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Based on observation, interview and record review, the facility failed to ensure the infection prevention control program were implemented by the facility staff when:

1. An Environmental Services (EVS) staff did not perform hand hygiene/handwashing after transferring the bagged trash.
2. A nursing staff did not perform hand hygiene when she entered and exited the patient's room.
3. An EVS staff did not wear Personal Protective Equipment (PPE) during the cleaning of a contact isolation room.
4. A Food Services staff (FSS) did not follow contact isolation precaution when she entered the contact isolation room.
5. A nursing staff did not disinfect a vitals machine after it was removed from a patient's room and stored in the equipment storage.
6. A nursing staff did not follow contact isolation precaution when she entered the contact isolation room.
7. A nursing staff did not perform hand hygiene after exiting a patient's room.
8. Dirty towels were observed under a sink cabinet, in the dialysis (type of treatment that helps body remove extra fluid and waste products from blood when the kidneys are not able to) storage room.
9. A dialysis staff was observed not wearing a Personal Protective Equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace illnesses) gown inside a contact isolation room, while setting up a hemodialysis machine.
10. A staff's personal item was found stored inside a cabinet in the patients' pantry (room where patients food, utensils are kept). This failure could result in the spread of infection to patients and staff.
These deficient practices had the potential to spread the bacteria to other patients, visitors, and staff.

Findings:

1. An observation and interview were conducted on 8/20/24 at 3:14 P.M., with EVS staff 11. EVS 11 was observed in the hallway across the trash collection bin area. EVS 11 transferred the trash bag from the trash barrel to the main trash container with bare hands. EVS 11 did not perform hand hygiene and went to push the button of the elevator. EVS 11 stated she did not perform hand hygiene after she touched the trash bag. EVS 11 stated she should have performed hand washing or hand hygiene to prevent the spread of infection.

An interview was conducted on 8/23/24 at 8:45 A.M., with Infection Preventionist (IP) 11. IP 11 stated staff should have performed hand washing or hand hygiene after touching and transferring the bagged trash to prevent the spread of infection for the safety of the patient, the visitors, and staff.

A review of facility's policy titled, Hand Hygiene last revised 6/13/24 indicated,"... III. Text: Performance of hand hygiene is required of all team members ... B. If hands are not visibly soiled, use either an SHC-approved ABHR or waterless antiseptic agent or soap and water for routinely decontaminating hands in clinical situations as described: ...6. After contact with inanimate objects in the immediate vicinity of the patient."

2. Patient 11 was admitted to the facility on 8/16/24 for diagnoses that included left bimalleolar ankle fracture (fracture of foot) per History and Physical dated 8/16/24.

An observation and interview were conducted on 8/20/24 at 3:37 P.M., with Registered Nurse (RN) 11. RN 11 was observed inside Patient 11's room. RN 11 was observed that she did not perform hand hygiene prior to entering and after exiting Patient 11's room. RN 11 stated she entered and exited Patient 11's room and was not able perform hand hygiene. RN 11 stated hand hygiene was important to prevent the spread of infection to other patient and staff.

An interview was conducted on 8/23/24 at 8:45 A.M., with Infection Preventionist (IP) 11. IP 11 stated every person should have been performing hygiene upon entering and exiting the patient's room to prevent the spread of infection for the safety of the patient, the visitors, and staff.

A review of facility's policy titled, Hand Hygiene last revised 6/13/24 indicated, "...III. Text: Performance of hand hygiene is required of all team members ... B. If hands are not visibly soiled, use either an SHC-approved ABHR or waterless antiseptic agent or soap and water for routinely decontaminating hands in clinical situations as described: ...1. Upon entry and exit of a patient room/area/surroundings."

3. Patient 12 was admitted to the facility on 8/16/24 for diagnoses that included acute perichondritis (infection of the ear) per History and Physical dated 8/16/24.

An observation was conducted on 8/21/24 at 10:53 A.M., with EVS staff 12 in Patient 12's room. Posted outside of Patient 12's room was the signage that indicated, "Contact Precaution ... To Enter: Clean Hands ...Put on and tie gown ... Cover cuffs with gloves ... To Exit: Remove gloves ... Remove gown in the room ... Clean hands ..." EVS 12 was observed inside Patient 12's room cleaning the room and mapping the floor. EVS 12 did not wear the gown while inside Patient 12's room.

An interview was conducted on 8/23/24 at 8:45 A.M., with the Infection Preventionist (IP) 11. The IP 11 stated staff were expected to wear the appropriate PPE in the isolation room to prevent the spread of infection for the safety of the patient, visitors, and staff.

A review of facility's policy titled, Standard Precaution and Transmission-Based Precautions for Hospitalized Patients last revised 5/31/24 indicated, " ...II. Text: 3. Contact Precautions: Use contact precautions for patients with known or suspected infections ... 1. PPE Required: Isolation Gown and Gloves. 1. Perform hand hygiene and don clean isolation gown and gloves upon entry into the patient room or cubicle. 3. Prior to exiting patient room or cubicle, doff isolation gown and gloves in a method to prevent self-contamination, and perform hand hygiene."

4. Patient 13 was admitted to the facility on 8/18/24 with diagnoses that included Weakness and Fall per Emergency Department Provider Note dated 8/18/24.

An observation and interview were conducted on 8/21/24 at 9:40 A.M., with the FSS 11 in Patient 13's room. Posted outside of Patient 13's room was the signage that indicated, "Contact Precaution ... To Enter: Clean Hands ...Put on and tie gown ... Cover cuffs with gloves ... To Exit: Remove gloves ... Remove gown in the room ... Clean hands ..." The FSS 11 entered and exited Patient 13's room and did not perform hand hygiene and did not wear the required contact precaution PPE. The FSS 11 stated she did not gown up when she entered the contact isolation room. The FSS 11 stated it was important to wear PPE to prevent the spread of infection for my safety and patient's safety.

An interview was conducted on 8/21/24 at 9:50 A.M., with the Women's Hospital Observation (WHO) Manager. The WHO Manager stated FSS 11 should have worn the PPE for contact isolation when she entered Patient 13's room. The WHO Manager stated it was important to wear PPE to control the spread of infection.

A review of facility's policy titled, Standard Precaution and Transmission-Based Precautions for Hospitalized Patients last revised 5/31/24 indicated, "...II. Text: 3. Contact Precautions: Use contact precautions for patients with known or suspected infections ... 1. PPE Required: Isolation Gown and Gloves. 1. Perform hand hygiene and don clean isolation gown and gloves upon entry into the patient room or cubicle. 3. Prior to exiting patient room or cubicle, doff isolation gown and gloves in a method to prevent self-contamination, and perform hand hygiene."

5. Patient 14 was admitted to the facility on 8/17/24 with diagnoses that included weakness per History and Physical dated 8/17/24.

An observation and interview were conducted on 8/21/24 at 11:04 A.M., with Nursing Assistant (NA) 11. NA 11 went out with a vitals machine from Patient 14's room and did not perform vitals machine cleaning and disinfection. NA 11 stated she should have disinfected the vitals machine before storing it in the equipment room.

An interview was conducted on 8/23/24 at 8:45 A.M., with the Infection Preventionist (IP) 11. IP 11 stated staff were expected to clean and disinfect the vital machine prior to leaving the patient room and before storing it the storage room. IP 11 further stated, it was important to do so to prevent the spread of infection for the safety of the patient, visitors, and staff.

A facility's policy titled, Standard Precautions and Transmission-Based Precautions for Hospitalized Patients last reviewed 5/31/2024 indicated, " ...II. Text: A. Standard Precaution ... 8. Environmental Cleaning: a. Reusable Medical Equipment (RME) and devices must be cleaned and disinfected and maintained according to the manufacturers' instruction to prevent patient-to-patient transmission of potential infectious material ... c. All patient care equipment used for more than one patient must be cleaned with a hospital-approved disinfectant between patients."

6. Patient 15 was admitted to the facility on 8/20/24 with diagnoses that included Sepsis due to Pneumonia (Infection of the lung) per History and Physical dated 8/20/24.

An observation and interview were conducted on 8/22/24 at 2:16 P.M., with Nursing Assistant (NA) 12 in Patient 15's room. Posted outside of Patient 15's room was the signage that indicated "Contact Precaution ... To Enter: Clean Hands ...Put on and tie gown ... Cover cuffs with gloves ... To Exit: Remove gloves ... Remove gown in the room ... Clean hands ..." NA 12 was observed and entered Patient 15's room and did not perform hand hygiene. NA 12 did not put on the PPE gown when she was inside Patient 15's room. NA 12 later exited Patient 15's room and did not perform hand hygiene. NA 12 stated she should have stopped and put on the PPE before entering Patient 15's room. NA 12 stated it was important to wear the required PPE to prevent the spread of infection and for the safety of everyone.

An interview was conducted on 8/23/24 at 8:45 A.M., with the Infection Preventionist (IP) 11. IP 11 stated staff were expected to wear the appropriate PPE in the isolation room to prevent the spread of infection for the safety of the patient, visitors, and staff.

A review of facility's policy titled, Standard Precaution and Transmission-Based Precautions for Hospitalized Patients last revised 5/31/24 indicated, " ...II. Text: 3. Contact Precautions: Use contact precautions for patients with known or suspected infections ... 1. PPE Required: Isolation Gown and Gloves. 1. Perform hand hygiene and don clean isolation gown and gloves upon entry into the patient room or cubicle. 3. Prior to exiting patient room or cubicle, doff isolation gown and gloves in a method to prevent self-contamination, and perform hand hygiene."


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7. On 8/20/24 at 10:03 A.M., during the initial hospital tour, Registered Nurse (RN)1 was observed exiting patient room (288). RN 1 did not perform hand hygiene.

On 8/20/24 at 10:05 A.M., an interview with RN 1 was conducted. RN 1 stated she should had performed hand hygiene right after exiting a patient's room to prevent cross contamination.

On 8/21/24 at 9:35 A.M., an interview with the Unit Manager (UM)1 was conducted. The UM 1 stated RN 1 should have performed hand hygiene right after exiting a patient's room. The UM 1 stated all nursing staff were expected to perform hand hygiene right after exiting a patient's room to prevent spread of infection.

On 8/23/24 at 8:55 A.M., an interview with the Infection Preventionist (IP) 11 was conducted. IP 11 stated all nursing staff were expected to perform hand hygiene when entering and exiting a patient's room. IP 11 stated performing hand hygiene will prevent spread of nosocomial infection and cross contamination.

During a review of the facility's policy and procedure (P&P) titled, "Hand Hygiene" revised 6/13/2024, the P&P indicated, "III. Text Performance of hand hygiene is required of all team members ...B ...upon entry and exit of a patient room/area/surroundings..."


8. On 8/20/24 at 10:24 A.M., during the initial hospital tour, an observation at the dialysis storage room was conducted. Three (3) pieces of dirty towels were observed under a sink cabinet in the dialysis storage room.

On 8/22/24 at 9:12 A.M., an interview with the Dialysis Charge Nurse (DCN) 1 was conducted. The DCN 1 stated dirty towels should have not been placed under the sink. The DCN 1 stated old, dirty towels were a possible source of infection.

On 8/23/24 at 9:15 A.M., an interview with Infection Preventionist (IP) 11 was conducted. IP 11 stated dirty towels should have been placed in dirty linens bag. IP 11 stated dirty linens and towels have moisture and could cause cross contamination.

During a review of the Fresenius Kidney Care (FKC- dialysis company, vendor) policy and procedure (P &P) titled, "Storage of Supplies and Supply Expiration Dates for Inpatient Services" dated 7/1/2024, the P&P indicated, "Policy ...Storage areas will be kept clean and in order."

9. On 8/20/24 at 2:45 P.M., during the initial tour of the hospital, a Dialysis Registered Nurse (DRN) 1 was observed not wearing a Protective Personal Equipment (PPE) gown, while inside a contact isolation room (513). Room 513 was on contact isolation for Pseudomonas (germ found in the environment that can cause infections in the blood, lungs and other parts of the body) and Multidrug-resistant organisms (MDRO- bacterias that have become resistant to certain antibiotics). The DRN 1 was setting up a hemodialysis machine. (a machine that filters wastes, salts, and fluid when kidneys are no longer healthy enough to work adequately).

On 8/20/24 at 2:55 P.M., an interview with the DRN 1 was conducted. The DRN 1 stated he usually wear a PPE gown inside a contact isolation room. The DRN 1 stated he should have worn a PPE gown to prevent cross contamination.

On 8/20/24 at 3:45 P.M., an interview with the Dialysis Charge Nurse (DCN) 1 was conducted. The DCN 1 stated DRN 1 should have worn a PPE gown while inside a contact isolation room (513). The DCN 1 stated the expectation was for all dialysis staff to wear PPE gown while inside a contact isolation room to prevent cross contamination.

On 8/23/24 at 9:10 A.M., an interview with Infection Preventionist (IP) 11 was conducted. IP 11 stated all staff should wear proper PPE when entering a contact isolation room. IP 11 stated it was important to wear proper PPE to prevent cross contamination and spread of infections to caregivers and patients.

During a review of the facility's policy and procedure (P&P) titled," Standard Precautions and Transmission- Based for Hospitalized Patients" revised 5/31/2024, the P&P indicated," ...II. Text ...2. Personal Protective Equipment (PPE) ...PPE should be worn ...Don PPE upon entry into the patient's room ..."


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10. During an observation of the Medical Intensive Care Unit (MICU) with the Unit Manager (UM) on 8/20/24 at 10:14 A.M. A jug with liquid was found inside the cabinet of the patients' pantry.

An interview was conducted with the UM on 8/20/24 at 2:16 P.M. The UM stated, the jug found inside the pantry belonged to a MICU staff. The UM further stated the personal jug should have been placed in the employee's locker and should have not been placed inside the patient's pantry to prevent cross contamination (transfer of harmful substances) to patients and facility staff.

An interview was conducted with the Infection Preventionist (IP) 11 on 8/20/24 at 2:30 P.M. IP 11 stated staff's personal items should not be kept in the patients' pantry to prevent the transmission of infection to patients and staff.

Review of the Food and Drug Administration's 2022 Food and Safety code section 6-305.11 indicated, "Designation. Street clothing and personal belongings can contaminate food, food equipment, and food-contact surfaces."