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.

SSM HEALTH DEPAUL HOSPITAL ST LOUIS 12303 DEPAUL DRIVE BRIDGETON, MO 63044 July 29, 2011
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation and interview the facility failed to ensure the privacy of patients seen in the Emergency Department in rooms #24 and #25. The unit had a total of 27 rooms. The facility census was 318.

Findings included:

1. During an Interview on 07/28/11 at approximately 9:12 AM Staff T, Team Leader of the Emergency Department, stated
-The two monitored rooms #24 and #25 did not have any signs letting patients know they were video monitored while in the rooms.
-Patients are notified of the video monitoring depending on how acute they are. Sometimes they are not notified.
-There is not any documentation to verify when patients are or are not notified of the video monitoring.

2. During an interview on 07/28/11 at 2:10 PM Staff III, Regulatory Coordinator, stated the following:
-There was not a policy for staff direction regarding the video monitors in the Emergency Department for rooms #24 and #25.
-The monitors did not record.
-The security officer could not see them.

3. During an interview on 07/28/11 at 4:25 PM Staff LLL, Interim Team Leader 3-11 Emergency Department stated the following:
-The staff cannot turn off the video monitors in rooms #24 and #25. We have to call security.
-We notified some patients and some we have not.
-We try to walk patients to the rest room, but if we can't it is my expectation that monitor would be turned off or use a sheet or screen to hide the patient if using a commode or involved activities requiring privacy.
-There is not a policy or documentation regarding the patient monitoring in the Emergency Department.

4. During an interview on 07/29/11 at 9:25 AM with Staff NNN, Team Leader for St. Joseph Health Center stated the following:
-There were two rooms in the Emergency Department that were video monitored (rooms #24 and #25).
-The two rooms had two cameras in each.
-The rooms were each psychiatric safe rooms.
-Security is unable to turn off the cameras in these rooms.
-Security does not have any responsibility for the cameras in the Emergency Department.

5. During an interview on 07/29/11 at 9:25 AM Staff T stated that it was the expectation when a patient was involved in an activity that needed privacy the door to the room would be shut and the patient would be observed on the monitor.

6. Observation on 07/29/11 at approximately 9:25 AM showed the following
-A monitor mounted close to the ceiling.
-The monitor had four screen shots (two views for each room) approximately 4 inches by 6 inches.
-A patient was in one of the rooms and could be seen from the walkway.

7. During an interview on 07/29/11 at 9:35 AM Staff T and Staff AAA, Team Leader Quality, Risk, Patient Safety, stated the following:
-The patient currently using one of the rooms could be visualized from the walkway.
-The walkway was a main walkway for visitors, patients, and staff.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and policy review the facility failed to ensure patients were provided care in a safe setting for 16 of 16 patients on Suicide Precautions on the Adult 1000 Unit, for seven out of 11 patients on Suicide Precautions on the Adult 1100 Unit, for five of 10 patients on suicide precautions on the Mentally Retarded/Developmentally Disabled and Geriatric 1400 unit, and for five of 12 patients on suicide precautions on the Adolescent 1200 unit. The facility census was 318.

Findings included:

1. Record review of the facility policy titled, "Precaution and Observation Levels, revised on 06/2011, showed the following direction:
-The levels of observation for patients are ordered by the attending psychiatrist. A Registered Nurse (RN) may initiate additional levels of observation based upon nursing judgment. However, the RN obtains a physician order after discussion with the attending psychiatrist.
-The levels of observation are 15 minute observation round documentation, Within-Line-of Sight at all times, and Within-arm-length-reach at all times.
-A Physician order specifies precautions that are used to identify the inherent risk of the specific patient.
-Suicide Precautions;
-Elopement Precautions;
-Assault/Violence Precautions;
-Sexual Abuse management Precautions;
-Seizure Precautions;
-Self Injurious Behavior Precautions;
-Fall Precautions;
-Isolation Precautions.
-All patients are monitored and documented on the Daily Observation Flowsheet a minimum of every 15 minutes.

2. Record review of the facility policy titled, "Patient Rights/Behavioral Health Services", revised 06/11, showed that the patient's have the right to considerate, respectful, and quality medical care provided in a safe and secure environment.

3. Observation on 07/26/11 at 12:45 PM on the Adult 1000 Unit showed a bathroom door within the patient's room with three beveled hinges (This created a gap between the door and the jamb where a ligature could be attached for hanging purposes.).

4. During an interview on 07/26/11 at 1:10 PM Staff RR, Team Leader for 1000 and 1100 Units and Staff YY, Director of Behavior Health Services stated that all the patient rooms had a bathroom door with three hinges and all the bathrooms were located on the inside of the patient's rooms. There were a total of 10 rooms.

5. During an interview on 07/27/11 at 1:15 PM Staff ZZ, Coordinator Regulatory and Risk for Behavioral Health Services, stated that the facility did not have a policy for staff direction when the doors of patient's rooms were shut for patient's on Suicidal Precautions.




6. Observation on 07/26/11 at 1:10 PM on the 1100 Unit (Intermediate Adult Behavior Health Unit) showed all patient doors and bathroom doors (ten semi-private rooms on unit) had three beveled hinges (creating a gap between the door and the jamb where ligature could be attached for hanging purposes).

7. On 7/28/11 Staff F, RN, Executive Director of Nursing for the Behavioral Unit verified that eleven of seventeen patients in this unit were on suicide precautions.

8. During an interview on 07/28/11 at 1:40 PM, Staff RR, RN, Team Leader on the 1000 and 1100 Adult Behavior Health Unit stated that:
- The patient room doors and bathroom doors are not locked during the day or evening.
- Patients can close their doors during the day if they choose.
- Staff enters all patient rooms for fifteen minute rounds.
- All bathroom doors are locked at 11:00 PM.
- Was not aware of a policy to direct staff when the patient bathroom doors are to be kept locked.







9. Observation on 07/26/11 at 11:50 PM, on the 1400 Unit, showed a telephone mounted on the wall (approximately four feet high) with a flexible metal cord from the telephone base to the head/mouthpiece that measured approximately 24-inches long. This phone cord was accessible to all patients on the unit, including the ones on suicidal precautions. This cord could potentially be used as a hanging device or as a weapon if disconnected.

10. Observation on 07/26/11 at 12:10 PM, on the 1400 Unit, showed electrical hospital-type beds in all of the geriatric rooms (12 total beds) and four beds in the (Mentally Retarded Developmentally Disabled) MRDD area. These beds had long cords (31-inches) accessible to the patients. The beds also had handle-type openings in the headboard and footboards, plus side rails, all of which posed a ligature hazard or potential hanging hazard.

11. During an interview on 07/28/11 at 1:47 PM, Staff D, Nurse Manager of the 1400 Unit, stated all of the hospital beds are electric and the patients on that unit do wander. Staff D stated the patient room doors are kept open and there were no alarms or barriers to keep patients out of any particular room.

12. Review of discharged Patient #68's record, and an Event Report, dated 11/09/10, showed Patient #6 was admitted on [DATE] with diagnoses of psychotic disorder and rule-out schizophrenia. The patient attempted to hang him/herself (staff heard a gurgling-type noise at 2:15 PM and found the patient hanging by a sheet-even though the rounds sheet documented the patient was visualized in the bathroom at 2:15 PM) by pushing a bed sheet through an opening between the shower curtain metal hanging device and the ceramic tile opening of the shower (some caulk was missing causing an opening).

Interview and observation of contraband/environmental and patient rounds on 07/27/11 at 1:50 PM showed the rounds were predictable and documented in pre-printed times (not actual time). Psychiatric technician, Staff NN confirmed he/she did rounds starting at one room working toward the opposite end each 12-hour shift. The contraband/environmental rounds did not specify what the technician had checked in the room, just that the rounds were done.

Even though the facility had a near hanging, staff failed to remove potential ligature hazards within the environment of suicidal patients.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on interview and record review the facility failed to provide inpatients with the correct telephone number of the Missouri Division of Health and Senior Services (DHSS) in which to file a grievance. This has the potential to affect all inpatients in the facility. The facility census was 318.

Findings Included:

1. Record review of the facility's Admission Packet that contains the Patient Rights and Responsibilities given to all patients admitted into the hospital showed the incorrect telephone number for the State Agency in which to file a grievance.

2. During an interview on 07/28/11 at 9:30 AM, Staff GG, Clinical Director of 3-North, 3-South, and 4-North, called the telephone number which was out of service, confirming the wrong number.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
Based on interview, record review and policy review the facility failed to obtain a copy of the Patient's Advance Directive for one (Patient # 65); and failed to ask two patients (Patients
#54 and #55) if they would like assistance to complete an Advance Directive of 14 medical records reviewed for Advanced Directive documentation. The facility census was 318.

Findings Included:

1. Record review of the facility's policy titled, "Advance Directives" dated 03/2009, showed the following direction:
-A copy of the Advance Directive (AD) document should be requested and placed in the medical record;
-If the document itself is not available and cannot be brought to the hospital, the nurse documents this in the multidisciplinary history and progress note section of the patient chart;
-The Physician will then discuss with the patient the contents of the Advance Directive (AD) and document the essence of the conversation in the patient record;
-If the patient does not have an advance directive, an opportunity to prepare one will be made available. A referral for assistance in completing the advance directive will be given to Spiritual Care.

2. Record review of current Patient #65 medical record showed that the patient had an Advance Directive (AD). The AD was not in the Patient's chart and there was no further documentation from the nurse's or the physician's caring for the patient that the content of the AD was discussed.

3. During an interview 07/28/11 at 9:15 AM, Staff OOO, Clinical Support Nurse, confirmed that it is documented the Patient has an Advance Directive (AD) and he/she was not able to provide any documentation of follow-up obtained from the Nurses and the Physician's.





4. Review of current Patient #54's admission nursing assessment ,dated 07/26/11, showed he/she was admitted on that date with a diagnosis of a foot infection. The patient was alert and oriented as determined by facility staff.

During an interview on 07/28/11 at 9:10 AM, patient #54 stated he/she was not aware of Advance Directives being offered to him/her by staff.

Further review of the patient's admission assessment showed staff failed to ask the patient if he/she would like assistance with completing an Advance Directive. There was no Advance Directive in the record.

5. Review of current Patient #55's admission nursing assessment , dated 07/17/11, showed he/she was admitted on that date with a diagnosis of an ear infection leading to meningitis (inflammation of the lining of the brain and spinal cord). The patient was alert and oriented as determined by facility staff.

During an interview on 07/28/11 at 10:03 AM, patient #55, and his/her spouse stated he/she did not have an Advance Directive. Patient #55 was not aware of being offered assistance to complete one, and would have liked to (earlier in stay).

Further review of the patient ' s admission assessment showed staff requested a copy on 07/19/11; however, it was documented there was no advance directive on the same date. As of 07/28/11, or nine days later, and an extended stay in the intensive care unit, staff failed to obtain a copy, or assist the patient with completion of an advance directive, whichever was actually correct.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0176
Based on interview and record review the facility failed to ensure all physicians whom order restraints and seclusion completed required training. The facility failed to put a policy in place regarding restraint and seclusion physician training requirements. The facility census was 318.

1. Record Review of facility document titled, "Medical Staff Rules and Regulations," dated 03/21/11, showed facility direction that all practitioners and providers shall comply with the health center policies concerning patient restraint and/or seclusion. In addition, practitioners and providers who may be involved in the use of restraints (i.e., hospitalists, intensivists, emergency department providers and psychiatry providers) shall receive ongoing education and training regarding application and implementation of restraints or seclusions as per the health center's policy.

2. During interviews on 07/28/11 at 3:20 PM and 3:45 PM Staff KKK, Chief Medical Officer, stated the following:
-The restraint and seclusion education was sent to physicians.
-There was not any documentation to verify they read the education material.
-The facility failed to have a policy regarding physician restraint and seclusion training requirements.

3. During an interview on 07/29/11at approximately 10:30 PM Staff III, Regulatory Coordinator, stated the following:
-63 physicians were sent the restraint and seclusion education.
-At a later date, the rest of the physicians would receive the education. Staff III estimated approximately 600 total physicians should eventually receive this education.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure one of two patients reviewed with a pressure sore and (partial thickness skin loss-Stage II) weight/nutrition problems (Patient #24) received , and consumed a liquid nutritional supplement (Ensure Plus with meals) as ordered by the physician. The facility census was 318.

Findings Included:

1. Facility staff failed to provide a policy regarding the process by which a liquid nutritional supplement is delivered and documented, even though requested.

2. Review of current Patient #24's initial nutrition assessments showed the following:

-Patient #24 was admitted on [DATE] with a diagnosis of acute renal failure.
- Patient #24 had a decreased appetite and inadequate energy intake.
- On 07/24/11 the Registered Dietitian (RD) recommended Ensure Plus three times a day with meals. The patient ' s intake averaged 22% over the prior 48-hours.
- On 07/25/11 the patient ' s intake remained poor.

Review of the initial nursing assessment, dated 07/19/11 showed the patient had a pressure sore on the coccyx (tailbone).

Review of the patient's laboratory results showed the following:

-The patient's albumin (protein in the blood -which can be indicative of wound healing ability (if low, a poor ability to heal) on admission was 3.6 (normal=3.5-5.0), and the Total Protein was 6.6 (normal=6.3-8.2). The patient ' s albumin level dropped to 2.8 by 07/24/11, and the Total Protein dropped to 6.4 by 07/20/11.

During an interview on 07/26/11 at 12:55 PM, Registered Nurse Staff L stated that the supplement consumption was included in the liquid oral intake; however, there was no specific way to identify how much of the supplement was consumed, if at all. Staff L said it was a nursing responsibility to document the supplement consumption.

During an interview on 07/26/11 at 1:26 PM, RD Staff K confirmed the supplement consumption should be documented and confirmed it was not for Patient #24.

Review of the documentation of the patient's intake, on 07/26/11, showed staff failed to document the provision and consumption of the Ensure Plus since ordered on [DATE], or for approximately five opportunities/meals.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation, interview, record review and policy review facility staff failed to follow facility policy to ensure medications were administered within 30 minutes of the scheduled time for eight patients (#29, #30, #31, #4, #5, #6, #7, #8) of sixteen patients observed receiving medications. The facility census was 318.

Findings Included:

1. Record review of the facility's policy titled, "Network Clinical Practice Policy," Subject: Medication Administration, revised on 04/2010, showed direction for facility staff that medication should be given within 30 minutes before or after the scheduled time.

2. Record review of facility undated document titled, "DPHC (De Paul Health Care) BHS 1100 (The Intermediate Adult Behavior Health Unit), Override times, Activity Assignment Rules," showed medications ordered daily were to be administered at 8:30 AM.

3. Observation of medication pass on the Adult 1000 Unit on 07/26/11 from 9:00 AM to 9:40 AM showed the following medications ordered for daily administration given at 9:12 AM for Patient #29:
-Aspirin Enteric Coated 81 mg (milligrams) by mouth
-Clonidine 0.1 mg by mouth
-Lisinopril 20 mg by mouth
-Seroquel XR 150 mg by mouth

4. Observation of medication pass on Adult 1000 Unit on 07/26/11 from 9:00 AM to 9:40 AM showed the following medications ordered for daily administrations given at 9:25 AM for Patient #30:
-Celexa 20 mg by mouth
-Prolixin 2.5 mg by mouth
-Miralax 17 g (grams) by mouth
-Aspirin Enteric Coated 81 mg by mouth administered at 9:26 AM

5. Observation of medication pass on Adult 1000 Unit on 07/26/11 from 9:00 AM to 9:40 AM showed the following medications ordered for daily administrations given at 9:30 AM for Patient #31:
-Norvasc 10 mg by mouth
-Symbicort 2 puffs by inhalation
-Toprol XL 25 mg by mouth
-Effexor XR 150 mg by mouth
-Nicoderm CQ 21 mg removed at 9:30 AM and applied at 9:32 AM.

6. During an interview on 07/26/11 at 10:23 AM Staff R, Clinical Support Nurse, stated that medication ordered daily is routinely given at 8:30 AM with a 30 minute window of time on each side of the 8:30 AM.

7. During an interview on 07/27/11 at 10:10 AM Staff III, Regulatory Coordinator, stated that times were similar on all psychiatric units and were similar on the medical-surgical units.


















8. Observation on 07/26/11 at 9:45 AM showed Staff E, RN administer the following medications to Patient #4:
- Cogentin 1mg. by mouth.
- Haldol 10mg. by mouth.
- Risperdal 2mg. by mouth.

Review of Patient #4's medical record showed:
- A document titled, "Medication Administration Record" (MAR) showed that the medications were scheduled to be administered at 8:30 AM and were charted as given at 8:30 AM.

9. Observation on 07/26/11 at 9:46 AM showed Staff E, RN administer the following medication to Patient #5:
- Lexapro 20mg. by mouth.

Review of the MAR in the patient's medical record showed that the medication was to be administered at 8:30 AM.

10. Observation on 07/26/11 at 9:50 AM showed Staff E, RN administer the following medication to Patient #6:
- Prozac 20mg. by mouth.
- Librium 10mg. by mouth.
- Seroquel 50mg. by mouth.

Review of the MAR in the patient's medical record showed that the medications were scheduled to be administered at 8:30 AM.

10. Observation on 07/26/11 at 10:00 AM showed Staff G, RN administer the following medication to Patient #7:
- Effexor 112mg. by mouth

Review of the MAR showed that the medication was scheduled to be administered at 8:00 AM.

11. Observation on 07/26/11 at 10:05 AM showed Staff G, RN administer the following medication to Patient #8:
- Cipro 500mg by mouth.
- Pepcid 20mg. by mouth.

Review of the MAR showed that the Cipro was scheduled to be administered at 8:00 AM, and the Pepcid was due to be administered at 8:30 AM.

12. During an interview on 07/26/11 at 10:05 AM, Staff G, RN stated some medications were late because patients were not out of bed at the time the medications were due.

13. During an interview on 07/26/11 at 10:15 AM, Staff E, RN stated some medications were late due to having to share the Pyxis (a machine which dispenses medication) with other nursing staff at the time of medication administration.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview, and policy review the facility failed to ensure staff performed hand hygiene (washed hands with soap and water or used hand sanitizer) between patients (Patient #30, #31, #32); failed to clean the One Touch machine and case and personal communication device (telephone) after patient use (Patient #40); failed to explain when to clean One Touch machine and case in the policy; failed to ensure crash/emergency carts are kept clean in three patient care areas; failed to prevent contamination of clothing and hands during patient care for two patients in contact isolation (Patient #36, #10); failed to perform hand hygiene after removing gloves for (Patient #39, #16); failed to date, time and initial intravenous (IV) tubing with the next change date as directed in the policy for four patients (Patients #10, #12, #54 and #56). The facility census was 318.

Findings Included:

1. Record review of the facility policy titled, "Network Clinical Practice Policy," Subject: Hand Hygiene revised 01/2011 showed direction for facility staff to:
- Perform hand hygiene before and after each patient contact.
- Perform hand hygiene after removing gloves.

2. Record review of the facility policy titled, "Sterilization, Disinfection and Cleaning Schedule for Disinfection of Non-Critical Items", revised 12/2008, showed direction for facility staff to disinfect the One Touch machines with Sani cloths (disinfectant wipes), but no direction given as to when to clean the One Touch machine and case.

3. Record review of the facility policy titled, "Wireless Communications" dated 08/08 showed direction to disinfect the phone when contaminated (comes in contact with patient or environment or touched with gloved hands) and at the end of the day.

4. Review of a facility policy titled, "Intravenous (IV) Therapy-Daily Care and Monitoring," reviewed 03/10, directed staff to label IV tubing with the date, time and initials.

5. Observation on 07/26/11 at 9:00 AM Staff Q, RN (Registered Nurse) performed a blood sugar check with a One Touch machine (device used to test blood sugar) in the day hall area and failed to cleanse machine or case with Sani cloth before setting machine (which was in case) and case back in the medication room.

6. Observation on 07/26/11 from approximately 9:00 AM to 9:40 AM showed Staff Q, failed to perform the following:
-Hand hygiene before or after medication administration for Patient #30 and #31.
-Hand hygiene before medication administration for Patient #32.

7. During an interview on 07/26/11 at 9:44 AM Staff Q stated that hand hygiene should be performed between patients and test technicians clean the One touch machine and case with the Sani wipes.

8. During an interview on 07/27/11 at 1:00 PM, Staff RRR, Infection Control Coordinator stated that it is the expectation for all patient equipment to be cleaned between patients, including the glucometer (One Touch Machine) and the case. Staff RRR also stated that this is not specifically reflected in the facility policy.






9. Observation on 07/26/11 at 9:05 AM showed a crash cart (a cart used for transportation and dispensing of emergency medication/equipment at site of medical/surgical emergency for life support protocols) on the Adult 1100 Behavioral Health Unit7 South Unit that was covered with a light layer of dust.
Staff F, Executive Director of Nursing for Behavior Health verifed that the crash cart was dusty.

10. Observation on 07/26/11 at approximately 2:30 PM showed a crash cart on the 7 North Unit that was covered with a light layer of dust.
Staff MM, RN, Clinical Director verified that the crash cart was dusty.

11. Observation on 07/26/11 at 3:15 PM showed a crash cart on the 7 South Unit that was covered with a light layer of dust.
Staff MM, RN, Clinical Director verified that the crash cart was dusty.

12. During an interview on 07/29/11 at 9:05 AM Staff #III, Regulatory Coordinator, stated that prior to June 20th cleaning the crash carts was the responsibility of the units, and not well defined. Now it has become the responsibility of environmental services.

13. Observation on 07/26/11 at 3:25 PM of Staff CC, Registered Nurse, providing patient care to Patient #36 on contact isolation showed the following:
- Don gown and gloves and enter patient room and flushed and then remove an intravenous line in the patients right hand.
- Push isolation gown aside with his/her soiled gloved hand and reached into his/her pocket to retrieve a dressing and tape.

14. Observation on 07/26/11 at 3:40 PM of Staff DD, RN conducting a dressing change to Patient #39 showed the following:
- Don gloves and removed a soiled dressing.
- Removed and don another pair of gloves without performing hand hygiene.
- Applied a dressing to the patient's left inner knee.

15. During an interview on 07/27/11 Staff RRR, Infection Control Coordinator and Staff SSS, Infection Control Specialist stated that:
- It is the expectation that staff would not contaminate clothing with a soiled gloved hand while conducting patient care.
- Staff had been in-serviced to remove gloves and perform hand hygiene after removing a soiled dressing and apply a new dressing.





16. Observation on 07/25/11 at 3:00 PM of Patient #22 showed the following:
- A 1000 milliliter (ml) bottle of Sterile Water half empty and sitting on shelf above the bedside table, without a date as to when opened;
-An opened irrigation kit that had clear fluid in it, that was not labeled what the solution was, and date the kit was opened.

17. During an interview on 07/25/11 at 3:00 PM, Patient #22 stated that he/she had a Nasogastric Tube (tube placed through nose that goes to stomach) removed this morning and the Sterile Water and Irrigation Kit is for rinsing that tube.

18. Observation on 07/25/11 at 3:30 PM showed the following:
- Staff H, Registered Nurse (RN) entered Patient #40's room to attend to the Intravenous (IV) Pump alarm. He/she reached into his/her pocket to answer the phone, then placed it on the Patient's IV pump;
-He/she proceeded to check the Patient's IV tubing, and picked the phone off the IV Pump and put it into his/her pocket;
-He/she failed to perform hand hygiene prior to and after touching the phone, and the Patient's IV Pump and IV tubing.
- He/she disconnected IV tubing from Patient and walked over to the trash can to flush bubbles out of the IV tubing without performing hand hygiene or wearing gloves.
- He/she then attempted to reconnect the IV tubing to the patient;
-He/she then proceeded to take the phone out of his/her pocket to call for assistance from another Nurse without performing hand hygiene.
-Staff I, RN entered room after sanitizing hands and donning gloves and proceeded in disconnecting the tubing from the Patient's IV catheter. He/she then cleansed the area around the IV catheter, removed gloves, and donned new gloves without performing hand hygiene.

19. Observation on 07/26/11 at 9:50 AM showed Staff A giving a bed bath to Patient #16 wearing same gloves to clean Patient's buttock area, then reached for the clean sheets to change the bed linen.

20. Observation on 07/26/11 at 9:50 AM showed Staff A applying lotion to the back of Patient #16 changing gloves but did not perform hand hygiene.

21. Observation on 07/26/11 at 10:15 AM showed Staff J, Registered Nurse (RN) put on gloves, helped Staff A to pull Patient #16 up in bed, then went to computer to document medication, dropped a pill package on the floor, picked it up placing it on the Patient's night stand, and continued to document on the computer without changing gloves or performing hand hygiene.












22. Observation on 07/27/11 at 10:45 AM showed wound care RNs, Staff OO and PP changed the dressing on patient #10's toe. Patient #10 remained in contact isolation. When the nurses finished the dressing change, Staff OO took the gloves off, sanitized his/her hands, but then roamed around the patient's room handling the patients overbed table and its contents, and re-arranged supplies on the window ledge contaminating his/her hands.

23. Observation on 07/26/11 at 9:43 AM showed RN, Staff PPP, performed a percutaneous intravenous central catheter (PICC) line dressing change on Patient #10. Patient #10 was in contact isolation related to MRSA in a toe. When staff PPP finished the procedure, he/she took the gown and gloves off, sanitized his/her hands, but then roamed around the patient's room handling the patients overbed table and its contents contaminating his/her hands and uniform.

Also observed was one IV line (tubing) with an adhesive tag on it that said it was to be changed, "Thursday." Staff failed to date, time and initial the tag as well, as directed in their policy.

24. Observation on 07/25/11 at 3:15 PM showed two IV lines (for Patient #12) with adhesive tags on them with a weekday pre-printed on them; however, staff failed to date, time and initial the tags as well, as directed in their policy. During a concurrent interview, RN Staff QQQ stated that the tags should be completed with the date, time and initials.

25. Observation on 07/28/11 at 9:40 AM showed four IV lines (for Patient #54) with an adhesive tag on them. Staff failed to date, time and initial the tags as to when they were to be changed, as directed in their policy.

26. Observation on 07/28/11 at 11:30 AM showed one IV line (for Patient #56) with an adhesive tag on it. Staff failed to date, time and initial the tags as to when it was to be changed, as directed in their policy.