MU Health Care inspection report reveals hygienic problems

Monday, January 10, 2011 | 12:18 p.m. CST; updated 6:22 p.m. CST, Monday, January 10, 2011

COLUMBIA — A registered nurse at University Hospital entered a patient's room without a hand-washing, removed the patient's IV lock without wearing gloves and left the room, again without washing. The nurse then went into another patient's room, opened a drawer, grabbed a flashlight and brought it back into the first patient's room.

The detail is among scores in a Centers for Medicare & Medicaid Services report from November 2010 that MU Health Care representatives said Monday they are addressing in preparation for a follow-up inspection by the regulator. The inspection report was obtained by the Missourian through a Freedom of Information Act request from the Centers for Medicare & Medicaid Services.


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"It's (hand-washing and gloves) so basic," a clinical improvement specialist told an inspector in a subsequent interview, according to the report. "I don't know why this happens."

The centers conducted an unannounced, on-site survey from Nov. 1 to Nov. 5 after receiving a complaint from a former employee, MU Health Care CEO Jim Ross confirmed.

Though the complaint was unsubstantiated by the inspection, other problems were cited with infection control and physical environment standards. Inspectors found expired supplies, inconsistent hand-washing procedures, dust on surfaces in the surgical unit, dirt and debris in kitchen preparation areas and stains on floors and equipment.

Hospital administrators said a follow-up inspection will occur within 60 days of the report was received, which was Dec. 6.

"These are issues we take seriously," said Dr. Les Hall, chief medical officer for MU Health Care. "We are going to do our due diligence to make sure that it's corrected." 

Dr. Hal Williamson, vice chancellor of MU Health System; Carey Smith, manager of regulatory affairs; Jo Ann Wait, spokeswoman for the hospital, Ross and Hall met Monday with Missourian reporters to talk about the report. They emphasized it was being taken seriously, though some observations were minute in detail.

About 120 University Hospital and Clinics employees put in overtime and unpaid hours in December cleaning up facilities, according to earlier reports in the Missourian.

"The staff has done great, and we may not agree with how (inspectors) looked at us and elevated the issue, but if they brought it up we are going to address it," Ross said.

He said hospital staff members have reviewed the national standards for hand-washing and are increasing their scrutiny of hand-washing habits by other employees.

Among the other problems cited by the inspectors:

Report: Black and brown residue accumulated in cracks where heat-sealed vinyl floor strips had separated in an operating room. Several tiles were buckled and black-colored debris was found in the sterile storage area.

Ross: Although some of the floors in question typically never come into contact with patients, they have been replaced.

Report: Dark red and brown dry spots were found on two infusion pumps at the Missouri Orthopedic Center's Post Anesthesia Recovery Unit. An interview with a supervisor stated that the "pumps had been cleaned by housekeeping and the spots on the pumps appeared to be either dried blood or Betadine."

Ross: Multiple staff members told the inspector that the spots were Betadine, an antiseptic used in surgery.

"When I've got staff telling them it's Betadine, not blood, and it still comes back in a report as it may be, it's very suggestive," Ross said.

Report: Dust was found on multiple surfaces throughout the facilities, including "the top horizontal surfaces of an anesthesia cart and a fluoroscopic camera." The report states, "When the surfaces were wiped, dust particles fell to the floor and onto the surgical table."

Hall: "All of us would say that the amount of dust they found in some areas of the hospital, even though many of those areas were not direct patient-care areas, is something that we want to take care of."

The hospital administrators said problems observed in the report have not affected their out-patient infection rates.

The centers will conduct a second unannounced inspection, and the hospital has been preparing, Ross said.

"We are absolutely prepared for it," he said. "The staff is anxious to get the survey team here because they want to show them (the improvements)."

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