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Based on observation, document review, and interview it was determined that the Hospital failed to ensure prevention, control, reporting, and investigation of infections and communicable diseases. Therefore, the Condition of Participation 42 CFR 482.42, Infection Control, was not met.

Findings include:

1. The Hospital's Infection Control officers failed to ensure the development and implementation of policies and procedures, which would restrict traffic into the milk preparation room. See A-0748

2. The Hospital Administration and Infection Control Officer(s) failed to report an identified cluster of an Illinois's Reportable Disease in the appropriate time frame. See A-0749 A

3. The Hospital failed to ensure proper hand washing was conducted. See A-0749 B

4. The Hospital failed to ensure the proper labeling, storage and disposal of patient milk products. See A-0749 C

5. The Hospital failed to have a system in place to identify and track patient milk products being used in the Hospital. See A-0749 D

6. The Hospital failed to ensure the Laminar Flow Hoods and the Milk Preparation room were monitored for compliance with daily cleaning requirements. See A-0749 E

7. The Hospital failed to ensure the proper utilization and maintenance of the "Nutritional Refrigerator". See A-0749 F

8. The Hospital failed to ensure staff followed infection control polices. See A-0749 G

9. The Hospital failed to ensure Contact Isolation was initiated in a timely manner. See A-0749 H

10. The Hospital failed to ensure competency records were complete and accurate. See A-0756

Based on observation, document review, and interview, it was determined for 1 of 1 NICU's (Neonatal Intensive Care Unit) milk preparation room, the Hospital's Infection Control officers failed to ensure the development and implementation of adequate policies and procedures, which would restrict traffic into the milk preparation room to decrease the potential of cross contamination. This has the potential to affect all patients serviced on the NICU.

Findings Include:

1. On 11/14/18 at 1:00 PM an observational tour of the NICU milk preparation room with the NICU Clinical Educator (E #14) was conducted. The milk preparation room contained a Laminar Airflow Hood (The hood provides an additional barrier to potential contaminants). The milk room lacked any signs or notifications which restricted traffic into the milk preparation room, while feedings are prepared.

2. On 11/14/18 at 5:00 PM the document titled "AIREGARD ES Energy Saver Horizontal Laminar Flow Clean Workstation" manufactures guidelines required that "6.2.1 D. Minimize Room Activity-Activity in the room itself should be held to a minimum. Unnecessary activity may cause disruptive air currents...

3. On 11/14/18 a policy for the NICU milk preparation room was requested. On 11/14/18 at 5:05 PM the document provided by the Hospital as a policy titled, "Guidelines for Preparation of Human Milk and Formula in Health Care Facilities" (no date) was reviewed. The document required that, "Physical Facilities...has the appropriate physical separation from direct patient care...must facilitate work flow that supports aseptic technique in feeding preparation...Feeding preparation and storage areas should be securable to prevent adulteration of formula, human milk, and supplies, and to control traffic of unauthorized individuals through the room(s). "

4. On 11/14/18 a policy for the NICU formula and milk preparation was requested. On 11/14/18 at 5:10 PM the document provided by the Hospital as a policy titled, "Formula Preparation and Handling" was reviewed. The document required that, "Preparation in the Infant Feeding Preparation Room...Formula and feeding containers should be handled under aseptic technique and locations where there is little risk of contamination with pathogenic microorganisms or undesirable environmental substances...During the time designated for preparation of formula for infants, no other activity should be permitted."

5. During an interview conducted with E #16 on 11/14/18 at 1:00 PM, E #14 confirmed that there were no signs posted or process to notify individuals about restricted traffic into the milk preparation room. E #16 stated that all staff on the NICU have access to the milk preparation room.

6. During an interview conducted with the Manager of Quality and Safety-Pharmacist (E #5) on 11/14/18 at 2:00 PM, E #5 stated that the doors of the milk preparation room needs be be closed as much as possible, in order to reduce air movement and the potential for increased air contaminants.

A. Based on document review and interview, it was determined in 4 of 4 (Pt #1, Pt #2, Pt #3, and Pt #4) patient's records reviewed, the Hospital Administration and Infection Control Officer(s) failed to report an identified cluster of an Illinois-Reportable Disease (Salmonella-enterobacteria that causes disease in humans and causes food poisoning, gastrointestinal inflammation, or body sepsis/infection) to the local Health Department in the appropriate time frame. This has the potential to affect all patients being served at the Hospital. This has the potential to affect all patients, staff and visitors.

Findings include:

1. On 11/7/18-11/8/18 Pt #1's clinical record was reviewed. Pt #1 was admitted on 10/02/18 to the Neonatal Intensive Care Unit (NICU). Pt #1's "Progress Note" indicated that on 10/13/18 at 4:45 PM Pt #1 was reported as having a seedy yellow stool with a moderate amount of bloody mucous, apnea, (altered breathing) and bradycardia (low heart rate). A blood culture was ordered and the results came back as no growth on 10/18/18 at 7:00 PM. Pt #1 continued to have bradycardia and apnea (possible indicators of sepsis-body infection) and Pt #1 had another blood culture drawn on 10/15/18 at 11:07 AM. GRAM STAIN results on 10/16/18 at 5:21 AM indicated the results of the blood culture drawn on 10/15/18 positive at 16 hours 14 min-Gram Negative Bacilli (positive for bacteria). On 10/17/18 at 3:41 PM CULTURE RESULTS Salmonella group PRESUMPTIVE IDENTIFICATION. On 10/18/18 at 9:22 AM CULTURE RESULTS Salmonella group SENT TO THE DEPARTMENT OF PUBLIC HEALTH FOR FURTHER TESTING. On 11/8/18 at 3:29 PM CULTURE RESULTS Salmonella confirmed by IDPH as Salmonella Agbeni.

2. On 11/07/18-11/14/18 Pt #2's clinical record was reviewed. Pt #2 was admitted on 9/24/18 to the NIC (Neonatal Intermediate Care). Pt #2's "Progress Note" on 10/14/18 indicated Pt #2 began experiencing bradycardia/apnea and had blood cultures drawn on 10/14/18 at 1:31 AM to rule out sepsis. GRAM STAIN results on 10/14/18 at 2:10 PM indicated positive after 11 hours and 11 min-Gram Negative Bacilli. On 10/16/18 at 7:09 AM CULTURE RESULTS Presumptive Salmonella species SENT TO THE DEPARTMENT OF PUBLIC HEALTH FOR FURTHER TESTING. On 11/8/18 AT 3:27 PM CULTURE RESULTS Salmonella confirmed by IDPH as Salmonella Agbeni.

3. On 11/07/18-11/14/18 Pt #3's clinical record was reviewed. Pt #3 was admitted 8/19/18 to NICU. Pt #3's "Progress Note" on 10/14/18 indicated Pt #3 began experiencing bradycardia/apnea and had blood cultures drawn on 10/14/18 at 3:51 PM to rule out sepsis. GRAM STAIN results on 10/15/18 at 3:00 AM indicated positive after 10 hours and 5 minutes-Gram Negative Bacilli. On 10/16/18 at 11:02 AM CULTURE RESULTS Presumptive Salmonella species. On 10/16/18 at 3:17 PM CULTURE RESULTS Presumptive Salmonella Species SENT TO THE DEPARTMENT OF PUBLIC HEALTH FOR FURTHER TESTING. On 10/25/18 AT 3:43 PM CULTURE RESULTS Identified as Salmonella Agbeni by IDPH.

4. On 11/7/18-11/14/18 Pt #4's clinical record was reviewed. Pt #4 was admitted 9/30/18 to the NICU. Pt # 4's "Progress Note" on 10/14/18 indicated Pt #4 began experiencing bradycardia/apnea and had blood cultures drawn on 10/14/18 at 8:17 PM to rule out sepsis. GRAM STAIN results on 10/15/18 at 10:35 AM indicated positive after 10 hours and 10 minutes-Gram Negative Bacilli. On 10/16/18 at 11:02 AM CULTURE RESULTS Presumptive Salmonella species. On 10/16/18 at 3:20 PM CULTURE RESULTS Presumptive Salmonella species SENT TO THE DEPARTMENT OF PUBLIC HEALTH FOR FURTHER TESTING. On 10/25/18 at 3:41 PM CULTURE RESULTS Identified as Salmonella Agbeni by IDPH.

5. The policy titled "Notification of IDPH (Illinois Department of Public Health) Reportable Diseases (revised 5/21/18) was reviewed on 11/13/18 at approximately 1:00 PM. The attachment: "Illinois Reportable Diseases" (effective 5/1/16) requires "Any unusual case or cluster of cases that may indicate a public health hazard (immediate)*
*For reporting purposes, "immediate" means as soon as possible within three hours.

6. On 11/13/18 at 9:00 AM-10:30 AM, an interview was conducted with the Laboratory Scientist (E#15) and the Infection Preventionist (E#10) concerning the timeline related to the four positive Salmonella Agbeni results for Pt #1, Pt #2, Pt #3, and Pt #4.

a. E#15 stated that on 10/16/18 at 7:04 AM the lab notified the APN (Advanced Practice Nurse)(E#20) on the NICU of the blood culture results of "Preliminary Presumptive Salmonella" on Patient #2, who was in the NIC (Neonatal Intermediate Care). E#15 then stated that the Lab had notified NICU Registered Nurse (RN)(E#22) on 10/16/18 at 11:02 AM that Pt #3 and Pt #4 had positive blood culture results of "Preliminary Presumptive Salmonella" E #15 stated that those results were automatically electronically sent to the IDPH Infectious Disease lab.

b. E#10 stated that on the morning of 10/16/18, E#10 was reviewing lab work and noticed the "Preliminary Presumptive Salmonella report" on Pt #2. E#10 then sent an email to the NICU Manager (E#21) and the Medical Director of the NICU (E#6) at 10:56 AM, advising them of this lab and also that a patient chart review would be completed. E#10 then went to the NICU and learned thru a discussion with E#20 and the NICU Manager (E#21) that 2 more patients (Pt #3 and Pt #4) on the NICU had symptoms of bradycardia and apnea on 10/14/18 and blood cultures were drawn to rule out sepsis. E#10 stated, "A potential cluster for Preliminary Presumptive Salmonella was identified. I wanted to make sure our findings supported a true cluster, so an investigation was done and was not completed until 10/17/18, at which time I notified the local Health Department by phone, of the cluster of three Preliminary Presumptive Salmonella cases. I provided the names and date of birth of the patients involved. Notification of a possible 4th case was also reported at this time. E #10 stated, "We determine a cluster as 2 unusual organisms within a short time frame, for example, 2 cases within 2 weeks that have an unknown source."


B. Based on observation, document review, and interview, it was determined for 1 of 1 NICU (Neonatal Intensive Care Unit)/NIC (Neonatal Intermediate Care), the Hospital failed to ensure proper hand washing was conducted to reduce the potential for cross contamination. This has the potential to affect all patients, staff and visitors.

Findings include:

1. On 11/07/18 at 12:45 PM, during an observational tour of the NICU with the NICU Clinical Educator (E #14), a Hospital housekeeper (E #25) left the NIC wearing a pair of gloves and pushing a cleaning cart. E #25 then entered the NICU, removed the gloves, donned a new pair of gloves and entered a NICU patient room, without the benefit of performing hand hygiene.

2. During an interview conducted with E #14 on 11/07/18 at 12:50 PM, E #14 stated that E #25 should have removed the gloves and performed hand hygiene after leaving the NIC and before entering the NICU.

3. On 11/14/18 at 2:54 PM during an observational tour of the NICU with the Quality Improvement Specialist (E #19), a RN (E#38) exited room #327 and proceeded to enter room #321, without the benefit of performing hand hygiene.

4. During an interview conducted with E#19 on 11/14/18 at 3:10 PM, E #19 stated, "I saw that as well, (E#38) should have done hand hygiene before entering room #321 patient's room."

5. The policy titled, "Hand Hygiene" (revised 7/30/18) was reviewed on 11/8/18 at 1:00 PM. Policy noted,"9. Hand hygiene is to be routinely performed in the following circumstances: b. Before and after each patient encounter (entering and exiting of patient care area, i.e. patient room)."

6. On 11/14/18 at 1:00 PM during an observation tour of the NICU with Clinical Educator (E #16), the NICU hand washing entry area contained a sink for hand washing. Two eight inch by ten inch signs titled "Scrubbing Instructions" were posted above the sink that gave instructions on how to wash hands. The area lacked any signs/postings which directed family, staff, and visitors to wash their hands before entry into the NICU.

7. On 11/14/18 at 1:15 PM, during an observation tour of the NICU with E #16, a visitor entered the NICU hand washing entry area and proceeded to enter room #312 without the benefit of washing their hands, or performing the required 2 minute scrub. E #16 confirmed that the visitor should have performed the 2 minute scrub before entering the NICU and a patient's room.

8. On 11/14/18 at 2:00 PM, the document titled "Neonatal Intensive Care Family Orientation" (no date) required, "Thoroughly scrub-in (Full two minutes)...Use hand sanitizer frequently..."

9. On 11/14/18 at 2:05 PM, the Facility policy titled "Hand Hygiene, Neonatal" (Reviewed 8/17/18) required, "Perform Hand hygiene routinely and thoroughly before entering the NICU..."

10. On 11/14/18 at 2:10 PM, the Facility policy titled "Visitor Management, Neonatal" (Revised 3/06/18) required, "Staff members are also responsible for protecting the neonate from safety risk, including infection..."

11. During an interview conducted on 11/14/18 at 1:50 PM, E #16 stated that the expectation is that everyone whom enters the NICU must wash their hands. E #16 confirmed that there were no signs instructing and directing individuals whom enters the NICU to wash their hands.


C. Based on observation, document review, and interview, it was determined for 1 of 1 NICU (Neonatal Intensive Care Unit), the Hospital failed to ensure the proper labeling, storage and disposal of patient milk products to mitigate the risks associated with infections. This has the potential to affect all patients serviced on the NICU.

Finding include:

1. On 11/14/18 at 2:30 PM, an observational tour of the NICU was conducted with Clinical Educator (E #16). In empty room #348, three syringes of a white substance were left unattended from 2:30 PM-2:40 PM. At 2:40 PM, E#16 placed the syringes of fluids into a patient refrigerator.

2. On 11/14/18 at 2:42 PM, E #16 stated that a baby from another unit was transferring to Room #348 and the three syringes contained milk, which staff had moved into Room #348 in anticipation of the move. E #16 stated that the syringes should not have been left unattended and should have been refrigerated.

3. On 11/14/18 at 2:45 PM during an observation tour of the NICU with E #16, unoccupied Room #325 contained an unattended 60 milliliter (ml) baby bottle of similac formula with approximately 45 milliliters of fluid left in it. The bottle lacked patient name, patient location, staff initials, and time and date of opening.

4. During an interview conducted with E #16 on 11/14/18 at 2:50 PM, E #16 stated that the bottle of formula should have included patient/baby's name, when opened, should not have been unattended, and should have been discarded after use.

5. On 11/14/18 at 4:00 PM the document (provided by the Hospital as a policy) titled, "Guidelines for Preparation of Human Milk and Formula in Health Care Facilities" (no date) required that, "Chapter 5. Formula Preparation and Handling. Each unit of prepared human milk or formula must have a label that includes the following items: a. patient name...patient location...and "refrigerate until use."

6. On 11/14/18 at 4:00 PM the document (provided by the Hospital as a policy) titled, "Delivery and Bedside Management of Infant Feedings" (no date) required that, "To avoid possible tampering or contamination, all formulas and expressed human milk, as well as, feeding additives and supplies, should be stored on the patient unit in either a secure area or an area with limited access."

7. On 11/14/18 at 4:00 PM the policy titled, "Breast Milk: Management and Administration" (Reviewed 8/18) required that, "Breast milk...Milk is never to be left at an infants bedside without the bedside RN (Registered Nurse) performing verification of the correct milk and correct infant."

8. On 11/14/18 at 3:27 PM an observation tour of the NICU Feather Neighborhood with the Clinical Educator (E#16) was conducted. The parent of Pt #12 brought 2 bottles of pumped breast milk to RN (E#39). E#39 took the 2 bottles of breast milk to the patient refrigerator and placed the 2 bottles of breast milk into the refrigerator without the benefit of wiping the two bottle of breast milk down prior to placing into the patient refrigerator.

9. On 11/14/18 at approximately 4:30 PM the policy titled, "Breast Milk: Management and Administration" (reviewed 8/18) was reviewed. Policy required that, " Staff Receiving Milk" 7. Wipe the container with a hospital approved disinfectant after receiving milk from parent."

10. On 11/14/18 at 3:00 PM an interview was conducted with the parent of Pt #13. The parent stated, "After I pump the staff takes the breast milk to put in the refrigerator, they do not wipe the bottles off before leaving our room."

11. On 11/14/18 at 3:10 PM an interview was conducted with E#16. E#16 stated, "Our policy is not being followed, the wipes are in the patient rooms and the expectation is the bottles of breast milk are to be wiped before leaving the patients room."


D. Based on document review and interview, it was determined that the Hospital failed to have a system in place to identify and track milk products being used in the Hospital NICU (Neonatal Intensive Care Unit)/NIC (Neonatal Intermediate Care). This has the potential to affect all patients serviced on the NICU/NIC.

Findings include:

1. The policy titled "Breast Milk: Management and Administration" (reviewed 8/2018) was reviewed on 11/14/18 at approximately 4:45 PM. The policy noted, "36. Upon delivery of the feeding to the bedside, a two person dual check will occur verifying that the generic/non-barcode label matches the EMR (Electronic Medical Record) barcode label (verify name and CNS). 38. Order is verified in EHR with the administration window open in the MAR (Medication Administration Record). Staff member then scan's his/her name badge, or "clicks" Accept. The documentation of the delivery of the feeding is now complete."

2. During an interview with the Clinical Educator (E#16) on 11/14/18 at 3:45 PM, E#16 stated that there is not a process in place to identify which exact milk product was given to an infant. E#16 stated that we scan the label barcode on the milk product prepared for the infant, to insure the right milk product goes to the right infant, after two people have identified the correct infant. Our system does not allow us to track the Lot # or expiration date of the milk product.


E. Based on document request and interview, it was determined in 1 of 1 Milk Preparation Room, the Hospital failed to ensure the Laminar Flow Hoods and the Milk Preparation room were monitored for compliance with daily cleaning requirements. This has the potential to affect all patients, staff, and visitors.

Findings include:

1. A request was made on 11/14/18 for the daily cleaning logs for the Laminar Flow Hoods and the Milk Preparation Room in the NICU (Neonatal Intensive Care Unit).

2. During an interview conducted with the Quality Improvement Specialist (E#19) on 11/14/18 at approximately 5:00 PM, E#19 stated, "We do not have daily logs for cleaning of the Laminar Flow Hoods or daily cleaning of the Milk Preparation Room, as this is part of the Patient Care Technicians (PCT's) daily routine, and it is expected."


F. Based on observation, document review, and interview, it was determined the Hospital failed to ensure the proper utilization and maintenance of the "Nutritional Refrigerator" to mitigate the risks associated with infections. This has the potential to affect all patient, staff, and visitors.

Findings include:

1. On 11/14/18 at 2:45 PM an observation tour of the NICU (Neonatal Intensive Care Unit) Feather Neighborhood and the Leaf Neighborhood (ICU sub-units) with Clinical Educator (E #16) was conducted. The unit contained a "Nutritional Refrigerator", which was used for patient's nutritional supplies.

2. On 11/14/18 at 4:15 PM, the documents titled, "Nutrition Refrigerator Temperature Logs-Feather Unit-NICU and Leaf Unit-NICU" were reviewed. The documents required that, "Acceptable Temperature Range 35 degrees-41 degrees F (Fahrenheit) ... If temperature(s) outside of acceptable range, document corrective action on the back of form. Recheck temperature later in the shift and document the corrected temperature on the back of the form." The documents indicated that on November 8, 2018 the Feather Neighborhood's refrigerator temperature was 34 degrees and on November 9, 2018 the refrigerator temperature was 34 degrees. The documents indicated that on November 7, 2018, the Leaf Neighborhood's refrigerator temperature was 32 degrees, on November 8, 2018 the refrigerator temperature was 32 degrees, and on November 9, 2018 the refrigerator temperature was 32 degrees. The documents lacked any corrective measures or temperature re-checks for the abnormal NICU refrigerator temperatures.

3. During an interview conducted with E #16 on 11/14/18 at 3:45 PM, E #16 confirmed the abnormal refrigerator temps for the NICU Feather Neighborhood and the Leaf Neighborhood (ICU sub-units) refrigerators.

4. On 11/14/18 at 3:00 PM during an observational tour of the NICU Leaf Neighborhood with E#16, the unit's refrigerator's freezer contained a lunch bag with a label stating "305". The bag lacked a patient label/sticker.

5. The policy titled "Food - Nutrition Floorstock Ordering" (revised 1/17/18) was reviewed on 11/14/18 at 4:30 PM. Policy noted, "6. c Food that is not labeled is discarded immediately. 7. ...If food is brought in from outside the facility for the patient and has not been in the patient room, the food may be placed in the patient refrigerator following this same process. a. Place item in a brown paper bag to avoid contamination of the clean items in the refrigerator. b. Label with a patient label/sticker."

6. During an interview conducted with E#16 on 11/14/18 at 3:10 PM, E#16 stated, "The bag is not labeled with the patient label, and we have no way to identify the owner of the bag. The bag should not be in the freezer."


G. Based on observation, document review and interview, it was determined in 1 of 1 Labor and Delivery Operating Room observed, the Hospital failed to ensure staff donned proper Personal Protective Equipment (PPE) to mitigate the risks associated with infections. This has the potential to affect all patients staff and visitors.

Findings include:

1. On 11/8/18 at 11:45 AM, Anesthesiologist (E# 18) entered the Labor and Delivery Operating Room #2 in street shoes, without PPE, (shoe covers).

2. The policy titled, "Dress Code for Surgical Areas" (revised 10/2/18) was reviewed on 11/8/18 at approximately 4:00 PM. Policy noted, "4. b. Shoe covers are worn in the following situations: i. When shoes are not dedicated to procedural area."

3. During an interview conducted with the Assistant Manager of Labor and Delivery (E#17) on 11/8/18 at 11:55 AM, E#17 stated, "Shoe covers should have been worn, the shoes worn by the Anesthesiologist were not dedicated shoes."


H. Based on document review and interview, it was determined for 2 of 4 (Pt #2, Pt #3) patients in contact isolation, the Hospital failed to ensure contact isolation was initiated in a timely manner. This has the potential to affect all patients, staff, and visitors.

Findings include:

1. A chart review was conducted on 11/13/18 at approximately 8 AM - 9:30 AM on NICU Pt #1. An order was entered for Pt #1 to be placed in contact isolation on 10/16/18 at 1:21 PM. Nursing documentation indicated the contact precautions were initiated on 10/16/18 at 8:45 PM, approximately 7.5 hours after the receipt of the physician's order.

2. A chart review was conducted on 11/13/18 at approximately 10 AM - 11:30 AM on NICU Patient #3. An order was entered for Pt #3 to be placed in contact isolation on 10/16/18 at 12:02 PM. Nursing documentation indicated the contact precautions were initiated at 8:49 PM, approximately 9 hours after the receipt of the physician's order.

3. During an interview conducted with Clinical Educator (E#16) on 11/8/18 at approximately 1:25 PM, E#16 stated, "The expectation is once the isolation order is received, the isolation precautions should be initiated within an hour."

Based on observation, document review, and interview, it was determined in 11 of 11 (E#27, E #28, E#29, E #30, E #31, E #32, E #33, E #34, E#35, E #36, and E #37) NICU (Neonatal Intensive Care Unit)/NIC (Neonatal Intermediate Care) Patient Care Technician's (PCTs) personnel files reviewed, the Hospital failed to ensure competency records were complete and accurate. This has the potential to affect all patients serviced on the NICU/NIC.

Findings include:

1. On 11/14/18 at 1:00 PM an observational tour of the NICU milk preparation room with the NICU Clinical Educator (E #14) was conducted. The milk preparation room contained a Laminar Airflow Hood (The hood provides an additional barrier to potential contaminants)

2. On 11/14/18 the NICU/NIC PCT's E # 27-E #33's competencies files were reviewed. The competency evaluations titled, "Competency Tool-Demonstrates ability to prepare mixed breast milk and mixed formulas (PCT)" lacked the complete date and/or year the competencies were completed.

3. On 11/14/18 the NICU/NIC PCT's competencies files were reviewed for E #34, E#35, E #36, and E #37. The competencies checklist lacked any competency evaluations for the use and cleaning of the milk preparations rooms Laminar Airflow Hood (The hood provides an additional barrier to potential contaminants) and the complete date the checklists were completed.

4. On 11/14/18 at 5:00 PM the document titled "AIREGARD ES Energy Saver Horizontal Laminar Flow Clean Workstation" manufactures guidelines required that " Protects the product from contamination... Ergonomics- an evaluation of normal work practices is extremely important for proper workstation usage...An evaluation of normal work practices should be performed with each user".

5. On 11/14/18, the policy titled "Competencies" was reviewed. The policy required that, "Staff competencies are reported to the board...Competency assessment occurs on a continuum...includes assessment upon hire, initial competencies during the orientation period and on-going...During orientation, each staff member completes specific competency assessments required for his/her position... In addition to external agency requirements area specific-competencies are identified annually for validation at the department level".

6. During an interview conducted with E #14 on 11/14/18 at 1:00 PM, E #16 confirmed that NICU/NIC PCTs are responsible for milk preparation and cleaning of the milk preparation room and it's equipment. The PCTs competencies are only done during initial hire orientation.