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Based on review of facility policy, credential files (CF), and interview with staff (EMP), it was determined the facility failed to ensure that Ephrata Community Hospital trained personnel expected to have contact with blood or other potentially infectious material in accordance with their hospital infection control policies for four of four credential files reviewed (CF1, CF2, CF3 and CF4).

Findings include:

A review on July 30, 2015, of the facility policy "Infection Prevention/Control Plan/Program" last revision date 10/14 revealed, "All Department Directors have the responsibility to provide infection prevention/control information to the Infection Control Coordinator to assist with timely identification and action for the safety of the employees as patients. The infection Control coordinator depends on this information to: 1. Ensure patient care practices approved by the Infection Control Committee are implemented in the practice of infection prevention and control. 2. Ensure all employees and practitioners are aware of the Infection Control Manual, Exposure control Plan and TB exposure Control Plan located on the hospital intranet...Coordinate & record attendance for annual education & other education as indicated by the specific needs of the department."

A review on July 30, 2015, of CF1, CF2, CF3 and CF4 revealed no documentation that the physicians who were not employees of the hospital were provided with infection control training annually or on a regular basis.

An interview conducted on July 30, 2015, at 10:45 AM with EMP6 confirmed that physicians that were not employees of the hospital did not receive hospital infection control training upon hire, annually, or on a regular basis.

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Based on review of Hospital policy, observation and interview with staff (EMP), it was determined the facility failed to ensure hospital staff followed the established contact precautions policy.
Findings include:
A review on July 30, 2015, of the facility policy "Contact Precautions" last revision date 10/14 revealed, "...Contact Transmission is the most important, most frequent mode of transmission of healthcare associated infections. D. Wear a gown entering the patient's room..."
An observation on July 29, 2015, revealed a sign for contact precautions posted on the outside door frame of a patient's room. The sign read that anyone that enters the patient room most wear gloves and a gown. Observation revealed a health care employee emptying urine from a urinary catheter bag without wearing a gown.
An interview conducted on July 29, 2015, at 1:00AM with EMP6 confirmed that the employee should have been wearing a gown.

Based on a review of facility documents, observations and interview with staff (EMP) it was determined that the facility failed to ensure it's policy was followed when intravenous (IV) tubing was disinfected with alcohol prior to reconnection and that surgical attire was worn in the semi-restricted area.

Findings include:

A review of Ephrata Community Hospital policy entitled "Intermittant Intravenous Therapy and Flushing Via Capped IV" last revised, April 2012 revealed, " ... Before any access (attaching syringe or tubing) is performed to an IV cap or port, the cap or port should be scrubbed with Alcohol Prep (70% isopropyl alcohol) and then allowed to dry. ... "

An observation on July 29, 2015, at 2:05 PM of a podiatry surgical case revealed the anesthesia provider reattached an IV line without disinfection with alcohol.

An interview conducted on July 29, 2015, at 2:15 PM with EMP3 confirmed that the IV should have been disinfected with alcohol prior to reconnection.

An observation on July 30, 2015, at 9:50 AM of a surgical case revealed the anesthesia provider administered two IV medications without disinfecting the port with alcohol.

An interview conducted on July 30, 2015, at 9:55 AM with EMP3 confirmed that the anesthesia provider administered two IV medications without disinfecting the port with alcohol.

A review of Ephrata Community Hospital policy entitled "Surgical Attire" last revised October 2014 revealed " ... All persons who enter the semi-restricted and restricted areas of the surgical suite will be dressed in surgical attire. ... "

An observation on July 29, 2015, at 1:30 PM revealed a physician dressed in street clothing crossed the corridor into the semi-restricted area of the surgical suite and entered the physician lounge.

An interview conducted on July 29, 2015, at 1:30 PM with EMP3 confirmed that the physician should have been in proper surgical attire to be in the semi-restricted area of the surgical suite.