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A. Based on observation, interview, record review, and policy review, the provider failed to maintain the following in a clean and sanitary manner:
-Three of three air vents in the purchasing department.
-The inventory storage bins in the purchasing department.
-One of one air vent in the clean utility room located in the patient care unit.
-The inside of the microwave in the nourishment room.
Findings include:

1. Observation and interview on 3/10/14 at 3:44 p.m. in the purchasing department with the purchasing manager revealed:
*The two air vents on the air handling unit were covered with a grey brown residue.
*The wall vent was also covered by a grey brown residue.
*All observed inventory storage bins had a light covering of a grey brown powder in them.
*She had walked past the air vents frequently and had not paid attention to them. She was not aware they were covered with the residue.
*The employee who had done most of the inventory work had been trained to visually inspect the bins daily for cleanliness and to clean the bins every time they had been emptied and as needed.
*The bins were not on a routine cleaning schedule.
*She was not aware the bins had the powder in them and agreed they were in need of cleaning.

Interview on 3/11/14 at 8:30 a.m. with the director of plant operations in the purchasing department revealed:
*The air vent on the wall was no longer used and could have been cleaned up and sealed off.
*The two air vents on the air handling unit were in use.
*Those air vents were in need of cleaning.
*The air vents were on a monthly maintenance schedule and should have been cleaned last month.

2. Observation on 3/11/14 at 10:00 a.m. in the clean utility room located in the patient care unit revealed the ceiling vent was covered with a grey brown residue.

3. Review of the monthly maintenance schedule and interview on 3/12/14 at 8:20 a.m. with the director of plant operations revealed:
*Only certain areas of the hospital such as the operating room and patient rooms were specifically listed on the monthly maintenance schedule.
*The purchasing room and clean utility room vents were not specifically listed.
*The last item listed in the vent section was "vents all other rooms" which would include all rooms in the hospital that were not specifically listed.

4. Observation on 3/11/14 at 9:42 a.m. in the nourishment room revealed:
*The inside of the microwave had multiple brown, red, and yellow food splatters on the sides and top.
*There was a small puddle of white liquid in the middle of the glass turntable.

Interview and review on 3/11/14 at 9:44 a.m. of the March nursing assistant cleaning duties schedule with registered nurse (RN) A revealed:
*The charge nurse was responsible for ensuring the nursing assistants cleaned the nourshment room.
*The outside of the microwave and all of the surfaces in the nourishment room were on a daily cleaning schedule.
*The inside of the microwave would have been cleaned on Tuesdays when the nourishment room was deep cleaned.
*The deep cleaning for 3/4/14 and 3/11/14 had not been signed off as completed.
*She was not aware the microwave had not been cleaned.
*She was not aware the inside of a microwave was considered a food contact surface and should have been cleaned daily when used.



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Preceptor: 15036
B. Based on observation and interview, the provider failed to ensure improperly sterilized surgical instruments were not available for use in one of two operating rooms (1). Findings include:

1. Observation on 3/10/14 at 4:25 p.m. in operating room one revealed nine scissors and one wire cutter had been sterilized with the cutting edges closed.

Interview on 3/11/14 at 3:00 p.m. with the director of operating room services confirmed the scissors and the wire cutter should have been processed with the handles and blades separated.

Review of the Association of PeriOperative Registered Nurse, PeriOperative Standards and Recommended Practices, 2014 Edition, Denver, CO, revealed:
*P.548: "Instruments with hinges should be opened for sterilization."
*P.548: "Instruments should be kept in the open and unlocked position during sterilization."
*P. 564: "Items to be sterilized should be positioned within packages to allow sterilant contact with all surfaces."

C. Based on observation, interview, and policy review, the provider failed to ensure:
*Outdated medical supplies were not available for use in three of three patient care areas (emergency room, obstetric unit, and recovery room).
*Opened single-use medical supplies were not available in one of one recovery room.

1.Observation on 3/10/14 at 3:10 p.m. in the recovery room revealed:
*Four Cobalt Ranger Glide Scopes (a device used to view a patient's airway) with an expiration date of 12/22/13.
*One opened intravenous (IV) start kit.
*One opened Sheridan/CF cuffed Murphy Eye tracheal tube set (a catheter placed for maintaining an open airway) with a syringe attached.

Interview on 3/11/14 at 1:00 p.m. with the director of operating room services and RN C revealed:
*Staff should have disposed of the unused IV start kit.
*Anesthesia services staff were responsible for checking the Glide Scopes and tracheal tubes for outdates.
*Anesthesia services should have discarded the Glides Scopes and tracheal tube.

Interview on 3/12/14 at 9:06 a.m. with certified registered nurse anesthetist D regarding the Glide Scopes revealed:
*He was aware they were expired and still would have used them in an emergency situation.
*They were not used on sterile cases.
*A patient's airway was not a sterile area.



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2. Observation on 3/10/14 at 1:30 p.m. of obstetrics rooms 111 and 124's cupboards and drawers revealed:
*Skin staple extractor expired 2000.
*All purpose sponge expired 2004.
*Steri strips expired 2005, 2006, and 2011.
*Fingercot with attached hooks expired 2009.
*Auto suture premium extractors expired 2009, 2010, and 2011.
*Benzoin tincture expired 2011.
*Tegaderm pads expired 2013.
*Povidone-iodine swabsticks expired 2013.

Interview on 3/12/14 at 1:00 p.m. with RN A and the chief nursing officer revealed the above medical supplies were rarely used. They confirmed the outdated medical supplies needed to be removed.




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3. Observation on 3/11/14 at 9:18 a.m. of the emergency department storage room revealed numerous Monojet sterile needles with expiration dates of October 2010 and April 2013.

4. Review of the provider's October 2013 Maintaining an Adequate Inventory of Supplies policy revealed the process for monitoring out-dated patient medical supplies was not addressed.

A. Based on interview, policy review, and label review, the provider failed to follow the manufacturer's directions for rinsing Metricide OPA from colonoscopes and gastroscopes (endoscopes).
Findings Include:

1. Interview, policy review, and label review on 3/11/14 at 2:00 p.m. with the director of operating room services revealed:
*The channels of the endoscopes were flushed with 120 milliliters (mL) of potable water as the endoscopes was rinsed in a tub with running potable water for three minutes.
*The MetriCide OPA Plus Solution directions for use stated "After manual processing: After removing the instrument from the MetriCide OPA Plus Solution, thoroughly rinse the device by immersing it completely in a large volume (approx. [approximately] 9 liters) of fresh water. Use sterile water unless potable water is acceptable (depends upon the intended use of the device). Keep the instrument totally immersed for a minimum of one minute unless a longer time is specified by the instrument manufacturer. Manually flush all lumens with large volumes of water (not less than 100 mL) unless otherwise noted by the device manufacturer. Repeat the procedure TWO additional times for a total of THREE rinses. THE VOLUME OF WATER USED IN EACH RINSE CYCLE SHOULD BE AT LEAST NINE LITERS."
*The facility policy was based on the endoscopes manufacturer's directions for use that called for the channels to be flushed with a minimum of 90 mL of potable water.
*She was not aware the MetriCide OPA Plus Solution directions for use called for two more additional rinses.



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B. Based on observation, interview, record review, and policy review, the provider failed to:
*Maintain contact isolation protocol and prevent cross-contamination during two of two observed patient dressing changes (16) by two of two nurses (B and E).
*Ensure one of one observed physician (F) had performed hand hygiene following a surgical procedure.
Findings include:

1. Observation on 3/10/14 at 2:15 p.m. of patient 16's dressing change performed by registered nurse (RN) B revealed:
*She put on an isolation gown and gloves and entered patient 16's room. She then:
-Failed to disinfect the overbed table prior to placing the clean dressing supplies on the overbed table next to a bag of Frito chips and a bag of Mounds candy bars.
-Removed the soiled dressings from the patient's lower legs and discarded them into the garbage can.
-Removed her soiled gloves, did not perform hand hygiene, and put on clean gloves.
-Cleansed the wounds by pouring water from an opened undated 1000 milliliter water bottle and patted the areas dry with a guaze wipe.
-Removed an Adaptic dressing from the package, placed it on the patient's right front leg, and covered it with an ABD (abdominal) dressing.
-Took the Ace wrap from the bed and began to wrap it around the patient's right lower leg, allowing the Ace wrap to come in contact with the floor.
-Removed an Adaptic dressing from the package and placed it on the patient's left lower leg.
-Took an Ace wrap from the bed and began to wrap it around the patient's left lower leg.
-Removed the Ace wrap.
-Took a new ABD dressing package and accidently dropped it into the garbage can.
-Picked up the patient's telephone to request an additional ABD dressing.
-Went into the hallway with the isolation gown on and discarded her gloves in a garbage can in the hallway.
-Returned to the room with the isolation gown on and without performing hand hygiene put on a clean pair of gloves.
-Took a sterile ABD dressing from the package and placed it over the Adaptic dressing on the patient's left lower leg.
-Wrapped the Ace wrap around the patient's left lower leg allowing the Ace wrap to come in contact with the garbage can.
-Removed the drape on the chair under the patient's feet and with the same pair of soiled gloves placed a new drape on the chair under the patient's feet.
-Collected the unused dressing packages and placed them on the window sill.
*Observation at the end of patient 16's dressing change revealed a sequential compression device (SCD) (device used to help assist with leg circulation) on the floor by the foot of the bed.

Review of patient 16's electronic health record revealed:
*A diagnosis for MRSA (Methicillin-resistant staphylococcus aureus (a bacteria responsible for difficult-to-treat infections in humans) in her urine.
*She was on contact isolation.
*An order for dressing changes to both ankles.

Interview on 3/10/14 at 4:45 p.m. with RN B regarding patient 16's dressing change revealed:
*The dressing change was not a sterile procedure.
*She had not established a clean field before performing the dressing change, because "everything had been in a wrapped container."
*She should have performed hand hygiene between glove changes.
*She had touched the clean dressings with soiled gloves.
*She should have obtained new Ace wraps after the above ones had touched the floor and the garbage can.
*Cross-contamination had occurred when she had touched the patient's telephone with her soiled gloves.
*She should have performed hand hygiene after she had removed her soiled gloves and should have taken the isolation gown off before going into the hallway.
*The area where the dressing change had occurred should have been disinfected after the procedure had been completed.
*The SCD should not have been on the floor.

Interview on 3/12/14 at 2:30 p.m. with the infection control RN regarding patient 16's dressing change revealed:
*The supplies and equipment should have been gathered prior to the procedure.
*A clean field should have been established.
*Hand hygiene should have been performed after removing the soiled gloves and prior to applying clean gloves.
*The saline should not have been poured directly from the bottle over the patient's wound area because of the possibility for splash back.
*The saline bottle should have been marked with the date and time it had been opened.
*Opened saline bottles needed to have been discarded after 24 hours.
*The best practice to obtain additional supplies would have been to remove the soiled gloves, perform hand hygiene, use the patient's call light, or get the supplies herself.
*The isolation gown should have been removed prior to going out in the hallway.
*Ace wraps should have been rolled up prior to applying to a patient.
*Any dressings that touched the floor or garbage can should have been discarded.
*Hand hygiene should have been performed when going from a dirty process to a clean process.
*The SCD should not have been on the floor.

2. Observation on 3/12/14 at 8:38 a.m. revealed patient 38 was carried into the operating room for placement of Myringotomy tubes (insertion of ear tubes). At the conclusion of the procedure surgeon F removed his gloves and without performing hand hygiene exited the operating room.

Interview on 3/12/14 at 9:35 a.m. with the director of operating room services confirmed surgeon F should have performed hand hygiene after removing his gloves.



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3. Interview and observation on 3/11/14 at 8:50 a.m. of RN E during the medication pass and treatment for patient 16 revealed:
*There was a sign posted on the door that required Contact Precautions of gown and glove before entering the room. The nurse explained the precautions was because the patient had tested positive for MRSA in her urine.
*RN E gowned and gloved prior to entering the patient's room. She then:
-Created clean fields with large absorbant pads on the floor beneath the patient's feet and on a nearby chair.
-Removed the Ace wrap and laid it on the chair.
-Removed the soiled bandages and laid them on the pad on the floor.
-Removed her soiled gloves and put on clean gloves.
-Used syringes with saline to cleanse the wounds on the patient's legs.
-Laid the contaminated empty syringes on the unprotected overbed table.
-Replaced the bandages to the patient's legs.
-Picked up the pads and prepared to dispose of them along with the other disposable items.
-Picked up the syringes with her soiled gloved hands touching the bedside table.
-Opened the window shades with her soiled gloved hands.
-Exited the room and removed her gown and gloves and disposed of them in the uncovered garbage can in the hallway.
-Used hand sanitizer outside the room.

Further observation during the above treatment with RN E and physician G revealed the physician:
*Entered patient 16's room and completed a brief assessment of the patient's legs without the bandages on them.
*Had not gowned or gloved before entering the room.

Observation on 3/12/14 at 8:15 a.m. of the uncovered garbage container outside patient 16's room contained the used isolation gowns in it.

Interview and review of the Contact Precautions: Level A guidelines on 3/12/14 at 8:00 a.m. with RN/swing bed coordinator A revealed:
*When they identified someone with an infection they followed a guide which directed them to the type of precautions required for that infection.
*Patient 16's infection was in her urine which required contact precautions. *Level A guidelines read "To enter the room 1. Gown. 2. Glove. Hand Hygiene."
*They had not tested her wounds to determine if there was an infection.
*They had mentioned the testing in their morning report, but she was unsure if it had been done yet.
*The physician should have gowned and gloved before he entered patient 16's room regardless of what his contact with the patient was going to have been.
*The nurse should have disinfected the overbed table after she had touched it while removing the empty syringes with her soiled gloves.
*The nurse should have removed her gloves and completed hand hygiene before opening the window shades.
*It was a questionable practice to dispose of the gown and gloves outside the patient's room.
*They should have placed the gown and gloves in the garbage in the patient's room.

Interview on 3/12/14 at 3:00 p.m. with the chief nursing officer revealed:
*When a patient required contact precautions of gowning and gloving everyone entering that room should have complied.
*RN E should have:
-Disinfected the overbed table after removing the syringes.
-Removed her gloves and performed hand hygiene before opening the window shades.
*The disposal of the gown and gloves after they were soiled should have occurred before exiting the patient's room.

4. Review of the provider's January 2014 Standard and Transmission-Based Precautions policy revealed:
*"Gloves will be removed promptly after use before touching clean items or environmental surfaces, and before going to another patient.
*Level A - Gown and glove to enter the room and remove PPE [personal protective equipment] upon leaving the room. Perform hand hygiene with an antiseptic upon leaving the room. Clean and disinfect equipment and supplies taken from the room."
*"All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spattering, or generations of droplets of body fluid."
*"Hand hygiene will be performed:
-Upon entering or leaving patient room.
-Before contact with patient.
-After glove removal.
-After contact with body fluids or excretions."

C. Based on observation and interview, the provider failed to store patient care supplies properly for one of one patient (16) requiring contact precautions. Findings include:

1. Observation on 3/11/14 at 9:15 a.m. of patient 16's room revealed her unlocked closet was stocked with personal care items including lotions, powder, body wash, a urine specimen cup, foot socks, and other miscellaneous items.

Interview on 3/11/14 at 9:18 a.m. with RN E after patient 16's dressing change revealed:
*The supplies in the patient's room were stocked so staff would not have to leave the room if they needed a supply.
*Any unused supplies in the room when the patient was discharged stayed in the room for the next patient.

Based on record review, interview, and policy review, the provider failed to ensure medical records were complete and accurately documented for one of two sampled obstetrical patients (9) and one of two sampled newborn patient's (10) charts reviewed. Findings include:

1. Review of patient 9's obstetrical record revealed:
*She had delivered patient 10 on 12/17/13 at 3:26 p.m.
*She had been discharged on 12/17/13 at 10:35 p.m.
*Uterine and fetal assessment monitoring had continued on 12/18/13 at 2:45 p.m., 3:00 p.m., and 3:15 p.m.
*No physician discharge summary had been documented.
*The mother/infant identification number had been documented as 69200.

Review of patient 10's newborn record revealed:
*He had been delivered on 12/17/13 at 3:26 p.m.
*His newborn identification bracelet number had been 69200.
*He had been transferred via air ambulance to another hospital's neo-intensive care unit.
*His infant identification number on his newborn admit/discharge summary form had been 69201.

Interview on 3/12/14 at 9:20 a.m. with registered nurse A revealed:
*An unscheduled electronic medical record downtime had occurred on 12/17/13 from 2:30 p.m. until 7:53 p.m.
*During downtimes paper documentation would have occurred.
*After the downtime had been completed the data would have been backloaded manually.
*The date for the uterine and fetal assessment monitoring appeared to have not been changed or had been entered in error.
*Patient 9's discharge summary had not been documented in her record.
*Patient 10's infant identification number had been incorrectly noted by the physician on his newborn admit/discharge summary form.
*No other babies had been delivered on 12/17/13.

Review of the provider's following policy and procedures revealed:
*Downtime policy dated September 2011: Each department would have been responsible to have downtime policy and procedures in place outlining workflow during the downtime period and the period immediately following resumption of system activity, including back loading of downtime.
*Medical Staff Rules and Regulations dated 2/27/13: Discharge documentation would have been required for all patients, including outpatients who were admitted to a room.
*Identification of the Newborn policy dated October 2013: Mother and infant would wear identically numbered bands for the duration of their hospitalization.