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Based on observation, interview, record review, and policy review, the facility failed to ensure that staff:
-Performed hand hygiene (either by washing with soap and water or using alcohol hand sanitizer) for five (#1, #3, #10, #11 and #14) out of 21 current patients observed during care and treatment and for one patient (#25) out of five discharged patient records reviewed when hand hygiene was indicated. Refer to A-0749 for examples.
-Utilized and changed gloves as directed in their policy and after touching inanimate objects/equipment (computer keyboard, computer mouse, scanner, ASCOM phone - wireless phones used by staff) or performed hand hygiene while in the patient's rooms for four (#1, #3, #10 and #14) out of 21 current patients observed receiving care, treatment and services by staff. Refer to A-0749 for examples.
-Clean and/or disinfect inanimate objects such as ASCOM phones, computer keyboards, computer mouse, scanner, and IV pump (machine programmed to infuse fluids or medications into a vein) as directed by facility policy. Refer to A-0749 for examples.
-Tied personal protective equipment (PPE - protective garments worn to protect the body from contamination, usually consist of gown, gloves and mask) in the back when provided care for two (#16 and #17) out of 10 current patients observed that were in isolation. Refer to A-0749 for examples.
-Did not place normal saline (fluid used to flush intravenous (IV) lines before administering medications) and Mastisol (liquid medical adhesive) on patient's beds for two (#10 and #18) out of two current patients observed. Refer to A-0749 for examples.
-Cleaned the stethoscope bell (equipment used to listen to heart, lung and abdominal sounds of a patient) after touched one (#10) out of one current patient being observed during assessment. Refer to A-0749 for examples.
-Changed gloves after handled contaminated items and before touching the patient for two (#1 and #3) out of two current patients observed during care and treatments. Refer to A-0749 for examples.
-Educated Pharmaceutical Students of the facility's hand hygiene practices prior to being allowed to perform injections, at a walk-in flu clinic within the hospital for two (#19 and #20) out of two visitors observed receiving a flu vaccine. Refer to A-0749 for examples.
-Educate and/or keep family members aware of infections/isolation for two (#26 and #27) out of 10 discharged patients reviewed in isolation. Refer to A-0749 for examples.
-Address concerns reported to the facility's grievance and complaint committee with concerns related to poor infection control practices for four (#25, #26, #27 and #15) out of five discharged patients reviewed. Refer to A-0749 for examples.
-Follow-up on deficiencies noted in the September 28, 2017, Infection Control Committee Meeting Minutes related to staff not wearing gloves appropriately, for example, not changing gloves when indicated, reaching into pockets to retrieve phones with gloves on and lack of education of students related to infection control policies related to hand hygiene and glove practices, and did not have a current action plan to correct the deficient practices observed. Refer to A-0756 for examples.
These failed practices had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infections. The facility identified 40 Hospital-Acquired infections in the prior 90 days.The facility census was 238.

The cumulative effects of these systemic failures resulted in the facility's non-compliance with 42 CFR 482.42 Condition of Participation (CoP): Infection Control and resulted in the facility's failure to ensure safe infection control practices to prevent infections and communicable diseases.

Please refer to A-0749 and A-0756 for additional information.

Based on observation, interview, record review, and policy review, the facility failed to ensure that staff:
-Performed hand hygiene (either by washing with soap and water or using alcohol hand sanitizer) for five (#1, #3, #10, #11 and #14) out of 21 current patients observed during care and treatment and for one patient (#25) out of five discharged patients records reviewed when hand hygiene was indicated.
-Utilized and changed gloves as directed in their policy and after touched inanimate objects/equipment (computer keyboard, computer mouse, scanner, ASCOM phone - wireless phones used by staff) or performed hand hygiene while in the patient's rooms for four (#1, #3, #10 and #14) out of 21 current patients observed receiving care, treatment and services by staff.
-Clean and/or disinfect inanimate objects such as ASCOM phones, computer keyboards, computer mouse, scanner, and IV pump (machine programmed to infuse fluids or medications into a vein) as directed by facility policy.
-Tied personal protective equipment (PPE - protective garments worn to protect the body from contamination, usually consist of gown, gloves and mask) in the back when provided care for two (#16 and #17) out of 10 current patients observed that were in isolation.
-Did not place normal saline (fluid used to flush intravenous (IV) lines before administering medications) and Mastisol (liquid medical adhesive) on patient's beds for two (#10 and #18) out of two current patients observed.
-Cleaned the stethoscope bell (equipment used to listen to heart, lung and abdominal sounds of a patient) after touching one (#10) out of one current patient being observed during assessment.
-Changed gloves after handled contaminated items and before touching the patient for two (#1 and #3) out of two current patients observed during care and treatments.
-Educated Pharmaceutical Students of the facility's hand hygiene practices prior to being allowed to perform injections, at a walk-in flu clinic within the hospital for two (#19 and #20) out of two visitors observed receiving a flu vaccine.
-Educate and/or keep family members aware of infections/isolation for two (#26 and #27) out of 10 patients reviewed in isolation.
-Address concerns reported to the facility's grievance and complaint committee with concerns related to poor infection control practices for four (#25, #26, #27 and #15) out of five discharged patients reviewed.

These failed practices had the potential to affect all patients, visitors, and staff by contaminating themselves, and/or contaminating others, or surfaces. The facility identified 40 Hospital-Acquired infections in the prior 90 days. The facility census was 238.

Findings included:

1. Record review of the facility's policy titled, "Standard Precautions," dated 10/05/16, showed:
-The facility's goal is to prevent or control the spread of infection or communicable diseases to both healthcare personnel and the patient.
-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.
-Use of gloves does not preclude the need for hand hygiene.
-Hand hygiene will be performed prior to putting gloves on and when gloves are removed.
-Change gloves: after handling contaminated items, before contact with another patient, and before touching environmental surfaces after soiling during care of the patient.
-Wear a disposable gown to protect skin and prevent soiling or contamination of clothing during procedures and patient care when contact with blood, body fluids, secretions or excretions is anticipated.

Record review of the facility's policy titled, "Hand Hygiene," revised 07/08/16, showed:
-All workforce members will consistently use hand hygiene practices that reduce transmission of microorganisms to others.
-Hand hygiene will be performed: before patient contact, before aseptic tasks, after body fluid exposure, after patient contact, and after contact with the environment.
-Alcohol-based hand rub (spray, gel or foam) may be used when there is no visible soiling.
-Do not wear gloves when using a computer, answering the telephone, etc.
-Change gloves between dirty and clean procedures.

2. Record review of current Patient #1's History and Physical (H&P) dated 10/16/17, showed that the patient was admitted on 10/16/17 to the Same Day Surgical area for removal of an extra appendage (a thumb duplication) near the right thumb.

Observation on 10/16/17 at 3:16 PM, showed Staff GG, Registered Nurse (RN), had gloves on and touched the crib rails, computer keyboard and then the patient. Then, Staff GG handled a medication vial, IV, and the computer again, all without changing gloves or performing hand hygiene.

Staff GG did not follow the facility's policy titled, "Hand Hygiene" when she wore gloves when she used the computer.

3. Record review of current Patient #3's H&P dated 04/09/17, showed that the patient was admitted on that date with cardiogenic shock (a heart condition). The patient required artificial respiratory assistance via a ventilator connected to a tracheostomy (an opening in the neck whereby air can be instilled into the lungs via a machine). The patient had a history of a systemic infection called sepsis.

Review of the most current laboratory values, dated 09/23/17, showed the patient's white blood cell count (wbc-an elevated level can be indicative of infection), dated 09/23/17, was 15.8, or elevated (normal=5-10).

Observation on 10/17/17 at 9:30 AM, in the patient's room, showed the following:
-Patient #3 was in contact isolation (contact isolation precautions apply to patients known or suspected to be infected or colonized (presence of microorganism in or on patient but without clinical signs and symptoms of infection) with important microorganisms that can be transmitted by direct or indirect contact) .
-Staff A, RN, had gloves on and touched multiple contaminated tracheostomy (trach) supply packages, and the over-bed table.
-Staff A, put sterile gloves on, over the contaminated gloves, to perform tracheostomy suctioning.
-Staff B, RN, failed to perform hand hygiene after removing her gloves to put sterile gloves on.

During an interview on 10/17/17 at 9:48 AM, Staff A stated that she put the sterile gloves over the regular gloves because it made the sterile gloves fit better. Staff A stated that Patient #3 had a facility-acquired infection with MRSA in her trach.

4. Record review of current Patient #10's medical record showed she was admitted to the facility on 10/11/17 with complaints of anemia and diarrhea.

Observation on 10/16/17 at 3:25 PM showed Staff D, RN:
-Entered the patient's room to administer blood products as ordered.
-Performed hand hygiene and put on a pair of non-sterile gloves. Wearing the same pair of gloves Staff D touched the following:
-Cleaned the patient's IV catheter saline lock (small flexible tube placed into a vein used to administer fluids, medications and blood that is used periodically as needed) and flushed the IV saline lock with normal saline (solution used to ensure the IV line is opened and unobstructed for use).
-After the IV saline lock was flushed, Staff D walked over to the computer and typed on the keyboard and when she finished typing on the keyboard, she picked up the scanner and scanned the patient's identification band (ID).
-Removed gloves and used hand hygiene and put on another pair of non-sterile gloves. Wearing the same pair of gloves Staff D touched the following:
-Opened IV tubing and attached it to the bag of blood products to be infused.
-Touched the patient's hand with the IV saline lock and cleansed the IV's saline lock connector hub (located at the end of the IV saline lock used to connect IV tubing) inserted the IV tubing into the connector hub.
-Reached into her right pocket and pulled out the ASCOM (wireless phone used by staff) phone that was ringing and touched the phone keypad.
-After checking the phone, Staff D placed the ASCOM phone back into her pocket.
-Then she touched the IV pump (machine used to infuse fluids, medications and blood at a prescribed rate) and programmed it to infuse the blood at the prescribed rate.
-Removed the gloves but did not perform hand hygiene and touched the following:
-Electronic blood pressure machine (machine used to take and monitor patient's blood pressure).
-The IV pump because it alarmed.
-Blood pressure cuff and patient's arm when she placed the cuff on the arm.
-Thermometer and placed it in the patient's mouth to take a temperature.
-Removed a pen and piece of paper from her pocket and wrote down the patient's blood pressure and temperature.
-Then removed the blood pressure cuff from the patient's arm.
-The side rail of the patient's bed.
-Removed the phone from her pocket and touched the phone keypad and when finished placed it back in her pocket.
-Removed her stethoscope (medical device used to listen to heart, lungs and abdomen) from around her neck and placed onto the patient's chest.
-Touched the patient's IV site to check the site because the patient complained of pain at the site.
-Performed hand hygiene and put on a pair of non-sterile gloves and touched the IV pump because it alarmed and the side rail of the bed.
-Removed the gloves but did not perform hand hygiene and touched the following:
-Touched the IV pump because it alarmed again.
-Reached into her pocket and removed the ASCOM phone and touched the phone keypad to call for needed supplies to remove the patient's IV saline lock.
-Touched the IV pump and turned the machine off because the patient complained of the pain at the site.
-Placed an alcohol wipe; cotton ball and normal saline flush in a wrapper on the patient's bed linens without a barrier between the supplies and linens.
-Allowed the patient to remove the outer wrapper of the flush without performing hand hygiene before removal of the wrapper.
-An unknown staff member entered the patient's room and placed a wrapped J-Tip (a sterile disposable injector that uses pressurized gas to propel medication under the skin to alleviate pain during IV insertion) on the computer keyboard that Staff D had touched with gloved hands and had not been cleaned/disinfected after being touched with the gloved hands.
-Wearing the same gloves Staff D touched numerous items in the room picked up the J-Tip off the computer keyboard.
-Removed the gloves but did not perform hand hygiene after removal.

Staff D did not follow the facility's policy titled, "Hand Hygiene" when she wore gloves when she used the computer and ASCOM phone.

5. Record review of current Patient #11's medical record showed he was admitted to the facility on 10/09/17 with complaints of respiratory distress.

Observation on 10/17/17 at 10:00 AM showed Staff E, RN, entered the patient's room to administer medication per his G-Tube (Gastrointestinal Tube - a tube surgically inserted into the abdominal wall of the stomach and used to administer fluids, medications or nutrition). Posted on the patient's door was a sign that stated the patient was in contact and droplet isolation and PPE needed to be put on before entry into the room. Staff E put on a pair of non-sterile gloves and administered medication per the patient's G-Tube. Wearing the same pair of gloves Staff E touched the scanner and computer keyboard.

Staff E did not follow the facility's policy titled, "Hand Hygiene" when she wore gloves when she used the computer.

6. Record review of current Patient #14's medical record showed he was admitted to the facility on 10/15/17 with complaints of pain in the abdomen/pelvis area.

Observation on 10/17/17 at 11:00 AM showed Staff I, RN, entered the patient's room to administer IV antibiotics. Staff I touched the computer keyboard with gloved hands, removed gloves but did not perform hand hygiene after removal of the gloves. Staff I then put on another pair of gloves and cleaned the IV hub and attached the bag of antibiotic. Wearing the same pair of gloves, Staff I, touched the computer mouse and then removed her gloves.

Staff I did not follow the facility's policy titled, "Hand Hygiene" when she wore gloves when she used the computer.

7. Record review of current Patient #16's medical record showed she was admitted to the facility on 10/03/17 with complaints of Cystic Fibrosis (CF - a genetic disease that causes persistent lung infections and limits one's ability to breathe over time), pancreatic insufficiency (the pancreas fails to provide necessary digestive enzymes and without these enzymes fats, protein and carbohydrates are not properly digested) and anxiety.

Observation on 10/17/17 at 2:20 PM showed Staff K, RN, entered the patient's room to perform a PICC (thin, soft, long catheter inserted into a vein used to administer long-term fluids, medications or nutrition) Line dressing change. A sign on the patient's door stated that she was in contact isolation and PPE needed to be worn before entry into the patient's room. Staff K put on a gown but failed to tie the back.

8. Record review of current Patient #17's medical record showed she was admitted to the facility on 10/12/17 with complaints of her G-Tube needed replaced and MRSA (Methicillin Resistant Staph Aureus-a contagious bacteria that is resistant to antibiotics).

Observation on 10/17/17 at 2:25 PM, showed Staff M, RN, entered the patient's room. On the patient's door was posted a sign that stated the patient was in contact isolation and PPE was to be worn before going into the room. Staff M put on a gown but failed to tie the back.

9. Record review of current Patient #18's medical record showed she was admitted to the facility with complaints of failure to thrive.

Observation on 10/17/17 at 2:45 PM showed Staff M, RN:
-Entered the patient's room to administer IV medication, performed hand hygiene and put on a pair of non-sterile gloves and touched the following:
-Cleaned the IV saline lock catheter hub.
-Flushed the IV saline lock with normal saline flush.
-Inserted the IV tubing into the IV saline lock catheter hub.
-Programmed the IV pump to infuse at the ordered rate.
-Walked over to the computer and used the mouse.
-Placed Mastisol swab on the patient's bed linens without a barrier between the supply and bed linens.

Staff M did not follow the facility's policy titled, "Hand Hygiene" when she wore gloves when she used the computer.

10. Observation in the walk-in flu clinic, within the hospital, on 10/18/17 at 11:26 AM, showed Pharmaceutical Student (PS) O put alcohol-based hand sanitizer on her gloves to administer a flu injection to current Patient #19. PS P handled contaminated paperwork, and supplies and put gloves on, without performing hand hygiene, and administered a flu injection to current Patient #20.

11. During an interview on 10/17/17 at 10:05 AM, Staff E, RN, stated that hand hygiene should be done at the following times:
-Every time staff enter a patient's room;
-Every time staff touch a patient;
-Before and after medication administration;
and
-Before leaving the patient's room.

During an interview on 10/17/17 at 11:00 AM, Staff I, RN, stated that:
-Hand Hygiene was expected from staff and indicated at the following times:
-Before going into a patient's room;
-Before touching a patient;
-When staff have anything to do with central
lines or other task; and
-Upon leaving a patient's room.
-Staff did not state that staff are to perform hand hygiene with glove removal and before putting on another pair.

During an interview on 10/17/17 at 1:20 PM, Staff D stated that:
-Staff are to perform hand hygiene:
-Upon entry into patient's room;
-Before touching a patient;
-Before IV line entry;
-Before and after task; and
-After glove removal.
-There are no set times when nursing staff are to clean up touch areas, for example, computer keyboard, mouse, scanner and side rails.
-Staff are expected to clean their stethoscope when they come into a patient's room.

During an interview on 10/17/17 at 3:20 PM, Staff M, RN, stated that the expectation of the facility was for the PPE gowns to be tied in the back. Staff M stated that she had watched a video on when to perform hand hygiene.

During an interview on 10/17/17 at 3:30 PM, Staff K, RN, stated that it was the facility expectation that staff tie the back of the gown when being worn.

During an interview on 10/18/17 at 11:35 AM, Staff N, the PS Instructor, stated that the students were taught to perform hand hygiene only after administering the injection and removal of gloves, irregardless of any contamination.

During an interview on 10/18/17 at 3:42 PM, Staff Q, Director of Infection Prevention, stated:
-It was not acceptable to put sterile gloves on over contaminated, non-sterile gloves.
-He expected staff to clean their stethoscope/bell in between patients.
-He expected staff to secure PPE gowns in the back when worn in isolation patient rooms.
-Staff should perform hand-hygiene:
-Before patient contact;
-Before aseptic procedures;
-After body fluid exposure;
-After touching a patient;
-After leaving patient surrounding/zone; and
-After glove removal.
-Staff should have a barrier between the bed linens and supplies/equipment if placed on a patient's bed.

12. Review of the facility's internal grievance documentation, dated 09/27/17, regarding discharged Patient #25, showed Patient #25 had open heart surgery approximately two weeks prior. The patient had been in the Pediatric Intensive Care Unit (PICU) the family witnessed staff not following good hand hygiene (staff rubbed his/her nose and then touched the patient's face) and touching Patient #25.

13. Review of the facility's internal grievance documentation, dated 09/06/17, regarding discharged Patient #26, showed the following:
-The patient was admitted to the PICU on 09/07/17 with spina bifida (a defect of the spine in which part of the spinal cord, and its components, are exposed through a gap in the backbone-also exposing the spinal column to organisms, a high risk condition) and pneumonia. The patient was already on antibiotics. The patient was in contact isolation until a laboratory result could show there was no respiratory viral infection.
-Staff failed to educate or make the patient's family aware of the isolation, any need to wear PPE, or about the reason for the isolation.
-The patient's family witnessed staff come into the room without wearing PPE, or taking the necessary precautions for isolation.

14. Review of the facility's internal grievance documentation, dated 08/01/17, regarding discharged Patient #27, showed the following:
-The patient was admitted on 07/10/17, after a left foot amputation. The patient had multiple wounds (abdomen, pressure sores and recent surgical incision).
-The patient had a history of an infected abscess and was on antibiotics.
-Laboratory culture results dated 07/23/17, showed Staphylococcus coagulase negative (an increasingly recognized normal flora that can cause clinically significant infection of the bloodstream and other sites).
-The patient's Discharge Summary, dated 09/06/17, showed the patient had pseudomonas (the frequent cause of facility-acquired infections which can be complicated and life threatening) and Vancomycin Resistant Enterococcus (VRE-antibiotic resistant bacteria) in his amputation site, and VRE Faecalis (a bacteria typically found in the gut and bowel which can be life threatening if transmitted to other sites) and Candida (a type of yeast) in his abdominal wound.
-The patient was in isolation from 07/19/17 through 09/06/17 for VRE in his foot wound that was identified on 07/16/17.
-Staff failed to keep the family informed of the types and sites of infection.

15. Record review of the facility's internal grievance documentation, dated 09/13/17, regarding discharged Patient #15 showed:
-The patient was admitted to the facility on 08/10/17 with complaints of heart issues.
-The patient contracted MRSA while a patient in the facility's NICU (Neonatal Intensive Care Unit).
-The patient became very sick with a blood infection.

Record review of the patient's H&P dated 08/10/17, showed the following:
-The patient was admitted to the facility on 08/10/17 from a local facility with complaints of critical pulmonary valve stenosis (narrowing/obstruction of blood flow from the right ventricle (a chamber within the heart responsible for pumping oxygen depleted blood to the lungs) to the pulmonary artery (responsible for carrying blood from the right ventricle of the heart to the lungs for oxygenation).
-Infectious Disease: Afebrile (free of fever) following delivery.
-No infectious risk factors.
-Lines & tubes present at admission: Umbilical venous catheter (catheter inserted into the umbilical vein, used to administer fluids and/or medications).

Record review of the patient's medical record showed the patient had the following procedures performed while in the NICU.
-On 08/11/17 the patient received a balloon valvoplasty (a procedure used to widen a heart valve that has narrowed).
-On 08/13/17 the patient received a PICC Line.
-On 08/16/17 the patient's PICC Line was removed because of continued positive blood cultures (microbiology test used to identify infection).

Record review of the patient's laboratory reports showed MRSA positive cultures on 08/14/17, 08/15/17, 08/16/17 and 08/17/17.

Record review of the patient's Orders showed the following:
-On 08/14/17 staff documented an order for Vancomycin (antibiotic used to treat antibiotic resistant infections).
-On 08/15/17 staff documented an order for Gentamicin (antibiotic used to treat infections).
-On 08/15/17 staff documented an order for the patient to be placed in contact isolation for positive MRSA culture.
The patient received six weeks of IV antibiotic medication to treat his infection.

Record review of the patient's Cardiology Consultation showed:
-On 08/14/17 staff documented that the patient developed fevers over the past 24 hours with a CRP (C-reactive Protein - a blood test that measures inflammation in the body and results can be used to help treat infections) of 14.5 (normal range=0.0 to 1.0). He was pancultured (blood culture-microbiology test used to identify infections) and started on antibiotics.
-On 08/15/17 staff documented that the patient's blood cultures (pancultures) have grown MRSA.
-On 08/18/17 staff documented that the patient's echocardiogram (sound waves used to create pictures of the heart chambers, valves, walls and blood vessels) revealed a large mass probably a vegetation (an abnormal outgrowth on the valves of the heart) or a thrombus (blood clot) at the junction of the middle hepatic vein (blood vessels that transport the livers deoxygenated (removed oxygen) blood that has been filtered by the liver) and the inferior vena cava (carries blood from the lower body). The duration of antibiotic therapy will be decided by the NICU team and other consultants. This will factor in the patient's culture positive staph bacteremia (serious infection) and the likelihood that the mass seen by echo may be infected.
-On 08/22/17 staff documented that the patient unfortunately developed an endovascular (a surgical procedure where a catheter containing medications or miniature instruments are inserted through the skin into a blood vessel to treat vascular disease) infection with an infected clot at the IVC/RA (IVC-Inferior Vena Cava, a large vein that carries deoxygenated blood from the lower and middle body into the right atrium - RA, one of the four chambers of the heart) junction. The patient is currently undergoing treatment for this.

The grievance reported to the facility showed that the patient did contract MRSA and a blood infection while a patient in the facility's NICU.



18018

Based on review of the facility's Infection Control Committee Minutes and interviews, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) for the Infection Control Program (ICP) addressed problems identified through their committee meetings. Staff failed to follow-up on deficiencies noted in the July 27, 2017 and September 28, 2017 Infection Control Committee Meeting Minutes related to staff:
-Not wearing gloves appropriately or changing when indicated.
-Reaching into their pockets to retrieve phones with gloves on.
-Poor injection and medication handling practices.
-Ensure students were educated on the facility's infection control policies on hand hygiene and glove practices.
-No action plan initiated to train/educate and monitor staff in the identified deficient areas.
-Not involving and utilizing Infection Control staff as needed to address gaps in infection control practices to prevent infections and cross contamination.
These failed practices placed all patients, visitors, and staff at increased risk to exposure to infections. The facility census was 238.

Findings included:

1. Record review of Infection Control Committee Meeting Minutes, dated 07/27/17, and 09/28/17, showed the following:
-Overall compliance with hand hygiene was at 93%, Adele Hall at 88% (no goals listed); however, no action plan or follow-up or improvement was documented.
-Non-adherence to isolation was at 88% in the Adele Hall; however, no action plan or follow-up for improvement was documented.
-Hand hygiene auditing quality discussed; however, no action plan or follow-up was documented.
-Staff not wearing gloves appropriately (not changing them when they need changed between procedures, reaching into pockets to retrieve phones with gloves on); however, no action plan or follow-up for improvement was documented.
-Deficient injection and medication handling, hand hygiene and PPE use in the outpatient areas; however, no action plan or follow-up for improvement was documented.

During an interview on 10/18/17 at 3:42 PM, Staff Q, Director of Infection Prevention, stated the following:
-He has not addressed with staff cleaning of the ASCOM phones and to date has not provided staff with any education initiatives for phone cleaning.
-He was unaware of utilized students' lack of facility's hand hygiene philosophy.
-Infection Prevention staff were not involved in infection related grievance and/or complaint investigation process unless specifically requested to do so. (Lack of Infection Prevention knowledge regarding infection related complaints/grievances could potentially lead to poor overall response, data collection and/or future prevention).
-Hand hygiene surveillance may not always include an observation of the entire procedure or opportunity (might see the staff go in the room, but not follow them in).











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