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ST LOUIS UNIVERSITY HOSPITAL 3635 VISTA AVE SAINT LOUIS, MO 63110 Feb. 16, 2017
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview and policy review, the facility failed to ensure that staff followed infection control policies and infection prevention standards when they failed to:
- Maintain sterile gloves prior to the insertion of a central venous catheter for one patient (#22) of one observed;
- Wear a protective face shield while placing a central venous catheter for one patient (#22) of one observed;
- Prevent possible cross contamination for four patient's (#21, #22, #23 and #24) of four observed when their blood pressure cuffs were placed in a file touching each other and then reused when the patients received their room assignment;
- Maintain sterile technique when changing a dressing for one patient (#11) of two observed.
These failed practices increased the potential to spread infection for all patients, visitors and staff. The facility census was 279.

Findings included:

Record review of the facility's undated policy titled, "Bundle Information for Central Venous Catheter (CVC) Placement Policy," showed that maximal sterile barrier precautions are used during the insertion of a central venous catheter. Aseptic technique should be used to include the use of a cap, mask, sterile gown, sterile gloves, face shield, and a large sterile sheet for the insertion of all CVC's.

Observation on 02/15/17 at 10:20 AM showed in the emergency room (ER), Trauma Bay #2, Staff Z, Emergency Medicine Resident, prepared to place a CVC for Patient #22. Staff Z:
- Opened the CVC packet on the stainless steel bedside cart at the head of the bed;
- Removed the sterile gloves covered with paper and walked across the room and placed them on the lid of a red biohazard trash can;
- Opened the paper the sterile gloves were in, which exposed them to the environment (the room was crowded with several employees who walked by the gloves and one employee who was unaware the gloves were placed there, draped a phone cord over the top of the sterile gloves);
- Left the sterile gloves on the biohazard trash can and walked back to the head of the patient's bed and prepared the site with Chloraprep (skin antiseptic with an applicator);
- Walked back to the biohazard trash can and placed the Chloraprep sponges on the floor in front of the trash can;
- Removed the sterile gloves and placed them on his hands; and
- Walked back to the head of the patient's bed and completed the CVC placement.

During an interview on 02/15/17 at 10:50 AM, Staff Z, stated that he put the sterile gloves on any spot available, threw the Chloraprep wherever needed and cleaned up at the end of the procedure.

During an interview on 02/15/17 at 10:55 AM, Staff BB, Team Leader (TL) for the ER, stated that she expected her employees to not use the biohazard trash can as a table.

During a telephone interview on 02/16/17 at 12:00 PM, Staff VV, Medical Doctor (M.D.), ER Attending, stated that she expected Staff Z to follow the policy for sterile preparation.

Observation on 02/15/17 at 10:20 AM showed in the ER, Trauma Bay #2, Staff Z, Emergency Medicine Resident, placed a mask (which covered the bottom half of his face) in preparation of insertion of a CVC for Patient #22. Staff Z completed the CVC placement without a face shield.

During an interview on 02/15/17 at 1:20 PM, Staff Z stated that he did not wear a face shield because he didn't anticipate a lot of blood spray back (spurt of blood released when accessing a blood vessel during the CVC placement).

During an interview on 02/15/17 at 1:25 PM, Staff BB, TL for the ER, stated that Staff Z should have worn a face shield during the CVC placement.

During a telephone interview on 02/16/17 at 12:00 PM, Staff VV, M.D. ER Attending, stated that she expected all physicians who placed a CVC to wear face shields and personal protective equipment (PPE).

Observation on 02/15/17 at 10:07 AM, showed Staff AA, ER Triage Nurse:
- Placed blood pressure cuff on Patient #23's arm;
- Took the patient's blood pressure;
- Removed the blood pressure cuff from patient;
- Attached the cuff to a sepsis screening sheet (a form the facility used to evaluate patients for sepsis, a bacterial infection that gets into the blood) with a paper clip;
- Placed the blood pressure cuff and the sheet in a file box next to other current patient's (#21, #22 and #24) blood pressure cuffs, and retrieved them to go with the patient when they were placed in a room.
This put all of these patients at risk for cross contamination.

During an interview on 02/15/17 at 10:45 AM, Staff AA, stated that the staff came up with this procedure in order to reuse the blood pressure cuffs.

During an interview on 02/15/17 at 10:55 AM, Staff BB, TL for the ER, stated that the process of reusing the blood pressure cuffs was a trial.

Record review of the facility's policy titled, "Hand Hygiene," revised 05/2015 showed that before and after direct contact with patients, blood/body fluids or equipment and environmental items touched by patients hand washing should be completed.

Observation and concurrent interview on 02/14/17 at 2:10 PM, showed Staff S, Registered Nurse, changed a left foot dressing on Patient #11, but contaminated the wound site. Staff S:
- Wiped down bedside table and placed clean pad on it with items needed for the procedure;
- Removed the old dressing;
- Removed his gloves, washed hands and regloved;
- Retrieved a tube of Silvastat (antimicrobial cream) from the patient's tub (a storage tub for patient's personal items);
- With the same gloves, Staff S opened the Silvastat, squeezed the tube and touched the patient's wound gauze with the tip of the tube; and
- Staff S, then placed the gauze directly on the patient's wound. Staff S stated that he didn't realize the tube was contaminated.

During an interview on 02/14/17 at 2:55 PM, Staff Q, Seven South TL, stated that Staff S should have cleaned the outside of the tube, and washed hands in between and before touching the patient again.

During an interview on 02/15/17 at 1:15 PM, Staff PP, Infection Control Practitioner, stated that sterile gloves should never be placed on a trash can. She did not believe the policy required that a face shield be worn when placing a central line and it would be up to the physician to assess the patient for risk of blood splatter. If staff were placing blood pressure cuffs in a folder and the cuffs could touch one another, cross contamination could occur; thus, it was not a good practice.