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A. Based on observation, interview, review of infection control documentation, and policy review, it was determined the hospital failed to develop an effective system for preventing and controlling infections, including full implementation of hospital policies and procedures for patients on contact precautions as required.

Findings include:

1. Review of the policy titled, "Standard Precautions with Transmission - Based Isolation Procedure," effective 11/07/2011, included the following internal requirements: "Contact Precautions...Wear gloves when entering the room..."

2. A tour of the medical unit was conducted with the Infection Prevention Coordinator on 09/05/2012 at 1400. During the tour, the coordinator stated that Patient B was on contact precautions. A sign was observed at the hallway entrance to Patient B's room. The sign included the following contact precautions: "...Gloves: [Every] time you enter room..."

On 09/05/2012 at 1410, S3, a nurse, entered Patient B's room. The patient was in the bed. S3 stood at the foot of the patient's bed, spoke to the patient, and then left the room. He/she did not don (put on) gloves when entering the room in accordance with the posted contact precautions and hospital policy. These observations were conducted with the Infection Prevention Coordinator present.

3. A tour of the intensive care unit was conducted on 09/05/2012 at 1320. During the tour, a "Contact Precautions" sign was observed at the hallway entrance to Patient A's room. At 1325, S1, a respiratory therapist, entered Patient A's room. The patient was in the bed. S1 walked to the side of the patient's bed, and then left the room. He/she did not don gloves when entering the room in accordance with the posted contact precautions and hospital policy.

4. An interview was conducted with the Infection Prevention Coordinator on 09/05/2012 at 1415. He/she stated that the hospital policy for glove and gown use during contact precautions was that staff were not required to wear gloves or a gown in the patient's room if they did not touch anything in the room.

B. Based on interview, policy review and review of documentation, it was determined the hospital failed to fully develop and implement a system for controlling and preventing infections, including a clearly defined terminal cleaning policy for the operating rooms as required.

Findings include:

1. The policy titled, "Service Procedures," effective 01/11/2010 was reviewed. The "Surgery, [Cardiac Catheterization Laboratory]" section included a list of "daily" cleaning procedures for the operating rooms. However, the policy was not fully developed to address a clearly defined schedule for terminal cleaning the operating rooms, including whether or not they were terminally cleaned each day surgeries were regularly scheduled and/or following emergency procedures.

2. A list of operating room surgical procedures conducted on weekends for 06/02/2012 through 08/26/2012 was reviewed. Surgical procedures were conducted nearly every Saturday during that time frame. The following were examples: Two procedures were conducted on Saturday, 06/02/2012; three procedures on Saturday, 06/23/2012; one procedure on Saturday, 07/07/2012; and three procedures on Saturday, 08/11/2012.

3. During an interview with the Infection Prevention Coordinator on 09/06/2012 at 1035, he/she stated that regularly scheduled surgeries were conducted each week, Monday through Friday. He/she further stated that last minute surgeries were often scheduled towards the end of each week for Saturday and/or Sunday. The coordinator stated that emergency surgeries were also conducted on Saturdays and Sundays as needed. Review of the policy above identified it was not fully developed to address whether or not the operating rooms were terminally cleaned on Fridays and Saturdays when they were used.

4. During an interview with the the Infection Prevention Coordinator and the Risk Manager on 09/07/2012 at 0830, the coordinator stated that the operating rooms were terminally cleaned in the evenings, Sunday through Thursday, and were not terminally cleaned on Fridays or Saturdays. He/she revealed that the hospital did not have a policy that specified which days the operating rooms were terminally cleaned. The coordinator further revealed that he/she had already identified that the terminal cleaning schedule for the operating rooms needed to be evaluated.

C. Based on observation and policy review, it was determined the hospital failed to develop an effective system for controlling and preventing infections, including full implementation of a policy and procedure for patients receiving IV (intravenous) medications as required.

Findings include:

1. Review of the policy titled, "Intravenous (IV) Medications: Preparation and Administration," effective 06/27/2011, included the following internal requirements: "IV Push...Scrub IV port with chlorhexidine/isopropyl alcohol for 15 seconds...Access injection site with luer-lock syringe."

2. An observation of a surgical procedure for Patient E was conducted on 09/06/2012 at 1030. The patient had an IV line in place to his/her right arm. At 1041, 1042, 1043 and 1055, S4, an anesthesiologist, used a syringe to administer an IV (push) medication and/or a flush solution into the port (injection site) of the patient's IV line. S4 did not disinfect the IV port prior to accessing the port with the syringe at any of those times. These observations were conducted with the Infection Prevention Coordinator present, and he/she acknowledged that the IV port should have been disinfected before it was accessed.