DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: 111'061?2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 B. WING 10H 5i'2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 W) ID SUMMARY STATEMENT OF DEPICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH (x5) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVEACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) TAG A 749 Continued: A 749' Continued From page 64 A 749 gloves. Wearing the same pair of gloves 5 Registered Nurse AM walked to the hemodialysis machine Of Patient and reset the hemodialysis machine of the patient. The Facility?s Director of Critical Care who was present notified Registered Nurse AM that she needed to change her gloves before touching the Patient's hemodialysis machine. Registered Nurse AM stated only used one hand of gloves Patient #28, Registered Nurse AM On 10/142015, at 11:15 am, was Registered Nurse AM observed on the bedside of Patient #28 Observation revealed the Registered Nurse donned a pair Of gloves, disconnected the patient's central venous catheter from the external blood line. After disconnecting the patient's external blood lines. the Registered Nurse removed her contaminated gloves, walked over to the Clean box of gloves located at the nurses station and picked up Clean gloves with her contaminated previoust gloved hands. The Surveyor immediately notified Registered Nurse AM that she did not wash/sanitize her hands. Registered Nurse AM said Observation on the Surgical Intensive Care Unit (ICU) on 10i13/2015. between the hours of 9:30 am. and 10:40 am. revealed the following information: Staff# ll Patient was observed in bed receiving hemodialysis treatment via a temporary Change in reporting structure to the I Additional training to the Governing Board regarding the Infection Control Program; Quarterly rounding with IC by GB members Evaluate new technology in the infection prevention discipline speci?c to hand hygiene compliance; Engage outside IC consultant to provide and assist with a gap analysis and implementation performance improvement plans; Authorized the IC Manager to implement corrective actions as necessary. Corporate Infection Control reviewed roles and responsibilities with the current infection control team and immediately increased oversight and supervision to ensure implementation of the organized Infection Control program and follow through on corrective actions. The team received education and direction relative to increasing visibility and accessibility throughout the hospital. An assessment of I core competencies utilizing the evidence based APIC Competency Mode! for the I infection Preventionfst is in progress for IC staff (Exhibit D). Results of the Infection Control core competency assessment are used to educate and guide the IC Team and identify areas where further education and skill set development is needed. The infection control manager attended the EVS staff meeting to perform hand hygiene 10/28/2015 and PPE competencies, and provide additional education and training on appropriate glove and PPE use. 10/16/2015 The plan for improvinq the processes that led, to the deficiency cited, including how the hospital is addressing improvements in its systems in order to prevent the likelihood of recurrence of the deficient practice: FORM Previous Versions Obsolete Event ID: 272U11 Facility ID: 810020 If continuation sheet Page 65 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: 11f06f2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 B. WING 10l15l2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH {x5} (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) TAG A 749 Continued: A 749 Continued From page 65 A 749 intravenous catheter. Staff Registered Nurse (RN) caring forthe patient was observed wearing gloves, and was documenting on a paper record attached to a Clip board. The staff went to the patient's bedside touch the patient's dialysis machine and supplies located on top of the dialysis machine. The Staff did not remove the gloves and sanitize his hands after touching the dialysis machine and supplies. He continued his documentation wearing the dirty gloves. Staff ll went back to the dialysis machine touched the machine, removed the gloves he was wearing and did not wash! sanitize his hands. He continued documenting on the paper record with his unwashed hands. Further observation on 10/13/2015, on the ICU revealed five (5) Physicians went into a patient's room(#4) and did not sanitize their hands prior to I entering the patient's room. I The physicians Spent approximately 10-15 minutes in the patient's room then left. Three (3) Of the five (5) physicians did not wash/sanitize their hands after leaving the patient's room. Hand sanitizer was located at the entry to each room and hand washing sink with soap and water was available in the patient's room. - Staff RR . Observation on 10l13f2015, at 11:45 am, in the I new born nursery revealed Staff RR Registered . Nurse providing care to an infant in his cot. Infection Control Committee meeting frequency 11/17/2015 was increased from quarterly to and a Istandardized agenda was revised to address the following: - Follow up on recent infection control I findings and tracking of initiatives - Results of department environmental rounds Effectiveness ofthe hand hygiene campaigni - Integration of CLABSI, CAUTI, Germ Squad (hand hygiene) performance improvement team findings and corrective actions In CLABSI, CAUTI and surgical site infection root cause and case discussion in Blood culture contamination rates 0 Each month on a rotating basis a department director/designee will present their infection control interventions and results. A schedule was created. Education will be provided to the Committee to 12/15/2015 further delineate its roles. responsibilities, and accountabilities relative to infection control initiatives going fonivard including humanizing hospital acquired infections through individual (case review and integration of a team. 'Procedures for implementing the acceptable . Iplans of correction for each deficiency cited: . Daily and weekly departmental speci?c Checklists (Exhibits and F-1) were developed to support ongoing review and analysis of gmas/2015 environmental and workplace activities for reducing infection risk and evaluating compliance with current healthcare regulatory standards. FORM Previous Versions Obsolete Event Facility 810020 If continuation sheet Page 66 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11t06f2015 FORM APPROVED OMB NO. 0938-0391 After completing her care the nurse removed her . gloves, did not wash her hands, she picked up I the patient's paper record, went to the desk at the I nurse's station and began documenting at the computer. Hand sanitizer and hand washing sinks were readily available in the nursery. During an interview on 10t13l2015, at 11:05 with the RN Manager on the unit she stated she saw the physicians go into the room without hand sanitization and addressed the issue with them. The RN Managerfurther stated the paper record used by Staff ll goes into the patient's paper chart at the end of the treatment. The Paper chart is kept at the Nurse 3 station and is handled by all staff. The observation revealed not all the physicians complied with the instructions when they left the patient's room. Patient #63 Patient #63 was observed on 10/13/2015, at 9:30 am, in bed. He had a Foley catheter to drain. Review of physician's orders progress and nurses notes dated 10/9/2015through 10/13/2015, revealed the patient was admitted to the unit on was admitted to the facility 10!8f2015, and had a left Carotid Endarterectomy(surgical procedure of the artery) done. He was transferred to the Intensive Care Unit ICU) on with a Foley Catheter in place. There was no orders or indication for Foley STATEMENT OF DEFICIENCIES {xii {x2} MULTIPLE CONSTRUCTION (x3) DATE AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 450035 B-WING 101159015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 W) In SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH Ixsi (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVEACTION SHOULD BE CRoss? COMPLETION TAG REGULATORY OR IDENTIFYING IN FORMATION) TAG REFERENCED To THE APPROPRIATE DATE DEFICIENCY) ITAG A 749 Continued: A 749 Continued From page 66 A 749I I lOversight of this Checklist process is performed by lC staff, who will validate departmental findings twice weekly on a rotating department basis via formal schedule (Exhibit D-4), with the exception of dietary, where validation rounds are: performed weekly. Findings are presented at the ICC meeting and reported to the QMOC. General departmental checklists address (Exhibits and F-1) the following areas: 0 Proper storage of clean and dirty linen a Ceiling tile replacement - Cleaning and dusting of air vents, light ?xtures, and sprinkler heads Equipment/wheeIs/casters free of rust - NO food or drink in patient areas - No cracked or torn furniture or floor covering; Re-education Of OR and EVS staff regarding .1 11309015 Cleaning procedures, including checking all rooms I for cleanliness at the start of the day and between I cases. Reviewed policies include: Sanitation of I Operating Room Suites and Equipment and I Cteanr'ng and Storage of Non-Criticat Reusable I Patient Equipment. The manufacturer of the OR surgical tables (Steris) is scheduled to be onsite 11l16t15 to determine the measures needed to remove the rust that is currently present on the OR surgical tables. They will also provide onsite education and training to staff, and the manager and coordinator on cleaning procedures to prevent the deVE-IOpment of rust on equipment going forward FORM Previous Versions Obsolete Event Facility 810020 If Continuation Sheet Page 67 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: 11/06/2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A, BUILDING 450035 WING 10/15/2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, Tx 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDERS PLAN OF CORRECTION (EACH (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL SHOULD BE CRoss- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) TAG A 749 Continued: A 7'49 Continued From page 67 A 749 Catheter use documented on the patient's medical record. Patient 65 Observation on 10/14/2015. at 10:05 am, on the ICU revealed Patient in bed with a Foley catheter to drain. Review of the patient's Interdisciplinary notes dated 10/9/2015 through 10/14/2015. revealed the patient was diagnosed with and was intubated. She was admitted to the the ICU on 10/13/2015, I with the Foley Catheter in-place. Review of Physician's orders revealed there was an order for Foley Catheter but no indication for use was documented. During an interview on 10/15/2015, at 10:05 am. .with the Infection Control Manager he stated there is a Foley Catheter protocol that Should be used on all units. According to Managerthere should be a written order with indication for use, for the Foley catheters. Intake Observation on 10/15/15, at 9:30 am, ofthe intake unit revealed an Environmental Services staff cleaning a large room. The room contained (4) pull out vinyl covered beds and the floor was smeared with copious amounts of what appeared to be brown fecal matter. The fecal matter was observed to trail out of the room into A comprehensive hand hygiene awareness I campaign and education on the appropriate use of PPE was initiated: Infection control initiated hospital wide hand hygiene and PPE training and competencies on November 1, 2015 for all hospital staff (Exhibit D-1). 12/15/2015 - A risk assessment for placement of hand . hygiene dispensers in the CBH was performed; dispensers will be installed in designated areas. - CBH unit secretaries were reeducated on ensuring adequate amounts of portable hand sanitizer are ordered and available for staff. - Comprehensive education on hand hygiene, appropriate glove use, and responding to environmental infection control issues will be provided to CBH staff by 11/20/15. A Frequently Asked Questions tool will be developed as a resource for behavioral health based on feedback during training. 0 Hand hygiene monitoring for dialysis specifically includes appropriate glove use during venous and arterial punctures and the use of sterile gloves when necessary. i- Charge nurse were reeducated on addressing the need for concurrent staff redirection for performing hand hygiene before and after entering patient rooms and after every patient interaction. - Staff was educated to raise awareness among co-workers to perform hand hygiene? - ?Stop and Wash? signage will be posted ?209015 above each hand hygiene dispenser outsideI patient rooms aS a visual prompt - Hospital Leadership, Infection Control, and Quality will monitor hand hygiene i1 190/2015 performance while performing daily rounds and dispense washed my hands? stickers for positive reinforcement. Stickers can be exchanged for tokens and used to purchase items in the cafeteria. 12/15/2015 FORM CM Previous Versions Obsolete Event ID1272U11 Facility ID: 810020 If continuation sheet Page 68 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: 111'0012015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 3- WING 10f15i'2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY. STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (X4) ID . SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (EACH PREHX . (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE COMPLETION TAG I REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 749 Continued From page 68 . the carpeted entry. There was a white towel placed over one large brown spot. There was no other barrier to prevent the three patients sitting in the outer room from accessing the area. Further observation revealed an unidentified i nurse dragging a soiled linen bag across the carpeted entry and out into the tiled hall by the I elevators; she placed the bag in an open laundry I hamper. When the surveyor asked what was in the bag, she stated it was the patient's fecal soiled clothes. Staff was observed walking in and out of i the unit wearing tan pants that were spotted with . fecal matter. Staff stated he was waiting I for a clean uniform to be delivered to the unit. When the clean uniform was delivered, he changed. He was observed taking the soiled uniform into the nursing station and placing the soiled uniform on the carpeted floor. There was no barrier to protect the floor from contamination. During an interview on 10/15/15, at 9:45 am, Staff stated, was going to place the dirty uniform in a plastic bag." During the observation period, the white towel was removed over the large brown spot on the carpeted entry, it had not been cleaned. Two (2) patients on two separate occasions were observed being escorted, by staff, through the fecal covered carpet. The patients were only wearing socks, and their feet could have come in contact with the fecal matter. Staff T, the TAG A 749 Continued: A 749 5- Hand hygiene scores will be posted for eachll/lg/zol5 i department every month in break rooms, communication board, and other staff areas so everyone can see how each unit is ranked. - A Hand Hygiene Campaign notification email will be sent to all medical staff and information about the campaign will be routinely included in the hospital Friday Facts weekly communication. 11/20/2015 Monitoring and Tracking procedures that will be implemented to ensure that the plan of correction is effective: 10/26/2015 Daily and weekly departmental enwronmental rounds are utilized to ensure compliance with maintaining a sanitary environment. Infection control validation rounds performed twice weekly' and rounds by leadership and quality will also include hand hygiene and PPE use surveillance. IC and EVS Director to identify a checklist for IC issues. The EVS staff will be trained to identify i11/20/2015 issues identi?ed during the performance of their routine duties and submit the checklist to the 3EVS Director at the end of each shift. The [0 Manager and EVS Director will collaboratively address identi?ed infection control issues on an i ongoing basis. Aggregated audit results are reported to the ICC and quarterly to the I EOC, QMOC, PIC, MEC and the Governing Board. Personfs) Responsible: i Infection Control Manager, Infection Control Coordinator, EVS Director, Director(s) of Surgical Services, Director of Quality, CEO, CNO, COO FORM Previous Versions Obsolete Event ID: 272U11 Facility 810020 If continuation sheet Page 69 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/06/2015 FORM APPROVED OMB NO. 0938-0391 Infection Control Director was informed, he stated he would ensure the carpet was cleaned immediately and would re-educate the staff. KITCHEN Observation on 10/12/15, at 2:00 pm, in the facility?s kitchen revealed: - A 55 gallon white plastic trash bag ?lled with I food and garbage and liquid refuse sitting on the kitchen floor. The plastic bag was leaking onto I the kitchen ?oor. - Five staff handwashing sinks did not have trash I receptacles to dispose Of used hand towels - The dry storage room had shelves with shipping boxes stored Over open disposable food supplies. The dietary floors were dirty and sticky throughout the department, creating an environment for pests and bacterial growth. - There were multiple cracked and chipped baseboards and tiles making the area not Cleanable; there was built-up dirt and debris in the cracks. - There were (4) boxes Of Chocolate Pretzels and (1) box of Cheddar crackers stored on the ?oor of an of?ce, making them accessible to pests and other contaminants. - There was a smoke alarm, several ceiling and air vents with dust and dirt residue over food - items and in the food preparation areas. STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 450035 8- 10/15/2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, Tx 77002 (x4) in SUMMARY STATEMENT OF DEFICIENCIES TD PLAN OF CORRECTION (EACH (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL SHOULD BE CRoss- COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TAG A 749 Continued: A 749 Continued From page 69 A 749 FOLEY CATHETERS The plan for correcting the specific deficiency cited: A multidisciplinary team was formed with representatives from IC Manager, Corporate IC Director, Quality Director and ICU Director to discuss Foley Catheter use. 0 A process for daily CAUTI rounds was revised and implemented to ensure that all Foleys have an appropriate physician order, and indications for use are identified. Validation audits by IC Manager are I conducted a minimum of twice weekly la The team developed a sticker (Exhibit De) I to document the need for continuing or 1 1/1 1/2015 discontinuing Foley catheters per physician's order. This sticker is placed on . the physician order sheets on a daily basis. 7 11/11/2015 IThe plan for improving the processes that led to the deficiency cited. including how the hospital is addressing improvements in its .systems in order to prevent the likelihood of Irecurrence of the deficient practice: The charge nurse will review orders and is responsible for placing sticker (Exhibit on the physician order sheet. A Checklist (Exhibit D-2) was developed and is utilized for the daily CAUTI rounding and evaluation Of sticker. The CAUTI Team will assure sticker is on chart and that completion of the sticker includes indications, discontinuation, and reasons for con?nuadon. 12/15/2015 Procedures for implementing the acceptable plans of correction for each deficiency cited: ICU Nursing and physician stan were educated 12/159015 FORM CM Previous Versions Obsolete Event Facility 810020 If continuation sheet Page 7'0 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: 11f06f2015 FORM APPROVED OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 3- WING 10f15f2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIEs ID PROVIDERS PLAN OF CORRECTION (EACH (x5; (EACH DEFICIENCY MUST BE PRECEDED BY FULL SHOULD BE CROSS- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) TAG A 749 Continued: A 749 Continued From page 70 A 749 - A metal can of Sesame Seed oil with (2) puncture holes was sitting on the spice rack and was accessible for use. - There was food debris on the Buffalo Chopper, electric food slicer, large floor mixer, and on various walls throughout the department. - The facility's (2) deep fat fryers had spilled Oil on the bottom shelves, and Old food debris in the fryer baskets. - Four (4) plastic food cutting boards had multiple deep gouges, making them dif?cuit to clean. The cutting boards had a dark residue in the gouges and were accessible for use. - Staff 8. the Dietary Manager was chewing gum in the kitchen creating possible saliva transfer to prepared foods. Further Observation ofthe facility kitchen on 10/12/15, at 3:00 pm, revealed the facility's large dishwashing machine had food debris floating in the wash tanks and the water was dirty. There was a built-up lime deposit on the inner doors. The lunch dishes had been completed and the dish machine had not been drained and Cleaned. During an interview on 10/12/15, at 2:40 pm, Staff S. the Dietary Manager when asked by the surveyor how often does the dish machine get cleaned and the water get Changed, he stated the I dish machine is drained and cleaned at the end Of the night. through daily huddles and on a one-tO?One basis regarding the use Of the sticker. The sticker was initially trialed in ICU for a period of 3 weeks and evaluated through CAUTI rounds. Compliance reached 100% and the team has determined that Implementation be house wide. House wide education ofthe nursing and physician staff will be conducted through daily huddles, one-on-one education, physician newsletter, and physician department meetings.(Exhibit Monitoring and Tracking procedures that will: be implemented to ensure that the plan of correction is effective: 5 Monitoring is accomplished through daily CAUTI rounds utilizing the Foley catheter data collection 11/11/2015 scorecard (Exhibit D-2) on 100% of patients with Foley catheters. Results, recommendations, and actions of monitoring and evaluation are reported to the ICC, QMOC, PIC, MEC and the GB not less than quarterly. Responsible Personis): Infection Controt Manager, Director of Quality Management, Nursing Directors. KITCHEN (As it relates to TAG A 749) IThe plan for correcting the specific ideficiencies: Hospital Administration, along with Infection Prevention, Clinical Dieticians, Director of Nutrition :Services, and Quality Management who took {immediate actions during the survey to address the Issues identified including: 110/12f2015 FORM Previous Versions Obsolete Event ID: 272U11 Facility ID: 610020 If continuation sheet Page 71 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/06/2015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 B. WING 10/15/2015 NAME OF PROVIDER OR SUPPLIER CITY. STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 ID SUMMARY STATEMENT OF DEFICIENCIEs ID PLAN OF CORRECTION (EACH {st (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) TAG A 749 Continued: A 749 I Continued From page 71 During an interview on 10/12/15, at 3:00 pm, Staff V, a DietaryAide? stated he does not empty and clean the dish machine after each meal, it is emptied at the end of the night. StaffV stated that sometimes if the water gets too bad, then he will change the water out. Observation on 10/13/15, at 11 :40 am, in the facility's kitchen revealed two (2) large 55 gallon white plastic trash bags filled with food and garbage and liquid refuse sitting on the kitchen floor. There was a large pool of pink milky substance on the kitchen ?oor under the leaking plastic bags. I Review of the facility provided DISH MACHINE CLEAN UP PROCEDURE (undated) reflected: How often: End of shift and/ or end of day. Review of the facility provided Hobart FT900 Series Dishwasher Manufacturer's Operation manual (dated Oct. 2007) reflected, CLEANING The dishwasher MUST be thoroughly cleaned at the end of each working shift or after each meal. Open all front access doors. Drain the machine and clean the curtains the interior and all tanks shelves using a good hose all debris toward the strainers Remove I end caps. Clean wash arms. Remove, clean and replace the strainers. a Contracting with an outside company to i10/15/2015 1 clean and sanitize the kitchen; - Floors were pressure washed; - Cutting boards were discarded and new ones purchased and placed into use - Kitchenware was inspected and replaced 510/13/2015 if it could not be cleaned adequately; - Ceiling and air vents were cleaned; - Dish machine was de-limed and cleaning 10/1 5/2015 was implemented following each meal 10/13/2015 service 10/12/2015 i1 0/1 3/2015 . I 11/12/2015 1. Purchased four 50 gallon rolling trash containers with lids attached. Staff is Instructed to empty soiled trays into these containers. 2. Placed five foot activated trash receptacles by each of the hand washing stations, with four gadditional foot activated receptacles ordered and Eplaced by all prep areas in the kitchen. I i3. Placed plastic shelf covers on the top and Ioweri10y12/2015 shelves to eliminate any debris falling from the top Istorage to the products below. Clerks are responsible for maintaining Cleanliness of the shelf I covers. 4. Floors throughout the kitchen and storage areas 10/12/2015 were power washed and scrubbed with hand 10/15/2015 ibrushes. An outside company has subsequently been contracted to power wash the floors I5xperweek until staff is hired. All products stored on the floor in the :procurement office were removed and relocated to appropriate store rooms. Can ofWD-40 was immediately removed and :1 0/13/2015 istaff retrained on the proper storage of Chemicals. I i7. The smoke alarms, along with sprinkler heads, 11 0/20/2015 were cleaned by an outside company and all I iceiling tiles replaced in the food preparation Iarea. Vents were taken down, cleaned, and repainted in the designated areas. Two back pack vacuums were purchased and are being 11/12/2015 10/15/2015 FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation sheet Page 72 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/06/2015 FORM APPROVED OMB NO. 0938-0391 During the tour Of the Facility's kitchen Staff T, the facility's Infection Control Director, confirmed the above findings. Stat/T stated he depends on the Department director to oversee the sanitation of I the kitchen. StaffT stated he did not perform routine inspections of the facility kitchen as part of the facility's Quality Program. An interview was conducted with the Infection Control of?cer forthe facility (Staff T) on I I 10/13/15, in the Conference Room ofthe QA Department. StaffT was asked how often he insepcted the kitchen ofthe facility. StaffT reported that the kitchen is visited but that the inspection by the Infection Control officer - is not as complete or thorough as the one conducted by the DSHS Survey staff. StaffT reported that the facility depends on the Directors of the various departments to report any issues with infection control to Staff T. The Chairman of the Governing Body, a physician, was interviewed on 10/13/2015, at noon in the Conference Room of the QA Department ofthe facility. The Board Chairman was asked how frequently he visited the kitchen of the facility, and he reported that he had been in the kitchen two times during his tenure as a physician at the facility. He stated that he depends on what is reported to the Board by the staff in terms of making decision or recommendations regarding the overall operation I ofthe facility and any expenditures required. I SURGICAL SERVICES STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3; DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 3- 10/15/2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY. STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX "/7002 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH (st (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVEACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCED To THE APPROPRIATE DATE DEFICIENCY) TAG A 749 Continued: A 749! Continued From page 72 A 749 utilized to maintain the cleaning of the vents, I ceiling tiles, smoke alarms and sprinkler heads. Sesame Seed Oil immediately discarded and staff was retrained on the storage procedures form/13?2015 food products. I 9. The buffalo Chopper, electric food slicer, large floor mixer were disassembled and terminally cleaned/sanitized and placed back into service. Walls cleaned by kitchen staff with food debris I 'removed. Walls have been added to the ?0115/2015 .cleaning schedule. 10. All fryers were degreased and power washed10M 312015 to remove all debris and residual grease. .11. Cutting boards were disposed of, new cutting boards purchased and placed into use. 12. Staff re-educated that chewing gum is strictly forbidden In the dietary area and disciplinary action will be taken for non- compliance. I 13. Dish Washing Machine: Staff was re- educated on the procedure and documentation for cleaning the dish machine in between each meal period according to the Hobart Instruction Manual. The dish machine is de-limed three times per week on Monday, Wednesday and Friday, paying close attention to the doorjams and outside Of machine. Eco-Lab will provide additional education on the proper maintenance 3 of the dish machine during November. 10/13/2015 :10/13/2015 31 0/13/2015 i 11/30/2015 The plan for improvinq the processes that ledE to the deficiencies cited, includinq how the I hospital is addressinq improvements in its systems in order to prevent the likelihood of lreoccurrence of the deficient practice: Developed and implemented a detailed action plan (Exhibit A-1) and Cleaning schedule (Exhibit 10/21/2015 FORM Previous Versions Obsolete Event ID2272 U11 Facility ID: 810020 If continuation sheet Page 73 of 83 PRINTED: 11i06i2015 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERJCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A, 450035 B. WING NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (X4) ID 1 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER's PLAN OF CORRECTION Ixsi PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX ACTION SHOULD BE CRoss- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) TAG A 749 Continued: A 749 Continued From page 73 A 749 A-Z) for maintaining an organized and sanitary On ions/15, at 9:15 am, during a tour of the kitchen. This action Plan includes: 10,26,201?) facility's Surgical Services revealed: 0 Daily checklist of cleaning activities by dietary staff to maintain an organized and i - Pre-operative unit revealed (2) chairs in the kItChe? (EXh'b't waiting room with torn vinyl, making them difficult TWICE mommy deep/termite C'ean'?9 Otthei11,11,2015 to clean. k'tCheni .- Purchase of new equipment to be utilized i10t28t2015 for cleaning: backpack vacuums; (16) Tf (16) medlcal records Chang had powenivashing restoration floor machine and adheSIve tape stuck to the outSIdes ofthe charts. 8 ?oor autoscrubber; :0 Addition Of4 FTES to clean (Using it 111 512015 The Charts were being transported beek and contracted company to powerwash ?oors i forth into the operating rooms and were not able after hours until FTEs are hired and trained); . to be Cleaned. - Oversight by Infection Prevention/COO to include bi?weekly environmental audit 1025/2015 - The Endoscopy room doors had numerous old validation in the kitchen area in collaboration adhesive tape residues left on the doors. With the department director} 0 Infection Control staff scheduled to attend Operating Room 17, which was in use, had (2) the Sewsate Food Safety Tra'mng :12r3i2015 i Certi?cation Class. I Procedures for implementing the acceptable i Iplans of correction for each deficiency cited: wheeled carts, and (1) table with rust on all the casters. There was a 12 inch hole in the wall, revealing the plaster. The instrument foot switch had debris on it. There was rust along the base of . Staff meetings were held to re-educate the the operating table. requirements for trash disposal, cleaning, 10113/2015 sanitizing equipment, food storage, labeling, - Operating Room the orthopedic room where handwashing) Chewing gum] proper they perform had an air vent and grate above the meaning of the dish machinel reporting of surgical table with (2) approximately4 inch by 5 broken or equipment in need of replacement inch stains with rust, and the air vent was - Implemented daily huddles to review and damaged from a possible leak. There were reinforce the Procedures necessary to 10/19/2015 several pieces of equipment with rust on the maintain an organized and sanitary kItChen- casters and surgical adhesive tape and residue in Re?edueatten 0t 3? dietary Stett related to Safe Food Handling (Exhibit A-4) and the maintenance Of an organized and sanitary the room. kitchen. This education will include the 11/30/2015 - Operating Room #16, the heart room where following: cardiac bypasses are performed was set up and Sanitation and Cleaning of ready for emergency surgery. There was blood Kitchenware, residue on the Rapid lnfuser and the Dish Machine Cleaning and Transesophageal echo scanner. There were Sanitizing FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation sheet Page 74 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11(08f2015 FORM APPROVED OMB NO. 0938-0391 several pieces of equipment with rust on the casters and surgical adhesive tape and residue in the room. - The ear, nose and throat operating room had a large microscope with adhesive tape on it and there were pieces of equipment with rust on the casters and surgical adhesive tape and residue in the room. - The Andrias table, used for laminectomy surgery, knee pad had multiple holes in it, making it not able to clean. - Operating Room #5 on the Woman's Unit revealed a Valley Lab cart with chipped paint and a large rusted area. There were several pieces of equipment with rust on the casters and surgical adhesive tape and residue in the room. Ther was a hole in the baseboard and a large chip in the I door. The arm board had (3) cracks in the vinyl, - making it not able to clean. During an interview on 10/13115, in the afternoon in the Infection Control Office with StaffT, the facility Infection Control Director and Staff the Corporate Director of Risk and Infection Control, StaffT stated the facility had discussed the rust on the Operating Room equipment in a Spick and Span committee meeting. Staff stated, "We are aware of the rust on the Operating Room equipment. StaffT had discussed it at a special Spick and Span meeting and then had brought it tO the Quality Committee, then to the Medical Executive Committee but it stopped at the Governing Body.? STATEMENT OF DEPICIENCIES (x1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 3- WING 10f15f2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (EACH (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREHX CORRECTIVEACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCEOTO THE APPROPRIATE DATE I DEFICIENCY) TAG A 749 Continued: A 749 Continued From page 74 A 749 1180/2015 TO re-enforce prior training, EcoLab will I provide education/competency regarding proper maintenance Of dish machine to all staff assigned to dish washing. Monitoring and Tracking procedures that will be implemented to ensure that the plan of correction is effective: An audit tool (Exhibit A-S) was developed and implemented to ensure compliance of dietary 'staff. Cleaning calendar (Exhibit A-2) was Ideveloped IZO- be completed and monitored by the11M 7/2015 [Director Of Dietary SerVIces. i10/26f2015 The Infection Control Manager in collaboration with the C00 will conduct bi-weekly audit validation in the kitchen area and give feedback to the Director Of Dietary Services, which is included with his audit results. These activities are reported not less than quarterly to the EOC, ICC, QMOC, PIC, MEC and the GB. ITitle of personfs) responsible: Director, Dietary Services, Chief Operating Of?cer (COO), Infection Control Manager, Director of Quality Management, Governing Board SERVICES (As it relates to TAG A I749) The plan for correcting the Specific deficiency cited: The leadership team began making immediate corrections during the survey on the following: 1. The preoperative waiting room chairs with 10/1 6/2015 torn vinyl were discarded FORM Previous Versions Obsolete Event ID: 272U11 Facility ID: 810020 If continuation sheet Page 75 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11f0612015 FORM APPROVED OMB NO. 0938-0391 POLICIES Review of the facility provided SANITATION OF OPERATING ROOM SUITES AND EQUIPMENT 88.26 (dated 9/17/13) revealed: POLICY: To keep the number of bacteria to the lowest possible level so that the Operating Room Suite will have a minimal amount of bio-load. PROCEDURE: 1. Between Cases: a. All horizontal surfaces including O.R. table, will be cleaned and disinfected. . b. Floors will be mopped with disinfectant. c. Lights, walls, footstools. kick buckets. I.V. poles, and any other equipment used will be spot cleaned as necessary. Review of the facility provided CLEANING AND STORAGE OF NON-CRITICAL REUSABLE PATIENT EQUIPMENT lC.10a (dated1 02912015) reflected: DEFINITIONS: Cleaning: The physical removal of foreign material dust, oil, organic material such as blood, secretions, excretions, and micro?organism). Cleaning reduces or eliminates the reservoirs of potential pathogenic organisms. Non-Critical Equipment: Those items that either touch only intact skin but not mucous membranes or do not directly touch the patient/ resident/ STATEMENT OF DEFICIENCIES (XI) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 SWING 1or15r2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, Tx 77002 (x4) TD SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH . (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE . DATE DEFICIENCY) TAG A 749 Continued: A 749 Continued From page 75 A 7'49 :1 Tape residue was removed from the [Endoscopy room doors 3. OR 17 - An outside service was contracted and a schedule was created for the systematic replacement of rusty casters and wheels; the I hole in the wall was repaired and instrument foot; iswitch was replaced; {1 12012015 @11114/2015 .4. OR 2 - air vent and grate was repaired; outside service was contracted and a schedule was created for the systematic replacement of 1 1/20l2015 rusty casters; tape residue Cleaned 5. OR 16 ?Residue on Rapid lnfuser cleaned; 11/16/2015 adhesive removed; casters replaced 6. ENT Room Microscope cleaned of all adheSIve, all casters replaced, 11209015 7. OR 10 knee pads for AndriaS table ordered 8. OR 5 (Women's Surgery) rusted casters ,11/163015 replaced; adhesive removed; hole in baseboard repaired; armboards replaced - In addition to the above, the hospital's leadership team has put into place plans for systemic correction to maintain disinfection procedures that include: repair/replacement of upholstered/covered items; preventionfremoval of adhesive residue; overall cleanliness of the surgical services area; and processes for I addressing rust on wheels, casters, and equipment. Leadership has approved the purchase of the following new replacement equipment: Laundry hampers, suction trees, IV poles, OR chairs/stools, 02 carriers, Pad forAndrias table, Chart backs, Adhesive free labeling system. FORM Previous Versions Obsolete Event ID1272U11 Facility ID: 810020 If continuation sheet Page 76 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11f06i?2015 FORM APPROVED OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 B. WING 1011 5f2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (EACH (x5) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TAG A 749 Continued: A 749 Continued From page 76 A 749 client. PROCEDUREA Equipment made of metal. plastic, vinyl, wood, leather or rubber IV poles, infusion pumps, diagnostic imaging equipment, monitoring equipment, wheelchairs) 2. Remove all tape and tape residue. (Equipment is not considered Clean unless all tape residues is removed.) Review of the facility provided INFECTION AND CONTROL PROGRAM PLAN 2015 (revised February 9,2015) revealed: IV. RESPONSIBILITIES AND PROGRAM I FRAMEWORD A. Governing Board The Governing Board has ultimate responsibility for ensuring the quality of patient care services . and operational performance of the hospital.. V. INFECTION CONTROL DEPARTMENT SERVICES Daily activities Infection control staff members provide ongoing review and daily analysis activities necessary for reducing infection risks and achieving the goals of the program. 2. Observation and Evaluation Observation and Evaluation includes: The plan for improving the processes that lead to the deficiency cited, including how the hospital is addressing improvements in its systems in order to prevent the likelihood of recurrence of the deficient practice: New daily environmental rounding tool was developed (Exhibit F) and implemented to address upholstery tears, adhesive residue, Cleaning of OR I'equipment, rust on equipment including wheels, casters and tables. The Director(s) and Managers of Surgical Services complete this tool and provide oversight to ensure that compliance is maintained and items identified are corrected. 10/25/2015 Additional were approved: - 1 EVS Working Lead for night shift to assist 11/15/2015 with all surgical services OR quality Checks and terminal cleaning procedures a 3 FTE for surgical services cleaning Director(s) of Surgical Services are responsible for contacting the outside contractor for iresurfacing I replacement of rusty quuipment/wheelslcasters on an ongoing basis. The Medical Staff will provide oversight over all I Isurgical services through the Department of ISurgery meeting on a quarterly basis with :reporting to the GB. Procedures for implementing the acceptable {plans of correction for each deficiency cited IRe-education of OR and EVS staff regarding gcleaning procedures, including checking all Irooms for cleanliness at the start of the day and between cases. FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation sheet Page 77 of 83 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 B. WING toi15i2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY HOUSTON, TX 77002 ST JOSEPH MEDICAL CENTER SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (EACH (X5) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TAG A 749 Continued A 749 Continued From page 77 A 749 New daily environmental rounding tool (Exhibit 10/25/2015 Monitoring and - F) was developed and implemented to address i upholstery tears, adhesive residue, cleaning of Establishing and maintaining routine activities OR equipment, rust on equipment including that address patients and personnel, including wheels, casters and tables. The Director(s) and I licensed independent practitioners, allied health, Managers of Surgical Services complete this tool I staff, volunteer, students/trainees, contract :and provide oversight to ensure that compliance I workers and visitors and families as warranted. 'is maintained and items identi?ed are corrected. in each area of the organization to ensure I compliance with current infection control Leadership has appFOVEd the 0f the 11/17/2015 Standards- ifollowing new i replacement equipment: [Laundry hampers, suction trees, IV poles, OR emironmenta' Ichairs/stools, 02 carriers, Pad for Andrias table, . lChart backs, Adhesive free labeling system. - Inspecting the environment, including patient . care areas and rooms and observing personnel Monitorinq and Tracking procedures that will activities for the purpose of detecting possible be implemented to ensure that the plan of infection hazards and evaluating compliance with Correction is effective; current healthcare and regulator standards. Monitoring is being accomplished through the use ofthe daily environmental rounding tool 10/25/2015 - Conducting routine environmental evaluations and workplace analyses, integrating evaluation criteria and partnering with other programs such as Safety, Environmental Services, and Risk Management. (Exhibit F) and sent to the Quality Management Department. Corrective action is taken as items of noncompliance are identi?ed. Results, recommendations, and actions are reported to ICC, QMOC, PIC, MEC, and the GB not less 4. Education than quarterly. Responsible Personis) ICOO, CNO, Infection Control Manager, EVS Director, Director(s) of Surgical 81 Women?s Services, Medical Staff Department of Surgical Services Chairman, Governing Board The Infection Control Department is responsible for: Specific practices established by the hospital to prevent disease transmission are identified and practiced. -Regu atory mandates associated with infection control are discussed and followed. 7. Occupational Health Support FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation sheet Page 78 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/06/2015 FORMAPPROVED OMB NO. 0938-0391 The Infection Control Department is responsible for: -Assisting in educating personnel in using 2 personal protective equipment. I 8. Supply and Equipment Evaluation I The Infection Control Department is responsible I for: I ?Monitoring products and equipment in use to ensure they are safe (for example, biologically and chemically) for patient and employees. A 951 482.51(b) OPERATING ROOM POLICIES Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. I This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop and implement disinfection procedures for the Surgery waiting room, Pre?Operative area and operating rooms, thus not assuring the achievement and maintenance of high standards of practice and patient care. Findings included: 'On 1011 3/15, at 9:15 am, during a tour Of the facility's Surgical Services revealed: STATEMENT OF DEFICIENCIES (x1) Ix2) MULTIPLE CONSTRUCTION (X3) DATE AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 450035 3- 10i15I2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES I ID PROVIDERS PLAN OF CORRECTION (EACH (XS) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) I TAG REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) A 749 Continued From page 78 A 749 ITAG A 951 Operating Room Policies Surgical Services IThe plan for correcting the specific A 951 :deficienc cited: ?The leadership team began making immediate corrections during the survey on the following: 10/16/2015 1. The preoperative waiting room Chairs with torn vinyl were discarded 2. Tape residue was removed from the i Endoscopy room doors 110/16/2015 3. OR 17 - An outside service was contracted and a schedule was created for the systematic replacement of rusty casters and wheels; the hole in the wall was repaired and instrument footi switch was replaced; 4. OR 2 - air vent and grate was repaired; . . 11/20/2015 outSIde serwce was contracted and a schedule was created for the systematic replacement of rusty casters; tape residue Cleaned 5. OR 16 ?Residue on Rapid Infuser cleaned; 11/16/2015 adhesive removed; casters replaced 6, ENT Room Microscope cleaned of all adhesive; all casters replaced; OR 10 knee pads for Andrias table ordered 8. OR 5 (Women?s Surgery) rusted casters 11/20/2015 replaced; adhesive removed; hole in baseboard repaired; armboards replaced 11/16/2015 FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation sheet Page 79 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: FORM APPROVED OMB NO. 0938-0391 STATEMENT OF (X1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 B. WING 10y15y2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (EACH (x5) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC INFORMATION) TAO REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) TAG A 951 (Continued from page 79) A 951 Continued From page 79 A 951 In addition to the above, the hospital's leadership - Pre-Operative unit revealed (2) chairs in the waiting room with tom vinyl, making them difficult I to Clean. - (16) Of (16) medical records charts had old adhesive tape stuck to the outsides Ofthe charts. The Charts were being transported back and forth into the Operating rooms and were not able to be cleaned. I - The Endoscopy room doors had numerous old adhesive tape residues left on the doors. Operating Room 17, which was in use, had (2) wheeled carts, and (1) table with rust on all the casters. There was a 12 inch hole in the wall, revealing the plaster. The instrument foot switch had debris on it. There was rust along the base of the operating table. Operating Room the orthopedic room where they perform had an air vent and grate above the surgical table with (2) approximately 4 inch by 5 inch stains with rust, and the air vent was damaged from a possible leak. There were several pieces Of equipment with rust on the casters and surgical adhesive tape and residue in the room. Operating Room #16, the room where cardiac bypasses are performed, was set up and ready for emergency surgery. There was blood residue on the Rapid Infuser and the Transesophageal echo scanner. There were several pieces of equipment with rust on the casters and surgical adhesive tape and residue in the room. - The ear, nose and throat operating room had a large microscope with adhesive tape on it and team has put into place plans for systemic Icorrection to maintain disinfection procedures (that include: repair/replacement of upholstered/covered items; preventioniremoval of adhesive residue; overall cleanliness Ofthe surgical services area; and processes for addressing rust on wheels, casters, and equipment. Leadership has approved the purchase Of the foltowing new 1 replacement equipment: 11/17/2015 Laundry hampers, suction trees, IV poles, OR chairs/stools, 02 carriers, Pad forAndrias table, Chart backs, Adhesive free labeling system. The plan for improvinq the processes that lead to the deficiency cited, including how the hospital is addressing improvements in its systems in order to prevent the likelihood of recurrence of the deficient practice: New daily environmental rounding tool was developed (Exhibit F) and implemented to address upholstery tears, adhesive residue, cleaning of OR I equipment, rust on equipment including wheels, casters and tables. The Director(s) and Managers of Surgical Services complete this tool and provide oversight to ensure that compliance is maintained and items identified are corrected. Additional were approved: - 1 EVS Working Lead for night shift to assist with all surgical services OR quality checks 11/15/2015 and terminai cleaning procedures a 3 FTE for surgical services cleaning Director(s) of Surgical Services are responsible for contacting the outside contractor for resurfacing replacement Of rusty equipment/wheels/casters on an ongoing basis. 5 10/25/2015 The Medical Staff will provide oversight over all surgical services through the Department Of Surgery meeting on a quarterly basis with reporting to the GB. FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation sheet Page 80 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 11/069015 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 B. WING 10i1512015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY. STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 my In SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVEACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG REFERENCED To THE APPROPRIATE DATE DEFICIENCY) TAG A 951 (Continued from page 80)_ A 951 Continued From page 80 A 951 Procedures for implementing the acceptable I there were pieces of equipment with rust on the casters and surgical adhesive tape and residue in the room. - The Andrias table?s, used for laminectomy surgery, knee pad had multiple holes in it, making it not able to clean. i - Operating Room #5 on the Woman's Unit revealed a Valley Lab cart with chipped paint and a large rusted area. There were several pieces of equipment with rust on the casters and surgical I adhesive tape and residue in the room. There i was a hole in the baseboard and a large chip in I the door. The arm board had (3) cracks in the Vinyl, making it not able to clean. During an interview on 10(13115, in the afternoon in the infection Control Office with Staff T, the facility Infection Control Director and Staff the Corporate Director of Risk and Infection I Controi, StaffT stated the facility had discussed the rust on the Operating Room equipment in a i Spick and Span committee meeting. Staff . stated. "We are aware of the rust on the I Operating Room equipment. StaffT had I discussed it at a special Spick and Span meeting I and then had brought it to the Quality Committee, then to the Medical Executive Committee but it I stopped at the Governing Body." Review ofthe facility provided SANITATION OF OPERATING ROOM SUITES AND EQUIPMENT 88.26 (dated 9/17/13) revealed: POLICY: plans of correction for each deficiency cited Re-education of OR and EVS staff regarding cleaning procedures, including checking all rooms for Cleanliness at the start of the day and between cases. r11/30/2015 New daily environmental rounding tool (Exhibit F) was developed and implemented to address upholstery tears, adhesive residue, cleaning of OR i equipment, rust on equipment including wheels, casters and tables. The Director(s) and Managers of Surgical Services complete this tool and provide oversight to ensure that compliance is maintained and items identi?ed are corrected. 10/26/2015 Leadership has approved the purchase of the following new replacement equipment: Laundry hampers, suction trees, lV poles, OR jchairs/stools, 02 carriers, Pad for Andrias table, (Chart backs, Adhesive free labeling system @11/17/2015 Monitoring and Tracking procedures that will be implemented to ensure that the plan of jcorrection is effective: IMonitoring is being accomplished through the !use of the daily environmental rounding tool E(Exhibit F) and sent to the Quality Management 3 Department. Corrective action is taken as items (11/26/2015 of noncompliance are identified. Results, recommendations, and actions are reported to I ICC. QMOC. PIC, MEC, and the GB not less than quarterly. Responsible Person(s} COO, CNO, Infection Control Manager, EVS Director, Director(s) of Surgical Women?s Services, Medical Staff Department Of Surgical Services Chairman. Governing Board FORM Previous Versions Obsolete Event Facility ID: 810020 If continuation sheet Page 81 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: FORM APPROVED OMB N0. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDERESUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 450035 5' 1011512015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY. STATE, ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (EACH (XE) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX I CORRECTIVEACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A 951 Continued From page 81 A 951 To keep the number of bacteria to the lowest possible level so that the Operating Room Suite will have a minimal amount of bio-load. PROCEDURE: 1. Between Cases: a. All horizontal surfaces including OR. table, will be cleaned and disinfected. . b. Floors will be mopped with disinfectant. I c. Lights,walls. footstools, kick buckets, poles, and any other equipment used will be spot cleaned as necessary. Review of the facility provided CLEANING AND STORAGE OF NON-CRITICAL REUSABLE PATIENT EQUIPMENT C.10a (dated10f9!2015) reflected: DEFINITIONS: Cleaning: The physical removal of foreign material dust, oil, organic material such as . blood, secretions, excretions, and micro-organism). Cleaning reduces or eliminates the reservoirs of potential pathogenic organisms. Non-Critical Equipment: Those items that either touch only intact skin but not mucous membranes or do not directly touch the patient] residenti client. PROCEDU REA ITHIS PAGE LEFT INTENTIONALLY BLANK FORM Previous Versions Obsolete EventlD1272U11 Facility ID: 810020 If continuation sheet Page 82 of 83 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11f06i?2015 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 450035 3- WING 10i15i?2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE 1401 ST. JOSEPH PARKWAY ST JOSEPH MEDICAL CENTER HOUSTON, TX 77002 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVEACTION SHOULD BE CRoss- COMPLETION TAG REGULATORY OR LSC IDENTIFYING I TAG REFERENCED To THE APPROPRIATE DATE . DEFICIENCY) i i A 951 Continued From page 82 A 951' Equipment made of metal, plastic, vinyl, wood, . leather or rubber (Le. IV poles, infusion pumps, diagnostic imaging equipment, monitoring I equipment, wheelchairs) 2. Remove all tape and tape residue. (Equipment is not considered Clean unless all tape residues is removed.) THIS PAGE LEFT INTENTIONALLY BLANK FORM Previous Versions Obsolete Event ID: Facility ID: 810020 If continuation sheet Page 83 of 83