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Based on observation, Medical Record Review, document review and interview, the facility failed to ensure that staff provided care in accordance with the acceptable standards of Infection Control Practices for hand hygiene, use of Personal Protective Equipment (PPE), cleaning of reusable medical equipment, and proper storage of medical equipment.

Findings include:

The facility Policy and Procedure titled "Standard Precautions to Prevent the Transmission of Bloodborne Pathogens and Other Pathogens," last revised 11/2019 contained the following statements: "Wearing gloves does not substitute for hand hygiene. Hand Hygiene should be performed before donning and doffing gloves ... PPE should be removed immediately after use and disposed of in the appropriate receptacle... Perform hand hygiene immediately after contact with respiratory secretions and contaminated objects/materials."

On 2/25/20 @10:15 AM, Staff C was observed cleaning a ventilator after being used. Staff C changed gloves twice without performing hand hygiene. The arms of the ventilator and the tubing were folded and clamped together while Staff C was wiping them down; Staff C did not use a timer or clock to monitor the 3 minutes contact time of the disinfectant on the surface of the ventilator; brown residue was observed on the base at the back of the ventilator after the cleaning. The surveyor asked Staff C to repeat the procedure.
Staff C also forgot to remove PPE (gown, gloves and mask) before entering a clean storage room.

Staff J, Director of Respiratory Care witnessed these findings at the time of the observations.

Observation conducted in the Endoscopy Department on 2/25/20 between 11:00 AM to 1:00 PM, identified the following:
Staff T picked up soiled linen from Endoscopy Room # 2 without wearing a gown, hand carried the linen and walked through the hallway, and finally disposed of the linen in a container located in the patient's recovery area.

Staff B was observed using one set of wipes to clean multiple equipment. Staff B picked up a sanitizing wipe from the floor and used it to clean the tubing of the anesthesia machine and failed to change gloves and perform hand hygiene.
Staff B and Staff T were observed cleaning other reusable equipment in the room without wearing proper PPE.

In Endoscopy Room #1, which was cleaned and where Staff C was preparing for the next patient, a mask and the circuit tubing attached to anesthesiology machine were found on the floor.

Staff U, Endoscopy Nurse Manager, confirmed these findings at the time of observation and during interview.

The facility's Policy and Procedure titled "Transmission-Based Precautions," last revised 02/2019 stated: "Hand hygiene must be performed before entering and when leaving the room of a patient on transmission-based precautions and after handling items which originated from the room."


During a tour of 6 West Unit, on 2/26/20 at 10:45AM, the following were observed:
Staff E exited an Airborne Infection Isolation room occupied by a confirmed case of Tuberculosis, with a surgical mask on and without performing hand hygiene. Staff E went to wash her hands using a sink located in the hallway and discard her mask in a nearby container. The Nurse Manager was present during the observation, and instructed Staff E about the missed opportunities. During interview with Staff E, she stated "I forgot this was an isolation room."

Office supplies were found on the floor in a clean storage room. Other boxes filled with medical supplies were found on a shelf. A cart which contained delivery supplies in boxes, was found unattended by the nursing station. This practice was observed to be contrary to the facility policy and posed an infection risk due to the other clean supplies being exposed to dust and dirt from the cardboard boxes.

The facility's policy and Procedure titled "Clean Supply Storage and Stocking," last reviewed 12/2019 stated: "Clean or sterile items to be transported to central processing and storage areas within the facility should be removed from their external shipping containers before they enter the storage areas of the department ..."

These observations were made in the presence of Staff Nurse Manager who confirmed these findings.


Observation in the NICU on 2/28/20 between 11:00AM to 12:30AM identified issues with the separation of clean and dirty equipment :
On KP3 Unit, a toy and a mirror were found in a basket with other emergency intubation supplies. In multiple rooms, milk warmer machines, breast milk, and cleaning supplies were stored on countertops in close proximity to sinks used for hand washing.

Room 342, which was occupied by a patient on contact precautions, revealed an unplugged milk warmer being stored on a windowsill with patient's soiled clothing.

On KP3 East Unit, the surveyors noted small refrigerators used for storing breast milk was on the floor in Room #s 335 and 358. The surveyors also noted that the staff were storing diaper scales on the refrigerator in KP3 North unit.

On K335 Unit, the refrigerator was stored next to a sharp container.

On KP4 unit, family belongings were laying on a box of gloves dedicated for staff use.

Staff I, NICU Nurse Manager, and Staff V, Hospital Epidemiologist, witnessed and confirmed these findings.

Based on review of Policies and Procedures, Engineering Logs, observation and Staff interview, the facility:
(a) failed to maintain the humidity in the Operating Rooms within acceptable range, specified by CDC, and (b) did not monitor the airflow in the Operating Rooms to maintain positive air pressure in relation to the corridor at all times.

Findings include:

(a) During Review of Temperature and Humidity Logs for the Operating Rooms in Guggenheim Pavilion, it was noted on some days, that there was sporadic decrease in humidity from the CDC's acceptable range of 30%-60%.

For Example: On 02/08/2020 at 5:00 AM, Operating Rooms #3, #4, #18, #19, #20, #21, #22 and #26, had humidity levels of 29%, 26%, 22%, 21%, 23%, 21%, 27%, 23%, 27%, and 26% respectively.

Upon interview of Vice President Of Engineering (VP), on 02/25/2020 at approximately 2:00 PM, it was stated that the humidity in Operating Rooms drop when the ambient (outside environment) temperature drops.

Upon request for a Governing Body approved policy and risk assessment regarding surgical procedures performed in Operating Rooms with low humidity, the VP of Engineering stated that all risk assessments were conducted and the policy based on the risk assessment was being finalized to be presented at the next Governing Body Meeting.

Therefore, it was determined that the Operating Rooms with low humidity, were being used for surgical cases without a proper policy that is approved by the hospital's Safety Committee and Governing Body.

(b) On 02/26/2020 between 1:40 PM and 2:15 PM, during the tour and testing of air pressure in the Operating Rooms of Annenberg Pavillion with smoke puff; 2 Cystoscopy Procedure Rooms #35 and #36, and Operating Room #2, were observed to have negative air pressure in relation to the corridor. The facility's engineering staff resolved the issue at approximately 2:15 PM.
During the time of this observation, interview with the Director of Peri-Operative Service revealed that the clinical staff were not aware of the HVAC failure and the clinical staff did not have any mechanism to ensure that the positive air pressure is maintained in the Operating Rooms at all times.

During the interview of the Vice-President of Engineering on 02/26/2020 at approximately 2:30 PM, it was stated that HVAC fan tripped caused the 2 Cystocopy Procedure Rooms #35 and # 36 and the Operating Room #2 to lose positive pressure. It was also stated that HVAC system was monitored electronically by the Engineering Department and that an alarm is generated upon its failure. Upon reviewing the documentation of alarm communication for the HVAC failure that occurred on 02/26/2020, it was noted that the alarm was generated at 2:15 PM, after the positive pressure was restored in the three (3) surgical rooms.

Review of the HVAC monitoring flow chart titled " Annenberg 6 Inner Cluster OR," noted that the chart did not show the loss of positive pressure that was identified in OR #2 on 02/26/2020 at approximately 2:00 PM. The Engineering Staff were not able to clearly identify the time when the HVAC failure actually occurred and therefore the Operating Room Clinical staff were not aware of the actual time period the two (2) Procedure Rooms and the Operating Rooms functioned without positive air pressure.

Therefore, it is determined that the facility is not able to ensure that the Operating Rooms are maintained with Positive Pressure in relation to the corridor at all times, using the current electronic system.