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, document review, and interview, in 3 of 6 observations of nursing staff providing patient care by the bedside, staff did not adhere to practices consistent with generally accepted infection control standards and hospital policy.

These lapses in infection control technique may place patients at increased risk for hospital-acquired infections.

On 09/11/2018, at 12:00, during a tour in the Emergency Department (ED), it was observed that Staff U (Registered Nurse in the Emergency Department) was unable to initiate an intravenous (IV) access on Patient #9's right vein. The staff removed the catheter needle sheath from the patient and placed it on the patient's bedside table thereby contaminating the table.

This finding was witnessed by Staff A (RN, Esq. Director of Risk Management) at the time of observation.

On 09/13/2018, at 11:10 am, Staff Q (Nursing Technologist) was observed performing a fingerstick on Patient #10. Upon completion of the procedure, Staff Q placed the used glucometer strip into a garbage container.

During interview with Staff Q at the time of observation she stated that she had always disposed used glucometer trip in the garbage container.

Review of the policy titled "Whole Blood Glucose," last reviewed 04/27/2018 states, "Discard used lancet and test strips into Sharps Container."

This finding was witnessed by Staff A (RN, Esq. Director of Risk Management) who acknowledged findings.

On 09/11/2018 at 11:20 am, Staff Q (Nursing Technologist) was observed providing personal care to Patient #11 who was on 'Contact Isolation' (Precautions used to prevent transmission of infectious agents).
Staff Q opened the garbage bin cover with a gloved hand and placed some trash in the bin. Staff Q with the same glove, proceeded to the patient's bedside and rearranged patient's property on the bedside table.

Staff Q did not change her gloves and perform hand hygiene before she moved on to another task.

Review of the policy titled "Standard Precautions & Isolation Policy" last reviewed 05/25/2018 notes: "perform hand hygiene... After touching blood and body fluids, secretions, excretions and contaminated items, whether or not gloves are worn - as well as immediately after gloves are removed, between patient contacts, prior to feeding patients and when otherwise indicated."

This finding was witnessed and acknowledged by Staff A (RN, Esq. Director of Risk Management) at the time of observation.