HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure that the pharmacy staff followed their policies and the infection prevention standards for The United States Pharmacopeia (USP) for compound sterile preparations (CSP) and failed to secure two crash carts when they failed to:
- Decrease the chance of contamination at Hospital A by placing the Compounding Aseptic Isolator (CAI, a positive pressure unit used to compound nonhazardous medications) which is the Primary Engineering Control (PEC, a device that provides an environment for compounding medications) for this ISO Class 7 environment, across from a sink;
- Provide a Compounding medication log at Hospital A and B;
- Place sterile gloves on over gauntlet gloves inside of the CAI prior to mixing compounding medications for Hospital A and B;
- Perform gloved fingertip sampling (tests performed to ensure that compounding personnel can successfully complete hand hygiene, gowning and gloving without contaminating the gloved hands) for initial certification and yearly at Hospital A and B; and
- Perform media fill testing (test performed to evaluate the aseptic technique of compounding personnel to ensure production of sterile compounds are without microbial contamination) for initial certification and yearly at Hospital A and B.
- Remove all paper products (particle shedding) from the SCA (segregated compounding area) at Hospital A and B.
- Put on a gown, gloves and mask prior to entering the SCA at Hospital A and B;
- Provide a line of demarcation (a line on the floor that signified to the staff the entrance of the SCA) at Hospital B; and
- Perform a terminal clean (a thorough, deep-cleaning of a room to include the ceiling, walls and floors) of the SCA monthly at Hospital A and B;
- Ensure the medication safety when they failed to ensure the integrity of the contents of two of three crash carts (a set of trays/drawers/shelves on wheels used in hospitals for transportation and dispensing of emergency medication/equipment for life saving protocols) at Hospital A.

Due to the potential risk and harm to all patients in both facilities, this resulted in the noncompliance with the Condition of Participation of Pharmaceutical Services CFR 482.25.

Please refer to the deficiencies at A0501 and A0502.

Based on observation, interview and policy review, deficiencies were found at both locations and the facilities failed to ensure staff followed infection control policies and infection prevention standards when they failed to:
- Remove feces from the top of a toilet seat and wall in bathroom for two patients (#32 and #33) of two observed;
- Remove dried blood with wheelchair tracks between two patient beds for two patients (#32 and #33) of two observed;
- Perform a sterile urinary catheter insertion for one patient (#23) of one observed.
- Clean a wheelchair wash cabinet that was used to service all wheelchair patients and eliminate the foul odor;
- Follow isolation precautions for one patient (#40) of one observed;
- Perform hand hygiene for eight patients (#3, #14, #16, #22, #23, #25, #26, #29) of 18 observed;
- Clean bedside tables for five patients (#6, #7, #23, #25 and #29) of five patients observed;
- Clean four computer medication carts;
- Place disposable blood pressure cuffs in the crash cart;
- Clean the blood glucose monitors and docking stations;
- Complete temperature logs for Physical Therapy Cold Therapy Master Chilling Unit;
- Check dietary refrigerators in the patient nutrition rooms for expired food;
- Clean two nutrition rooms;
- Label opened items in the walk-in refrigerator;
- Perform temperature checks on patient food trays;
- Label and/or develop a system for identifying expiration dates of dried spices in the kitchen;
- Follow the dress code for two of two current staff (Staff P and Staff Q);
- Date foods prior to placing in storage areas;

These failures had the potential to lead to negative outcomes for patients through the increased risk of cross contamination that placed all patients, visitors and staff at risk for infection.

Please refer to A-0749 for additional information.

SSBased on interview, and record review the facility failed to analyze Quality Assessment Performance Improvement (QAPI) data and show that data collected resulted in activities to improve the care and safety to all patients. These failures have the potential to lead to negative patient outcomes for 3 out of 3 current indicators (#1 Fall Rate, #2 Inpatient Therapy Hand off Communication, #3 Health Associated Infection rate) reviewed.. The facility census was 99.

Findings Included:
SSReview of Event Reports for dates 01/02/18 through05/30/18 showed 163 Patient Falls reported.

SSReview of Quality Report Minutes for indicator #1 Fall Rate showed:
- Fall Data was not analyzed or evaluated to identify opportunities for improvement.
- There was no evidence of fall reduction strategies that prevented future incidents and ensured performance was sustained.
- There was no evidence that falls were trended in order to identify common areas for concern.

SSReview of Quality Report Minutes for indicator #2 Inpatient Therapy Hand off Communication and #3 Health Associated Infection rate showed data was not analyzed or evaluated to identify opportunities for improvement and there was no evidence that strategies to improve patient care had been performed.

During an interview on 05/31/18 at 9:15 AM, Staff DD, Director of Quality, stated that:
- The fall incident report showed falls to include those that were guided to floor, witnessed and unwitnessed falls.
- She was aware they were not performing analysis of data, providing strategies to prevent future incidents or showing improvements and sustainability.
- She was working on the issue at this time but it was not ready to be introduced to the Quality Committee.

Based on observation, interview, record review and policy review, deficiencies were found at both locations where the facilities failed to:
- Ensure nursing staff followed physician orders for wound dressing changes for one current patient (#20) of five current patients with wounds reviewed.
- Ensure nursing staff consistently prevented, identified, treated and documented skin and wound care for four current patients (#15, #28, #31, and #41) of five current patients with wounds reviewed.
- Ensure Workstation On Wheels (WOW) medication bin was locked to prevent patient and family access to medication.
- Ensure suction flowmeter and cannister was set up at bedside for eight current patients (#40, #46, #48, #51, #52, #53, #54, #56) of eight current patients that was admitted for a stroke.
These failures had the potential to lead to negative outcomes for patients through the development of wounds or deterioration of existing wounds, ingestion and or confiscation of medication not intended for the correct patient, possible choking and aspiration (to choke or inhale liquid into lungs) related to swallowing issues of stroke patients and could affect all patients in the facility. The facility census was 79 in St. Louis and 20 in St. Peters.

Findings included:

Review of the facility's policy titled, "Wound Assessment, Prevention, and Documentation," dated 03/06/18, showed that the physician assumed leadership over clinical interventions and wound care treatment.

Review of Patient #20's medical record showed:
-The History and Physical (H&P), included that he was a 26 year old male admitted to the facility on 05/21/18 for rehabilitation from a gunshot wound to the left flank and a exploratory laparotomy (a surgical incision into the abdomen) to remove his right kidney, repaired a spleen laceration, and duodenum (part of the small intestine) repair on 04/17/18. The patient had a second exploratory laparotomy on 04/19/18 to remove his gallbladder (small organ beneath the liver in which bile is stored) and part of the small intestine. The patient had a midline abdominal incision that was partially open and packed with gauze.
-A Physician Order written by Staff HH, Medical Doctor (MD), on 05/21/18 at 5:55 PM included the directive for staff to pack the midline abdominal wound with saline dampened gauze and cover with a dry dressing twice a day.
-That from 05/22/18 through 05/26/18 there was no documentation of a midline abdominal wound dressing change for five days. On 05/27/18 through 05/30/18 the midline abdominal wound dressing was changed once a day, not twice a day as ordered.
This had the potential to put Patient #20 at an increased risk for infection when his midline abdominal incision was not changed twice a day as ordered.

During an interview on 05/30/18 at 3:45 PM, Staff HH, MD, stated that his expectation was that nursing staff follow the physician orders and that the midline abdominal dressing should be changed twice a day as ordered.

During an interview on 05/30/18 at 3:30 PM, Staff F, RN, Third Floor Manager, stated that her expectation of staff was to follow physician orders and to document if the dressing was changed.

During an interview on 05/31/18 at 10:30 AM, Staff A, CNO, stated that his expectation of nursing staff was to follow the physician orders.

Record review of the facility's policy titled "Wound Assessment, Prevention, and Documentation" dated 03/06/2018 showed that an RN will inspect each patient's integument on admission, daily, weekly, and as often as indicated. An RN will describe the wound precisely on admission and documentation will be recorded by the RN as part of the daily nursing assessment. The type of specialty bed or support surface used to assist with preventing and/or treating skin breakdown will be included in the documentation.

Record review of Patient #15's History and Physical (H&P) dated 05/25/18 showed the patient was admitted with a diagnosis of decreased functional status, gait (a person's manner of walking) instability, status post (condition after) gunshot wound with multiple injuries, and wound care. Orders were to continue wound vacuum (negative pressure wound therapy using a vacuum dressing to promote wound healing) to her right groin wound; change every three days and saline (a solution of salt in water) wet to moist dressings for wound care to her right outer calf, and to consult with wound clinician.

Record review of the Nurses admission notes dated 5/25/18 showed that skin integrity was documented "not intact" and there was no documentation of location or description; also documented "wound vacuum in place" and there was no location of wound vacuum documented. Pictures of the wounds were taken on admission on 5/25/18, but there were no precise descriptions and no documentation on the treatments that were ordered on the admission assessment.

During an interview on 05/31/18 at 10:30 AM, Staff A, CNO, stated that his expectation of nursing staff was to follow the Wound Assessment, Prevention, and Documentation policy.

Record review of Patient #28's H & P dated 05/20/18 showed the patient was admitted with a diagnosis of decreased functional status, gait instability secondary to deconditioning (loss of strength and endurance), generalized weakness, and peripheral vascular disease (a blood circulation disorder that causes the blood vessels to narrow, block, or spasm), status post multiple revascularizations (restore delivery of blood). He was admitted with a wound vacuum to his left anterior thigh, an incision with sutures extending from his mid-thigh to distal femur, black eschar to the fourth toe on his left foot, and an open wound to his fifth toe, left foot. Orders were to maintain wound vacuum and for Betadine and dry dressings to fifth toe.

Record review of the Nurses admission notes dated 05/19/18 showed that skin integrity was documented "intact, with abnormalities" and there was no documentation of location or description of wounds; also documented "drainage tube to left thigh" instead of the wound vacuum located at left anterior thigh and there was no documentation describing wound in this area. Pictures of the wounds were taken the next day, 05/20/18, but there were no precise descriptions and no documentation of the treatments that were ordered on the admission assessment 05/19/18.

During an interview on 05/31/18 at 10:00 AM, Staff L, wound nurse, stated that it was expected that nursing documents on wounds and treatments on admission assessment and daily.

During an interview on 05/31/18 at 10:30 AM, Staff A, CNO, stated that his expectation of nursing staff was to follow the Wound Assessment, Prevention, and Documentation policy.

Review of Patient #31's medical record showed:
-The H&P dated 05/11/18, included that he was a 66 year old male admitted on 05/11/18 for rehabilitation following spinal surgery that lead to surgical site infection, decreased independence with mobility, impaired activity tolerance and decreased function in activities of daily living (ADL). Back incision is closed except for a lower part with yellow slough, small amount of serous fluid on the dressing, fluctuation of the surrounding skin is present on examination.
- There was no description or measurements of patient's surgical wound on the nursing admission record.
- There was no documentation of wound description by the RN or the Wound Care Nurse related to new epithelium, swelling/edema or any improvements from admission through 05/29/18.
- There was no documentation for wound measurements in the nursing progress notes or flow sheet from admission through 05/29/18

During interview on 05/29/18 at 9:30 AM, Staff H, RN stated that:
- There should have been a complete assessment of the patient's wound documented in the chart within eight hours of admission.
- There should have been documentation of the measurement of the wound.
- The wound she be described by color, size, and changes.
- She was unable to find documentation of the measurements, color or noted changes.

Review of Patient #41's medical record showed:
-He was a 69 year old man admitted on 05/28/18 with multiple co-morbidities (chronic diseases or conditions) including a left above the knee amputation in 2017 and right lower leg lymphedema (Swelling in the leg caused from a blockage of the network of vessels through which fluid drains from the tissues into the blood). He has cellulitis in his right leg, weakness and deficits in activities of daily living.
- There was no description or measurements of patient's leg wound on the nursing admission record.
- There was no documentation of wound description from the RN or the Wound Care Nurse related to new epithelium, swelling/edema or any improvements from admission through 05/31/18.
- There was no documentation for wound measurements in the nursing progress notes or flow sheet from admission through 05/31/18.
- Although Staff L, RN, Wound Care Nurse had written an order for the nursing staff to apply Silvadene Cream (A topical antimicrobial drug indicated for the prevention and treatment of wound infections), he had not documented an assessment of the wound.
- Staff H, Director of Therapy operations could not find documentation of measurements, location or description of the patient's right leg wound in the medical record.

During interview on 05/29/18 at 10:00 AM Staff H, Director of Therapy Operations stated that he could not find the documentation in the medical record.

During interview on 05/31/18 Staff A, RN, CNO stated that his expectation was the nursing staff would follow policy and document the entire wound assessment.

These failures had the potential to lead to negative outcomes for patients through the development of wounds or the deterioration of existing wounds and could affect all patients in the facility.

Observation of WOW carts showed:
- On 05/29/18 at 3:45 PM on the second floor showed two medication carts were unlocked.
- On 05/30/18 at 9:11 AM on the second floor showed one medication cart was unlocked.
- On 05/30/18 at 10:00 AM on the fourth floor showed one medication cart was unlocked.
- On 05/30/18 at 2:30 PM on the fourth floor showed one medication cart was unlocked.

During an interview on 05/29/18 at 3:45 PM, Staff B, Registered Nurse (RN) stated that the medication carts were to be locked at all times.

During an interview on 05/29/18 at 3:45 PM, Staff A, RN, Chief Nursing Officer stated that medication carts were to be locked at all times and stated that they did not have a policy for the medication carts.

During an interview on 05/30/18 at 9:42 AM, Staff I, RN stated that the medication carts were to be locked at all times.

During an interview on 05/30/18 at 2:30 PM, Staff M, Certified Rehabilitation Registered Nurse (CRRN) stated that the medication carts were to be locked at all times.
These failed practices by staff affected the security of medications for the entire facility.

Review of the facility's document titled, "Dysphagia Program," stated that dysphagia (difficulty swallowing) is an extremely prevalent impairment following stroke and potentially leads to the development of aspiration (to choke or inhale liquids into lungs) pneumonia (infection of the lungs) and other medical complications. It is evaluated upon admission by the speech-language pathologist (SLP) to determine the appropriate diet, supervision level, and feeding management program.

Review of the facility's policy titled, "Aspiration Precautions," dated 10/2016 showed the directive for staff to identify risks of aspiration such as complaint of swallowing difficulty, decreased mental status, and patients with neurological (brain) disorder, for example, stroke. Staff are to keep suction equipment available at bedside based on patient assessment.

Review of the facility's feeding management program showed that they followed the Academy of Nutrition and Dietetics National Dysphagia Diet (NDD) Levels for all stroke patients. The levels are:
- Level 1 diet consists of pureed (liquids and cooked foods that have been blended to the consistency of pudding) foods. This diet is designed for people who have moderate to severe dysphagia and reduced ability to protect their airway. Close or complete supervision may be required. Patient education tips for NDD Level 1 diet stated that you have been diagnosed with a severe chewing and/or swallowing problem by the health care professionals treating you.
- Level 2 diet consisted of foods that are moist, soft, and easily formed into a ball. Meats are ground or minced no larger than ¼ inch pieces. The textures on this level are appropriate for patients with mild to moderate dysphagia. Patient education tips for NDD Level 2 diet stated that you have been diagnosed with difficulty chewing regular textured foods by the health care professionals treating you, and will need to modify your food to make them easier to chew and swallow.
- Level 3 diet consisted of nearly regular food with the exception of very hard, sticky, or crunchy foods. Food still needed to be moist and in bite sized pieces. The textures of this diet are appropriate for patients with mild dysphagia. Patient education tips for NDD Level 3 diet stated that you have been diagnosed with difficulty chewing regular textured foods by the health care professionals treating you, and you will need to modify your food to make them easier to chew and swallow.

Review of Patient # 46's medical record showed the following:
- She was admitted to the facility on 05/29/18 for stroke rehabilitation;
- Her diet consistency recommendation was NDD Level 1, which is recommended for moderate to severe dysphagia and reduced ability to protect the airway;
- Education was needed on aspiration precautions and swallowing strategies; and
- Safe swallowing instructions was to sit upright at 90 degrees when eating and drinking, take small bites of food and sips of liquid, clear food out of the right side of her mouth.

Review of Patient #53's medical record showed that she was admitted to the facility on 05/25/18 for stroke rehabilitation. The patient diet was nothing by mouth (NPO) and she failed two swallow studies.

Review of Patient #48's medical record showed the following:
- He was admitted to the facility on 05/29/18 for stroke rehabilitation;
- The patient's diet type was NDD Level 2, which is recommended for patient s with mild to moderate difficulty swallowing;
- On 5/31/18 it was noted by the SLP that the patient needed to focus on swallowing and taking small bites of food;
- He had increased lip spillage when he ate and drank;
- Safe swallowing instructions was to sit upright at 90 degrees when eating or drinking;
- Alternate between food and liquid;
- Take double swallows after each bite of food;
- Clear food out of the right side of his mouth; and
- 100% supervision when he ate.

Review of Patient #52's medical record showed the following:
- She was admitted to the facility on 05/25/18 for stroke rehabilitation;
- The patient's diet type was NDD Level 2 and was advanced to NDD Level 3 on 05/30/18;
- It was noted by the SLP that the patient demonstrated severe fluctuations in alertness; and
- Safe swallowing instructions was to sit upright at 90 degrees when eating or drinking, alternate between food and liquid, and double swallow each bite of food.

Review of Patient #56's medical record showed that she was admitted to the facility on 05/29/18 for stroke rehabilitation. The patient's diet type was NDD Level 2 and she was on aspiration precautions.

Review of Patient #51's medical record showed that she was admitted to the facility on 05/25/18 for stroke rehabilitation. The patient's diet type was NDD Level 3, which is recommended for patients with mild difficulty swallowing. The patient needed to be fed.

Review of Patient #54's medical record showed that he was admitted to the facility on 05/22/18 for stroke rehabilitation. The patient's diet type was NDD Level 3.

Review of Patient #40's medical record showed the following:
- He was admitted to the facility on 05/11/18 for stroke rehabilitation;
- The patient's diet type on admission was npo due to clinical signs and symptoms of aspiration;
- His diet was advanced to NDD Level 4 (regular diet) on 05/29/18 with safe swallowing instructions of sit upright at 90 degrees when eating or drinking, take small bites, sips and no straws; and
- The patient was to take medications whole in applesauce or pudding.

Observation on 05/31/18 at 3:00 PM showed Staff QQ, RN, administered oral medications in applesauce to patient #40 while he was positioned in bed at a 30 degree angle, he was not sitting upright as recommended. There was no suction flow meter or suction canister set up in the patient's room.

Observation on 05/31/18 at 10:15 AM, at the St. Louis location and 3:15 PM, at the St. Peter's location, showed that there was no suction flowmeter or suction cannister setup in any of the above patient rooms.

During an interview on 05/31/18 at 10:30 AM, Staff A, CNO, stated that all patients admitted to the facility for stroke rehabilitation have an increased chance of aspiration and should have suction set up in each stroke patient's room.

During a phone interview on 06/06/18 at 11:00 AM, Staff SS, Lead Speech Therapist, stated that a patient on an NDD Level 1, 2, or 3 diet had difficulty swallowing and could be at risk for aspiration.

This had the potential to lead to poor patient outcomes if any of these patients began to choke and aspirate because of swallowing difficulties. The nearest suction machine was on the crash cart at the nurse's station.










39089




39563




39840

Based on observations, interview, policy review, and record review, the facility failed to ensure care plans for three patients (#15, #16, and #28,) of three patients reviewed had individualized problems, interventions and goals specific to the patients' medical and nursing needs. The facility census was 79 on the main campus in St. Louis and 20 on the campus in St. Peter's.

Findings included:

1. Record review of the facility policy titled "Care Planning" reviewed date 03/06/2018 showed:
-The purpose of the policy is to define a mechanism to document an individualized interdisciplinary Plan of Care (IPOC) for the patient and that all inpatients will have a plan of care;
-The policy states that each patient admitted will have an IPOC developed, which will be based on his/her needs assessed individual needs, family caregiver needs, physical, cognitive, and functional impairments, and co-morbid conditions;
-The Registered Nurse (RN) will initiate the IPOC within 24 hours of admission on each patient. The evaluating IDT and rehab physician will complete the IPOC following the patient assessment by day 4;
- IDT members have primary responsibility for completion of the IPOC including goal setting as per their discipline and area of expertise.

2. Record review of the facility policy titled "Wound Assessment, Prevention, and Documentation" reviewed date 03/06/2018 showed:
-The purpose of the policy is to improve patients' skin integrity through timely and consistent clinical practices for assessment and prevention of wounds and ensure standard documentation of assessment of skin and wounds;
-All patients admitted to the hospital will be screened within eight hours for risk of skin breakdown and for alteration in skin integrity by a RN. For a Braden Scale score (used for predicting pressure ulcer risk with a total score of 23 points; a higher score meaning a lower risk) of 18 or less, the Skin Breakdown Prevention Protocols will be initiated and incorporated into the plan of care;
-The Plan of Care documents the current risk for skin breakdown through the use of the Braden Scale and a status update, including progress toward goals.

3. Record review of Patient #15's History and Physical (H&P) dated 05/25/18 showed the patient was admitted with a diagnosis of decreased functional status, gait (a person's manner of walking) instability, status post (condition after) gunshot wound with multiple injuries, and wound care. Orders were to continue wound vacuum (negative pressure wound therapy using a vacuum dressing to promote wound healing) to her right groin wound; change every three days and saline (a solution of salt in water) wet to moist dressings for wound care to her right outer calf. Consult wound clinician.

Record review of the patient's IPOC initiated on 05/26/18 showed a problem with wounds of the Integument (the outer protective covering of the body) and goals for these wounds to be free of new infection or drainage. No interventions were listed. The IPOC also showed the patient/caregiver demonstrated knowledge of skin care measures. There were no interventions listed.

During an interview on 5/29/18 at 3:30, Staff L, wound nurse, stated that narratives or notes could not be entered in the IPOC. There are only selection check boxes.

During an interview on 5/31/18 at 3:30 PM, Staff M, Certified Rehabilitation Registered Nurse (CRRN), stated that the IPOC consist of check boxes for problems and interventions. She stated that additional problems or narratives could not be added.

Staff failed to individualize the IPOC specific to the patient's needs and to update the IPOC as needed.

4. Record review of Patient #16's H & P dated 05/16/18 showed the patient was admitted following surgery for bilateral lower extremity fasciotomies (a surgical procedure to treat the loss of circulation to an area of tissue or muscle). Orders were to maintain wounds with wet to moist dressing changes, continue wound vacuum therapy, and consult with the Acute Care Surgery team to assess his wounds and establish follow up care in their wound clinic.

Record review of the patient's IPOC initiated on 05/15/18 showed no problem addressing wounds. There were no interventions listed.

During an interview on 5/29/18 at 3:30, Staff L, wound nurse, stated that narratives or notes could not be entered in the IPOC. There are only selection check boxes.

During an interview on 5/31/18 at 3:30 PM, Staff M, Certified Rehabilitation Registered Nurse (CRRN), stated that the IPOC consist of check boxes for problems and interventions. She stated that additional problems or narratives could not be added.

Staff failed to individualize the IPOC specific to the patient's needs and to update the IPOC as needed.

5. Record review of Patient #28's H & P dated 05/20/18 showed the patient was admitted with a diagnosis of decreased functional status, gait instability secondary to deconditioning (loss of strength and endurance), generalized weakness, and peripheral vascular disease (a blood circulation disorder that causes the blood vessels to narrow, block, or spasm), status post multiple revascularizations (restore delivery of blood). He was admitted with a wound vacuum to his left anterior thigh, an incision with sutures extending from his mid-thigh to distal femur, black eschar to the fourth toe on his left foot, and an open wound to his fifth toe, left foot. Orders were to maintain wound vacuum and for Betadine and dry dressings to fifth toe.

Record review of the patient's IPOC initiated on 05/19/18 showed no problem addressing wounds. There were no interventions listed.

During an interview on 5/29/18 at 3:30, Staff L, wound nurse, stated that narratives or notes could not be entered in the IPOC. There are only selection check boxes.

During an interview on 5/31/18 at 3:30 PM, Staff M, Certified Rehabilitation Registered Nurse (CRRN), stated that the IPOC consist of check boxes for problems and interventions. She stated that additional problems or narratives could not be added.

Staff failed to individualize the IPOC specific to the patient's needs and to update the IPOC as needed. This failure had the potential to lead to negative outcomes for patients through the development of wounds or the deterioration of existing wounds and could affect all patients in the facility.

Based on observation, interview and record review, the facility failed to ensure that the pharmacy staff followed their policies and the infection prevention standards for The United States Pharmacopeia (USP) for compound sterile preparations (CSP) when they failed to:
- Decrease the chance of contamination at Hospital A (St. Louis), by placing the Compounding Aseptic Isolator (CAI, a positive pressure unit used to compound nonhazardous medications) which is the Primary Engineering Control (PEC, a device that provides an environment for compounding medications) for this ISO Class 7 environment, across from a sink;
- Provide a Compounding medication log at Hospital A and B (St. Peters);
- Place sterile gloves on over gauntlet gloves inside of the CAI prior to mixing compounding medications for Hospital A and B;
- Perform gloved fingertip sampling (tests performed to ensure that compounding personnel can successfully complete hand hygiene, gowning and gloving without contaminating the gloved hands) for initial certification and yearly at Hospital A and B; and
- Perform media fill testing (test performed to evaluate the aseptic technique of compounding personnel to ensure production of sterile compounds are without microbial contamination) for initial certification and yearly at Hospital A and B.
- Remove all paper products (particle shedding) from the SCA (segregated compounding area) at Hospital A and B.
- Put on a gown, gloves and mask prior to entering the SCA at Hospital A and B;
- Provide a line of demarcation (a line on the floor that signified to the staff the entrance of the SCA) at Hospital B; and
- Perform a terminal clean (a thorough, deep-cleaning of a room to include the ceiling, walls and floors) of the SCA monthly at Hospital A and B;
These failures had the potential to increase the risk of cross contamination with infection and the risk of harm to any patients who received medications compounded at both A and B locations, which placed all of the patients at risk. The facility census for Hospital A was 79 and Hospital B was 20.

Findings include:

Record review of the USP, Chapter 797, dated 2013, showed that:
- The CAI must be located in an SCA in an ISO Class 7 environment.
- There must be a line of demarcation to designate where the SCA starts.
- The pharmacy must provide a record of compounding mixtures (compounding log).
- The compounding staff must apply sterile gloves on over the gauntlet gloves, inside the CAI prior to mixing compound medications.
- Gloved fingertip sampling required for initial testing and retested yearly for all compounding personnel.
- Media-fill testing required for initial testing and retested yearly.
- Particle shedding objects (pencils, corrugated cardboard, paper towels, and cotton items) prohibited in the SCA.
- The compounding staff must Don a gown, gloves and mask prior to entering the SCA.
- The SCA floor cleaning requirements are cleaning the floors and walls daily, ceilings and storage shelving monthly and documented on a cleaning log.

Record review of the facility's policy titled, "Compounding Sterile Products - Pharmacy Low Risk Compounding," dated 03/06/18, showed that the facility's sterile admixture services performed by the Pharmacy department were to maintain compliance with USP, 797 regulations.

Observation on 05/30/18 at 10:05 AM in the Pharmacy Sterile Compounding room, for Hospital A showed the following:
- A sink located directly across from the CAI (regulation states at least 36 inches and the sink counter was 30 inches from the CAI);
- Paper towel dispenser (particle shedding) next to the CAI;
- One cardboard box (particle shedding) in the SCA; and
- Multiple containers with supplies in the SCA.
- A dust covered manufacturer's manual underneath the CAI that was for a different isolator.

During an interview on 05/30/18 at 10:15 AM, Staff BB, Director of Pharmacy for Hospital A and hospital B, stated that he was unaware that the location of the sink was an issue and should have removed the particle shedding items to include the old manual from the SCA.

Although requested, the Pharmacy staff was not able to produce a Gloved Fingertip Sampling log and a Media Fill Testing log for Hospital A and B.

During an interview on 05/31/18 at 9:20 AM, Staff JJ, Pharmacist, stated that she did not use sterile gloves in the CAI.

During an interview on 05/30/18 at 10:30 AM, Staff BB, Director of Pharmacy, stated that during compounding that he and his staff did not gown before entering the SCA and they only gloved. He also stated that in the CAI they did not apply sterile gloves over the gauntlet gloves prior to compounding at Hospital A and Hospital B.

Observation on 05/31/18 at 3:00 PM, in the Pharmacy Sterile Compounding room, in Hospital B, showed no line of demarcation (a line on the floor placed to designate the SCA).

Although requested, the Pharmacy staff for Hospital A and B was not able to produce a monthly deep cleaning log for the SCA.

During an interview on 05/30/18 at 9:20 AM, Staff JJ, Pharmacist, stated that the SCA was so small it was difficult to do a deep clean.

During an interview on 05/30/18 at 11:07 AM, Staff CC, Environmental Services Lead, stated that they cleaned the floors and emptied the trash daily and did not perform monthly terminal cleaning in the SCA.

These failures had the potential to place all patients that received a Compounded medication at the facility at an elevated risk for cross contamination with infection.

Based on observation, interview and record review, the facility failed to ensure medication safety when they failed to ensure the integrity of the contents of two of three crash carts (a set of trays/drawers/shelves on wheels used in hospitals for transportation and dispensing of emergency medication/equipment for life saving protocols). The facility census for Hospital A (St. Louis) was 76.

Findings included:

Record review of the facility's policy titled, "Emergency Medications," dated 03/06/18, showed that the crash cart should have been secured with a numbered lock that was recorded on the crash cart log.

Review of the facility's policy titled, "Emergency Carts," dated 03/06/18, stated that breaking the integrity of the Emergency Cart and utilizing supplies for non-emergencies was prohibited. Every 24 hours, an assigned Registered Nurse (RN) will evaluate the completeness of the Emergency Cart and verify the cart was locked and intact. Documentation by the RN will be completed daily as a record of integrity and accountability.

Observation on 05/29/18 at 3:37 PM on the Second Floor of Hospital A, showed that the crash cart had an unnumbered yellow tag that secured the medications.

Observation on 05/29/18 at 3:37 PM in the crash cart drawer two, showed 20 yellow unnumbered tags.

During an observation on 05/29/18 at 3:00 PM, on the Third Floor of Hospital A, showed that the crash cart was unlocked with a broken red tag on it. The facility Crash Cart Log showed that the crash cart had been checked for 05/29/18 and circled yes, that the crash cart was locked. In drawer two of the crash cart, showed 10 yellow unnumbered tags.

During an observation on 05/30/18 at 10:15 AM, on the Third Floor of Hospital A, showed that the crash cart had been checked for the day and the red tag lock number was 0199467. The drawer on the crash cart was easily opened by this surveyor. The number on the red tag was 0199453, a different number that was written in the Crash Cart Log.

During an interview on 05/30/18 at 10:20 AM, Staff F, Third Floor Manager, stated that her expectation of the nursing staff was to check the crash cart daily and check it correctly. If the crash cart was used or the lock was broken, the staff needed to call the pharmacy as soon as possible to have it checked and the lock replaced.

During an interview on 05/31/18 Staff A, Chief Nursing Officer (CNO), stated that he expected all of the crash carts to have been locked with red tags and if they were opened, they should have been replaced right away. He also stated that Pharmacy kept track of the tags.

During an interview on 05/30/18 at 11:00 AM, Staff BB, Director of Pharmacy, stated the temporary yellow tags were placed on the crash carts after they were opened until the pharmacy staff was able to service them and replace with a red tag. He stated that the nursing staff emailed him or called when they had been opened.

Although requested, the facility failed to provide a log of the red tag numbers.

The unnumbered plastic locks and the failure to secure the crash carts, had the potential to allow staff to access the medications in the crash cart without accountability. This rendered the medications unsecured.






39562

Based on observation, interview, record review and policy review, deficiencies were found at both locations where the facility failed to ensure:
- Nursing staff performed a sterile (free from living germs) urinary catheter (a hollow, flexible tube that drains urine from the bladder, an organ that stores urine) insertion for one patient (#23) of one patient observed;
- Nursing staff followed isolation precautions (measures taken to prevent the transmission of infection) for one patient (#40) of one patient;
- Nursing staff performed hand hygiene for eight patients (#2, #14, #16, #22, #25, #26, #29 and #40) of eight patients observed;
- Cleanliness of over bed tables for five patients (#6, #7, #23, #25 and #29) of five patients observed;
- Cleanliness of the Workstation on Wheels (WOWs) for four patients (#22, #25, #26 and #40) of four current patients observed;
- Cleanliness of the wheel chair washer;
- Cleanliness of the Blood Glucose Monitor (device used to measure the amount of glucose in the bloodstream) and the docking station;
- Cleanliness of a patient room for one patient (#32) of one patient room observed;
- Complete temperature logs for Physical Therapy (PT) chilling unit;
- Dietary staff removed expired food from the patient nutrition rooms, appropriately dated/labeled items in the walk in refrigerator, food storage area and kitchen, performed temperature checks on patient food trays;
- Dietary staff followed the dress code for two staff (P and Q) of two dietary staff observed;
- Staff placed disposable blood pressure cuffs in the crash cart (a set of trays/drawers/shelves on wheels used in hospitals for transportation and dispensing of emergency medication/equipment for life saving protocols); and
- Staff cleaned the Nutrition rooms on the Second Floor.
These deficient practices had the potential to increase the risk of infection and cross contamination to all patients, staff, and visitors. The facility census was 79 on the main campus in St. Louis and 20 on the campus in St. Peter's.

Findings included:

1. Observation on 05/30/18 at 9:40 AM, in Hospital A, Staff II, Occupational Therapist (OT) prepared Patient #32 to be transferred to the shower. There was dried blood on the floor between the two patient beds. In the bathroom the toilet seat and the wall behind it were covered in feces. Staff II, OT and two Nursing Technicians did not acknowledge the blood or the feces. Staff II, OT had to remove a mechanical lift (A hydraulic lifting device for patients that require 100% assistance to be transferred from a bed or chair) that was stored beside the shower for patient #33. The mechanical lift was then used for patient #33 without being cleaned.

During an interview on 05/31/18 at 10:20 AM, Staff A, RN, Chief Nursing Officer and Staff LL, Registered Nurse (RN), Infection Preventionist, both stated the staff in the room should have acknowledged the blood and feces and either cleaned them or contacted the appropriate person to clean the bathroom before the patient was allowed to enter. They also stated that everyone was responsible to keep the areas and equipment clean.

The failure of staff to acknowledge the presence of blood and feces and initiate a clean-up effort places all patients, visitors, staff and both patients who shared that room at risk for exposure to infection and cross contamination of disease.

2. Review of the facility's policy titled, "Intermittent Catheterization," (insertion of a hollow, flexible tube into the bladder to drain urine and then removed) dated 09/2017, stated that for infection control purposes, this procedure will be done using sterile technique.

Review of the facility's policy titled, "Indwelling (left inside the body) Urinary Catheter," dated 09/2017, showed directive for staff to insert urinary catheters using aseptic (free from contamination) technique and sterile equipment. Perform hand hygiene immediately before and after insertion or any manipulation of the catheter device or site.

Observation on 05/30/18 at 11:00 AM on the Third floor of Hospital A, showed the following:
- Staff Z, Nurse Intern, gathered supplies to catheterize (insert a urinary catheter) Patient #23.
- At patient #23's bedside, with gloves on, she touched the trash can and over bed table, cleaned the patient's penis with a wet washcloth, opened the intermittent catheter tubing package on an uncleaned over bed table, opened an antiseptic (substance used to prevent infection) swab package, placed it upright on the patient's bed and placed a package of lubricating jelly on the bed.
- She removed gloves, did not perform hand hygiene, put the sterile glove package on the bed and put sterile gloves on.
- When she put on the sterile gloves, the tips of the antiseptic swabs hit the bed frame, which contaminated the antiseptic swabs. Staff Z picked up the antiseptic swabs (unsterile) with sterile gloves on, and cleaned patient's penis.
- She opened the lubricating jelly package (unsterile), and dispensed jelly on sterile glove packaging, removed the urinary catheter from the package, inserted the tip of the catheter into the lubricating jelly and inserted the catheter into the patient's penis and bladder (organ that stores urine).

During an interview on 05/30/18 at 11:45 AM, Staff Z, Nurse Intern, stated that she should perform hand hygiene after she removed gloves and before she put on new gloves. Staff Z did not realize she broke sterile technique during the catheter insertion, and added that she used a catheter kit she was not familiar with.

During an interview on 05/30/18 at 11:55 AM, Staff F, Third Floor Manager, stated that her expectation of nursing staff was to perform sterile technique when a urinary catheter was inserted.

3. Review of the facility's policy titled, "Isolation Precautions," dated 03/06/18, showed directives for staff to:
- Use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment.
- Perform appropriate hand hygiene upon entering and leaving a patient room, and as otherwise needed during patient care.
- Wear gloves and/or gowns as patient care tasks dictate and when direct contact with the patient or patient's environment is anticipated, apply appropriate barrier.
- Any equipment used by the patient must be cleaned in the room prior to removal.

Observation on 05/31/18 at 2:30 PM, at Hospital B, showed the following:
- Staff QQ, RN, entered Patient #40's room, a contact isolation (to separate from others, due to infections, diseases or germs that are spread by touching the patient or items in the room) room, and failed to put on a gown or gloves.
- She wheeled the mobile blood pressure machine into the room and touched Patient #40's arm with an ungloved hand, and placed a disposable blood pressure cuff on his arm.
- She scanned the patient's arm band and failed to clean the scanner before she placed the scanner back in the holder of the WOW, which was located outside of the patient's room.
- She failed to clean the mobile blood pressure machine before she placed it outside of Patient #40's room.
- She did not clean the scanner, WOW surface, or keyboard.
- She wheeled the WOW down the hallway and into the therapy room, touched the scanner, keyboard, medication drawer and administered oral medication to Patient #61.

During an interview on 05/31/18 at 3:00 PM, Staff QQ stated she should have put on a gown and gloves before she entered the contact isolation room, she was nervous and forgot. She cleaned the WOW and scanner every morning, but not between patient use.

During an interview on 05/31/18 at 3:10 PM, Staff A, CNO, stated that he expected staff to follow isolation precautions and to gown and glove before they entered a patient's room. WOWs, scanners and patient equipment should be cleaned after patient use and as needed.

4. Review of the facility's policy titled, "Hand Hygiene," dated 01/2018, and the guidelines from Seventh Edition Perry and Potter 2010 (which the facility followed), showed directives for staff to perform hand hygiene:
- Before having direct contact with patients;
- Before putting on sterile gloves;
- After contact with a patient's intact skin;
- After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings;
- When moving from a contaminated body site to a clean body site during care;
- After contact with inanimate objects, including medical equipment, in the immediate vicinity of a patient; and
- After removal of gloves.

Review of the facility's policy titled, "Disinfection and Sterilization," dated 03/06/18, showed that all equipment that touched patients should be disinfected in between patient contact. The patient caregiver has ultimate responsibility for ensuring that only clean equipment is used to care for patients.

Observation on 05/30/18 at 9:30 AM, on the Third Floor of Hospital A showed the following:
- Staff W, RN, wheeled the WOW into Patient #26's room.
- Staff W scanned Patient #26's armband with the scanner, touched the computer keyboard and removed medications out of the medication drawer.
- Staff W failed to perform hand hygiene before he put on gloves.
- He wheeled the WOW into the hallway and did not clean the scanner or surface of the WOW before he went into another patient's room.

Observation on 05/30/18 at 10:00 AM, on the Third Floor of Hospital A, showed the following:
- Staff X, RN, outside of Patient #22's room with the WOW.
- Staff X entered Patient #22's room and failed to perform hand hygiene.
- She scanned Patient #22's armband with the scanner, touched the computer keyboard, opened up the medication drawer, dropped an empty medication cup on the floor, picked it up, threw it in the trash and failed to perform hand hygiene before she put on gloves.
- She then administered oral medications to Patient #22, removed gloves and did not perform hand hygiene.
- She touched the computer keyboard, removed Heparin (blood thinning medication) from the medication bin, drew up the Heparin into a syringe, put on gloves without performing hand hygiene and administered the subcutaneous (SQ, under the skin) Heparin.
- Staff X did not clean the scanner, the computer keyboard, or surface of the WOW after she administered medications to Patient #22.

During an interview on 05/30/18 at 10:15 AM, Staff X stated that she performed hand hygiene when she entered and exited a patient's room and put on gloves when she administered medications and performed patient care. She cleaned the WOW every morning before she started her day.

Observation on 05/30/18 at 12:15 PM, on the Third Floor of Hospital A showed the following:
- Staff AA, RN entered Patient #25's room and placed supplies for a Peripherally Inserted Central Catheter (PICC, a thin, long tube placed into a vein to administer medication and/or fluid) line dressing change on Patient #25's over bed table.
- The over bed table had two spots of dried brown liquid, Staff AA did not clean the over bed table before she laid supplies on the table or before she opened the PICC line dressing kit.
- Staff AA touched the bedside table and Patient #25's arm, and failed to perform hand hygiene before she put on gloves.
- She took off Patient #25's old PICC line dressing located near the bend of her left arm, removed gloves and did not perform hand hygiene.
- She opened the PICC line dressing kit package, placed the sterile glove package on the unclean table and put on the sterile gloves.
- She cleaned the PICC line insertion site and applied the new dressing.
- She removed the sterile gloves and did not perform hand hygiene.
- She then brought the WOW into Patient #25's room and did not clean the scanner, keyboard or any surface of the workstation.
- She scanned Patient #25's armband, touched the keyboard, removed Intravenous (IV, in the vein) antibiotic bag from the medication bin, put gloves on without performing hand hygiene.
- She hung the IV antibiotic, touched the IV pole, the IV machine and did not change gloves or perform hand hygiene before she attached the tubing to the port of the PICC line to infuse the antibiotic.
- She wheeled the WOW outside of Patient #25's room and did not clean the scanner or any surface of the workstation.

During an interview on 05/30/18 at 12:45 PM, Staff AA, stated that she knew that she should perform hand hygiene before and after glove changes but there was not any hand sanitizer nearby and she did not want to turn her back on the sterile field.

Observation on 05/31/18 at 10:00 AM, on the Second floor of Hospital A showed the following:
- Staff MM, Registered Respiratory Therapist (RRT), RT Supervisor, entered Patient #29's room gowned and gloved for contact isolation precautions to perform tracheostomy (trach, a tube placed in a surgically created hole in the neck for access to the windpipe) care and suction (to withdraw fluids from) Patient #29;
- She did not clean the over bed table or remove Patient #29's water bottle and laid two paper towels on the table;
- She opened a trach care kit package and laid the cotton swabs used to clean around the trach on the paper towels;
- She opened a suction kit package next to the paper towels and the cotton swabs moved and the tips of the cotton swabs laid on the unclean bedside table;
- She put the sterile gloves on over the unsterile gloves and suctioned Patient #29's tracheal (windpipe) secretions;
- She removed one sterile glove and performed trach care with the dirty (unsterile) gloved hand;
- When Patient #29 needed to be suctioned again, she removed the other sterile glove, leaving the initial pair of gloves on that she entered the room with, and opened up a new suction kit package;
- She put on sterile gloves over her existing, unsterile gloves:
- One of the sterile gloves ripped and she suctioned the patient with the ripped glove;
- She took off both sterile gloves, left the unsterile gloves on and listened to patient #29's breath sounds with disposable stethoscope; and
- She did not clean the disposable stethoscope and left it laying on the bedside table.

During an interview on 05/31/18 at 10:20 AM, Staff MM stated that patient suctioning was a sterile procedure. She did not know that she should take off unsterile gloves and do hand hygiene before she put sterile gloves on for suctioning. Respiratory therapy staff was taught to put sterile gloves on over unsterile gloves when the patient was suctioned.

During an interview on 05/31/18 at 3:30 PM, Staff RR, RRT, stated that she put sterile gloves on over unsterile gloves when a patient was suctioned, and had done so for 10 years.

During an interview on 05/31/18 at 10:30 AM, Staff LL, Infection Preventionist, stated that her expectation of nursing staff and RT staff was that unsterile gloves should be removed, hand hygiene performed and sterile gloves put on when a patient was suctioned.

Observation on 05/30/18 at 9:11 AM, Staff I, RN, failed to perform hand hygiene before she put on gloves and administered medications to Patient #2.

Observation on 05/30/18 at 9:20 AM, Staff I, RN, failed to perform hand hygiene before she put on gloves and administered medications to Patient #14.

During an interview on 05/30/18 at 9:42 AM, Staff I, RN, stated that hand hygiene should be performed when staff entered and exited a patient room and before and after staff put on gloves.

During an interview on 05/31/18 at 10:22 AM, Staff A, CNO, stated that hand hygiene should be performed before staff entered a patient room, when they exited a patient room, and between glove changes.

Observation on 05/31/18 at 9:00 AM, Staff L, RN, Wound Care Nurse failed to perform hand hygiene after he removed his gloves when he performed a dressing change on Pt #16.

During an interview on 05/31/18 at 10:03 AM, Staff L, RN, Wound Care Nurse, stated that he missed an opportunity for hand hygiene while he performed a dressing change.

Observation on 05/29/18 at 4:00 PM showed Patient #6 and Patient #7 had dirty bedside tables with dried food and sticky areas on them.

During an interview on 05/29/18 at 4:00 PM, Patients #6 and #7 both stated that the bedside tables had never been cleaned.

5. Review of the wheelchair washer manufacturer's recommendations showed directions to:
- Check that all water has been drained from the cabinet. If not, depress the manual drain switch until all water has been drained.
- Wipe out the floor so that it is clean and shiny.
- Leave the front door slightly open so the washer can dry.
- Clean washer inside and out with stainless steel polish.

Observation on 05/29/18 at 3:00 PM at Hospital A, showed the wheelchair washer cabinet was excessively dirty. Staff H, Director of Therapy Operations, opened the door. Water was pooled on the floor with red stains on the floor, it had a noxious odor and the entire inside was wet.

During an interview on 05/29/18 at 3:00 PM, Staff H stated that the technician was responsible for cleaning the machine.

6. Review of the facility's policy titled, "Blood Glucose Monitoring Bedside," dated 09/2017, showed directives for staff to do the following:
- Clean blood glucose monitor daily and as needed;
- Whenever the test area looks dirty; and
- After each patient use.

Observation on 05/30/18 at 11:30 AM on the Third Floor of Hospital A, showed the following:
- The docking station where the blood glucose monitors were placed to charge and download information, was dirty and dusty.
- Staff Z, Nurse Intern, took the blood glucose monitor from the docking station in the medication room and placed it inside the transport box, and took it into Patient #23's room.
- She removed the blood glucose monitor from the box and laid it on the over bed table.
- She did not clean the blood glucose monitor or the over bed table.
- She performed fingerstick (to prick a finger for a blood sample) on Patient #23 and placed the blood glucose monitor back into the transport box.
- She returned to the medication room, removed the blood glucose monitor from the transport box and placed it on the dirty and dusty docking station.
- She did not clean the blood glucose monitor after patient use, and did not clean the docking station.

During an interview on 05/30/18 at 11:45 AM, Staff Z, Nurse Intern, stated that she forgot to clean the blood glucose monitor after she used it on Patient #23 and she didn't notice the docking station was dirty and dusty.

During an interview on 05/30/18 at 11:55 AM, Staff F, Third Floor Manager, stated that her expectation of nursing staff was that blood glucose monitors should be cleaned before and after patient use and staff should clean docking stations daily and as needed.

These failed infection control practices by staff placed all patients, staff and visitors at increased risk for exposure to infections.

7. Review of the temperature log for the month of May, at Hospital A, showed the chilling unit in the Physical Therapy Department did not have the temperature recorded 14 out of 29 days.

During an interview on 05/29/18 at 3:15 PM, Staff H, Director of Therapy Operations stated that the temperatures should be recorded daily.

8. Review of the policy titled, "Food and Supply Storage", dated 01/2018, directed staff to date and rotate items; first in, first out and to label and date unused portions and open packages.

Observation on 05/30/18 at 9:00 AM, in the nutrition room, showed the patient refrigerator was
dirty on the inside with dry spills from liquids on shelves and on the bottom of the refrigerator. There was a gallon of iced tea and a gallon of chocolate milk opened and not dated. In the cabinet there was an expired carton of liquid nutrition with an expiration date of 04/2018. The cartons of liquid nutrition were not being rotated properly to prevent expired dates from being pushed to the back.

Observation on 05/29/18 at 3:45 PM on the Second Floor of Hospital A in the large nutrition room patient refrigerator, showed one turkey sandwich with an expiration date of 05/27/18 and in the small refrigerator (used for food brought in by patient's families) was a large container with an entrée that was not dated or labeled with the patient's name.

Observation on 05/29/18 at 4:00 PM on the Second Floor of Hospital A in the small nutrition room patient refrigerator showed:
- Six sandwiches with no date;
- Four sandwiches with an expired date of 05/28/18;
- One fast food bag with no name or date;
- One pear cup with no date;
- One peach cup with no date; and
- One pudding in a paper bowl in a ziplock with no name or date.

Observation on 05/30/18 at 9:48 AM in the walk-in refrigerator at Hospital A showed:
- One covered container of buttered noodles with an opened date of 05/26/18 and no expiration date;
- One undated, opened bag of grated parmesan cheese; and
- One covered pan of brisket with an opened date of 05/27/18 and no expiration date.

During an interview on 05/30/18 at 9:52 AM, Staff J, Food Services Director, stated that all items in the walk-in cooler should have a sticker with the open date and the expiration date, if the item has been opened.

Observation on 05/31/18 at 2:10 PM at Hospital B showed:
- One carton opened milk in the reach in cooler with no expiration date;
- One serving of cheesecake with an expiration date of 05/30/18;
- Seven undated opened spice containers;
- One bag of swiss cheese with an expiration date of 05/03/18;
- One 25 pound bag of onions with no expiration date; and
- Three bags of potatoes with no expiration date.

During an interview on 05/31/18 at 2:10 PM, Staff NN, Interim Director of Food Services and Staff OO, Area Customer Service Manager, both stated that opened items should be labeled with an expiration date.

During a telephone interview on 05/31/18 at 10:22 AM, Staff LL, Infection Preventionist stated that once items were opened, they were to be labeled with an expiration date.

Observation on 05/30/18 at 2:48 PM showed four open containers of dry spices with no expiration date.

During an interview on 05/31/18 at 2:48 PM, Staff J, Food Services Director stated that spices should be labeled with an expiration date once they were opened.

9. Review of the facility's policy titled, "Test Tray Evaluation", dated 01/2017, showed the directive for staff to perform a temperature check of a test tray at least once a week. The policy showed that the point of service temperatures should be:
- Salad at less than or equal to 41 degrees;
- Fruit, no defined temperature;
- Hot Entrée at greater than or equal to 140 degrees; and
- Vegetable at greater than or equal to 140 degrees.

Observation on 05/30/18 at 11:45 AM at Hospital A, the requested test tray had the following temperatures recorded:
- Cole slaw at 72.1 degrees;
- Grapes at 64.7 degrees;
- Sandwich at 128.6 degrees; and
- French Fries at 126.3 degrees.

During an interview on 05/30/18 at 2:48 PM, Staff J, Food Services Director stated that there were no logs for test trays.

10. Review of the policy titled, "Uniform Dress Code", dated 01/2017 directed staff to wear the approved hair restraint when on duty and to restrain facial hair as per local and state regulations.

Observation on 05/30/18 at 11:00 AM at Hospital A, showed Staff P and Staff Q failed to restrain beards and mustaches.

During an interview on 05/30/18 at 11:05 AM, Staff J, Food Services Director stated that facial hair should be restrained.

During a telephone interview on 05/31/18 at 10:22 AM, Staff LL, Infection Preventionist stated that a mustache or beard should be covered with a covering separate from the head covering.

11. Review of the facility's policy titled, "Receiving," dated 01/2017, showed the directive for staff to rotate items: first in, first out and to date foods prior to placing in storage areas.

Observation on 05/30/18 at 9:52 AM at Hospital A, dry storage area walk in refrigerator, and walk in freezer, showed no dates on any items.

During an interview on 05/30/18 at 9:52 AM, Staff J, Food Services Director stated that they used the delivery sticker on the outside of the box as the received date and then labeled the items when the boxes are opened, using the guide attached to the policy. While in the storage areas, Staff J confirmed that many of the boxes did not have a delivery sticker on them and none of the bins were dated.

During an interview on 05/31/18 at 9:54 AM, Staff EE, Dishwasher stated that he was responsible for stocking the dry storage area, walk in refrigerator, and walk in freezer. He stated that he knew when the items came in and rotated them every time.

During a telephone interview on 05/31/18 at 10:22 AM, Staff LL, Infection Preventionist stated that items were to be dated upon receipt and if there were no individual dates, then the bin should be dated.

During an interview on 05/31/18 at 10:20 AM, Staff A, CNO and Staff LL, Infection Preventionist, stated that all food should have been labeled and not kept after the expiration date.

12. Observation on 05/29/18 at 3:37 PM on the Second Floor of Hospital A (St. Louis) inside the crash cart showed three non-disposable blood pressure cuffs in the second drawer. These blood pressure cuffs were used for all patients that required life saving procedures and had the potential to spread infection.

During an interview on 05/31/18 at 10:20 AM, Staff A, CNO and Staff LL, Infection Preventionist, stated that the crash carts should have had disposable blood pressure cuffs.

13. Observation on 05/29/18 at 4:00 PM on the Second Floor of Hospital A, in the small nutrition room showed that the lower cabinets were visibly dirty and a ceiling tile was swollen and brown in color.

During an interview on 05/30/18 at 11:07 AM, Staff CC, Environmental Services Lead, stated that her staff cleaned all of the nutrition rooms one time per day.

During an interview on 05/31/18 at 10:20 AM, Staff A, CNO and Staff LL, Infection Preventionist, stated that the nursing staff and patient care technicians were to clean the nutrition rooms and housekeeping was to clean the floors and take out the trash.

The unclean and neglected areas used to prepare and retrieve patient food, placed all patients at a greater risk for infection. This was detrimental to their well-being and increased the impact on patients that were already compromised..





















39089




39562




39563




36473