HospitalInspections.org

Based on observation, interview and policy review, the hospital failed to:
- Prepare a clean work surface prior to performing patient care for two current patients (#5 and #6) of 11 patients observed;
- Perform hand hygiene (HH, washing hands with soap and water or alcohol-based hand sanitizer) during patient care for four current patients (#4, #5, #6 and #15) of 19 patients observed;
- Perform glove changes for four current patients (#4, #5, #6 and #15) of 17 patients observed;
- Ensure intravenous (IV, in the vein) lines were dated and timed for one current patient (#6) of 14 patients observed;
- Ensure that an isolation gown was tied in the back for two current patients (#4 and #6) of 14 patients observed;
- Ensure that isolation personal protective equipment (PPE) was removed prior to exiting a patient's room for one current patient (#23) of 14 patients observed;
- Discard expired (past the date of safe use) food items in the patient nutrition room for two patient care units of two patient care units observed;
- Ensure expiration dates were marked on frozen food items in the freezer for one patient care unit of two patient care units observed; and
- Ensure expiration dates were marked on dried food item bags and bins for two patient care units of two patient care units observed.

The severity and cumulative effects of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs and resulted in the hospital's failure to ensure quality health care and safety.

Please refer to A-0749 for details.

Based on observation, interview and policy review, the hospital failed to:
- Prepare a clean work surface prior to performing patient care for two current patients (#5 and #6) of 11 patients observed;
- Perform hand hygiene (HH, washing hands with soap and water or alcohol-based hand sanitizer) during patient care for four current patients (#4, #5, #6 and #15) of 19 patients observed;
- Perform glove changes for four current patients (#4, #5, #6 and #15) of 17 patients observed;
- Ensure intravenous (IV, in the vein) lines were dated and timed for one current patient (#6) of 14 patients observed;
- Ensure that an isolation (to separate those known or suspected to be contagious)
gown was tied in the back for two current patients (#4 and #6) of 14 patients observed;
- Ensure that isolation personal protective equipment (PPE, such as gloves, gowns, goggles and masks) was removed prior to exiting a patient's room for one current patient (#23) of 14 patients observed;
- Discard expired (past the date of safe use) food items in the patient nutrition room for two patient care units of two patient care units observed;
- Ensure expiration dates were marked on frozen food items in the freezer for one patient care unit of two patient care units observed; and
- Ensure expiration dates were marked on dried food item bags and bins for two patient care units of two patient care units observed.

Findings included:

Although requested, the hospital failed to provide a clean work surface or use of a barrier policy.

Observation on 07/30/24 at 10:42 AM, showed that Staff I, RN, failed to place a clean barrier down when she placed a clean dressing directly onto Patient #5's stool soiled bed pad, removed the soiled dressing, cleaned the patient and then prepared and applied the new dressing to the patient's wound.

Observation with concurrent interview on 07/29/24 at 3:00 PM, showed Staff E, Registered Nurse (RN) failed to set up a barrier to assemble sterile field for the dressing change supplies. Dressing change supplies were placed on Patient #6's bed, without any barrier protection. Patient #6 was in contact isolation. Staff E stated she should have cleaned Patient #6's bedside table and assembled the mid-line dressing supplies on a surface with a barrier.

Review of hospital policy titled, "Hand Hygiene," dated 04/2023, showed staff were to perform HH:
- Before and after every patient contact;
- Between patient care activities within the same episode of care;
- When moving from high contamination patient care activities to cleaner activities/if moving from a contaminated body site to a less contaminated body site;
- Before donning either sterile or non- sterile gloves;
- Between glove changes and after removing gloves after any contact with body fluids, dressings, or patient linens;
- Before any patient procedure or medication administration; and
- Before going into a patient room and before leaving a patient room.

Review of hospital policy titled, "Standard Precautions," dated 04/2023, showed:
- Gloves will be changed after every patient contact, when moving from dirty to clean
task and will never be washed between patients;
- Gloves must be removed before one exits the room or work area;
- HH must be performed prior to putting on gloves and after removing gloves; and
- Gloves do not replace the need for HH.

Review of the hospital's policy, "IV Therapy: Short Peripheral and Midline IV Therapy," revised 07/01/24, showed when changing a mid-line catheter staff will remove gloves used to remove previous dressing, then perform HH before donning sterile gloves to cleanse skin and apply new dressing.

Observation on 07/29/24 at 3:18 PM, showed Staff D, RN, entered Patient #4's isolation room and failed to perform HH before placing an isolation gown on and donning gloves.

During an interview on 07/29/24 at 3:20 PM, Staff D, RN, stated that she did not realize that she had not performed HH before putting her gloves on and stated she should have.

Observation on 07/30/24 at 8:47 AM, showed Staff I, RN entered Patient #5's room, performed a blood pressure check and scanned the patient identification band. She failed to perform HH after scanning the patient's identification band and before preparing medication for administration through the gastrostomy tube (G-tube, soft, flexible tube inserted through the skin of the abdomen and into the stomach). She then failed to perform HH before donning clean gloves and administering the prepared medication through the G-tube.

Observation on 07/30/24 at 10:42 AM, showed that Staff I, RN, failed to perform HH and change gloves after she removed a soiled wound dressing and cleaned stool off Patient #5 and before she applied the new dressing to the wound.

Observation with concurrent interview on 07/29/24 at 3:00 PM, Staff E, Registered Nurse (RN), failed to remove contaminated gloves, perform HH and don sterile gloves when she changed Patient #6's mid-line catheter dressing. Staff E stated that she should have removed her contaminated gloves before she donned sterile gloves over the contaminated gloves.

Observation on 07/30/24 at 9:15 AM, showed that Staff I, RN, failed to perform hand hygiene after scanning the patient identification band for Patient #15 and before preparing medication for administration via G-tube.

Review of the hospital's policy, "IV Therapy: Short Peripheral and Midline IV Therapy," revised 07/01/24, showed IV tubing will be labeled with the date and time changed.

Observation with concurrent interview on 07/29/24 at 3:00 PM, showed Patient #6's IV tubing was not labeled with the date and time it was changed. Staff E confirmed the tubing was not labeled with the date or time it was changed. She stated that all IV tubing should be labeled with the date and time it was changed.

Review of the hospital's policy titled, "Standard Precautions," dated 04/2023, showed gowns are to be tied securely covering the back and removed before leaving the patient's environment.

Observation on 07/29/24 at 3:18 PM, showed Staff D, RN, failed to tie the isolation gown in the back prior to providing care to Patient #4.

During an interview on 07/29/24 at 3:20 PM, Staff D, RN, stated that per policy she was to have tied her isolation gown in the back and she had not.

Observation on 07/29/24 at 3:00 PM, showed Staff E, RN, failed to tie the isolation gown in the back prior to providing care to Patient #6.

Observation on 08/01/24 at 9:35 AM, showed Staff X, RN, stepped out of Patient #23's room into the hallway with her isolation gown and gloves on and moved the workstation on wheels (WOW) closer to the door.

During an interview on 08/01/24 at 10:00 AM, Staff X, RN, stated that she was not sure what the policy stated. She added she should not have stepped out of a patient's room and into the hallway wearing an isolation gown.

Review of the hospital's policy titled, "Food and Nutrition," dated 11/01/15, showed food must be rotated using the first-in, first-out method so that those with the earliest use-by or expiration dates are used first. Food was to be discarded when it reached its use-by date or expiration date. There was no direction provided to ensure there was an expiration date on all food and condiments to show when perishable items were to be discarded.
Observation on 07/30/24 at 2:51 PM, in the nutrition room, at the Town and Country location, showed:
- A bag that contained individual mustard packets had no expiration date;
- A bin with seven individual syrup cups had no expiration date;
- A bin full of mayonnaise packets had no expiration date;
- A bin full of sugar packets had no expiration date;
- A bin full of sweetener packets had no expiration date;
- A bin full of tea bags had no expiration date;
- A bin full of individual broth packets had no expiration date; and
- 25 packets of food and liquid thickener that expired on 06/29/24.

During an interview on 07/30/24 at 3:00 PM, Staff A, Chief Executive Officer (CEO), stated that Food and Nutritional Services in the main hospital was responsible for stocking the food items and he was unsure how often they checked the dates. He added that he expected staff to check to ensure there were expiration dates on food items and that expired food was removed.

Observation on 07/31/24 at 3:00 PM, in the nutrition room, at the St. Charles location, showed:
- Two plastic bags that contained individual sugar packets that were expired.
- One plastic bag that contained individual Splenda packets that was expired.
- Eight sorbet cups were not labeled with an expiration date.

During an interview on 07/31/24 at 3:00 PM, Staff AA, Nurse Tech, stated the two bags containing individual sugar packets and the bag containing Splenda packets were expired. She verified that the eight sorbet cups did not have an expiration date.

During an interview on 08/01/24 at 1:33 PM, Staff B, Quality Management Director and Infection Preventionist, stated:
- Staff should perform hand hygiene with all the five moments of patient care, coming in or out of a room, when working with dirty areas and moving to clean areas, after touching patients or supplies and to follow the policies.
- Staff should change gloves anytime they were considered dirty.
- Staff should clean a surface with the wipes and appropriate dry time or a barrier should be placed down for a clean work surface.
- A patient's bed was not a clean work surface.
- It was not acceptable to step outside of a patient's isolation room with a gown on. The expectation would have been for the nurse to have removed all PPE and perform HH before leaving the room.
- The hospital was responsible for stocking the nutrition room and staff were responsible for checking the expiration dates on all food items.

During an interview on 08/01/24 at 1:42 AM, Staff C, Chief Nursing Officer (CNO), Town and Country location, stated:
- Hand hygiene and glove changes should be performed per the policy and specifically anytime the nurse goes from a dirty process to a clean process;
- A clean work surface would be expected to be used for all procedures, including wound care;
- A clean work surface would be an area cleansed with the appropriate disinfectant and allowed proper dry time prior to use or placing a clean barrier on the work surface; and
- A patient's bed was not a clean work surface.

During an interview on 08/01/24 at 12:50 PM, Staff S, CNO, St. Charles location, stated that it was not appropriate to leave a patient's room with an isolation gown on.




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