HospitalInspections.org

Based on observations, interviews and document review, the facility staff failed to ensure they followed the facility's infection prevention and control program by ensuring staff were performing hand hygiene after adjusting their facemask (Staff Members #7, #15, #16) and after removing their gloves (Staff Members #8. #9. #10); wearing face shield or goggles in patient care areas (Staff Member #7); wearing facemask appropriately (Staff Member #15); cleaning reusable equipment between patients (Staff Member #14); and ensuring paper towels were stored so when used remaining towels do not become wet, soiled apron and cleaning rag were not stored on clean surfaces, scoops were stored on hooks in food storage bins, pans were not stacked wet, and joints in kitchen floors were sealed.

The findings include:

1. On December 6, 2021 a tour of the facility was performed and the following items were noted as breaches in their infection control policies.
The Kitchen area was toured with Staff Member #11 (Dietician) on 12/6/21 at 11:30 A.M.

The paper towel dispenser next to hand washing sink by the entrance door had no paper towels in the dispenser. There were towels stacked on top of the dispenser. When one towel was removed, the remaining towels would become wet from dripping water.

Infection Control Hospital Epidemiology 21(7); 442-8; Boyce, JM, Kelliher, S., Vallande, N. (2000).
http://www.ncbi.nlm.nih.gov/pubmed/10926393.
"For healthcare settings, closed paper towel dispensers are preferred over a roll or stack of paper towels sitting beside the sink because of the risk of re-contamination through splashes..."

A used apron and a cleaning rag were observed lying on clean patient trays with clean disposable placemats on the trays. Staff Member #11 directed Staff Member #3 to remove the apron and the cleaning rag and the top layer of placemats.

Staff Member #12 was observed with disposable gloves on their hands slicing romaine lettuce. Staff Member #12 removed the disposable glove from their right hand, wadded it up and held it in their left hand while they entered information into a label maker. Staff Member #12 then put the same disposable glove back on and proceeded to handle food again. Staff Member #11 stated, "They should have discarded the disposable glove and put on a clean glove."

In the dry storage area, a scoop was lying on top of the rice in the rice bin rather than hanging on the hook inside the bin.
On the pan storage rack, four (4) pans were put away and stacked wet. (The 1999 Food and Drug Administration Food Code specifies air-drying of all dishware as an important step in preventing bacterial growth on food-contact surfaces.)

In the middle of the food preparation area, there was a gap in the floor approximately an inch wide and three to four (3 to 4) feet long that left exposed porous concrete. The porous surface would not have been able to be cleaned to prevent insects and vermin from being drawn to debris caught in the concrete.

The kitchen items were discussed with Staff Member #17 (Dietary Manager) on 12/6/21 at approximately 12:00 noon and they stated, "The glove should have been discarded and they should have washed their hands. We put a work order in for that probably back in August." A work order for the floor with no date it was generated was provided. The work order had a date printed as 12/6/21.

The policy titled Production, Purchasing and Storage; Subject: Food and Supply Storage #B003 Revised 1/21 documents the following:
"Dry Storage: Store foods in their original packages. Foods that must be opened must be stored in NSF (formerly the National Sanitation Foundation) approved containers that have tight fitting lids. Label both the bin and the lid. Hang scoop...
Hands must be washed before putting on and after removing disposable gloves when working in the kitchen...Disposable gloves must be changed and hands washed when the gloves are dirty or ripped and when moving from one task to another, such as moving from handling dirty dishes to handling clean dishes."


At approximately 12:40 P.M., Staff Member #14 was observed on Four South in Patient #5's room. Staff Member #14 was observed examining Patient #5 with a stethoscope and gloves on their hands. Staff Member #14 used their gloved hands to place the stethoscope around their neck then removed the gloves and performed hand hygiene. Staff Member #14 was not observed cleaning the stethoscope or removing any protective covering from the stethoscope.

With Staff Member #19 present, Staff Member #14 was asked if they could please clean the stethoscope prior to placing it around their neck. Staff Member #14 responded by stating, "I used a glove over the diaphragm and no other part of the stethoscope touched the patient."

Staff Members #2 and #4 were present during the tours of the units and kitchen.


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2. On December 6, 2021 between 11:00 a.m. and 1:30 p.m. the following were observed:

At 11:10 a.m. during a tour of the Emergency Department (ED), Staff Member # 7 was observed coming out of a Patient area (either Room # 7 or # 8, there were curtains separating the two rooms). Staff Member # 7 was not wearing a face shield or goggles. Staff Member # 7 adjusted the face mask by touching the front of the face mask and failed to perform hand hygiene.

At 11:11 a.m., an interview with Staff Member # 4 revealed "Yes, [Staff Member # 7] should be wearing either a face shield or goggles in the Patient Care area."

At 11:35 a.m. during a tour of the kitchen, Staff Members # 8, # 9 and # 10 were observed removing dirty gloves and donning clean gloves without performing hand hygiene.

At 12:55 p.m. during a tour of Unit 5 S, Staff Member # 15 was observed sitting at the nurse's station with the face mask below the chin. Staff Member # 15 pulled the face mask up above the nose by touching the front of the mask. Staff Member # 15 failed to perform hand hygiene after touching the front of the face mask.

At 1:00 p.m., during a tour of Unit 5 S, Staff Member # 16 was observed pulling mask down below chin and then back up above nose by touching the front of the mask. Staff Member # 16 failed to perform hand hygiene after touching the front of the face mask.

The facility policy provided by Staff Member # 6 on December 6, 2021 at 3:00 p.m. titled "Hand Hygiene" reads in part "Personnel should use an alcohol-based hand rub or wash with soap and water for the following: immediately aft glove removal".

The facility guidance provided by Staff Member # 6 on December 6, 2021 at 3:00 p.m. titled "Use of Personal Protective Equipment (PPE)" reads in part "Donning: If the respirator has a nosepiece, it should be fitted to the nose. Respirator/facemask should be extended under chin. Both mouth and nose should be protected. Do not wear respirator/facemask under your chin.
Doffing: Facemask: Carefully untie and pull away from face without touching the front. Perform hand hygiene after removing the respirator/facemask."

The findings were discussed with Staff Member # 1 on December 6, 2021 at 3:00 p.m. during the end of day exit interview.