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Based on observation, interview, and policy review, the hospital failed to properly screen for, prevent, and/or contain COVID-19 (highly contagious, and sometimes fatal, virus) and ensure that staff followed infection control policies and infection prevention standards when they failed to:
- Properly screen all visitors entering the hospital during the COVID-19 pandemic;
- Properly remove soiled gloves and/or properly sanitize gloves after screening patients;
- Perform proper hand hygiene/glove use after contact with inanimate (not alive, for example, computer keyboard, computer scanner, bed lines, medication lock boxes, etc.) objects in the patient environment for six current patients (#33, #34, #35, #36, #38, and #40);
- Wear appropriate eye wear in the Operating Room (OR);
- Appropriately cover or remove earrings while in the OR;
- Ensure that the floor and the top of a computer located in the treatment room of the OR, were clean and free of dust;
- Remove all cardboard and paper from the OR treatment room and supply cart;
- Remove expired intravenous (IV, in the vein) fluids from the fluid warmer;
- Maintain the cleanliness of the dietary department;
- Properly store personal drinks in the dietary department, and at the entrance screening table; and
- Properly cleanse the rubber stoppers of medication vials prior to withdrawing medications.

These failed practices had the potential to expose all patients, visitors and staff to COVID-19, cross contamination (germs that are spread from one person or surface to another), and increased the risk of infection and foodborne illness.

The cumulative effects of these systemic failures resulted in the hospital's non-compliance with §42 CFR 482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs and resulted in the hospital's failure to ensure safe infection control practices to prevent infections and communicable disease. The hospital census was 104.

Please refer to A-0749.

Based on observation, interview, and policy review, the hospital failed to properly screen for, prevent, and/or contain COVID-19 (highly contagious, and sometimes fatal, virus) and ensure that staff followed infection control policies and infection prevention standards when they failed to:
- Properly screen all visitors entering the hospital during the COVID-19 pandemic;
- Properly remove soiled gloves and/or properly sanitize gloves after screening patients;
- Perform proper hand hygiene/glove use after contact with inanimate (not alive, for example, computer keyboard, computer scanner, bed lines, medication lock boxes, etc.) objects in the patient environment for six current patients (#33, #34, #35, #36, #38, and #40);
- Wear appropriate eye wear in the Operating Room (OR);
- Appropriately cover or remove earrings while in the OR;
- Provide a clean environment in the OR area, and the Dietary Department;
- Remove all cardboard and paper products from the OR setting;
- Properly store N95 masks (type of mask that filters 95% of particles in the air, and prevents them from being inhaled);
- Properly change and monitor the cubical curtains within all patient care areas;
- Remove expired intravenous (IV, in the vein) fluids from the fluid warmer;
- Properly store personal beverages in the Dietary Department, and at the entrance screening table; and
- Properly cleanse the rubber seals (allows for passage of needle without loss of medication) of medication vials prior to withdrawing medications.

These failures increased the risk of COVID-19 exposure, cross-contamination and infection for all patients admitted to the hospital. The hospital census was 104.

1. Review of Centers for Disease Control and Prevention (CDC) document titled, "Visitors in Healthcare Facilities," updated 09/15/20, showed that:
- Hospitals should establish policies and procedures for managing, screening, educating, and training all visitors;
- Hospitals should have a designated entrance;
- Hospitals should encourage visitors to be aware of signs and symptoms;
- Visitors that have a fever or other symptoms should be asked to leave the hospital and to seek care;
- Signs and posters should be placed at the hospital entrances instructing visitors with a fever or respiratory symptoms not to enter;
- Signs should include the symptoms, and whom to contact if visitors have symptoms;
- Visitors should be educated on performing hand hygiene and respiratory hygiene/cough etiquette (e.g., covering mouth and nose with disposable tissue when coughing or sneezing); and
- Hospitals should provide adequate supplies for visitors to perform hand hygiene.

Observation on 01/12/21 at 8:15 AM, showed Staff S, Entrance Screener, failed to ask the COVID-19 screening questions upon entry to the hospital for two surveyors.

During an interview on 01/14/21 at 10:24 AM, Staff AAA, Lead Entrance Screener, stated that her expectations were that every person be asked the COVID-19 screening questions every time they entered the hospital.

During an interview on 01/12/21 at 9:18 AM, Staff P, Infection Prevention Director, stated that the entrance screeners were expected to ask the screening questions when people arrived at the COVID-19 screening station.

2. Review of CDC Guidelines, "Strategies for Optimizing the Supply of Disposable Medical Gloves," updated 12/23/20, showed that:
- Crisis capacity strategies are to only be used when the supply is not able to meet the hospital's current or anticipated utilization rate.
- The disinfection of disposable gloves falls under the crisis capacity strategies.
- CDC does not recommend the disinfection of disposable medical gloves, except in times of extreme shortages.
- The preferred method of sanitizing disposable gloves would be to utilize an alcohol-based hand sanitizer (ABHS).
- Disposable medical gloves may only be sanitized with ABHS for a maximum of six applications.

Observation on 01/12/21 at 9:55 AM, showed Staff R, Entrance Screener, used hand sanitizer on his disposable gloves while working at the COVID-19 screening station.

During an interview on 01/12/21 at 9:55 AM, Staff R, Entrance Screener, stated that he used hand sanitizer on his disposable gloves after each person presented at the screening station and he changed his gloves after every 10 times of using hand sanitizer.

During an interview on 01/13/21 at 7:30 AM, Staff Y, Entrance Screener, stated that she used hand sanitizer on her disposable gloves and changed her gloves after every five people. When asked how she kept track of every five times, her response was that she just counted to herself.

During an interview on 01/13/21 at 3:55 PM, Staff TT, Entrance Screener, stated that she changed her disposable gloves after every five people she screened, or when she used a disinfecting wipe.

During an interview on 01/14/21 at 10:24 AM, Staff AAA, Lead Entrance Screener, stated that she used hand sanitizer on her gloves between each screening and she used to change her gloves after every eight times, but that changed to every five times on 01/13/21. When asked how she kept track of when to change her gloves, her response was she just kept track on her own.

During an interview on 01/14/21 at 1:05 PM, Staff P, Infection Prevention Director, stated that there were shortages of certain glove sizes, but they were utilizing multiple vendors to ensure that they had an adequate supply.

During an interview on 01/14/21 at 1:40 PM, Staff B, Clinical Quality Management Director, stated that she did not know specifics about a glove shortage, just that the hospital had reached out to multiple vendors to obtain supplies.

During an interview on 01/12/21 at 3:19 PM, Staff A, Patient Care Services Director, stated that she was unsure of the guidelines for using hand sanitizer on disposable gloves and that gloves could be used until they were visibly soiled, or maybe changed after five times of using the hand sanitizer on the disposable gloves. She also stated that gloves should be changed after use of a disinfecting wipe.

Review of email documents supplied by the hospital in relation to a perceived glove shortage, and justification for use of ABHS on disposable gloves, showed that:
- The hospital received an email from a glove supplier, dated 07/17/20, which reassured them that they would not be affected by the banning of imports from Malaysia.
- An internal email, dated 08/20/20, discussed their order with one manufacturer in order to receive gloves on their shipments, and that there was a two week delay of shipment at that time.
- A third internal email, dated 12/04/20, showed that there was potential for future glove shortages from a manufacturer that experienced an outbreak of COVID-19; the reference listed for use of ABHS on disposable gloves was from the CDC recommendation, dated 2019, "Personal Protective Equipment (PPE, such as gloves, gowns, and masks) Strategies for Gloves."

3. Review of the hospital's Infection Prevention policy titled, "Hand Hygiene," reviewed 12/2019, showed that hand hygiene should be practiced according to the five moments of hand hygiene:
- Before touching a patient;
- Before clean/aseptic (process that is maintained free of germs or bacteria) procedure;
- After body fluid exposure risk;
- After touching a patient; and
- After touching patient surroundings.

Observation on 01/12/21 at 9:55 AM, showed Staff R, Entrance Screener, failed to perform hand hygiene after screening one visitor and prior to screening the next visitor.

Observation on 01/13/21 at 8:13 AM, showed that Staff T, Registered Nurse (RN), failed to perform proper hand hygiene when:
- She removed her gloves, opened a drawer on the computer cart, re-applied gloves, and administered IV medications to Patient #33.
- Without wearing gloves, she handed Patient #33 nasal spray for self-administration, applied gloves, then placed the nasal spray back into the box for storage.
- Immediately after storing the nasal spray, while she continued to wear the same gloves, she opened a bottle of eye drops, and instilled the eye drops into the patient's eye.

Observation on 01/13/21 at 8:40 AM, showed that Staff X, RN, failed to perform hand hygiene after contact with Patient #34's arm and bed linens, when she immediately moved to the computer keyboard to co-sign the medication administration.

Observation on 01/13/21 at 8:57 AM, showed that Staff V, RN, failed to perform hand hygiene or glove changes between touching/scanning medications, opening medications, and administering medications to Patient #35.

Observation on 01/13/21 at 8:57 AM, showed that Staff V, RN, failed to cleanse the rubber seal of the medication vial prior to withdrawal of the medication for subcutaneous (SQ, beneath all the layers of the skin) injection for Patient #35.

Observation on 01/13/21 at 9:06 AM, showed that Staff W, RN, failed to remove gloves and perform proper hand hygiene when she opened the lock box to retrieve a pill splitter and proceeded to hand Patient #36 his medications while wearing the same gloves.

Observation on 01/13/21 at 9:44 AM, showed Staff II, RN, failed to perform hand hygiene prior to glove application when starting an IV on Patient #38.

Observation on 01/13/21 at 3:40 PM, showed Staff RR, RN, failed to perform hand hygiene prior to glove application and after glove removal, during medication administration for Patient #40.

During an interview on 01/13/21 at 3:45 PM, Staff RR, RN, stated that she failed to perform hand hygiene after she removed her gloves.

During an interview on 01/13/21 at 3:48 PM, Staff QQ, RN, Emergency Department (ED) Director, stated that staff should perform hand hygiene after glove removal.

During an interview on 01/14/21 at 1:05 PM, Staff P, Infection Prevention Director, stated that:
- Their department uses secret surveyors to monitor staff for proper hand hygiene.
- Most observations were entry and exit of patient rooms, not while in the patient room or with patient contact.
- During orientation, staff are educated about the five moments of hand hygiene, and provided a copy of that information.
- Her expectation was for staff to perform hand hygiene upon entry and exit of patient rooms, with patient care, and any time they touched an object or removed their gloves.
- Based on department audits of hand hygiene, the percentage of staff that properly performed hand hygiene in the month of December 2020, was 83%.

During an interview on 01/14/21 at 1:42 PM, Staff B, Clinical Quality Management Director, stated that hand hygiene should be performed using the five moments of hand hygiene, which included before glove application and after glove removal.

During an interview on 01/14/21 at 2:00 PM, Staff A, Patient Care Services Director, stated that hand hygiene should be performed before glove application and after glove removal.

4. Review of the hospital's Surgical Services policy titled, "Attire in Surgery," reviewed 01/31/20, directed staff that appropriate eye shields should be worn during direct care of patients, any time there is risk of contamination, and when they are working in a sterile field.

Observation on 01/13/21 at 8:30 AM, showed that Staff AA, RN, Circulator, failed to wear eye protection in the OR during a surgical procedure for Patient #37.

Observation on 01/13/21 at 8:30 AM, showed that Staff DD, Certified Registered Nurse Anesthetist (CRNA), failed to wear eye protection in the OR during a surgical procedure for Patient #37.

Observation on 01/13/21 at 10:18 AM, showed that Staff JJ, Certified Scrub Technician (CST), failed to wear eye protection in the OR during a surgical procedure for Patient #39.

During an interview on 01/13/21 at 10:28 AM, Staff FF, RN, Surgical Services Assistant Director, stated that the expectation was for all OR staff to have eye protection in place while in the OR during surgical procedures.

During an interview on 01/14/21 at 1:05 PM, Staff P, RN, Infection Prevention Director, stated that all OR staff should have eye protection in place during surgical procedures.

During an interview on 01/14/21 at 1:42 PM, Staff B, Clinical Quality Management Director, stated that all OR staff should have eye protection in place during surgical procedures.

During an interview on 01/14/21 at 2:00 PM, Staff A, Patient Care Services Director, stated that all OR staff should have eye protection in place during surgical procedures.

5. Review of the hospital's Surgical Services policy titled, "Attire in Surgery," reviewed 01/31/20, directed staff that jewelry, including earrings, necklaces, watches, and bracelets, that could not be contained or confined within the appropriate surgical attire, should not be worn in the OR.

Observation on 01/13/21 at 8:30 AM, showed that Staff BB, CST, had earrings in place that were not covered by her surgical cap while in the OR during a surgical procedure for Patient #37.

Observation on 01/13/21 at 8:30 AM, showed that Staff CC, Certified Scrub First Assistant (CSFA), had earrings in place that were not covered by her surgical cap while in the OR during a surgical procedure for Patient #37.

Observation on 01/13/21 at 10:18 AM, showed that Staff JJ, CST, had earrings in place that were not covered by her surgical cap while in the OR during a surgical procedure for Patient #39.

During an interview on 01/13/21 at 10:28 AM, Staff FF, RN, Surgical Services Assistant Director, stated that the expectation was for all OR staff to have earrings covered by the surgical cap while working in the OR.

During an interview on 01/13/21 at 1:05 PM, Staff P, Infection Prevention Director, stated that earrings worn by staff needed to be covered by surgical attire.

During an interview on 01/14/21 at 1:42 PM, Staff B, Clinical Quality Management Director, stated that she would expect OR staff to have earrings covered during a surgical procedure.

During an interview on 01/14/21 at 2:00 PM, Staff A, Patient Care Services Director, stated that OR staff should have earrings covered during a surgical procedure.

6. Review of the hospital's Environmental Services (EVS) policy titled, "General Cleaning and Sanitation," reviewed 12/28/20, showed that all patient and non-patient rooms should be thoroughly cleaned and/or disinfected.

Observation on 01/13/21 at 8:52 AM, in the procedure room within the OR, showed dust accumulation on the computer that was located on the desk, and dust accumulation in the corner of the room by the desk.

During an interview on 01/14/21 at 10:46 AM, Staff FF, Surgical Services Assistant Director, stated that dust accumulation should not be present in the procedure room within the OR.

During an interview on 01/14/21 at 9:42 AM, Staff YY, EVS Assistant Director, stated that EVS staff were responsible to clean in the procedure room within the OR on a daily basis. The expectation was for the staff to sweep and mop the floors. She would not expect to see dust accumulation in the procedure room within the OR.

During an interview on 01/14/21 at 9:42 AM, Staff ZZ, EVS Manager, stated that EVS staff cleaned the procedure room within the OR every day, and they were expected to sweep and mop the floors.

During an interview on 01/14/21 at 1:05 PM, Staff P, Infection Prevention Director, stated that there should not be any dust accumulation in the OR area.

During an interview on 01/14/21 at 1:42 PM, Staff B, Clinical Quality Management Director, stated that dust in the procedure room within the OR was unacceptable.

During an interview on 01/14/21 at 2:00 PM, Staff A, Patient Care Services Director, stated that dust accumulation in the procedure room within the OR should not be present.

7. Review of the hospital's Food Services policy titled, "Cleaning of Equipment - Hood Ventilation System," reviewed 12/28/20, showed that the grease filters directly above the deep fat fryers and the grill area would be removed weekly, and all other filters above hot food production would be removed monthly, to be cleaned and sanitized.

Review of the hospital's Food Service policy titled, "Cleaning of Equipment - Ovens," reviewed 12/28/20, showed that:
- The cooks are responsible for cleaning the ovens.
- Racks should be removed from the interior, washed and sanitized.
- While the oven remained warm, spray oven cleaner should be used on all interior surfaces, and allowed to sit for a few minutes.
- Ovens should be cleaned often to avoid excessive build up.
- No clear direction for frequency of cleaning was provided.

Review of the hospital's Food Service policy titled, "Cleaning of Equipment - Can Openers," reviewed 12/28/20, showed that the table-mounted can opener should be disassembled, cleansed thoroughly, rinsed and sanitized daily. The policy did not provide clear direction for rust removal.

Observation of the Dietary Department on 01/13/20 at 3:34 PM, showed heavily soiled, grease build-up, on two air vents over the fryer area, and two air vents over the oven area.

Observation of the Dietary Department on 01/13/21 at 3:35 PM, showed heavily soiled, grease build-up on the interior of two of four ovens.

Observation of the Dietary Department on 01/13/21 at 3:36 PM, showed rust along the teeth edge of a table-mounted industrial sized can opener.

During an interview on 01/13/21 at 3:34 PM, Staff VV, Cook/Supervisor, stated that the air vents above the fryer area were removed weekly to clean and sanitize them.

During an interview on 01/13/21 at 3:20 PM, Staff UU, Food Services Director, stated that each station in the department had a cleaning log and the staff assigned to that station were to complete the tasks on the cleaning log each shift.

During an interview on 01/14/21 at 1:05 PM, Staff P, Infection Prevention Director, stated that she only does rounds in the Dietary Department once a month and she was unsure of cleaning schedules.

During an interview on 01/14/21 at 1:40 PM, Staff B, Clinical Quality Management Director, stated that she would expect the can opener in the Dietary Department to be free of rust.

During an interview on 01/14/21 at 2:00 PM, Staff A, Patient Care Services Director, stated that she would expect that the can opener be rust-free, the vents be free of grease build-up, and that the interior ovens would be clean.

Review of the hospital's document titled, "Hot Food Production Cleaning Checklist," beginning the weeks of 12/14/20, showed that as of 01/13/21, the hood filters had not been cleaned, and the ovens had not been cleaned since 12/23/20.

8. Review of the hospital's Surgical Services policy titled, "Traffic Control," reviewed 01/31/20, showed that:
- The amount of traffic in the OR should be limited to protect personnel, patients, supplies, and equipment from cross-contamination.
- Restricted areas would include the OR suites, corridors leading to the OR suites, equipment rooms, soiled holding room, and the clean core.
- Surgical attire, including hair coverings, masks, and shoe coverings are required in these areas.
- Contaminated items are not to enter the clean supply room or the clean core.

Observation on 01/13/21 at 8:52 AM, in the procedure room within the OR, showed a cardboard box on the table and a cardboard box on top of the supply cart.

Observation on 01/13/21 at 8:46 AM, in the OR hallway, showed a cardboard sign located on the supply cart in the main hallway.

During an interview on 01/13/21 at 10:28 AM, Staff FF, RN, Surgical Services Assistant Director, stated that the expectation was that no cardboard boxes were to be in the procedure room or on the supply cart in the OR.

During an interview on 01/13/21 at 1:05 PM, Staff P, Infection Prevention Director, stated that there should not be any cardboard in any form in the OR rooms.

During an interview on 01/14/21 at 1:42 PM, Staff B, Clinical Quality Management Director, stated that there should be no cardboard in the OR.

During an interview on 01/14/21 at 2:00 PM, Staff A, Patient Care Services Director, stated that cardboard was not allowed in the OR.

9. Review of the hospital's Surgical Services policy titled, "Disinfection of N95 Masks," initiated 04/2020, showed that reuse of the N95 mask would be the practice of wearing the same N95 mask for several encounters; when stored, the N95 mask should be placed in a clean brown paper bag.

Observation on 01/13/21 at 10:25 AM, showed Staff KK, RN, placed a paper bag on top of the supply cart in the OR during a surgical procedure for Patient #39. The paper bag was ragged and torn.

During an interview on 01/13/21 at 10:25 AM, Staff KK, RN, stated that the paper bag was used to store her N95 mask after she removed it. She stated that she would get a new bag every couple of weeks and that she was probably due for a new one.

During an interview on 01/13/21 at 10:38 AM, Staff FF, RN, Surgical Services Assistant Director, stated that the paper bag should not be in the OR. There was an area outside of the OR where staff were to keep their paper bags and that staff were responsible for replacement when the bags showed wear.

During an interview on 01/14/21 at 1:05 PM, Staff P, Infection Prevention Director, stated that N95 masks should not be stored in a damaged paper bag in the OR or on the supply cart.

During an interview on 01/14/21 at 1:42 PM, Staff B, Clinical Quality Management Director, stated that she would not expect to see a paper bag in the OR.

During an interview on 01/14/21 at 2:00 PM, Staff A, Patient Care Services Director, stated that a paper bag should not be in the OR.

10. Review of the hospital's EVS policy titled, "Cubicle Curtain Cleaning," reviewed 12/28/20, showed that cubicle curtains should be changed when they become soiled, or after isolation patients are discharged, to prevent cross-contamination. The policy does not provide guidance for the frequency of routine changes, nor a process for tracking those curtains that have been changed.

Observation on 01/13/21 at 9:20 AM, showed cubicle curtains hanging in the preoperative and postoperative areas of patient care with no dates that indicated when the curtains had been changed.

Observation on 01/13/21 at 3:20 PM, showed cubicle curtains hanging in the ED with no dates that indicated the curtains had been changed.

During an interview on 01/13/21 at 9:32 AM, Staff HH, EVS Technician, stated that the curtains in the cubicle would be changed if a patient were in isolation.

During an interview on 01/14/21 at 9:42 AM, Staff YY, EVS Assistant Director, stated that the cubicle curtains were changed every six months or when soiled. There was no log for when the curtains had been changed and she was not sure when the curtains had been changed.

During an interview on 01/14/21 at 9:42 AM, Staff ZZ, EVS Manager, stated that it was the responsibility of the OR EVS staff on day shift to change the curtains when necessary. If the curtains needed to be changed on the weekend, the ED EVS staff would be responsible to change the curtains. There was no log of when the curtains had been changed.

During an interview on 01/13/21 at 3:20 PM, Staff QQ, ED Director, stated that the cubicle curtains were changed based on the infection risk of the patient.

During an interview on 01/14/21 at 1:05 PM, Staff P, Infection Prevention Director, stated that she would expect cubicle curtains to be changed on a routine basis, after being used for an isolation patient, and that EVS personnel would document those changes and be able to track which curtains had been changed.

During an interview on 01/14/21 at 1:42 PM, Staff B, Clinical Quality Management Director, stated that she would expect the cubicle curtains to be changed when they became soiled and on a scheduled basis.

During an interview on 01/14/21 at 2:00 PM, Staff A, Patient Care Services Director, stated that she would expect the cubicle curtains to be changed on a regular basis and that a log would be maintained.

11. Even though requested, the hospital failed to provide a policy for expired supplies in the OR.

Observation on 01/13/21 at 10:10 AM, showed two bags of IV fluids in the warmer in the main OR area with an expiration date of 01/12/21.

Observation on 01/13/21 at 10:18 AM, showed two bags of IV fluids in the warmer in OR Room #5 with no expiration dates on the label.

During an interview on 01/13/21 at 10:10 AM, Staff FF, RN, Surgical Services Assistant Director, stated that the expired IV fluids should not be in the warmer.

During an interview on 01/14/21 at 1:05 PM, Staff P, Infection Prevention Director, stated that expired IV fluids should not be in the warmer.

During an interview on 01/14/21 at 1:42 PM, Staff B, Clinical Quality Management Director, stated that expired fluids should not be present in the OR.

During an interview on 01/14/21 at 2:00 PM, Staff A, Patient Care Services Director, stated that expired fluids should not be in the OR.

12. Even though requested, the hospital did not provide a policy regarding proper storage of employee food and drinks.

Observation on 01/13/21 at 4:00 PM, showed two drinks on the screeners' table of the hospital's main entrance COVID-19 screening station.

Observation on 01/13/21 at 7:30 AM, showed two drinks on the screeners' table of the hospital's main entrance COVID-19 screening station.

Observation on 01/12/21 at 9:55 AM, showed one drink on the screeners' table of the hospital's main entrance COVID-19 screening station.

Observation on 01/13/21 at 3:20 PM, showed an employee's half-empty, 20-ounce plastic soda bottle stored on the wire rack inside the refrigerator cooler in the Dietary Department.

Observation on 01/13/21 at 3:25 PM, showed an employee's clear plastic cup with lid and straw, filled with clear liquid, stored on the lower shelf, and an employee's metal travel mug filled with liquid, stored on the upper shelf of the prep table at the beginning of the patient tray line.

During an interview on 01/14/21 at 10:24 AM, Staff AAA, Lead Entrance Screener, stated that one covered drink was allowed at the COVID-19 screening station.

During an interview on 01/13/21 at 3:25 PM, Staff UU, Food Services Director, stated that she did not have any issues with staff storing their beverages in the hospital cooler or having their beverages on the patient tray line. She stated that it was warm in the kitchen and there was not an employee-designated refrigerator in their department.

During an interview on 01/14/21 at 1:05 PM, Staff P, Infection Prevention Director, stated that she would not expect to see open beverages at the COVID-19 screening station, nor on the patient tray line, and that the house-wide policy would be that employees should not store their personal beverages in any patient refrigerator.

During an interview on 01/14/21 at 1:40 PM, Staff B, Clinical Quality Management Director, stated that staff were not to have beverages at the work area or desk, this would include the patient tray line. Staff at the COVID-19 screening table would be allowed to have a beverage as long as it could be closed, no open containers or straws.

During an interview on 01/14/21 at 2:00 PM, Staff A, Patient Care Services Director, stated that staff beverages should not be stored in patient refrigerators of any kind. Staff beverages should not be on the patient tray line, the line is for food preparation only. Staff at the COVID-19 screening tables should have a closed beverage; however, they had not addressed the use of straws.

13. Review of the hospital's Nursing Clinical Practice policy, titled, "Nursing Procedure Guide," revised 12/2017, showed that nursing staff should utilize Perry and Potter, Clinical Nursing Skills and Techniques, 9th Edition, copyright 2018, as a reference for procedures done in the hospital setting.

Review of "Perry and Potter, Clinical Nursing Skills and Techniques," 9th Edition, copyright 2018, page 584 of Parenteral Medications, showed that:
- The cap should be removed from the vial to uncover the rubber seal, and the surface of the seal should be firmly and briskly wiped with an alcohol swab, then allowed to dry before medication would be withdrawn.
- Not all manufacturers guarantee that the rubber seals of unused vials are sterile (without bacteria).
- Swabbing with alcohol would reduce the transmission of microorganisms (organisms, such as bacteria, too small for the naked eye).

Observation on 01/13/21 at 8:22 AM, showed that Staff AA, RN, Circulator, failed to wipe the rubber seals of three medication vials with an alcohol swab prior to medication withdrawal during a surgical procedure for Patient #37.

Observation on 01/13/21 at 8:34 AM, showed that Staff T, RN, failed to wipe the rubber seal of a medication vial with an alcohol swab prior to medication withdrawal for a SQ injection for Patient #34.

During an interview on 01/13/21 at 8:47 AM, Staff T, RN, stated that she should have cleaned the rubber seal of the medication vial prior to medication withdrawal.

During an interview on 01/13/21 at 8:57 AM, Staff V, RN, stated that she did not need to cleanse the rubber seal of a medication vial if it was sealed with a cap. She would only cleanse the seal if it were a multi-dose vial.

During an interview on 01/14/21 at 10:46 AM, Staff FF, Surgical Services Assistant Director, stated that the rubber seal should be wiped with an alcohol swab prior to medication withdrawal.

During an interview on 01/14/21 at 1:05 PM, Staff P, Infection Prevention Director, stated that her expectation of staff was that they would always clean the rubber seals of every medication vial prior to medication withdrawal.




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