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Based on observation, interview, record review and policy review, the facility failed to ensure staff followed infection control policies and standards for patient care when staff failed to:
- Appropriately clean an implanted port (a device placed just under the skin on the upper part of the chest wall to deliver medication, chemotherapy or fluids). (A749)
- Appropriately wear required Personal Protective Equipment (PPE),when caring for patients in Contact Isolation (CI, special precautionary measures, practices, and procedures used in the care of patients with contagious or communicable diseases), and clean a computer on wheels after it was removed from a CI room in the Intensive Care Unit (ICU). (A749)
- Clean a blood glucose monitor (the device used to measure the blood glucose) and supply case used for three of three patients who had a blood glucose test (a procedure to check the amount of sugar in their blood). (A749)
- Perform indwelling urinary catheter (a tube placed in the bladder to drain urine) care (cleansing of the catheter, genitals and anus) without cross contamination. (A749)
- Ensure catheter bags (bag to collect urine that drained from the bladder) were not in contact with the floor. (A749)
- Perform hand hygiene (clean hands with sanitizer or soap and water) before and after glove use, after touching inanimate objects, and failed to change gloves between patient tasks. (A749)
- Perform hand hygiene after glove use while cleaning a colonoscope (instrument used to look at the distal part of the small bowel). (A749)

These failed practices had the potential to expose all patients to cross contamination and increase the potential to spread infection to all patients, staff and visitors. The facility census was 256.

As a result of this survey, the complaint was substantiated and the Condition of Participation: Infection Control, was found to be out of compliance. Please see the 2567.





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Based on observation, interview, record review and policy review the facility failed to ensure staff followed infection control policies for patient care when staff failed to:
- Appropriately clean an implanted port (a device placed just under the skin on the upper part of the chest wall to deliver medication, chemotherapy or fluids) for one patient (#30) of one patient observed.
- Appropriately wear required Personal Protective Equipment (PPE, a gown) when caring for one patient (#9), failed to put on a PPE gown for one patient (#13) and failed to clean a computer on wheels (COW) after it was removed from a Contact Isolation (CI, special precautionary measures, practices, and procedures used in the care of patients with contagious or communicable diseases) room for one patient (#26) of three patients observed in the Intensive Care Unit (ICU).
- Clean a blood glucose monitor (device used to measure the blood sugar) and supply case used for three of three patients (#34, #35, and #36) who had a blood glucose test.
- Perform indwelling urinary catheter (tube placed in the bladder to drain urine) care (cleansing of the catheter, genitals and anus) without cross contamination for one of one patient (#2) observed.
- Ensure catheter bags (bag to collect urine that drained from the bladder) were not in contact with the floor for two of two patients (#2 and #4)
observed.
- Perform hand hygiene (clean hands with sanitizer or soap and water) before and after glove use, after touching inanimate objects, and failed to change gloves between patient tasks for five patients (#26, #22, #37, #29, #30) of 19 patients observed.
- Perform hand hygiene after glove use while cleaning a colonoscope (instrument used to look at the distal part of the small bowel) by one of one staff (GG).
These failed practices had the potential to expose all patients to cross contamination and increase the potential to spread infection to patients, staff and visitors. The facility census was 256.

Findings included:

1. Record review of the facility's policy titled, "Intravenous Access Management Policy," dated 10/2011, showed that two percent chlorhexidine (topical antiseptic) based preparation was to be used for cleaning of the site for accessing of an implanted port.

During an interview on 03/23/16 at 3:30 PM, Staff E, Vice President, (VP) of Quality, stated that the facility used Lippincott's Nursing Procedures (a book of detailed descriptions of procedures used as a reference for nursing staff) as the reference for nursing procedures.

2. Record review of facility provided document titled, "Lippincott Procedures, Implanted port accessing," revised 04/03/15, showed:
- Vascular catheter associated infections were reasonably prevented using various infection prevention techniques such as hand hygiene, properly preparing the access site and maintaining sterile technique.
- Clean the implanted port access site with an antiseptic solution.
- For Chlorhexidine, apply with an applicator using a back and forth scrubbing motion for at least 30 seconds and allow the area to dry.

3. Observation on 03/22/16 at 3:05 PM on four North showed Staff UU, Registered Nurse (RN) in Patient #30's room and prepared to de-access and re-access the patients implanted port. Staff UU used a Chlorhexidine cleansing swab and with a circular motion she cleaned the area beginning at the insertion site and worked her way outwards. She placed her left fingers on the device at the insertion site then swabbed over that area again with the cleansing swab. She then proceeded to insert the needle into the port.
The circular motion for cleaning that Staff UU used was in contradiction to the facility policy in regards to the use of Chlorhexidine and when she touched the insertion site after the initial cleaning she contaminated the site.

During an interview on 03/22/16 at 3:15 PM, Staff UU, RN, stated that she used a Chlorhexidine swab to clean the site and it was her personal preference to feel for the device and the insertion site prior to inserting the needle and that since she had felt it with her fingers she always cleaned it again with the swab prior to accessing it. Staff UU stated that the facility policy and procedure was to clean in a circular motion and move the circle outwards.

4. Record review of the facility policy titled, "Isolation Precautions" dated 05/2015 showed direction to staff to immediately put on and wear gowns when entering the room of a patient in Contact Isolation (CI).

5. Observation on 03/22/16 at 9:16 AM in the ICU showed Staff LLL, Infectious Disease Physician, in Patient #9's room who was in a CI room with Methicillin Resistant Staphylococcus Aureus (MRSA), an infection which is resistant to many antibiotics. The gown, which is part of the required PPE's was below his nipple line and untied at his neck and waist which exposed his clothes to the MRSA and then had the potential to be transferred to other patients, staff and visitors.

During an interview on 03/22/16 at 9:21 AM, Staff LLL stated that he did not have his gown on properly because he was distracted when he walked in the room because someone from "Your team asked me who I was". The physician had been observed for two minutes or so before he was asked his name by the facility administration.

6. Observation on 03/21/16 at 2:30 PM in the ICU showed Staff Q, RN, in Patient #13's CI room with Clostridium Difficile (C-Diff), a bacteria which can cause diarrhea to life threatening inflammation of the colon. Staff Q did not have the required PPE gown on which had the potential to contaminate her clothes and to potentially spread germs to other patients, staff and visitors.

During an interview on 03/22/16 at 2:40 PM, Staff Q stated, "I didn't have a gown on; I'm too busy. I'm stressed. I need more help " .

7. Record review of the facility's policy titled, "Guidelines for Cleaning, Disinfecting, and Sterilization," dated 10/2014, showed facility directive to staff to clean equipment between each patient use.

8. Observation with concurrent interview in the ICU on 03/22/16 at 2:30 PM showed:
- Staff JJ, Respiratory Therapist (RT), used a COW in Patient #26's room, who was on contact isolation.
- He touched the patient, the patient's linen, and the COW.
- Staff JJ then left the room and walked across the ICU with the contaminated COW and failed to clean the COW.
- Staff JJ later returned to Patient #26's room with a different COW, and the COW arm (attached the computer to the wheels on the bottom) touched the patient's linens. Staff JJ touched the patient and the COW keyboard and scanner. He left again without cleaning the COW.
- Staff JJ stated that when he cleaned the COW, he only cleaned the monitor and keyboard and not the entire COW.
- He took the COW across the ICU to a room for RT and completed the cleaning of the COW in the room.
- He would clean the COW if going directly into another patient's room.
Taking a dirty COW throughout the ICU greatly increased the risk for transmission of infectious bacteria to other patients, staff, and visitors in the ICU.

9. Record review of Patient #26's lab showed on 03/14/16 MRSA, of his sputum (a mixture of saliva and mucous coughed up from the lungs and respiratory passages).

During an interview on 03/22/16 at 3:00 PM Staff KK, Director of RT, stated that a COW should not be used in the isolation room.

10. Record review of facility provided document titled, "Lippincott Procedures, Blood Glucose Monitoring," revised 04/03/15, showed facility directive for staff to clean and disinfect the blood glucose monitor because contaminated equipment increases the risk of infection.

11. Observation on 03/22/16 between 11:05 AM and 11:30 AM showed:
- On the sixth floor, Staff KKK, Registered Nurses (RN), performed a blood glucose test on Patient #34,
- On the sixth floor,Staff GGG, RN performed a blood glucose test on Patient #35.
- On three North, Staff HHH, RN, performed a blood glucose test on Patient #36.
- Each RN failed to clean the blood glucose monitor and the supply case used when they left the patient's room.

During an interview on 03/22/16 at 11:10 AM, Staff KKK, RN, stated that it would make sense to clean the blood glucose monitor and the case after she left the patient's room, but typically she did not.

During an interview on 03/22/16 at 11:25 AM, Staff GGG, RN, stated that she was nervous and failed to clean the blood glucose monitor and the case.

During an interview on 03/22/16 at 11:35 AM, Staff HHH, RN, stated that she should have cleaned the blood glucose monitor and case after she left the patient's room.

During an interview on 03/22/16 at 11:40 AM, Staff QQ, Assistant Chief Nursing Officer (CNO), stated that she expected the blood glucose monitor and supply case to be cleansed after each patient use.

12. Record review of facility provided document titled, "Lippincott Procedures, Indwelling Urinary Catheter Care and Management," revised 10/02/15, showed facility directive for staff to avoid contamination, to always clean by wiping away from the urinary meatus (external opening where urine exits the body). The urinary catheter bag should not be in contact with the floor to reduce the risk of contamination and a subsequent patient infection.

13. Observation with concurrent interview on five East, on 03/21/16 at 2:45 PM showed Patient #2's urinary catheter bag in contact with the floor (increased risk for the patient to acquire a urinary tract infection). Staff F, RN, performed catheter care for Patient #2. She cleaned the catheter tube by starting approximately three inches from the urinary meatus and washed toward the meatus. She rinsed her cloth in water and cleansed the meatus and then worked back up the tube over what she had just cleaned. Staff F stated that she should not have cleaned from the meatus up the tube because she contaminated what she just cleaned.

14. Observation with concurrent interview on four West, on 03/21/16 at 4:10 PM showed Patient #4's urinary catheter bag in contact with the floor. Staff G, RN, stated that the urinary catheter bag should not have been on the floor.

15. Record review of the facility's policy titled, "Hand Hygiene," dated 10/2015, showed facility directive for staff:
- That gloves were to be used for hand-contaminating activities;
- That gloves should be changed during the care of a single patient when moving from one procedure to another;
- Hand hygiene must be performed:
- Before and after patient contact;
- After contact with a source of microorganisms;
- After removal of gloves;
- When moving from a contaminated body site to a clean body site during
patient care; and
- After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

Record review of the facility's document titled, "Isolation Precautions," dated 05/2015, showed facility directive for staff that gloves shall be changed between tasks and procedures on the same patient.

16. Observation with concurrent interview in the ICU on 03/22/16 at 2:40 PM showed Staff JJ, RT, with gloved hands suctioned Patient #26's tracheostomy (incision in the windpipe made to remove an obstruction for breathing). With the same gloves in place he preceded to administer a medication per aerosol (an enclosed substance placed under pressure which allows release in a fine mist) route. Staff JJ stated that he should have removed his gloves, performed hand hygiene, and put on new gloves before the medication administration.

17. Observation with concurrent interview in Operating Room (OR) #14 with Patient #22, on 03/22/16 at 9:25 AM showed Staff Y, RN, was wearing gloves and was carrying bed pads, which he placed on a cart. He removed his gloves and failed to perform hand hygiene. He stated that he typically sanitizes with foam between glove changes and just forgot.

18. Observation with concurrent interview in the Emergency Department (ED) on 03/22/16 at 3:15 PM showed Staff LL, Physician, in Patient #37's room. He removed his gloves, left the patient's room and walked to the nurse's station. Staff LL failed to perform hand hygiene after he removed his gloves. Staff LL stated that he should have performed hand hygiene after he removed his gloves.

19. Observation on four East on 03/22/16 at 2:55 PM showed Staff TT, RN, entered Patient #29's room and immediately put on a pair of gloves and failed to perform hand hygiene. After he emptied the urinary catheter bag he removed his gloves, touched many inanimate objects, opened the door, exited the room and did not wash his hands until he got to the nurses' station. He failed to perform hand hygiene after his glove removal.

During an interview on 03/22/16 at 3:02 PM, Staff TT, RN, stated that he guessed he didn't perform hand hygiene when he entered the room because he had just exited the same room after he obtained a urine sample and washed his hands when he had finished. He stated that he should have washed his hands immediately after he removed his gloves and shouldn't have waited until he got to the nurses station.

20. Observation on four North on 03/22/16 at 3:05 PM showed Staff UU, RN, in Patient #30's room. Staff UU touched many inanimate objects then put on gloves to assist another nurse to reposition the patient in bed. Staff UU failed to perform hand hygiene after touching the inanimate objects and prior to putting on gloves.

During an interview on 03/22/16 at 3:15 PM, Staff UU, RN, stated that she had performed hand hygiene upon entering the patients' room but didn't think about doing it again prior to putting on gloves but realized now that she should have. She stated that the facility policy directed staff to do hand hygiene before and after glove use.

21. Observation with concurrent interview in the Endoscopy (procedure that looks at the interior of a hollow organ or cavity) Lab scope (instrument used in the Endoscopy procedure) cleaning room, on 03/22/16 at 1:30 PM, Staff GG, Gastrointestinal (GI) Technician, placed a clean scope (not disinfected) into a tub, removed her gloves, and put on new gloves and failed to perform hand hygiene. She took the tub into the adjoining room to prepare the scope for the disinfection process. Staff GG stated that typically, she did not perform hand hygiene when she removed her gloves at that point in her cleaning process.

During an interview on 03/23/16 at 2:00 PM and 3:10 PM, Staff EEE, RN, Infection Prevention/Employee Health, stated that:
- An implanted port site should not be touched after the initial cleaning.
- The staff should wear gown and gloves in contact isolation patient rooms.
- She expected staff to clean and /or disinfect the COW and the blood glucose monitor between patients and if it touched any area of the patient care area.
- Staff should ensure urinary catheter bags were not on the floor and during catheter care staff were expected to start cleaning at the urinary meatus and work outward.
- She expected staff to perform hand hygiene after removal of gloves, after touching the patient and patient environment, and after emptying a urinary catheter bag. She expected staff to change gloves and perform hand hygiene between patient care tasks.









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