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Based on findings from document review and interview, the hospital's Infection Control (IC) Plan is not consistent with its Infection Control Risk Assessment (ICRA). Also the IC Plan has not been fully implemented. Additionally, the Infection Control Committee Meeting (ICCM) minutes lacked documentation of infection control related information from the Nursing Department since 7/2011.

Findings include:

--Per review of the ICRA dated 2012, numeric risk levels (1 lowest risk - 12 highest risk) were assigned to various events (i.e., increasing populations with MRSA, surgical site infections, poor hand hygiene, inappropriate use of personal protective equipment (PPE), and improper cleaning and disinfection of equipment and supplies.)

During interview of the hospital's Infection Control Nurse (ICN) on 6/5/12 at 1:30 pm, she indicated a risk level at 8 or above should be addressed in the hospital's Infection Control Plan.

However, per review of the hospital 's Infection Prevention and Control Plan Goals dated 2012, not all of the identified risk levels of 8 or above were addressed in the Plan (i.e., inappropriate use of PPE, improper cleaning and disinfection of equipment and supplies, improper cleaning and disinfecting of environment.) Also, per review of the Infection Prevention and Control Plan Goals dated 2012, it indicated one of the identified risks was hand hygiene compliance. (Poor hand hygiene was a risk level 8 on the ICRA.) However per review of the Infection Control Committee Meeting (ICCM) minutes for 2012 (dated 1/15/12 and 4/25/12) hand hygiene compliance has not been monitored.

--Also per review of the ICCM minutes dated 4/2512, 1/15/12, and 10/26/11, they all lacked documentation of any report from the Nursing Department. The most recent documented nursing report to the ICCM was of the meeting dated 7/27/11. At that time it was documented under section titled "Nursing Report," "Staff need to be aware of dwell times of disinfectants." Action and responsibility stated "Need to increase awareness/knowledge." There was no plan on how to do this and no completion date documented.

--During interview of the ICN on 6/5/12 at 1:45 pm, the above findings were acknowledged.

Based on findings from observations, interviews, and document review, the hospital did not ensure that all generally accepted infection control measures were implemented and followed. Specifically, 1) the hospital's policy and procedure (P & P) for contact isolation was not consistent with the Center for Disease Control and Prevention (CDC) guidelines, 2) staff and visitors did not follow contact isolation practices required by the CDC (i.e., donning isolation gown, performing hand hygiene upon exiting patient room), 3) isolation gowns were not available at point of use, 4) communication of patient contact isolation status to staff and visitors was not clear and consistent, 5) intravenous (IV) medication ports on IV tubing were not cleaned with a disinfectant prior to medication administration though the port, 6) nursing staff were not all aware of the need to clean glucometers between patient uses, 7) contact time for disinfectant applied to an operating room table did not last 10 minutes before use, as required by the manufacturer, 8) hand held nebulizers used by patients were not cleaned with sterile water after each use, 9) clean and dirty linens were held in the same location, risking cross-contamination, and 10) horizonal surfaces in the operating room were not damp dusted before the first procedure of the day.

Findings regarding 1) above include:

--The CDC document titled "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings," states "when Contact Precautions are used (i.e., to prevent transmission of an infectious agent that is not interrupted by Standard Precautions alone and that is associated with environmental contamination), donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental surfaces...Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens."

--The hospital's P & P titled "Standard Precautions/ Transmission-Based Precautions," last reviewed 4/10, indicated that when caring for patients on contact precautions, staff should wear gowns for direct patient care or when soiling is likely.

The hospital's P & P did not require staff to wear isolation gowns upon entrance to contact isolation rooms per CDC guidelines.

--Also, during interview with registered nurse (RN) #1 on 6/5/12 at 9:00am, he/she indicated isolation gowns are not required to be worn when entering rooms of patients who are on contact isolation if care is not going to be provided to the patient.

--During interview with the ICN and Director of Nursing (DON) on 6/5/12, these findings were acknowledged.

Findings regarding 2) above include:

--The CDC document titled "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings," states "Hand hygiene following glove removal further ensures that the hands will not carry potentially infectious material that might have penetrated through unrecognized tears or that could contaminate the hands during glove removal...Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens"

--The hospital's P & P for "Standard Precautions/Transmission-Based Precautions" referenced above indicated that for contact precautions, gloves should be worn, hands washed and gown removed prior to leaving the room.

--Per observation on 6/4/12 at 9:10 am, RN #1 was noted in room 2008 B without an isolation gown on. (The patient was on contact precautions.)

-Per observation on 6/4/12 at 10:35 am, respiratory therapist (RT) #1 administered a respiratory aerosol treatment to the patient in the intensive care unit (ICU), room #4, without wearing an isolation gown or gloves. (The patient was on contact precautions.)

--Per observation on 6/4/12 at 3:35 pm, RN #2 entered Room #1 in the ICU, performed an assessment and provided care to the patient. He/she did not don an isolation gown. Also, while RN #2 did don gloves and performed hand hygiene after removing them, he/she then pulled the curtain open with bare hands and did not perform hand hygiene again prior to exiting the room. (The patient was on contact precautions.)

--Per observation on 6/4/12 at 3:45 pm, a visitor to room #4 in ICU exited the room without being required to perform hand hygiene. (The patient was on contact precautions.)

--Per observation on 6/4/12 at 4:00 pm, Physician #1 entered room #5 in the ICU. He/she did not don a gown or gloves and did not perform hand hygiene prior to exiting the patient's room. (The patient was on contact precautions.)

--Per observation on 6/4/12 at 4:40 pm, RT #2 donned an isolation gown prior to entering room #4 in the ICU. However, RT #2 did not tie the gown so it was falling off his/her shoulders while administering a respiratory treatment. He/she exited the room without first removing the gown. RT #2 then placed the contaminated gown on the clean isolation supply cart in the corridor of the ICU, not in a designated receptacle. (The patient was on contact precautions.)

Findings regarding 3) above include:

--Per observations on 6/4/12 at 9:15 am and 6/5/12 at 9:35 am, isolation supply carts positioned at the entrance to rooms 2008 on unit 2 Memorial and 18 A on unit 4 Central lacked isolation gowns. This was acknowledged by the Director of Nursing (DON) and Nurse Manager (NM) of 4 Central respectively.

Findings regarding 4) above include:

--Per interviews with the DON on 6/4/12 at 9:45 am and 11:00 am, isolation signs are placed on the wall outside of patients' rooms above or below the room number placard (indicating which patient is on contact precautions). Medical records (MRs) are also labeled with stickers indicating the type of precautions staff should take.

-- Per observation on 6/4/12 at 9:15 am, Patients D and E, who shared a room, were both on contact precautions. However, only one contact precaution sign was placed on wall outside room. It indicated that Patient E was on contact precautions. There was no contact isolation sign to indicate Patient D was on contact precautions.

--Per MR review, Patient F was on contact precautions. However, per observation on 6/4/12 at 9:15 am, a contact precaution sign was placed in such a way outside the room that it indicated the roommate was on contact precautions, not Patient F.

-- Per observation in the ICU on 6/4/12 at 11:00 am, Patients A, B, and C were on contact precautions. However, their MRs were not labeled with this information.

--During interviews with the DON and ICN on 6/5/12, these findings were acknowledged.

Findings regarding 5) above include:

--Per observation on 6/4/12 at 10:07 am, Certified Registered Nurse Anesthetist (CRNA) #1 administered IV medication to a patient. He/she did not wipe the port (that the medication was administered through) with a disinfectant as required by generally accepted standards of infection control.

Also, per observation on 6/5/12 at 9:00 am, CRNA #2 administered IV medication to a patient. He/she did not wipe the port (that the medication was administered through) with a disinfectant as required by generally accepted standards of infection control.

--During interview with the ICN on 6/4/12 at 1:45 pm, he/she acknowledged IV medication ports should be wiped with alcohol prior to medication administration.

Findings regarding 6) above include:

--A letter issued to health care facilities by the Department of Health on 2/11/11, titled "New York State Health Advisory: Preventing Exposure to Bloodborne Pathogens during Diabetes Care Procedures and Techniques" stated" Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions."

--However, the hospital's P & P titled "Point-of-Care Blood Glucose Testing," last reviewed 11/10, stated "cleaning of the Accu-Chek Inform System is performed on a weekly and/or needed basis."

Also, during interview with RN #3 on 6/4/12 at 11:00 am, he/she was not aware it was necessary to clean glucometers between patient uses.

Findings regarding 7) above include:

--Per observation on 6/4/12 at 10:30 am, RN #2 cleaned a contaminated operating room table with a product called HDQL10. Within 1 minute and prior to the product drying on the table, he/she applied a clean sheet to the OR table.

--Per interview with the Director of Housekeeping on 6/5/12 at 11:00 am, the manufacturer ' s directions for use for HDQL10 indicate a 10 minute contact time is required for disinfection of surfaces.

Findings regarding 8) above include:

--Per interview with RT #1 on 6/4/12 at 1:30 pm, he/she rinses nebulizer pieces (cup/mask/ mouthpiece) with sterile water only when a patient requests that it be done. He/she does not routinely rinse nebulizers.

-- Per interview with the DON on 6/5/12, the hospital does not have a P & P that addresses nebulization therapy for non-ventilated patients on the inpatient units.

Findings regarding 9) above include:

---Per observation on 6/5/12 at 2:30 p.m., the soiled laundry and clean linens were not segregated in separate rooms in the laundry area as required by the Guidelines for Design and Construction of (Hospital) and Health Care Facilities (1997; 2010). Further, the soiled and clean linens were not maintained under negative and positive pressures, respectively, as required by Table 2 of the same 1997 Guidelines and Table 7-1 of the 2010 Guidelines.

Per interview with the Housekeeping Director on 6/4/12 at 2:30 pm, contaminated clothing (from the nursing home) is delivered to the hospital laundry area for laundering. He/she acknowledged that staff wash and dry the resident linen and hang it up, all in the same area, before then returning it to the nursing home.

---Per generally accepted standards of infection control, there is to be clear separation of clean and dirty laundry and there shall be no cross contamination of the dirty and clean textiles/linens.

Findings regarding 10) above include:

--The Association of Operating Room Nurses guidelines dated 2011 state the following: "All horizontal surfaces in the OR (e.g. furniture, surgical lights, booms, equipment) should be damp dusted before the first case of the day. Plasma and monitor screens should be cleaned according to the manufacturer's instructions. "

--During interview with the operating room Nurse Manager on 6/4/12 and the Medical Director on 6/5/12, they indicated that the operating rooms are not damp dusted in the morning, before the first case of the day.