Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 670031 (X3) Date Survey Completed 01/12/2012
Name of Provider or Supplier St Luke's Patients Medical Center Street Address, City, State 4600 East Sam Houston Parkway South, Pasadena, TX
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0749 INFECTION CONTROL OFFICER RESPONSIBILITIES
CFR(s): 482.42(a)(1)

The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.


This STANDARD is not met as evidenced by:
Based on observation, interview and record review, facility failed to maintain a sanitary environment in that facility ' s nursing staff failed to wear gloves, wash hand and maintain infection control practices when providing direct care and administering medication to patient's ; failed to clean droplet of blood from used equipment and failed to ensure expired supplies were not available for use in patient care areas in 6 of 32 sampled patients. #s 1, 7, 15, 16, 29, 32 Findings: Review of the facility's current policy and procedure on Medication therapy # PHA136 directed staff as follows: " Medication administration will be in compliance with infection control guidelines ( standard Precautions) " Standard Precaution " Assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting and apply the following infection control practices during the delivery of health care: During the delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. Wear disposable medical examination gloves for providing direct patient care. Wear gloves when it is reasonably anticipated that contact with blood or potentially infectious materials, mucous membrane, non intact skin or potentially contaminated intact skin ( e.g. of a patient incontinent of stool or urine could occur.) Perform Hand hygiene before direct contact with patients, After removing gloves. " Patient #15 On 01/ 11/2012 at 7:20 a.m. registered nurse (5 E) was observed in the room of patient # 15. Observation at that time revealed the patient ' s chart was stored on top of the dirty linen cart stored in the patient ' s room. The cart was holding a yellow bag containing soiled linen. Registered nurse (5 E) picked up the chart from off the soiled linen cart and returned it to the chart rack at the nurses ' station. Registered nurse (5 E) did not clean the contaminated chart or wash her hand after touching the soiled linen cart. She then proceeded to make a telephone call at the nurse station. On 01/11/2012 at 7:24 a.m. the surveyor informed registered nurse (5 E) that she the surveyor had observed her with the patient ' s chart stored on the dirty linen cart and that she had not cleaned the chart or wash her hands after handling potentially contaminated items. Registered Nurse (5 E) stated " You can't do that? " Patient # 7 On 01/11/2012 at 7:30 a.m. registered nurse (7 G) was observed in the room of patient # 7. Observation at that time revealed registered nurse ( 7 G) picked up soiled linen stored on top of the dirty linen cart and placed them in a yellow bag. Registered nurse (7 G) was not wearing gloves when handling the soiled linen and did not wash or cleansed her hands after handling the soiled linen. She then placed her contaminated hand in her pocket and retrieved a marker which she used to write on the board in the patient ' s room. After writing on the board, she returned the contaminated marker to her pocket, picked up the clip board in the room, along with containers from the patient ' s bedside table. The nurse opened the door with her contaminated hands then walked to the nurses ' station where she placed the items on the nurses ' station and in the garbage. On 01/11/2012 at 7:36 a.m. during an interview with registered nurse (7 G) the surveyor informed the nurse that she the surveyor had observed her handled soiled linen with her ungloved hands and that she the nurse did not wash her hands after handling the contaminated linen. Registered nurse (7 G) stated " I am sorry. " Patient #16 On 01/11/2012 at 8:00 a.m. registered nurse # 6F was observed at the bedside of patient #16 administering oral and intravenous medication to the patient. On entering the patient ' s room registered nurse (6F) pulled a dirty linen cart that was located in the patient ' s room. The cart was holding dirty linen in a yellow bag. She then placed a packet containing patient #16 ' s home medication on top of the dirty linen cart, placed a clip board on top of the cart and poured medication that were in a bag on top of the cart and some unto the clip board. After administering oral medication to patient #16, registered nurse (6F ) then proceeded to administer intravenous medication of Protonix and Lasix to patient #16. Registered nurse (6F) removed an alcohol swab from the packet, placed the swab directly on the patient ' s bedside table which was not cleaned during medication administration procedure. Registered nurse (6F) used the same contaminated alcohol swab to clean the intravenous port of patient #16 prior to administering Lasix and Protonix to patient #16. After administering medication to patient #16, registered nurse 6F picked up the contaminated packet containing the patient ' s home medication and the clip board and left the room . Registered nurse (6F) placed the contaminated clip board unto the nurses ' station and returned the contaminated packet containing patient ' s home medication to the medication room. During an interview with registered nurse (6 F) on 01/11/2012 at 08:10 a.m. registered nurse said patient # 16 was receiving antibiotic therapy for a urinary tract infection. Subsequent interview on 01/11/2012 at 8:15 a.m. in the medication room, the surveyor informed her that she the surveyor observed her set up patient ' s medication on the dirty linen cart and that she had removed alcohol swab from the packet and placed it directly on the dirty bedside table of patient # 16. Registered nurse #6F stated " You are so right I will correct it " Review on 01/11/2012 of patient #16 ' s clinical record revealed a physician ' s order dated 01/07/2012 for antibiotic therapy of Intravenous Levaquin 750 mgs daily for urinary tract infection. Review of the patient ' s clinical record revealed a history and physical dated 01/07/2011 which indicated the following " Diagnosis , sepsis secondary to urinary tract infection, bilateral pneumonia. " 12000 Observation 1/10/12 at 9:40 a.m. in the Cardiac Cath Lab revealed the patient table had red specs / splatter / hair and dirt on the base of the table. The red specs could be wiped clean using an alcohol swab. 23032 Patient #32 Observation on 01-11-12 at 9:10 a.m. revealed Registered Nurse (RN) (ID # 9-I) prepared to administer morning medication to Patient (ID #32). She went directly from the computer keyboard to the medication room and obtained the patient ' s (ID # 32) medication. The RN failed to wash or sanitize her hands before entering and prior to exiting the medication room. Further observation revealed RN (ID # 9-I) went directly from the medication room to the patient ' s (ID # 32) room. RN (ID # 9-I) entered the room and donned a pair of gloves without first washing or sanitizing her hands. RN (ID #9-I) administered several medications to Patient (ID # 32); removed her gloves, and washed her hands prior to exiting the room. During an interview on 01-12-12 at 9:45 a.m. with the Interim Chief Nursing Officer (CNO) (ID # 28 B), she stated the RN should have washed her hands prior to entering the medication room and also upon entering the patient ' s room and prior to donning gloves. 17028 Patient #1 Observation on 01/11/12 at 9: 30 a.m. revealed Patient # 1 had a pressure sore on the buttocks opened to air and wounds on both feet which were bandaged. Staff # 1 A, (Registered Nurse) started to clean the patients ' buttocks then decided to administer Intra venous (IV) Morphine to the patient. The Nurse administered the IV medication and did not remove the gloves and wash her contaminated hands. After administering the medication with the same contaminated gloves she was wearing , she completed cleaning the wound on the patient's buttocks, placed the Xenaderm ointment on her gloved hand and applied the ointment to the patient's buttocks. The nurse did not change the gloves and wash her hands prior to the application of the ointment. Staff # 29C (Licensed Vocational Nurse) who was assisting with the procedure removed a pair of scissors from her pocket and cut through the bandages covering wounds on both feet of the patient. Staff # 1 A removed the dressings from the patient ' s left foot, removed her gloves and left the room without washing her hands. Soon after, she returned to the room and donned a clean pair of gloves, assisted staff # 29C with changing the patient ' s disposable towel. She then proceeded to clean the wound on the patient ' s left foot with normal saline poured from a bottle onto gauze swabs. After cleaning the wounds without changing her gloves Staff # 1 A placed the Iodosorb gel on a gauze swab and applied the gel to the wounds moving from one wound to the next using the same swab. She then bandaged the patient's wounds. The Nurse never changed her gloves and wash her hands between tasks. The nurse then used the contaminated gloves to remove the soiled dressing from the patient ' s right foot, she changed one hand of her gloves and replaced it with a clean glove; she poured saline solution from the bottle onto a swab and cleaned the wound on the patient's heel. Without changing her gloves the staff applied Xenaderm ointment to one gloved hand and applied the ointment to the wound, she then applied a bandage, then remove one hand of glove and wrote on the bandages. After the wound care procedure staff #1 A and # 29 C repositioned the patient in bed. Staff # 29 C returned the soiled pair of scissors to her pocket without cleaning the scissors. After completing wound care staff # 1 A removed her gloves, picked up a clipboard she took to the room along with the saline bottle and tubes of medication started to leave the room, and then decided to wash her hands at the sink. She proceeded to the nurses ' station with the contaminated tubes of medication, clipboard and saline bottle without cleaning them. The medication was returned to the clean medication room. All these items were handled with soiled gloves. Patient # 29 Observation on 1/11/12 at 9:25 am revealed Patient # 29 had a surgical incision on her left hip. There was orders to clean with normal saline and apply dry dressing. Staff # 9 I ( Registered Nurse) donned a pair of gloves, removed the soiled dressing, changed her gloves, put on clean gloves and used the saline soaked gauze to clean the wound. She then removed those gloves, put on clean gloves and applied the dry dressing. She did not wash her hands after each glove change. During an interview with Staff # 9I on 1/11/12 at 10:00 am she stated she realized she should have cleaned or washed her hands after the glove change. 30124 Surveyor observed at 09:30 a.m. of January 11, 2012 in the operating room # 4 a surgical procedure on patient #22. Surveyor observed the circulating nurse (ID # 11K) opening a sterile scrub pack for pre-operative cleaning of a surgical site. Circulating nurse (ID#11K) applied sterile gloves and preformed scrubbing/disinfection of the surgical area. Surveyor then observed staff (ID#11K) after completion of scrubbing/disinfection of surgical area collected the items used and discard the items into the trash. Surveyor then observed staff (ID#11K) removed her gloves and drop them into trash. Employee (ID#11K) them proceeded over to counter and began documenting on a piece of paper. Employee (ID#11K) failed to disinfect or wash her hands per hospital policy. Operating Room Director (ID# 8H) on January 11, 2012 stated the circulating nurse (ID#11K) should have left the operating room and washed her hands right outside the door or used a hand sanitizer. During initial tour surveyor observed at 1000 AM on January 10, 2012 along with Quality Assurance Director, (ID# 26Z) and OR Nurse (ID# 25Y) in the Operating Room Clean Supply room the following expired items readily available for use: Packing Strips 1 inch x 5 yards: 1 Bottle expired 10/09 1 Bottle expired 12/09 12 Bottles expired 01/10 2 Bottles expired 09/11 Packing Strips ? inch x 5 yards: 9 Bottles expired 9/11 8 Bottles expired 12/09 Packing Strips ? inch x 5 yards 3 Bottles expired 10/09 During initial tour surveyor observed at 1030a.m on January 10, 2012 along with Quality Assurance Director, (ID# 26Z) and OR Nurse, (ID# 25Y) in the Operating Room supply area the following expired items readily available for use: 4 Packages - Providen-Iodine Swabs Expired 07/2011 1 Box - Surgical Blade 6200 Expired 10/2010 6 Packages - Small Chisel Mini Blade S-6200 Expired 07/2011