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Based on observation, interview and record review, the facility failed to ensure staff followed their policy and procedure (P&P) for infection control when

1. A staff did not perform hand hygiene (cleaning hands) after removal of soil mask.
2. A staff did not remove a disposable isolation gown after exiting patient's room.
3. A staff did not disinfect (kill germ) medical equipment used after patient's care.

These failure had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact the patient's health and safety and causing preventable spread of hospital acquired infection.

Findings:

1. During an observation, on December 16, 2020, at 9:30 AM, in the holding area outside the fifth Medical Surgical Unit (MSU) an unidentified hospital staff was observed exiting the MSU unit into a holding space area. He removed his surgical (a face mask used in operating rooms) mask from his face, removed his N95 (a respirator type face mask), replaced his used surgical mask onto his face, placed his used N95 mask into the designated brown paper bag, and hung the brown bag on the wall. He exited the unit and did not perform hand hygiene.

During a concurrent observation and interview, on December 16, 2020, at 9:33 AM, with the Infection Control Preventionist (ICP), an unidentified hospital staff was observed in the holding area outside the fifth floor MSU. The ICP agreed, a staff did not perform hand hygiene after removing his used masks. Thge ICP stated, everyone should perform hand hygiene after touching soil personal protective equipment (PPE).

During a review of the facility's Policy and Procedure (P&P) titled, "Infection Prevention: Interim Infection Control Guidance for Confirmed or Persons-Under-Investigation (PUI) for Novel Coronavirus 2019 (COVID-19)," effective date August 31, 2020, the P&P indicated

" ...Policy and/or Procedure ...
9. Hand Hygiene
a. Hand hygiene should be performed before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves.
b. Hand hygiene should be performed by using alcohol based hand sanitizer with 60-95% alcohol base or using soap and water for at least 20 seconds. If hands are visibly soiled, used soap and water before an alcohol based hand sanitizer ..."

2. During an observation, on December 16, 2020, at 9:50 AM, in the hallway of the fifth floor MSU, a Laboratory Technician (LT 1) was observed walking in the hallway while wearing a blue disposable isolation gown. LT 1 stopped in front of a patient's room and talked to an unidentified staff. She entered the patient's room with her supplies. She exited the patient's room and walked out to the hallway wearing the same blue disposable gown. The ICP pulled her over and talked to her. LT 1 proceeded to exit the hallway.

During a concurrent observation and interview, on December 16, 2020, at 2:23 PM, with the ICP, LT 1 was observed in the hallway of the fifth floor MSU. The ICP stated, she already had a conversation and educated LT 1. The ICP agreed, LT 1 should not be wearing an isolation gown outside the patient's room. She stated, LT 1 should have removed the isolation gown after she finished with the patient's care, it was an "education fell off."

During a review of the facility's P&P titled, "Infection Prevention: Isolation Precautions-General Infection Control," effective date December 2, 2020, the P&P indicated the following:

" ...2.0 Standard Precautions ...
2.3 Personal protective equipment (PPE)
2.3.6.1 Wear a gown, that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and patient-care activities when contact with blood, body fluids, secretions, or excretions is anticipated.
2.3.6.2 Gowns are always worn in combination with other PPE.
2.3.6.3 Wear a gown for direct patient contact if the patient has uncontained secretions or excretions.
2.3.6.4 Remove gown and perform hand hygiene before leaving the patient's environment ..."

3. During an observation, on December 16, 2020, at 10:00 AM, in the fifth floor Telemetry Unit, a Registered Nurse (RN 1) was observed exiting a patient's room, pushed the computer on wheels (COW), and sat down at the nursing station. She did not disinfect her COW after exiting the patient's room.

During a concurrent observation and interview, on December 16, 2020, at 10:05 AM, with the ICP, the fifth floor Telemetry Unit (TU) was observed to not have disinfectant wipes readily available to be used. The ICP agreed, there was no disinfectant wipes readily available and staff should use them to clean their equipment and the COW after each patient encounter.

During a concurrent observation and interview, on December 16, 2020, at 10:10 AM, with Registered Nurse 1 (RN 1) and the ICP, the nursing station and the supply room were observed. RN 1 was unable to provide any disinfectant wipes that were readily available to be used. RN 1 stated, she knew the unit was in short supply this morning, they might have "just ran out." She further stated, she did not disinfect her COW after she finished her patient's care.

During a follow-up interview, on December 16, 2020, at 10:15 AM, with the ICP, the ICP stated, RN 1 should disinfect her COW after patient care and the disinfect wipes should always be readily available in the unit for frequent use.

During a review of the facility's P&P titled, "Infection Prevention: Patient Care Equipment: Cleaning of," effective date February 5, 2020, the P&P indicated

" ...Policy and/or Procedure
1. All patient care equipment should be cleaned between patients using hospital approved germicidal disinfectant cleaner per manufacturer recommendations ..."