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A. Based on document review, observational tour, and interview, it was determined for 1 of 5 staff (MD #1) in Interventional Radiology and 1 of 7 staff (E #6) in Operating Room (OR) 12, the Hospital failed to ensure staff hair was completely covered when participating in surgical procedures involving sterile instruments.

Findings include:

1. On 9/1/16 at 10:15 AM, Hospital policy #4040-D-005, titled, "Dress Code for Surgical Environment", revised 5/13/13, was reviewed. The policy required, "3. Surgical head covers or hoods that confine all hair will be worn by all personnel entering a surgical environment."

2. On 8/30/16 between 2:25 PM and 3:15 PM, an observation tour was conducted in Interventional Radiology room 6. An Intervential Radiologist (MD #1) was performing a central line insertion. MD #1's cap did not cover the lower back of his head, leaving approximately 1 inch of hair exposed.

3. On 8/30/16 at 3:15 PM, an interview was conducted with the Vice President of Clinical Services (E #4). E #4 stated she would talk to MD #1 regarding his exposed hair.

4. On 8/31/16 between 7:35 AM and 8:15 AM, an observational tour was conducted in Operating Room 12. At 7:50 AM, a Regstered Nurse (E #6) entered the room where sterile instruments were open. E #6's hair was exposed approximately 2 inches at the back of her head.

5. On 8/31/16 at 8:15 AM, an interview was conducted with the Director of Perioperative Services (E #7). E #7 agreed E #6's hair was hanging below the cap and stated she would discuss it with E #6.

B. Based on document review, observational tour, and interview, it was determined for 1 of 2 Student Respiratory Therapist (Z #1), the Hospital failed to ensure non-staff individuals providing patient care, did not contaminate bandage tape.

Findings include:

1. On 9/1/16 at 10:30 AM, Hospital policy #6020-10-001, titled, "Isolation Precautions", revised 1/24/05, was reviewed. The policy required, "Contact Precautions... Restrict use of non-critical patient care equipment to use by the isolated patient only... transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, such as contaminated... dressings..." The policy did not specifically mention tape.

2. On 8/30/16 between 1:15 PM and 2:15 PM, an observational tour was conducted in the Intensive Care Unit (ICU). At 1:45 PM, a Respiratory Therapist Student (Z #1) assisted a Respiratory Therapist, listening to breath sounds for Pt. #3, in a contact isolastion room (room 7118). Z #1 used a dedicated stethescope for Pt. #3 in room 7118. However, Z #1's own stethescope, present in the isolation room, had a roll of tape hanging from an ear piece. Z #1 wore the stethescope with the tape roll into the ICU hall after leaving the isolation room. The potentially contaminated tape was available for use on other patients.

3. On 9/30/16 at 1:50 PM, an interview was conducted with Z #1. Z #1 stated she was not aware the tape roll should not be carried from room to room.

C. Based on document review, observational tour, and interview, it was determined for 3 of 3 Anesthesiologists (MD #2, 3, & 4), the Hospital failed to ensure anesthesiologists did not carry prepared medication syringes in their pockets, labeled prepared syringes, dated open medication vials, and disposed of syringes in a sharps container.

Findings include:

1. On 9/1/16 at 10:45 AM, Hospital policy #6000-M-017, titled, "Medication Administration", revised 6/21/16, was reviewed. The policy required, "Procedure... 16. Medications prepared for a procedure or sterile field, but not administered immediately: medications must be appropriately labeled with: a. medication name and quantity... d. expiration time when expiration occurs within 24 hours.... e. the initials of the person preparing the medication... 18. Medication storage: medications are secured at all times in designated areas..." The policy did not include prepared medication syringes were not to be carried in a shirt pocket.

2. On 8/31/16 between 7:10 AM and 7:35 AM, an observational tour was conducted in the preop holding area in the Center for Short Stays (outpatient). Pt. #5 was in room I5 awaiting a femoral nerve block. At 7:20 AM, an Anesthesiologist (MD #2) entered room I5 with 2 prepared medication syringes in his scrub shirt pocket. MD #2 administered some of the contents of 1 syringe into Pt. #5's intravenous line and returned the syringe to MD #2's pocket. It was not determined if the syringes were labeled.

3. On 8/31/16 at 8:15 AM, an interview was conducted with the Director of Perioperative Services (E #7). E #7 agreed MD #2 should not carry prepared medication syringes in his pocket and stated she would talk to him.

4. On 8/31/16 at 8:25 AM, an observational tour was conducted in Operating Room 1. OR 1 was not occupied and sterile supplies were not open. The anethesia cart was unlocked and contained 2 prepared medication syringes (Neostigmine, 10 ml, with no date, time, or initials of preparer and a white liquid in a 20 ml syringe, without a label). There was also 1 open, undated vial of Ephedrine.

5. On 8/31/16 at 8:25 AM, an interview was conducted with an Anethesiolgist (MD #3). MD #3 stated he had drawn up the medication today and would use it in the next procdure and he intended to dispose of the Ephedrine. E #7 was present during the interview.

6. On 8/31/16 at 9:35 AM, an observational tour was conducted in the Endoscopy area, room 4. Room 4 was not occupied and there were 3 used syringes and 1 empty medication vial in the regular trash, not in a sharps container.

7. On 8/31/16 at 9:35 AM, an interview was conducted with an Anethesiolgist (MD #4). MD #4 stated "the sharps container was almost full", but did not explain why he disposed of the syringes and medication vial in the regular trash. E #7 was present during the interview.

D. Based on document review, observational tour, and interview, it was determined for 1 of 5 physicians (MD #2), the Hospital failed to ensure physicians disinfected their hands before performing a procedure and after removing gloves.

Findings include:

1. On 9/1/16 at 2:30 PM, Hospital policy #6020-19-001, titled, "Handwashing and Hand Hygiene", revised 7/12/05, was reviewed. The policy required, "At a minimum, staff will wash hand during the following times... [may use] alcohol-based hand rubs, after touching contaminated surfaces, after removing gloves..."

2. On 8/31/16 between 7:10 AM and 7:35 AM, an observational tour was conducted in the preop holding area in the Center for Short Stays (outpatient). Pt. #5 was in room I5 awaiting a femoral nerve block. At 7:20 AM, an Anesthesiologist (MD #2) entered room I5 and donned gloves and scrubbed Pt. #5's right femoral area. MD #2 removed the gloves and donned sterile gloves, without disinfecting his hands, and performed a femoral nerve block. At 7:35 AM, when the procedure was completed, MD #2 removed the gloves and left the preop area without disinfecting his hands.

3. On 8/31/16 at 7:35 AM, an interview was conducted with the Director of Perioperative Services (E #7). E #7 stated she would talk to MD #2 about disinfecting his hands before an invasive procedure and after removing his gloves.

E. Based on document review, observational tour, and interview, it was determined, for 1 of 1 transporter (E #9), the Hospital failed to ensure staff did not touch blankets covering patients with contact precautions.

Findings include:

1. On 9/1/16 at 10:30 AM, Hospital policy #6020-10-001, titled, "Isolation Precautions", revised 1/24/05, was reviewed. The policy recquired, "Contact Precautions... Gloves - Required for contact with patient, environmental surfaces, and patient care items.

2. On 9/1/16 between 10:50 AM and 11:30 AM, an observational tour was conducted in the Interventional Radiology (IR) area. Pt. #6 was waiting on a cart in the corridor for a video swallow test. Pt. #6 was in contact isolation and being attended by a Radiology Technician. Pt. #6 had been transported to IR by a Transporter (E #9). The Surveyor asked E #9 what was required to transport a patient with contact precautions. E #9 provided a satisfactory answer, but while leaving, intentionally touched the foot of Pt. #6 through the blanket. E #9 left the IR area without disinfecting her hands.

3. On 8/31/16 at 10:55 AM, an interview was conducted with the Vice President of Support Services (E #4). E #4 stated she also saw E #9 touch the Patient's blanket with an ungloved hand, which E #9 should not have done.

A. Based on document review, observational tour, and interview, it was determined for 1 of 5 staff (MD #1) in Interventional Radiology and 1 of 7 staff (E #6) in Operating Room (OR) 12, the Hospital failed to ensure staff hair was completely covered when participating in surgical procedures involving sterile instruments.

Findings include:

1. On 9/1/16 at 10:15 AM, Hospital policy #4040-D-005, titled, "Dress Code for Surgical Environment", revised 5/13/13, was reviewed. The policy required, "3. Surgical head covers or hoods that confine all hair will be worn by all personnel entering a surgical environment."

2. On 8/30/16 between 2:25 PM and 3:15 PM, an observation tour was conducted in Interventional Radiology room 6. An Intervential Radiologist (MD #1) was performing a central line insertion. MD #1's cap did not cover the lower back of his head, leaving approximately 1 inch of hair exposed.

3. On 8/30/16 at 3:15 PM, an interview was conducted with the Vice President of Clinical Services (E #4). E #4 stated she would talk to MD #1 regarding his exposed hair.

4. On 8/31/16 between 7:35 AM and 8:15 AM, an observational tour was conducted in Operating Room 12. At 7:50 AM, a Regstered Nurse (E #6) entered the room where sterile instruments were open. E #6's hair was exposed approximately 2 inches at the back of her head.

5. On 8/31/16 at 8:15 AM, an interview was conducted with the Director of Perioperative Services (E #7). E #7 agreed E #6's hair was hanging below the cap and stated she would discuss it with E #6.

B. Based on document review, observational tour, and interview, it was determined for 1 of 2 Student Respiratory Therapist (Z #1), the Hospital failed to ensure non-staff individuals providing patient care, did not contaminate bandage tape.

Findings include:

1. On 9/1/16 at 10:30 AM, Hospital policy #6020-10-001, titled, "Isolation Precautions", revised 1/24/05, was reviewed. The policy required, "Contact Precautions... Restrict use of non-critical patient care equipment to use by the isolated patient only... transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, such as contaminated... dressings..." The policy did not specifically mention tape.

2. On 8/30/16 between 1:15 PM and 2:15 PM, an observational tour was conducted in the Intensive Care Unit (ICU). At 1:45 PM, a Respiratory Therapist Student (Z #1) assisted a Respiratory Therapist, listening to breath sounds for Pt. #3, in a contact isolastion room (room 7118). Z #1 used a dedicated stethescope for Pt. #3 in room 7118. However, Z #1's own stethescope, present in the isolation room, had a roll of tape hanging from an ear piece. Z #1 wore the stethescope with the tape roll into the ICU hall after leaving the isolation room. The potentially contaminated tape was available for use on other patients.

3. On 9/30/16 at 1:50 PM, an interview was conducted with Z #1. Z #1 stated she was not aware the tape roll should not be carried from room to room.

C. Based on document review, observational tour, and interview, it was determined for 3 of 3 Anesthesiologists (MD #2, 3, & 4), the Hospital failed to ensure anesthesiologists did not carry prepared medication syringes in their pockets, labeled prepared syringes, dated open medication vials, and disposed of syringes in a sharps container.

Findings include:

1. On 9/1/16 at 10:45 AM, Hospital policy #6000-M-017, titled, "Medication Administration", revised 6/21/16, was reviewed. The policy required, "Procedure... 16. Medications prepared for a procedure or sterile field, but not administered immediately: medications must be appropriately labeled with: a. medication name and quantity... d. expiration time when expiration occurs within 24 hours.... e. the initials of the person preparing the medication... 18. Medication storage: medications are secured at all times in designated areas..." The policy did not include prepared medication syringes were not to be carried in a shirt pocket.

2. On 8/31/16 between 7:10 AM and 7:35 AM, an observational tour was conducted in the preop holding area in the Center for Short Stays (outpatient). Pt. #5 was in room I5 awaiting a femoral nerve block. At 7:20 AM, an Anesthesiologist (MD #2) entered room I5 with 2 prepared medication syringes in his scrub shirt pocket. MD #2 administered some of the contents of 1 syringe into Pt. #5's intravenous line and returned the syringe to MD #2's pocket. It was not determined if the syringes were labeled.

3. On 8/31/16 at 8:15 AM, an interview was conducted with the Director of Perioperative Services (E #7). E #7 agreed MD #2 should not carry prepared medication syringes in his pocket and stated she would talk to him.

4. On 8/31/16 at 8:25 AM, an observational tour was conducted in Operating Room 1. OR 1 was not occupied and sterile supplies were not open. The anethesia cart was unlocked and contained 2 prepared medication syringes (Neostigmine, 10 ml, with no date, time, or initials of preparer and a white liquid in a 20 ml syringe, without a label). There was also 1 open, undated vial of Ephedrine.

5. On 8/31/16 at 8:25 AM, an interview was conducted with an Anethesiolgist (MD #3). MD #3 stated he had drawn up the medication today and would use it in the next procdure and he intended to dispose of the Ephedrine. E #7 was present during the interview.

6. On 8/31/16 at 9:35 AM, an observational tour was conducted in the Endoscopy area, room 4. Room 4 was not occupied and there were 3 used syringes and 1 empty medication vial in the regular trash, not in a sharps container.

7. On 8/31/16 at 9:35 AM, an interview was conducted with an Anethesiolgist (MD #4). MD #4 stated "the sharps container was almost full", but did not explain why he disposed of the syringes and medication vial in the regular trash. E #7 was present during the interview.

D. Based on document review, observational tour, and interview, it was determined for 1 of 5 physicians (MD #2), the Hospital failed to ensure physicians disinfected their hands before performing a procedure and after removing gloves.

Findings include:

1. On 9/1/16 at 2:30 PM, Hospital policy #6020-19-001, titled, "Handwashing and Hand Hygiene", revised 7/12/05, was reviewed. The policy required, "At a minimum, staff will wash hand during the following times... [may use] alcohol-based hand rubs, after touching contaminated surfaces, after removing gloves..."

2. On 8/31/16 between 7:10 AM and 7:35 AM, an observational tour was conducted in the preop holding area in the Center for Short Stays (outpatient). Pt. #5 was in room I5 awaiting a femoral nerve block. At 7:20 AM, an Anesthesiologist (MD #2) entered room I5 and donned gloves and scrubbed Pt. #5's right femoral area. MD #2 removed the gloves and donned sterile gloves, without disinfecting his hands, and performed a femoral nerve block. At 7:35 AM, when the procedure was completed, MD #2 removed the gloves and left the preop area without disinfecting his hands.

3. On 8/31/16 at 7:35 AM, an interview was conducted with the Director of Perioperative Services (E #7). E #7 stated she would talk to MD #2 about disinfecting his hands before an invasive procedure and after removing his gloves.

E. Based on document review, observational tour, and interview, it was determined, for 1 of 1 transporter (E #9), the Hospital failed to ensure staff did not touch blankets covering patients with contact precautions.

Findings include:

1. On 9/1/16 at 10:30 AM, Hospital policy #6020-10-001, titled, "Isolation Precautions", revised 1/24/05, was reviewed. The policy recquired, "Contact Precautions... Gloves - Required for contact with patient, environmental surfaces, and patient care items.

2. On 9/1/16 between 10:50 AM and 11:30 AM, an observational tour was conducted in the Interventional Radiology (IR) area. Pt. #6 was waiting on a cart in the corridor for a video swallow test. Pt. #6 was in contact isolation and being attended by a Radiology Technician. Pt. #6 had been transported to IR by a Transporter (E #9). The Surveyor asked E #9 wha