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Based on observation, facility policy review, and staff interview, it was deterred the hospital failed to provide a sanitary environment and follow infection control measures to avoid transmission of potential infection. Failure to ensure proper infection control processes has the potential to impact the health of patients and staff. Findings include:

1. Refer to tag A - 750 as it relates to failure of the facility to ensure that all staff are following infection prevention and control policies and procedures and infection control measures in the hospital during patient care and interaction.

Based on observation, interview, and policy review, the facility failed to ensure staff maintained a clean and sanitary environment to limit the potential transmission of infection. These failures directly affected 5 of 5 Patients (#7, #8, #9, #11 and Patient #12) whose care was observed. This had the potential for infections to be transmitted throughout the hospital and potentially affect all patients and staff in the hospital. Findings include:

The hospital policy titled "IV therapy - Peripheral IV Line," dated 10/24 included under the section titled "Procedure:

...13. Maintain the sterility of the male leur end of the administration set before and during connection to the IV hub ....

16. Perform a vigorous mechanical scrub of the needleless connector of the primary line that's closest to the primary solution bag for at least 15 seconds with an antiseptic pad and allow it to dry completely."

Additionally, under the section titled "Administering an IV push medication," it stated:

"8. Perform a vigorous mechanical scrub of the needleless connector for at least 15 seconds and let it dry completely." This policy was not followed.

The hospital had a policy titled, "Hand Hygiene - Policy and Procedure per CDC Guidelines" with a last approved date of 10/24. The policy stated, "In accordance ...IFCH's infection prevention and control program requires all staff to use the approved hand-hygiene techniques...

3. Before each patient encounter ...

6. After coming in contact with patient intact skin ...

10. After contact with medical equipment/supplies in a patient's area. ...

11. Always after removing gloves."

The hospital had a policy titled "Employee Dress and Appearance Policy" with a last approved date of 3/2025. The policy stated, "Employees conducting business in an area that treats, touches, or interacts with patients should wear close-toed shoes at all times."

These policies were not followed. Examples include:

1. Patient #8 was a 58 year old female admitted to the hospital on 7/31/25 at 12:31 AM with admission reason listed as "AMS."

An ICU RN's care for Patient #8 was observed on 8/05/25 beginning at 10:15 AM. The RN was observed to go into Patient #8's room and assist patient to the bathroom. The RN was observed to throw away soiled chucks from the patient's bed while wearing gloves. The RN was then observed administering an IV medication to Patient #8. The RN did not perform hand hygiene and change gloves prior to administering medications to Patient #8's IV line.

2. Patient #7 was an 82 year old male admitted to the hospital ICU on 8/03/25 at 8:46 PM with admission reason listed "urine problem."

An ICU RN's care for Patient #7 was observed on 8/05/25 beginning at 10:00 AM. The following breaches in infection control were observed.

- The RN was observed to not use hand hygiene prior to touching the patient.

- The RN was further observed to not perform hand hygiene prior to donning clean gloves.

- The RN was observed to not clean the top of the vial of medication before drawing up the dose and then observed to not clean/alcohol swab the IV port before administering medication.

The RN was interviewed on 8/05/25 beginning at 11:30 AM. The RN was asked if he cleaned the vial before drawing up the medication or before administering the medication into the patient's IV line. The nurse reported he "didn't recall." When asked if cleaning the vial and IV port were normal expected duties prior to administering medication the nurse stated "6s." When asked what he meant the nurse reported "6 of one half a dozen of the other." When asked what is meant by that statement the nurse said it meant sometimes he does it.

3. A cardiologist was observed on 8/5/25 beginning at 10:35 AM in Patient #7's room. The cardiologist was observed to apply hand hygiene foam to one but not both hands while walking into patient room. Cardiologist was observed to lift the bedsheet of Patient #7 with her non-foamed hand and touch the patient with the other.

The cardiologist was also observed to be wearing sandals. The sandals were slotted and open on the sides and top. The cardiologist was observed to touch and lift the catheter bag with a sandaled foot and then leave the room without further hand hygiene or other infection control practices.

4. Patient #9 was a 74 year old male admitted to the hospital medical - surgical unit on 8/04/25 with admission reason listed "weakness."

On 8/05/2025 at 9:45 AM, an RN was observed providing care to Patient #9. During medication administration, Foley catheter adjustment, and bedside documentation, the nurse changed gloves on three occasions without performing hand hygiene between glove changes.

During the same observation Patient #9's RN was noted to have supplies (e.g., saline syringes, IV port caps) stored loosely in her uniform pocket. After performing cares for Patient #9, while wearing gloves, she retrieved a sterile IV port cap from her pocket and used it for Patient #9. She exited the room with the remaining supplies still in her pocket, potentially contaminated.

Patient #9's RN was interviewed on 08/05/25 beginning at 10:15 AM after the observations. She confirmed she should have performed hand hygiene after glove removal.

The Medical Surgical unit manager was interviewed on 8/05/25 beginning 1:00 PM and the above observations were reviewed with her. She confirmed all staff should perform hand hygiene after glove changes. Additionally, she stated clean supplies should not be accessed without hand hygiene prior.

5. Patient #12 was an 80 year old male admitted to the hospital stepdown unit 8/02/25 for influenza. His care was observed between the stepdown unit and the medical -surgical unit.

On 8/05/2025 at 10:30 AM, the CNA caring for Patient #12 was observed. Patient #12 was on droplet precautions for influenza. The CNA donned appropriate PPE (gown, mask, gloves) and performed tasks including repositioning the patient and arranging belongings. While still wearing gloves, he retrieved a cell phone from his pocket, answered a call, and returned the phone to his pocket without removing gloves or sanitizing the device.

The stepdown unit manager was interviewed on 8/05/25 beginning at 2:00 PM and the above observations were reviewed with her. She stated usage of interdepartmental phones for communication being used in the patient rooms had posed a problem. She confirmed the phone should be either cleaned after usage or hand hygiene performed before and after usage of the phone.

6. Patient #13 was a 68 year old male who was admitted to the ICU on 8/04/25.

On 8/05/25 beginning at 3:15 PM, the care team which included 3 RN's, a CNA, an RT, and a CRNA for Patient #13 were observed. The CRNA was observed touching the computer keyboard and then touching the patient, specifically the patient's ET tube, without changing gloves or performing hand hygiene. The CRNA was observed pulling an unpackaged uncapped syringe out of her pocket and administering IV medication to the patient. The CRNA did not clean the IV needleless connector before administering the medication. The RT was observed with gloved hands touching bags that were hanging from the IV pole and pulling out various pieces of equipment and then touching the patient's ET tube without changing gloves or performing hand hygiene. At 3:36 PM an RN was observed administering medication to the patient's IV needleless connector. The RN did not clean the connector before attaching a syringe to the connector and injecting the medication to the patient's IV line.

The facility failed to ensure policies and procedures for infection control were followed.