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.

SALEM MEMORIAL DISTRICT HOSPITAL PO BOX 774, SALEM, MO 65560 March 11, 2020
VIOLATION: INFECTION PREVENT & CONTROL & ABT STEWAR PROG Tag No: C1200
Based on observation, interview, record review, and policy review the hospital failed to:
- Perform hand hygiene during the care of patients;
- Label intravenous (IV, in the vein) tubing with an expiration date.
- Ensure the cleanliness of the Workstations on Wheels (WOW, mobile computer station that can easily be transported between patient rooms and around the hospital);
- Ensure the cleanliness of pill splitters between patients.
- Ensure the cleanliness of one refrigerator in the acute care area;
- Ensure that one expired milk was removed from a refrigerator on the inpatient unit;
- Ensure temperature logs were completed for five logs in the dietary area and one in the inpatient unit;
- Ensure that expired foods were removed from cold food storage refrigerator and freezer in dietary; and
- Ensure that dry bulk foods were labeled with open date and use by date;

These failed practices had the potential to expose all patients, visitors and staff to cross contamination (germs that are spread from one person or surface to another). The hospital census was 12 including swing beds.

Refer to the 2567 for additional information.
VIOLATION: INFECTION PREVENT & CONTROL POLICIES Tag No: C1206
Based on observation, interview, and policy review, the hospital failed to ensure that staff performed hand hygiene during the care of eight patients (#12, #13, #14, #15, #24, #25, #27, and #29) of 11 patients observed and failed to label intravenous (IV, in the vein) tubing with an expiration date for five patients (#11, #12, #14, #15, and #27) of five patients observed.

These failed practices had the potential to expose all patients, visitors and staff to cross contamination (germs that are spread from one person or surface to another). The hospital census was 12 including swing beds.

Findings included:

1. Review of the hospital policy titled, "Hand Hygiene," dated 12/09/18, directed staff to wash their hands with soap and water or cleanse with an alcohol-based waterless hand sanitizer:
- Between all patient contacts;
- Before medication preparation;
- Before application and after removal of gloves; and
- After contact with inanimate objects in the immediate vicinity of the patient, such as medical equipment, furniture, linens, etc.

Observation on 03/09/20 at 3:40 PM, showed Staff C, Registered Nurse (RN), failed to perform hand hygiene before she put on her gloves, when she cared for for Patient #12 and Patient #15, who were cohorted (patients who are in the same room and have a similar diagnosis).

Observation on 03/09/20 at 3:45 PM, showed Staff C, RN, failed to perform hand hygiene after she cared for Patient #12 and before she cared for Patient #15.

Observation on 03/10/20 at 8:52 AM, showed Staff L, Licensed Practical Nurse (LPN), failed to perform hand hygiene before he put on his gloves, during medication administration for Patient #24.

Observation on 03/10/20 at 9:05 AM, showed Staff L, LPN, failed to perform hand hygiene before he put on his gloves, during medication administration for Patient #25.

Observation on 03/10/20 at 10:00 AM, showed Staff L, LPN, failed to perform hand hygiene after he removed his gloves, during medication preparation for Patient #12.

Observation on 03/10/20 at 10:03 AM, showed Staff L, LPN, failed to perform hand hygiene before he put on is gloves, when he cared for Patient #12 and Patient #15, who were cohorted.

During an interview on 03/10/20 at 2:47 PM, Staff L, LPN stated that hand hygiene should be performed before you went into a patient's room, when you left a patient's room, between patients, and when you removed your gloves.

Observation on 03/10/20 at 3:30 PM, showed Staff D, Certified Respiratory Technician, failed to perform hand hygiene upon entrance and exit from Emergency Department (ED) Patient #29's room, with the same gloves in place.

Observation on 03/10/20 at 3:30 PM, showed Staff GG, Paramedic, Certified Respiratory Technician, failed to perform hand hygiene during entrance and exit from ED Patient #29's room, with the same gloves in place.
During an interview on 03/11/20 at 9:00 AM, Staff A, ED Director, stated that hand hygiene should be performed upon entering and exiting a patient's room, even during an emergency situation.

Observation on 03/10/20 at 10:12 AM, showed Staff W, LPN, failed to perform hand hygiene before she put on her gloves, during medication administration for Patient #27.

Observation on 03/10/20 at 9:34 AM, showed Staff W, LPN, failed to perform hand hygiene before she prepared medication for Patient #14.

Observation on 03/10/20 at 10:55 AM, showed Staff Y, RN, failed to perform hand hygiene before she put on her gloves and provided care for Patient #13.

During an interview on 03/10/20 at 4:00 PM, Staff K, Acute Care Services Director, stated that hand hygiene should be performed before you put on gloves and after you removed gloves.

During an interview on 03/10/20 at 4:32 PM, Staff BB, RN, Infection Control Nurse, stated that hand hygiene should be performed before you went in a patient's room, when you left a patient's room, before you put on gloves, and after you removed gloves.

During a telephone interview on 03/12/20 at 12:00 PM. Staff JJ, Chief Nursing Officer (CNO), stated that hand hygiene should be performed before you entered a patient's room, when you left a patient's room, and before you put on gloves or when gloves were removed. She stated that included the ED during an emergency situation.

2. Review of the hospital policy titled, "Intravenous Infusion," dated 01/17/19, directed staff to change IV tubing every 96 hours, label tubing with date and time changed, and include that information in the nurse's notes.

Observation on 03/09/20 at 3:40 PM, showed no label on two IV antibiotic tubing's for Patient #15.

Observation on 03/10/20 at 10:00 AM, showed no label on the IV tubing for Patient #12.

Observation on 03/10/20 at 10:00 AM, showed a label on the IV antibiotic tubing with an expiration date of 03/08/20, that had not been changed, for Patient #12.

Observation on 03/10/20 at 10:03 AM, showed no label on two IV antibiotic tubing for Patient #15.

Observation on 03/10/20 at 10:12 AM, showed no label on the IV tubing for Patient #27.

Observation on 03/10/20 at 10:39 AM, showed no label on the IV tubing for Patient #14.

Observation on 03/09/20 at 3:30 PM, showed no label on the IV tubing for Patient #11.

During an interview on 03/10/20 at 2:47 PM, Staff L, LPN, stated that IV tubing should be labeled with an expiration date and should be changed every four days.

During an interview on 03/10/20 at 4:00 PM, Staff K, Acute Care Services Director, stated that IV tubing should be labeled with an expiration date.

During an interview on 03/10/20 at 4:32 PM, Staff BB, RN, Infection Control Nurse, stated that IV tubing should be labeled with an expiration date.

During a telephone interview on 03/12/20 at 12:00 PM, Staff JJ, CNO, stated that IV tubing should be labeled with an expiration date.
VIOLATION: INFECTION PREVENT SURVEIL & CONTROL OF HAIs Tag No: C1208
Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure that expired foods were removed from cold food storage refrigerator in dietary;
- Ensure that expired frozen foods were removed from the freezer in dietary;
- Ensure that dry bulk foods were labeled with open date and use by date;
- Ensure that one expired milk was removed from a refrigerator on the inpatient unit;
- Ensure the cleanliness of the Workstations on Wheels (WOW, mobile computer station that can easily be transported between patient rooms and around the hospital);
- Ensure the cleanliness of one refrigerator in the acute care area;
- Ensure temperature logs were completed for five logs in the dietary area and one in the inpatient unit; and
- Ensure the cleanliness of pill splitters between patients.
These failed practices had the potential to expose all patients, visitors and staff to cross contamination (germs that are spread from one person or surface to another). The hospital census was 12.

Findings included:

1. Review of the hospital policy titled, "Food Storage," dated 01/2006, showed the following:
- All refrigerated food, after opened, would be thrown out in 30 days if no use by date existed;
- Flour bin would be cleaned and rotated one time per month; and
- Sugar bin would be cleaned and rotated one time per month.

Observation on 03/10/20 at 9:30 AM, in the cold food refrigerator in the dietary department, showed:
- An opened container of apricot nectar with no opened date;
- An opened container of pear juice with the open date of 01/20;
- An opened container of coleslaw with the open date of 01/20; and
- An opened container of honey mustard with the open date of 01/20.

Observation on 03/10/20 at 9:30 AM, showed in dietary's small freezer, there was an opened frozen garlic bread and a bag of parmesan cheese with the date of 02/20.

Observation on 03/10/20 at 9:45 AM, in the dietary's spice cabinet, showed:
- An opened box of barley with the opened date of 01/18;
- An opened box of barley with no opened date; and
- An opened box of cream of wheat with no opened date.

Observation on 03/10/20 at 9:50 AM, in the dietary department, showed the three large storage containers for bulk food such as sugar and flour, did not have an open or expiration date.

During an interview on 03/10/20 at 9:39 AM, Staff R, Dietary Cook, stated dates for food storage were as follows:
- Leftovers were good for four days;
- Frozen foods that were received frozen were good for 30 days;
- If they cooked and froze food, it was good for 15 days; and
- Opened pantry foods were good for 15 days.

2. Review of the hospital undated policy titled, "Patient Nourishments," showed that Nutritional Services Department staff were responsible for the preparation and delivery of all nourishment to the patient care units. Patient refrigerator temperatures were to be checked daily and a log maintained with temperature ranges.

Observation on 03/10/20 at 10:00 AM, in the dietary department showed;
- For cooler #129 for 03/20, there were eight missed temperature readings;
- For cooler #1259 for 03/20, there were eight missed temperature readings;
- For cooler #9014 for 02/20, there were two missed temperature readings; and
- For the patient menu refrigerator for 03/20, there were nine missed temperature readings.

During an interview on 03/10/20 at 10:30 AM, Staff T, Dietary Aide, stated that she was responsible for the temperature checks, but she did not always document them.

During an interview on 03/10/20 at 10:40 AM, Staff S, Director of Food Services, stated that the food outdates should have been discarded, and that he had not noticed the temperature logs were not complete.

3. Review of the hospital policy titled, "Cleaning of Equipment," dated 07/01/17, showed the following:
- All patient-related equipment would be cleaned and maintained on a regular basis;
- Routine cleaning of patient care equipment was performed by the department staff; and
- Cavi-Wipes (towelettes that clean and disinfect surfaces) were used unless a specifically soiled area required a different solution.

Observation on 03/10/20 at 9:08 AM, showed the patient nourishment refrigerator on the inpatient care unit was visibly soiled on the interior, it contained two nutritional shakes with expiration dates of 09/01/19, and no temperature logs had been completed.

During an interview on 03/10/20 at 10:40 AM, Staff S, Director of Food Services, stated that he did not think the dietary department was responsible for the cleaning and temperature documentation for the patient refrigerator on the acute care unit.

During an interview on 03/10/20 at 4:03 PM, Staff K, Acute Care Services Director, stated that temperatures for the patient nourishment refrigerator on the inpatient care unit had not been logged and that she was unsure for how long.

During a telephone interview on 03/12/20 at 12:00 PM, Staff JJ, Chief Nursing Officer, stated that she would expect that expired foods were removed from refrigerators and freezers, that foods were labeled with open dates and use by dates, and that refrigerators were cleaned and temperature logs were completed in the dietary area and on inpatient units.

4. Observation on 03/10/20 at 10:12 AM, showed Staff W, Licensed Practical Nurse (LPN), failed to clean the WOW between patient care for Patients #14, #26, and #27.

During an interview on 03/10/20 at 2:50 PM, Staff W, LPN, stated that WOWs should be wiped down with disinfecting cleaning wipes at the beginning of each shift and throughout the shift, if needed. Staff W stated WOWs would be wiped down after contact with patients or gloves.

During an interview on 03/10/20 at 4:03 PM, Staff K, Acute Care Services Director, stated that the expectation was that the WOWs would be cleaned at the beginning of each shift and if they became soiled throughout the shift. Staff K stated that there was no current policy and procedure specific to the WOWs.

5. Observation on 03/10/20 at 8:52 AM, showed Staff L, LPN, used a pill splitter when he prepared medication for Patient #24, and failed to clean the device after it was used.

During an interview on 03/10/20 at 8:52 AM, Staff L, LPN, stated that:
- The pill splitter was used for multiple patients;
- He didn't think the pill splitter had been used that day; and
- The pill splitter should be cleaned after each use.

During an interview on 03/11/20 at 4:00 PM, Staff K, Acute Care Services Director, stated that there was one pill splitter per computer cart and it should be wiped down after each use.

During an interview on 03/11/20 at 4:32 PM, Staff BB, RN, Infection Control Nurse, stated that the pill splitter should be cleaned after each use.