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Based on interview, record review, and policy review, the facility failed to provide a working number to the Quality Management Department for patients to report a concern or grievance (a complaint that cannot be resolved in a reasonable amount of time) about their care while a patient at the facility. This had the potential to affect all patients who wanted to file a grievance. The facility census at Bridgeton campus was 39 and the facility census at Richmond Heights campus was 28.

Findings included:

1. Record review of the facility's policy titled, "Patient Rights," revised 08/12, showed direction for patients to share a concern or grievance about their care verbally or they could call (314) 768-5341 to reach the Quality Management Department.

2. Record review of the facility's admission binder (a book with information about the hospital) showed the same number for patients to reach the Quality Management Department for concerns or grievances about their care as the patient rights policy.

3. During an interview on 01/08/14 at 12:28 PM, Staff RA, Director of Nursing (DON), stated that each patient admitted to the facility, on each campus, received an admissions binder. Staff RA called the number provided in the admission binder for the Quality Management Department and confirmed it was a non-working number.

4. During an interview on 01/09/14 at 1:28 PM, Staff BB, Chief Operating Officer (COO), stated that the documented phone number for the Quality Management Department became a non-working number approximately 07/18/13. Staff BB stated that since that date Bridgeton admitted 621 patients and Richmond Heights admitted 355.

The facility failed to give these patients the correct phone number to reach the Quality Management Department for concerns or grievances about their care.

Based on observation, interview, medical record review and policy review, the facility's Bridgeton campus failed to ensure:
- Nursing staff administered medications which were prepared immediately prior to patient administration for one of one patient (#B15);
- Nursing staff documented the location of injections for one of one patient (#B15); and
- Staff verified medications prior to administration for seven of seven patients (#B3, #B4, #B5, #B6, #B15, #B17, and #B19) observed with unlabeled medications at their bedside.
The failure to ensure medications were prepared, administered and documented correctly had the potential to cause serious medication errors which included the administration of medications that may have had compromised effectiveness or increase risks of infection/contamination. All patients admitted to the facility who received medications were placed at risk for harm. The facility census at the Bridgeton campus was 39 and the facility census at Richmond Heights campus was 28.

Findings included:

1. Record review of the facility's policy titled, "Medication Preparation and Administration," revised on 01/12, showed the following direction for staff:
- All medications shall be verified by the person administering the medication prior to administration.
- Multi-dose vials shall be marked with the date and time of expiration.
- The location and site of all injections will be documented on the medication administration record (MAR).
- Medication packages will be opened at the bedside by the nurse immediately prior to administration.

Record review of the facility's policy titled, "Labeling of Medications," revised on 07/11, showed the following direction for staff:
- Label all medications of any form including solutions of any kind, cleaning solutions, injectable, topical and oral (specific label requirements required for various medications and forms).
- Immediately discard medications found in-use if unlabeled and used for multi-dose injection or intravenous (administered into the blood stream) infusion.
- All medication labels were to include at a minimum: drug name, strength, dose, amount (if not apparent), and expiration time and date.

2. Observation on 01/09/14 beginning at 8:35 AM showed Staff BT, Registered Nurse (RN), prepared medications from a medication cart. Upon entering the medication bin for Patient #B15, two tablets, not labeled, had been placed in a white paper medication cup and were in the bin (had been previously prepared). Staff BT removed three additional medications from single dose packages and placed the medications in the cup and returned the filled cup to the patient's medication bin and left the medication cart while she performed patient care in another area. She returned to the medication cart and removed the medication cup with the previously prepared unlabeled medications and administered them to Patient #B15.

3. During interview on 01/09/14 at approximately 9:00 AM, Staff BT stated that she began medication preparation for Patient #B15 around 8:00 AM and had taken care of other patients before finishing with Patient #B15.

4. Observation on 01/09/14 at approximately 9:00 AM showed Staff BT administer a subcutaneous injection of insulin (administration of medication to prevent and treat high blood glucose levels into and under the skin tissue above the muscle tissue) into the bruised (tender areas of skin discoloration caused by blood leaking from blood vessels damaged by previous injections, pressure or impact) abdomen of Patient #B15. Patient #B15 stated that the injection was painful and when he was not at the facility he was given injections in other areas of his body.

5. Record review of Patient #B15's medication administration record showed administration of daily subcutaneous injections of insulin on 01/07/14, 01/08/14, and 01/09/14. Documentation of injections did not include the site or location of injection.

6. During an interview on 01/09/14 at approximately 9:00 AM, Staff BT stated that she always administered insulin injections into Patient #B15's abdomen despite the bruising because he was thin and didn't have enough muscle in his arms and legs. She stated that she did not check the MAR for documentation of previous injection locations because he had always gotten the injections in the abdomen.

7. Observation on 01/08/14 at 9:45 AM showed the following medications in Patient #B3's room not labeled per policy:
- One empty (had been administered) 50 milliliter (ml=a unit of measure) IV fluid bag of 0.9% Sodium Chloride (fluid administered into the blood stream through a small tube inserted in a vein) hanging on a IV pole connected to an infusion pump (used to deliver IV fluids) was not labeled with the patient's name, patient's location (room number), prescribed route of administration, infusion rate, dose, schedule, and expiration date of fluid.
- Seven pre-filled syringes containing 10 ml 0.9% Sodium Chloride IV flush (administered by nursing staff through IV site for medication and/or IV fluid administration) hanging in a bag from an IV pole not labeled with the patient's name, location, intended route of administration, dose and schedule.
- One 500 ml bottle of sterile water for irrigation (administered with a syringe into tubes which are placed in a patient other than intravenously (i.e., feeding tubes) was not labeled "FOR IRRIGATION ONLY - NOT FOR IV ADMINISTRATION ", and was not labeled with the patient name, location, intended route of administration, dose and schedule.
- Three 50 mg (milligram= unit of measure) tubes of Santyl ointment (a medication applied to the skin to remove dead skin tissue and aid in wound healing) was not labeled with the patient's name, location, intended route of administration, dose, schedule and expiration date.
- One 250 ml bottle of wound cleanser was not labeled with the patient's name, location, intended route of administration, dose, schedule and expiration date.
- One 30 mg tube of triple antibiotic ointment (TAO [an anti-infective medication used to prevent and /or treat skin infection]) was not labeled with the patient's name, location, intended route of administration, dose, schedule and expiration date.

8. Observation on 01/08/14 at 9:50 AM showed one Albuterol inhaler (a medication inhaled through the mouth and into the lungs to treat breathing disorders) lying on the bedside table in Patient #B17's room was not labeled with the patient's name, location, intended route of administration, dose, schedule and expiration date.

9. Observation on 01/08/14 at 9:55 AM showed one four-ounce container of Calmoseptine ointment (a medication used to prevent and treat skin conditions associated with pain, infection and itching) lying on the window sill in Patient #B19's room was not labeled with the patient's name, location, intended route of administration, dose, schedule and expiration date.

10. Observation on 01/08/14 at 10:30 AM showed one empty 50 ml IV fluid bag of 0.9% Sodium Chloride on a pole and connected to an IV infusion pump in Patient #B5's room which was not labeled with the patient's name, location, intended route of administration, dose, schedule and expiration date.

11. Observation on 01/08/14 at 10:45 AM showed one 30 gm (gram = unit of measure) tube of triple antibiotic ointment lying on the window sill in Patient #B4's room not labeled with the patient's name, location, intended route of administration, dose, schedule and expiration date.

12. Observation on 01/08/14 at 11:10 AM in Patient #B6's room showed one half empty 500 ml IV fluid bag of 0.9% Sodium Chloride on a IV pole and connected to an infusion pump not labeled with the patient's name, location, intended route of administration, dose, schedule and expiration date. One opened 250 ml bottle of sterile water was not labeled "FOR IRRIGATION ONLY-NOT FOR IV ADMINISTRATION" and was not labeled with the patient's name, location, intended route of administration, dose, schedule and expiration date.

13. Observation on 01/08/14 at 11:15 AM showed the following medications in Patient #B15's room:
- One 500 ml IV fluid bag of 0.9% Sodium Chloride connected to an infusion pump which was not labeled with the patient's name, location, intended route of administration, dose, schedule and expiration date.
- One half empty 250 mg bottle of sterile water was not labeled "FOR IRRIGATION ONLY-NOT FOR IV ADMINISTRATION" and was not labeled with the patient's name, location, intended route of administration, dose, schedule and expiration date.
- One open 16 ounce bottle of CaraKlenz (wound cleanser) not labeled with the patient's name, location, intended route of administration, dose, schedule and expiration date.

14. Observation on 01/08/14 at 11:20 AM of the medication cart J showed one open (had been used/protective cap was removed) multiple dose vial (dispensed from a bottle used for multiple patients) of Humulin N Insulin and one open bottle of Humulin 70/30 Insulin. The vials were not labeled with the specific date of expiration which would have been 28 days from the date the vials were opened. The vials did not contain a written date of when opened or expired and were available for nursing staff to administer to patients.

15. Observation on 01/08/14 at 2:50 PM of the medication cart L showed one half empty 10 ml multiple dose vial of Lantis Insulin not labeled in writing of the specific date of expiration which would have been 28 days from the date the vial was opened. The vial did not contain a written date of when opened or expired and it was available for nursing staff to administer to patients.

16. During an interview on 01/08/14 at 10:30 AM Staff BK, Nursing Supervisor, stated that:
- All IV fluids expire 24 hours after accessed.
- All IV fluid bags should have been labeled and verified prior to administration.
- All medications, including wound care products, left at the patient bedside should be labeled and verified prior to administration.
- Medications left in patient rooms are not kept in designated/secure areas.

17. During an interview on 01/08/14 at 3:30 PM, Staff BU, Wound Care Nurse for both facility locations, stated that she was not aware of the policy to label medications left at the bedside and that the wound care medications were not typically labeled. She stated that medications and solutions used for wound care expired on the date listed by the manufacturer on the container and she was not aware of a policy related to expiration dates of open multiple use medications left in patient rooms.

18. During an interview on 01/08/14 at 2:50 PM, Staff BDD, RN, stated that:
- She wasn't sure if medications left in patient rooms required a label or special storage.
- Opened vials of insulin (used for multiple patients) kept in the medication carts should have probably been labeled to ensure it wasn't expired.
- She had recently administered insulin from the unlabeled open/accessed insulin vials kept in medication cart L but probably shouldn't have without making sure it was safe.
- Staff nurses don't secure multiple use medications kept at the bedside because it wouldn't be convenient.
- She verified medications from the MAR and changed IV bags when the tubing (on the infusion pump) expired.

19. During an interview on 01/09/14 at approximately 8:40 AM, Staff BL, Nursing Manager, stated that medications left at the patient bedside should be labeled and verified prior to placing in the room and prior to administration. He stated that nursing staff should ensure all medications including multiple dose vials and multiple use medications and solutions were labeled according to policy prior to patient administration.

20. The Director of Pharmacy was not available for interview at the time of survey.

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Based on observation, interview, medical record review and policy review, the facility failed to ensure the safety and security of medications available for seven of seven patients (#B3, #B4, #B6, #B15, #B17, #B19 and #R7) observed with unsecured medications at their bedside. The failure to ensure medications are safeguarded from tampering or diversion and ultimately safe and available for administration as ordered by the physician had the potential to affect all patients admitted to the facility. The facility census at Bridgeton campus was 39 and the facility census at Richmond Heights campus was 28.

Findings included:

1. Record review of the facility's policy titled, "Medication Preparation and Administration," revised on 01/12, showed the following direction for facility staff:
- Pharmacy was responsible for preparation and distribution of all medications.
- No medication will be dispensed without a valid order.
- No medications would be left at the patient bedside unless there was a valid physician order.

Record review of the facility's policy titled, "Bedside Storage of Medications," revised on 01/12, showed the following direction for staff:
- Pharmacy will indicate on the patient's medication administration record (MAR) which medications are being stored at the bedside.
- A physician's order was required for any and all medications kept at the patient's bedside.
- The physician's order was required to have been written to clearly state that the medication was for self-administration and may be kept at the patient's bedside.
- Medications kept at the patient's bedside must be properly labeled and placed in a secure location.

2. Observation on 01/08/14 at 9:45 AM showed unsecured medications in Patient #B3's room:
- Seven pre-filled syringes containing 10 ml (ml= milliliter, a unit of measure) 0.9% Sodium Chloride IV flush (fluid administered by nursing staff into the blood stream through a tube placed in a vein for medication and/or IV fluid administration);
- One 500 ml bottle of sterile water for irrigation (administered with a syringe into tubes which are placed in a patient i.e., feeding tubes);
- Three 50 mg (milligram= unit of measure) tubes Santyl ointment (a medication applied to the skin to help remove dead skin tissue and aid in wound healing);
- One 250 ml bottle of wound cleanser; and
- One 30 mg tube of triple antibiotic ointment (TAO [an anti-infective medication used to prevent and or treat skin infection]).

3. Observation on 01/08/14 at 9:50 AM showed an Albuterol inhaler (a medication inhaled through the mouth and into the lungs to treat breathing disorders) on the bedside table in Patient #B17's room.

4. Observation on 01/08/14 at 9:55 AM showed one four-ounce container of Calmoseptine ointment (a medication used to prevent and treat skin conditions associated with pain, infection and itching) lying on the window sill in Patient #B19's room.

5. Observation on 01/08/14 at 10:45 AM showed one 30 gm (gram = unit of measure) tube of triple antibiotic ointment on the bedside table in Patient #B4's room.

6. Observation on 01/08/14 at 11:10 AM showed one 250 ml bottle of sterile water on the bedside table in Patient #B6's room.

7. Observation on 01/08/14 at 11:15 AM in Patient #B15's room showed one 250 ml bottle of sterile water and one 16 ounce bottle of CaraKlenz (wound cleanser) on the widow sill.

8. Observation on 01/08/14 at approximately 9:00 AM showed Staff RE, Registered Nurse (RN), administering medications to Patient #R7 in the rehabilitation gym. She stated that the patient's prescribed ipratropium 0.06% nasal spray (used to reduce nasal secretions) was not in the medication cart. She went to the patient's room and the nasal spray was observed on the bedside table.

9. Record reviews on 01/08/14 of the medical records for Patients #B3, #B4, #B6, #B15, #B17, #B19, and #R7 showed no physician orders for the patients' medications to be kept at the patient bedside.

10. During an interview on 01/08/14 at approximately 4:00 PM, Patient #B3 stated that medications left in his room was applied by staff during wound care to his leg and that they had been lying around on the window sill, on his bedside table, and on the food table.

11. During an interview on 01/08/14 at 10:30 AM Staff BL, Nursing Supervisor, stated that medications left in patient rooms are not kept in a secure designated area.

12. During an interview on 01/08/14 at 3:30 PM Staff BU, Wound Care Nurse for both facility locations, stated that wound care medications were not kept in a secure location.

13. During an interview on 01/08/14 at 2:50 PM Staff BDD, RN, stated that medications at the bedside were usually taken from the storage area and not labeled. She stated there weren't any labels in the storage area to lable the medications and if she had to use a label she would take one from the patient's chart. She stated medications are not stored in a secure location in the patient rooms.

14. The Director of Pharmacy was not available for interview at the time of survey.

Based on observation, interview and policy review, the facility failed to follow their hand hygiene policy for eight patients (#R1, #R2, #R3, #R4, #R5, #R7, #R12 and #B14) of 16 patients observed for hand hygiene. These failed practices increased the risk of infection and cross contamination and placed all patients and personnel at risk for hospital acquired infections. The facility census at Bridgeton campus was 39 and the facility census at Richmond Heights campus was 28.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene" revised 12/01/13, showed facility staff were to wash or sanitize their hands:
- Before having direct contact with patients;
- After contact with a patient's intact skin;
- Before moving from a contaminated body site to a clean body site while providing patient care;
- After contact with inanimate (miscellaneous items such as computers, phones, door handles) objects (including medical equipment) in the immediate vicinity of a patient; and
- After removing gloves.

2. Observation on 01/07/14 at 4:45 PM showed Staff RE, Registered Nurse (RN), administered medication to Patient #R3. During the medication administration, Staff RE touched the computer keyboard, computer mouse and medication scanner (identifies medications by scanned bar codes), which were all located on top of a medication cart, and failed to perform hand hygiene before she administered medication to the patient.

3. Observation on 01/08/14 at 9:50 AM showed Staff RV, RN, administer medications to Patient #R12. During the medication administration, Staff RV failed to perform hand hygiene upon entering the patient's room. Staff RV used a blood pressure cuff, stethoscope, medication scanner , computer keyboard, computer mouse, phone and in-room medication lock box keypad, and failed to perform hand hygiene before she removed a pill from protective packaging with her bare hands and administered it to the patient.

4. During an interview on 01/08/14 at 10:20 AM, Staff RV stated that staff should perform hand hygiene prior to entering a patient's room. Staff RV stated that she didn't know if staff were required to perform hand hygiene after touching inanimate objects during patient care, but understood that it could be an infection control risk if it wasn't done. Staff RV added that the computer keyboard, computer mouse, medication scanner and medication carts were cleaned once every 12 hours by staff, and not between each patient use.

5. Observation on 01/08/14 at 12:20 PM showed Staff RU, Occupational Therapist, entered Patient #R12's room and touched the door handle. Staff RU failed to perform hand hygiene before she put on gloves and provided care to the patient.

6. During an interview on 01/08/14 at 1:50 PM, Staff RU stated that she should have performed hand hygiene before she put on gloves and provided care to the patient.

7. Observation on 01/07/14 at approximately 4:30 PM showed Staff RD, RN, enter Patient #R1's room to administer medications. She failed to perform hand hygiene before entering the room and administering an injection to the patient.

8. Observation on 01/07/14 at approximately 4:40 PM showed Staff R, in Patient #R2's room to administer medications. She failed to perform hand hygiene before using the medication cart to prepare medications for the patient.

9. Observation on 01/08/14 at approximately 9:00 AM showed Staff RE, RN, failed to perform hand hygiene upon entering the medication room and removing medications for Patient #R7 from the locked medication dispenser machine.

10. Observation on 01/07/14 at 4:28 PM showed Staff RC, RN, identified Patient #R4 by touching her hand and scanning the patient's arm band. She then typed on the computer keyboard. Staff RC failed to perform hand hygiene after touching the patient.

11. Observation on 01/08/14 at 9:45 AM showed:
- Staff RL, Certified Nurse Assistant (CNA), in Patient #R5's room.
- Staff RL had gloves on each hand, removed the glove on the right hand, and then pulled a corner of the bed sheet over a corner of the bed. She failed to perform hand hygiene after removing her right glove.
- Staff RL removed her left glove and then picked up clean linen sitting on a chair in the patient's room. She failed to perform hand hygiene after removing her left glove.
- Staff RL put on a glove on her right hand, placed the clean linen in a bag, and then left the patient's room. She failed to perform hand hygiene prior to putting on the right glove and upon leaving the patient's room.

12. During an interview on 01/08/14 at 10:15 AM, Staff RL stated that staff should perform hand hygiene before entering and after leaving a patient's room and before putting on gloves and after removing gloves. She stated that she forgot to perform hand hygiene and thought hand hygiene was not necessary because the linen was clean.

13. Observation on 01/08/14 at approximately 9:45 AM showed:
- Staff RK, RN, entered Patient #R5's room and failed to perform hand hygiene.
- Staff RK put on gloves and placed a medicated patch on Patient #R5's back. She failed to perform hand hygiene before putting on gloves.
- Staff RK removed her right glove and touched the Patient #R5's call light. She failed to perform hand hygiene after she removed her right glove.

14. During an interview on 01/08/14 at 10:00 AM, Staff RK stated that staff should perform hand hygiene before entering and after leaving a patient's room and before putting on and after removing gloves. Staff RK stated that she failed to perform hand hygiene because she was not involved in a major procedure.

15. Observation on 01/09/14 at 9:25 AM showed Staff BT, RN, entered Patient #B14's room and touched the door, bed, bed linens, and bedside table. Staff BT failed to perform hand hygiene prior to entering or exiting the room.

16. During an interview on 01/09/14 at 9:30 AM, Staff BV, Director of Quality Management, stated that staff are trained to perform hand hygiene:
- Before entering and upon exiting patient rooms;
- Before and after glove use;
- Before and after touching inanimate objects in patient care areas; and
- Before handling medications.



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