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.

BON SECOURS HOSPITAL 2000 W BALTIMORE STREET BALTIMORE, MD 21223 March 18, 2016
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
I. Based on observations of randomly selected patient and staff areas of the building and staff interviews it was determined that the physical environment of the hospital was not maintained at an acceptable level of safety and quality.

Emergency Department:
1. In the men's restroom the bowl of the hand sink was cracked. The crack had caulk that created an unsmooth and difficult to clean surface.
2. In the women's restroom, the paper towel dispenser was covered with tape, making the surface sticky and not easily cleanable.

Fourth Floor/Behavioral Health Unit:
1. The tile on the employee restroom floor was torn, creating an area that was not cleanable.
2. In the women's shower room, the floors were unclean with visible soil. The caulk for the soap dispenser was soiled with a black substance.
3. The floors in patient rooms 422, 426, 433 and 427 and toilet rooms were visibly soiled An interview of the Nurse Clinical Care Leader on 3/17/2016 revealed that room 427 was unoccupied and was ready for a newly admitted patient.
4. In room 405, at 10:11 AM, the floors in the patient room and toilet room were covered with numerous wet blankets and towels. An interview of the Nurse Clinical Care Leader revealed that rounds were completed every fifteen to thirty minutes and the soiled linens would be removed at that time. At 11:00 AM, the surveyor returned to the room and the conditions were unchanged.
5. In the men's shower room, the floors and wall tiles were visibly soiled. One wooden door to a shower stall was severely damaged and delaminated, with a splintered surface. This surface had sharp areas and was not cleanable.
6. The air ducts in the patient rooms had a red and black substance on them.
7. On the Behavioral Health Unit the doors to the patient rooms open inward. This could potentially create a barricade situation for patients with behavioral health diagnoses.
8. In the patient snack refrigerator, two plastic bags of food with no labels were observed.

Intensive Care Unit (ICU):
1. The Respiratory Isolation Room, plastic was partially covering the windows to the outside. The window frames were soiled with a dark substance.
2. The monitor for negative air pressure for the Respiratory Isolation Room was malfunctioning with an electronic message that read "Alarm Condition." The room was filled with computers and other electronic equipment and was not being used for patient care at that time.

II. Based on observations in the Emergency Department (ED) on 3/17/16 and interviews with the Infection Preventionist (IP) and ED Manager if was determined that hospital staff failed to maintain the designated patient refrigerator stocked with food items that were in date and also failed to label food/drink items that were partially empty with the date and time of opening.

Observations in the ED on 3/17/16 revealed 3 open single serving milk bottles that were partially empty in the designated patient refrigerator. These milk bottles were not labeled with the date and time of opening and with the name of the patient who had been consuming the milk. A fourth single serving milk bottle was also observed in the designated patient refrigerator with an expiration date/use by date of 3/4/16. Temperatures for the refrigerator were being recorded as required. The IP, who had been present for and confirmed the observed findings, stated that the nutrition staff who monitor the refrigerator temperatures should also inspect the refrigerator content for expired food/drink items and discard items as appropriate.
Failure of staff to properly label food/drink items at the time of opening (if saving for the patient) and to discard single service and expired food items may potentially contribute to the outbreak of food-borne illness in patients.
VIOLATION: VENTILATION, LIGHT, TEMPERATURE CONTROLS Tag No: A0726
Based on observations during a tour of the facility it was determined that the patient refrigerator is kept locked and nursing is to monitor temperatures. For the month of March 2016 there were many days when the temperature was not recorded by the nursing staff. The dates on which temperatures were not recorded were 03/02/16, 03/05/16, 03/06/16, 03/07/16, 03/08/16, 03/11/16, 03/11/16 and 03/16/16. Therefore, the ability of the refrigeration unit to maintain safe food temperatures could not be determined.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observations of various procedures and processes, interviews with staff and review of documentation, it was determined that the Condition of Infection Control was not met based on the following breeches in good infection control practices.

1. Based on observations in the GI Endoscopy Suite, interviews of staff, and review of policies, it was determined that staff failed to follow infection prevention and nationally recognized precautions while performing high level disinfection of an endoscope.

Staff A was observed performing high level disinfection of an endoscope. Staff A donned appropriate PPE, pre-cleaned and flushed the endoscope prior to its transport to the disinfection processing room.

The disinfection room contains 2 sinks that are used in the disinfection process prior to the endoscope being placed in the automatic processor. The first sink contains clean tap water and the second sink contains the enzymatic detergent.

The endoscope was initially submerged in the first sink, and the leak test was performed. The endoscope was then transferred to the second sink containing the enzymatic detergent. The endoscope was submerged, and the lumens of the scope cleaned manually with a single use brush. Staff A then used Intraflush to flush the endoscope lumens with the fluid in which the endoscope was submerged. Staff A then transferred and submerged the endoscope back into the first sink, which contained contaminated water from the initial submersion. This sink had not been drained of the contaminated water and the sink had not been cleaned after the initial submersion of the dirty endoscope. Staff A resumed cleaning and attached the endoscope to the Intraflush device to flush the scope lumens of the detergent. The contaminated water was used to flush the lumens of the scope. The endoscope was then placed in the automatic processor to complete the high-level disinfection process.

The Infection Preventionist (IP) confirmed that the observed process on 3/17/16 was the process used by staff to disinfect the endoscopes. The first sink of contaminated water is not drained or cleaned prior to returning the endoscope from the enzymatic detergent sink. The Cleaning, Disinfection and Sterilization Policy (Policy # BAL.IC.001) was reviewed with the IP in regard to the high-level disinfection process. This policy failed to list the step of the Intraflush utilized as part of the disinfection process. The IP and staff A stated that the Intraflush system was initiated at the end of 2015 and had not been incorporated into policy as of the survey date. It was confirmed with the IP on 3/17/16 that after the enzymatic detergent flush and submersion for the endoscope is completed the endoscope should be returned to clean water that had not been previously contaminated and that while being limited to 2 sinks in the processing room the original water should be drained and the sink cleaned and refilled with clean water prior to the endoscope being flushed of the enzymatic detergent. This process would reduce the bioburden (bacteria amount) on the endoscope prior to the automatic processing final step of high level disinfection. On 3/21/2016, a revised copy of the high level disinfection process to include use of the Intraflush system, draining, and cleaning of the first sink of water prior to the endoscope being returned for final flushing was submitted to the surveyor for review.

Failure of staff to develop, implement and evaluate measures that adhere to infection control standards and guidelines for the disinfection of all reusable equipment places patients at risk for acquiring device associated infections. Policies that outline staff direction while performing infection control procedures should be updated prior to new equipment being used for infection control purposes.

2. Based on observations made during the disinfection process it was determined that the hospital failed to maintain logs of equipment with correct dates and time.

Observation of the disinfection process on 3/17/16 revealed that the automatic processor log identified a "power failure" during processing of endoscopes on 3/15/16 at 11:53 PM. Staff A was asked what were the outcomes and findings of the power failure that had occurred at that time. Staff A stated that Bio Med/Clinical Engineering was contacted to assess the cause of the power failure and that Clinical Engineering staff maintain logs of work orders and requests. Staff B from Clinical Engineering presented one work order request from 3/15/2016. However this work order was reported at 10:40 AM. Staff B could not produce a work order for the power failure that had occurred on 3/15/2016 at 11:53 PM. Staff B stated that he was the technician assigned to assess and repair the processor and that the failure log was set to the wrong time. Staff B also stated that on 3/13/2016 the time on the processor was changed due to Daylight Savings Time and he believed that the time was set with a 12 hour incorrect difference. Staff B confirmed that the work order initially provided was the only repair request for the processor on 3/15/2016. Staff B also confirmed that the times on all disinfection sterilizers and processors were being inspected and corrected at the time of finding during survey on 3/17/2016. Clinical Engineering staff made corrections to all automatic processors to show appropriate time during the survey.

Failing to verify that proper changes are made to time logs on infection control equipment places the hospital staff at risk for maintaining false repair work order logs. These logs are maintained in order for the hospital to track events and issues with the processing of reusable equipment and must be maintained with correct dates and times of occurrences.

3. The procedure for isolation patients in the ICU was reviewed by the surveyors. The ICU has 5 bays that are separated from each other by privacy curtains. The isolation Personal Protective Equipment (PPE) should be donned before coming in contact with the patient. However the PPE station is at the head of the patient bed requiring the care provider to pass the patient before donning the equipment. The placement of the PPE station may not allow the care provided to avoid contact prior to donning PPE.