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.

VIRTUA MEMORIAL HOSPITAL OF BURLINGTON COUNTY 175 MADISON AVE MOUNT HOLLY, NJ 08060 Feb. 25, 2016
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
A. Based on observation and staff interview, it was determined that the facility failed to ensure all patients are provided privacy.

Findings include:

1. On 2/5/16 at approximately 11:00 AM a tour of the Emergency Department was conducted with Staff #7.

2. During the tour a patient was being examined by Staff #10 (Physician) in the hallway, by the Close View Area.

3. Staff #10 was examining the patient's abdomen. The patient's shirt was pulled up leaving his/her abdomen exposed.

4. There was no privacy curtain provided for the patient.

5. Staff #7 confirmed the above.






B. Based on observation it was determined that the facility failed to protect all patients' personal information.

Findings include:

1. On 2/5/16 at 11:00 AM the Emergency Department (ED) was toured in the presence of Staff #4 and Staff #7. Patient labels with protected information were found easily obtainable in patient bays or on a patient stretcher as follows:

a. Patient #12 was sleeping in his/her stretcher in ED Room A-2. A sheet of patient labels (twenty-two labels) with the patient's full name, date of birth, medical record number, account number, and date of arrival was found on a bedside rolling table within the room.

b. Patient #13 was sleeping in his/her stretcher in ED Room A-8. A sheet of patient labels (twenty-six labels) with the patient's full name, date of birth, medical record number, account number, and date of arrival was found on a counter top within the room, next to the sink.

c. Patient #16 was on a hallway stretcher outside ED Room A-2. A sheet of patient labels (twenty-six labels) with the patient's full name, date of birth, medical record number, account number, and date of arrival was found on back of the stretcher, behind the head of the stretcher.





d. Patient #14 was out of his/her room in ED Room C-19. A sheet of patient labels with the patient's full name, date of birth, medical record number, account number, and date of arrival was found on the counter top within the room.

e. Patient #15 was out of his/her room in ED Fast Track Bay-C. A sheet of patient labels with the patient's full name, date of birth, medical record number, account number, and date of arrival was found on the counter top within the room.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
A. Based on observation, review of facility policy, and staff interview, it was determined that the facility failed to ensure its policy for direct care observation of a patient is implemented.

Findings include:

Reference: Facility Policy, Titled; Observation: Direct Care Observer, Psych/Violent Patient, page 2, under Role of the Direct Care Observer, 2. b. states, "Maintain visualization of the patient at all times." 2. c. states, "Do not leave patient alone. i. The observer must stay at the patient's bedside at all times including when family and/or physicians/psychiatrist/LIP are present in the room ..."

1. On 2/5/16 at approximately 11:15 AM a patient (Medical Record #3) was observed to be on direct observation in the hallway for suicidal ideations.

2. On 2/5/16 at approximately 11:15 AM a patient (Medical Record #4) was observed to be on 15 minute checks related to confusion, and interfering with his/her medical care (pulling on O2 and IV tubing), in Room #5.

3. Staff #9 was assigned to watch Patient #3 in the hallway, and Patient #4 in Room #5 at the same time.

4. Staff #9 failed to ensure a safe environment for Patient #3 when he/she walked into the room of Patient #4, turning his/her back on Patient #3.

5. At approximately 11:20 AM Staff #9 was told by the RN that he/she was only to watch Patient #3 related to the patient being on direct observation.

6. Approximately 5 minutes after being directed by the RN, Staff #9 again walked away from Patient #3 turning his/her back to the patient and walking to the nurses station.

7. Staff #7 confirmed the above.

B. Based on observation and staff interview, it was determined that the facility failed to ensure all patients are provided with a means to call staff for assistance.

Findings include:

1. On 2/5/16 at approximately 11:00 AM a tour of the Emergency Department was conducted with Staff #7.

2. There were six (6) patients on stretchers in the hallway.

3. The six (6) patients had not been provided with a way to call the nurse (Call Bell) if in need of assistance.

4. Staff #7 confirmed the above.

C. Based on a tour of 6 Stokes with Staff #23 on 2/11/16, it was determined that the facility failed to ensure a safe environment for all psychiatric patients.

1. The three (3) patient shower rooms on the unit all have door handles, inside and outside the shower room, that are not ligature resistant.

2. All sinks on the unit have faucets that are not ligature resistant.

3. The patient bathroom in the hallway on the unit has door handles, inside and outside the bathroom, that are not ligature resistant.

4. All of the toilets on the unit have a steel rectangle box above the toilets, covering the plumbing, that are approximately 6" deep x 12" wide x 18" high and 18" above the floor that are not ligature resistant.

5. Staff #23 confirmed the above.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on a review of nurse staffing, review of the facility's Emergency Department (ED) staffing plan, and staff interview it was determined that the facility failed to implement its ED staffing plan.

Findings include:

Reference: The facility's policy and procedure 'Subject: Staffing Plan ED 2015' states, "DEPARTMENT STAFF: (fluctuates daily based on volumes and acuity)
7:00 AM - 11:00 AM 1 CC, 7 RN's, 4 PCT's
11:00 AM - 3:00 PM 1 CC, 11 RN's, 7 PCT's
3:00 PM - 7:00 PM 1 CC, 11 RN's, 7 PCT's
7:00 PM - 11:00 PM 1 CC, 11 RN's, 7 PCT's
11:00 PM - 7:00 AM 1 CC, 7 RN's, 3-2 PCT's ..."

1. On 2/8/16, the nurse staffing for the ED for the date of 1/9/16, and the above referenced ED staffing Plan was reviewed in the presence of Staff #4 and Staff #14 at 10:40 AM. The ED was short staffed as follows:

a. From 7:00 AM- 11:00 AM there were seven (7) RNs staffing the ED. There was no indication as to which RN was the Care Coordinator (CC).

i. In interview, Staff #4 stated that one of the seven (7) RNs assumed the CC role.

ii. The above staffing plan calls for seven (7) RNs and one (1) CC, for a total of eight (8) RNs. The ED was short staffed one (-1) RN.

b. From 11:00 AM- 3 :00 PM there were ten (10) RNs and five (5) PCTs staffing the ED. The ED staffing plan calls for eleven (11) RNs and seven (7) PCTs. The ED was short staffed one (-1) RN and two (-2) PCTs.

c. From 3:00 PM- 7:00 PM there were nine (9) RNs and four (4) PCTs staffing the ED. The ED staffing plan calls for eleven (11) RNs and seven (7) PCTs. The ED was short staffed two (-2) RNs and three (-3) PCTs.

d. From 7:00 PM- 11:00 PM there were ten (10) RNs and four (4) PCTs staffing the ED. The ED staffing plan calls for eleven (11) RNs and seven (7) PCTs. The ED was short staffed one (-1) RN and three (-3) PCTs.

e. From 11:00 PM- 7:00 AM there were six (6) RNs staffing the ED. There was no indication as to which RN was the Care Coordinator (CC). The above staffing plan calls for seven (7) RNs and one (1) CC, for a total of eight (8) RNs. The ED was short staffed two (-2) RNs.

2. The ED Staffing was reviewed for the week of Sunday January 10, 2016 thru Saturday January 16, 2016 in the presence of Staff #4. The following staffing shortages were evident as compared to the above referenced ED Staffing Plan:

a. For Sunday, January 10, 2016:

i. From 7:00 AM- 11:00 AM, the staffing sheet indicates there were six (6) RNs, no CC was indicated, and there were three (3) PCTs. The ED was short staffed two (-2) RNs and one (-1) PCT.

ii. From 11:00 AM- 3:00 PM, the staffing sheet indicates there were ten (10) RNs, one (1) CC, and five (5) PCTs. The ED was short staffed one (-1) RN and two (-2) PCTs.

iii. From 3:00 PM- 7:00 PM, the staffing sheet indicates there were ten (10) RNs, one (1) CC, and five (5) PCTs. The ED was short staffed one (-1) RN and two (-2) PCTs.

iv. From 7:00 PM- 11:00 PM, the staffing sheet indicates there were eleven (11) RNs, one (1) CC, and three (3) PCTs. The ED was short staffed four (-4) PCTs.

v. From 11:00 PM- 3:00 AM, the staffing sheet indicates there were seven (7) RNs, no CC was indicated, and two (2) PCTs. The ED was short staffed one (-1) CC.

vi. From 3:00 AM- 7:00 AM, the staffing sheet indicates there were six (6) RNs, no CC was indicated, and two (2) PCTs. The ED was short staffed one (-1) CC and one (-1) RN.

b. For Monday, January 11, 2016:

i. From 11:00 AM- 7:00 PM, the staffing sheet indicates there were eleven (11) RNs, a CC, and five (5) PCTs. The ED was short staffed two (-2) PCTs.

ii. From 7:00 PM- 11:00 PM, the staffing sheet indicates there were nine (9) RNs, a CC, and five PCTs. The ED was short staffed two (-2) RNs and two (-2) PCTs.

iii. From 11:00 PM- 7:00 AM, the staffing sheet indicates there were seven (7) RNs, no CC indicated, and four (4) PCTs. The ED was short staffed one (-1) CC. Two (2) of the seven (7) RNs were scheduled to leave at 5:00 AM, leaving the ED short staffed with an additional two (-2) RNs from 5:00 AM- 7:00 AM.

c. For Tuesday, January 12, 2016:

i. From 7:00 AM- 11:00 AM, the staffing sheet indicates there were three (3) PCTs. The ED was short staffed one (-1) PCT.

ii. From 11:00 AM- 3:00 PM, the staffing sheet indicates there were five (5) PCTs. The ED was short staffed two (-2) PCTs.

iii. From 3:00 PM- 7:00 PM, the staffing sheet indicates there were nine (9) RNs, a CC, and five (5) PCTs. The ED was short staffed two (-2) RNs and two (-2) PCTs.

iv. From 7:00 PM- 11:00 PM, the staffing sheet indicates there were nine (9) RNs, a CC, and two (2) PCTs, with an additional PCT at 10:00 PM. The ED was short staffed two (-2) RNs and five (-5) PCTs until 10:00 PM. At 10:00 PM the ED had a remaining PCT shortage of four (-4).

v. From 11:00 PM- 1:00 AM, the staffing sheet indicates there were seven (7) RNs, but no CC was indicated. The ED was short staffed one (-1) RN/ CC. From 1:00 AM-3:00 AM, the ED had six (6) RNs, no CC, leaving the ED short staffed a total of two (-2) RNs.

vi. From 3:00 AM-7:00 AM, the staffing sheet indicates there were six (6) RNs, and no CC was indicated. The ED was short staffed one (-1) CC and one (-1) RN.

d. For Wednesday, January 12, 2016:

i. From 7:00 AM- 11:00 AM the staffing sheet indicates there were three (3) PCTs. The ED was short staffed one (-1) PCT.

ii. From 11:00 AM- 3:00 PM, the staffing sheet indicates there were five (-5) PCTs. The ED was short staffed two (-2) PCTs.

iii. From 3:00 PM- 7:00 PM, the staffing sheet indicates there were ten (10) RNs, one (1) CC, and five (5) PCTs. The ED was short staffed one (-1) RN and two (-2) PCTs.

iv. From 7:00 PM-11:00 PM, the staffing sheet indicates there were nine (9) RNs, one (1) CC, and four (4) PCTs. The ED was short staffed two (-2) RNs and three (-3) PCTs.

v. From 11:00 PM-3:00 AM, the staffing sheet indicates there were seven (7) RNs, and no CC was indicated. The ED was short staffed one (-1) RN/CC.

vi. From 3:00 AM- 7:00 AM, the staffing sheet indicates there were six (6) RNs, and no CC was indicated. The ED was short staffed one (-1) RN and one (-1) CC.

e. Thursday, January 14, 2016:

i. From 11:00 AM- 3:00 PM, the staffing sheet indicates there were five (5) PCTs. The ED was short staffed two (-2) PCTs.

ii. From 3:00 PM- 7:00 PM. the staffing sheet indicates there were ten (10) RNs, one (1) CC, and six (6) PCTs. The ED was short staffed one (-1) RN and one (-1) PCT.

iii. From 7:00 PM- 11:00 PM, the staffing sheet indicates there were four (4) PCTs. The ED was short staffed three (-3) PCTs.

iv. From 3:00 AM- 7:00 AM, the staffing sheet indicates there were seven (7) RNs, no CC was indicated. The ED was short staffed one (-1) CC.

f. Friday, January 15, 2016:

i. From 11:00 AM- 3:00 PM, the staffing sheet indicates there were six (6) PCTs. The ED was short staffed one (-1) PCT.

ii. From 3:00 PM- 7:00 PM, the staffing sheet indicates there were nine (9) RNs, one (1) CC, and six (6) PCTs. An additional RN arrived at 5:00 PM. The ED was short staffed two (-2) RNs from 3:00 PM- 5:00 PM, one (-1) RN from 5:00 PM- 7:00 PM, and one (-1) PCT.

iii. From 7:00 PM- 11:00 PM, the staffing sheet indicates there were nine (9) RNs, one (1) CC, and three (3) PCTs. The ED was short staffed two (-2) RNs and four (-4) PCTs.

iv. From 3:00 AM- 7:00 AM, the staffing sheet indicates there were seven (7) RNs and no CC was indicated. The ED was short staffed one (-1) RN/ CC.

g. Saturday, January 16, 2016:

i. From 7:00 AM- 11:00 AM, the staffing sheet indicates there were seven (7) RNs, no CC indicated, and three (3) PCTs. The ED was short staffed one (-1) CC and one (-1) PCT.

ii. From 11:00 AM- 3:00 PM, the staffing sheet indicates there were ten (10) RNs, one (1) CC, and five (5) PCTs. The unit was short staffed one (-1) RN and two (-2) PCTs.

iii. From 3:00 PM- 7:00 PM, the staffing sheet indicates there were nine (9) RNs, one (1) CC, and five (5) PCTs. The ED was short staffed two (-2) RNs and two (-2) PCTs.

iv. From 7:00 PM- 11:00 PM, the staffing sheet indicates there were eight (8) RNs, one (1) CC, and three (3) PCTs. The ED was short staffed three (-3) RNs and four (-4) PCTs.

v. From 11:00 PM- 3:00 AM, the staffing sheet indicates there were seven (7) RNs, no CC was indicated, and one (1) PCT. The ED was short staffed one (-1) CC and one (-1) PCT.

vi. From 3:00 AM- 7:00 AM, the staffing sheet indicates there were six (6) RNs, no CC indicated, and one (1) PCT. The ED was short staffed one (-1) CC, one (-1) RN, and one (-1) PCT.

2. The above findings were reviewed with and confirmed by Staff #4.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
A. Based on observation, medical record review, and review of facility policy it was determined that the facility failed to implement its policy for tube feeding administration.

Reference: Facility policy name: 'Tube Feeding: Administration Protocol' states, "... PROCEDURE: ... C. Administration of Tube Feeding: 1. PUMP METHOD a. ... * Pump sets should not be reused after 24 hours of initial usage b. "Ready to Hang" Containers ... 2. Complete information on label provided for feeding container, i.e. patient name, room number, date, start time, and rate. 3. Label feeding with start date and time. ..."

1. On 2/11/16 at 10:30 AM the Intensive Care Unit (ICU) was toured in the presence of Staff #6 and Staff #29. Patient #24 in Room #222 was observed to have a tube feeding of Vital with about 700 ml in the ready to hang container, and 1000 ml in the water irrigation bag.

a. Review of Medical Record #24 in the presence of Staff #25 indicated a physician order dated and timed 1/28/16 at 17:12 for Vital AF 1.2 via GT [gastric tube] 240 ml QID at 6 A-12 N-6 P- 12 A and flush 75 ml H20 [water] every one hour bolus.

2. The bottle of TPN and tubing was not labeled with a date and time of initiation. The bottle of feeding did not have the patient's name, room number, and rate indicated on it's label.

3. Without a date and time of initiation of the tube feeding indicated on the bottle as per facility policy, it could not be determined if the tube feeding was within its 24 hour time of expiration as per facility policy.

B. Based on observation, review of facility policy and procedure, and staff interview it was determined that the facility failed to implement its policy and procedure for crash cart maintenance.

Findings include:

Reference #1: Facility policy name: 'Crash Cart Check, Broselow Code' states, "PURPOSE: To ensure that appropriate emergency equipment is readily available for the resuscitation of the pediatric individual within a --- facility. PROCEDURE: ... 3. All checks should be documented on the Broselow Code Cart log and Code Cart Checklist with signature, date and appropriate numbers from locks, daily. If department operating hours are Monday-Friday/ and closed weekends and holidays, write "closed" on appropriate dates. ..."

Reference #2: Facility policy name: 'Crash Cart Maintenance: Daily checks and Exchange after use (Adult Carts) states "... PROCEDURE: A. Crash Cart Check Procedure: 1. The department is responsible for completing daily crash cart checks based on the Crash Cart Checklist. In areas that are closed this must be recorded on the Crash Cart Checklist. ... D. --- Hospital 1) Crash Cart Check Procedure ... e) Code cart readiness will be ensured by completing the Code Cart Checklist. 2) Crash Cart Exchange ... h) Plug defibrillator into red outlet. ..."

1. On 2/5/16 a tour of the Emergency Department (ED) was completed in the presence of Staff #4 and Staff #7.

a. A Pediatric Code Cart was observed by the Sub-acute Charge Nurses' Station. The Code Cart daily check was not completed on 2/4/16 as per policy in reference #1.

b. The Adult Code Cart was observed in the Close View section of the ED. For the month of February, the Code Cart checklist was only checked today, 2/5/16. The areas for signature for 2/1/16 thru 2/4/16 were blank.

i. In interview, Staff #4 stated that this area of the ED is typically opened every day. Staff #4 later confirmed that this area was opened every day this week.

ii. The Code Cart defibrillator was not plugged into a red emergency power supply outlet. Staff #4 confirmed this at 12:50 PM.

c. The Code Cart checklist in Fast Track was not completed 2/1/16-2/4/16. The areas indicated were blank.

d. The ED staff did not implement the code cart check procedures in reference #2.

2. On 2/11/16 at 10:30 AM the ICU was toured in the presence of Staff #6 and Staff #29. The Code Cart Defibrillator was not plugged into a red power supply outlet.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on medical record review, review of facility policy and procedure, and staff interview it was determined that the facility failed to implement its policy for intravenous (IV) guidelines in two (2) of two (2) medical records reviewed for administration of IV Cardizem (Medical Records #1 and #17).

Findings include:

Reference: Facility policy 'IV GUIDELINES' states for Cardizem administered in the ED, under NOTES, "... [2nd bullet] Monitor vital signs including pulse, respirations, blood pressure and pulse oximetry: *Immediately prior to bolus or change in rate *5 min (sic) after bolus or rate change *Every 15 min (sic) X 1 h [every 15 minutes times one hour]; then q [every] 1h X1. *Resume q4h VS while on Cardizem infusion ..."

1. On 2/8/16 a review of Medical Record #1 was conducted, and indicated the patient arrived to the ED on 1/9/16 at 18:11 for complaints of an irregular heart rate.

a. A physician order for Cardizem intravenous Dose 10 mg IV was dated and timed 1/9/16 at 18:45.

b. The medication was documented as given by the nurse on 1/9/16 at 18:41. The nurse documented "... Pre-administration assessment shows Patient on cardiac monitor showing atrial fibrillation, ... Dr. --- gave verbal order for 10 mg cardizem bolus, dr. --- in room while bolus administered."

i. There was not a documented completed assessment of vital signs, including pulse, respirations, and pulse oximetry immediately prior to the Cardizem bolus administration as per facility policy referenced above. The most recent blood pressure prior to the Cardizem administration was at 18:35 and Patient #1's BP=112/74.

ii. There was no evidence of vital signs including pulse, respirations, blood pressure and pulse oximetry five (5) minutes after the bolus administration at 18:46.

2. A physician order for Cardizem intravenous Dose 5 mg/hr: IV is dated and timed 1/9/16 at 18:45 in Medical Record #1.

a. The medication is documented as given by the nurse on 1/9/16 at 18:45. The nurse documented "... Pre-administration assessment shows Patient on cardiac monitor showing atrial fibrillation, ... Dr. --- gave verbal order for cardizem drip to be started at 5 mg/hr after 10 mg bolus. Dr. --- in room while drip started at 5 mg/hr."

i. There was not a documented completed assessment of vital signs, including pulse, respirations, and pulse oximetry immediately prior to the Cardizem drip initiation, at 18:45, as per facility policy referenced above. The most recent blood pressure prior to the Cardizem administration was at 18:35 and Patient #1's BP=112/74.

ii. Vital signs including pulse, respirations, blood pressure and pulse oximetry were documented fifteen (15) minutes after the Cardizem drip initiation at 19:01, but there was not subsequent vitals signs every fifteen (15) minutes, at 19:15 or 19:30. Vital signs were taken at 19:45.

iii. Vital signs were then taken at 20:03, and then fifty-two (52) minutes later at 20:55, and then fifty-one minutes later at 21:46. Vital signs were not taken every thirty (30) minutes for an hour as per facility policy.

3. A nursing note in Medical Record #1 at 23:25 stated, "Spoke to Dr. -- and informed his (sic) that pt's heart rate drops to 59 at time (sic). As per Dr. ---, discontinue cardizem drip ..."

4. The above was reviewed with Staff #4. Staff #4 confirmed the vitals signs were not assessed as per policy for a patient receiving Cardizem IV.

5. On 2/8/16 a review of Medical Record #17 was conducted. Patient #17 arrived to the ED on 1/9/16 at 14:26 with a complaint of A-Fib [atrial fibrillation].

a. A physician order for Cardizem intravenous Dose 15 mg IV is dated and timed 1/9/16 at 15:01.

b. The medication is documented as given by the nurse on 1/9/16 at 15:13.

c. Vital signs were re-assessed sooner than five (5) minutes after the bolus administration, at 15:15. The next vital signs re-assessment were at 15:50, and 16:14. Vital signs were not taken every fifteen (15) minutes times one hour as per policy.

6. A physician order for Cardizem 20 mg IV is dated and timed 1/9/16 at 16:13.

a. The medication is documented as administered by the nurse at 16:19.

b. Vital signs were re-assessed by the nurse five (5) minutes after the second bolus administration of Cardizem at 16:24 per facility policy.

c. There was no evidence of every fifteen (15) minute vital signs re-assessment times one hour following the second IV Cardizem bolus administration. The subsequent vital sign recording after 16:24 was at 17:30.

d. There was no evidence of vital sign recordings every thirty (30) minutes times one hour following the every fifteen (15) minute vital signs. Vital signs were taken at 17:30 and 18:45.

7. The above was reviewed with and confirmed by Staff #14.
VIOLATION: SECURE STORAGE Tag No: A0502
Based on observation it was determined that the facility failed to ensure all drugs and biologicals are kept in a secured and locked storage area.

Findings include:

1. On 2/5/16 a tour of the Emergency Department was completed in the presence of Staff #4 and Staff #7. The following drugs were observed unsecured:

a. In Bay A-8, in a counter top cabinet:

i. A 1000 ml bottle of 0.9% Saline for irrigation

ii. An eight ounce bottle of Scrub Care 10% Povidone-Iodine

iii. Compound Benzoin Tincture USP Alcohol 77%

iv. A bottle of Cetacaine topical anesthetic

b. In Bay A-9, in a counter top cabinet:

i. An eight ounce bottle of Scrub Care 10% Povidone-Iodine

ii. A Pro-Vent Arterial blood sampling kit that contained dry lithium heparin for gases and electrolytes

iii. An eight ounce bottle of Baza Cleanse and Protect Odor Control Skin Protectant All-in-one Perineal Lotion with Odor Control

iv. A 1000 ml bottle of 0.9% sodium chloride

c. In an unlocked laceration care rolling cart, located outside the sub-acute charge nurses' station, the following unsecured drugs were found on top of the cart:

i. A 100 ml bottle of 0.9% sodium chloride for irrigation

ii. A 16 ounce bottle of 3% hydrogen peroxide

iii. A 16 ounce bottle of Isopropyl 70% Alcohol

iv. Two (2) opened bottles of 0.9% sodium chloride irrigation solution

v. A 50 ml bottle of lidocaine hydrochloride topical solution USP 4%

vi. A 2 ounce bottle of Benzoin Compound Tincture USP Alcohol 77%

vii. A 3.5 ounce bottle of Gebauer's Ethyl Chloride Mist Spray

d. In an unlocked laceration care rolling cart, located outside the sub-acute charge nurses' station, the following unsecured drugs were found within the cart's drawers:

i. Bupivicaine 30 ml bottle

ii. A bottle of Xylocaine 1% 200 mg/20 ml

iii. A 20 ml bottle of Xylocaine 1% epinephrine 1:100, 000

iv. Two (2) 30 ml opened single dose bottles of Bupivicaine HCL 0.5% and Epinephrine 1:200,000

e. In the unlocked Close View (CV) Supply Cabinet #1, a bottle of Scrub Povidone Iodine 10%solution

f. In the unlocked Close View (CV) Supply Cabinet #2, a bottle of 70% rubbing alcohol

g. In the unlocked Close View (CV) Supply Cabinet #1, a 20 ml vial of Xylocaine with epinephrine 1:100, 000

h. On the counter next to the sink outside Room-B, an opened 1000 ml bottle of sterile water for irrigation

i. On the counter in Close View (CV) #19, six (6) vials of 10 ml sodium chloride injection

2. On 2/8/16, during an observation of a procedure in Labor and Delivery Operating Room #1, in the presence of Staff #1, a 16 ounce bottle of hydrogen peroxide 3%, with an expiration date of 10/14 was found opened and available for use.

2. On 2/5/16 a tour of the Emergency Department was completed in the presence of Staff #4 and Staff #7. The following needles and syringes were observed unsecured:

a. In Bay A-9, in a counter top cabinet, there was a Pro-Vent Arterial blood sampling kit that contained a 23 and 25 gauge needles, and a 5 ml syringe

b. In an unlocked laceration care rolling cart, located outside the sub-acute charge nurses' station, the following unsecured needles and syringes were found within the cart's drawers:

i. Seven (7) 3 cc syringes

ii. Seven (7) 5 cc syringes

iii. Three (3) 10 cc syringes

iv. Eighteen (18) 25 gauge needles

v. Twenty-four (24) 27 gauge needles

vi. Ten (10) 18 gauge needles

vii. Twenty-six (26) BD blunt fill 18 gauge needles

viii. Thirty-two (32) count of BD 27 1/2 gauge precision glide needles

c. In Close View Room #19, the following unsecured needles and syringes were found in the first unlocked counter top drawer to the right of the sink:

i. One (1) 21 gauge Push Button Blood Collection Set [butterfly needle]

ii. Two (2) 20 gauge needles

iii. Three (3) 22 gauge needles

d. In Close View Room #19, the following unsecured needles and syringes were found in the first unlocked counter top drawer to the right of the sinck:

i. Two (2) BD Vacutainer Push Button Blood Collection Set, 0.8 x 19 mm x305 mm, 21 gauge x 3/4" x 12"

ii. Twenty-six (26) BD Insyte Autoguard BC 20 gauge 1.88 in, 1.1 x 48 mm

iii. Sixteen (16) count BD Insyte Autoguard BC 22 gauge 1.00 in, 0.9 x 25 mm

iv. Eight (18) count BD Insyte Autoguard BC 18 gauge 1.88 in, 1.3 x 48 mm

v. One (1) BD 3 ml syringe
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation, staff interviews, review of facility policies and procedures, and review of other facility documentation, it was determined that the facility failed to ensure the provision of a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Findings include:

1. The facility failed to ensure all patient care equipment is cleaned after patient use, and designated as clean when available for patient use. (Refer to Tag 0749).

2. The facility failed to dispose of single patient use solutions that are taken into the immediate patient treatment areas. (Refer to Tag 0749).

3. The facility failed to implement its policy and procedure for single dose and multi-dose vials of medications, and failed to ensure that single use vials and multi-dose vials accessed in an immediate patient care area were used for one patient and immediately discarded. (Refer to Tag 0749).

4. The facility failed to implement its cleaning procedure for all point of care testing devices. (Refer to Tag 0749).





5. The facility failed to ensure a sanitary environment for the provision of invasive and non-invasive procedures. (Refer to Tag 0749).

6. The facility failed to adhere to professionally acceptable standards for hand washing. (Refer to Tag 0749).
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
A. Based on observation and staff interview, it was determined that the facility failed to ensure all patient care equipment is cleaned after patient use, and designated as clean when available for patient use.

Findings include:

Reference: Facility policy and procedure titled 'CLEANING OF PATIENT CARE EQUIPMENT' states, "POLICY: The responsibility for insuring the cleanliness of patient equipment is a shared responsibility of multiple departments, see tables below. Procedure for Cleaning [1st bullet] All equipment will be cleaned/disinfected using hospital approved disinfectant or germicidal product. Follow manufactures [sic] guidelines for contact time. ... Equipment ... Oxygen flow meter ..." the table indicates the nurse will discard tubing and daily cleaning by Environmental Services (EVS); "... Patient chairs/recliners" the table indicates daily cleaning by EVS, and "... Stretcher and wheelchairs ..." the table indicates after patient use by staff using equipment.

1. On 2/5/16 during tour of the Emergency Department (ED) in the presence of Staff #4 and Staff #7, the following stretchers were observed without indication if they were clean or dirty:

a. A hallway stretcher located outside ED Bay CV#16 did not have a sheet on it. It could not be determined if the stretcher was clean and available for patient use, or if it was dirty.

i. In interview on 2/5/16 at 12:40 PM, Staff #4 stated that typically if a folded sheet was on top of the stretcher in the corner, then it would be considered clean. Staff #4 stated that this stretcher would be dirty.

b. In unoccupied ED Admit Room #1, the stretcher within the room did not have a sheet on top of its surface. Per Staff #4, this stretcher would be considered dirty.

i. The mattress of this stretcher was lifted and a heavy accumulation of dust was observed on the metal components of the stretcher.

c. There is no indication in the facility policy and procedure of the procedure to indicate if a stretcher is clean or dirty.

2. On 2/5/16 during tour of the Emergency Department (ED) in the presence of Staff #4 and Staff #7, the following surfaces were observed covered with an ABD Pad and/or tape:

a. In Room A-1, an ABD Pad was observed mounted over the nurse call system and secured with silk tape.

i. Staff #4 stated he/she is not sure why the ABD Pad and tape was covering the nurse call system.

b. In Close View Room #19, the wall mounted oxygen gauge had a phone receiver taped over its face plate with silk tape.

c. In Close View Bay #18, the wall mounted nurse call system was covered with silk tape.

d. The surfaces with ABD pads and tape applied, are not able to be cleaned.

3. The following surfaces were observed with tears in their materials, exposing the foam within which is not able to be cleaned:

a. In the ED waiting room, there were ten (10) chairs that had tears in their surfaces. Some of the chairs' foam interior was exposed.

B. Based on observation, it was determined that the facility failed to dispose of single patient use solutions, that are taken into the immediate patient treatment areas, are disposed of immediately after use, in accordance with facility policy and procedure.

Findings include:

Reference: Facility policy and procedure titled 'MEDICATION: MULTI-DOSE VIAL DATING AND EXPIRATION' states, "... Definition: ... 3. "Immediate Patient Treatment Area" is defined as patient rooms, patient bays and procedural areas (including operating rooms). ... 6. Oral Solutions a. all bulk oral solutions not requiring reconstitution may be used until the manufacturer's expiration date. ... 8. Irrigation Solutions a. Most irrigation solutions DO NOT contain antimicrobial agents. Therefore, they are considered single-patient use products and should be dated and discarded within 24 hours of opening. b. Antimicrobial solutions such as povidone-iodine, hydrogen peroxide, rubbing alcohol, kept in a non-patient area, may be used until the manufacturer's expiration date. Solutions taken into the "immediate patient treatment area" are considered single patient use items. ..."

1. On 2/5/16 from 11 AM- 1:50 PM, a tour of the Emergency Department (ED) was completed in the presence of Staff #4 and Staff #7. The following single use bottles of solutions were found opened and available for use in immediate patient care areas beyond their beyond use expiration timeframe, per facility policy and/or manufactures instructions as follows:

a. In Patient Room A-8, in a cabinet above the counter top the following was found:

i. A 1000 ml open bottle of 0.9% Sodium Chloride irrigation was found. The bottle had a date of opening written on it as "11/21/15". The manufacturer's printed instructions on the bottle label states "... warning ... single-dose container. Contains no bacteriostat. Discard unused portion. ...". The bottle of saline irrigation was available for patient use. The bottle was not discarded within 24 hours of opening as per facility policy. The bottle was not dedicated to one patient.

ii An eight ounce open bottle of Scrub Care 10% Povidone-Iodine Paint with a written date of opening as 12/18 [no year indicated] on it. The bottle was 1/4 to 1/2 full. The manufacturer's printed instructions on the bottle states "Antiseptic non-sterile solution ... For single use only ...". The manufacturer indicates that the bottle of povidone iodine is for single use only. The facility's policy and procedure states povidone-iodone may be used until the manufacturer's expiration date, which is not in accordance with the manufacturer's instructions.

iii. A bottle of Cetacaine Topical anesthetic spray with a date of opening of 10/3/15 written on it. The manufacturer's expiration date is 7/2017. The bottle has an access pin inserted on top of the bottle, thru the rubber septum, that activates the spray when pressed. Although the facility allows for oral solutions to be used thru the manufacturer's expiration date, staff were not able to explain how the access pin, that is inserted into a patient's mouth and then activated to spray the anesthetic, is cleaned in between patients.

b. In Patient Room A-9, in a cabinet above the counter top the following was found:

i. An open eight ounce bottle of Scrub Povidone Iodine 10%solution

c. On top of a laceration care rolling cart, located outside the sub-acute charge nurses' station:

i. A 100 ml bottle of 0.9% sodium chloride for irrigation

ii. A 16 ounce bottle of 3% hydrogen peroxide

iii. A 16 ounce bottle of Isopropyl 70% Alcohol

iv. Two (2) opened bottles of 0.9% sodium chloride irrigation solution

d. In the unlocked Close View (CV) Supply Cabinet #1, an open eight ounce bottle of Scrub Povidone Iodine 10%solution

e. In the unlocked Close View (CV) Supply Cabinet #2, an opened bottle of 70% rubbing alcohol

f. On the counter next to the sink outside Room-B, an opened 1000 ml bottle of sterile water for irrigation

2. On 2/8/16, during an observation of a procedure in Labor and Delivery Operating Room #1 in the presence of Staff #1, a 16 ounce bottle of hydrogen peroxide 3%, with an expiration date of 10/14 was found opened and available for use.

C. Based on observation and review of facility policy and procedure, it was determined that the facility failed to implement its policy and procedure for single dose and multi-dose vials of medications.

Findings include:

Reference #1: Reference: Facility policy and procedure titled 'MEDICATION: MULTI-DOSE VIAL DATING AND EXPIRATION' states, "... Definition: 1. Single-Dose Vials - Injectable products (preservative free): a single dose vial is to be used once and discarded. 2. Multi-dose Vials- Injectable products (contain preservative): a. the expiration date of an opened vial is 28 days or the manufacturer's expiration date, whichever is sooner. ... b. Multi dose vials may not enter "immediate patient treatment areas". Vials entering a patient treatment area are considered a single patient use vial for a single scheduled procedure timeframe (not to exceed 24 hours). 3. "Immediate Patient Treatment Area" is defined as patient rooms, patient bays and procedural areas (including operating rooms). ... "

Reference #2: Center for Disease Control (CDC) question and answer guidelines for multi-dose vials <http://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html>, states, "Can multi-dose vials be used for more than one patient? How? Multi-dose vials should be dedicated to a single patient whenever possible. If multi-dose vials must be used for more than one patient, they should not be kept or accessed in the immediate patient treatment area. This is to prevent inadvertent contamination of the vial through direct or indirect contact with potentially contaminated surfaces or equipment that could then lead to infections in subsequent patients. If a multi-dose vial enters the immediate patient treatment area, it should be dedicated to that patient only and discarded after use." And "What are examples of the immediate patient treatment area"? Examples of the immediate patient treatment area include patient rooms or bays, and operating rooms."

1. On 2/5/16 from 11 AM- 1:50 PM, a tour of the Emergency Department (ED) was completed in the presence of Staff #4 and Staff #7. An unlocked laceration care rolling cart was observed located outside the sub-acute charge nurses' station. This location and the rolling cart is an immediate patient treatment area. The following unsecured and opened drugs were found within the cart's drawers, available for repeated patient use:

i. A 30 ml opened single use bottle of Bupivicaine 0.5%, 5 mg/ml

ii. A 20 ml opened multi-dose bottle of Xylocaine 1%, 200 mg/20 ml

iii. Two (2) 30 ml opened single dose bottles of Bupivicaine HCL 0.5% and Epinephrine 1:200,000

2. In the unlocked Close View (CV) Supply Cabinet #1, an opened 20 ml vial of Xylocaine with epinephrine 1:100, 000, 200 mg/20 ml

3. The availability of opened single dose or multi-dose vials for repeated use in an immediate treatment area is not in accordance with the above referenced facility policy (Reference #1) or CDC guidelines (Reference #2). These findings resulted in an Immediate Jeopardy which immediately curtailed this practice. The Immediate Jeopardy was removed on 2/5/16, the day of survey, upon receipt of an acceptable plan of correction.

D. Based on observation and review of facility policy and procedure, it was determined that the facility failed to implement its cleaning procedure for all point of care testing devices.

Findings include:

Reference #1: Facility policy and procedure titled 'CLEANING OF PATIENT CARE EQUIPMENT' states, "... Procedure for Cleaning [1st bullet] All equipment will be cleaned/disinfected using hospital approved disinfectant or germicidal product. Follow manufactures [sic] guidelines for contact time. ... All reusable unit based equipment such as ... glucometer ... must be cleaned after every patient use and stored in designated clean equipment area in department. ..."

Reference #2: Facility Procedure # POC-GLU-101, titled '--[manufacturer's name]-- ACCU-CHEK INFORM II PROCEDURE FOR USE' states, "... Cleaning and Disinfecting the ACCU-CHEK Inform II System Components [1st bullet] Meter cleaning and disinfecting- ... Meters used with multiple patients may require more frequent cleaning and disinfecting. Follow recommendations from the FDA, CDC, and CMC and your facility's policies and procedures for infection control. NOTE: ... If dedicating blood glucose meters to a single patient is not possible, the meters must be properly cleaned and disinfected after every use following the guidelines given in this procedure. [1st bullet] Base Unit cleaning and disinfecting- Base units are cleaned and disinfected with Clorox(R) Germicidal Wipe EPA reg. no. -12 or Super Sani-Cloth(R) Germicidal Disposable Wipes EPA reg. no. 9480-4 [2nd bullet] Accessory box cleaning and disinfecting- Accessory boxes are cleaned and disinfected with Clorox(R) Germicidal Wipe EPA reg. no. -12 or Super Sani-Cloth(R) Germicidal Disposable Wipes EPA reg. no. 9480-4 [3rd bullet] Cleaning and disinfecting are companion procedures that are generally performed together at the same time. Cleaning removes visible soil and organic material. Disinfecting destroys most recognized pathogenic microorganisms but not necessarily all microbial forms (e.g., bacterial spores). ..."

1. On 2/11/16 during tour of the ICU a staff nurse was observed performing bedside glucose testing to a patient in Room 233. The nurse swiped a drop of blood off the patient's finger with a two by two gauze pad, and placed the blood stained gauze on top of the patient's bedside over table. The nurse then completed the bedside glucose testing and discarded the gauze. He/she did not sanitize the bedside table that the blood soiled gauze pad had rested.

a. The nurse then carried the glucometer testing device back to the nurses station and docked it in the base unit. He/she did not clean the glucometer after performing patient bedside glucometry and prior to docking the glucometer at the nurses station.





E. Based on observation and staff interview conducted on 2/25/16, it was determined that the facility failed to ensure a clean and sanitary environment for the provision of surgical services.

Findings include:

1. During a tour of the Early Treatment Area (ETA) of the Emergency Department (ED) at 10:25 AM, the following was observed:

a. A Mayo table was soiled with reddish residues and stains.

b. Debris soiled the table and the floor.

c. These findings were confirmed with Staff #39.

2. At 10:30 AM, in the ED Admit Room, a fabric-upholstered chair was observed to be soiled with white residues and stains.

a. The fabric is an uncleanable surface.

b. This finding was confirmed with Staff #39.

3. At 10:35 AM, in the Procedure Room of the Radiology Department, the following was observed:

a. The floor was marred with a divot.

i. The marred surface is uncleanable.

b. An arm-board was covered with adhesive cloth tape that is soiled with brownish stains.

c. These findings were confirmed with Staff #1 and Staff #42.

4. During a tour of the Radiology Oncology Procedure Room, in the presence of Staff #1, Staff #44, Staff #45, and Staff #46, the following was observed:

a. At 10:55 AM, reddish-brown stains soiled the general exterior of the UPS power regulator.

i. Staff #44 stated they are "rust stains."

b. A layer of dust soiled the surface of the GE System Dual Powerware UPS.

i. Staff #45 stated, "No one is designated to clean this."

c. The interior of a container identified as a "water bath" by Staff #44 was stained with brown and yellowish stains.

d. A slide board was marred with scratches and soiled with black stains.

e. These findings were confirmed with Staff #1, Staff #44 Staff #45, and Staff #46.

F. Based on observation, lack of facility documentation, and staff interview conducted on 2/25/16, it was determined that the facility failed to ensure that its Infection Control practices adhere to the nationally recognized guidelines it has selected.

Findings include:

Reference: AORN Perioperative Standards and Recommended Practices; RP: Care of Instruments, 2013 edition, Recommendation I.a. states, "The manufacturer's written instructions should be used to determine how to replicate the validated cleaning and processing methods."

1. During the entrance interview from 8:30 AM to 9:00 AM with Staff #1, Staff #29, Staff #32, Staff #34, Staff #35, and Staff #36, this surveyor was informed that the facility has selected CDC, AAMI, OSHA, APIC and AORN guidelines and recommended practices for its Infection Control program.

2. During a tour of the Procedure Room of the Radiology Department, in the presence of Staff #42 and Staff #43 at 10:40 AM, a GE Logiq S7 Expert keyboard was observed.

a. Staff #42 stated the GE Logiq S7 Expert keyboard is "cleaned with PDI Sanicloth wipes."

i. The manufacturer's IFU for the GE Logiq S7 Expert keyboard was requested and not received while in the area at 10:40 AM.

b. During review of facility documents between 12:00 PM to 1:00 PM, the manufacturer's IFU for the GE Logiq S7 Expert keyboard was received. Upon review, the IFU stated, "Use a fluid detergent in warm water on a soft, damp cloth to carefully wipe the entire system."

3. At 10:45 AM, a number of X-ray aprons were observed to contain stains. The policy and procedure for cleaning the X-ray aprons was requested from Staff #41 and Staff #42.

a. Staff #41 stated he/she was not aware of such policy and procedure.

b. Staff #42 stated that the facility uses PDI wipes to clean the aprons weekly.

c. The manufacturer's IFU for the Bar Ray X-ray aprons was requested but not received during the tour.

d. Upon review of the manufacturer's IFU for the Bar Ray X-ray aprons stated, "Remove stains immediately when they occur. If this is not possible, clean with warm water and a non-bleach dishwashing soap. Do not use harsh or abrasive cleansers. ... Do's [sic] ... clean it regularly."

4. The facility failed to ensure that the device manufacturer's IFUs are available at the point of use and followed.

5. These findings were confirmed with Staff #42 and Staff #43.

G. Based on observation and staff interview conducted on 2/25/16, it was determined that the facility failed to ensure that its clean linen supply are kept clean and stored in a manner that maintains cleanliness.

Findings include:

1. During a tour of the Laundry Department at 1:58 PM, in the presence of Staff #38, the following was observed:

a. The floor of the Clean Linen Room contained black and brown residues throughout the room.

b. The eyewash station was soiled with debris.

i. The maintenance record attached to the eyewash station indicated it was checked on 2/23/16.

c. Containers of clean linen were stored in an area of the Receiving Dock separated by a pull down gate. The blue plastic covers were drawn up on all linen containers. Linen carts were observed to be uncovered or partially covered with plastic.

d. The Clean Linen Room appeared untidy and disheveled with dust and debris littering the floors.

2. The facility failed to ensure its clean linen supply are kept clean.

H. Based on observation, review of facility policies and procedures and staff interview conducted on 2/25/16, it was determined that the facility failed to ensure that its Infection Control policies and procedures are implemented.

Findings include:

Reference #1: Facility policy titled, "O.R. Dress Code" states, "... Procedure: ... 3. Hair must be covered by anyone entering the Operating Room suite. ... b. Any male with long sideburns or beard must wear a hood. ... 4. Non-scrubbed personnel should wear a long sleeved jacket that is buttoned or snapped close during use. a. A clean disposable non-fleece jacket or a freshly laundered jacket should be worn everyday. ... c. Other garments- should be contained completely within or covered by surgical attire. ..."

1. At 11:35 AM, during a tour of the O.R., in the presence of Staff #47 and Staff #48, Staff #50 was observed to have uncovered facial hair and a t-shirt that was not contained within his/her scrub suit attire.

2. This finding was confirmed with Staff #47 and Staff #48.

Reference #2: Facility policy titled, Standard and Transmission Based Precautions, states, "... 1) Hand Hygiene: ... Always wash hands before and after each patient contact... 2) Gloves... Gloves are not a substitute for hand hygiene... Are to be changed between tasks and procedures on the same patient... Remove gloves promptly after use; perform hand hygiene, before touching non-contaminated items and environmental surfaces, and before going to another patient..."

1. During a tour of the Endoscopy Department at 1:30 PM, Staff #53 removed a pair of soiled gloves while performing scope decontamination without performing hand hygiene before touching the environmental surfaces within the room.

a. This finding was confirmed with Staff #53.

2. The facility failed to ensure its O.R. Dress Code and Hand Hygiene policies and procedures are implemented.

I. Based on observation and staff interview conducted on 2/25/16, it was determined that the facility failed to ensure that sterile supplies are stored in a manner that maintains sterility.

Findings include:

Reference: AAMI (Association for the Advancement of Medical Instrumentation) Sterilization in Health Care Facilities, 2014 edition ST 79 section 8.9.2 states, "Sterile items should be stored in a manner that reduces the potential for contamination."

1. During a tour of the O.R. at 11:00 AM, in the presence of Staff #1 and Staff #47, two boxes containing UHS Lithotripsy fibers were observed to be stored on the counter next to a hand washing sink.

a. The items were labeled "sterile".

i. Storing sterile items next to a hand washing sink exposes them to increased potential of contamination.

2. This finding was confirmed with Staff #1 and Staff #47.






J. Based on observation, a review of policies and procedures, and staff interview, it was determined that the facility failed to adhere to professionally acceptable standards for hand washing.

Findings include:

Reference #1: Guideline for Hand Hygiene in Health Care Settings: Recommendation of the Healthcare Infection Control Practices Advisory Committee[HICPAC] and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force, published in the CDC (Centers for Disease Control and Prevention) Morbidity and Mortality Weekly Report at MMWR 2002; 51 (No. RR-16) page 32 states, "Recommendations: 1. Indications for Handwashing and Hand antisepsis ... C. Decontaminate hands before having direct contact with patients ... E. Decontaminate hands before inserting ... peripheral vascular catheters, or other invasive devices ...
F. Decontaminate hands after contact with a patient's intact skin ...
G. Decontaminate hands after contact with ... a patient's nonintact skin ...
I. Decontaminate hands after contact with inanimate objects ... in the immediate vicinity of the patient. J. Decontaminate hands after removing gloves ..."

Reference #2: Facility policy titled, Standard and Transmission Based Precautions, states, "... 1) Hand Hygiene: ... Always wash hands before and after each patient contact ... 2) Gloves ... Gloves are not a substitute for hand hygiene ... Are to be changed between tasks and procedures on the same patient ... Remove gloves promptly after use; perform hand hygiene, before touching non-contaminated items and environmental surfaces, and before going to another patient ..."

1. During an observation in the Emergency Department on 2/5/16 at 11:58 AM, Staff #13 was observed having physical contact with both a clean stretcher, and a stretcher occupied by a patient, without performing a glove change or hand hygiene between contacts.

2. The above was confirmed with Staff #4.

3. During an observation in Labor and Delivery Operating Room (O.R.) #1 on 2/8/16 between 1:10 PM and 2:49 PM, the following was observed:

a. Staff #19 removed sterile gloves, without decontaminating his/her hands.

b. Staff #18 performed multiple glove changes, without decontaminating his/her hands.

c. Staff #20 performed multiple glove changes, without decontaminating his/her hands.

4. During an observation in the Labor and Delivery Recovery Room on 2/8/16, the following was observed:

a. At 2:49 PM, Staff #28 removed his/her gloves, without decontaminating his/her hands.

b. At 2:52 PM, Staff #18 performed a glove change, without decontaminating his/her hands.

5. The above was confirmed with Staff #1.

Reference #3: Facility policy titled, Standard and Transmission Based Precautions, states, "... 1) Hand Hygiene: ... Hand Hygiene with soap and water is recommended for patients diagnosed or suspected of having Clostridium difficile or norovirus, Alcohol hand gels are ineffective for these organisms ..."

6. During an observation on 4 Northeast on 2/11/16 at 1:51 PM, Staff #33 was observed using an alcohol based hand rub upon exiting the room of a patient with suspected [DIAGNOSIS REDACTED]. He/she was then observed obtaining a soiled linen basket from further down the hallway, and bringing it back to the patient room to assist another staff member with dirty linen before decontaminating his/her hands with soap and water.

7. The above was confirmed with Staff #32.

K. Based on observation, a review of policies and procedures, and staff interview, it was determined that the facility failed to adhere to professionally acceptable standards for aseptic technique.

Findings include:

Reference: Facility policy titled, Aseptic Technique, states, "... 15. A sterile field will be prepared as close as possible to the time of surgery ... B. Every team member will observe for events that may contaminate the sterile field and corrective action must be initiated ... E. Nonsterile equipment brought into and over the sterile field will be draped with a sterile material or covering ... G. All persons moving within and around the sterile field must do so in a manner to maintain the integrity of the sterile field ..."

1. During observation of an indwelling urinary catheter insertion for Patient #18 on 2/8/16 at 1:25 PM, the following was observed:

a. Staff #18 cleaned the perineum prior to catheter insertion. After each cleansing wipe, he/she brought the contaminated cleansing swab over the sterile field to discard.

2. During an observation of Patient #18 in Labor and Delivery O.R. #1 on 2/8/16, the following was observed:

a. At 1:29 PM, Staff #20 was observed carrying a sterile glove away from its sterile package, turned on a light, and placed the sterile glove down on a table for later application.

b. Between 1:36 PM and 1:49 PM, Staff #20 was observed touching a fetal monitor, touching a chart, and using the phone twice, while wearing sterile gloves and gown.

c. The above was confirmed with Staff #1.

L. Based on observation, and review of policies and procedures, it was determined that the facility failed to ensure the maintenance of a sanitary physical environment.

Findings include:

Reference #1: Facility policy titled, Bloodborne Pathogens, states, "... All contaminated work surfaces will be decontaminated immediately after completion of procedures, or as soon as feasible, after any spill of blood or other potentially infectious material, and at the end of the work shift ..."

1. During an observation of Patient #18 in Labor and Delivery O.R. #1 on 2/8/16, the following was observed:

a. At 2:37 PM, a contaminated surgical sponge was dropped on the floor of the O.R., leaving two (2) residual areas on the floor streaked with a red substance.

b. Staff #18 was observed walking on the red residue, without wearing a cover on his/her shoes.

c. O.R. equipment was observed being wheeled over the top of the red residue.

Reference #2: Facility policy titled, Environmental Cleaning in the Operating Room Setting, states, "... B. Intraoperative Practices: ... Accidental spills of contaminated debris in area outside the surgical field will be cleaned as promptly as possible ... D. Terminal Cleaning Practices: All surgical suites will be terminally cleaned daily at the completion of the daily schedule ... 2. High dust with treated duster 3. Wash-wipe down walls 4. Damp wipe surgical lights and external arms, fixed and ceiling mounted equipment and cabinets from highest to lowest ... 6. Clean phone, computer table, door handles and push plates ..."

2. During an observation in Labor and Delivery O.R. #1 on 2/8/16, the following was observed:

a. Dried tape residue and dust was visible on the back of a light over the procedure table.

b. Peeling and chipped paint was visible behind a clock on the wall.

c. A layer of thick dust was visible between two (2) ceiling panels that were not flush with the ceiling.

d. Rust was visible on a doorstop against the O.R. wall and on a metal outlet cover.

e. Tape was wrapped around the base of a cordless phone hanging on the O.R. wall.