy

10:50 AM - CNA #2 entered a patient room requiring contact precautions without tying the isolation gown at the waist as per hospital policy

10:52 AM - Wound Care Nurse A, in the contact isolation room:
- Removed isolation gown and gloves
- Performed hand hygiene
- Opened privacy curtain
- Performed hand hygiene

Wound Care Nurse A:
- Touched potentially contaminated surfaces/items after the isolation gown and gloves were removed
- Failed to follow the hospital's isolation guidelines

During an interview with Director of Accreditation A, Infection Prevention Manager A, Infection Prevention Coordinator A and Infection Preventionist A on 7/18/12 at 3:05 PM, it was confirmed that CNA #'s 1 and 2 and Wound Care Nurse A failed to adhere to the hospital's Isolation Guidelines.

V. Based on observation, policy review and staff interview, it was determined that staff failed to adhere to hospital infection prevention policies for the perioperative environment: including 3 of 3 operating rooms (ORs) (OR #'s 2, 8 and 10) and 1 of 1 housekeeping closets located in the semi-restricted area of the OR suite. Findings include:

The hospital policy entitled "Infection Prevention Guidelines for Perioperative Services" stated, "...The Surgical Attendant will: Clean all horizontal surfaces of furniture and equipment with antimicrobial solution...All Operating and Procedure Rooms, in which procedures may be performed...must be terminally cleaned once during every 24 hour period during the regular work week...cleaning should include...all furniture and equipment in the room..."

The hospital policy entitled "Infection Control Guidelines for Anesthesia" stated, "...External portion of anesthesia machines are to be thoroughly cleaned daily with an approved disinfectant..."

The hospital policy entitled "Infection Prevention Guidelines For Plant Operations" stated, "...Plant Operations maintains the environment of care. This includes the building environment and the various utility systems used to support patient care. Plant Operations management, in consonance with Infection Prevention, develops and implements maintenance and repair strategies designed to provide a safe environment...Maintenance and repair activities will be developed and implemented to assure that systems and components are sustained as designed...Walls...and other surfaces that make up the patient environment shall be maintained..."

The hospital policy entitled "Cleaning of Equipment" stated, "...For surgery department, all specialty specific equipment will be cleaned between use by departmental staff..."

A. During a tour of the surgical suite on 7/18/12 with Risk Specialist A, Clinical Manager A and Infection Preventionist B, the following observations were made and confirmed at the time of discovery:

10:04 AM - OR #8 - anesthesia machine with moderately dusty top shelf, dusty wall storage boxes for anesthesia supplies, moderately dusty shelves on cart supporting camera and computer equipment

10:15 AM - OR #2 - paper signs taped to horizontal pull out tray on anesthesia machine

10:38 AM - OR #10 - dusty anesthesia machine surfaces

B. Observation in the semi-restricted area of the surgical suite on 7/19/12 with Risk Specialist A and Clinical Manager A revealed the following:

8:58 AM - Housekeeping closet - 3 feet tall by 1 foot wide ragged drywall hole at the base of the rear wall of the closet, exposing pipes and insulation

This finding was confirmed at the time of discovery by Risk Specialist A and Clinical Manager A.