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.

STRATEGIC BEHAVORIAL CENTER-GARNER 3200 WATERFIELD DRIVE GARNER, NC 27529 March 27, 2014
VIOLATION: GOVERNING BODY Tag No: A0043
Based on medical record reviews, policy and procedure reviews, physician credential file reviews, hospital documentation reviews, physician and staff interviews the hospital's Governing Body failed provide oversight and assure the Nursing Staff was organized under the direction of a qualified Director of Nursing, the nursing staff failing to monitor and assess patients ensuring safe care for adolescent patients and maintain an effective, hospital-wide, data-driven quality assessment and performance improvement program to ensure safe and effective patient care.

The findings include:

1. The Quality Assessment Performance Improvement program failed to ensure an effective, hospital-wide, data-driven quality assessment and performance improvement program to ensure the safe and effective care of the adolescent patient.

~Cross refer to 482.21 Quality Assessment Performance Improvement, Condition Tag A0263.


2. The hospital failed to ensure nursing services were organized under the direction of a qualified Director of Nursing and the nursing staff failed to demonstrate an organized nursing service as evidenced by failing to monitor and assess patients ensuring safe care for adolescent patients.

~Cross refer to 482.23 Nursing Services, Condition Tag A0385.
VIOLATION: MEDICAL STAFF - APPOINTMENTS Tag No: A0046
Based on physician credential file reviews and staff interviews, the hospital failed to ensure
a physician had current medical malpractice insurance prior to appointment for provisional privileges as a medical staff member providing direct patient care in 1 of 7 credential files reviewed (Physician #2).

Review of Physician #2's credential file revealed documentation on October 23, 2013, the physician was reappointed with provisional privileges to provide patient care for the acute hospital. Credential file review revealed no documentation of current medical malpractice insurance at the time of reappointment. Credential file review revealed documentation the physician's medical malpractice insurance expired September 2013 (approximately 1 month before reappointment).

Interview with Administrative Staff #3 and Administrative Assistant #1 on 03/20/2014 at 1640 revealed there was no documentation available of current malpractice insurance for physician #2 at the time of reappointment on October 23, 2013. The interview revealed documentation indicated there was a lapse in coverage from September 2013 until February 2014. During the interview documentation presented, revealed current medical malpractice insurance as of February, 2014.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy review, open medical record reviews, video review and staff interviews, the facility failed to use the least restrictive intervention for 1 of 3 restraint records reviewed (Patient #1).

Review of the hospitals policy, "NS 2.4.3(-) Restrictive Interventions REVIEWED/REVISED: 03/14/2014 revealed, "PROCEDURES (4) Restrictive interventions are only utilized in an emergency,When a Resident's behavior presents imminent danger to the Resident, staff, or others. Problematic behavior that does not present an immediate risk to the Resident, staff, or others shall be addressed by less restrictive strategies ...Documentation for Emergency Safety Interventions: 1. b. Time and results of the emergency safety intervention when it actually began and ended ...

Open medical record review revealed of Patient #1; revealed a [AGE] year old male admitted to the facility on [DATE]. Record review revealed the patient had a history of ADHD (define), ODD (define), and aggression toward family members and others. Review of "PHYSICIAN ORDER FOR RESTRICTIVE INTERVENTIONS FOR BEHAVIORS" dated 3/17/14 at 1705 revealed documentation "TRANSPORT METHOD: Escort. RESTRICTIVE INTERVENTION: Manual Hold, Sitting, Standing. REASON FOR INTERVENTION: Aggressive against others." Review of "Restrictive Intervention Reporting Form" dated 3/17/14 at 1705 revealed the patient was released from the restrictive intervention at 1701. Review of the facility's "RESIDENT OBSERVATION SHEET" dated 3/17/2014 revealed documentation at 1700 the patient was in the room awake. Further review revealed the patient entered the quiet/seclusion room at 1715. Review revealed documentation the patient was no longer in the quiet/seclusion room at 1815. Video observation on 3/21/14 at 1625 and 3/27/14 at 1100 revealed on 03/17/2014:

1706.10 (hours/seconds) - Patient #1 enters the quiet/seclusion room hallway
1706.15 - Patient #1 enters the quiet/seclusion room unaccompanied by staff
1706.21 - Residential Coordinator (RC) #1 enters the quiet/seclusion room hallway
1706.34 - RC #1 enters quiet/seclusion room
1706.53 - RC #1 stands at door of quite room, Patient #1 not in camera view
1707.06 - Patient #1 sitting on quiet/seclusion room floor, RC #1 enters quiet room (no observation of the patient exhibiting behavior requiring restrictive intervention)
1707.10 - RC #1 holding Patient #1 in standing position (restrictive intervention)
1707.46 - RC #1 holding Patient #1 in sitting position (restrictive intervention)
1708.00 - RC #1 holding Patient #1 in sitting position (restrictive intervention)
1709.25 - RN #4 enters quiet/seclusion room
1709.32 - RC #1 and Patient #1 in sitting position; RN #4 standing beside RC#1 and
Patient #1
1710.12 - RC#1 and Patient #1 stand up
1710.22 - RN #4 holding Patient #1 face forward against the wall; RC #1 is standing at the back of Patient #1
1710.29 - RC #1 walks out of quiet/seclusion room; RN #4 holding patient face forward
against the wall
1711.50 - Patient #1 sits on quiet/seclusion room floor and begins eating
Further observation reveals Patient #1 is in the quiet/seclusion room at 1732.19.

Interview with Milieu Manager (MM) #1 and Administrative Staff #3 on 3/21/14 at 1625 revealed there was not a reason (behavior) for RC #1 entering the room and performing a hold. Further interview with MM #1 and Administrative Staff #3 on 3/25/14 at 1500 revealed a staff member would go into the quiet/seclusion room to restrain a patient if the patient is demonstrating self injurious behavior or property destruction. The interview indicated there was no evidence of the patient demonstrating self injurious behavior or property destruction for the patient to be placed in a restrictive intervention.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on Quality Improvement documentation reviews and administrative staff interviews the hospital failed to have Quality Assessment Performance Improvement program monitoring the effectiveness and safety of patient care services.

The findings include:

Review of hospital Quality data for restrictive interventions revealed documentation of the number of patients that had an intervention (restraint/seclusion) for December, 2013, January, 2014 and February, 2014. Review of each month revealed the total number of restrictive interventions (RI) , the number of patients with no RIs and the number of patients with RI's.

Interview with administrative staff #2 and #3 on 03/27/2014 at 1230 revealed the hospital monitors the number of patients that have a RI and the number of patients that do not have a RI for each month. The interview revealed the number of episodes per patient is not collected or monitored. The interview revealed documentation in the medical record is not reviewed (physician's order, time limitations, assessment/reassessments). The interview revealed the hospital looks at the numbers but does not look at any actions regarding the number of patients having an RI.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy review, open and closed medical record reviews and staff interview, the facility failed to ensure physician orders for restraint and/or seclusion were time documented according to facility policy for 2 of 3 sampled patients (#7, #4)

The findings include:

Review of facility policy, "NS 2.4.3(-)" titled "restrictive interventions" revised 03/03/2014 revealed any order for restraint/seclusion must be dated and timed.

Review of facility policy "CS 6.1.8-Resident Safety Committee" reviewed/revised 03/04/2014 revealed, "7. The Resident Safety Committee shall review the restrictive intervention paperwork and related documentation for the following: (b)The information gathered verifies that each order includes the justification and specified time period for restraints or seclusion, (c) Evaluate any patterns of use and if appropriate, that orders were obtained..."3. Review of the facility's "Restrictive Intervention" policy effective 06/12/2008 revealed "... 6. The ordering psychiatrist shall sign the verbal order within 24 hours."

The findings include:

1. Open medical record review of Patient #7 revealed a [AGE] year-old male was admitted on [DATE] for oppositional defiant disorder. Medical record review revealed a physician order documented on the "Physician Order For Restrictive Interventions For Behaviors" form for restraint/seclusion dated 03/02/2014 no time documented. Review of the order revealed the physician signed the order on 03/03/2014, no time documented. Medical record review revealed a physician order documented on the "Physician Order For Restrictive Interventions For Behaviors" form for restraint/seclusion dated 03/09/2014 no time documented. Review of the order revealed the physician signed the order on 03/12/2014, no time was documented.

Interview with Administrative Staff #1 on 03/19/2014 at 1300 revealed per hospital policy physician were supposed to sign, date and time the restraint/seclusion order.The interview revealed patient #7's restraint/seclusion respective orders did not have the time documented.

Interview with the Administrative Staff #2 on 03/27/2014 at 1130 revealed the respective orders dated 03/02/2014 and 03/09/2014 did not have the time documented per hospital policy.




2. Closed medical record review of patient #4 revealed a[AGE]-year-old female admitted on [DATE] with oppositional defiant disorder, post traumatic stress disorder and mood disorder. Review of the restraint documentation revealed the patient was placed in a restraint on 11/27/2013 at 1745 for increased aggression and verbally threatening a peer. Review of the physician's order revealed a verbal order was obtained on 11/27/2013 at 1800. Review revealed the physician authenticated the order on 11/30/2013 at 0900 (3 days and 14 hours after order was obtained).

Interview on 03/26/2014 at 1515 with Administrative staff #2 revealed verbal orders for restraints should be signed by the physician within 24 hours of obtaining the order. Interview confirmed the order for the restraint on patient #4 on 11/27/2013 was not signed within 24 hours of obtaining the order.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy reviews, open medical record reviews and staff interview, the facility failed to ensure physician orders for restraint and/or seclusion were time limited for 2 of 3 sampled patients (#1 and #4).

The findings include:

Review of the hospitals policy, "NS 2.4.3(-) Restrictive Interventions REVIEWED/REVISED: 05/16/2012 revealed, "Justification, Physician ' s Order, and Documentation 1. Restrictive Interventions and Orders (b) Any order for restrictive intervention must be... time limited ... "

Review of facility policy "CS 6.1.8-Resident Safety Committee" reviewed/revised 03/04/2014 revealed, "7. The Resident Safety Committee shall review the restrictive intervention paperwork and related documentation for the following: (b)The information gathered verifies that each order includes... the specified time period for restraints or seclusion..."

Review of the facility's "Restrictive Intervention" policy effective 06/12/2008 revealed "... 1. b. Any order for restrictive intervention must be dated, timed, behaviorally specific, and time limited, (e.g., 2-15-11, 1800. - physical restrictive intervention or seclude now and up to one (1) hour to prevent harm to self or others.) ..."

1. Open medical record review of Patient #1 revealed a [AGE] year old male admitted to the facility on [DATE]. Record review revealed the patient had a history of ADHD, ODD, and aggression toward family members and others. Review of "PHYSICIAN ORDER FOR RESTRICTIVE INTERVENTIONS FOR BEHAVIORS" dated 3/17/14 at 1635 revealed, "TIME (Not to exceed 1 hour for adolescents) Check appropriate box; Up to 1 hour authorized for Manual Restraint or Seclusion: " Review of record revealed the box was not marked. Review of "Other (Specify Time and reason): " revealed the box was not marked. Review of "PHYSICIAN ORDER FOR RESTRICTIVE INTERVENTIONS FOR BEHAVIORS" dated 3/17/14 at 1705 revealed, "TIME (Not to exceed 1 hour for adolescents) Check appropriate box; Up to 1 hour authorized for Manual Restraint or Seclusion: " Review of record revealed the box was not marked. Review of "Other (Specify Time and reason): " revealed the box was not marked.

Interview with the Administrative Staff #2 on 03/27/2014 at 1130 revealed restraint/seclusion orders did not have documentation of time limit per the facility policy.





2. Closed medical record review of patient #4 Revealed a [AGE]-year-old female admitted on [DATE] with oppositional defiant disorder, post traumatic stress disorder and mood disorder. Review of the restraint documentation revealed the patient was placed in a restraint on 12/06/2013 at 1436 for fighting with a peer. Review of the physician's order revealed no documentation of a time limitation for the restrictive intervention.

Interview on 03/26/2014 at 1515 with Administrative staff #2 revealed there was no documentation of a time limited order for the restrictive intervention on 12/06/2013. Interview confirmed restraint orders should be time limited.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record review and staff interview, the facility failed to ensure a one hour face-to-face assessment was documented after a restrictive intervention for 1 of 3 sample patients (#4).

The findings include:

Review of the facility's "Restrictive Intervention" policy effective 06/12/2008 revealed "... Once a restrictive intervention has been implemented the qualified RN shall conduct a face-to-face assessment. The RN shall inform the psychiatrist of the resident's current condition. The psychiatrist will decide whether not to continue the restrictive intervention or seclusion. ... 1. A face-to-face evaluation is conducted with the resident post restrictive intervention by qualified RN which indicates physical condition, mood, behavior, and any unusual finding. This evaluation will be completed prior to the termination of the RN's shift. ..."

Closed medical record review of patient #4 Revealed a[AGE]-year-old female admitted on [DATE] with oppositional defiant disorder, post traumatic stress disorder and mood disorder. Review of the restraint documentation revealed the patient was placed in a restraint on 12/06/2013 at 1436 for fighting with the peer. Record review revealed no documentation of a face-to-face assessment within one hour after the intervention.

Interview on 03/26/2014 at 1515 with Administrative staff #2 revealed there was no documentation of a face-to-face assessment of the patient's condition within one hour after the restrictive intervention on 12/06/2013. Interview confirmed the nursing staff failed to follow the restraint policy.
VIOLATION: QAPI Tag No: A0263
Based on Quality Improvement documentation reviews and administrative staff interviews the hospital failed to maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program.

The findings include:


1. The hospital failed to have Quality Assessment Performance Improvement program monitoring the effectiveness and safety of patient care services.

~Cross refer to 482.21 (b) Quality Assessment Performance Improvement, Standard Tag A0273.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of facility policies, medical record reviews, observations during tour, staff interviews, administrative staff interviews, review of hospital documents, review of nursing personnel records and review of unit nursing assignments the hospital failed to ensure: nursing services were organized under the direction of a qualified Director of Nursing and the nursing staff failed to demonstrate an organized nursing service as evidenced by failing monitor and assess patients ensuring safe care for adolescent patients.

The findings include:

1. The hospital failed to ensure psychiatric nursing services were directed by a Registered Nurse (RN) who has a master's degree in psychiatric or mental health nursing or its equivalent from a school of nursing accredited by the National League for Nursing, or be qualified by education and experience in the care of the mentally ill.

~Cross refer to 482.62 (d)(1) Nursing Services, Standard Tag B0147.

2. The nursing staff failed to supervise the delivery of care to ensure a safe setting by failing to search and seize potentially harmful items upon admission for 1 of 8 sampled patients reviewed (#13) and failing to ensure a one to one level of supervision was provided as ordered for 1 of 1 observed patient on one to one supervision (#8).

~Cross refer to 482.23(b)(3) Nursing Services, Standard Tag A0395.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on administrative and staff interviews and nurse assignment schedule review the hospital failed to maintain a plan of administrative authority and delineation of responsibilities for patient care.

The findings include:

Interview with RC #3 on 03/20/2014 at 1945 revealed there was no RN scheduled for the 1500 to 2300 House Supervisor for the past 3 weeks.

Review of the nurse assignment sheet on 03/20/2014 at 2000 revealed no documentation of a House Supervisor assigned for 1500 to 2300.

Interview with administrative staff member #3 and #2 on 03/25/2014 at 1040 revealed the the House Supervisor is the RN in administrative authority during the 1500 to 2300 shift. The interview revealed there was no coverage on 03/19/2014, 03/ 20/2014 and 03/ 21/2014 from 1900 until 2230. The interview revealed the Director of Nursing generally covers but the Director was out of State. The interview revealed the Director was on call while out of State.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review,medical record review, incident report review and staff interview, nursing staff failed to supervise the delivery of care to ensure a safe setting by failing to search and seize potentially harmful items upon admission for 1 of 8 sampled patients reviewed (#13) and failing to ensure a one to one level of supervision was provided as ordered for 1 of 1 observed patient on one to one supervision (#8).

The findings include:

1. Review of the facility's "Scope of Care" policy effective 07/02/2012 revealed "It is the policy of (facility name) to maintain a safe environment for its residents and staff by ensuring that potentially harmful items are to be prevented from being in the facility. The process of search or seizure is done when the resident is admitted to the facility, after being on therapeutic leave and if there is a significant reason to believe that the resident is in possession of contraband that could cause injury to the resident or staff. ... 3. Every search or seizure shall be documented. Documentation shall include: a) scope of search; b) reason for search; c) procedures followed in the search; d) a description of any property seized; and e) an account of the disposition of seized property."

Closed medical record review of Patient #13 revealed a [AGE] year-old male that was admitted on [DATE] for mood disorder, not specified and oppositional defiant disorder. Review of the admission nursing assessment dated [DATE] at 1535 revealed no evidence of a search for contraband documented. Further review of the acute medical record revealed no evidence that a search for potentially harmful items was conducted. Record review revealed the patient discharged from the acute setting and was admitted to the Psychiatric Residential Treatment Facility (PRTF) on 01/17/2014.

Open medical record review of Resident #13 revealed a "Psychiatric Assessment/Evaluation" documented by the patient's physician and dated 01/17/2014 at 2030 that recorded the patient "reports 'I will burn the place down.' ... Patient had been a resident of (facility name) PRTF from 08/2013 through 01/11/2014. At that time, he was transported to (acute hospital name) ED (emergency department) for report of overdose. However, it was determined that patient had ingested small styrofoam pieces, telling staff that they were pills. Patient was placed on IVC (Involuntary Commitment) and admitted to (name of facility) acute on 01/12/2014. He returned to (name of facility) PRTF on 01/17/2014. for continued treatment of impulsive, aggressive behaviors, and SI (suicide ideations) statements. ... When interviewed by MD, patient was agitated and reported not wanting to come back to the PRTF. He voiced, 'I will burn the place down.' He would not cooperate with further assessment. ..." Review of the record revealed no documented evidence of a search for contraband was conducted.

Review of an Incident Report recorded on 01/18/2014 revealed the patient "set fire in the bathroom with a lighter" on 01/18/2014 at 1021 on the 400 hall.

Interview on 03/26/2014 at 1500 with RA#7 revealed he witnessed the fire in the bathroom on 01/18/2014. Interview revealed the staff member "smelled burning and there was slight smoke" when he arrived on the 400 hall. Interview revealed the patient set fire to toilet paper in the commode with a lighter. The staff member stated "He smuggled in the lighter." Interview revealed a search for potentially harmful items should be done on admission.

Interview on 03/21/2014 at 1635 with administrative staff #1 revealed there was no evidence of a search for potentially harmful items that was documented when the patient was admitted on [DATE] or upon readmission to the PRTF on 01/17/2014. Interview revealed there should be documentation of a search for contraband upon admission. Interview further confirmed that the patient started a fire in the bathroom with a lighter on 01/18/2014.

2. Review of "level of patient observation" policy reviewed/revised 03/04/2014 revealed "... (Facility name) has a primary responsibility to ensure the safety and well-being of individuals within our care. It is recognized it all patient units are locked is one measure safety. Nursing personnel implements these levels of observation throughout the 24-hour period. Each patient is a sign to staff member and staff must have really present before leaving their sign patients. ... One to one observation: this is the only and sole assignment of one staff member who documents the location, behavior, and activities of the patient every 15 minutes. The staff member assigned is in constant visual range of the patient (including bathing/toileting) and is within arm's length of the patient at all times, including bathing and hours of sleep unless otherwise specified in the psychiatrist order. ... Decreasing the level of observation requires a verbal/written psychiatrist's order and assessment of the patient is documented in the medical record. ... They RN (registered nurse) in charge is responsible for assuring that the level of observation is implemented appropriately. The RN is responsible for ensuring that assignments are clear on assignment sheets and staff assigned to one to one observation has no other patient assigned to them."

Open medical record review of patient #8 revealed a [AGE]-year-old female admitted on [DATE] with adjustment disorder with disturbance of conduct. Review of a physician's order dated 03/20/2014 at 1414 revealed " Place patient on one-to-one level of observation and turtle suit for safety." Review of nursing notes dated 03/20/2014 at 1415 revealed the patient was placed on one-to-one level of observation and turtle suit due to placing a "jacket around her neck."

Observation during tour of the 100 hall on 03/20/2014 at 1940 revealed patient #8 located in a dayroom with eight other female patients. Observation revealed one staff member (# X) was observing the nine female patients. Observation revealed patient #8 was located across the room from staff member # X who was located in the doorway (not within arms reach of patient #8).

Interview during the tour on 03/20/2014 at 1945 with staff member # X revealed the staff member (# X) assigned as one to one with patient #8 left at 1930 and no one had replaced her. The staff member stated "There is no one the one staff, so I am watching her."

Interviewed during tour on 03/20/2014 at 1950 with RN # X revealed she was not aware there was no one-to-one staff member assigned to patient #8. Interview revealed one-to-one observation meant a staff member is within arms reach of the patient at all times.

Interview on 03/25/2014 at 1045 with the director of nursing revealed nurses are responsible to get a physicians order for one to one level of observation. Interview revealed the nurse notifies the milieu manager of the need for a one-to-one observation and the milieu manager is responsible for assigning the staff member to the one to one level of observation.

Interview on 03/21/2014 at 1545 with the milieu coordinator revealed she was responsible for ensuring staffing needs were met for acute halls 100 and 200. Interview revealed she was aware patient #8 was on one-to-one observation during the evening shift on 03/20/2014. Interview revealed she had arranged for staff # X to stay to do the one the one observation with patient #8. The staff member stated "I am not sure why she left."
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on administrative and staff interviews and patient assignment documentation review the nursing staff failed to assign the care of patients to other staff members.

The findings include:

Interview with administrative staff members #2 and #3 on 03/25.2014 at 1040 revealed the nursing staff do not assign patient care to other staff embers. The interview revealed the assignment of a patient's care is assigned by the Milieu Manager (MM) or the Resident Coordinator (RC). The interview revealed the MM nor the RC are registered Nurses.

Review of the patient assignment documentation for 700/800 hall on 03/20/2014 at 1945 during tour revealed no documentation of staff assigned to any patient. Interview with RC #3 during tour revealed no specific staff are assigned to any patient, "The patients are the responsibility of all the staff." The interview revealed staff are not assigned to patients on special observation such as close observation Interview during tour with RN #8 revealed the nurse does not assign patient care to any staff member.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation and staff interviews the hospital failed to have a system or process in place for hand hygiene for the staff after handling potential contaminated materials with gloved hands.

The findings include:

Observation on 03/20/2014 at 2015 on 700/800 hall revealed the soiled utility room with house keeping equipment in the sink (completely full) and equipment in front of the sink. Observation revealed no hand hygiene materials in the room or outside the door of the room. Observation revealed hand hygiene materials were located behind the nursing station in the medication preparation (prep) room and in the staff bathrooms. Observation revealed staff would have to walk around the perimeter of the nursing station (approximately 30 feet), go through 2 locked doors to get into the station and then through a third door to get to the medication prep room to get hand hygiene materials.

Interview with RC #3 on 03/20/2014 at 2015 during observation revealed the staff used the medication prep room to wash hands after removing gloves. The interview revealed the staff are to wear gloves when in contact with "dirty" bed linens.

Interview on 03/21/2014 at 1455 with RN #9 revealed she was the Infection Control nurse for the hospital. The interview revealed she had been in the Infection Control position since December, 2013. The interview revealed all soiled utility rooms were exactly the same including the hospital's soiled utility room. The interview revealed there was no hand hygiene material in the soiled utility rooms. The interview revealed the staff did not identify the soiled utility room needing hand hygiene material. The interview revealed infection control rounds were done every month and it had been about a month since the last rounds. The interview revealed staff carry hand sanitizer in their uniform pockets and use it after glove removal. The interview revealed all staff should have hand sanitizer. The interview revealed the staff did not identify after glove removal the hands are considered "dirty" and the staff would be putting dirty hands into their pockets.

Interview with RC #4 on 03/21/2014 at 1105 during tour revealed the staff member was carrying soiled bed linens with gloved hands. The interview revealed to perform hand hygiene the staff member demonstrated going through double doors, down a hall through two locked doors to use the bathroom in the staff lounge. The interview revealed he generally washes his hands after glove removal in the staff bathroom.

Interview with Administrative staff #3 on 03/21/2014 at 1000 revealed the hospital did not have a process in place for the staff to wash their hands after removing dirty gloves in the soiled utility room. The interview revealed the hospital policy is for staff to wash hands after glove removal.

NC 060