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A. Based on document review, observation, and interview, it was determined that for 3 of 3 staff (E#5, E#7, and E#8), the Hospital failed to ensure that hand hygiene was performed as required in order to control the potential spread of infection.

Findings include:

1. The Hospital's policy titled, "Hand Hygiene" (undated), was reviewed on 9/10/19 and required, "... Use soap and water OR alcohol-based hand rub: ... c) Before and after handling an invasive device... e) After removing gloves..."

2. Observational tours of the Hospital included the following:

- On 9/9/19, at approximately 1:30 PM and again at 1:55 PM, a Registered Nurse (E#5) was in a patient's room (#3222) on the Intensive Care Unit (ICU) and was attempting to draw blood from the patient's arms. In both instances, after attempting to draw blood, E#5 did not change her gloves and perform hand hygiene before accessing the nursing supply cart to retrieve clean supplies.

- On 9/10/19, at approximately 9:33 AM, a Surgical Support Technician (E#7) grabbed a pile of wipes on the floor, that were used to clean up a blood spill, in OR (Operating Room) suite #12. E#7 then removed his gloves and did not perform hand hygiene prior to opening the door to exit the room.

- On 9/10/19, at approximately 10:05 AM, the Circulating Nurse (E#8) was disinfecting some equipment left on the floor in OR suite #12. E#8 removed his gloves and did not perform hand hygiene prior to touching clean supplies on the tables and surgical bed.

3. An interview was conducted with the Registered Nurse (E#5) on 9/9/19, at approximately 2:32 PM. E#5 stated that hands should be disinfected after drawing blood and before gathering clean supplies. E#5 stated, "I should've changed gloves and washed my hands... I was nervous... I didn't really get any blood but yes I would normally change gloves and do hand hygiene after a blood draw..."

4. An interview was conducted with the Manager of the OR (E#9) on 9/10/19, at approximately 10:10 AM. E#9 stated that hand hygiene should always be performed after removing gloves.


B. Based on document review, observation, and interview, it was determined that for 2 of 2 contact isolation (precaution used for infections, diseases, or germs that are spread by touching the patient or items in the room) rooms (#3221 and #3222) in the Intensive Care Unit (ICU), the Hospital failed to ensure that equipment and supplies were dedicated for the patient on contact isolation in order to control the potential spread of infection. This had the potential to affect all 16 patients on census and future patients admitted to the unit.

Findings include:

1. The Hospital's policy titled, "Transmission Based Isolation Precautions and Procedures" (undated), was reviewed on 9/9/19 and required, "...Patient supplies and equipment: Dedicated equipment, if available, is used for isolation patients..."

2. An observational tour of the ICU was conducted on 9/9/19, at approximately 1:27 PM. Two rooms (#3221 and #3222) had signs posted on the door indicating that contact isolation precautions were in place. Each room had a cart for nursing supplies inside the room. At approximately 1:30 PM, a Registered Nurse (E#5) was in patient room (#3222) attempting to draw blood. At approximately 1:35 PM, E#5 gathered two medication (unidentified) vials, an unopened blood draw kit, and additional items) from the side table and top of the supply cart and returned them to the supply cart drawer.

3. An interview was conducted with the Director of ICU (E#6) on 9/9/19, at approximately 1:40 PM. E#6 stated that nursing supply carts are available in each room. E#6 stated that once a patient is discharged, the outside of the cart is cleaned during room turnover; however, the supplies within the cart "stay in there" for the next patient. E#6 stated that all opened and exposed supplies (supplies not contained in a drawer) within an isolation room are disposed of when the patient is discharged.

4. An interview with the Registered Nurse (E#5) was conducted on 9/9/19, at approximately 2:32 PM. E#5 stated that only nurses have access to open the supply cart and stated that the cart contains items such as needles and syringes. E#5 stated that unopened supplies can be returned to the supply cart if they are not "dirty or potentially contaminated" by having direct contact with the patient. E#5 stated that the drawers are not cleaned and supplies within the cart are not discarded after a patient is discharged. E#5 stated that after a patient is discharged, the room and supply cart may be used for any other patient admitted to the unit.

5. An interview with the Infection Prevention Coordinator (E#4) was conducted on 9/9/19, at approximately 3:00 PM. When asked about nursing supply carts in contact isolation rooms, E#4 stated, "Any supplies that go into an isolation room, do not come back out. They should only be used for that patient and disposed of once the patient is discharged."


C. Based on document review, observation, and interview, it was determined that for 1 of 2 staff (E#10) observed on the Intensive Care Unit (ICU), the Hospital failed to ensure that staff wore the appropriate personal protective equipment upon entering a contact isolation (precaution used for infections, diseases, or germs that are spread by touching the patient or items in the room) room in order to control the potential spread of infection.

Findings include:

1. The Hospital's policy titled, "Transmission Based Isolation Precautions and Procedures" (undated), was reviewed on 9/9/19 and required, "...When caring for a patient on Contact Precautions, hospital-approved gowns are donned [put on] prior to entering the patient's room... When caring for a patient on Contact Precautions, hospital-approved gloves are donned prior to entering the patient's room..."

2. An observational tour of the ICU was conducted on 9/9/19, at approximately 1:27 PM. At approximately 1:43 PM, a Registered Nurse (E#10) entered a patient's room (Pt. #5) who was on contact isolation for a MRSA (methicillin-resistant staphylococcus aureus) infection. E#10 did not put on a gown or gloves before entering the room and lifting up the left side rail of the bed.

3. An interview was conducted with the Registered Nurse (E#10) on 9/9/19, at approximately 2:42 PM. E#10 stated that a gown and gloves should always be worn before entering a contact isolation room. E#10 stated that she did not see the contact isolation sign, indicating the need for a gown and gloves upon entry, on Pt. #5's door.


D. Based on document review, observation, and interview, it was determined that for 3 of 3 staff (E#11, E#12, and MD#3), the Hospital failed to ensure that staff followed the surgical attire policy as required in order to control the potential spread of infection.

Findings include:

1. The Hospital's policy titled, "Attire in the Surgical Suite" (undated), was reviewed on 9/10/19 and required, "... Face masks which cover the nose and mouth will be donned [put on] by each person upon entering the restricted areas where open sterile supplies are present and will be worn at all times... Masks will not be... permitted to dangle around the neck... Stud type earrings may be worn but must be inside head cover at all times. No dangling earrings are allowed..."

2. An observational tour of the OR (Operating Room) Area was conducted on 9/10/19, at approximately 9:07 AM.

- At approximately 9:08 AM, a Surgeon (MD#3) walked down the OR corridor and out of the OR Area with a mask dangling around his neck.

- At approximately 9:45 AM, in OR suite #12, the sterile field was opened and assembled by a Scrub Technician (E#11). E#11 was opening sterile supplies and organizing items on the sterile field while wearing exposed hoop earrings on both ears.

- At approximately 9:47 AM, a Student Scrub Technician (E#12) entered OR suite #12 while holding an unsecured mask to her face.

3. An interview was conducted with the Manager of the OR (E#9) on 9/10/19, at approximately 10:10 AM. E#9 stated that the Scrub Technician should not wear any exposed and/or dangling jewelry when assembling the sterile field and equipment. E#9 stated that masks should be tied and secured before entering an OR suite with an opened sterile field. E#9 stated that masks should be removed and discarded immediately after use and should not be left hanging around the neck.