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300 FIRST CAPITOL DRIVE

SAINT CHARLES, MO null

INFECTION PREVENTION CONTROL ABX STEWARDSHIP

Tag No.: A0747

RN SUPERVISION OF NURSING CARE

Tag No.: A0395

Based on interview, record review and policy review the hospital failed to provide appropriate hygiene for four patients (#3, #4, #18, and #19). The lack of appropriate skin care could result in increased infections and impaired skin integrity. These failures had the potential to affect all patients admitted to the hospital. The combined hospital census for both campuses was 58.

Review of the hospital's policy, "Guidelines and Protocols, Clinical," dated 10/01/22, outlined the frequency of certain tasks for staff to complete in order to ensure that quality patient care and standards of care were upheld. Patients are to be bathed, have their hair combed, and be shaved daily.

Review of Patient #3's medical record showed only eight showers were given out of 14 days of his hospitalization.

During an interview on 04/10/23 at 3:30 PM, Staff F, Clinical Coordinator Nurse, stated that baths were given on a daily basis and at that time, linens were changed.

During an interview on 04/10/23 at 3:45 PM, Patient #3's wife, stated that the patient had not received a bath for two weeks and his bed had not been changed.

During an interview on 04/11/23 at 9:45 AM, Patient #3's mother, stated that there was a problem with bathing and that her son was not bathed daily. She stated that she often had to clean him the best she could.

Review of Patient #4's medical record showed two showers and two baths were given out of 32 days of hospitalization.

During an interview on 04/10/23 at 3:20 PM, Patient #4, stated that he had just completed his first shower in two weeks.

Review of Patient #18's medical record showed no showers or baths were given out of nine days of hospitalization.

Review of Patient #19's medical record showed two baths were given out of eight days of hospitalization.

During an interview on 04/11/23 at 3:30 PM, Staff T, Certified Nursing Assistant (CNA), stated that all baths and showers should have been documented daily. She stated that the day shift did the even numbered rooms and night shift did the odd numbered rooms. She stated that all bathing and/or showers refused should have been documented.

During an interview on 04/11/23 at 3:35 PM, Staff M, CNA, stated that all baths should have been documented daily and if a patient refused, it should have been documented as a refusal.

During an interview on 04/11/23 at 3:20 PM, Staff A, Chief Nursing Officer (CNO), stated that all patients should have received a daily bath and if anyone refused it was to have been documented as refused. She stated that patients who were able to shower received a shower once per week.

40189

INFECTION CONTROL PROGRAM

Tag No.: A0749

Based on observation, interview and policy review, the hospital failed to ensure infection prevention policies were followed when:
- Staff did not perform hand hygiene (HH, washing hands with soap and water or alcohol-based hand sanitizer) with glove changes when providing care for five patients (#1, #3, #4, #5, and #16) of 11 patient's observed;
- Staff did not appropriately duff and don personal protective equipment (PPE, such as gloves, gowns, goggles and masks) upon exiting and re-entering one patient's (#4) room while providing care;
- Staff did not prepare a clean work surface prior to a dressing change for one patient (#4) of two patients observed;
- Staff did not ensure that one patient's (#2) urinal was appropriately stored at the bedside;
- Staff did not ensure the proper storage of large paper towel rolls, within the touch free dispenser;
- Staff did not properly label the tube feeding container or tubing for two patients (#3 and #5) of five patients observed;
- Staff did not date or time intravenous (IV, in the vein) fluid bag or tubing for one patient (#8) of two observed;
- Staff did not date and/or discard opened, undated multi-use bottles in two patient (#4 and #5) rooms of two patients observed;
- Seven staff members (Staff B, E, F, M, Q, R, and S) were allowed to wear decorative and/or gel nail polish when providing direct patient care;
- Staff did not remove undated beverages and cookies from the nourishment room; and
- Staff did not remove expired supplies from stock.

These failures had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The combined hospital census for both campuses was 58.

Review of the hospital's policy titled, "HH," dated 07/2021, showed that HH should be performed before and after every patient contact, between patient care activities within the same episode of care, when moving from dirty area of the body to a clean area, before placing on either sterile gloves or non-sterile gloves, between glove changes, before any patient procedure or administering medications, before going into a patient's room and upon leaving the patient's room.

Review of the hospital's policy titled, "Contact/Contact Enteric (occurring in the intestines) Precautions," dated 10/2022, showed that:
- Sufficient precautions to control cross-infection in this category of isolation include proper HH, handling of linen, dressings and contaminated instruments, and the use of gowns, masks and gloves when stipulated.
- Patients with contagious enteric infections will be placed on contact enteric precautions. HH will be performed using soap and water.
- Gowns should be worn when soiling will be likely to occur or when contact with the patient or environmental surfaces that have been contaminated will occur.
- HH with alcohol based cleanser must be performed upon entering and leaving the patient's room.
- Non-sterile gloves are to be worn by persons having direct contact with the patient and the environment. Gloves must be removed before leaving the room.
- All equipment that needs to be shared will be disinfected between patients.
- A safe zone that is considered clean in a patient's room will be no more than three feet into the room while maintaining a distance of at least three feet from the patient's bed. Staff are not to touch anything in the room without putting on PPE.
- Staff is to put on appropriate PPE, cover the scan gun with a bag from the isolation gown or glucometer sleeve before use in the patient's room.

Review of the hospital's policy titled, "Standard Precautions (SP, also known as universal precautions, avoiding contact with patients' bodily fluids by means of wearing gloves, goggles and face shields)," dated 10/2022, showed that:
- SP are designed to reduce the risk of transmission of microorganisms (organisms, such as bacteria, too small for the naked eye) from both recognized and unrecognized sources of infection in hospitals.
- The components of SP include hand HH and use of appropriate PPE.
- SP apply to blood, all body fluids, secretions and excretions regardless of whether or not they contain visible blood, non-intact skin and mucous membranes.
- HH is required before and after every patient interaction even when gloves are used.
- Gloves are to be worn when giving direct patient care.
- HH must be performed prior to putting on gloves and after removing gloves. Gloves do not replace the need for HH.
- Articles dropped on the floor will be disinfected or discarded.

1. Review of Patient #1's medical record showed he was a 69 year-old male admitted with respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) due to Klebsiella pneumonia (a drug resistant bacteria that can cause infections such as pneumonia, bloodstream, wounds or surgical sites) and was placed on contact precautions (precautions used to minimize the risk of infection spreading through touching an infected person or contaminated object).

Concurrent observation and interview on 04/10/23 at 3:20 PM, showed Staff Q, Registered Nurse (RN), retrieved the phone out of a pocket and answered it with dirty gloves on in Patient #1's isolation room. Staff Q failed to perform HH or change gloves prior to or after the use of the phone. Staff F, Clinical Coordinator Nurse (CCN), stated that the use of a phone in an isolation room was not appropriate. She stated that the nurse's PPE should have been removed and HH performed prior to answering the phone outside the contamination area. She stated that the PPE process would have had to start all over again after the phone call was completed.

Review of Patient #3's medical record showed he was a 43 year-old male admitted for a traumatic brain injury (TBI).

Observation on 04/11/2023 at 09:45 AM, showed Staff M, Certified Nursing Assistant (CNA), failed to perform HH when she left and reentered Patient #3's room.

Review of Patient #4's medical record showed he was a 33 year-old male admitted with sepsis (life threatening condition when the body's response to infection injures its own tissues and organs) and placed on contact precautions for pseudomonas (a type of bacteria that can cause lung, urine, and/or wound infections, it is contagious, transferred through contact of contaminated surfaces, or equipment, or person to person touch) in his left hip wound beds.

Observation on 04/10/23 at 3:20 PM, showed Staff I, RN, and Staff H, Wound Care Nurse (WCN), cleansed a wound on Patient #4's left hip, applied a dressing over the wound, and secured the dressing with the tape that was lying on the bed linens. Without removing her gloves or performing HH, she obtained the dry erase marker, dated and initialed the exterior of the dressing, and returned the marker to the dry erase board without cleansing it. She then removed the collection canister from a wound vacuum, placed the wound vacuum into the case, cleansed the outside of the case, placed it into a plastic bag that had been lying on the seat surface of a chair without a clean barrier, wearing the same pair of gloves throughout the entire process. No HH or glove changes were completed.

During an interview on 04/10/23 at 3:40 PM, Staff I, RN, stated that HH should be performed before and after each glove change, after dressing removal, and prior to application of a clean dressing. Dry erase markers should not be utilized to document on patient's wound dressings, but if used, they should be cleaned.

During an interview on 04/10/23 at 3:45 PM, Staff H, WCN, stated that all nurses received dressing change instruction and HH expectations, upon hire during their orientation.

Review of Patient #5's medical record showed she was a 76 year-old female that was admitted with acute respiratory failure, had a tracheostomy (an opening created in the neck in order to place a tube into a person's windpipe that allows air to enter the lungs) and was on a ventilator (a machine that supports breathing).

Concurrent observation and interview on 04/10/2023 at 3:50 PM, showed Staff K, RN, changed Patient #5's mid-line sterile dressing. She failed to change her sterile gloves after she lifted the patient's arm and placed the patient's arm on the sterile barrier pad prior to the dressing change. Staff K stated that her gloves should have been changed after lifting the patient's arm off the bed onto the sterile barrier pad.

Observation on 04/11/23 at 10:54 AM, showed Staff N, RN, touched a monitor, then proceeded with the same gloves on to readjust Patient #5's ventilator tubing. Staff N failed to perform HH or change gloves after touching the monitor and before she provided respiratory care to the patient.

During an interview on 04/11/23 at 11:02 AM, Staff N, RN stated that her gloves should have been removed, HH performed and then placed on new gloves after touching equipment in the room and prior to providing direct patient care.

During an interview on 04/12/23 at 11:43 AM, Staff B, Infection Control Preventionist (ICP), stated that monitors were considered dirty in patient rooms and gloves should have been removed and HH performed prior to further care provided; when moving from dirty to clean, HH was to be performed and gloves were to have been changed.

During an interview on 04/12/23 at 2:34 PM, Staff A, Chief Nursing Officer (CNO), stated that HH and a glove change was expected after touching objects in the patient room and before care was again provided.

Observation on 04/11/2023 at 2:10 PM, showed Staff S, RN, failed to perform HH and change gloves after picking up a pill that was dropped on the floor in Patient #16's room during medication administration.

During an interview on 04/11/2023 at 2:30 PM, Staff F, CCN, stated that Staff S, RN, should have performed HH and changed gloves after picking up a pill that was dropped on the floor.

During an interview on 04/12/23 at 11:34 AM, Staff B, ICP, stated that after the nurse dropped the pill and picked it up, she would have expected that HH was performed and new gloves were placed on before the medication was administered.

2. Observation on 04/10/23 at 3:20 PM, showed Staff I, RN, obtained the dry erase marker from the room's dry erase board to date and initial the exterior of Patient #4's left upper hip wound. She then replaced the marker on the board without cleansing it. She removed her gloves and exited the room wearing her isolation gown. She obtained supplies for the care and re-entered the room, wearing the same gown.

During an interview on 04/10/23 at 3:40 PM, Staff I, RN, stated that PPE, such as an isolation gown should not be worn outside of the patient room. If it was necessary to exit the room, all PPE should be removed and clean PPE re-applied upon re-entry.

During an interview on 04/12/23 at 11:34 AM, Staff B, ICP, stated that the use of a marker off the board on the wall was not appropriate if the nurse had not performed HH and placed on new gloves prior to labeling the dressing; she stated that it was not appropriate for staff to have crossed the demarcation line, into a clean area after they were in the dirty room.

During an interview on 04/12/2023 at 7:10 AM, Staff CC, CNA, stated that there had been times when she did not put on the required PPE before entering a room.

3. Observation on 04/10/23 at 3:20 PM, showed Staff I, RN and Staff H, WCN, placed sterile dressing packages, tape, and wound cleanser directly onto Patient #4's bed linens, without placing a clean barrier. Once wound care was completed, Staff H, WCN, removed the collection canister from a wound vacuum, placed the wound vacuum into the case, cleansed the outside of the case, placed it into a plastic bag that had been lying on the seat surface of a chair without a clean barrier. No HH or glove change was completed during this process.

During an interview on 04/10/23 at 3:40 PM, Staff I, RN, stated that a clean surface or a clean barrier for supplies should be used, they should not be placed directly on a patient's bed linens.

During an interview on 04/12/23 at 11:34 AM, Staff B, ICP, stated that she would have expected that if a table was utilized for patient care that it was sanitized and a barrier placed down; she was surprised to find that Staff H, WCN, had not placed a barrier down before wound care supplies were opened.

4. Concurrent observation and interview on 04/10/23 at 3:40 PM, showed Patient #2's urinal on the over-bed table next to a drinking cup. Staff F, CCN, stated that the urinal should not have been on the over-bed table and that the table needed sanitization.

During an interview on 04/10/23 at 3:43 PM, Staff L, RN, stated that the urinal should not have been on the over-bed table, but that the patient kept using it and had placed it there several times.

During an interview on 04/12/23 at 11:43 AM, Staff B, ICP, stated that a urinal should not have been on the over-bed table, next to a clean drinking cup and that she would have expected the table was sanitized once the urinal was found and removed.

5. Concurrent observation and interview on 04/10/23 at 3:45 PM, showed a clean roll of paper towels sitting on a dirty linen cart inside Patient #3's room. Patient #3's wife stated that the paper towel roll had been there at least a week.

Observation on 04/11/2023 at 09:45 AM, showed a roll of opened paper towels lying on the sink in Patient #5's room.

During an interview on 4/11/23 at 10:45 AM, Staff F, CCN, stated that a clean roll of paper towels were not to have been placed on a dirty linen cart in a patient's room, they should have been placed in the automatic dispenser.

During an interview on 04/12/23 at 2:34 PM, Staff A, CNO, stated that it was not acceptable to have placed a clean roll of paper towels on a dirty linen cart or on the edge of the sink.

During an interview on 04/12/23 at 11:43 AM, Staff B, ICP, stated that it was not acceptable to have had clean paper towels on a dirty linen cart; clean paper towels should have been placed in the automatic dispenser.

6. Review of the hospital's policy titled, "Gastric/Duodenal Tube Guidelines," dated 04/01/23, showed directive for staff to label tube feeding bags with the patient name, date of birth, date, time, and rate of infusion.

Observation on 04/10/23 at 3:45 PM, showed Patient #3's tube feeding bottle and tubing with no patient name, date of birth or date or time it was hung.

Observation on 04/10/2023 at 3:50 PM, showed Patient #5's tube feeding with no patient name, date of birth, time, or rate of infusion on the tube feeding bag. There was no date on the tubing or water bag that was hanging to be infused throughout the designated tube feeding.

During an interview on 04/10/23 at 3:50 PM, Staff K, RN, stated that tube feedings should be labeled with patient name, date, and time it was started and that the tubing and the bag of water used during the administration of the feeding should have a date on it.

During an interview on 04/11/23 at 10:45 AM, Staff F, CCN, stated that tube feeding bottle and tubing was to have been dated and timed at a minimum and sometimes initialed.

During an interview on 04/12/23 at 2:34 PM, Staff A, CNO, stated that tube feeding bottles and tubing were to have been labeled with the date and time it was hung.

During an interview on 04/12/23 at 11:43 AM, Staff B, ICP, stated that when tube feeding was started, night shift was to have dated and timed both the bottle of tube feeding and the tubing itself.

7. Review of the hospital's policy titled, "Guidelines and Protocols, Clinical," dated 10/01/22, outlined the frequency of certain tasks for staff to complete in order to ensure that quality patient care and standards of care were upheld. Primary IV tubing should be labeled with the date, time, and initials upon initiating.

Review of Patient #8's medical record showed he was a 77 year-old male that was admitted for post-surgical wound care.

Observation on 04/11/23 at 11:10 AM, in Patient #8's room, showed one bag of IV fluids and tubing were not dated or timed.

During an interview on 04/11/23 at 11:15 AM, Staff O, RN, stated that IV fluids and tubing were to have been dated and timed when they were hung.

8. Review of the hospital's policy titled, "Guidelines and Protocols, Clinical," dated 10/01/22, outlined the frequency of certain tasks for staff to complete in order to ensure that quality patient care and standards of care were upheld. Irrigation solutions should be dated and initialed when opened and discarded after 24 hours.

Observation on 04/10/23 at 3:20 PM, showed an undated, open bottle of sterile saline sitting on top of the sharps container in Patient #4's room.

Observation on 04/10/2023 at 3:50 PM, showed an undated, open bottle of sterile saline sitting on the sink in Patient #5's room.

Observation on 04/10/2023 at 3:50 PM, showed an undated, unlabeled, tube irrigation kit sitting on the sink in Patient #5's room.

During an interview on 04/10/2023 at 4:00 PM, Staff K, RN, stated that all opened saline bottles should be labeled with the date and time it was opened.

During an interview on 04/12/23 at 2:34 PM, Staff A, CNO, stated that she would have expected that open saline bottles and tube irrigation kits would have been dated and timed.

9. Review of the hospital's policy titled, "HH," dated 07/2021, showed the use of artificial nails or nail extenders, which includes wraps, tips, acrylics, silks, fiberglass bonding, gel nail polish and gel nail extenders by direct care staff are not allowed.

Review of the hospital's policy titled, "Contact/Contact Enteric (occurring in the intestines) Precautions," dated 10/2022, showed no direct caregiver staff may have artificial fingernails which includes any type of acrylic, gel or press on. No natural nails that are longer than one fourth inch.

Review of the hospital's document, "HH Competency Checklist," dated 11/20/20, showed there were to be no artificial nails or enhancements, which include gel, thickening agents and any form of topical treatment other than nail polish.

Concurrent observation and interview on 04/11/23 at 2:00 PM, showed Staff Q, RN, had gel nail polish on her nails, which she verbally confirmed.

Concurrent observation and interview on 04/11/23 at 2:10 PM, showed Staff S, RN, had gel nail polish on her nails, which she verbally confirmed.

Concurrent observation and interview on 04/11/23 at 2:15 PM, showed Staff R, RN, had gel nail polish on her nails, which she verbally confirmed.

Concurrent observation and interview on 04/11/23 at 2:30 PM, showed Staff F, CCN, had gel nail polish on her nails, which she verbally confirmed.

Concurrent observation and interview on 04/11/23 at 2:45 PM, showed Staff M, CNA, had gel nail polish on her nails, which she verbally confirmed.

Concurrent observation and interview on 04/11/23 at 3:00 PM, showed Staff E, House Supervisor (HS), had gel nail polish on her nails, which she verbally confirmed.

Concurrent observation and interview on 04/11/23 at 3:15 PM, showed Staff B, ICP, had gel nail polish on her nails, which she verbally confirmed.

During an interview on 04/12/2023 at 3:30 PM, Staff B, ICP, stated that she participated in direct patient care.

During an interview on 04/11/2023 at 3:30 PM, Staff A, CNO, stated that staff should not have gel nail polish on according to the policy. She stated that Staff B, ICP, Staff E, HS, and Staff F, CCN, were in leadership roles but did participate in direct patient care and should not have gel nail polish on.

During an interview on 04/12/23 at 11:43 AM, Staff B, ICP, stated that staff were allowed to wear gel nail polish but were not allowed to wear gel nail extenders; natural nails were to be no longer than one-fourth of an inch past the tip of the finger.

During an interview on 04/12/23 at 2:34 PM, Staff A, CNO, stated that staff were told they were allowed to wear gel nail polish, but she disagreed with that practice.

10. Review of the hospital's policy titled, "Food and Nutrition Policies and Procedures," dated 01/2021, showed perishable food should be labeled with the patient's name and date, and once the food is taken into the patient's room it may not be returned to the patient refrigerator.

Observation on 04/11/2023 at 10:30 AM, in the designated patient nutrition room, showed:
- Two individual cookies in plastic bags on the counter without a patient name and date;
- One container of peaches covered with plastic wrap in the refrigerator without a patient name and date; and
- Two slushies in the freezer without a patient name and date.

During an interview on 04/11/23 at 10:30 AM, Staff A, CNO, stated that all food items in the refrigerator and freezer should be labeled with a patient name and date.

During an interview on 04/12/23 at 11:43 AM, Staff B, ICP, stated that all patient food should have had a patient sticker with the date and time; dietary was responsible for the removal of expired food and drinks.

11. Concurrent observation and interview on 04/10/23 at 3:35 PM, showed in the supply room there were three expired urinary leg bags dated 04/01/23 out of six bags observed. Staff F, CCN, stated that environmental rounds by the materials manager were conducted weekly to check for expired supplies and agreed the three bags should have been removed.

During an interview on 04/12/23 at 11:43 AM, Staff B, ICP, stated that the materials manager was responsible for the removal of outdated supplies.

40189

HospitalInspections.org

SELECT SPECIALTY HOSPITAL-ST LOUIS

INFECTION PREVENTION CONTROL ABX STEWARDSHIP

RN SUPERVISION OF NURSING CARE

INFECTION CONTROL PROGRAM