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, INC 1001 SAM PERRY BOULEVARD FREDERICKSBURG, VA 22401 May 23, 2017
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observations, interviews and document review it was determined the facility staff failed to reduce the risk of the spreading infectious agents as evidenced by:

1. The failure to perform hand hygiene or required hand washing post removal of gloves during blood glucose monitoring by glucometer for two (2) of three (3) observations. (Staff Members #11 and #12)

2. The failure to ensure Emergency Department (ED) bays were cleaned between patients in a manner that removed supplies used on previous patients (tape removed from the roll and applied to a cart) was not available to be utilized on the following patients in six (6) of thirteen (13) ED rooms/bays deemed clean and available for observation and incoming patients. (Bays #9, #11, #12, #16, #31, and #35)

3. The failure to ensure Emergency Department (ED) bays were cleaned between patients in a manner that removed food particles or soiled areas from the previous patient in three (3) of thirteen (13) ED rooms/bays deemed clean and available for observation. (Bays #29, #33, and #34)

The findings included:

1 A. An observation was conducted on 05/23/2017 from 10:59 through 11:10 a.m., with Staff Member #11. Staff Member #11 prepared to perform blood glucose monitoring for Patient #5. Staff Member #11 placed the supplies needed (alcohol pads, unwrapped gauze, and a lancet) in his/her pocket and carried the glucometer in his/her hand. On entering Patient #5's room, Staff Member #11 and the surveyor put on a yellow isolation gown and gloves related to the patient's contact precaution status. Staff Member #11 explained to the surveyor Patient #5 was contact precautions related to having "C-diff" [Clostridium difficile ([DIAGNOSIS REDACTED] or C. diff) is a specific kind of bacterial infection that causes mild to life-threatening forms of diarrhea and colitis.]

Staff Member #11 placed the glucometer on Patient #5's contaminated over-the-bed table. Staff Member #11 removed the supplies from his/her pocket and placed them on Patient #5's contaminated over-the-bed table. Staff Member #11 performed Patient #5's blood glucose testing and placed the glucometer back on Patient #5's contaminated over-the-bed table. Using the same contaminated gloves Staff Member #5 handled the yellow over the door supply holder, in order to retrieve a disinfectant wipe from a canister housed in the supply holder. Staff Member #11 began to wipe the glucometer for approximately fifty (50) seconds, timed by the clock in the room, then placed the glucometer on Patient #5's contaminated over-the-bed table. Staff Member #11 discarded the contaminated gloves he/she was wearing and without washing his/her hands retrieved a second pair of gloves from the yellow over the door supply holder. Staff Member #11 donned the new pair of gloves picked up the glucometer and wiped for forty (40) seconds as timed by the clock in the room. Staff Member #11 reported Patient #5's blood glucose numbers and handed Staff Member #10 the glucometer. Staff Member #10 asked Staff Member #11 if he/she had used the disinfectant wipe to clean and disinfect the glucometer for the full four (4) minutes required. Staff Member #11 looked at the clock then reported he/she had wiped the glucometer for five (5) minutes.

Staff Member #11 and the surveyor removed their yellow isolation gowns prior to leaving Patient #5's room. Staff Member #11 performed hand hygiene using an alcohol based hand rub. Staff Member #11 went directly to a computer to enter data. Staff Member #11 did not was his/her hands with soap and water as required for direct patient care of a patient with C-diff.

An interview was conducted with Staff Member #11 related to the observation. Staff Member #11 stated, "I stopped and changed gloves. I think I was supposed to change them before I started cleaning the meter." The surveyor informed Staff Member #11 he/she had set the glucometer down on the patient's contaminated over-the-bed table in between glove changing and had not wiped the glucometer for five (5) minutes. Staff Member #11 stated, "I guess I should have started my count all over again, since I contaminated the meter."

An interview was conducted on 05/23/2017 at approximately 11:18 a.m., with Staff Members #3. The surveyor informed Staff Member #3 of the findings and requested the facility's policy on hand hygiene and glove changes.

2. Observations were conducted on 05/23/2017 from 8:01 a.m. through 9:30 a.m., with Staff Members #2, #3, #4, #6 and #14. Staff Members #3 and #14 walked with the surveyor during the observations and verified the ED bays were cleaned and ready to receive patients. The observations revealed:
Trauma room/bay #9 - the right corner of the "Metro Flex Line Cart" had two strips of tape;
Room/bay #11- the left corner of the "Metro Flex Line Cart" had tape strips and tape residue;
Room/bay #12- the right corner of the "Metro Flex Line Cart" had strips of tape;
Room/bay #16- the top of the of the "Metro Flex Line Cart" had tape stripes and tape residue; and
Room/bay #31- the right corner of the "Metro Flex Line Cart" had strips of tape.

An interview was conducted with Staff Member #14 verified the strips of tape should have been removed when the room/bay was cleaned after the last patient, who received care. Staff Member #14 stated, "I'm not sure why staff is placing the tape on the cart." Staff Members #3 and #14 verified the "Metro Flex Line Cart" should be part of the cleaning performed between patients.

An observation conducted with Staff Member #6 and the surveyor revealed an approximately eighteen (18) inch strip of tape on the front top edge of the "Metro Flex Line Cart" in Room/bay #35. Staff Member #6 verified the findings.

The surveyor requested the facility's policy for ensuring the carts and other equipment within the ED rooms/bays were cleaned between patients.

An interview was conducted on 05/23/2017 at approximately 3:40 p.m., with Staff Member #3. Staff Member #3 reported the facility did not have a policy related to cleaning the "Metro Flex Line Cart." Staff member #3 reported the facility's policies focused on cleaning and disinfection of equipment used in direct contact with the patient.

Review of the environmental services cleaning and checklist for the ED included a column for "Carts" without specification of which carts. The facility did not provide additional information prior to exit on 05/23/2017.





1 B. On 05/23/17 at 11:08 a.m., the following was observed with Staff Member #12 (Certified Nursing Assistant) during use of a point of care device: Staff Member #12 donned gloves to perform a blood glucose check on Patient #4. Staff Member #12 did not perform hand hygiene prior to putting on gloves. Staff Member #12 placed all supplies including alcohol pad, gauze pads, a finger stick lancet device, glucometer strips container and glucometer on Patient #4's bedside table. Staff Member #12 retrieved Patient #4's arm from under his/her covers and scanned the patient's armband. Staff Member #12 performed a finger prick, picked up the glucometer and applied a blood sample to the strip. After obtaining the test results, Staff Member #12 removed the strip from the glucometer and discarded the strip in the bio-hazard red box. The glucometer was then placed on the countertop located next to the sink in the patient's room. Staff Member #12 removed his/her gloves and performed hand washing.

Staff Member #12 exited Patient #4's room and placed the dirty glucometer on the countertop adjacent to Patient #4's room. Staff Member #12 was observed walking to another room to get a new pair of gloves, he/she donned new gloves without performing hand hygiene. Staff Member #12 walked back to the countertop located adjacent to Patient #4's room and picked up the glucometer, informed the surveyor the glucometer needed to be cleaned with the "purple-top disinfectant cloth because they have alcohol and were used when patients were not on any type of precautions." Staff Member #12 wiped the countertop with a "sani-cloth," then wiped the glucometer, re-wiped the countertop and glucometer and waited two (2) minutes for the contact time, placed the glucometer into the clean docking station, then removed gloves without performing hand hygiene. The surveyor asked Staff Member #12 regarding the wet contact time for the "purple-top" disinfectant wipes; Staff Member #12 stated, "Two (2) minutes."

Review of the Sani-Cloth Alcohol Germicide Disposable Wipe's label read in part" "Disinfects in 2 minutes."

An interview was conducted on 05/23/17 at approximately 11:22 a.m., with Staff Member #3 (Risk Manager) after the observation. Staff Member #3 was informed of the findings. The surveyor requested the facility's policy for hand hygiene and gloving.

The surveyor received the facility's policy on 05/23/17. Review of the policy titled "Handwashing and Hand Hygiene" read in part: "Objective: To prevent the direct or indirect spread of organisms through contact with hands. Indications for Hand Hygiene and Antisepsis: 2. Wash hands with soap and water when caring for patients with diarrhea, [DIAGNOSIS REDACTED] infections, or if exposure to Bacullus anthracis is known or suspected. The physical action of soap and water is recommended because alcohols and other antiseptics have poor activity against spores. 4. If hands are not visibly soiled, use an alcohol-based hand rub routinely for decontaminating hands in all other clinical situations described in items 5-12. 5. Decontaminate hands before having direct contact with patients. 8. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient). 11. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. 12. Decontaminate hands after removing gloves and other personal protective equipment (PPE). If care involves exposure to [DIAGNOSIS REDACTED] and/or there is no blood or body fluid exposure, soap and water will be used instead of alcohol-based rub. Other Aspects of Hand Hygiene: 9. Wearing gloves does not replace handwashing. Perform appropriate hand hygiene after removal of gloves and other PPE."

3. During a focused tour of the emergency department at 9:00 a.m. on 05/23/17 with Staff Member #6 (Emergency Department Director), the surveyor requested to observe rooms that were clean and ready for patient care. Staff Member #6 acknowledged the following rooms were available for observation because each were clean and ready for patient care: Room #29, #33, #34, #35, #37 and #41. Staff Member #6 pulled the curtain back to validate no patient was in Room #33 and preceded to turn the light on. The surveyor observed in Room #33 a metal rolling table partially covered with what appeared to be cracker crumbs. The surveyor inquired to Staff Member #6 if the room was clean and ready for patient care. Staff Member #6 stated, "Yes, the room has been cleaned but this does appear to be cracker crumbs that didn't get cleaned up, but this will be taken care of right now." Staff Member #6 was observed cleaning up the cracker crumbs with a "sani-cloth."

Staff Member #6 pulled the curtain back in Room #34 to ensure no patient was located in the room and then preceded to turn the light on for observation. The surveyor observed a dark wooden table with what appeared to be cracker crumbs in the top right corner of the table. Staff Member #6 validated the observation was cracker crumbs as he/she observed a torn cracker package that was thrown into the clean trash bag that was ready for a new patient. Staff Member #6 stated, "This is one of our mental health rooms and it is clean and ready for a patient and we should not be seeing this." Staff Member #6 immediately cleaned the cracker crumbs with a "sani-cloth."

Staff Member #6 pulled the curtain back in Room #29 to ensure no patient was located in the room and preceded to turn the light on for observation. The surveyor observed a dark circle spot in front of the sink and inquired to Staff Member #6 if the spot was a part of the floor or dirt. Staff Member #6 immediately attempted to clean the spot with a "sani-cloth." Staff Member #6 stated, "This must be dirt because I was able to remove it." During the conclusion of the surveyor's and Staff Member #6's observation in Room #29, Staff Member #1 (Vice President to Risk) and other facility administration staff joined the observation. Staff Member #1 reported the Environmental Services staff acknowledged he/she had not cleaned the floors in the rooms that had the room light on. Staff Member #7 (Assistant Director of Environmental Services) reported the light on in a room was a signal to the staff members assigned to the Emergency Department that the room was not completely cleaned. The surveyor inquired to Staff Member #6 that the previous rooms observed were stated to be clean and ready for patient care. Staff Member #6 stated, "I thought the rooms were clean also. I don't recall which rooms I turned the lights on and which rooms already had the lights on when we entered."

The surveyor discussed the concerns regarding improper infection control procedures with Staff Members #1, #3 and #6 at the time of the observations. The concerns were again discussed with the administrative staff on 05/23/17 at approximately 4:15 p.m. prior to the exit conference.