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Based on observation, interview, and record review, the facility failed to implement their infection control program as demonstrated by the following:
1. The infection control consultant who was hired on 6/05/15 will not start until 7/01/15. Currently, there is no qualified infection control coordinator who can implement and monitor the program to ensure the plan of correction from the last sample validation survey was instituted.
2. As a result, infection control practices were still breached in the facility's operating room.

Findings:

1. Document review showed the "Letter of Agreement" that outlined the hiring contract for the new infection coordinator stated the following: "The letter of Agreement... is made and entered into as of this June 5, 2015 ("Effective Date"), by and between Chinese Hospital... and (the infection control consultant), with reference to the following facts: WHEREAS Hospital owns and operates a licensed general acute care hospital..., WHEREAS, Contractor is in the business of consulting, with expertise in infection control, public health preparedness, disaster response, and presentation skills for varies settings. WHEREAS, Hospital wishes to obtain services on an independent contractor basis from Contractor and Contractor wishes to and is qualified to provide those services...". This contract was signed by the hospital's Chief Executive Officer on 6/05/15 and by the consultant on 6/06/15.

During an interview on 6/15/15 at 10:30 am, the current infection control coordinator stated the consultant had not been at the hospital yet and will start on 7/01/15. The infection control coordinator also stated he will be taking the CBIC (Certification Board of Infection Control) in July 2015.


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2. During an observation on 6/15/15 at 2:00 PM, housekeeping staff did not follow the facilities policy and procedure, "Clean Between Cases" when cleaning the surgical suite in-between cases. The housekeeping staff did not:

a. Wash the yellow bucket which contained the mop and the liquid in the bucket was not changed before mopping the surgical suite number 1.
b. Change the mop head before or after the housekeeping staff mopped the surgical suite's floor.
c. Keep the mattress clean after placing it on the dirty floor.
d. Clean the tray table.
e. Change dirty gloves before moving the clean gurney.
f. Remove the garbage in the surgical suite before cleaning.
g. Prevent the possible spread of bacteria when the garbage bags were shook open before placing them in their garbage holders.

During an interview on 6/15/15, at 2:50 PM, the infectious control nurse, stated," the garbage in the operating room should have been removed before the cleaning. The housekeeping staff should have changed gloves before moving the gurney and before getting the mop. The housekeeping staff also should not have shook the bags, this action can spread bacteria."

Review of the facility's policy and procedure,"Clean Between Cases", Policy Number 115.100, revised date 5/15, indicated," remove waste, soiled linen and infectious waste (red container) from the surgical suite... After mopping, change the mop head, germicides solution and then clean and rinse the bucket."