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Based on observation, interview, and record review, the facility failed to develop and implement a policy to ensure the inclusion of the facility's Infection Preventionist when the facility's clean rooms had mold and bacteria growing in the Intravenous (IV) preparation room. The preventionist did not participate in the mitigation of the infection risk or monitor for compliance.

Findings include:

During an interview on 10/12/20, in the facility conference room, Staff #3, Chief Operating Officer, reported the facility had found mold and bacteria growth in the facility's IV clean room. The facility had reported the event to the State and had worked to correct the issue. The facility had been going through renovations during the occurances; once the air filters were changed out, there was no further growth.

During a telephone interview on the morning of 10/12/20, Staff #8, Infection Control Nurse, when asked if she was aware of the mold and bacteria issues in the facility's pharmacy and if she had participated in the plan of correction, Staff #8 stated, "I wasn't aware of the complaint ...I wasn't invited to any specific meeting about it ...We do environmental rounds twice a year." Staff #8 was not aware the facility was conducting Monthly survey rounds and was not conducting infection control audits for the continued absence of mold and bacteria.

Observations on 10/12/20, of the facility's Strictly Pediatric pharmacy department, revealed Staff #5, Pharmacist, wearing two disposable gowns over her street clothes. The two gowns were not secured in the back; the staff's pants and shirt were visible as she moved around the Pharmacy's Clean room.

Review of the facility provided policy Clean Room Washing and Garbing, (effective date 2/2012) reflected, " ...Fasten the closures of the gown completely ..."

During an interview on 10/12/20, in the Strictly Pediatric Pharmacy, Staff #5 reported the gowns should be secured.

During an interview on 10/12/20, in the facility conference room, Staff #3, Chief Operating Officer, confirmed the Infection Control Preventionist was not included in facility's Pharmacy infection control corrections and compliance oversight.