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.

ST JOHN'S EPISCOPAL HOSPITAL AT SOUTH SHORE 327 BEACH 19TH STREET FAR ROCKAWAY, NY 11691 Aug. 20, 2018
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
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Based on observation, document review and interview, the facility did not ensure that patient information was not discussed in public areas within earshot of people passing by.

Findings:

On 8/16/18 at 11:30AM, a group of medical students and residents were observed near the elevator and were overheard discussing the medical treatment plan and diagnosis of a patient, within ear shot of individuals passing by.

This was observed in the presence of Staff A, Director of Quality Assurance, who intercepted the discussion and acknowledged that the medical students should not have been discussing the patients protected health information in the hallway and near the elevators.

The facility's policy and procedure titled "Safeguards for Protected Health Information," last revised March 1st, 2017, states: "It is the responsibility of all medical staff and hospital staff members to comply with this policy. Hospital staff members include all employees medical or other students, trainees, residents, interns, at the hospital ...Episcopal health services staff members must refrain from discussing patient information in public areas, such as elevators and cafeterias.
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0147
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Based on observation, document review and interview, in eight (8) of eight (8) medical records observed, the facility did not ensure that patients electronic medical record was kept secured. (Patients #18-24).

Findings:

During a tour of the facility, the following was observed:

On 8/15/18 at 9:15 AM, Patients #17 and #18's electronic health record was observed unsecured and unattended on a nursing medication cart in the patient care area, visible to people walking by.

These findings were acknowledged by Staff S, Registered Nurse at the time of the observation.

Similar findings were observed for Patients #19, 20, 21, 22, 23, and 24.

The facility's policy and procedure titled "Safeguards for Protected Health Information," last revised March 1st, 2017, states: "It is the responsibility of all medical staff and hospital staff members to comply with this policy. Hospital staff members include all employees medical or other students, trainees, residents, interns, at the hospital ...information should not be left on counters where the information may be accessible to the public."
VIOLATION: SECURE STORAGE Tag No: A0502
Based on observation, document review and interview the facility did not ensure that medication, needles and syringes were kept secured and stored in a safe manner.

Findings:

During a tour of the facility between 9:30AM and 10:45AM on 08/15/18 the following were identified:

On Tower 8, an unattended medication cart was in the hallway with the draws open. Inside the draws were one vial of Heparin (a medication used to prevent and treat blood clots) with a needle and syringe, and packages of Medications.

Staff O, Registered Nurse, who was administering medications at the time of the observation, stated "I was in the medication room checking for medications."

Staff O continued down the hallway administering medications. He entered a patient's room and left the medication cart in the hallway unlocked and unsecured with the draws open exposing the medications, syringes and needles.

Similar finding was observed when Staff K, Registered Nurse, left the medication cart with medications, needles and syringes unattended and unsecured in the unit hallway.

The policy and procedure titled "Handling and Storage of Medications," last revised 03/18, states the following: "All drugs storage areas within the hospital where patient care is provided, must be locked and secured by... A locked storage area can be a cabinet, medication cart or closet, which are under the supervision of a nurse, pharmacist, or health care administrator."

Staff J, Accreditation Coordinator and Staff M Nurse Manager, were present at the time of the observation and acknowledged the finding.


On 8/16/18 during a tour of the Emergency Department between 1:00PM and 1:45PM the following was identified:
The clean supply rooms in the Rapid Evaluation Unit and the "old Emergency Intake Area" were not locked. The supply rooms contained various needles and syringes. The room is located in the visitor hallways and across from patient treatment areas.

Staff A, Director of Quality Assurance who was present at the time of the observation, confirmed the finding.
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
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Based on observation, document review and interview, the facility did not ensure expired medications and otherwise unusable drugs were not available for patient use.

Findings:

During tour of the facility's Intensive Care Unit (ICU) on 8/15/18 at 11:25 AM, the following was observed:

The medication refrigerator had one multi-dose vial of Novolog insulin labeled with an expiration date of 8/2/18 and one multi-dose vial of Novolin R insulin (Regular Insulin) labeled with an expiration date of 8/13/18.

This was observed in the presence of Staff U, ICU Nurse Manager, and Staff S Registered Nurse, who acknowledged the findings.

The facility policy and procedure titled "Expiration Date of Multi-Dose Vials," last revised March 2018, states:
"The after use expiration of the multi-dose vials shall be checked to make sure the medication is still in date ...the vial should be appropriately discarded, if a previously opened vial has passed its after use expiration date."
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation, interview, and document review, the facility failed to ensure compliance with the Condition of Participation of Infection Control as evidenced by the significant systemic deficient practices identified during the survey.

These findings place all patients at risk for cross contamination and facility acquired infections.

Findings include:

The facility failed to ensure that:

Infection Control Officers developed comprehensive and accurate policies and procedures to educate staff in infection control practice and the prevention and transmission of infection; and

Orientation is provided for medical students and education on the principles and practices for preventing transmission of infectious agents within the hospital.

See Tag A 748.

Multidisciplinary Staff provide care and services in a sanitary environment in accordance with standard infection control practices.
b) maintain safe and appropriate storage of medications and patient care equipment and supplies.

See Tag A 749.

Infection Control Officers develop and implement corrective action plans for infection control problems identified:
Nurse managers develop Nursing processes and attend the bimonthly Infection Control Committee meetings:
Performance Improvement measures were developed for identified hand hygiene noncompliance.

See Tag A 756.

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VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
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Based on observation, document review and interview, the facility failed to ensure: (a) that Infection Control Officers developed comprehensive and accurate policies and procedures to educate staff in infection control practice and the prevention and transmission of infection, (b) medical students received orientation to the hospital policies and site specific mandates for preventing transmission of infectious agents within the hospital (Staff AA and Staff FF).

These lapses in infection control practices places patients and staff at risk for facility acquired infections.

Findings:

Observation of Staff CC, Housekeeping, at 10:15 AM on 08/16/18, noted he was performing the daily cleaning of an occupied room where the patient was on Gown and Glove Isolation. The following breeches in infection control were identified:
-As he went to don (put on) a new gown, he shook open the gown and the front of the gown had contact with the garbage bin.
-After donning his gloves, he placed his right hand in his pocket to get his keys to the housekeeping cart.
-After emptying the garbage in the isolation room, he walked to the entrance of the room and with his "dirty" gloves he opened the lid to the garbage bin in the hallway contaminating the container.
-With the same "dirty" gloves he took clean bags from the garbage pail contaminating the container.
-Without changing his "dirty" gloves he obtained the broom and pan from the housekeeping cart contaminating the cart.
-He repeatedly used his "dirty" gloves to remove cleaning wipes from the clean wipe bucket. His "dirty" gloves had contact with the bucket and remaining wipes.
-With the same "dirty" gloves he cleaned the light switch, door handles and panel, sharps container, Sani dispenser and the lid of the garbage pail in the room.
-He removed his "dirty" gloves and without performing hand hygiene entered the housekeeping cart to obtain the toilet bowl cleaner. After cleaning the toilet in the isolation room, he returned the toilet bowl cleaner to the housekeeping cart.
-He placed the contaminated broom and pan inside the unit housekeeping cart garbage bin for transportation to the next room.
-Approximately five "dirty" microfiber clothes were observed on the housekeeping cart. A "dirty" microfiber was observed being placed on the housekeeping cart by the housekeeper after he cleaned an isolation room with it.

-On three (3) occasions, Staff CC was observed using hand sanitizer after removing his gloves. He wiped the hand sanitizer off with a paper towel.

During interview of Staff CC at the time of the observation, he explained he uses the same toilet bowl cleaner in each room, whether it is an isolation room or not. He stated he puts the broom and pan in the garbage bin to transport it. After using hand sanitizer to clean his hands, he stated he wipes his hands with a paper towel because "my hands are sweating. I can't get my hands in the gloves if they are wet." He does not allow the hand sanitizer to dry as required.

During interview at the time of the observation, Staff B, Director of Environmental Services and Staff H, Director of Infection Control, confirmed the findings.

The facility policy and procedure titled "Microfiber Mops," last revised 1/18, stated the following: "After each use, soiled microfibers are bagged and taken to the environmental services soiled bin and sent out for cleaning."


On 8/15/18 at 1:15 PM Staff R, Environmental Staff, was observed removing trash from a recently vacated droplet Isolation room without gloves. This was observed in the presence of Staff B, Director of Support/ Environmental Services, who confirmed the findings.

The facility policy and procedure (P&P) titled "Isolation room Daily and Discharge Cleaning," last revised March 1st 2018, contained the following statements: check isolation sign and follow instructions for proper Personal Protective Equipment (PPE) ....gloves and gown, mask if needed ...place a wet floor sign at the entrance of the room ...hand hygiene ...empty trash containers in the bathroom and room.."
The policy lacked guidance regarding the correct order for donning PPE, specifically when to don gloves. The policy does not contain instructions how the staff should assemble and bring the cleaning supplies and equipment into an isolation room. This will stop the staff from going to the housekeeping cart and contaminating the cart when obtaining supplies.
Step 2 incorrectly instructs staff to "glove, gown, mask if needed. Place wet floor sign at the entrance of the room. Hand hygiene." Hand hygiene is performed prior to donning PPE.
Step 4 only documents "hand hygiene." It does not include the donning and doffing of the gloves.
Step 6 and 7 does not define to "spot" clean the walls with wipe.
Step 7 does not include that the toilet bowl cleaner is disposable and should be discarded after use.
Step 8 does not define for staff that they need to doff PPE, perform hand hygiene and don PPE.
Step 15 Does not instruct staff to remove and discard PPE in the isolation room and perform hand hygiene.

During interview on 08/17/18 at 10:20 AM, of Staff B, Director of Environmental Services and Staff H, Director of Infection Control confirmed these findings.

On 8/15/18 at 1:15 PM Staff R, Housekeeping, was observed doing a terminal clean of an unoccupied Droplet isolation room. The staff member failed to clean all surfaces of the wall, bed, intravenous pole and other equipment located in the room.
This observation was made in the presence of Staff B and Staff U who acknowledged the findings.


During observations of a daily cleaning of Operating Room (OR) #2 on 8/17/18 at 11:00AM, Staff SS, Environmental Services staff was observed cleaning equipment. The staff member failed to clean all exposed surfaces of the OR overhead procedure lights, OR table, mattress pads, tables, Mayo stands (an adjustable stand that holds sterile instruments), and Neptune machine (a machine used to collect and dispose of surgical fluids).

During observations of the daily cleaning in OR # 4 Staff TT, Environmental Services, was observed cleaning an Intravenous (IV) pole. The staff member removed the cardiac wires, and blood pressure cuff from the rings of the pole, cleaned the rings, then replaced the contaminated wires back onto the rings of the IV pole. The same staff member was again observed cleaning the wheels of the IV pole then using the same wipe cleaned the lower section of the IV pole.

During interview with Staff TT at the time of the observation, he stated that the anesthesia staff cleaned the wires, therefore he didn't think he needed to clean them.

These observations were made in the presence of Staff NN, Director of Operative Services and Staff A, Director of QA, who acknowledged the findings.

Similar findings of failure to clean all surfaces and cross contamination of surfaces during cleaning were observed with Environmental Staff Members R, T, SS), TT, and UU.

The facility policy and procedure (P&P) titled "Surgical Areas Cleaning" last revised January 1st, 2018, lacked instructions for staff regarding the sequence and process for cleaning and disinfection of patient and Operating rooms.

During interview on 8/20/18 at 1:45 PM Staff B, Director of Support/ Environmental Services, confirmed these findings.

(b)

Review of personnel file for Staff DD, Medical Student revealed the student had no documented evidence of education on the principles and practices for preventing transmission of infectious agents within the hospital although he started at the hospital 06/25/18, two months prior.

Lack of required orientation and education specific to infection control hospital policies was found in personnel file for Staff FF and Staff AA, Medical Students.

Policy and procedure titled "Orientation Program," last revised 1/18 states the following: "Episcopal Health Services (EHS) will ensure that all individuals serving in the hospital or any other EHS facility have a solid understanding of EHS and its priorities and are determined competent for their assignment before they provide patient care or patient related services. This includes but is not limited to: Medical Students... In orientation, EHS will provide all individuals with policies, procedures, ...Attendance is mandatory."

During interview with Staff GG, Chief Medical Officer at 1:30 PM on 08/20/18, he confirmed the finding.

During an interview on 8/20/18 at 1:45 PM Staff W Director of Quality Assurance, stated, "Medical students are utilized to observe, monitor and collect data related to breaches in handwashing compliance throughout the hospital."
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**







Based on observation, document review, and interview, the infection control officers failed to ensure the multidiciplinary staff provide care and services in a sanitary environment, in accordance with standard infection control practices.

These findings place all patients at risk for cross contamination and facility acquired infections.

Findings:

(a) Staff failed to perform Central Venous Catheter (CVC) dressing changes in accordance with the facility's Policy and Procedures (P&P)

The facility policy and procedure (P&P) titled "Care of Central Catheters, Intermediate and Long Term," last revised September 2017, instructs staff to cleanse site with chlorhexidine/ alcohol swab stick using circular motion extend 3"x 3 allow to dry."

The facility policy and procedure (P&P) titled "Criteria based competency assessment tool: central Venous Catheter-Dressing change," instructs staff to cleanse site twice with Chlorascrub using a circular motion-starting at the exit site and outward 3 inches."

On 8/16/18 at 1:50PM, Staff LL, Registered Nurse, was observed performing a central venous catheter (CVC) dressing change, on Patient# 23. The staff member removed the old dressing, removed her contaminated gloves, then without performing hand hygiene, donned sterile gloves to continue with the dressing change until intercepted by Staff G, Director of Risk Management and instructed to remove gloves and perform hand hygiene. Staff LL went on and scrubbed the catheter site with an alcohol swab stick. This procedure is contrary to the hospital policy that states to cleanse with a chlorhexidine/alcohol swab stick using a circular motion.

On 8/20/18 at 12:15 PM, Staff RN (Registered Nurse), was observed in Room 1117 performing a CVC dressing change on Patient # 15. The staff member removed the old dressing and cleansed the catheter site without using a circular motion.

During observation on 08/20/18 at 12:40 PM, Staff EE, Registered Nurse was performing CVC (Central Venous Catheter) care on Patient #15. The patient was on Gown and Glove Isolation. After Staff CC completed the task she removed her gloves and gown. Then, she removed the mask from the patient's face, pulled up the bed siderail and picked up a piece of paper from the floor. The nurse's scrubs and hands had contact with the patient and the environmental surfaces in the isolation room.

These observations were made in the presence of Staff G, Director of Risk Management and Staff WW, Nurse Manager, who confirmed the findings.

Review of Nursing Leadership: Infection Control Log dated June 13th, 2018 documented, eight (8) CLABSI Central Line Associated Blood Stream Infections reported so far this year January to August. This number exceeds the NYS average rate of 0.7% year.
This finding was confirmed by Staff H, Director of Infection Control on 8/17/18 at 11:40 AM.

(b) Staff failed to perform hand hygiene as per facility's Policy and Procedure::

During observations in the operating suite on 8/16/18 at 11:05AM, Staff MM, Circulating Registered Nurse, was observed in Operating Room (OR)#1 passing supplies to another staff member across a patient on the operating table. The wrapper for the instrument fell on the floor, the staff member picked up the wrapper, placed it in the garbage and without performing hand hygiene retrieved other supplies from the OR cabinets and continued passing them to staff.

This was acknowledged by Staff NN, Director of Peri-operative services at the time of the observation.

On 8/15/18 at 9:35 AM, Staff R, Environmental Service, was observed cleaning an isolation room in the cardiac care unit (CCU). The staff member removed her contaminated gloves, retrieved alcohol-based sanitizer and without allowing it to dry retrieved a new pair of gloves and donned them.

This was observed in the presence of Staff U, ICU/ CCU Nurse Manager, who acknowledged the finding.

Similar findings of failure to perform hand hygiene were observed for Staff Members S, RN; Staff RR, Pulmonologist, and Environmental Services Staff SS, TT, and UU.

The facility policy and procedure (P&P) titled "Hand hygiene," last revised February 2017, contained the following statements: "hand hygiene with either waterless hand sanitizer or soap and water is required before donning and after removing gloves ...if moving from a contaminated body site during patient care ...hand hygiene using alcohol based hand rub technique ...apply the product to one hand. Rub hands together covering all surfaces until hands are dry."

(c) Staff failed to use appropriate PPE and appropriately donning (put on) and doffing (take off) PPE:

On 08/15/18 at 10am while touring Tower 8 (pulmonary/respiratory care unit), Staff D a Patient Care Associate (PCA), was observed entering the room of patient # 2 who is identified on contact precautions for Candida Auris and the multi-drug resistant organism (MDRO), Acinetobacter Baumannii (ACBA) without donning gloves.
Staff D proceeded to tidy the patient's room using ungloved (bare) hands, removed soiled bed linens from the chair and placed into a garbage bin in the patient's room. The garbage bin in which the dirty linen was placed, was left in the room.

On interview with Staff D on 08/20/18 at 10:30 am acknowledged entering the room of Patient #2 without proper use of Personal Protective Equipment (PPE).

On 8/20/18 at 10:30 AM, Staff G, Risk Manager and Staff M, Nurse Manager, who were present and witnessed the breach of the infection control practice, confirmed the findings.

During additional observations on 8 Tower:

On 08/15/18 at 12:45 PM, Patient #10 was on Gown and Glove Isolation. Two ambulance attendants were transferring the patient out of the isolation room to a nursing home. In the presence of Staff Z, Registered Nurse, the attendants did not follow infection control practice. At no time did the nurse intervene, stop or correct the breeches in infection control. The following breeches in infection control were identified;

The attendants did not perform hand hygiene prior to donning PPE.
The attendants incorrectly donned gloves prior to gowning.
The patient's gown was not changed prior to transferring him out of the isolation room.
The patient's pillow and sheets were transferred to the stretcher and were taken out of the isolation room.
A clean sheet was not placed over the patient when he was transported out of the isolation room.
One of the attendants doffed their gown, with gloved hands, ripped the front of the gown exposing the front of their uniform. The attendant then with gloved hand ripped off each arm of the gown. This was observed twice.

Per interview of Staff H, Director of Infection Control and Staff I, Infection Control Coordinator at 1:00 PM on 08/15/18, they acknowledged the findings. Staff H stated the linen should not be taken out of the isolation room. The patient's gown should have been changed and he should have been covered with a clean sheet prior to leaving the isolation room.

The facility policy and procedure titled "Transportation and Ambulating of Patients with an Infection or Communicable Disease," last revised 4/17, stated the following: "Patients on Gown and Glove Isolation must be transported on a stretcher or wheelchair covered with a sheet or physical barrier."

The policy lacks instructions to change the isolation patient into a clean gown and to cover the patient with a clean sheet prior to exiting the isolation room.

During observation of Staff K, Registered Nurse at 10:00AM on 08/15/18 , she was donning PPE to enter a Gown and Gloves Isolation room. Without performing hand hygiene, she donned the gown.
When she doffed the PPE, she did not follow facility policy and procedure. She removed the gown first then she removed her gloves.

When preparing to enter a Gown and Glove Isolation Room Staff L, Registered Nurse, donned her gown without first performing hand hygiene.
After removing her gloves with her bare hands, she touches the front of the "dirty" gown to remove it.
Staff L left elbow area was torn approximately 4 inches exposing the area under the gown as she provided patient care.

The same lack of not performing hand hygiene prior to donning and/or not following the correct sequence when doffing was observed twice with Staff N, Respiratory Therapist and Staff Q, PCA, between 9:30AM - 11:45AM on 08/15/18.

During observation Tower 8 (medical unit) at 10:20AM on 08/15/18, a Nurse was donning PPE to enter a Gown and Gloves Isolation room. Without performing hand hygiene, she donned the gown and left it untied. She placed gloves into her pocket to use later.

The facility policy and procedure titled "Isolation Precautions/Transmission Based Precaution," last revised 3/17, stated the following: "Sequence for Putting on PPE 1. Gown, 2. Mask or Respirator, 3. Goggles or Face Shield and 4. Gloves. How to Safely Remove PPE 1. Gloves, 2. Goggle or Face Shield, 3. Gown, and 4. Mask or Respirator. Gown removal: Gown front and sleeves are contaminated! Unfasten gown ties, taking care that sleeves don't contact your body when reaching for ties. Pull gown away from neck and shoulders, touching inside of gown only. Turn gown inside out. Fold or roll into a bundle and discard in a waste container. Articles contaminated with infective material should be discarded or bagged..."

During observation of Staff AA, Medical Student at 10:30 AM on 08/16/18, he was asculating the Patient #12's lungs. The patient was on Droplet and Gown and Glove Isolation. He exited the room without disinfecting the stethoscope.

During interview of Staff AA at the time of the observation, he stated he was looking for a wipe to clean it (stethoscope). Staff AA could not provide an explanation why he would be looking for a "wipe" when he was already exiting the unit.

During observation of Staff BB, Physician 3rd year, at approximately 10:40 AM on 08/16/18, she was exiting the patient's room donning a mask. The patient was on Droplet and Gown and Glove Isolation. In the hallway she removed her mask and placed it in the housekeeping receptacle.
During interview of Staff BB at the time of the observation, she could not verbalize the steps of doffing.

During interview of Staff G, Director of Risk Management at the time of the observation, she confirmed the finding.

During observation at 10:30 AM on 08/16/18, in room 1016 Patient #12 was on Droplet and Gown and Glove Isolation. A "dedicated" stethoscope could not be located in the room. The patient stated, "They took it (the stethoscope) this morning."

During observation at approximately 12:00 noon on 08/16/18, in room 1015 Patient #13 was on Gown and Glove Isolation. A "dedicated" stethoscope could not be located in the room.

During interview of Staff G, Director of Risk Management at the time of the observation, she confirmed the finding.

The facility policy and procedure titled "Isolation Precautions/Transmission Based Precaution," last revised 3/17, stated that in addition to standard precautions, staff should use gown and glove precautions for patients known or suspected to have serious illnesses easily transmitted by direct contact or by contact with items in the patient's environment. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients or environments. After glove removal ... ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room to avoid transfer of microorganisms to other patients or environments. When possible, dedicate the use of noncritical patient-care equipment to a single patient (or cohort of patients infected or colonized with the pathogen requiring precautions) to avoid sharing between patients. If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another patient. Remove all PPE (personal protective Equipment) before exiting the patient room.''

(d) Staff failed to appropriately place urinary catheter to prevent contamination:

During observations in the ICU on 8/15/18 at 9:15AM, the Foley catheter bag of patient #20 was observed on the floor of the isolation room that housed a patient positive for Methicillin Resistant Staphylococcus Aureus (MRSA) in their sputum.

During interview of Staff S, RN, at the time of the observation, she acknowledged the Foley bag should have been off the floor.

During tour of Tower 8 (medical unit) on 08/15/18 at 10:15 AM, in Room 811b: Foley catheter tip and tube of Patient #1 was on the floor beside the patient's bed. The catheter bag was still attached to the patient's bed; When asked about the Foley tip on the floor, Staff O, Registered Nurse responded "I noticed it was there when I went to give the patient medication."

The facility policy and procedure (P&P) titled "Urinary Catheterization," last revised 6/6/18, stated the following: "Keep the bag off the floor and the drainage port from resting on the side of the container over the urine to prevent contamination of the system."

(e) Staff failed to perform environmental cleaning appropriately to prevent cross contamination:

During observations on 08/15/18 in Tower 8 Staff KK, Registered Nurse at 10:40 AM, was in Patient #26's room suctioning his mouth with a yankauer (a rigid suction tube tip). When she completed the task, she discarded the blood filled yankauer in the regular receptacle waste bin (not a biohazard bin) in the patient's room.

During interview of Staff KK at the time of the observation, she had no response when asked if it was correct to discard the bloody yankauer in the garbage bin, not the biohazard waste.
Staff M, Nurse Manager interjected and stated "The yankauer needs to be discarded in biohazard waste."

The facility policy and procedure titled "Removal of Infectious Waste," last revised 2/17, stated the following: "All infectious waste being disposed is required to be placed in an infectious waste container lined with a red bag."

During observations on 08/15/18 in Tower 8 in patient isolation room a multi-patient use bottle of glucose monitoring strips was seen left on top of the patient's BiPaP machine;
At the time of the findings, Staff O, Registered Nurse assigned to the patient was asked to explain the findings. He stated "I don't know who left the bottle of glucose monitoring strip there. It must be one of the PCA's who do the finger sticks."

In two (2) of two (2) finger stick procedures observed on 8/17/18 at 11:26 am, Staff Hh a PCA, did not clean around the test strip port or the barcode scan window. She was also observed placing the glucometer on a dirty surface (the patient's bedside table) after cleaning. Staff Hh then proceeded to remove the glucometer with her bare hands while still wet and placed it on the clean supply cart.

This practice places the staff member as well as other patients at risk for hospital acquired infections.

On interview immediately following observation, Staff Hh acknowledged the findings to surveyor and stated that "the scanner is sensitive and could go bad with too much cleaning."

Staff G, Risk Manager who was present during the observation, acknowledged the findings.

Review of facility's Patient Care Policy and Procedure Manual titled: Bedside Glucose Testing with ACCU-CHECK INFORM II BG Monitoring System last reviewed 2/20/17, revealed that the meters should be placed on a level surface prior to cleaning ...cleaned with Sani-cloth by holding meter facing strip end down and wiping meter down with a downward motion. Gluco Chlor wipes or approved bleach wipe should be used to wipe clean around the meter test strip port area.

Review of facility's Nurse Leadership Meeting dated April 6, 2018 revealed that "Accu strips or solutions should not be stored on the units."


During tour of Tower 8 on 8/15/18 at 10:05 AM, uncovered (dirty) Ivac machines used for taking patient's temperature was noted being charged on the wall in room T828 a clean storage room.

This practice serves as cross-contamination of clean equipment and is a divergence from standard infection control practices.

On interview with Staff H, Director of Infection Control, in the afternoon of 8/15/18, she stated that "All equipment that has been cleaned should be covered with a plastic cover. If it is not covered, it is not considered clean."

On review of Infection Control Policy and Procedure Manual titled: "Cleaning of portable Equipment," last reviewed [DATE], the policy states that when a patient is discharged or transferred, contaminated equipment that is not a normal part of the room is to be removed by nursing and placed in the dirty utility room for cleaning by nursing or designated staff. Clean equipment is stored in the clean utility room or clean storage room. Equipment is identified as clean with a plastic bag covering them


On 08/15/18 at 10:15 am Patient #1 had a Nasogastric tube (NGT) attached to feeding bottle with liquid nutrition hanging from the IV pole at the head of the patient's bed; used unlabeled bulb syringe coated with residual orange-red colored liquid on the patient's bedside table;

During interview on 08/20/18 Staff O was asked why the NGT was still hanging at the patient's bedside. He stated that "The patient was not on NGT. The patient was nothing by mouth (NPO). That was not on my shift. I got the patient at 7AM. When you got there, I didn't remove it yet."
Review of the medical record of Patient #1 revealed nurses note written by Staff Gg on 8/15/18 at 4:30 am noted that the patient attempted to remove the NGT and BiPaP. A follow-up nurses note by the same staff at 5:17 am noted that the patient removed the NGT.


Observation in the facility's linen processing area during a tour between 11:40AM and 12:00PM on 8/16/18 identified the following:

In the dirty linen processing room, Staff VV, Housekeeper, was observed without an isolation gown and mask on. During interview of Staff B, Director of Environmental Services on 8/20/18 at 1:10PM, the staff member acknowledged that Staff VV, should have been wearing PPE (gown, gloves and mask) at all times in accordance to facility policy when handling soiled linen.

The facility policy and procedure (P&P) titled "Dirty linen" last revised January 2017, contained the following statements: "Personal will don appropriate PPE including gloves and an isolation gown when working the soiled linen room .... always wear gloves and isolation gown when handling soiled linen."

On the loading dock, one (1) cart of chucks designated for patient use, was observed uncovered and exposed to dust and debris.

In the clean linen processing room, OR drapes/ cloths were observed on top linen carts exposed to debris and also in bags untied.

In the clean linen processing room, 3 (three) bins of linens intended for patient use, had dusty plastic covers lying directly on top the linens.
The facility policy and procedure (P&P) titled "Clean Linen," last revised January 2017, contained the following statements: "Linen must not be left un-covered while being held in the holding area. .... Linen bins in the holding area will also be covered."

These observations were made in the presence of Staff B, Director of Environmental Services and Staff A, Director of QA, who acknowledged that clean linens/ textiles were not appropriately stored and processed.


On 08/15/18 at 10:20 AM, an uncovered blood pressure machine was observed on Tower 8 across from Room 821.
Per interview with Staff AAA, PCA, she stated she found the machine in the hallway. She was going to cover it with plastic and put it in the Clean Utility Room. When asked how she knew it was clean she stated, "I just know." Staff L, Registered Nurse interjected and stated "It's (vital sign machine) uncovered in the hallway. I would not assume it is clean. It has to be cleaned."

The facility policy and procedure titled "Cleaning of Portable Equipment," last revised 10/16, stated the following: "Clean equipment is stored in the clean utility room or the clean storage room."

Per interview of Staff H, Director of Infection Control in the afternoon of 08/15/18, she stated equipment covered in plastic in a patient room is considered "dirty." "It needs to be recleaned." Cleaned equipment should be placed in the clean utility room.

The facility policy and procedure titled "Cleaning of Portable Equipment," last revised 10/16, stated the following: "Clean equipment is stored in the clean utility room or the clean storage room."