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.

MEMORIAL HOSPITAL 4500 MEMORIAL DRIVE BELLEVILLE, IL 62226 June 18, 2015
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
A. Based on observation, document review and interview it was determined in 1 of 2 staff observed (E #5) on the telemetry unit, the Hospital failed to ensure staff, removed personal protective equipment (gloves) before leaving the patient care area, potentially affecting all patients receiving respiratory care in the telemetry unit.

1. On 6/15/15 at 11:15 AM, while conducting a tour of 2 North (telemetry unit) with the Director of Infection Control (E #6), registered nurse (E #5) was observed coming out of room 294 with gloves on. Room 294 was occupied by a patient on droplet isolation.

2. On 6/15/15 at 2:00 PM, Hospital policy "Infection Prevention Standard Precautions" effective January 2014, was reviewed. Under "5. contaminated personal protective equipment (PPE) should not be worn in hallways and should be discarded at the site of use."

3. On 6/15/15 at 11:25 AM, an interview with E #6 was conducted. E #6 stated, "The nurse should have removed the gloves in the patients room prior to exiting the room."

B. Based on observation, document review and interview it was determined in 2 of 3 staff (E #11, #12) observed in the intensive care unit, the Hospital failed to ensure staff, used proper personal protective equipment (gloves) to prevent exposure to infectious agents or chemicals. This has the potential to affect all patients receiving care in the intensive care unit.

1. On 6/15/15 at 4:00 PM, while conducting a tour of the intensive care unit (2 north), the respiratory therapist (E #11) was observed adjusting a bi-level positive pressure airway mask on patient #1, in room 1, without wearing gloves.

2. On 6/15/15 at 2:00 PM, Hospital policy "Infection Prevention Standard Precautions" approved January 2014, was reviewed on 6/15/15 at 2:00 PM. Under "II. Policy, barrier precautions (gloves, gowns, masks, face shield) are used when employees anticipate contact with any patients' blood, any body fluid, secretion or excretion."

3. On 6/15/15 at 4:10 PM, an interview with E #6 was conducted. E #6 stated, "The respiratory therapist (E #11) should have been wearing gloves while providing respiratory therapy treatment."

4. On 6/15/15 at 11:15 AM, while conducting a tour of the telemetry unit with the Director of Infection Control (E #6), registered nurse (E #5) was observed wiping down a mobile computerized cart with PDI super sani-cloth, germicidal disposable wipes without wearing personal protective equipment (gloves).

5. On 6/15/15 at 11:25 AM, the container instructions for PDI super sani-cloth, germicidal wipes was reviewed. Under "personal protect" it indicated "When using this product, wear disposable protective gloves."

6. On 6/15/15 at 11:20 AM, an interview with E #6 was conducted. E #6 stated, "The nurse should have been wearing gloves when handling the germicidal wipes."

C. Based on observation, document review and interview it was determined in 1 of 3 staff (E #12) observed in the intensive care unit, the Hospital failed to ensure staff performed proper hand hygiene after patient contacts, potentially affecting all patients in the intensive care unit.

1. On 6/17/15 at 9:15 AM, while conducting a tour of the intensive care unit, room 9, with the Vice President of Patient Care Services (E #2), respiratory therapist (E #12) was observed leaving the patient's room without performing hand hygiene; between patient contacts.

3. On 6/17/15 at 9:30 AM, Hospital policy "Infection Prevention Standard Precautions" approved January 2014, was reviewed. Under "Points of Emphasis" it indicated hand hygiene should be performed "between patient contacts".

4. On 6/17/15 at 9:20 AM, an interview with E #12 was conducted. E #12 verbalized that hand hygiene was not performed after leaving room 9 and E #12 had patient contact while in the room.

5. On 6/17/15 at 9:25 AM, an interview with E #2 was conducted. E #2 verbalized that E #12 should have performed hand hygiene between patient contacts.