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.

MARY WASHINGTON HOSPITAL 1001 SAM PERRY BOULEVARD FREDERICKSBURG, VA 22401 March 22, 2017
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review it was determined the facility staff failed to ensure:
1. Informed consents for general treatment were completed with appropriate signatures, timed, and dated for thirteen (13) of thirty-one (31) Emergency Department patients in the survey sample (Patients #3, #4, #5, #11, #12, #13, #19, #20, #21, #25, #29, #30 , and #35);

2. The transfer form included the required documentation for five (5) of eight (8) Emergency Department patients transferred from the facility to a higher level of care (Patients # 8, #10, #14, #17, and #27);

3. The physician documented consulting with the accepting physician at the receiving hospital for one (1) of eight patients transferred from the facility to a higher level of care (Patient #18);

4. The consulting physician failed to document an examination for one (1) of three (3) Emergency Department consultations (Patient #3)

5. The triage nurse failed to document the patient's acuity level for one (1) of thirty-one (31) patients in the survey sample, who were triaged in the Emergency Department (Patient #24)

The findings included:

1. Review of the facility's form titled "General Consent for Treatment/Guaranty of Payment" was performed as part of the medical record review during a complaint investigation. The facility's form titled "General Consent for Treatment/Guaranty of Payment" on the front side contains information for "Consent for Examination and Treatment; Patient's Rights, Grievance process, Advance Directives; Interpreter Services and Auxiliary Aids; Deemed Consent/Prescription Monitoring; Personal Valuable; and Notice of Privacy Practices." The back of the form includes additional information and agreements regarding the patient's financial responsibilities. The facility's "General Consent for Treatment/Guaranty of Payment" form has two (2) lines on the front of the form for the patient to initial and date. The back of the "General Consent for Treatment/Guaranty of Payment" form has lines for "Patient/Legal Surrogate" with lines for "Date/Time" and "Relationship to Patient." Below the "Patient/Legal Surrogate" signature line the form had a line for a "Witness" signature with a "Date/Time" line. The review of Emergency Department (ED) electronic medical records (EMRs) revealed:

Patient #3 was admitted on [DATE] related to a hand laceration. Patient #3's "General Consent for Treatment/Guaranty of Payment" did not have initials and date on the front of the form and the back of the form was blank. Staff Member #8 verified the findings at 8:49 a.m. on 03/17/2017.

Patient #4, a child, was admitted on [DATE] related to a hand laceration. Patient #4's "General Consent for Treatment/Guaranty of Payment" did not include initials and date on the front of the form. The back of the form failed to include the date, time, and the relationship of the person that signed for the patient. The form did not have a witness signature with date and time. Staff Member #8 verified the findings at 9:35 a.m. on 03/17/2017.

Patient #5 was admitted on [DATE] related to "bleeding from multiple spots." Patient #5's "General Consent for Treatment/Guaranty of Payment" was an electronic version. An interview was conducted with Staff Member #8 at approximately 10:16 a.m. on 03/17/2017. Staff Member #8 reported the electronic version of the "General Consent for Treatment/Guaranty of Payment" time stamps the patient's name, date and time of signature. Staff Member #8 reported he/she was not sure how the form was witnessed by facility staff.

Patient #11 was admitted on [DATE] for a hand laceration. Patient #11's "General Consent for Treatment/Guaranty of Payment" documented the patient gave "verbal consent." The facility staff failed to document the time the verbal consent was given and failed to document the time of their signatures. Staff Member #8 verified the findings at 11:29 a.m. on 03/20/2017.

Patient #12 was admitted to the ED in 02/23/2017 for "injury to right hand." Patient #12's electronic version of the facility's "General Consent for Treatment/Guaranty of Payment" did not have a documented witness signature with date and time. Staff Member #8 verified the findings at 11:44 a.m. on 03/20/2017.

Patient #13 was admitted on [DATE] related to being twelve-weeks pregnant with cramping and bleeding. Patient #13's "General Consent for Treatment/Guaranty of Payment" form did not have a documented witness signature with date and time. Staff Member #8 verified the findings at 10:13 a.m. on 03/20/2017.

Patient #19 was admitted on [DATE] related to a crushed finger. Patient #19's "General Consent for Treatment/Guaranty of Payment" form did not have a witness signature with date and time. Staff Member #8 verified the findings at 2:44 p.m. on 03/20/2017.

Patient #20 was admitted on [DATE] related to a finger injury. Patient #20's "General Consent for Treatment/Guaranty of Payment" form documented the patient gave "Verbal Consent." The facility staff failed to document the time the verbal consent was obtained. Staff Member #8 verified the findings at 12:28 p.m. on 03/21/2017.

Patient #21 was admitted on [DATE] related to "Orange drainage from nares" after a fall. Patient #21's electronic "General Consent for Treatment/Guaranty of Payment" form did not have a documented witness signature with date and time. Staff Member #8 verified the findings at 1:24 p.m. on 03/20/2017.

Patient #25 was admitted on [DATE] related to "deep cut to right arm." Patient #25's "General Consent for Treatment/Guaranty of Payment" form had a staff witness signature, which was not dated or timed. Staff Member #8 verified the findings at 9:48 a.m. on 03/21/2017.

Patient #29 was admitted on [DATE] and 03/08/2017 related to headache and possible allergic reaction. Patient #29's "General Consent for Treatment/Guaranty of Payment" form for his/her 03/08/2017 admission failed to have a witness signature with date and time. Staff Member #8 verified the findings at approximately 10:50 a.m. on 03/21/2017.

Patient #30 was admitted on [DATE] related to a foot injury with continued bleeding. Patient #30's "General Consent for Treatment/Guaranty of Payment" form failed to have a witness signature with time and date. Staff Member #8 verified the findings at 2:00 p.m. on 03/21/2017.

Patient #35 was admitted on [DATE] related to a chief complaint of "sliced foot." Patient #35's "General Consent for Treatment/Guaranty of Payment" form had a witness signature, which failed to have a date or time. Staff Member #8 verified the findings at 2:28 p.m. on 03/21/2017.

Review of the facility's policy titled "Consents (Informed, General, Informed Refusal)" read in part: "Policy objective: To affirm the patient's right to participate in his or her treatment decisions and to delineate the process, responsibility and requirements for obtaining patient consent for both general medical treatment at the facility as well as a particular procedures or operations ... General Consent[:] The Hospitals require that patient's sign the General Consent for Treatment/Guaranty of Payment which covers routine hospital services as well as a separate consent form for specific procedures/treatments. 1. The General Consent is required for all patients (Inpatient and Outpatient/Emergency) no matter what the point of entry with the exception of a Documented Medical Emergency ... Informed Consent Process ... The witness for informed consent will sign and date the form after the patient/consentor, and will physically observe the patient/consentor's signature. The witness will be a health care professional involved in the patient's care ... Documentation 1. General Consent: ... c. If the patient is unable to or refuses to give general consent, "Unable to Sign" or "Refuses to Sign" shall be documented on the Patient Signature space with the name of the person who attempted to obtain General Consent for Treatment. If a legal surrogate is contacted, his/her name shall be noted on the Patient Signature line with notation of the relationship to the patient. d. The date and time of the patient's or representative's signature on the General Consent will be documented on the form by the Associate presenting the form for signature ... [Sic]"


2. Failure to ensure transfer forms were complete:

Review of Patient #8's EMR revealed he/she was admitted to the facility's ED on 07/23/2016. Patient #8 presented with multiple deep lacerations to his/her left hand, distal fractures of his/her third and fourth digits and tendon laceration. Patient #8 reported his/her injuries were inflicted while using a table saw. Patient #8's EMR documented the emergency department physician contacted the orthopedic surgeon on-call. Patient #8's EMR documented the on-call orthopedic surgeon made the recommendation the patient should be transferred to a facility with a hand surgeon on-call. Patient #8's EMR contained a "Transfer Certification Form" that had only been partially completed. The "Reason for Transfer" section of Patient #8's "Transfer Certification Form" was blank. The "Nurse (Manager/Supervisor/Charge RN in ED) signature line was blank within the "Transfer Checklist" section. The "Nurse Signature" line and date was blank in the "Discharge Vitals" section and the "Transfer Time" was blank in the "Discharge Condition at Transfer" section. Staff Member #8 verified the findings at 11:56 a.m. on 03/17/2017.

Review of Patient #10's EMR revealed the patient presented to the facility's ED on 05/08/2016. Patient #10's chief concern was listed as "No bowel movement for five days" and episodes of "vomiting." The emergency department physician documented the recommendations offered by the surgeon on-call to transfer the patient to a facility with the ability to perform a "colonic stent." Review of Patient #10's "Transfer Certification Form" revealed the "Reason for Transfer" section was blank. The emergency department physician failed to date and time his/her signature in the "Patient Condition" section on Patient #10's "Transfer Certification Form." Staff Member #8 verified the findings at 10:51 a.m. on 03/20/2017.

Review of Patient #14's EMR revealed the patient was admitted on [DATE] with the complaints of neck and back pain after being involved in a motor vehicle accident. Patient #8, a pediatric patient was transferred to another facility. The "Reason for Transfer" section of Patient #14's "Transfer Certification Form" was blank. The emergency department physician failed to date and time his/her signature. Nursing staff failed to complete the patient's "Discharge Condition at Transfer" section and failed to enter the "Transfer Time" on Patient #14's "Transfer Certification Form." Staff Member #8 verified the findings at 11:49 a.m. on 03/20/2017.

Review of Patient #27's EMR revealed the patient was admitted to the facility's ED on 10/04/2016. Patient #27 and his/her family were traveling from another facility after the patient had received an intravenous infusion treatment. Patient #27 presented to the Facility's ED with complaint of fever. The sections related to the "Reason for Transfer," "Benefits of Transfer," "Risks of Transfer," "Consent for Transfer (signature line with date and time)," "Transfer Checklist (along with nursing staff signature with date and time)," "Discharge Vitals" and "Transfer Time" were blank on Patient #27's "Transfer Certification Form." The emergency department physician had failed to complete the "Patient Condition" section and failed to dated and time his/her signature on Patient #27's "Transfer Certification Form." Staff Member #8 verified the findings at 9:00 a.m. on 03/21/2017.

3. Review of Patient #18's EMR revealed the patient was admitted to the facility on [DATE] after a gunshot wound to his/her hand. Patient #18's "Transfer Certification Form" listed the name of the receiving facility and the name of the accepting physician. Review of the "emergency room Physician Report" for Patient #18 did not include documentation the physician had consulted with or spoken to the accepting physician at the receiving facility. Staff Member #8 reviewed Patient #18's EMR for notation the emergency department physician with the time he/she spoke with accepting physician at the receiving hospital. Staff Member #8 verified the emergency department physician did not include the information in his/her "emergency room Physician Report" documentation. Staff Member #8 verified other than the listed information by nursing staff Patient #18's EMR did not contain documentation of physician to physician communication regarding Patient #18's transfer to another facility.

4. Review of Patient #3's EMR revealed the patient was admitted on [DATE] related to a hand laceration. Patient #3's EMR revealed he/she was initially seen by an emergency service physician (Staff Member #14) at 7:31 a.m. on 06/18/2016. Staff Member #14 documented reviewing Patient #3's nursing assessment. Staff Member #14's initial assessment of Patient #3 included a review of body systems. Staff Member #14 documented Patient #3 had a "5.0 cm (centimeter) laceration to right hand ... Right palm: tenderness, swelling ... Neuro (neurological), Vascular and Tendons: Sensory deficit. Weakness. Tendon injury seen. Pt (Patient) cannot flex [his/her] 3rd and 4th digit and has decreased sensation in both ..." Staff Member #14 documented consulting Staff Member #16 the Orthopedic physician on call for the Emergency Department (ED) at 7:50 a.m. on 06/18/2016. Staff Member #14 documented consulting Staff Member #15 and receiving instructions to close the skin and obtain images and splint Patient #3's right hand. Patient #3's EMR contained documentation Staff Member #14 ordered "stat (immediately)" radiologic studies of the patient's right hand and right wrist at 8:17 a.m. on 06/18/2016.

A telephone interview was conducted on 03/20/2017 at 4:35 p.m. with Staff Member #15. Staff Member #15 reported he/she had the opportunity to review Patient #'s EMR. Staff Member #15 reported he/she had not been the Ortho-physician on call for 06/18/2017. Staff Member #15 stated, "I was actually doing a case in the OR [Operating Room] when I received the call." Staff Member #15 reported stabilization for Patient #3 involved stopping the bleeding, making sure the patient did not have a fracture or glass within the wound. Staff Member #15 reported the radiologic studies performed on Patient #3's right hand and wrist was the proper protocol. Staff Member #15 reported once the bleeding was controlled then the right splint was needed.

Staff Member #15 stated, "Clinically, severed tendons or nerves are not an orthopedic emergency. You stabilize the hand with a splint and schedule surgery. You need to have the right tools." Staff Member #15 reported in some cases specific implants/grafts have to be ordered prior to the surgery.

Staff Member #15 reported the Ortho physician on-call 06/18/2016 for the ED did not feel comfortable making the treatment decision. Staff Member #15 stated, "I saw the patient as a courtesy both to my colleagues and the patient. When I saw the patient [his/her] vital signs were stable. When I examined [him/her] there was profusion of the fingers. There was no active bleeding in the wound. I made my recommendations for the splint. Based on my examination the patient was stable." Staff Member #15 stated, "I did not make a note in the medical record, I didn't want [him/her] to be charged for a consult. And [Staff Member #14's name] had charted my recommendations."

Review of the facility's "Medical Bylaws and Rules and Regulations" read in part: "6. Responsibilities of the Appointee Requesting a Consultation ... all request for consultations shall be recorded in the physician's order section of the medical record ... 7. Responsibilities of the Consultant 7.1 Documentation in the patient's medical record of the consultation, including, as appropriate; clinical and laboratory findings ..."

Review of Patient #3's EMR was conducted with Staff Member #8. Staff member #8 verified Patient #3's EMR did not include an physician ordered consult and the consulted hand surgeon did not document his/her examination of Patient #3.

5. Review of Patient #24's EMR revealed the patient was admitted to the facility's ED on 10/01/2016. Patient #24 presented to the facility's ED with a chief complaint of laceration to his/her left palm. Review of the nursing "triage" assessment failed to include the patient's level of acuity. Staff Member #8 reviewed Patient #24's EMR with the surveyor and verified the findings.

Review of the facility's policy titled "Emergency Care and Treatment" read in part: " Supportive Data: ... 2. Emergency care incorporates pre-hospital care; triage; nursing and physician assessment; diagnostics; implementation of therapy; specialty consultation and admission when indicated; patient and family education; disposition; and referral. Pre-hospital care providers, multiple hospital departments, consulting physicians, and community agencies collaborate with emergency care personnel to coordinate services delivered to the patient and family ... Admission to the Emergency Department: Triage[:] 2. g. Once the triage assessment is completed, the nurse assigns an acuity level and an appropriate treatment area. The acuity level determines the priority for care Patients are admitted to a treatment area based on the urgency of their complaint ... Specialty Consultation[:] 1. Consult Decision Making: The need for consultation is the decision of the emergency department physician and the consultation process shall be governed by the Medical Staff Bylaws and Rules and Regulations. 2. On-Call Roster: a. On-call rosters for specialty and private group call are prepared by the Communications Department daily and posted in the emergency care department ... [Sic]."
VIOLATION: INFECTION CONTROL Tag No: A0747
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observations, interviews and documents reviewed, it was determined the facility staff failed to implement a system to ensure staff practiced infection reducing behaviors as evidenced by:

1. Ensuring a sanitary physical environment is protected to prevent the spread of infection and prevent harm by the inability to disinfect porous wood surfaces between patients; and failure to thoroughly clean and disinfect patient rooms after discharge.

2. Failure to ensure sutures and specimen collection supplies available for use were not expired and available for use in direct patient care.

3. Failure to maintain a sanitary physical environment by an opened trash container with a tied red bag of unknown contents located in with regular trash and four (4) disposable blue rubber gloves lying on the concrete next to the trash container.

4. Ensuring facility protocols were followed for a blood spill.

5. Failure to handle contaminated glucometers in a manner to prevent the spread of infectious agents and to disinfect glucometers in a manner to prevent the spread of infectious agents for two (2) of three (3) observations.

The findings included:

Some observations related to this deficient practice began on 3/15/17, during the investigation of another complaint at the facility.

1 A. On 03/15/17 at 12:10 p.m., the survey team conducted the initial tour of the Emergency Department with Staff Member #5 (Administrator), Staff Member #6 (Director of Nursing), Staff Member #7 (Director of Emergency Services), Staff Member #8 (Manager of Clinical Risk), and two (2) Medical Facilities Inspectors. At approximately 12:40 p.m. in Room #1, observations revealed a sink cabinet with an area missing pieces of countertop exposing wood. The porous surface of the wood could not be disinfected between patients.

The surveyor requested the facility's policy for sanitary environment from Staff Member #6. The surveyor made additional requests for the policy that had not been received. On 03/22/17 at 12:55 p.m., Staff Member #11 presented the surveyor a policy titled "Infection Control for Environmental Services." The policy read in part the following: "Objective: The Environmental Services Department Infection Control Policy will identify housekeeping operations involving substantial risk or direct exposure to blood and body fluids and will address the proper precautions to be taken while cleaning rooms and blood or body fluid spills. Statement: 1. The Environmental Services Department (EVS) will assure that the hospital is maintained in a clean and sanitary condition. The Environmental Services Department will determine and implement the appropriate written schedule for cleaning and method of disinfection based upon the location within the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being performed....3. All places of work, passageways, storerooms and service rooms will be kept clean and orderly and in a sanitary condition..." .

2 A. On 03/15/17 at 1:05 p.m., during an observation in a suture cart located next to the nurse's station the following expired items were located: Four (4) suture packs labeled "18" Mensilene White Braided Suture" which had expired "4 [DATE]", and one (1) P-3 needle pack which expired "4 [DATE]" and were available for use during direct patient care. Staff Member #7 verified the expired sutures should have been discarded and were not. The surveyor requested the facility's policy for expired supplies.

An interview was conducted on 03/15/17 at approximately 1:10 p.m. with Staff Member #7. Staff Member #7 acknowledged expired supplies should not be available for potential use during patient care. Staff Member #7 continued to report the Emergency Medical Technician (EMT) personnel fill the suture carts when the supplies need to be replenished and the supplies are not rotated.

A copy of the facility's policy that addressed expired supplies was requested on 03/15/17. At the time of the exit conference on 03/22/17, no policy was provided for review. Staff Member #11 stated, "We do not have a policy for expired supplies, because it is standard expectation that staff not use expired supplies."

3. On 03/15/17 at 12:32 p.m., the following observation took place in the secured Ambulance bay that connect Emergency Medical Services (EMS) personnel and their patients to the triage area of the hospital. Observation revealed a disposal area with two (2) gray trash containers; one (1) trash container had a designated biohazard label and a closed lid; the second trash container revealed an opened lid with active trash being blown out in the bay area from the force of the wind. The survey team observed four (4) disposable blue rubber gloves turned inside out laying on the concrete pad next the trash container with no label, an opened yankauer for suctioning, and a tied red bag of unknown contents located in the container with regular trash.

An interview was conducted on 03/15/17 at 12:31 p.m. in the Ambulance bay with Staff Member #7 in regard to observations of the disposal area. Staff Member #7 stated, "This container should have the lid on it and I'm not sure what is in the red bag, but it should not be in with the regular trash." Staff Member #7 took the four (4) blue disposable gloves and disposed of them in the trash container and performed hand hygiene. Staff Member #7 identified the trash can with the red bag should have had a bio-hazard sticker, if staff was using it for bio-hazard waste.

The survey team held a discussion of the observations and concerns with Staff Member #2 (Vice President of Regulator Compliance), Staff Member #5 (Administrator), Staff Member #8 (Manager of Clinical Risk), and Staff Member #9 (License and Accreditation) on 03/15/17 during the end of the day meeting at 3:45 p.m. and again at the exit conference with the Administrative Team on 03/22/17 at 1:10 p.m.

1 B. Ensuring a sanitary physical environment to prevent the spread of infection:

An observation and interview was conducted during the initial of the Emergency Department (ED) on 03/15/2017 at 12:39 p.m., with Staff Members #5, #6, and #7. Staff Member #7 identified ED Room #1 as clean and ready for a patient. On entering the room to the left of the privacy curtain on the floor was a grayish ball of material including hair approximately two (2) inches in size. Staff member #7 identified the grayish ball as a "dust bunny." The surveyor asked if the floors of the ED rooms were wet mopped between patients. Staff Member #7 stated, "No, they are dry mopped between patients and are wet mopped once daily. Unless there is an obvious spill or contamination." Staff Member #7 and the surveyor observed a reddish dime-size spot on the floor next to the exam stretcher. Staff Member #7 donned gloves and obtained a disinfectant wipe/cloth from a container in the room. Staff Member #7 utilized the disinfectant wipe/cloth to wipe the reddish spot on the floor. The disinfectant wipe/cloth removed the reddish spot. The surveyor asked Staff Member to identify reddish material he/she had cleaned from the floor. Staff Member #7 stated, "I don't know what it was." The surveyor inquired if the reddish spot could possibly be a blood droplet. Staff Member #7 stated, "It could have been, I'm not able to say what the spot was."

2 B. Failure to ensure expired supplies was not available for use during direct patient care for one (1) of one (1) labeled "GYN (Gynecology) Cart" observed:

Observations and interviews were conducted on 03/15/2017 at approximately 1:18 p.m., with Staff Member #6. The surveyor and Staff Member observed the contents of the GYN Cart. The observation revealed three (3) of three (3) "Xpert CT/NG Vaginal/Endocervical Specimen Collection Kits," which had expired "12/2016." Staff Member #6 verified the dates on each "Xpert CT/NG Vaginal/Endocervical Specimen Collection Kit" and confirmed the item was expired and available for direct patient care. Staff Member and the surveyor reviewed the form on the top of the "GYN Cart." The Form read in part: "GYN CART Month: Jan Year: 2017 ... During monthly check, remove and replace item(s) that expire within that month. Replace items as they are used ... First Item to Expire: Culture Swabs Date: 8/17 Location: Drawer 1." The form listed four (4) items with documented expiration dates. The form was signed by a facility staff and the staff's signature was dated "1-13-17." Staff Member #6 verified the date on the form and the date of the facility's staff signature. Staff Member #6 verified when the "GYN Cart" was inspected by facility staff in January 2017 the "Xpert CT/NG Vaginal/Endocervical Specimen Collection Kits" should have been removed related to having been expired at the time of the cart check on "1-13-17." Staff Member #6 verified the "GYN Cart" form documented the GYN Cart" was supposed to be checked monthly. The surveyor inquired if there were February 2017 and March 2017 "GYN Cart" checks. Staff Member #6 reported he/she would check to see if the ED manager had removed the "GYN Cart" checks for February 2017 and March 2017.

An interview was conducted on 03/16/2017 at 8:08 a.m., Staff Members #2 and #8. The surveyor inquired whether the "GYN Cart" checks for the months of February 2017 and March 2017 had been located.

An interview was conducted on 03/16/2017 at approximately 3:00 p.m., with Staff Member #8. Staff Member #8 reported Staff Member #7 relayed the "GYN Cart" forms for February 2017 and March 2017 could not be located. Staff Member #8 verified the only documentation of the "GYN Cart" check was for January 2017.

4. Ensuring facility protocols were followed for a blood spill:

Observations were conducted on 03/15/2017 at 12:05 p.m., with Staff Members #5, #6 and #7 during the initial tour of the facility's Emergency Department (ED). The surveyors requested to enter the ED as if patients seeking emergency services. Staff Member #6 walked the patients to the patient entrance of the ED. The observation revealed an apparent spill or fluid poured on the accessible walkway of the drive up entrance. The surveyor asked Staff Member #6 to walk outside. The observation revealed an approximately eighteen (18) inches by twelve (12) inches area of multiple bright red dime-size droplets of blood. The area appeared to have had a fluid pour over the droplets of blood. Related to the weather conditions the blood and fluid had congealed. Staff Member #6 readily identified the multiple droplets as blood. The carpet positioned between the outer and inner automatic ED entrance doors was brown in color and it could not be determined if the carpet was contaminated with droplets of blood. Staff Member #6 informed Staff Member #5 of the findings. Staff Member #5 contacted environmental services. The surveyor requested the protocol for blood spills and frequency of monitoring of the ED entrances.

An interview was conducted on 03/20/2017 during the end of day conference, related to the surveyor's previous request for information related to the blood spill at the ED entrance and which staff was responsible to monitor and clean blood spills. Staff Member #8 informed the surveyor the day of the observation (03/15/2017) the security officer at the ED entrance had noticed a patient came in bleeding. Staff Member #8 reported the security officer had attempted to pour water over the area to clean the area. Staff Member #8 reported the security officer contacted environmental services (EVS) regarding the need to take care of the blood spill. Staff Member #8 reported the security officer had stated the EVS personnel was "tied-up" with an ED room cleaning. Staff Member #8 explained the surveyor's tour and findings had occurred between the security officer's notification of EVS and the EVS staff arriving to clean up the blood spill. The surveyor requested any documentation related to the security officer's call or documentation by EVS related to the call and need to clean up the blood spill.

An interview was conducted on 03/22/2017 at 11:14 a.m., with Staff Member #8. Staff Member #8 reported he/she had spoken with Staff Member #10. Staff Member #8 reported Staff Member #10 had disclosed during the day a security officer rounds the outside of the facility's perimeter hourly. Staff Member #8 reported Staff Member #10 had explained the security officer at the ED front desk had noticed a patient came in bleeding and went outside to look. Staff Member #8 reported Staff Member #10 explained the security officer had a verbal conversation with EVS personnel. Staff Member #8 reported Staff Member #10 relayed the EVS personnel assigned to the ED for that day, poured "some kind of fluid" over the spill to wash it down and had planned to come back and clean the area. Staff Member #8 stated, "In the meantime, we (the facility staff and the surveyors) came through before [he/she] could come back and clean the area." Staff Member #8 stated, "The conversations were verbal and there is no documentation to offer." The surveyor requested the EVS's protocol for cleaning up blood spills inside and outside.

On 03/22/2017 at 12:05 p.m. Staff Member #8 presented and reviewed with the surveyor a document titled "WeeklyMinders Blood Spills." The document read in part: "Process Remove excess blood with towels or paper towels. Dispose of paper towels in biohazardous waste. Flood the area with germicide solution. Do not allow mop to touch spill. Allow solution to sit for 10 minutes. Pick up solution with wrung-out mop. Place mop in soiled laundry container ... Don't Forget Tips: Make sure you are wearing all required safety protective gear ..." The pictures on the document included placing a sign near the spill. Staff Member #8 verified the blood spill observed on 03/15/2017 did not have a sign placed near the spill or any other object to indicate the area of blood spill should be avoided.

5. Failure to handle contaminated glucometers in a manner to prevent the spread of infectious agents and to disinfect glucometers in a manner to prevent the spread of infectious agents for two (2) of three (3) observations:

An observation was conducted on 03/20/2017 at 12:28 p.m., with Staff Member #17 during the performance of blood glucose check for Patient #31. Patient #31's door indicated the patient was on "Contact Precautions" requiring isolation gown and gloves. Staff Member #17 introduced his/herself while standing in Patient #31's doorway. Staff Member #17 started donning personal protective equipment (PPE) his/her gown and gloves; Staff member #17 did not perform hand hygiene prior to putting on gloves. Staff Member #17 obtained permission for the surveyor to observe the blood glucose check; the surveyor performed hand hygiene gowned and gloved. Staff #17 sat the glucometer on the sink counter within the patient's room and performed the required scanning of the glucose strips. Staff Member #17 retrieved Patient #31's arm from under his/her covers and scanned the patient's armband. Staff Member #17 placed the glucometer on the patient's over the bed table, performed a finger prick, picked up the glucometer and applied a blood sample to the strip. After obtaining the test results Staff Member #17 removed the strip from the glucometers and discarded the strip in the bio-hazard red box. Staff Member #17 removed his/her gloves and donned new gloves without performing hand hygiene. Staff Member attempted to hold the glucometer and remove his/her PPE. Staff Member #17 decided to sit the glucometer on the patient's counter closest to the door. After removing his/her PPE Staff Member #17 gloved, without performing hand hygiene, picked up the glucometer, informed the surveyor the glucometer needed to be cleaned with the "gold-top disinfectant cloths because they have bleach and the patient is on isolation." Staff Member #17 wiped the glucometer for less than two minutes. Staff Member #17 carried the glucometer and placed it on a desk across from the medication preparation area. The surveyor asked Staff Member #17 regarding the wet contact time for the "gold-top" disinfectant wipes; Staff Member #17 stated, "Two (2) minutes."

Review of the Sani-Cloth Bleach Germicide Disposable Wipe's label read in part" "Disinfects in 4 minutes."

An observation was conducted on 03/21/2017 at 11:42 a.m., with Staff Member #24. Staff Member #24 performed two glove changes without performing hand hygiene between donning new gloves. Staff Member #24 used the "purple-top" disinfectant wipes. Staff member #24 explained the "purple-top wipes were used when patients were not on any type of precautions." Staff Member #24 reported the wet contact time was two (2) minutes. Staff Member #24 did not use a timing device and wiped the glucometer for less than a minute then docked the glucometer at the nurse's station.

An interview was conducted on 03/21/2017 at 12:15 p.m., with Staff Member #6 after the third observation. Staff Member #6 was informed of the findings. The surveyor requested the facility's policy for cleaning the glucometer.

The surveyor received the facility's policy on 03/22/2017. Review of the policy titled "Glucose Meter (Stat Strip), Use of" read in part: "Care and Maintenance ... 2. Cleaning the Bedside Unit: a. Clean with a germicidal wipe. Immediately follow with a water dampened cloth to remove all cleaning residue. Dry thoroughly with a lint free tissue. b. Clean the meter after every patient use ..."