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.

CHRISTIAN HOSPITAL NORTHEAST 11133 DUNN ROAD SAINT LOUIS, MO 63136 Nov. 30, 2017
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review and policy review, the facility failed to provide adequate nursing supervision of patient care as evidenced by failures with inconsistent/incorrect implementation of fall risk identifiers for six current patients (#11, #20, #16, #26, #27, and #28) of eight current patients reviewed for fall risks. These failures had the potential to affect all patients admitted to the facility. The facility census was 236.

Findings included:

1. Review of the facility's policy titled, "Patient Admission" revised 04/2013, showed the directives for staff to assess for fall risk upon admission and a yellow color coded/patient identification wristband would be applied to wrist for fall risk alert, if applicable.

Review of the facility's undated policy titled, "Care Practice Guideline-Safety," showed directives for staff to implement the following fall risk levels:
- Low risk (5 or less) - apply non-skid socks, place bed in lowest position and upper side rails raised.
- Moderate risk (6-13) - apply yellow fall risk armband, apply yellow non-skid socks and institute fall risk signage.
- High risk (14 or greater) - apply bed and chair alarms and move the patient near the nursing area.

2. Record review of the facility's monthly performance summary from September through November 2017, showed that:
- In September, total falls were 25, with seven falls that resulted in harm;
- In October, total falls were 32, with six falls that resulted in harm; and
- In November, total falls were 13, with two falls that resulted in harm.

3. Observation on 11/28/17 at 1:30 PM, on the fourth floor, showed Staff XX, Laboratory Associate, perform a blood draw (removal of blood from a vein, through a metal needle) on Patient #11. The patient was in bed, with the bed in high position. Fall signage was noted in the patient's room, and a yellow arm band and yellow socks were on the patient. Staff XX completed the blood draw, left the bed in high position and exited the room, leaving the patient unattended.

Record review of Patient #11's History and Physical (H&P), dated 11/12/17, showed that she was a [AGE] year old female that presented to the facility with mental status changes. The patient was alert and oriented to her name only.

Record review of Patient #11's fall assessment, dated 11/28/17, showed that the patient's score was 11, a moderate risk.

During an interview on 11/28/17 at at 1:35 PM, Staff O, RN, stated that Patient #11 was at high risk for falls and that Staff XX should have lowered the bed before she left the patient unattended, and/or exited the room.

4. Observation on 11/28/17 at 2:50 PM, on the eigth floor, showed there was no fall signage posted in Patient #20's room, and the patient did not have yellow socks or a yellow arm band on.

Record review of Patient #20's H&P, dated 11/26/17, showed that he was a [AGE] year old male that presented to the facility with abdominal pain, after recent surgery to both knees. The patient currently had a wound vaccuum (Wound vac, medical device that applys gentle suction to a wound dressing, acts as a vacuum to improve/speed the healing process) on his left lower leg following a (surgical procedure where the skin was cut and left open, to relieve pressure to treat loss of circulation).

Record review of Patient #20's fall assessment, dated 11/28/17, showed that the patient's score was six, a moderate risk.

During an interview on 11/28/17 at at 2:52 PM, Staff U, RN, stated that Patient #20 was at risk for falls and did not have a yellow arm band or fall signage in place, but should have.

5. Observation on 11/28/17 at 3:00 PM, on the eighth floor, showed Patient #16 without a yellow arm band.

Record review of Patient #16's H&P, dated 11/24/17, showed that he was a [AGE] year old male that presented to the facility with alcohol withdrawal (medical condition related to an alcoholics lack of alcohol intake - can cause confusion, tremors or violent, uncontrollable shaking). The patient also had swelling of both lower legs.

Record review of Patient #16's fall assessment, dated 11/28/17, showed that the patient's score was three, a low risk.

During an interview on 11/28/17 at at 3:10 PM, Staff S, RN, stated that Patient #16 was at risk for falls, verified that the patient did not have a yellow arm band on, but should have.

6. During an interview on 11/28/17 at 3:10 PM Staff W, Nursing Manager, stated that:
- Nursing staff performed a reassessment of the patient's fall risk every eight hours;
- The fall risk identifiers for falls should be added or removed based on the fall risk assessment;
- The fall risk identifiers for falls should be consistent to appropriately identify and/or prevent patients for falls; and
- The nurses were responsible to adhere to the facility's policy.

7. During an observation on 11/28/17 at 12:30 PM, on the seventh floor, showed the following:
-The white board in patient #26's room stated that he was a fall risk.
-Patient #26 was not wearing a yellow armband on his wrist.
-Patient #26 was not wearing yellow socks.
-There was no fall signage on the outside of Patient #26's door.

Record review of Patient #26's H&P, dated 11/27/17, showed the following:
-The patient was a [AGE] year old male that presented to the facility with abdominal pain.
-The patient was wheelchair and bed bound (restricted to, due to illness or disease that limits self movement).
-The patient had partial quadriplegia (paralysis caused by illness or injury that results in partial or total loss of use of all four limbs and torso) due to [DIAGNOSES REDACTED] (a rare disorder in which a cyst forms within the spinal cord, compressing and damaging the spinal cord over time).

Record review of Patient #26's fall assessment, dated 11/28/17, showed that the patient's score was nine, a moderate fall risk.

During an interview on 11/28/17 at 12:30 PM, Staff DD, RN, stated that moderate fall risk patients needed a yellow armband, yellow socks, and the bed low to the ground. She did not know why Patient #26 did not have on a yellow armband or yellow socks.

8. Record review of Patient #5's H&P, dated 11/22/17, showed that he was a [AGE] year old male that presented to the facility with complaints of abdominal distention and shortness of breath. He had a history of mild cognitive (of or relating to the mental processes of perception, memory, judgement and reasoning) impairment and [DIAGNOSES REDACTED] Syndrome (an imbalance or rocking/swaying sensation that occurs after exposure to motion).

Record review of Patient #5's fall assessment, dated 11/28/17, showed that the patient's score was 15, a high fall risk.

Observation on 11/28/17 at 9:30 AM, on the seventh floor, showed Patient #5 had no fall signage on the outside of the door.

During an interview on 11/28/17 at 12:40 PM, Staff EE, RN, Nurse Manager of the seventh floor, stated that nursing should have fall signage on the outside of the door for all fall risk patients.

9. Record review of Patient #27's H&P, dated 11/25/17, showed that she was a [AGE] year old female that presented to the facility with altered mental status. She had a history of stroke (damage to the brain from interruption of its blood supply) with right sided residual and seizures (uncontrolled electrical activity in the brain which may produce irregular movement of the body).

Record review of Patient #27's fall assessment, dated 11/28/17, showed no score, but was documented as a high fall risk.

Observation on 11/28/17 at 1:00 PM, on Floor 10, showed no fall signage on the outside of Patient #27's door.

10. Record review of Patient #28's H&P, dated 11/27/17, showed that she was an [AGE] year old female that presented to the facility with swelling, redness and pain to the lower left leg.

Record review of Patient #28's fall assessment, dated 11/28/17, showed that the patient's score was eight, a moderate fall risk.

Observation on 11/28/17 at 1:30 PM, on Floor 10, showed no fall signage on the outside of Patient #28's door.

During an interview on 11/28/17 at 1:00 PM, Staff FF, RN, Nurse Manager of Floor 10, stated that fall signage on the outside of patient doors was reserved for high fall risk patients.

11. During an interview on 11/30/17 at 1:10 PM Staff FFF, Interim Chief Nursing Officer (CNO), stated that the facility had room for improvements related to fall risks and that all nurses should adhere to all the facility's policies.




















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VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation, interview and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards when they failed to:
- Perform hand hygiene and glove changes after the removal of contaminated dressings and prior to placing clean dressings on wounds during wound care dressing changes for three current patients (#23, #28 & #40) of three dressing changes observed.
- Perform hand hygiene and glove changes after touching contaminated objects and prior to touching the patient for two patients (#41, #42) of two patients observed during nursing procedures.
- Dispose of two contaminated cotton swabs used for wound care prior to placing them next to clean items used for sterile dressing changes for one patient (#40) of one observed.
- Dispose of a contaminated cotton swab after performing wound care and used the same swab for a second wound, contaminating the second wound during a dressing change for one patient (#40) of one observed.
- Ensure that Sterile Processing Department (SPD, where contaminated surgical equipment and instruments were cleaned) staff followed manufactures guidelines for Prolystica detergent (alkaline detergent used for washing/disinfector on surgical instruments) concentration when soaking contaminated surgical instruments, prior to sterilization (process that eliminates viruses and bacteria).
- Date, time and initial peripheral IV dressings (sterile dressing which covers the entrance of a small flexible tube placed into a vein in order to administer medication or fluids) for seven patients (#9, #7, #16, #5, #6, #26, and #28) of 16 patients observed, which should be changed every 96 hours to prevent infection.
- Follow facility policies for wearing Personal Protective Equipment (PPE, items such as gowns, glove and masks worn to prevent the spread of infection) in contact isolation rooms for two patients (#18, and #31) of two patients observed in isolation (precautions taken in the hospital to prevent the spread of infection).
- Dispose of outdated foods and label open food containers in the kitchen coolers.
- Dispose of expired foods for two patient galley refrigerators of two observed.
These failures had the potential to lead to negative outcomes for patients through the development of wounds or deterioration of existing wounds and increased the risk of cross contamination placing all patients, visitors and staff at risk for infection.

Please refer to A-0749 for additional information.

The cumulative effect of these systemic failures resulted in the facility's non-compliance with 42 CFR 482.42 Conditions of Participation: Infection Control and resulted in the facility's failure to ensure safe infection control practices to prevent infections and communicable diseases.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 11/30/17, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

On 11/30/2017, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Obtaining a wound care consultant to reeducate wound care nurses and to oversee all wound care provided to the patient population.
- Education was to begin on 11/30/2017 on Wound Care for all current nursing staff prior to the start of staff's next scheduled shift.
- Education was to focus on proper application of dressings and hand hygiene related to dressings. Bedside observation and monitoring was to begin on 11/30/2017.
- Wound care nurses identified as noncompliant during the survey were given one on one training, and final written warning, with 100% of the care they provide being monitored at bedside by the wound care consultant until revisit.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards when they failed to:
- Perform hand hygiene and glove changes after the removal of contaminated dressings and prior to placing clean dressings on wounds during wound care dressing changes for three patients (#23, #28 & #40) of three dressing changes observed.
- Perform hand hygiene and glove changes after touching contaminated objects and prior to touching the patient for two patients (#41, #42) of two patients observed during nursing procedures.
- Dispose of two contaminated cotton swabs used for wound care prior to placing them next to clean items used for sterile dressing changes for one patient (#40) of one observed.
- Dispose of a contaminated cotton swab after performing wound care and used the same swab for a second wound, contaminating the second wound during a dressing change for one patient (#40) of one observed.
- Ensure that Sterile Processing Department (SPD, where contaminated surgical equipment and instruments were cleaned) staff followed manufactures guidelines for Prolystica detergent (alkaline detergent used for washing/disinfector on surgical instruments) concentration when soaking contaminated surgical instruments, prior to sterilization (process that eliminates viruses and bacteria).
- Date, time and initial peripheral IV dressings (sterile dressing which covers the entrance of a small flexible tube placed into a vein in order to administer medication or fluids) for seven patients (#9, #7, #16, #5, #6, #26, and #28) of 16 patients observed, which should be changed every 96 hours to prevent infection.
- Follow facility policies for wearing Personal Protective Equipment (PPE, items such as gowns, glove and masks worn to prevent the spread of infection) in contact isolation rooms for two patients (#18, and #31) of two patients observed in isolation (precautions taken in the hospital to prevent the spread of infection).
- Dispose of outdated foods and label open food containers in the kitchen coolers.
- Dispose of expired foods for two patient galley refrigerators of two observed.
These failures had the potential to lead to negative outcomes for patients through the development of wounds or deterioration of existing wounds and increased the risk of cross contamination placing all patients, visitors and staff at risk for infection. The facility census was 236.

Findings included:

1. Record review of the facility's policy titled, "Standard Precautions," dated 04/2016, showed that hand hygiene should be performed for the following:
- Before and after patient contact;
- After removing gloves (do not wash or reuse gloves);
- After touching the patient's immediate environment;
- After contact with blood, body fluids, excretions or wound dressings;
- Prior to performing an aseptic task; and
- When moving from a contaminated body site to a clean body site.

Record review of the facility's policy titled, "Maintenance of Inpatient Skin Integrity," dated 04/2015, showed that the direction for complete skin cleansing was referred to Mosby Nursing Skills.

Even though a wound assessment policy was requested, the facility supplied the "Mosby's Wound Assessment Document," dated 05/2006, that showed the following direction to staff, for wound care dressing changes:
- Perform hand hygiene and don gloves.
- Carefully remove the soiled dressing.
- Discard dressing in a disposable waterproof biohazard bag.
- Remove gloves, perform hand hygiene, and don clean gloves.
- For undermining and measuring of tunneling, use a saline-moistened cotton-tipped applicator (swab) to gently probe the wound edges.
- After the use of the cotton swab, discard in a disposable biohazard bag.
- Remove gloves, perform hand hygiene and don clean gloves.
- Cleanse the wound and change the wound dressing per the physician's orders.
- Label the dressing, discard supplies and perform hand hygiene.

Record review of the facility's policy titled, "Hospital Acquired Infection Rates," showed that their current overall infection rate was infecting one patient every three days.

2. Record review of the History and Physical (H&P) dated 11/23/17 in Patient #40's medical record showed the following:
- The patient was a bedridden [AGE] year old male.
- The patient had decubitus ulcers (bed sores) on bilateral (affecting both sides) hips and one on his left buttock.
- The ED physician ordered a wound care nurse consult.

Observation on 11/29/17 at 10:40 AM on the fourth floor, during a wound vac dressing change that connected four wounds (bilateral hip and bilateral buttocks) for Patient #40, showed Staff NNN, Certified Wound Care Nurse and Educator, performed the following dressing change:
- Performed hand hygiene and applied gloves.
- Set up her supplies for the dressing change on the patient's bed (a contaminated object).
- Removed the dirty dressing with drainage from the right hip (wound #1), threw in the patient's trash (not a biohazard bag) then rolled the rest of the wound vac tubing under the patient.
- Wearing soiled gloves used the cotton tipped applicator to check for tunneling (touching the wound bed) and measured the wound.
- Placed the contaminated applicator in an open package on the patient's bed next to and touching the clean scissors (used throughout to cut the clean dressings for each wound).
- Cut the dressing with the contaminated scissors and applied the new dressing wearing the same contaminated gloves.
- Staff NNN failed to wash the wound before applying the new dressing.
- Staff NNN proceeded to change the right buttock (wound #2) dressing, removed the dirty dressing with drainage, threw in the same trash can.
- Wearing soiled gloves, she opened a new cotton tipped applicator and placed it on the wound to check for tunneling (touching the wound bed) and measured the wound.
- She placed the contaminated applicator in the same open package on the patient's bed next to the other contaminated applicator and touching the scissors.
- She cut the new dressing with contaminated scissors, placed the new dressing on the wound wearing the same soiled gloves and failed to clean the wound before she placed the clean dressing.
- She proceeded to change the left buttock (wound #3) dressing, removed the dirty dressing with drainage and threw in the same trash can.
-Wearing soiled gloves, she picked up one of the contaminated cotton tipped applicators from the open package on the patient's bed and used to check tunneling (touching the wound bed) and measured the wound. She used the same applicator for two wounds.
- She placed the contaminated applicator in the same open package on the patient's bed next to the other contaminated applicator and touching the scissors.
- She cut the new dressing with the contaminated scissors and with soiled gloves placed the new dressing on the wound. She failed to clean the wound before she applied the new dressing.
- She proceeded to change the left hip (wound #4) dressing, removed the dirty dressing with drainage and threw in the same trash can.
- Wearing soiled gloves, she opened a new cotton tipped applicator, placed it on the wound to check for tunneling (touching the wound bed) and measured the wound.
- She placed the contaminated applicator in the same open package on the patient's bed next to the other contaminated applicator and touching the scissors.
- She cut the new dressing with the contaminated scissors and with soiled gloves placed the new dressing on the wound. She failed to clean the wound before she applied the new dressing.

During an interview on 11/30/17 at 10:16 AM, Staff NNN, Wound Care Nurse and Educator, stated that:
- Typically she performed hand hygiene and glove changes between clean and dirty procedures.
- Even though there were two openings, they were the same wound and this was why she used the same cotton tipped applicator for both wounds.
- She didn't realize the applicator touched the scissors.
- She had gauze and cleaner on the side table but forgot to use it.

During an interview on 11/30/17 at 11:00 AM, Staff QQQ, Patient Care Manager and Wound Care Manager, stated that:
- The nurse should have performed hand hygiene and glove changes between clean and dirty procedures.
- They should have followed their policy.
- Staff NNN should not have placed the same cotton tipped applicator in two separate wounds.
- She was not a wound care specialist; she was a medical surgical nurse.
- Staff NNN was the chair and a presenter for a local seminar for wound care, which they all have participated in.

3. Record review of the H&P dated 10/31/17 in Patient #41's medical record showed that the patient was a [AGE] year old diabetic male with Hepatitis C, Cirrhosis of the liver and acute kidney failure.

Observation on 11/29/17 at 9:47 AM on the Dialysis Unit, showed Staff LLL, RN, Dialysis, attaching Patient
#41 to the dialysis (the process of removing excess water, solutes and toxins from the blood for those whose kidneys have lost the ability to perform) machine and performed the following:
- Staff LLL set up her supplies on the bedside table next to the patient's chart (contaminated object) and the patient's paperwork with stickers (contaminated object).
- She performed hand hygiene and applied PPE.
- She touched the dialysis machine (contaminated object) and the machine cords (contaminated objects), then touched the patient with the contaminated gloves.
- She picked up the blood pressure cuff (contaminated object) that came from another nursing floor, attached to the patient's bed and placed it on the patient.
- She then touched the dialysis machine, thermometer and readjusted the patient with the same contaminated gloves.
- She removed gloves, performed hand hygiene and applied new gloves.
- She then picked up stickers (contaminated objects) from the bedside table, removed her gloves and performed hand hygiene.
- She applied new gloves, then cleaned the IV hubs with alcohol, gave 500 units of Heparin (blood thinner) and flushed both IV's.
- She laid bloody syringes (contaminated objects) on the same bedside table with her clean supplies and proceeded to document with the contaminated gloves.
- She removed gloves, performed hand hygiene, applied new gloves and attached the patient to the dialysis machine.

During an interview on 11/29/17 at 10:20 AM, Staff LLL, RN, Dialysis, stated that:
- They always placed the charts and patient stickers on the bedside table next to the set up.
- They usually used the same blood pressure cuff that was on the patient's bed.
- The dialysis machine and cords are cleaned prior to her set up.

During an interview on 11/29/17 at 10:30 AM, Staff MMM, Dialysis Unit Manager, stated that:
- She expected Staff LLL to put the bloody syringes back in the plastic and not on the bedside table.
- She should have changed gloves every time she touched the dialysis machine.
- She should have placed a new blood pressure cuff on Patient #41.
- When they change to computer charting next week, they won't have to place the paper chart on the bedside tables.

4. Record review of the H&P dated 11/02/17 in Patient #43's medical record showed that the patient's medical history included insulin dependent diabetes, hypertension (high blood pressure), congestive heart failure and chronic kidney disease (which compromised the immune system and left the patient easily susceptible to infection).

Observation on 11/28/17 at 10:22 AM on the intensive care unit, showed Staff SSS, RN, performed the following for Patient #43:
- Performed hand hygiene and applied gloves.
- Cleaned stool off of the patient's buttocks and with the same contaminated gloves grabbed a clean gown from the bedside table and placed on the patient.
- She removed the soiled gloves and applied new gloves without performing hand hygiene.
- She removed a soiled foley (a flexible tube placed in the urethra and into the bladder to drain urine) statlock (a device placed on the patient's thigh to secure the foley in place) and placed a clean statlock on the patient's thigh without changing gloves or performing hand hygiene.

During an interview on 11/28/17 at 11:05 AM, Staff SSS, RN, stated that she usually double gloved when she cleaned patients and that she never realized she had to perform hand hygiene between glove changes.

5. Record review of the History and Physical (H&P) dated 11/13/17 in Patient #38's medical record showed the following:
- The patient was a quadriplegic (a person affected by paralysis of all four limbs), that presented with acute mental status changes.
- The patient had been on IV antibiotics at home for recent sepsis (the presence in tissues of harmful bacteria and their toxins, typically through infection of a wound) and polymicrobial (of, relating to, or caused by several types of microorganisms) infection of multiple decubiti (open wound on the skin), and he was a total care patient.
- The patient presented to the ED with multiple polymicrobial wound infections of multiple decubitus.
- The patient had a past medical history of diabetes and sacral (relating to the sacrum, a triangular bone in the lower back) debridement (the removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue).

During an observation on 11/29/17 at 1:00 PM in the Intensive Care Unit during wound vac dressing change of sacrum and bilateral ischial pressure ulcers and dressing change of bilateral trochanter pressure ulcers for Patient #38, showed the following:
- Staff YY, RN, Certified Wound Care Nurse, put on 3 pair of disposable gloves. Throughout the dressing change, Staff YY removed a pair of disposable gloves without performing hand hygiene and continued with the dressing change.
- During wound vac dressing change of sacrum and bilateral ischial pressure ulcers, Staff YY wiped stool out of sacral pressure ulcer with gauze. She placed clean black foam in the sacral ulcer wearing the same soiled gloves.
- Staff Z, RN, Certified Wound Care Nurse, assisted Staff YY with dressing change. Staff Z removed a dirty dressing from Patient #38's back and handed the dirty dressing to Staff YY, which contaminated Staff YY's gloves. Staff YY placed the dressing in wastebasket. Staff YY wore the same soiled gloves and placed a clean dressing over another pressure ulcer on Patient #38's left trochanter.
- Staff YY opened a cabinet with soiled gloves and wore the same gloves to place a clean dressing over a wound.
- Several times during Patient #38's dressing change, Staff YY cut different sized dressings to fit around the pressure ulcers. Staff YY did not change gloves or do hand hygiene between cutting and placing of dressings.
- All dressing change materials were placed on Patient #38's bed (a contaminated object), not on a separate clean table.

During an interview on 11/30/17 at 10:36 AM, Staff YY stated the following:
- She wore multiple gloves for protection from bone shards.
- She had on more than 3 pair of disposable gloves, probably 5 pair.
- She should have changed gloves and performed hand hygiene after wiping stool from sacral ulcer and before clean foam placement.
- She should have changed gloves and performed hand hygiene after touching dirty dressing.
- She should have changed gloves and performed hand hygiene after touching the cabinet doors.

During an interview on 11/30/17 at 11:00 AM, Staff QQQ, Wound Care Manager, stated that her expectation of the wound care nurses was to change gloves and perform hand hygiene during dressing changes according to hospital policy.

6. Record review of Patient #23's medical record showed Patient #23 was admitted on [DATE] with fever and history of non-healing diabetic ulcer (wound) to left foot. The wound culture was positive for Methicillin-resistant Staphylococcus aureus (MRSA, an infection caused by bacteria that are resistant to common antibiotics) on 11/24/17.

Observation on 11/28/17 at 1:47 PM on the fifth floor showed the following:
- Patient #23 received wound care to the left great toe from Staff Z, Certified Wound Care Nurse;
- She wore Personal Protective Equipment (PPE), including gown and gloves;
- She cleansed the wound with normal saline and gauze;
- After cleansing wound, she applied pressure to the toe, expelling purulent matter (discharging pus-viscid substance produced by suppuration and found in abscesses, sores) from the wound;
- She changed gloves without performing hand hygiene;
- She obtained a culture of expelled material wearing the same gloves;
- After obtaining culture, she changed gloves without performing hand hygiene; and
- She dressed the toe wound wearing the same gloves and assessed another wound on the back of the patient's neck.

During an interview on 11/30/17 at 10:50AM, Staff Z, stated, "I knew it as soon as you left that I didn't foam in or out" when I changed gloves for Patient #23's wound care.

During an interview on 11/30/17 at 11:00AM, Staff QQQ, Wound Care Manager, stated that removing soiled dressings requires the wound care nurses to change gloves and perform hand hygiene, to follow facility policy.

7. Even though requested, the facility failed to provide a policy related to the procedure used to soak contaminated surgical instruments in the SPD.

Review of the facility's undated orientation titled, "Central Sterile Processing Department Specific Duties," showed directives for staff to follow manufacturer's instructions with any new technology, to produce a safe product for patient use. How items were prepared before sterilization will determine the end result.

Review of the AORN "Guideline for Cleaning and Care of Surgical Instruments," dated 2015, showed the cleaning product's manufacturer's written instructions for use should be followed for concentration and dilution.

Review of the facility used enzymatic cleaner's (hospital specific cleaner used to disinfect instruments used in the body during medical or surgical procedures) manufacturer's directions, showed that the cleaner should be dispensed at 1/8 - 1/2 fluid ounces (oz., unit of measure - 1/8 oz equals 3/4 teaspoon, and 1/2 oz equals 3 teaspoons) per gallon (gal, unit /of measure) of water, depending on water quality and application. Fill sink or basin with warm water to the appropriate level to fully immerse surgical instruments.

The facility's used an automatic, pre-set, enzymatic cleaner dispenser, which dispensed the same amount of cleaner every time the dispenser was manually activated.

During an observation and concurrent interview on 11/29/17 at approximately 3:45 PM, in Sterile Processing, showed a pan of instruments not fully submerged in enxymatic cleaner water, and the water was approximately four inches below the premarked water level line. Staff ZZ, Instrument Technician, stated that the instruments were ready for sterilization. When asked if the water in the sink was to be filled to the marked water level line, Staff ZZ stated that the sink should have been filled with water to the marked water level line (for appropriate concentration of enzymatic cleaner and water).

During an interview on 11/29/17 at approximately 3:50 PM, Staff BBB, Supervisor of Sterile Processing stated that Staff ZZ should have filled the sink to the water line, which was the manufacturer's instruction.

During an interview on 11/29/17 at approximately 4:00 PM, Staff CCC, Manager of Sterile Processing stated that:
- Sterile Processing Department processed 136 pans of instruments per day, with an average of 600 pans of instruments per month;
- The operating room had an average of 500 cases per month; and
- Staff ZZ should have followed the manufacture's recommendations on the enzymatic cleaner to water concentration.
This had the potential to lead to high levels of bioburden (the number of bacteria living on a surface that has not been sterilized) remaining on the surgical instruments, which could lead to contamination, infection, or surface breakdown of the instrument.

8. Record review of the Facility's policy titled, "Isolation Policy: Contact Precautions," revised 04/2016, showed the directive for staff wearing PPE that included the gown to fully cover torso from neck to knees, arms to ends of wrists, and wrapped around the back.

Record review of the Facility's undated document titled, "Attention Providers-Urgent Communication," showed that isolation gowns should be worn over the head and tied at the waist. Gowns, gloves, and/or masks should be put on immediately on entry to an isolation room.

9. Observation on 11/28/17 at 2:35 PM, on the eighth floor, showed Patient #18 setting on side of bed in a contact isolation room. Staff T, Infection Control Physician, was within arm's length of the patient, with PPE gown untied, and not around his neck, exposing his torso, arms, and back.

Record review of Patient #18's History and Physical (H&P) on 11/23/17, showed she was a [AGE] year old female that presented to the facility with complaints of diarrhea for three days and history of shingles on her right shoulder and neck, which were in various stages of healing with some weeping, and the patient was placed on contact isolation.

During an interview on 11/28/17 at 2:40 PM, Staff T, Infection Control Physician, stated that he should have tied the gown around his neck and was not wearing the PPE appropriately. The purpose of wearing the gown appropriately was to stop the spread of infection.

10. Record review of the Facility's policy titled, "Isolation Policy: Contact Precautions," revised 04/2016, showed the directive for staff to remove PPE at the doorway or anteroom (before entrance into another room).

Observation on 11/29/17 at approximately 10:40 AM, in the Operating Room (OR) holding area (specialized area of OR where patients wait before surgery), showed Patient #31 lying on a bed with a contact isolation sign. Staff PP, RN, had PPE on that touched the patient and linens. Staff PP walked out of the contaminated area with contaminated PPE, walked down the hall, opened the post-anesthesia care unit (PACU, specialized area where patient recover after surgery) door and entered PACU with current patients recovering.

11. Record review of Patient #31's H&P on 11/28/17, showed he was a [AGE] year old male that presented to the facility with rectal abscess (collection of pus around the anus) that had blood and mucus discharge, and was placed on contact isolation.

During an interview on 11/29/17 at approximately 10:45 AM, Staff PP, RN, stated that she could wear the contaminated PPE in the clean areas. Contact isolation only refers to contact with patients.

During an interview on 11/29/17 at approximately 10:50 AM, Staff QQ, OR Director, stated that Staff PP should have removed her PPE prior to leaving the contaminated area, and should have not walked down the hall and/or entered PACU.

12. Record review of the facility's undated policy titled, "Intravenous (IV, in the vein) Line Care," showed after IV insertion, a sterile dressing should be applied and labeled with the date, time of insertion, and initials.

Observation on 11/28/17 at 10:30 AM, in the emergency room (ER), showed Patient #9 with an IV to the left antecubital (AC, the depression area in front of the elbow) space. There was no date, time of insertion or initials on the dressing that covered the IV site.

During an interview on 11/28/17 at 10:45 AM, Staff L, RN, verified that the IV dressing was not labeled.

During an interview on 11/29/17 at approximately 2:15 PM, Staff KKK, ER Director, stated that nurses should adhere to the facility's policies. If the policies directed staff to label the IV dressings, the IV dressings should be labeled.

13. Observation on 11/28/17 at 10:15 AM, on the fourth floor, showed Patient #7 with an IV to the right AC space. There was no date, time of insertion, or initials on the dressing that covered IV site.

During an interview on 11/28/17 at 10:20 AM, Staff K, RN, verified that the IV dressing was not labeled and that the IV dressing should have been labeled as directed by policy.

14. Observation on 11/28/17 at 3:00 PM, on the eighth floor, showed Patient #16 with an IV to the lower left arm. There was no date, time of insertion or initials on the dressing that covered the IV site.

During an interview on 11/28/17 at 3:05 PM, Staff S, RN, stated that the peripheral IV dressing was not labeled and should have been labeled.

15. Observation on 11/28/17 at 9:30 AM, on the seventh floor, showed Patient #5 with an IV to the Right forarm. There was no date, time of insertion or initials on the dressing that covered the IV site.

During an interview on 11/28/17 at 10:00 AM, Staff E, RN stated that Patient #5's IV dressing should have the date, time of insertion and initials.

16. Observation on 11/28/17 at 10:30 AM, on the seventh floor, showed Patient #6 with an IV to the right lower arm. There was no time of insertion or initials on the dressing that covered the IV site.

During an interview on 11/28/17 at 11:00 AM, Staff F, RN stated that she started Patient #6's IV on 11/27/17. When asked what the hospital policy was for labeling IV dressings, Staff F stated that IV dressings should have a time, date and initials.

17. Observation on 11/28/17 at 12:30 PM, on the seventh floor, showed Patient #26 with an IV to the left AC. There was no time or initials on the dressing that covered the IV site.

During an interview on 11/28/17 at 12:40 PM, Staff EE, RN, Nurse Manager of the seventh floor, stated that after an IV was started, nurses should date, time and initial the IV dressings.

18. Observation on 11/28/17 at 1:30 PM, on the 10th floor, showed Patient #28 with a left AC IV. There was no date, time or initials on dressing that covered the IV site.

During an interview on 11/28/17 at 1:30 PM, Staff HH, RN, stated that she did not write anything on IV dressings.

During an interview on 11/28/17 at 1:45 PM, Staff FF, RN, Nurse Manager of the 10th floor, stated that after starting an IV, the nursing staff should date, time, and initial the IV dressings.

19. Record review of the "United States Department of Health and Human Services Food Code," dated 08/2015, stated that a food shall be discarded if the food is not consumed before the expiration date and if it was in a container or package which does not bear a date.

Record review of the facility's policy titled, "Food and Supply Storage," dated 01/2017 showed that foods should be dated, rotated and foods past the "use by" or expiration date, should be discarded. Unused portions and open packages should be covered, labeled and dated.

Observation on 11/29/17 at 3:55 PM in the facility kitchen walk-in freezer showed the following opened containers:
- One box of crunchy raw cod squares, open to air with no expiration date;
- Two meatloaf trays with expiration date of 11/22/17;
- 10 packages of rice pilaf with no date;
- One box of chicken tenders, open to air with no date;
- 10 hot dogs, open to air with no date; and
- Two pork loin chops with no date.

Observation on 11/29/17 at 4:05 PM in the facility kitchen produce cooler, showed the following opened containers:
- Two sour cream light containers opened with expiration date of 11/19/17;
- One tomato paste container opened with expiration date of 11/25/17; and
- One Ranch dressing container opened with no label and an expiration date of 11/30/17.

Observation on 11/29/17 at 4:11 PM in the facility kitchen desert cooler, showed 10 angel food cakes on a desert cart with an expiration date of 11/27/17 and three open to air jellow trays with no date.

During an interview on 12/07/17 at 12:23 PM, Staff GGGG, Executive Chef, stated that he was the one in charge of inspecting the coolers and was unaware that after a food was opened, it had to be labeled.

Observation on 11/29/17 at 4:37 PM in the retail kitchen cooler, showed the following opened containers:
- One box of hot dogs, open to air with no date;
- One container of vegetable salad, opened with expiration date of 11/28/17; and
- One container of pasta salad, opened with expiration date of 11/28/17.

During an interview on 12/07/17 at 12:15 PM, Staff FFFF, Retail Kitchen Service Manager, stated that they missed the expired food items due to they were open until 2:00 AM and her walk through wasn't until 5:00 PM that day.

Observation on 11/29/17 at 4:00 PM on the Fifth Floor, in the Patient Food Galley, showed signage on the refrigerator that stated food brought from the outside of the hospital and any opened food containers must be discarded after 24 hours.

Observation on 11/29/17 at 4:05 PM on the Fifth Floor, inside the Patient Food Galley Refrigerator, showed a sub sandwich wrapped in brown plastic grocery bag dated 11/27/17.

During an interview on 11/29/17 at 4:05 PM, Staff AAAA, RN, Nurse Manager of the Fifth Floor, stated that staff should adhere to signage posted on refrigerator door.

Observation on 11/29/17 at 4:20 PM on the Sixth Floor, in the Patient Food Galley area, showed signage on the refrigerator that stated food brought from the outside of the hospital and any opened food containers must be discarded after 24 hours.

Observation on 11/29/17 at 4:25 PM on the Sixth Floor, inside the Patient Food Galley Refrigerator, showed turkey and mashed potatoes on a paper plate wrapped in foil dated and timed 11/28/17, 7:00 AM.

Observation on 11/29/17 at 4:25 PM on the Sixth Floor, inside the Patient Food Galley Refrigerator Freezer, showed an opened bottle of Ensure (nutritional drink with protein, vitamins and minerals) dated 11/27/17.

During an interview on 11/29/17 at 4:30 PM, Staff QQQ, RN, Nurse Manager of the Sixth Floor, stated that staff should adhere to signage posted on refrigerator door.
































Surveyor: GRIMSHAW, JULIE