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.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene between patient care and proper glove use, appropriately stored patients' belongings, and the infection control nurse (ICN) actively participated in identifying, developing, implementing, and evaluating the facility's infection control program. These failure had the potential for the development and transmission of infection.


1. During an observation on 10/3/17 at 8:20 a.m., Mental Health Technician C (MHT C) was checking patients' blood pressure (BP) in Unit 4. MHT C kept wearing one pair of gloves, did not perform hand hygiene between patient contact, and used one BP cuff without disinfection for all patients.

During a concurrent interview at 8:45 a.m., MHT C stated he checked 13 patients' BP on that day. He stated he did not change gloves, perform hand hygiene between patient care, and disinfect BP cuff between patient use.

2. During an observation on 10/31/17 at 9:02 a.m. MHT L wore gloves and cleaned the blood pressure machine's cuff with a disinfectant wipe. He went to a patient's room pushing the machine and brought it back to the nursing station, still wearing the same gloves. Then, MHT L went to the the linen storage and brought lines to a patient room, he continued to move to the neighbor unit to get paperbacks, which he contributed to a patient. The whole time MHT L wore the same pair of gloves.

During an interview on 10/31/17 at 9:10 a.m., MHT L stated he should have changed his gloves between tasks. He did not mentioned handwashing.

During an observation on 10/31/17 at 9:20 a.m. licensed psychiatric technician (LPT M) was gloved and gave a patient medications at the nursing station. To open a packed medication she needed to use a scissor. LPT M went with her gloved hands into her scrub pocket, got the scissor out , opened the medication wrap, and put the scissor back in her pocket.

During a concurrent interview, LPT M stated: "Oh I should not keep the gloves on when I get items out of my pocket? What should I do then?" When asked what the facility's policy was on glove use, LPT M was not able to recall the policy.

During a medication room observation on 10/31/17 at 9:25 a.m. seven paper bags with patients' belongings were found on the floor.

During a concurrent interview, LPT M stated these bags were from patients who would be discharged . When questioned if they were properly stored, LPT M stated: "Where should they go? Can you tell me."

3. During an interview on 10/31/17 at 12 p.m., the facility's infection control program was reviewed. the ICN stated she usually worked 2 hours per month to make a monthly infection report. She stated she received the infection data from the pharmacist and review the use of antibiotics. She stated she looked infections from the past month and could not monitor the current infection, could not identify infection if patients did not take antibiotics, and did not perform infection surveillance. She stated she could not have many chances to directly observe staff for their infection control practices because she had the limited time to work. She stated she did not provide staff in-services regarding infection control and participated in developing infection control program or performance improvement activities.

Review of Registered Nurse D (RN D)'s employee file indicated her date of hire was 3/24/16 and there was no annual TB (tuberculosis, a contagious lung disease) test in 2017.

During an interview with the Human Resources Director (HRD) on 10/30/17 at 1:40 p.m., she stated she was in charge to check the employee's TB test.

Review of the facility's undated Job Description "Infection Control Nurse" indicated the ICN participate in performance improvement activities, exhibit initiative by suggesting process changes with compliance supported by direct observation, meeting minutes, input into supervision process, and staff growth and development survey. Work as with facility department heads and physicians to develop and maintain an effective infection surveillance, prevention and control program. Assist department heads in developing specific infection surveillance and prevention and control policies and procedures. Responsible for management of established employee health program to include record keeping, administration of TB test upon hire and annually with review.
Based on observations and interviews, all four units of the hospital had white boards posted by the wall of the nursing station and can be viewed by everyone. The white board had patient's full names and level of observations. This had the potential for breach of confidentiality.


During an observation on 10/30/17, at 10:30 a.m. and 10/31/17, at 7:25 a.m., a white board at Unit 1 nursing station posted 15 patients' information with patient's room number, patient's name, admitted , level and observation, hold status date and time, assigned nurse, doctor and social worker's name.

During an observation on 10/30/17, at 10:35 a.m., and 10/31/17, at 7:07 a.m., a white board at Unit 2 nursing station posted 20 patients's information with patient's room number, patient's name, admitted , level and observation, hold status date and time, assigned nurse, doctor and social worker's name.

During a tour of Units 3 and 4 on 10/30/17 at 7:55 a.m., white boards were noted by the nursing stations. The white board each had first and last names of all the patient in the units.
During a concurrent interview, the charge nurses confirmed the names of their patients in the unit by comparing her census sheet and the names on the white board. The information on the white boards were exposed to patients or visitors walking through the hallway, passing by the nursing stations, staying by the nursing stations, and waiting for their medications or needs.