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Based on observation, interview, and record review, the hospital failed to ensure infection control standards were implemented and sufficient personal protective equipment (PPE-gowns, gloves, facemasks, goggles worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) were available when:

1. COVID-19 positive patient rooms were not cleaned by the housekeeping staff throughout the duration of the patient's stay in the hospital.
2. Housekeeping carts were inconsistently stocked with proper disinfectants to clean and disinfect the environment.
3. PPE were not readily available in the Emergency Department.
4. Housekeeper (HKS) 1 and Registered Nurse (RN) 1 did not perform hand hygiene after touching contaminated items.

These failures had the potential for transmission of infectious illness or diseases to be spread to patients and staff.

Findings:

1. During an interview on 6/15/20, at 10:48 AM, with Facilities Director (FD), FD stated, "housekeeping staff have not been cleared" to enter COVID-19 positive patient rooms. Acknowledged, COVID-19 positive patient rooms are only cleaned by housekeeping staff when the patient is discharged from the room.

During an interview on 6/15/20, at 10:55 AM, with Infection Preventionist (IP), IP stated housekeepers are not entering rooms to clean rooms, bathrooms, or mopping the floors.

During an interview on 6/18/20, at 3:02 PM, with FD, FD stated it is the hospital's expectation for all occupied patient rooms to be cleaned daily by housekeeping staff, regardless of the patient's diagnosis. FD was unable to provide a policy for cleaning of patient rooms.


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2. During a concurrent observation and interview on 6/15/20, at 9:08 AM, with Housekeeping staff (HSK) 1, in the hallway, the housekeeping cart was observed to contain Quat-Stat 5 (one-step disinfectant) spray bottle and a Sure-Bet 1 (Vermicidal disinfectant) spray bottle. HSK 1 stated she uses the Quat-Stat 5 to disinfect high touched surfaces, and the Sure-Bet 1 is used to clean the toilet bowls and the restrooms.

During a concurrent observation and interview on 6/15/20, at 9:28 AM, with HSK 2, in the Emergency Department (ED), the housekeeping cart was observed to contain a spray bottle of Quat-Stat 5 and Comet (bleached powder cleanser). The housekeeping cart did not have the Sure-Bet 1 disinfectant. HSK 1 stated when she comes to work she picks up the cart and is not aware of the disinfectants and cleansers each cart should have. "I go to my area and start cleaning. I used the Quat-Stat-5 for everything, even in cleaning the restroom."

During a concurrent observation and interview on 6/15/20, at 9:34 AM, with FD, in the ED, FD observed the yellow bucket on the side of the housekeeping cart did not have disinfectant solution. He noted five rags were inside the bucket, and were not soaked in a disinfectant solution. FD acknowledged the bucket was dry and should have been filled with a disinfectant solution, and the rags should be soaked in the solution to achieve proper cleaning and disinfection. FD stated there is a list of what should be in the housekeeping carts for consistency. He acknowledged the housekeeping cart did not have all the necessary chemicals, disinfectants, and solutions needed to clean and disinfect the areas.

During a review of the facility's policy and procedure (P&P) titled, "Guidelines for Infection Control in the Environmental Services Department" dated 1/10/20, the P&P indicated, "Patient Care Areas. . .Wet mop all tile areas with germicidal solution. . .Products Used Surface Cleaner - Quat Stat SC Disinfectant. . .Bathroom Cleaner - Sure Bet Foaming Shower, Restroom Cleaner. . ."

3. During a concurrent observation and interview on 6/15/20, at 10:11 AM, with the ED Director (EDD) and the ED Charge Nurse (EDCN), in the ED, it was noted PPEs were not available in the locations where PPE supplies were kept. Room 8 did not have different sizes of gloves; the PPE cart located by the ambulance area only had one disposable gown, and there were no gloves and face masks available on the cart. EDCN was able to find only one packet of extra-large gowns in the cabinets where the PPEs were stored, no other sizes were found. EDCN attempted to open several cabinets in the room, but was unable to find PPE supplies. EDD acknowledged PPEs were not readily available in the department.

During a review of the facility policy and procedure titled, "COVID-19 Personal Protective Equipment Management" dated 3/24/20, the P&P indicated ". . .We want to ensure that staff have the right protection at the right time to protect all within the company health system."

4. During a concurrent observation and interview, on 6/15/20, at 10:15 AM with HKS 1, in the ED, HKS 1 was observed taking out one trash bag from a patient room and another trash bag from the restroom without gloves on. HSK 1 then put on a pair of gloves without hand hygiene. HKS 1 acknowledged she did not have gloves on when she removed the trash bags, and stated, "I removed my gloves after I cleaned the patient room and the bathroom. I should have washed my hands and put on a new pair of gloves when I took the trash out and then wash my hands again."

During a review of the facility's policy and procedure (P&P) titled, "Guidelines for Infection Control in the Environmental Services Department" dated 1/10/20, the P&P indicated, "Mandatory Use of Gloves During All Cleaning Procedures . . .B. Gloves are to be worn during all cleaning procedures in all patient care areas. C. Gloves are to be changed immediately following cleaning of any unit in a patient care area. . .D. Through (sic) hand washing shall follow removal of gloves after performing any procedure requiring use of gloves. . ."

During a concurrent observation and interview, on 6/15/20, at 10:23 AM, with RN 1, in the hallway of the Surgical Pavilion, (hospital designated COVID-19 area for patients who tested positive) RN 1 was observed coming out of a COVID-19 positive patient room. She removed her gown, her faceshield, and her shoe covers without performing hand hygiene. RN 1 proceeded to wheel her computer cart to the nurses' station and she laid down a biohazard bag with blood filled laboratory blood tubes on the counter. RN 1 acknowledged she had not performed hand hygiene and stated she should have washed her hands.

During a review of the facility policy and procedure (P&P) titled, "Hand Hygiene-CDC Guidelines" dated 12/19, the P&P indicated, "All staff will use hand-hygiene techniques. . .The CDC (Centers for Disease Control) has recommended guidelines on when to use non-antimicrobial soap and water, an antimicrobial soap and water, or alcohol-based hand rub: . . .before each patient encounter. . .after coming in contact with patient's intact skin. . .after coming in contact with bodily fluids. . .leaving an isolation area. . ."