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Based on observations, record reviews and interviews, the hospital failed to ensure patients' right to personal privacy during personal hygiene activities for 2 of 5 current patients (#1, 4) and 3 of 5 (#2, 3 and 5) discharged patients in a total sample of 5. Findings:

Review of the hospital's policies and procedures revealed a policy dated 05/2012 and titled "Patient Hygiene Showers/Baths." Further review reflected "The shower room is located on the unit and contains one shower and one bath tub. Both are handicapped accessible. Patients (male/female) are scheduled for showers/baths. Assisted showers/baths are a requirement of this facility. The MHT will unlock the shower room door and accompany the patient until the shower is completed and the patient is back in his/her room.......Under no circumstances are patients allowed to be unattended in the shower area."

Observation during the tour of the hospital on 9/25/12 beginning at 11:40 a.m. revealed a bathroom with 2 shower stalls and a bathtub. A shower curtain was observed on the bottom shelf in the bathroom. However, there were no privacy curtains/screens noted to provide privacy during personal hygiene activities.

Interview with the Chief Executive Officer (CEO) and Director of Nursing (DON) at the above time revealed only one patient "at a time" was allowed in the shower room. They stated staff remained at the door during shower time to allow patient privacy.

During a further interview with the CEO and DON on 9/27/12 at approximately 6:00 p.m., the CEO stated there was one shower curtain in the bathroom on the shelf but it was not being used. The CEO and DON confirmed there were no shower curtains/screens to provide privacy for patients. They further stated that staff was to remain outside of the door at all times when patients were taking showers/baths.

Based on observations, record reviews and interviews, the hospital failed to have active surveillance of infection control monitoring for hand hygiene and/or aseptic practices for blood collections monthly from June 06, 2012 through September 27, 2012 as outlined in the facility's "Infection Control Plan" and policies. The hospital was licensed on 6/1/12.

Findings:

During tours of the hospital on 09/25/12 from 11:40 a.m. through 12:36 p.m. and on 09/26/12 from 7:15 a.m. through 12:25 p.m., revealed the following:

1) S5MHT was observed standing in the hallway across from the dining room wearing gloves on both hands. Further observation revealed S5MHT had a clipboard with "Observation Check Sheets" for patient #4, R1, and R2.

2) At 12:15 p.m., the S5MHT had an ink pen and was observed documenting the locations of R1 and patient #4 while wearing gloves on both hands.

3) S5MHT was also observed to walk from the hallway into the dining room area, wiped the drool from the patient's (R2's) mouth with his right-handed glove and walk back into the hallway.

4) Further observation at 12:17 p.m., revealed S5MHT was observed wearing gloves while giving S6MHT the clipboard with the "Observation Check Sheets" for Patient #4, R1 and R2. During an interview with S5MHT at 12:19 p.m., S5MHT indicated he was S6MHT's lunch relief. The S5MHT reported that he was wearing gloves on both hands because he assists with R2 who drools a lot and has to assist with R1 who has to be constantly redirected.

5) At 12:20 p.m., S5MHT was observed degloving and discarding the gloves in the exam room without performing hand hygiene.

6) At 12:21 p.m., S5MHT was observed donning gloves. At this time, S5MHT, confirmed wiping the drool from R2's mouth with his right, handed glove without discarding them and/or performing hand hygiene prior to donning gloves. S5MHT indicated that he failed to perform hand hygiene after coming into contact with R2's drool and prior to donning gloves as per policy. S5MHT denied knowledge the clipboard and ink pen were dirty requiring hand hygiene prior to donning gloves.

On 09/26/12 from 12:55 p.m. through 1:25 p.m., observations of the dining room revealed the following:

1) S8MHT was observed in the dining room wearing gloves on both hands and sitting to the right of a patient (R2) who was sitting at the head of the table with her head down. S8MHT was observed to touch the patient's left, forearm with his gloved hand.

2) At 12:55 p.m., S8MHT was observed walking to get a trash can that was located on the back wall behind the patient (R2), and he removed fourteen styrofoam food containers/plates from the tables and discarded them into the trash can. S8MHT moved the big trash can with him while he removed all containers/plates from the tables and discarded them into the trash can. Then, the S8MHT moved the trash can back up against the back wall behind R1.

3) At 12:56 p.m., S8MHT was observed getting a paper towel from the dispenser and he wiped the drool from R2's mouth. The S8MHT walked to the trash can, removed his gloves, and discarded them into the trash can.

4) S8MHT was then observed to performed handwashing in the sink area.

5) At 1:14 p.m., S8MHT was observed donning a glove on his left hand and sat down next to R2. The S8MHT went and got a paper towel from the dispenser and wiped the drool from R2's mouth. S8MHT walked and got four paper towels from the dispenser, squirted soap onto them, wiped both tables down with the paper towels, and discarded them in the trash can.

6) Continued observation at 1:16 p.m., revealed S8MHT was observed sitting next to R2. S8MHT pulled out an ink pen from his pocket, and charted each patient's food intake onto an "Observation Sheet" that were located on a clipboard. S8MHT got a paper towel from the dispenser and wiped R2's drool with it. At 1:18 p.m., the S8MHT discarded the paper towel and left handed glove into the trash can and performed handwashing in the sink area.

Interview at this time with S8MHT confirmed he did not perform hand hygiene after wiping the drool from R2's mouth and/or handling the dirty food containers/plates. S8MHT denied knowledge the ink pen and clipboard were dirty requiring hand hygiene to be performed.

On 09/26/12 from 8:50 a.m. through 9:00 a.m., the contracted Phlebotomist, S15 was observed standing in the hallway, next to the nursing station, holding a tray. S15 was then observed to enter into patient #4's room without performing hand hygiene, donned gloves on both hands, wiped the right, forearm area with alcohol, applied a tourniquet, and drew a vial of blood from patient's (#4's) right, forearm.

Further observation revealed S15 removed the tourniquet from the #4's right, forearm, removed the vial of blood, a tube, and placed the vial into the tray. S15 removed the needle from the patient's forearm, three squirts of blood was noted on the right side of the patient's forearm. S15 applied gauze and tape to the area and discarded the needle into the biohazard container located on the tray. S15 confirmed the patient's name and date of birth with the patient, picked up the vial of blood from the tray, labeled the vial with the patient's name and date of birth, and placed the vial of blood in the tray again.

At 8:57 a.m., S15 was observed removing both gloves and placed them into a white cup located on the tray. S15 exited patient's (#4's) room at this time and walked down to the nurses station without performing hand hygiene. The contracted Phlebotomist, S15 handed a copy of the requisition slip to S6MHT and left the nurses station without performing hand hygiene. As S15 was exiting the building at 9:00 a.m. and was stopped by the surveyor, S15 confirmed she did not perform hand hygiene prior to drawing patient's (#4's) blood and/or after drawing the patient's (#4's) blood as per policy. The contracted Phlebotomist, S15 indicated she could not perform hand hygiene prior to drawing blood in the patient's rooms because one patient's (whom she could not identify and/or recall) sink did not work. The contracted Phlebotomist, S15 further indicated she normally performed hand hygiene, after drawing the patient's blood in the nurses station sink in which she did not because the surveyor made her nervous.

Although the facility was licensed in 6/1/2012, there were no "Infection Surveillance, Prevention, ex Control Observation Tour of Facilities" forms presented for the monitoring of the environment monthly from June 06, 2012 through 09/27/12.

Review of the policy titled, "Environmental Surveillance", Infection Control 06, Original Date of Issue on 05/2012, Date of Approval on 05/2012, with the Revision Date of Issue and/or Date of Approval sections left blank indicated, "the Infection Control Officer (ICO) will conduct monthly environmental surveillance rounds to identify deficiencies. The results will be communicated with the department heads with a plan to make needed improvements. Quarterly, the infection control committee will review the process and make any needed recommendations. It is hospital procedure for the ICO to make monthly rounds and focus on environmental issues relating to infection control. The ICO will notify staff responsible for correcting any deficiencies and assist with the corrective actions. A copy of the worksheet will be routed to the appropriate Department Heads. This report will be presented in the Performance Improvement Committee on a monthly basis".

There was no documentation of infection control monitoring for hand hygiene, environmental rounds and/or aseptic practices monthly from June 06, 2012 through September 27, 2012.

The "Infection Control Plan", with no effective date, review date and/or revised date, revealed that the goals of the infection control program were to limit unprotected exposure to pathogens throughout the hospital, enhance hand hygiene throughout the organization, minimize the risk of infections associated with procedures, medical equipment, and medical devices, perform continuing surveillance to monitor known risks and identify new ones, reduce the risks of infection for patients, employees, and visitors, and develop plans to reduce the incidence of those specific infections with highest risk morbidity on our campus. Contaminated hands are a primary source of infection throughout healthcare. Without an effective surveillance process, new problems and trends cannot be identified and interventions cannot be assessed. Our fifth goal is to develop and maintain a surveillance process that meets the needs of the hospital. One strategy used to minimize the risks for acquisition and transmission of infection is to monitor the use of hand sanitizer, and report results to the Infection Control Committee, to the Environment of Care Committee, and to the areas monitored. Develop and maintain an effective surveillance process by developing and maintaining a surveillance method in the Infection Control Committee, by describing the method in the Infection Control Committee Manual, by utilizing the method to identify baseline rates and outbreaks of disease, by utilizing the data to develop interventions and to evaluate their effectiveness, by reporting and analyzing the data at each Infection Control Committee meeting, and by summarizing the data and analyzing it at the Environment of Care, Nursing Coordinator, and include it in the Quarterly Quality Assurance Report.

Review of the policy titled, "Provision of Infection Control Care Program", Infection Control 01, Original Date of Issue on 05/2012, Date of Approval on 05/2012, with the Revision Date of Issue and/or Date of Approval sections left blank revealed that it was the responsibility of the Infection Control Officer to perform frequent procedures, services, processes and functions by having:
1) an active Infection Control Program by having Infection Control Surveillance, Education, monitoring environmental infection control issues, evaluation of products and cleaning agents; 2) monitoring and reporting of communicable disease to public health agencies;
3) investigation of suspected outbreaks;
4) appropriate action taken in the event of an outbreak;
6) Collaborates with Environment of Care to identify and reduce the risk of infection;
7) Works closely with nursing staff to detect disease, and infection as early as possible; and 8) The Medical Director on call will be notified of infection control issues after hours. The Infection Control Officer will perform hospital surveillance to identify possible infection control related problems and assists in identifying possible solutions. The Infection Control Officer will keep current and work with additional standards of practice adopted/adapted by department/services such as Center for Disease Control and Epidemiology and Department of Health and Hospitals-Office of Public Health.

During an interview on 09/27/12 from 3:50 p.m. through 5:15 p.m., S2DON indicated there was no documented evidence of infection control monitoring monthly for hand hygiene, environmental rounds and/or aseptic practices, as per policy from June 06, 2012 through September 27, 2012. The S2DON confirmed there were no "Infection Surveillance, Prevention, ex Control Observation Tour of Facilities" active surveillance of the environment performed monthly from June 06, 2012 through 09/27/12 as per policy- (blank forms were submitted) during the survey on 09/27/12. S2DON indicated handwashing was expected to be done by all nursing staff when coming into contact with a patient's drool as per policy.

The S2DON denied knowledge of the contracted Phlebotomist, S15 not performing hand hygiene prior to and after drawing blood. S2DON further indicated all staff including the contracted Phlebotomist, S15 were expected to perform hand hygiene prior to and after drawing a patient's blood as per policy.

Based on record reviews and interviews, the hospital failed to ensure that the nursing care provided for each patient was in accordance with accepted standards of nursing practice and hospital policy. the nursing staff failed to ensure physician's orders for aftercare was followed for 1 of 3 discharged patients (#2) in a total sample of 5. Findings:

Review of the medical record for patient #2 reflected a physician's telephone order dated 9/11/12 at 1015 (10:15 a.m.) for discharge to home.......follow-up primary care and Dr. [psychiatrist not affiliated with hospital]..." Further review reflected the telephone order was taken by S2DON.

Review of the patient's discharge instruction sheet reflected "SPECIAL DISCHARGE INSTRUCTIONS:.....Continue meds -- Follow up with MD......Suicide Hotline........"

There was no documentation in the medical record to reflect the patient was given discharge instructions concerning the need to follow-up with another psychiatrist.

Interview on 9/27/12 at approximately 2:30 p.m. with S14Psychiatrist, confirmed an order was written for patient #2 to follow up with another psychiatrist.

Interview with S3LCSW on 9/27/12 at approximately 3:25 p.m. revealed that the hospital did not make outside appointments for the patients. S3LCSW stated that the nurses were responsible for providing discharge instructions. S3LCSW further confirmed that there was no documentation to reflect discharge planning for patient #2 other than an appointment with the patient's primary care physician.

Interview with S2DON on 9/27/12 at approximately 4:00 p.m. confirmed that there was no documented evidence to reflect patient #2 was given instructions concerning the need for follow-up with another psychiatrist.

Based on record reviews, observations, and interviews, the hospital failed to meet the
Condition of Participation for Infection Control as evidenced by:

1) failed to have a system for controlling infections and communicable diseases of patients; (Cross Reference A0273)

2) failed to have a policy in place to ensure the consistent implementation of procedures for cleaning and disinfecting the shower/bath area before and after each patient's use. There was no policy/procedure for disinfecting the showers/bathtub between patient usage. S5Mental Health Technician (MHT) reported that staff did not clean the showers/bathtub between use. S6MHT reported disinfecting the shower/bathtub with half and half bleach. S7MHT reported disinfecting the shower/bath with pure bleach. S9MHT reported disinfecting the shower/bathtub with one quarter bleach. S2DON confirmed there was no policy/procedure regarding how staff were to disinfect the bath/shower before and after each patient usage. (Cross Reference A0748)

3) failed to have a policy in place to ensure the implementation of procedures for cleaning and disinfecting the washer before and after each patient's use as confirmed by S2DON; (Cross Reference A0748)

4) failed to ensure that a sanitary environment was maintained. the hospital failed to implement interventions to safeguard patients against the transmission of communicable diseases and socially transmitted conditions. The facility failed to implement procedures to clean the clothing and personal belongings of one Random Patient (R1) treated for pubic lice. (Cross Reference A0749);

5) failed to ensure that aseptic technique and standard precautions were implemented consistently by staff members providing direct care to patients. MHTs were observed to wipe drool, touch equipment and clean items without performing hand hygiene as needed. S15, Contracted Phlebotomist was observed to draw blood, touch equipment and not perform hand hygiene as per infection control protocol (Cross Reference A0273).

25059



Based on record reviews, observations, and interviews, the Infection Control Officer failed to have a system in place for controlling infections and communicable diseases of patients as evidenced by:

1) failed to have a policy and procedure in place for cleaning and disinfecting the shower/bath area before and after each patient's use;

2) failed to have a policy in place to clean/disinfect the washer before and after each patient's use.

3) failed to ensure that a sanitary environment was maintained. The hospital failed to implement interventions to safeguard patients against the transmission of communicable diseases and socially transmitted conditions. The facility failed to implement procedures to clean the clothing and personal belongings of one Random Patient (R1) treated for pubic lice.

Findings:

1) Observation of the shower/bath area on 09/25/12 at approximately 12:33 p.m. revealed there were 2 shower stalls and a bathtub. Interview at that time with S1CEO (Chief Operating Officer) and S2DON (Director of Nursing) revealed that patients use the shower or bathtub and staff remains at the door during the time patients are using the shower or bath tub. S2DON further stated that staff cleans the shower or bathtub after each patient's use.

Review of the hospital's policies and procedures revealed there were no policies/procedures to indicate the procedure for staff to follow when cleaning the showers/bathtubs between each patient's use.

During an interview on 9/25/12 at approximately 4:00 p.m. with S5MHT revealed they worked the day shift mostly but also worked on the night shift. S5MHT revealed most showers/baths of patients were done on the night shift. S5MHT further revealed staff did not clean the showers/bathtub between patient's use. S5MHT stated that the only cleaning supply used was "bleach" and that was used for washing patient's clothing.

Interview with S9MHT on 9/26/12 at 7:10 a.m. revealed that he has been employed at the facility for approximately one month and he worked from 7:00 p.m. to 7:00 a.m. full-time. S9MHT revealed that showers/baths of patients were usually done on the night shift, and after each patient's use, staff disinfects the shower/bath with "bleach/water". S9MHT stated that he mixed "1/4 bleach per bucket of water" and wiped down the shower/bathtub.

Interview on 9/26/12 at 7:20 a.m. with S6MHT revealed that staff was responsible for cleaning the shower/bathtub after each patient's use. S6MHT stated that staff "try" to clean between each patient's shower/bath with "bleach/water'. S6MHT further stated that staff dilute "1/2 bleach to 1/2 water" to clean the shower/bathtub. S6MHT further stated that a "spray bottle" was used and S6MHT revealed there was no time frame required for patients to wait between shower/baths.

Observation on 9/26/12 at 7:30 a.m., of the housekeeping room where the cleaning supplies were stored, revealed there were no spray bottles for cleaning the shower/bathtubs noted.

In an interview on 09/26/12 from 7:15 a.m. to 7:45 a.m., the S7MHT indicated that all baths are provided to the patients from the hours of 7:00 p.m. through 10:30 p.m. during the night shifts; no exceptions. S7MHT indicated that all showers/baths are cleaned with straight bleach after each patient usage as per policy.

An interview with S2DON on 9/26/12 at 7:40 a.m. revealed that staff were responsible for cleaning the shower/bathtub by spraying a disinfectant into the shower stall and/or bathtub. S2DON revealed there was no time frame for the disinfectant to remain in the shower stall or bathtub between each patient's use, and staff were to spray the disinfectant and rinse the shower/bathtub. S2DON stated that when staff used bleach then they were to mix 1/2 bleach to 1/2 water in a "bucket" to clean the shower/bathtub.

Interview with S10RN on 9/26/12 at approximately 7:48 a.m. revealed that she worked on the night shift from 7:00 p.m. until 7:00 a.m. S10RN stated she has been employed with the hospital since 6/12. S10RN further stated that showers/baths were completed on the night shift and MHTs were responsible for cleaning the shower/bathtub between each patient's use. S10RN stated that staff used a spray bottle that contained bleach/water to clean the shower. S10RN revealed that staff spray the bleach/water and then wipe "around" the shower. S10RN further stated that staff poured bleach in water to clean the bathtub. S10RN revealed that she was not sure how much bleach/water was used to disinfect because the "techs" were responsible for that.

During an interview on 9/26/12 at 8:00 a.m. and on 09/27/12 from 3:50 p.m. through 5:15 p.m., S2DON denied knowledge that the nursing staff and MHTs were not aware of the concentration amount required to mix the bleach with water to disinfect/clean the shower/bath after each patient use. S2DON confirmed there was no policy/procedure regarding how staff were to disinfect the bath/shower before and after each patient usage.


2) Review of the hospital's policies and procedures revealed there was no policy/procedure to indicate the proper procedure to use to clean/disinfect the washer between patient's use.

In interviews on 09/27/12 at 11:40 a.m. and at 2:25 p.m. and from 3:50 p.m. through 5:15 p.m., S2DON indicated there was no hospital policy/procedure for cleaning/disinfecting the washer between patient's use.

3) Review of the medical record for Patient R1 revealed that she was admitted on 9/5/12 at (2210) 10:15 p.m. with an admitting diagnosis of Schizophrenia and a history of Chlamydia Infection. Further review revealed the "Multidisciplinary Progress Notes"dated/timed 9/19/12 at (1610) 4:10 p.m. which reflected "....Notified S12Medical Physician [MD] of pt c/o itching &burning in pelvic & vaginal and pubic area. Tech reported seeing something of a spider-like appearance crawling in that area during her toileting care. Pt refused to let nurses assess...At 8:20 p.m. (2020), S12MD on unit. Pt refused to let him exam her. [No] treatment provided...".

Review of a telephone Physician's Orders dated 9/20/12 at 10:15 a.m. indicated [kwell] treatment times 1.

There was no documented evidence to reflect any measures were implemented to ensure other patients had not been exposed and/or required treatment. There was also no documentation to reflect proper measures were implemented to ensure the potential for infectious disease was decreased.

Review of the hospital's policies and procedures revealed there was no policy/procedure to indicate the proper procedure to clean/disinfect the washer between patient's use.

Interview with S2DON on 9/27/12 beginning at 3:50 p.m. revealed that the patient was ordered a treatment of "kwell", which was provided. S2DON confirmed the patient's laundry was washed in the regular washer that was used for all patients. S2DON confirmed that no extra precautions were taken to ensure other patients were not exposed. S2DON indicated there was no hospital policy/procedure for cleaning/disinfecting the washer between patient's use.

25059



Based on record reviews, observations, and interviews, the Infection Control Officer failed to ensure that a system in in place to identify, report and control infections and communicable diseases of patients. The hospital failed to ensure that staff performed hand hygiene after the Mental Health Techs (S5MHT and S8MHT) wiped drool from one random patient's mouth (R2), touched equipment and cleaned when providing care. The facility also failed to ensure that the contracted phlebotomist (S15) implemented appropriate infection control measures when collecting blood samples for 1 of 2 currently admitted patients (#4's) who had blood drawn in a total sample of 5 patients. Findings:

S5MHT
During tours of the hospital on 09/25/12 from 11:40 a.m. through 12:36 p.m.; on 09/26/12 from 7:15 a.m. through 12:25 p.m., and at 8:00 a.m., S5MHT was observed standing in the hallway across from the dining room wearing gloves on both hands. Further observation revealed S5MHT had a clipboard with "Observation Check Sheets" for patient #4, R1, and R2. At 12:15 p.m., the S5MHT had an ink pen and was documenting the locations of R1 and R4 while wearing the gloves.

Further observation revealed S5MHT was observed walking from the hallway into the dining room area and wiped drool from patient's (R2's) mouth with his right gloved hand and walked back into the hallway. At 12:17 p.m., S5MHT was observed giving S6MHT the clipboard with the "Observation Check Sheets" for Patient #4, R1 and R2. At 12:19 p.m., S5MHT indicated he was S6MHT's lunch relief. S5MHT reported wearing gloves on both hands because he assists with R2 who drools a lot and assists with R1 who has to be constantly redirected. At 12:20 p.m., S5MHT was observed degloving and discarding both gloves in the exam room without performing handwashing.

At 12:21 p.m., S5MHT was observed donning gloves on both hands. At this time, the MHT, S5 confirmed wiping the drool from R2's mouth with his right handed glove without discarding them and/or performing hand hygiene prior to donning gloves on both hands. S5MHT indicated he failed to perform hand hygiene after coming into contact with R2's drool and prior to putting on gloves as per policy. S5MHT denied knowledge the clipboard and ink pen were dirty requiring hand hygiene prior to putting on gloves.

S8MHT:
On 09/26/12 from 12:55 p.m. through 1:25 p.m., observations of the dining room were conducted. S8MHT was observed in the dining room wearing gloves on both hands. S8MHT was sitting to the right of patient (R2), and he touched her left forearm. At 12:55 p.m., S8MHT was observed walking to get a trash can that was located on the back wall behind the patient, (R2), removing fourteen Styrofoam food containers/plates from the tables and discarding them into the trash can. S8MHT moved the big trash can with him while he removed all containers/plates from the tables and discarded them into the trash can. Then, S8MHT moved the trash can back up against the back wall behind R2.

At 12:56 p.m., the S8MHT was observed getting a paper towel from the dispenser and wiping the drool from R2's mouth. S8MHT walked to the trash can, removed his gloves, and discarded them into the trash can. S8MHT performed handwashing in the sink area. At 1:14 p.m., S8MHT was observed putting on a left glove and sitting down next to R2 at the head of the table. The S8MHT went and got a paper towel from the dispenser and wiped the drool from R2's mouth. S8MHT walked and got four paper towels from the dispenser, squirted soap on them, wiped both tables down in the dining room area, and discarded them in the trash can.

At 1:16 p.m., S8MHT was observed sitting next to R2 at the head of the table, pulled out an ink pen from his pocket, and charted each patient's food intake onto an "Observation Sheet" that were located on a clipboard laying on the table. S8 got another paper towel from the dispenser, wiped R2's drool with it, and placed the towel on the table next to the clipboard. At 1:18 p.m., the S8MHT discarded the paper towel and left handed glove into the trash can. S8MHT performed handwashing in the sink area. At this time, S8MHT confirmed he did not perform hand hygiene after wiping the drool from R2's mouth and/or handling the dirty food containers/plates as per protocol. S8MHT denied knowledge the ink pen and clipboard were dirty requiring hand hygiene to be performed.

S15 Contracted Phlebotomist:
On 09/26/12 from 8:50 a.m. through 9:00 a.m., S15 was observed standing in the hallway next to the nursing station holding a laboratory tray with needles, vials, gloves, biohazard counter, white cup, alcohol preps, gauze, and tape. At 8:50 a.m., S15 Contracted Phlebotomist was observed entering into Patient #4's room without performing hand hygiene, pulled gloves out of the tray, put gloves on both hands, wiped the patient's (#4's) right, forearm area with an alcohol prep, applied a tourniquet to the patient's right forearm, and drew one vial of blood.

Further observation revealed S15 removed the tourniquet from the patient's right, forearm, removed the tube of blood (vial), placed it into the tray, and removed the needle from the patient's forearm. Three squirts of blood was observed on the patient's right, forearm. S15 applied gauze and tape to the area, and discarded the needle into the biohazard container located on the tray. S15 confirmed the patient's name and date of birth with the patient at this time. S15 picked up the vial of blood vial from the tray and labeled it with the patient's name and date of birth. At 8:57 a.m., S15 was observed removing both gloves and placed them in a white cup on the tray. S15 opened the door, exited patient's (#4's) room, and walked down to the nurses station without performing hand hygiene. The contracted Phlebotomist, S15 handed a copy of the laboratory requisition slip to S6MHT and exited the nurses station without performing hand hygiene.

At 9:00 a.m., S15 Contracted Phlebotomist was observed going to exit the building, and she was stopped by the surveyor. The S15 Contracted Phlebotomist confirmed that she did not perform hand hygiene prior to drawing the patient's vial of blood and/or after drawing the patient's blood as per policy. S15 Contracted Phlebotomist indicated that she could not perform hand hygiene prior to drawing blood in the patient's rooms because one patient's (whom she could not identify and/or recall) sink did not work.

The "Infection Control Plan", with no effective date, review date and/or revised date, indicated that the goals of the infection control program were to limit unprotected exposure to pathogens throughout the hospital, enhance hand hygiene throughout the organization, minimize the risk of infections associated with procedures, medical equipment, and medical devices, perform continuing surveillance to monitor known risks and identify new ones, reduce the risks of infection for patients, employees, and visitors, and develop plans to reduce the incidence of those specific infections with highest risk morbidity on our campus. Contaminated hands are a primary source of infection throughout healthcare. Our first priority is to increase compliance with hand hygiene measures as recommended by the Centers for Disease Control. Many serious infections are transmitted through blood or body fluids. Our second priority is to educate all employees about these infections and how they can protect themselves and their patients. The equipment we use (syringes, and other devices) can transmit infections. Our third priority is to minimize these risks by using equipment that is designed for safety and educating employees about how the equipment should be used. One strategy used to minimize the risks for acquisition and transmission of infection is to monitor the use of hand sanitizer, and report results to the Infection Control Committee, to the Environment of Care Committee, and to the areas monitored.

Review of the policy titled, "Infection Control: Standard Precautions", Infection Control 7, and Infection Control 10, Original Date of Issue on 05/2012, Date of Approval on 05/2012, with the Revision Date of Issue and Date of Approval sections left blank read as follows, "...Standard Precautions are designed to prevent or reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection. Standard Precautions apply to all patients regardless of their diagnosis or presumed infection status. Standard Precautions should be practiced whenever handling blood, other potentially infectious material (OPM) like all body fluids, secretions, excretions, and mucous membranes. Hand hygiene for removing transient bacteria and visible soiling when hands are visibly soiled or contaminated with blood. Hand washing with soap and water for at least 20 seconds is the only option. If hands are not visibly soiled, new hand hygiene guidelines issued by the CDC recommend the use of alcohol-based hand rubs due to the effectiveness in killing organisms on the hands and the ability to stop hospital-acquired (nosocomial) infections. Hand hygiene is the single best way to prevent the spread of infection".

During interviews on 09/26/12 at 8:00 a.m. and on 09/27/12 from 3:50 p.m. through 5:15 p.m., the S2DON indicated that she expected all staff including the MHTs, (S5 and S7) to perform hand hygiene after touching R2's drool and prior to donning gloves as per protocol. S2DON further indicated the clipboard and ink pen are dirty requiring hand hygiene practices to be performed prior to providing direct patient care and prior to donning gloves as per policy. The S2DON reported that all MHTs were expected to perform hand hygiene after coming into contact with contaminated containers/plates and/or trash cans and prior to providing direct patient care as per policy. S2DON denied knowledge that the MHTs (S5 and S7) failed to perform hand hygiene practices after touching R2's drool, ink pen and clipboard. S2DON further denied knowledge of the S15 Contracted Phlebotomist failure to perform hand hygiene prior to and after drawing a patient's (#4's) blood. The S2DON indicated that S15 Contracted Phlebotomist is expected to follow the infection control standards precautions when handling blood products that require handwashing practices with soap and water for at least 20 seconds whether the contracted employee's gloves are contaminated with blood or not as per policy.

Based on observations, record reviews and interviews, the hospital failed to ensure that the hospital-wide Quality Assessment and Performance Improvement (QAPI) programs addressed problems identified through the infection control program as evidenced by not having an active surveillance of hand hygiene and aseptic practices monthly from June 06, 2012 through September 27, 2012 required by the hospital's Infection Control Plan and policies. Findings:

During tours of the hospital on 09/25/12 from 11:40 a.m. through 12:36 p.m. on 09/26/12 from 7:15 a.m. through 12:25 p.m., and at 8:00 a.m., S5MHT was observed standing in the hallway across from the dining room wearing gloves on both hands. Further observation revealed S5MHT had a clipboard with "Observation Check Sheets" for patient #4, R1, and R2. At 12:15 p.m., the S5MHT had an ink pen and was documenting the locations of R1, l and patient #4 while wearing gloves on both hands. S5MHT was observed walking from the hallway into the dining room area and wiped the drool from the patient's (R2's) mouth with his right-handed glove and walked back into the hallway.

At 12:17 p.m., S5MHT was observed giving S6MHT the clipboard with the "Observation Check Sheets" for Patient #4, R1 and R2. At 12:19 p.m., S5MHT indicated he was S6MHT's lunch relief. The S5MHT reported wearing gloves on both hands because he assists with R2 who drools a lot and had to assist with R1 who had to be constantly redirected. At 12:20 p.m., S5MHT was observed degloving and discarding the gloves in the examination room without performing hand hygiene. At 12:21 p.m., S5MHT was observed donning gloves. At this time, the S5MHT confirmed wiping the drool from R2's mouth with his gloved right hand without discarding them and/or performing hand hygiene prior to donning gloves. The S5MHT indicated that he failed to perform handwashing after coming into contact with R2's drool and prior to donning gloves as per policy. S5MHT denied knowledge the clipboard and ink pen were dirty requiring hand hygiene prior to donning gloves.

On 09/26/12 from 12:55 p.m. through 1:25 p.m., observations of the dining room were conducted. S8MHT was observed in the dining room wearing gloves on both hands and sitting to the right of a patient (R2). S8MHT was observed to touch Patient R2's left forearm with his gloved hand. At 12:55 p.m., S8MHT was observed walking to get a trash can that was located on the back wall behind the patient, (R2) and he removed fourteen Styrofoam food containers/plates from the tables and discarded them into the trash can. S8MHT moved the big trash can with him while he removed all containers/plates from the tables and discarded them into the trash can. Then, S8MHT moved the trash can back up against the back wall behind R1.

At 12:56 p.m., S8MHT was observed getting a paper towel from the dispenser, and he wiped the drool from R2's mouth. S8MHT walked to the trash can, removed his gloves, and discarded them into the trash can. Then, S8MHT performed handwashing in the sink area. At 1:14 p.m., S8MHT was observed donning a glove on his left hand and sat down next to R2. The MHT, S8 went and got a paper towel from the dispenser and wiped the drool from R2's mouth. S8MHT walked and got four paper towels from the dispenser, squirted soap onto them, wiped both tables down with these paper towels, and discarded them in the trash can. At 1:16 p.m., S8MHT was observed sitting next to R2, pulled out an ink pen from his pocket, and charted each patient's food intake onto an "Observation Sheet" that were located on a clipboard. S8MHT got a paper towel from the dispenser and wiped R2's drool with it. At 1:18 p.m., the MHT, S8 discarded the paper towel and left handed glove into the trash can and performed handwashing in the sink area. At this time, S8MHT confirmed he did not perform hand hygiene after wiping the drool from R2's mouth and/or handling the dirty food containers/plates as per protocol. S8MHT denied knowledge the ink pen and clipboard were dirty requiring hand hygiene to be performed.

On 09/26/12 from 8:50 a.m. through 9:00 a.m., the S15 Contracted Phlebotomist was observed standing in the hallway next to the nursing standing holder a tray. S15 Contracted Phlebotomist entered patient #4's room without performing hand hygiene, donned gloves on both hands, wiped the right, forearm area with alcohol, applied a tourniquet, and drew a vial of blood from the patient's (#4's) right, forearm. Further observation revealed S15 Contracted Phlebotomist removed the tourniquet from the #4's right, forearm, removed the vial of blood, placed it into the tray, removed the needle from the patient's forearm, three squirts of blood was noted on the right side of the patient's forearm. S15 applied gauze and tape to the area and discarded the needle into the biohazard container located on the tray. S15 confirmed the patient's name and date of birth with the patient, picked up the vial of blood from the tray, labeled the vial with the patient's name and date of birth, and placed the vial of blood in the tray. At 8:57 a.m., S15 was observed removing both gloves and placed them into a white cup located on the tray. S15 exited the patient's (#4's) room at this time and walked down to the nurses station without performing hand hygiene.

The S15 Contracted Phlebotomist handed a copy of the requisition slip to S6MHT and left the nurses station without performing hand hygiene. As S15 Contracted Phlebotomist was exiting the building at 9:00 a.m. she was stopped by the surveyor. S15 Contracted Phlebotomist confirmed that she did not perform hand hygiene prior to drawing the patient's (#4's) blood and/or after drawing the patient's (#4's) blood as per policy. The S15 Contracted Phlebotomist indicated that she could not perform hand hygiene prior to drawing blood in the patient's rooms because one patient's (whom she could not identify and/or recall) sink did not work.

The facility was licensed on 6/1/12. There were no "Infection Surveillance, Prevention, ex Control Observation Tour of Facilities" forms presented for the monitoring of the environment monthly from June 06, 2012 through 09/27/12.

Review of the policy titled, "Environmental Surveillance", Infection Control 06, Original Date of Issue on 05/2012, Date of Approval on 05/2012, with the Revision Date of Issue and/or Date of Approval sections left blank indicated, "the Infection Control Officer (ICO) will conduct monthly environmental surveillance rounds to identify deficiencies. The results will be communicated with the department heads with a plan to make needed improvements. Quarterly, the infection control committee will review the process and make any needed recommendations. It is hospital procedure for the ICO to make monthly rounds and focus on environmental issues relating to infection control. The ICO will notify staff responsible for correcting any deficiencies and assist with the corrective actions. A copy of the worksheet will be routed to the appropriate Department Heads. This report will be presented in the Performance Improvement Committee on a monthly basis".

Although the facility was licensed on 6//1/12, there was no documentation of infection control monitoring for hand hygiene, environmental rounds, asepsis practices, and/or obtaining blood culture collections monthly from June 06, 2012 through September 27, 2012.

The "Infection Control Plan", with no effective date, review date and/or revision date, revealed that the goals of the infection control program were to limit unprotected exposure to pathogens throughout the hospital, enhance hand hygiene throughout the organization, minimize the risk of infections associated with procedures, medical equipment, and medical devices, perform continuing surveillance to monitor known risks and identify new ones, reduce the risks of infection for patients, employees, and visitors, and develop plans to reduce the incidence of those specific infections with highest risk morbidity on our campus. Contaminated hands are a primary source of infection throughout healthcare. Without an effective surveillance process, new problems and trends cannot be identified and interventions cannot be assessed. Our fifth goal is to develop and maintain a surveillance process that meets the needs of the hospital. One strategy used to minimize the risks for acquisition and transmission of infection is to monitor the use of hand sanitizer, and report results to the Infection Control Committee, to the Environment of Care Committee, and to the areas monitored. Develop and maintain an effective surveillance process by developing and maintaining a surveillance method in the Infection Control Committee, by describing the method in the Infection Control Committee Manual, by utilizing the method to identify baseline rates and outbreaks of disease, by utilizing the data to develop interventions and to evaluate their effectiveness, by reporting and analyzing the data at each Infection Control Committee meeting, and by summarizing the data and analyzing it at the Environment of Care, Nursing Coordinator, and include it in the Quarterly Quality Assurance Report.

Review of the policy titled, "Provision of Infection Control Care Program", Infection Control 01, Original Date of Issue on 05/2012, Date of Approval on 05/2012, with the Revision Date of Issue and/or Date of Approval sections left blank revealed that it was the responsibility of the Infection Control Officer to perform frequent procedures, services, processes and functions by having: 1) an active Infection Control Program by having Infection Control Surveillance, Education, monitoring environmental infection control issues, evaluation of products and cleaning agents; 2) monitoring and reporting of communicable disease to public health agencies; 3) investigation of suspected outbreaks; 4) appropriate action taken in the event of an outbreak; 6) Collaborates with Environment of Care to identify and reduce the risk of infection; 7) Works closely with nursing staff to detect disease, and infection as early as possible; and 8) The Medical Director on call will be notified of infection control issues after hours. The Infection Control Officer will perform hospital surveillance to identify possible infection control related problems and assists in identifying possible solutions. The Infection Control Officer will keep current and work with additional standards of practice adopted/adapted by department/services such as Center for Disease Control and Epidemiology and Department of Health and Hospitals-Office of Public Health.

During an interview on 09/27/12 from 3:50 p.m. through 5:15 p.m., S2DON indicated there was no documented evidence of monthly infection control monitoring for hand hygiene, environmental rounds and/or aseptic practices as per the facility's policy from June 06, 2012 through September 27, 2012.

The S2DON confirmed that there were no "Infection Surveillance, Prevention, ex Control Observation Tour of Facilities" active surveillance of the environment performed monthly from June 06, 2012 through 09/27/12 as per policy. Review of the forms at the above time revealed the forms were blank. S2DON denied knowledge of no hand hygiene practices performed by the MHTs (S5, S8) after touching a patient's (R2's) drool. The S2DON indicated hand hygiene is expected by all nursing staff when coming into contact with a patient's (R2's) drool as per policy. The S2DON further denied knowledge of the S15 Contracted Phlebotomist not performing hand hygiene prior to and after drawing blood. S2DON further indicated all staff including the S15 Contracted Phlebotomist were expected to perform hand hygiene prior to and after drawing a patient's (#4's) blood as per policy.

Based on record reviews and interviews, the hospital failed to ensure a patient identified as needing post-hospital services were provided the availability of the services. The hospital failed to ensure that patients were made aware of aftercare follow-up appointments for 1 of 3 discharged patients (#2) in a total sample of 5. Findings:

Review of the medical record for patient #2 reflected the patient was admitted to the hospital on 9/6/12. Review of the patient's Physician's Emergency Certificate (PEC) completed on 9/6/12 at 0340 reflected that the patient was suicidal, dangerous to self and unable to seek voluntary admission. Further review reflected that the patient was positive for "SI [suicidal ideation] attempts in past x 2".

Review of the Psychiatric Evaluation reflected "ADMITTING DIAGNOSIS: AXIS I: Generalized Anxiety Disorder; AXIS II: Deferred; AXIS III: HTN [hypertension]; AXIS IV: Overwhelming Stress - Difficulty [to] Cope..." Further review of the evaluation reflected patient #2 "took an overdose of her blood pressure pills....."

Review of the psychiatric evaluation reflected "TENTATIVE DISCHARGE AFTERCARE PLAN: A........C. ANTICIPATED FOLLOW UP: Out pt follow-up". Review of Physician Orders dated 9/11/12 at 1015 (10:15 a.m.) reflected an order to "Discharge to Home, Continue meds [medications] as ordered, Follow-up primary care and Dr. [Psychiatrist not affiliated with hospital].

Review of the hospital's Master Treatment Plan documentation reflected "Discharge Planning:.....Follow UP Plans....Other: To follow up with her PCP [primary care physician]". There was no documentation to reflect the need for a follow up appointment with another psychiatrist.

Interview on 9/27/12 at approximately 2:30 p.m. with S14Psychiatrist, confirmed an order was written for patient #2 to follow up with another psychiatrist.

Interview with S3LCSW [licensed social worker] on 9/27/12 at approximately 3:25 p.m. revealed that the hospital did not make outside appointments for the patients. S3LCSW stated that the nurses were responsible for providing discharge instructions. S3LCSW further confirmed there was no documentation to reflect discharge planning for patient #2 other than an appointment with the patient's primary care physician.

Based on record reviews and interviews, the hospital failed to ensure the initial implementation of the patient's discharge plan. The hospital failed to arrange/educate a patient concerning post-hospital care for 1 of 3 discharged patients in a total sample of 5 (#2). Findings:

Review of the medical record for patient #2 reflected that the patient was admitted to the hospital on 9/6/12. Review of the patient's Physician's Emergency Certificate (PEC) completed on 9/6/12 at 0340 reflected that the patient was suicidal, dangerous to self and unable to seek voluntary admission. Further review reflected the patient was positive for "SI [suicidal ideation] attempts in past x 2".

Review of the Psychiatric Evaluation reflected "ADMITTING DIAGNOSIS: AXIS I: Generalized Anxiety Disorder; AXIS II: Deferred; AXIS III: HTN [hypertension]; AXIS IV: Overwhelming Stress - Difficulty [to] Cope..." Further review of the evaluation reflected that patient #2 "took an overdose of her blood pressure pills....."

Review of the psychiatric evaluation reflected "TENTATIVE DISCHARGE AFTERCARE PLAN: A........C. ANTICIPATED FOLLOW UP: Out pt follow-up". Review of Physician Orders dated 9/11/12 at 1015 (10:15 a.m.) reflected an order to "Discharge to Home, Continue meds [medications] as ordered, Follow-up primary care and Dr. [Psychiatrist not affiliated with hospital].

Review of the hospital's Master Treatment Plan documentation reflected "Discharge Planning:.....Follow UP Plans....Other: To follow up with her PCP [primary care physician]". There was no documentation to reflect the need for a follow up appointment with another psychiatrist.

Review of patient #2's discharge instructions revealed no documented evidence to reflect an appointment with another psychiatrist that was scheduled for the patient. There was also no evidence to reflect that the patient was made aware of the need for after care services with another psychiatrist.

Interview on 9/27/12 at approximately 2:30 p.m. with S14Psychiatrist confirmed that an order was written for patient #2 to follow up with another psychiatrist. S14Psychiatrist confirmed there was no evidence to reflect that the patient had been made aware of the order to refer to another psychiatrist.

Interview with S3LCSW (licensed social worker) on 9/27/12 at approximately 3:25 p.m. revealed that the hospital did not make outside appointments for the patients. S3LCSW stated that the nurses were responsible for providing discharge instructions. S3LCSW further confirmed there was no documentation to reflect discharge planning for patient #2 other than an appointment with the patient's primary care physician.

Based on record reviews and interviews, the hospital failed to ensure services were furnished in accordance with acceptable standards of practice and established policies and procedures. The hospital failed to ensure that psychosocial assessments were completed timely for 2 of 3 current sampled patient records, (#1, #4) in a total sample of 5. Findings:

Patient #1
Review of the medical record for patient #1 revealed that he was admitted to the hospital on 9/22/12 with Axis I diagnoses to include "Bipolar Disorder, Depressed Type I and Cocaine Abuse, 1 time".

Review of the "Multidisciplinary Integrated Assessment & Treatment Plan " reflected the Psychosocial Assessment component for the patient was not completed.

During the review of the Psychosocial Assessment and interview with S3LCSW (licensed social worker) on 9/26/12 at approximately 9:44 a.m., he confirmed that the Psychosocial assessment had not been completed. S3LCSW stated that the Psychosocial assessment should be completed within 72 hours of admission.

Patient #4:
Review of the medical record for patient #4 revealed that she was admitted to the hospital on 09/25/12 with Axis I diagnoses to include,"Major Depression, Recurrent" and Axis IV diagnosis to include, "Severe Stress."

Review of the "Multidisciplinary Integrated Assessment & Treatment Plan" for Patient #4 reflected the Psychosocial Assessment component for this patient was not completed-the form was blank.

During an interview and record review on 9/27/12 from 3:30 p.m. through 3:45 p.m., S3LCSW confirmed that the Psychosocial Assessments were not completed for Patient #4. S3LCSW indicated that the Psychosocial Assessments for #4 should have been completed within 72 hours of admission as per policy.

Review of the hospital's policy and procedure dated 05/2012 No. 1.1 and titled "Scope of Services", reflected that Social Services were responsible for Psychosocial assessment; individual, group, and family therapy; discharge planning; patient transfer, referral and placement; and aftercare coordination.



25059

Based on observations, record reviews and interviews, the hospital failed to have active surveillance of infection control monitoring for hand hygiene and/or aseptic practices for blood collections monthly from June 06, 2012 through September 27, 2012 as outlined in the facility's "Infection Control Plan" and policies. The hospital was licensed on 6/1/12.

Findings:

During tours of the hospital on 09/25/12 from 11:40 a.m. through 12:36 p.m. and on 09/26/12 from 7:15 a.m. through 12:25 p.m., revealed the following:

1) S5MHT was observed standing in the hallway across from the dining room wearing gloves on both hands. Further observation revealed S5MHT had a clipboard with "Observation Check Sheets" for patient #4, R1, and R2.

2) At 12:15 p.m., the S5MHT had an ink pen and was observed documenting the locations of R1 and patient #4 while wearing gloves on both hands.

3) S5MHT was also observed to walk from the hallway into the dining room area, wiped the drool from the patient's (R2's) mouth with his right-handed glove and walk back into the hallway.

4) Further observation at 12:17 p.m., revealed S5MHT was observed wearing gloves while giving S6MHT the clipboard with the "Observation Check Sheets" for Patient #4, R1 and R2. During an interview with S5MHT at 12:19 p.m., S5MHT indicated he was S6MHT's lunch relief. The S5MHT reported that he was wearing gloves on both hands because he assists with R2 who drools a lot and has to assist with R1 who has to be constantly redirected.

5) At 12:20 p.m., S5MHT was observed degloving and discarding the gloves in the exam room without performing hand hygiene.

6) At 12:21 p.m., S5MHT was observed donning gloves. At this time, S5MHT, confirmed wiping the drool from R2's mouth with his right, handed glove without discarding them and/or performing hand hygiene prior to donning gloves. S5MHT indicated that he failed to perform hand hygiene after coming into contact with R2's drool and prior to donning gloves as per policy. S5MHT denied knowledge the clipboard and ink pen were dirty requiring hand hygiene prior to donning gloves.

On 09/26/12 from 12:55 p.m. through 1:25 p.m., observations of the dining room revealed the following:

1) S8MHT was observed in the dining room wearing gloves on both hands and sitting to the right of a patient (R2) who was sitting at the head of the table with her head down. S8MHT was observed to touch the patient's left, forearm with his gloved hand.

2) At 12:55 p.m., S8MHT was observed walking to get a trash can that was located on the back wall behind the patient (R2), and he removed fourteen styrofoam food containers/plates from the tables and discarded them into the trash can. S8MHT moved the big trash can with him while he removed all containers/plates from the tables and discarded them into the trash can. Then, the S8MHT moved the trash can back up against the back wall behind R1.

3) At 12:56 p.m., S8MHT was observed getting a paper towel from the dispenser and he wiped the drool from R2's mouth. The S8MHT walked to the trash can, removed his gloves, and discarded them into the trash can.

4) S8MHT was then observed to performed handwashing in the sink area.

5) At 1:14 p.m., S8MHT was observed donning a glove on his left hand and sat down next to R2. The S8MHT went and got a paper towel from the dispenser and wiped the drool from R2's mouth. S8MHT walked and got four paper towels from the dispenser, squirted soap onto them, wiped both tables down with the paper towels, and discarded them in the trash can.

6) Continued observation at 1:16 p.m., revealed S8MHT was observed sitting next to R2. S8MHT pulled out an ink pen from his pocket, and charted each patient's food intake onto an "Observation Sheet" that were located on a clipboard. S8MHT got a paper towel from the dispenser and wiped R2's drool with it. At 1:18 p.m., the S8MHT discarded the paper towel and left handed glove into the trash can and performed handwashing in the sink area.

Interview at this time with S8MHT confirmed he did not perform hand hygiene after wiping the drool from R2's mouth and/or handling the dirty food containers/plates. S8MHT denied knowledge the ink pen and clipboard were dirty requiring hand hygiene to be performed.

On 09/26/12 from 8:50 a.m. through 9:00 a.m., the contracted Phlebotomist, S15 was observed standing in the hallway, next to the nursing station, holding a tray. S15 was then observed to enter into patient #4's room without performing hand hygiene, donned gloves on both hands, wiped the right, forearm area with alcohol, applied a tourniquet, and drew a vial of blood from patient's (#4's) right, forearm.

Further observation revealed S15 removed the tourniquet from the #4's right, forearm, removed the vial of blood, a tube, and placed the vial into the tray. S15 removed the needle from the patient's forearm, three squirts of blood was noted on the right side of the patient's forearm. S15 applied gauze and tape to the area and discarded the needle into the biohazard container located on the tray. S15 confirmed the patient's name and date of birth with the patient, picked up the vial of blood from the tray, labeled the vial with the patient's name and date of birth, and placed the vial of blood in the tray again.

At 8:57 a.m., S15 was observed removing both gloves and placed them into a white cup located on the tray. S15 exited patient's (#4's) room at this time and walked down to the nurses station without performing hand hygiene. The contracted Phlebotomist, S15 handed a copy of the requisition slip to S6MHT and left the nurses station without performing hand hygiene. As S15 was exiting the building at 9:00 a.m. and was stopped by the surveyor, S15 confirmed she did not perform hand hygiene prior to drawing patient's (#4's) blood and/or after drawing the patient's (#4's) blood as per policy. The contracted Phlebotomist, S15 indicated she could not perform hand hygiene prior to drawing blood in the patient's rooms because one patient's (whom she could not identify and/or recall) sink did not work. The contracted Phlebotomist, S15 further indicated she normally performed hand hygiene, after drawing the patient's blood in the nurses station sink in which she did not because the surveyor made her nervous.

Although the facility was licensed in 6/1/2012, there were no "Infection Surveillance, Prevention, ex Control Observation Tour of Facilities" forms presented for the monitoring of the environment monthly from June 06, 2012 through 09/27/12.

Review of the policy titled, "Environmental Surveillance", Infection Control 06, Original Date of Issue on 05/2012, Date of Approval on 05/2012, with the Revision Date of Issue and/or Date of Approval sections left blank indicated, "the Infection Control Officer (ICO) will conduct monthly environmental surveillance rounds to identify deficiencies. The results will be communicated with the department heads with a plan to make needed improvements. Quarterly, the infection control committee will review the process and make any needed recommendations. It is hospital procedure for the ICO to make monthly rounds and focus on environmental issues relating to infection control. The ICO will notify staff responsible for correcting any deficiencies and assist with the corrective actions. A copy of the worksheet will be routed to the appropriate Department Heads. This report will be presented in the Performance Improvement Committee on a monthly basis".

There was no documentation of infection control monitoring for hand hygiene, environmental rounds and/or aseptic practices monthly from June 06, 2012 through September 27, 2012.

The "Infection Control Plan", with no effective date, review date and/or revised date, revealed that the goals of the infection control program were to limit unprotected exposure to pathogens throughout the hospital, enhance hand hygiene throughout the organization, minimize the risk of infections associated with procedures, medical equipment, and medical devices, perform continuing surveillance to monitor known risks and identify new ones, reduce the risks

25059



Based on record reviews, observations, and interviews, the Infection Control Officer failed to have a system in place for controlling infections and communicable diseases of patients as evidenced by:

1) failed to have a policy and procedure in place for cleaning and disinfecting the shower/bath area before and after each patient's use;

2) failed to have a policy in place to clean/disinfect the washer before and after each patient's use.

3) failed to ensure that a sanitary environment was maintained. The hospital failed to implement interventions to safeguard patients against the transmission of communicable diseases and socially transmitted conditions. The facility failed to implement procedures to clean the clothing and personal belongings of one Random Patient (R1) treated for pubic lice.

Findings:

1) Observation of the shower/bath area on 09/25/12 at approximately 12:33 p.m. revealed there were 2 shower stalls and a bathtub. Interview at that time with S1CEO (Chief Operating Officer) and S2DON (Director of Nursing) revealed that patients use the shower or bathtub and staff remains at the door during the time patients are using the shower or bath tub. S2DON further stated that staff cleans the shower or bathtub after each patient's use.

Review of the hospital's policies and procedures revealed there were no policies/procedures to indicate the procedure for staff to follow when cleaning the showers/bathtubs between each patient's use.

During an interview on 9/25/12 at approximately 4:00 p.m. with S5MHT revealed they worked the day shift mostly but also worked on the night shift. S5MHT revealed most showers/baths of patients were done on the night shift. S5MHT further revealed staff did not clean the showers/bathtub between patient's use. S5MHT stated that the only cleaning supply used was "bleach" and that was used for washing patient's clothing.

Interview with S9MHT on 9/26/12 at 7:10 a.m. revealed that he has been employed at the facility for approximately one month and he worked from 7:00 p.m. to 7:00 a.m. full-time. S9MHT revealed that showers/baths of patients were usually done on the night shift, and after each patient's use, staff disinfects the shower/bath with "bleach/water". S9MHT stated that he mixed "1/4 bleach per bucket of water" and wiped down the shower/bathtub.

Interview on 9/26/12 at 7:20 a.m. with S6MHT revealed that staff was responsible for cleaning the shower/bathtub after each patient's use. S6MHT stated that staff "try" to clean between each patient's shower/bath with "bleach/water'. S6MHT further stated that staff dilute "1/2 bleach to 1/2 water" to clean the shower/bathtub. S6MHT further stated that a "spray bottle" was used and S6MHT revealed there was no time frame required for patients to wait between shower/baths.

Observation on 9/26/12 at 7:30 a.m., of the housekeeping room where the cleaning supplies were stored, revealed there were no spray bottles for cleaning the shower/bathtubs noted.

In an interview on 09/26/12 from 7:15 a.m. to 7:45 a.m., the S7MHT indicated that all baths are provided to the patients from the hours of 7:00 p.m. through 10:30 p.m. during the night shifts; no exceptions. S7MHT indicated that all showers/baths are cleaned with straight bleach after each patient usage as per policy.

An interview with S2DON on 9/26/12 at 7:40 a.m. revealed that staff were responsible for cleaning the shower/bathtub by spraying a disinfectant into the shower stall and/or bathtub. S2DON revealed there was no time frame for the disinfectant to remain in the shower stall or bathtub between each patient's use, and staff were to spray the disinfectant and rinse the shower/bathtub. S2DON stated that when staff used bleach then they were to mix 1/2 bleach to 1/2 water in a "bucket" to clean the shower/bathtub.

Interview with S10RN on 9/26/12 at approximately 7:48 a.m. revealed that she worked on the night shift from 7:00 p.m. until 7:00 a.m. S10RN stated she has been employed with the hospital since 6/12. S10RN further stated that showers/baths were completed on the night shift and MHTs were responsible for cleaning the shower/bathtub between each patient's use. S10RN stated that staff used a spray bottle that contained bleach/water to clean the shower. S10RN revealed that staff spray the bleach/water and then wipe "around" the shower. S10RN further stated that staff poured bleach in water to clean the bathtub. S10RN revealed that she was not sure how much bleach/water was used to disinfect because the "techs" were responsible for that.

During an interview on 9/26/12 at 8:00 a.m. and on 09/27/12 from 3:50 p.m. through 5:15 p.m., S2DON denied knowledge that the nursing staff and MHTs were not aware of the concentration amount required to mix the bleach with water to disinfect/clean the shower/bath after each patient use. S2DON confirmed there was no policy/procedure regarding how staff were to disinfect the bath/shower before and after each patient usage.


2) Review of the hospital's policies and procedures revealed there was no policy/procedure to indicate the proper procedure to use to clean/disinfect the washer between patient's use.

In interviews on 09/27/12 at 11:40 a.m. and at 2:25 p.m. and from 3:50 p.m. through 5:15 p.m., S2DON indicated there was no hospital policy/procedure for cleaning/disinfecting the washer between patient's use.

3) Review of the medical record for Patient R1 revealed that she was admitted on 9/5/12 at (2210) 10:15 p.m. with an admitting diagnosis of Schizophrenia and a history of Chlamydia Infection. Further review revealed the "Multidisciplinary Progress Notes"dated/timed 9/19/12 at (1610) 4:10 p.m. which reflected "....Notified S12Medical Physician [MD] of pt c/o itching &burning in pelvic & vaginal and pubic area. Tech reported seeing something of a spider-like appearance crawling in that area during her toileting care. Pt refused to let nurses assess...At 8:20 p.m. (2020), S12MD on unit. Pt refused to let him exam her. [No] treatment provided...".

Review of a telephone Physician's Orders dated 9/20/12 at 10:15 a.m. indicated [kwell] treatment times 1.

There was no documented evidence to reflect any measures were implemented to ensure other patients had not been exposed and/or required treatment. There was also no documentation to reflect proper measures were implemented to ensure the potential for infectious disease was decreased.

Review of the hospital's policies and procedures revealed there was no policy/procedure to indicate the proper procedure to clean/disinfect the washer between patient's use.

Interview with S2DON on 9/27/12 beginning at 3:50 p.m. revealed that the patient was ordered a treatment of "kwell", which was provided. S2DON confirmed the patient's laundry was washed in the regular washer that was used for all patients. S2DON confirmed that no extra precautions were taken to ensure other patients were not exposed. S2DON indicated there was no hospital policy/procedure for cleaning/disinfecting the washer between patient's use.

25059



Based on record reviews, observations, and interviews, the Infection Control Officer failed to ensure that a system in in place to identify, report and control infections and communicable diseases of patients. The hospital failed to ensure that staff performed hand hygiene after the Mental Health Techs (S5MHT and S8MHT) wiped drool from one random patient's mouth (R2), touched equipment and cleaned when providing care. The facility also failed to ensure that the contracted phlebotomist (S15) implemented appropriate infection control measures when collecting blood samples for 1 of 2 currently admitted patients (#4's) who had blood drawn in a total sample of 5 patients. Findings:

S5MHT
During tours of the hospital on 09/25/12 from 11:40 a.m. through 12:36 p.m.; on 09/26/12 from 7:15 a.m. through 12:25 p.m., and at 8:00 a.m., S5MHT was observed standing in the hallway across from the dining room wearing gloves on both hands. Further observation revealed S5MHT had a clipboard with "Observation Check Sheets" for patient #4, R1, and R2. At 12:15 p.m., the S5MHT had an ink pen and was documenting the locations of R1 and R4 while wearing the gloves.

Further observation revealed S5MHT was observed walking from the hallway into the dining room area and wiped drool from patient's (R2's) mouth with his right gloved hand and walked back into the hallway. At 12:17 p.m., S5MHT was observed giving S6MHT the clipboard with the "Observation Check Sheets" for Patient #4, R1 and R2. At 12:19 p.m., S5MHT indicated he was S6MHT's lunch relief. S5MHT reported wearing gloves on both hands because he assists with R2 who drools a lot and assists with R1 who has to be constantly redirected. At 12:20 p.m., S5MHT was observed degloving and discarding both gloves in the exam room without performing handwashing.

At 12:21 p.m., S5MHT was observed donning gloves on both hands. At this time, the MHT, S5 confirmed wiping the drool from R2's mouth with his right handed glove without discarding them and/or performing hand hygiene prior to donning gloves on both hands. S5MHT indicated he failed to perform hand hygiene after coming into contact with R2's drool and prior to putting on gloves as per policy. S5MHT denied knowledge the clipboard and ink pen were dirty requiring hand hygiene prior to putting on gloves.

S8MHT:
On 09/26/12 from 12:55 p.m. through 1:25 p.m., observations of the dining room were conducted. S8MHT was observed in the dining room wearing gloves on both hands. S8MHT was sitting to the right of patient (R2), and he touched her left forearm. At 12:55 p.m., S8MHT was observed walking to get a trash can that was located on the back wall behind the patient, (R2), removing fourteen Styrofoam food containers/plates from the tables and discarding them into the trash can. S8MHT moved the big trash can with him while he removed all containers/plates from the tables and discarded them into the trash can. Then, S8MHT moved the trash can back up against the back wall behind R2.

At 12:56 p.m., the S8MHT was observed getting a paper towel from the dispenser and wiping the drool from R2's mouth. S8MHT walked to the trash can, removed his gloves, and discarded them into the trash can. S8MHT performed handwashing in the sink area. At 1:14 p.m., S8MHT was observed putting on a left glove and sitting down next to R2 at the head of the table. The S8MHT went and got a paper towel from the dispenser and wiped the drool from R2's mouth. S8MHT walked and got four paper towels from the dispenser, squirted soap on them, wiped both tables down in the dining room area, and discarded them in the trash can.

At 1:16 p.m., S8MHT was observed sitting next to R2 at the head of the table, pulled out an ink pen from his pocket, and charted each patient's food intake onto an "Observation Sheet" that were located on a clipboard laying on the table. S8 got another paper towel from the dispenser, wiped R2's drool with it, and placed the towel on the table next to the clipboard. At 1:18 p.m., the S8MHT discarded the paper towel and left handed glove into the trash can. S8MHT performed handwashing in the sink area. At this time, S8MHT confirmed he did not perform hand hygiene after wiping the drool from R2's mouth and/or handling the dirty food containers/plates as per protocol. S8MHT denied knowledge the ink pen and clipboard were dirty requiring hand hygiene to be performed.

S15 Contracted Phlebotomist:
On 09/26/12 from 8:50 a.m. through 9:00 a.m., S15 was observed standing in the hallway next to the nursing station holding a laboratory tray with needles, vials, gloves, biohazard counter, white cup, alcohol preps, gauze, and tape. At 8:50 a.m., S15 Contracted Phlebotomist was observed entering into Patient #4's room without performing hand hygiene, pulled gloves out of the tray, put gloves on both hands, wiped the patient's (#4's) right, forearm area with an alcohol prep, applied a tourniquet to the patient's right forearm, and drew one vial of blood.

Further observation revealed S15 removed the tourniquet from the patient's right, forearm, removed the tube of blood (vial), placed it into the tray, and removed the needle from the patient's forearm. Three squirts of blood was observed on the patient's right, forearm. S15 applied gauze and tape to the area, and discarded the needle into the biohazard container located on the tray. S15 confirmed the patient's name and date of birth with the patient at this time. S15 picked up the vial of blood vial from the tray and labeled it with the patient's name and date of birth. At 8:57 a.m., S15 was observed removing both gloves and placed them in a white cup on the tray. S15 opened the door, exited patient's (#4's) room, and walked down to the nurses station without performing hand hygiene. The contracted Phlebotomist, S15 handed a copy of the laboratory requisition slip to S6MHT and exited the nurses station without performing hand hygiene.

At 9:00 a.m., S15 Contracted Phlebotomist was observed going to exit the building, and she was stopped by the surveyor. The S15 Contracted Phlebotomist confirmed that she did not perform hand hygiene prior to drawing the patient's vial of blood and/or after drawing the patient's blood as per policy. S15 Contracted Phlebotomist indicated that she could not perform hand hygiene prior to drawing blood in the patient's rooms because one patient's (whom she could not identify and/or recall) sink did not work.

The "Infection Control Plan", with no effective date, review date and/or revised date, indicated that the goals of the infection control program were to limit unprotected exposure to pathogens throughout the hospital, enhance hand hygiene throughout the organization, minimize the risk of infections associated with procedures, medical equipment, and medical devices, perform continuing surveillance to monitor known risks and identify new ones, reduce the risks of infection for patients, employees, and visitors, and develop plans to reduce the incidence of those specific infections with highest risk morbidity on our campus. Contaminated hands are a primary source of infection throughout healthcare. Our first priority is to increase compliance with hand hygiene measures as recommended by the Centers for Disease Control. Many serious infections are transmitted through blood or body fluids. Our second priority is to educate all employees about these infections and how they can protect themselves and their patients. The equipment we use (syringes, and other devices) can transmit infections. Our third priority is to minimize these risks by using equipment that is designed for safety and educating employees about how the equipment should be used. One strategy used to minimize the risks for acquisition and transmission of infection is to monitor the use of hand sanitizer, and report results to the Infection Control Committee, to the Environment of Care Committee, and to the areas monitored.

Review of the policy titled, "Infection Control: Standard Precautions", Infection Control 7, and Infection Control 10, Original Date of Issue on 05/2012, Date