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Based on observation, interview, record review and policy review, the facility failed to:
- Terminally clean (detailed cleaning to ensure complete elimination of all pathogens from the environment) the Operating Room (OR) sterile processing clean and dirty rooms (rooms used to process instruments used in all operating room suites).
- Maintain a clean environment during a colonoscopy (a long flexible tube inserted into the rectum to detect abnormalities in the large intestine and rectum).
- Perform hand hygiene (use of alcohol foam products or use of soap and water), after inanimate objects were handled in one patient's (#15) room, and before a pill was handled with bare, contaminated hands, cut in half, and administered to one patient (#15) of three patients observed that received oral medications.
- Perform hand hygiene and glove changes after inanimate objects were handled in three patients' (#16, #17, and #18) rooms, and before blood glucose (sugar) testing was performed on three patients observed that received blood glucose testing.
- Label intravenous (IV, a plastic tube placed into the vein so medication and/or fluid can be administered) tubing, as directed in the facility policy, with the date and time of tubing change for two patients (#2 and #18) of seven patients observed with IVs.
- Label peripheral (away from the center of the body) IV sites, as directed in the facility policy, for four patients (#8, #16, #17, and #18) of seven patients observed with IVs.
These failed practices had the potential to expose all patients, visitors and staff to cross contamination and increase the potential to spread infection. The facility census was 12 .

Findings included:

1. Review of the Association of Operating Room Nurses (AORN) and the Association for the Advancement of Medical Instrumentation (AAMI) of the cleaning of the sterile processing rooms dated 02/10/16, showed the recommendation to terminally clean the sterile processing rooms daily the same as the operating, delivery and invasive procedure rooms. AAMI also stated that the sterilizer's water hardness and discoloration can affect the purity of the steam used and can carry over excessive chemicals into the steam used for sterilization.

Review of the facility's policy titled, "Best Practices for Packaging for Sterile Processing," dated 02/25/16, showed the directive for staff to use AORN and AAMI recommended practices for packaging and sterilizers.

Review of the facility's policy titled, "Infection Control in the Surgery Area," reviewed 02/27/18, showed the directive for staff that terminal cleaning should be performed at the end of the day's schedule.

Observation on 02/13/19 at 10:05 AM, in the OR Sterile Processing Clean room showed:
- Multiple paper (particle shedding) products on the walls;
- Personal cell phone (contaminated object) next to the wrapping table; and
- Multiple paper products on the tables next to the wrapping table.

2. Observation on 02/13/19 at 10:15 AM in the Sterile Processing Dirty room showed a layer of discolored residue on the drain and dirt on the floor to the left of the washer.

During an interview on 02/13/19 at 1:32 PM, Staff DD, Materials Management Manager, stated that:
- She expected housekeeping to terminally clean the sterile processing areas.
- She was unaware of the multiple paper products in the room.
- Cell phones should not be in the sterile processing area.
- There was no cleaning log for these areas.

During an interview on 02/13/19 at 1:45 PM, Staff EE, Environmental Service Manager, stated that as far as he knew, the housekeepers performed daily cleaning in the sterile processing areas.

During an interview on 02/13/19 at 2:30 PM, Staff GG, Infection Control and Employee Health Specialist, stated that the sterile processing rooms should be minimally stocked to ensure thorough terminal cleaning.

3. Review of the facility's policy titled, "Sterilizer, Cart and Area Cleaning," dated 11/28/18, showed that routine cleaning of the sterilizers must be made to decontaminate, eliminating microorganism (organisms, such as bacteria, too small for the naked eye) growth and keep maximum cleaning effectiveness. The inside of the sterilizer should be cleaned with mild detergent when cooled every quarter, or as needed.

Review of the manufacturer cleaning recommendations for the steam sterilizer, showed that the inside of the chamber should be cleaned with mild detergent as needed and professionally cleaned yearly to maintain a peak operating condition.

Observation on 02/13/19 at 2:10 PM in the OR sterile processing area, showed brown discoloration on the rim inside the sterilizer, around the door opening, .

During an interview on 02/13/19 at 2:20 PM, Staff DD, Materials Management Manager, stated that she was unaware of the brown discoloration in the sterilizer.

4. Review of the facility policy titled, "Hand Hygiene," revised 05/24/17, showed staff were to perform hand hygiene:
- Whenever hands were visibly soiled.
- Before having direct contact with patients or their immediate surroundings.
- After contact with a patient's immediate surroundings.
- Before putting on gloves.
- To reduce facility-acquired infections in the patient population.

Review of the facility's policy titled, "Colonoscopy and Flexible Sigmoidoscopy," showed that during a colonoscopy, clean gloves should be worn throughout the procedure.

Observation on 02/12/19 at 9:00 AM, showed Staff Q, Certified Nurse Anesthetist (CRNA), during a colonoscopy, performed the following:
- Performed Hand hygiene;
- Touched the patient multiple times;
- Touched the bed;
- Retrieved medication out of cart;
- Injected medication into the patient's intravenous catheter;
- Touched the patient;
- Touched the monitor screen; and
- Touched the patient.
Throughout the procedure, Staff Q failed to wear gloves per facility policy.

During an interview on 02/12/19 at 9:30 AM, Staff Q, stated that she felt that the use of hand sanitizer was sufficient.

During an interview on 02/12/19 at 9:40 AM, Staff M, Registered Nurse for the Gastrointestinal (GI, pertaining to the stomach and intestines) procedures, stated that some of the CRNAs wore gloves and some did not wear gloves during the colonoscopies.

During an interview on 02/12/19 at 9:50 AM, Staff C, Manager of the GI and Pain Clinic, stated that Staff Q should have worn gloves during the colonoscopy.

During an interview on 02/13/19 at 2:30 PM, Staff GG, Infection Control and Employee Health Specialist, stated that Staff Q contaminated the procedure and should have worn gloves.

5. Observation on 02/12/19 at 9:15 AM, showed the following:
- Staff K, Registered Nurse (RN), opened multiple medication packages, touched the patient's bedding, touched the blood pressure monitor, tubing, blood pressure cuff, and computer scanner.
- Staff K opened a medication called Amiodarone (a medication used to treat an irregular heart beat), picked up the pill bare-handed, failed to perform hand hygiene, and placed it into a pill cutter.
- Staff K cut the pill in half and took the pill out of the cutter, bare-handed, and administered the contaminated pill to the patient.
- Staff K failed to perform hand hygiene after the patient's immediate surroundings were touched.

During an interview on 02/13/19 at 11:18 AM, Staff E, RN, Medical-Surgical and Intensive Care Unit Manager and Inpatient Services Director, stated that he expected staff to perform hand hygiene before pills were handled.

During an interview on 02/13/19 at 2:31 PM, Staff GG, RN, Infection Control and Employee Health Specialist, stated that she expected staff to re-arrange their tasks to eliminate contamination of gloves/hands before pills were handled.

6. Observations on 02/12/19 at 11:00 AM, 11:09 AM, and 11:20 AM, showed that Staff U, Certified Nurse's Assistant (CNA), donned gloves, touched inanimate objects, obtained blood samples from three patients' (#16, #17, and #18) fingers, conducted blood glucose tests, and failed to perform hand hygiene and change gloves after the patients' immediate surroundings were touched and before patient care was provided.

During an interview on 02/13/19 at 2:10 PM, Staff U, CNA, stated that she was not taught to perform hand hygiene and change gloves after she touched inanimate objects and before she performed patient care.

During an interview on 02/13/19 at 1:57 PM, Staff E, RN, Medical-Surgical and Intensive Care Unit (ICU, an area whereby patients are more critically ill, requiring more intensive treatment and/or monitoring) Manager and Inpatient Services Director, stated that when staff performed blood glucose tests, he expected staff to perform hand hygiene and change gloves after contact with inanimate objects and before patient care was provided.

During an interview on 02/13/19 at 2:32 PM, Staff GG, RN, Infection Control and Employee Health Specialist, stated that staff should perform hand hygiene and change gloves after inanimate objects were touched and before patient care was provided.

7. Review of the facility policy titled, "Intravenous Access & Management," revised 06/11/18, showed:
- IV tubing should be changed every four days, or whenever the IV site was changed.
- Staff should label IV tubing with the date and time to be changed.
- IV sites should be labeled.

Observations on 02/12/19 at 9:02 AM, 11:00 AM, 11:09 AM, and 11:20 AM, showed that four patients (#8, #16, #17, and #18) had IV sites that were not labeled as directed by the facility policy.

Observation on 02/12/19 at 11:20 AM showed that Patient #18 had five bags of IV fluids that hung from the IV pole, with tubing attached. The IV tubing was not labeled to indicate when each was originally hung, or when tubing was due to be changed, as directed by the facility policy.

During an interview on 02/13/19 at 11:18 AM, Staff E, RN, Medical-Surgical and Intensive Care Unit Manager and Inpatient Services Director, stated that he expected staff to label IV tubing.

During an interview on 02/11/19 at 2:38 PM, with concurrent observation showed:
- Patient #2 stated that he had been admitted to the ICU on 02/10/19 for a blood clot in his lung and pneumonia.
- Patient #2 stated that he was on an antibiotic for the pneumonia.
- Patient #2 had an IV in his right arm. There was an empty bag of Levofloxacin (an antibiotic) 750 milligrams (mg, a unit of measure), with tubing attached, which hung from the IV pole. The IV tubing was not labeled to indicate when it was originally hung, or when staff should have changed it.

During an interview on 02/13/19 at 1:57 PM, Staff E, RN, Medical-Surgical and ICU Manager and Inpatient Services Director, stated that she expected IV site dressings to be dated, timed, and initialed. He further stated that labeling kits were included with the IV starter kits or staff could label the outside of the dressing.




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