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.

WARREN MEMORIAL HOSPITAL 1000 NORTH SHENANDOAH AVE FRONT ROYAL, VA 22630 July 15, 2015
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on observations, interviews and document review, it was determined the facility staff failed to ensure an effective Infection Control program as identified by the facility failing to provide adequate resources allocated for measuring, assessing, improving and sustaining the performance required by the designated individual as its Infection Control Officer; and the Infection Control Officer developing and implementing policies in Environmental Services governing the control of infections and communicable diseases.

The findings included:

During the survey conducted 07/13/2015 through 07/15/2015, the survey team identified multiple areas of infection control related deficient practice throughout the facility areas.

An interview was conducted with Staff #21 on 07/14/2015 at approximately 8:30 a.m. regarding who was the Infection Control designee and how many hours is devoted to infection control in a week. Staff #21 stated he/she was only part-time as the Infection Control Officer. Staff #21 stated, "I spend approximately twenty (20) hours per week involved in the infection control program and that time is split between the hospital and long-term care." Staff #21 acknowledged he/she was also the CDI Coordinator. When asked who the Infection Control Designee was when Staff #21 was out or attending to other duties, Staff #21 stated "No one, except the lab would notify the appropriate people, but no investigation or contacts would be done until I returned." "We do not have it in writing or in a job description that there is a backup for the Infection Control Officer."

During a tour of the Environmental Services area on 07/14/2015 at approximately 10:20 a.m., Staff #12 and Staff #41 stated they had policies and procedures but could not locate them. Staff #41 stated the policies and procedures are locked behind the office door and the other staff members did not have access to them when the office was locked. During an interview with Staff #12 and Staff #21, the surveyor inquired if the Infection Control Officer had input into developing the environmental services policies and procedures related to governing the control of infections and communicable diseases, Staff #12 and Staff #21 stated, "No."

On 07/14/2015 at 6:30 p.m. the survey team discussed the multiple concerns regarding the survey findings with Staff #2, Staff #3 and Staff #21.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observations, interviews and document review, it was determined the facility staff failed to ensure they followed their Infection Control plan by identifying, reporting, investigating and controlling potential areas and behaviors that could result in the spread of infection by:

A. Staff's failure to have a written protocol in place for the backup in the absence of the Infection Control Officer; Inability to implement the Infection Control system to train personnel expected to have contact with potentially infectious material and practices for preventing transmission of infectious agents as evidenced by Staff #34 stating, "They receive training on products they use to clean from the vendors and EVS (environmental services)."

B. Ensuring proper hand hygiene was followed during five (5) of eight (8) observations;

C. Safe injection practices were followed during one (1) of two (2) observations;

D. Failed to use personal protective equipment and use it appropriately for one (1) of one (1) observation;

E. Staff lack of knowledge related to the manufacturer's appropriate contact tinme for disinfecting various surfaces for seven (7) of nine (9) interviews; to maintain and clean two (2) of two (2) ice machines observed; linen contract failed to show hydrocollator packs were laundered; failure of staff to ensure equipment was maintained in a manner to promote disinfection between use for one (1) of one (1) Intensive Care Unit equipment observation.

F. Failure to disinfect endoscopes observed touching side of storage cabinet in the reprocessing room between patients for one (1) of one (1) observation;

G. Failed to perform hand hygiene after cleaning patient's back prior to inserting spinal needle during a spinal injection procedure for one (1) of one (1) observation;

H. Staff failure to perform hand hygiene before and after patient contact and appropriately disinfect point of care device for two (2) of two (2) observations;

I. Staff being unaware of which personal protective equipment (PPE) was needed to enter a room of a patient on contact precaution; failure to utilize PPE when crossing the threshold of a room with a patient on contact isolation; failure to wear personal protective equipment correctly and sanitize their hands prior to entering patient's room for three (3) of three (3) observations;

J. Staff failed to follow infection control practices in surgical and clean areas for one (1) of one (1) observation;

K. Facility staff failed to ensure facility was in good repair, equipment maintained and environment protected to prevent the spread of infection and harm.

The findings included:


1. On 07/13/2015 through 07/15/2015 observations were made in the ED (Emergency Department), ICU (Intensive Care Unit), Medical-Surgical Unit (Med/Surg) and the following was noted:

A. Staff #21 was interviewed on 07/14/2015 at approximately 1:30 p.m. Staff #21 acknowledged he/she was in charge of the materials utilized for training the staff regarding infection control. Staff #21 stated, "I'm not involved in the education except I give the materials to the Educators for infection control training, I just don't have the time." Staff #21 further stated the material is given to the unit Educator. The Educator trains personnel upon hire and during annual updates administered on the computer in the "Halogen" program. Staff #21 stated if there are changes that are implemented because of a product change or staff need to be re-educated, than additional education computer courses are presented to the employee and an email is sent out hospital wide. Staff #21 acknowledged when a product change is implemented he/she contacts the vendor of the product and the vendor educates the hospital employees. During an interview in the ED, Staff #34 stated, "They [Staff] receive training on products they use to clean from the vendors and EVS [Environmental Services]." On 07/15/2015 there was evidence of inservices conducted annually and for identified specific needs for each unit during employee record review.

During an interview with Staff #21 on 07/14/2015 at approximately 8:30 a.m., he/she stated there is no written protocol for the backup in the absence of the Infection Control Officer. The hospital established system to ensure prompt notification to the Infection Control Officer when a novel resistance pattern based on microbiology results is detected by daily lab results viewed on the computer, computer system flags patients, laboratory calls the Infection Control Officer. The surveyor asked Staff #21 what happens when he/she is on vacation or out attending to other duties, Staff #21 stated "It waits until I return, however the lab will call for things that need immediate attention." When asked who the Infection Control Designee was when Staff #21 was out or attending to other duties, Staff #21 stated "No one, except the lab would notify the appropriate people, but no investigation or contacts would be done until I returned." "We do not have it in writing or in a job description that there is a backup for the Infection Control Officer."

B. Observations conducted in the ICU on 07/15/2015 from approximately 8:35 a.m. through 11:00 a.m. revealed Staff #48 entering ICU Room #1 with clean linen but did not perform hand hygiene before entering patient's room. Staff #50 was observed entering ICU Room #2 (Patient #6) for patient care donning gloves without hand hygiene and exiting patient's room without performing hand hygiene. Staff #47 entered Patient #6's room for a.m. nursing care and failed to perform hand hygiene. Staff #48 stopped at the entrance to the contact isolation room, donned a gown and gloves, but failed to perform hand hygiene prior to donning gloves.

E. Three (3) various staff (Staff #18, #19 and #47) were asked in various locations (ICU and Med/Surg) what type of product was used for cleaning surfaces and what the process was for cleaning. The staff identified the "Gray top Containers" (PDI Sani Cloth Wipes). None of the staff interviewed could tell what the wet time for this product was or the purpose of the wet time.

I. An observation conducted in ICU Room #6 on 07/14/2015 at approximately 4:00 p.m. revealed Staff #55 crossing the entrance threshold into a contact isolation (Patient #7) room to throw trash into the trash can. Staff #55 entered into the contact isolation room without donning personal protective equipment (PPE) and failed to perform hand hygiene before and after exiting Patient #7's room.

A second observation conducted in ICU Room #6 on 07/15/2015 at approximately 8:35 a.m. revealed Staff #47 performing patient care on contact isolation (Patient #7). Staff #47 stopped at the entrance to the contact isolation room, donned a gown and gloves, but failed to perform hand hygiene prior to donning gloves and tie the gown. Staff #48 entered the contact isolation room to assist with Patient #7, but failed to perform hand hygiene prior to donning gloves and tie the gown which was visibly hanging off of the shoulders of Staff #48.

Staff #21 was not present during the findings, however was interviewed by the surveyor to verify if this observation of contact isolation precautions is consistent with hospital infection control policies and procedures. Staff #21 reported that Staff #47, #48 and #55 failed to follow contact isolation procedures because the staff members should have performed hand hygiene before entering patient's room and the gown should have been tied to prevent cross contamination. Staff #21 verified that Staff #55 failed to have the proper PPE on because he/she did cross the threshold of entering Patient #7's room.

A record review on 07/15/2015 revealed Patient #7 was placed on contact isolation because Vancomycin Resistant Enterococci (VRE) was found in the urine on a previous admission and the computer databank had flagged Patient #7 upon admission to the hospital.

An interview was conducted 4:30 p.m. on 07/14/2015 during the end of the day meeting. The facility staff were informed of the findings and a policy/procedure was requested.

Review of the facility's policy titled "Contact Precautions," revised 07/2015 which read in part: "I. Policy A. All patients suspected or confirmed to have one of the following diseases/conditions will be cared for utilizing Contact Precautions. Vancomycin Resistant Enterococcus (VRE) until 1 negative culture of original site and 3 negative rectal swabs are obtained." Facility policy titled "VRE: (Vancomycin-Resistant Enterococcus) Prevention and Surveillance" revised 01/2014 which read in part: "Purpose: To reduce the risk of nosocomial transmission of Vancomycin-Resistant Enterococcus (VRE) through early detection and isolation of patients and to state the process for discontinuing isolation of patients previously known to be positive for VRE. I. Patients with Prior History of VRE. 2. Patients remain active in the database for 2 years. 3. Upon readmission or transfer, the following occurs: a. During the admitting process the following message appears Contact Isolation Required..... b. Patient is placed on Contact Precautions. II. Procedure for Contact Precautions - When Indicated: 2. Patient is placed in Contact Precaution (patients with same organism may share room). 3. An Isolation Sticker is placed on the binding of the chart. 4. Hang an Isolation Caddy on the outside of the patient's door using designated hangers. 5. Post the correct Isolation Category Sign outside of room using the sign Holder or paper clip sign to the Isolation Caddy, so that the sign is visible. 8. Continue Contact Precaution policy, specifically: Gown > close or direct patient contact, Gloves > Close or direct patient/environment contact, Mask > Productive sputum/pneumonia."

K. On 07/13/2015 during observations of the surgical area; in Room #1 was observed a ring stand and lead shield with rust around the four (4) wheel holders. A black chair located near the anesthesia cart had tape wrapped around the right arm rest. In Room #2, one (1) ring stand, ESU cart and a long table against the wall had rust located around the wheel holders. Staff #22 stated, "How do you fix rust, I guess we will need to replace those items." Staff #22 acknowledged that equipment is cleaned between each patient and the rust surfaces could not be properly disinfected.

Review of the facility's policy titled "Hand Hygiene" revised 03/09 and last reviewed 12/12 which read in part: "Purpose: Hand hygiene is a general term that applies to either hand-washing, antiseptic hand-wash, antiseptic hand or surgical hand antisepsis. Hand-washing is the single most important means of interrupting transmission of infection to patients and employees... Policy: A. Employees should wash hands: 1. prior to performing invasive procedures; 2. before taking care of newborns or other immuno compromised patients; 3. before and after touching wounds; 4. after contact with mucous membranes, blood or other body fluids or items contaminated with these substances; 5. between contact with different patients; and 6. after taking care of an infected patient or one colonized with multiply resistant organisms. B. Hands should be washed whether or not gloves have been worn; they should be washed immediately after gloves have been removed. "

An interview was conducted on 07/15/2015 at approximately 3:30 p.m. with Staff #21 regarding the policy titled "Hand Hygiene." The surveyor inquired about the policy only stating hands should be washed immediately after gloves have been removed. Staff #21 stated this policy should be updated. Staff #21 verified this policy would be updated using the reference material from Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR) dated October 25, 2002 / Vol. 51 / No. RR-16 Guideline for Hand Hygiene in Health-Care Settings recommendations which state, "Decontaminate hands before having direct contact with patients."





2. B. On 7/14/15 during the observations of a C-Section, Staff Member #31 was observed 3 of 3 times not performing hand hygiene. Staff Member #31 placed gloves on her/his hands without first performing hand hygiene and scrubbing Patient #11's back in preparation for an epidural. After performing the scrub Staff Member #31 removed the gloves, did not perform hand hygiene and placed on a sterile set of gloves. Staff Member #31 then performed the epidural and removed the sterile gloves, did not perform hand hygiene and put on a non-sterile pair of gloves.

On 7/15/15 observations were made in the Emergency Department (ED). In the triage area there was no sink to perform hand hygiene with soap and water. To use soap and water staff had to exit the triage room and go to another room approximately 10 feet down the hallway to perform hand hygiene with soap and water.

C. On 7/14/15 observations of Patient #10; Staff Member #27 withdrew medications from 3 vials. Staff Member #27 removed the covering from the septum but failed to wipe the septum with an alcohol wipe prior to inserting the needle to withdraw the medication from all 3 vials.

D. On 7/14/15 during 2 of 2 surgical observations of Patient #31 Staff Member #54 failed to cover facial hair with a face protector. Staff Member had hair on the sides of both cheeks which was visible. Staff Member #23 wore a surgical skull cap during the procedure but the surgical skull cap failed to cover Staff Member #23's hair entirely. Staff Member #23 had approximately 2 to 2 and 1/2 inches of exposed hair on the back of the head.
Staff Member #31 placed gloves on her/his hands without first performing hand hygiene and scrubbing Patient #11's back in preparation for an epidural. After performing the scrub Staff Member #31 removed the gloves, did not perform hand hygiene and placed on a sterile set of gloves. Staff Member #31 then performed the epidural and removed the sterile gloves, did not perform hand hygiene and put on a non-sterile pair of gloves.

E. Interviews were conducted with various staff (Staff Member #27, 42 and 56) through out the facility and off site (surgical services, ED and physical therapy) regarding how to use of the facility's disinfectant wipes (PDI AF3 Germicidal Disposable wipe). No staff member knew the surface had to remain wet for 3 minutes in order for the disinfection to work properly. Staff Member #42 stated, "We were in-serviced on how to use the wipes by the product rep (representative) and EV (environmental services)."
PDI AF3 Germicidal Disposable wipe package states, "...wet time is 3 minutes for disinfecting hard non-porous environmental surfaces".

On 7/1315 and 7/15/15 observations of the counter top ice machines were made in the PACU (Post Anesthesia Care Unit) and ED. The ice machine in PACU was leaking on the counter and the drain area under the counter inside the cabinet appeared damp and black/brown in color. The ice machine in the ED had a black colored substance in the drain pipe and debris under, behind and on top of the machine.

The off-site physical therapy/rehabilitation clinic was observed at approximately 9 A.M. on 7/15/15. The clinic had approximately 8 to 12 damp hydrocollator pack covers hanging above the hydrocollator machine. Staff Member #44 was asked when and where the covers were laundered and stated, "I don't believe we launder them, but I don't really know." Staff Member #45 stated, "I think they are done on Mondays and Tuesdays but I will defer to (Name of Person) who takes care of that." Staff Member #56 stated, "They are laundered by a laundry service twice a week." Staff Member #56 was asked to provide evidence of the laundering of the covers. A laundry contract was provided but no evidence the hydrocollator pack covers were a part of the laundry service.

On 7/15/15 a blood pressure machine was observed in the clean equipment closet. Staff Member #42 stated, "Anything in this closet has been cleaned prior to placing it in the closet." The blood pressure machine had a knob on top of the machine which had a roll of paper tape pushed down over the knob. Staff Member #42 stated, "Well obviously this was not cleaned prior to placing it in the closet."

F. On 7/13/15 during the observations of the surgical suite the cabinet where the colorectal scopes were hung was observed. There were 4 sigmoidoscopes (blue, red, yellow and purple and orange) hung with the tips touching the surface where the cabinet door latched to the cabinet or the inside wall of the cabinet. Staff Member #22 stated, "All of those will need to be reprocessed."

G. On 7/14/15 during the observations of a C-Section Staff Member #31 was observed 3 of 3 times not performing hand hygiene. Staff Member #31 placed gloves on her/his hands without first performing hand hygiene and scrubbing Patient #11's back in preparation for an epidural. After performing the scrub Staff Member #31 removed the gloves, did not perform hand hygiene and placed on a sterile set of gloves. Staff Member #31 then performed the epidural and removed the sterile gloves, did not perform hand hygiene and put on a non-sterile pair of gloves.

J. On 7/14/15 during 2 of 2 surgical observations of Patient #31 Staff Member #54 failed to cover facial hair with a face protector. Staff Member had on the sides of both cheeks that was visible.
Staff Member #23 wore a surgical skull cap during the procedure but the surgical skull cap failed to cover Staff Member #23's hair entirely. Staff Member #23 had approximately 2 to 2 and 1/2 inches of exposed hair on the back of the head.
Staff Member #30 was observed allowing the surgical mask to slip off the bridge of his/her nose during the surgical procedure.

K. The facility staff failed to ensure the facility was in good repair, equipment was maintained and the environment protected to prevent the spread of infection and prevent harm.

In the process of reviewing the facility's policies related to medication management Staff Member #21 provided a policy titled Medication Management with a last revised date of 01/13. The policy states under section #3 Wasting Controlled Drugs part B "Controlled dugs are wasted by pouring down sink drain. Any items that are unable to be wasted via this method are returned to the Pharmacy. Staff Member #21 stated, "I don't think we do that; we collect medications to be destroyed from the community".

On 7/13/15 at 3:45 P.M. during the initial tour of the surgical suite with Staff Member #22 a Buffalo Filter (As instruments are used to cauterize vessels and destroy (vaporize) tissue, fluid and blood, they create a gaseous material known as smoke. Buffalo Filters removes smoke from the use of lasers, electrosurgical pencils, ultrasonic devices and other surgical instruments.) The Bio-Med label indicated the machine was a demo and had date of 8/14. There was a section on the label to indicate A (annual inspection), S (semi-annual inspection), Q (quarterly) and M (monthly) none of which was marked. Staff Member #57 stated, "The machine is not a demo. It was purchased and the machine label should have indicated it was checked for safety when it was purchased."
Also on 7/13/15 during the surgical suite tour of OR (operating room) #1 a bottle of Sevoflurane Inhalant Anesthetic was found opened and accessed with no date indicating when it was opened or who opened it.
Also during the surgical site tour 2 syringes were found in an unlocked anesthesia cart one labeled Ephedrine and one labeled Rocuronium neither had a dosage amount, time, date or initials indicating when, who or how much was in the syringe. There was also a tube of Lidocaine Jelly 2% opened and accessed with no date, time or initials. Staff Member #23 took the medications and disposed of them in the waste basket rather than the sharps container. Also in the anesthesia cart available for use were 3 Surflash IV catheters 24 gauge that had expired in 09/2013. The chair used by anesthesia had torn arms that were covered with a light orange colored tape. There were numerous cracks/tears in the floor. The torn chair and tears in the floor left an exposed surface that could not be disinfected.
In OR #2 the paint was peeling off the ceiling beside the surgical lights directly above the surgical table, the door was rusted where metal was and had splinters where wood was leaving a porous surface that could not be disinfected. The floor had numerous tears in the surface. In OR #2 there was a pediatric anesthesia cart which contained the following expired items: 3 IV catheters 24 gauge that had expired in 09/2013, 2 vacutainers expired 05/2015 and 1 laryngeal mask 1 and 1/2 expired 03/2015.
On 7/14/15 during the observations of a C-Section Staff Member #31 was observed to have medications in the pocket of the lab jacket being worn. Staff Member #31 stated, "That should have been given to the patient (Xopenex inhalant, which had been opened and accessed) and I should have discarded that (Glycopyrrolate 0.2 mg (milligrams/ milliliter)."

OR #4 was observed on 7/14/15 and the following concerns were noted: ceiling paint peeling directly over the surgical table next to the surgical lights, both doors to the room had splinters. The floor had numerous tears in the floor. In the PACU area there were counter tops with worn stained area and area where the wood was exposed. Both the doors and counter tops could not be disinfected due to exposed porous surfaces.

References: American Society of Consultant Pharmacists
Pharmaceutical Waste Practice Resource Center
White House Office of National Drug Control Policy (ONDCP)
The White House Office of National Drug Control Policy September 08, 2014 provided guidelines on drug disposal. The following is a summary of the White House for the Proper Disposal of Prescription Drugs:
Do not flush prescription drugs down the toilet or drain unless the label or accompanying patient information specifically instructs you to do so. For information on drugs that should be flushed, visit the FDA's website.
To dispose of prescription drugs not labeled to be flushed, you may be able to take advantage of community drug take-back programs or other programs, such as household hazardous waste collection events, that collect drugs at a central location for proper disposal. Call your city or county government's household trash and recycling service and ask if a drug take-back program is available in your community.
The facilty's policy titled Medication Administration with a last review date of 4/15 was provided by Staff Member #3. The policy states under Medication Labeling:
a. Medications taken from their original container and placed in a different container for use at another time must be labeled (i.e. solution taken from a bag/bottle and placed in a bowl or cup; a medication from a vial or ampule drawn into a syringe).
b. The receiving container must be labeled with the following: i. Medication name, ii. Concentration, if appropriate, iii. Dose, iv. Expiration date, v. Date and time, vi. Name of person
c. Surgical Services: v. Once the medication is passed to the sterile container, the scrub nurse is not to be distracted until the labeling process is complete. The label will include the medication name, strength and expiration date. Medication vials, etc. will be kept in the room until the of the procedure. ix. Discard any solution or medication found on or off the sterile field without and identification label.
The facility's policy titled Provision of Care last reviewed on 9/12 states, "The Nursing Department has adopted Mosby's Nursing Consult and Mosby's Nursing Skills as the accepted nursing procedures book for (Name of facility). Mosby's Skills Regional Blocks (Perioperative) Quicksheet 1. Perform hand hygiene before patient contact, 10. Perform hand hygiene and don gloves, 15. Monitor the environment to ensure aseptic technique in maintained during the procedure. 16. Provide assistance to the anesthesia provider during the procedure. a. Epidural and spinal block. iii. ...Be aware that placing a sterile dressing requires sterile gloves and 20. Discard supplies, remove gloves and perform hand hygiene.
The policy titled Environment of Care with a last revised date of 3/2014 under Inspect, Test and Maintain Medical Equipment to Assess and Minimize Clinical and Physical Risks of Equipment section #2 states, "All medical equipment regardless of ownership is evaluated for inclusion to the Medical Equipment Plan. (Initials of the Name of organization) utilizes a risk-based system and all equipment is assigned a severity index. The severity index is a assigned based on the equipment's risk, function and maintenance requirements and history. Preventive maintenance is the scheduled and completed ratios reported monthly for Tier 1 and quarterly for Tier 2 to the Safety Committee.





3. B. Staff #35 and Staff #38 failed to perform hand hygiene prior to donning gloves for point of care device use as related to observations listed in J.

E. The following was observed during environmental cleaning of Room 203 on July 14, 2015 at approximately 4:30 p.m.:

Staff #41 washed hands, donned gloves and prepared supplies for terminal cleaning of patient room. Staff #41 was observed removing all trash and dirty linens. Staff #41 was observed dusting all high areas, cleaning all high touch surfaces, walls, recliner, bed and bathroom; scrubbing toilet. Staff #41 was observed using a separate clean cloth saturated with the disinfectant Oxycide for each area. Staff #41 was observed removing separate clean cloth from pocket several times to wipe sweat from his/her face while wearing dirty gloves and replacing cloth back in pocket.

Staff #41 was observed cleaning call bell and telephone for 203 door. After cleaning, Staff #41 placed the call bell on the clean bed and adjusted sheets with dirty gloves. After cleaning of the telephone Staff #41 placed it on the bed side table with dirty gloves. Staff #41 then removed gloves and washed hands. Staff #41 failed to change gloves and perform hand hygiene after cleaning "dirty" areas before touching "clean" areas and failed to follow manufacture's guidelines to ensure surfaces are sanitized between patients.

An interview with Staff #41 revealed that contact time for Oxycide is ten (10) minute wait time for only the bed to dry. Staff #41 acknowledged that the bed is made with clean linen after the ten (10) minute wait and the floor is mopped using separate mop for bathroom.

Manufacture's guidelines for oxycide states contact time 5 minutes for all surfaces.

H. The following was observed during the use of a point of care device on July 14, 2015:
At approximately 3:00 p.m. Staff #35 failed to follow policy and procedure by not performing hand hygiene before donning gloves prior to blood glucose check for Patient #13. The holder containing the glucometer was placed on the bedside table while gauze, alcohol wipe and a finger stick device was placed in the bed with Patient #13. Staff #35 failed to place supplies on a clean surface prior to procedure. Staff #35 cleaned the site with alcohol prior to finger stick for blood sample. The first drop of blood was wiped away with gauze pad and second drop was placed on strip in glucometer. All supplies were placed in the trash after use and the glucometer was wiped once with sani cloth bleach and placed back in the holder. The holder was then placed back on a rolling device. Staff #35 failed to follow manufacture's guidelines to ensure equipment was sanitized between patient use.

An interview with Staff #35 revealed that the holder with the glucometer is only cleaned if it goes in an isolation room. Staf f #35 stated that the rolling device does go into other patient rooms. Staff #35 was unable to verbalize contact time for sani cloth bleach.


At approximately 4:00 p.m., Staff #38 failed to follow policy and procedure by not performing hand hygiene before donning gloves prior to blood glucose check for Patient #14. The glucometer, gauze, alcohol wipes and finger stick device was placed in the bed with Patient #14. Before finger stick Staff #38 moved gauze, alcohol pads and fingerstick device to the top of the intravenous pump where a drink cup with straw and lip balm were setting. Staff #38 failed to place supplies on a clean surface prior to procedure. Staff #38 cleaned the site with alcohol prior to finger stick for blood sample. The first drop of blood was wiped away with gauze pad and second drop was placed on strip in glucometer. All supplies were placed in the trash after use and the glucometer was wiped once with sani cloth bleach and placed back in the holder in the medication room. Staff #38 failed to follow the manufacturer's guidelines to ensure equipment is sanitized between patient use.

The facility policy and procedure titled "Blood Sugar -Whole Blood Glucose Monitor Testing Procedure" states in part: "Wash hands and apply protective gloves".

Manufacture's guidelines for sani cloth bleach states four (4) minute contact time.




4. J: An observation was conducted on July 13, 2015 from 3:44 p.m. to 4:10 p.m., on the Intensive Care Unit (ICU). The surveyor observed a yellow kit hanging on the door of ICU room #6. The surveyor observed Staff #9 in ICU room #6 with Patient #7. Staff #9 was observed touching Patient #7's equipment and the patient. Staff #9's clothing was not covered with any type of personal protective equipment (PPE). Patient #7's family members were in the patient's room they did not have PPE covering their clothes. Staff #9 exited Patient #7's room and sat at a mobile workstation. Staff #9 responded to the patient in ICU room #5 and then returned to his/her mobile workstation. Staff #9 rolled his/her rolling chair into the doorway, crossing the threshold of Patient #7's room, and was talking to Patient #7 and his/her family members. The observation did not reveal signage, which specified the type of precautions that had been instituted for Patient #7.

An observation was conducted on July 13, 2015 at 4:06 p.m., in the ICU as Staff #5 entered Patient #7's room without donning PPE.

An interview was conducted on July 13, 2015 at 4:08 p.m., with Staff #9 as he/she sat in the doorway, across the threshold of Patient #7's room. The surveyor inquired regarding the yellow kit with PPE supplies that was hanging on Patient #7's room door. Staff #9 stated, "The yellow bag (kit) indicates the patient is on isolation." The surveyor asked if Patient #7 was on isolation precautions, Staff #9 stated, "Yes. An order came up so I placed the precaution bag on [his/her] door." The surveyor asked which type of isolation precautions Patient #7 was on; Staff #9 stated, "I'm not sure. I don't know why [he/she] is on precautions." The surveyor asked if Staff #9 had been in Patient #7's room without the appropriate PPE; initially Staff #9 reported he/she was "just in the doorway." The surveyor asked again if Staff #9 had been inside Patient #7's room without PPE on; Staff #7 stated, "Yes, I did not have PPE on. I don't know why [Patient #7's name] is even on isolation. I'm going to call the physician and ask." The surveyor asked since the yellow kit was on the door indicating Patient #7 was on some type of isolation what would be the proper PPE to wear into the patient's room? Staff #9 stated, "Probably a yellow gown and gloves if you plan to touch the patient or [his/her] equipment." The surveyor performed hand hygiene, donned a yellow gown, and entered Patient #7's room to interview the patient and family members.

An observation and interview was conducted on July 13, 2015 at 4:15 p.m., with Patient #7 and his/her family members. The observation within Patient #7's room revealed the patient had multiple pieces of equipment surrounding his/her bed. The observation revealed in order to maneuver in Patient #7's room equipment would have to be touched or moved to interact with the patient. The observation revealed when Patient #7's family members sat in the chair provided, they would be in close contact with the equipment attached to Patient #7. Patient #7's family members reported they had not been instructed by staff to wear the yellow gowns or put on gloves while taking care of Patient #7.

An interview was conducted on July 13, 2015 at approximately 4:20 p.m., with Staff #5. Staff #5 verified he/she had entered Patient #7's room and had not donned
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on interview and document review, it was determined the facility staff failed to include quality activities by case management related to the reassessment of identified concerns in their discharge planning processes, data collection, and evaluation of interventions.

The findings included:

An interview was conducted on July 14, 2014 at 4:08 p.m., with Staff #4. The surveyor requested to review the documents related to case management's review of their responsiveness to the patient's post-discharge needs, the effectiveness of their discharge planning and whether there were elements that led to preventable readmission. Staff #4 reported the facility had a task force that looked at readmissions. Staff #4 reported he/she was a member of the task force but did not take notes or maintain documentation related to the evaluation of case management's effectiveness or preventable readmissions. Staff #4 reported the task force forwarded information to quality improvement "I think."

An interview was conducted on July 14, 2014 at approximately 5:05 p.m., with Staff #2, Staff #3, Staff #4, and Staff #21. Staff #2 stated, "The data is present in a more global manner." Staff #3 reported the quality program did not have a quality activity based on case management, the effectiveness of the facility's discharge plans, or review of preventable readmissions. Staff #2 reported he/she would follow up with a meeting for the surveyor on July 15, 2015.

An interview was conducted on July 15, 2015 at 9:15 a.m., with Staff #2, Staff #3, Staff #4, and Staff #53. Staff #53 presented information for one of the patients included in the sample that had multiple readmissions within 30 days. Staff #53 reported that Staff #60 presents a summary of information rather than a review of individual cases. Staff #53 was not sure if that summary was used to draw conclusions whether the system failed to provide adequate discharge planning. Staff #2 reported the information is presented as numerical and offered an example of "fifty percent (50 %)" of appointments made for patients to their clinic were "No shows." Staff #2 verified the data was not evaluated as to why or the underlying cause for fifty percent of the referrals not keeping their appointments. Staff #2 verified the case management did not have an ongoing quality activity, which reviewed individual readmission cases for potential problems in the discharging process, or information on preventable readmission cases.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on the extent of observations related to breaches in infection control practices it was determined the Infection Control Condition of Participation was not in compliance; as evidenced by the facility staff's failure to ensure:

1. Implementation of the Infection Control Program. The facility failed to provide adequate resources: allocated for measuring, assessing, improving and sustaining the performance required by the individual designated as the Infection Control Officer. The Infection Control Officer failed to develop and implement policies in Environmental Services governing the control of infections and communicable diseases;

2. Problems identified in the Infection Control Program showed evidence of documentation for the development and implementation of corrective interventions and an ongoing evaluation of implemented interventions to ensure success, sustainability and reduction of risk to patients;

3. The Hospital leadership implemented successful corrective action plans in affected Infection Control problem areas;

4. A written protocol was in place for the backup personnel in the absence of the Infection Control Officer;

5. The Infection Control system trained personnel, who were expected to have contact with potentially infectious material and practices for preventing transmission of infectious agents;

6. Proper hand hygiene was followed during 5 of 8 observations;

7. The performance of safe injection practices during 1 of 2 observations;

8. Utilization of appropriate personal protective equipment in 1 of 1 observation;

9. Appropriate knowledge about manufacture's appropriate contact time for disinfecting various surfaces for 7 of 9 observations; facility equipment was maintained to prevent the spread of infection between patients in 2 of 2 observations; to include the hydrocollator packs laundering in the linen contract; and appropriate cleaning of equipment for 1 of 1 observation;

10. Appropriate storage for semi-critical equipment in a manner to protect from contamination for 1 of 1 observation;

11. Appropriate infection control practices were followed during a spinal injection procedure for 1 of 1 observation;

12. Point of care devices were properly disinfected between patients and appropriate infection control practices were followed in 2 of 2 observations;

13. Appropriate precautions were followed when caring for a patient on isolation in 3 of 3 observations;

14. Appropriate attire was worn in surgical and clean areas to prevent cross contamination and the spread of infectious agents in 1 of 2 observations;

15. Facility was in good repair, equipment was maintained and environment protected to prevent the spread of infections and harm.

See Citations 0286, 0748, 0749, and 0756 for further details.
VIOLATION: QUALIFIED PERSONNEL Tag No: A0818
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview it was determined case management failed to include identified needs in the discharge plans for three (3) of five (5) patients included in the sample for discharge planning. (Patients #1, #3 and #5)

The findings included:

Review of Patient #1's electronic medical record (EMR) was conducted on July 14, 2015 from 9:20 a.m. to 11:02 a.m., with Staff #4. Patient #1 had the following inpatient admissions to the facility: February 2 - 7, 2015; February 19 - 25, 2015; March 10 - 18, 2015; April 7 - 8, 2015: and June 16-18, 2015. Each admission identified substance abuse or substance intake as part of the patient's concern and history. Review of the discharge instructions provided to Patient #1 only the March 18, 2015 instructions encouraged follow-up with pain management. Patient #1 arrived at the facility's Emergency Department (ED) on April 7, 2015 and during the admission assessment, became unresponsive related to substances ingested prior to admission. An interview was conducted with Staff #4 during the review of Patient #1's EMR. Staff #4 reported the physician, nursing staff and case management documented Patient #1's substance use/abuse. Staff #4 verified that substance use or recommendations documented by the physician regarding the need for drug rehabilitation was not addressed in the patient's discharge plan or instructions.

Review of Patient #3's EMR was conducted on July 14, 2015 from 11:59 a.m. to 12:10 p.m., with Staff #4. Patient #3 had the following observation and inpatient admissions: February 10 -14, 2015; February 16 - 19, 2015; February 25, 2015 [observation]; and March 1 -5, 2015. On Patient #3's February 10, 2015 admission the patient had fell at home, the ED toxicology results indicated alcohol use, the patient sustained a fractured Humerus, which needed surgery. On February 25, 2015 Patient #3 was admitted to the facility for observations post a fall and the fracture of his/her right hip. The physician's assessment documented Patient #3 has a history of chronic alcohol abuse. Patient #3 was readmitted to the facility on on [DATE] after falling and sustaining a dislocation of the Humerus hardware placed during the February 10 -14, 2015 admission. Staff #4 verified the discharge plans and instructions for Patient #3's four admissions did not address or include recommendations related to the patient's substance use/abuse.

Review of Patient #5's EMR was conducted on July 15, 2015 from 8:28 a.m. to 9:08 a.m., with Staff #4. Patient #5 was admitted to the facility on on [DATE] and discharged back to an assisted living facility on June 3, 2015. The facility documented Patient #5 had a pressure ulcer on arrival (May 30, 2015) and on discharge. Review of the June 3, 2015 discharge plan and instructions did not include wound care orders. Patient #5 was readmitted to the facility on on [DATE]. The ED assessment on June 16, 2015 documented Patient #5's pressure ulcer had a "foul odor." Staff #4 verified the above findings. Staff #4 reported the directions or order for Patient #5's pressure ulcer wound care was not included in the discharge instructions for the assisted living facility staff.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
Based on interview it was determined the facility's case management staff failed to document the performance of an on-going reassessment of their discharge planning process and ensure data collected was a part of the facility's quality activities.

The findings included:

An interview was conducted on July 13, 2015 at approximately 3:15 p. m., with Staff #4. Staff #4 reported the facility's software flagged admissions that were readmissions. Staff #4 reported he/she had a system of interviewing the patients on their return to the facility. Staff #4 offered the surveyor a form created by Staff #4, which was part of an interview conducted by case management staff; but not scanned into the patient's electronic medical record (EMR).

An interview was conducted on July 14, 2014 at 4:08 p.m., with Staff #4. The surveyor requested to review the documents related to case management's review of their responsiveness to the patient's post-discharge needs, the effectiveness of their discharge planning and whether there were elements that led to preventable readmission. Staff #4 reported the facility had a task force that looked at readmissions. Staff #4 reported he/she was a member of the task force but did not take notes or maintain documentation related to the evaluation of case management's effectiveness or preventable readmissions. Staff #4 reported a special position (Staff #60) was created by the task force to review patient's follow-up and readmissions. Staff #4 stated, "We share the office, so we talk a lot but I don't necessarily document the conversations. [He/she] is on vacation right now, so I don't have access to that information." Staff #4 reported for the four (4) readmissions currently inpatient, he/she did not have access to information related to their post discharge follow-up and assessment of their ability to access care.

An interview was conducted on July 14, 2014 at approximately 5:05 p.m., with Staff #2, Staff #3, Staff #4, and Staff #21. The above findings related to case management's failure to document an evaluation of the services provided, readmissions, the effectiveness of their discharge planning, and an evaluation of preventable readmissions. Staff #2 reported an assessment of readmissions was performed by Staff #60 who reported findings to the task force. Staff #2 was not aware Staff #4 did not have access to Staff #60's post discharge information for readmissions. Staff #2 reported he/she would follow up with a meeting for the surveyor on July 15, 2015.

An interview was conducted on July 15, 2015 at 9:15 a.m., with Staff #2, Staff #3, Staff #4, and Staff #53. Staff #53 presented information for one of the patients included in the sample that had multiple readmissions within 30 days. Staff #53 reported that Staff #60 presents a summary of information rather than a review of individual cases. Staff #53 was not sure if that summary was used to draw conclusions whether the system failed to provide adequate discharge planning. Staff #2 reported the information is presented as numerical and offered an example of "fifty percent (50 %)" of appointments made for patients to their clinic were "No shows." Staff #2 verified but data was not evaluated for why or the cause for fifty percent of the referrals not keeping their appointments. Staff #2 reported the task force was in the process of coming up with an assessment tool. Staff #2 verified the case management did not have an ongoing quality activity, review individual readmission cases for potential problems in the discharging process, or follow up on preventable readmission cases.