HospitalInspections.org

Based on observations, interviews and record review, the hospital failed to have an effective governing body that is legally responsible for the conduct of the hospital when:

1. Environmental Services (EVS) staff did not follow various disinfectant's (a chemical solution used to sanitize surfaces and devices and approved to destroy bacteria and viruses) manufacturer's instructions for use (IFU) of contact time (time the disinfectant needs to stay wet on surface in order to work) when disinfecting the hospital's environmental surfaces. (Refer to A-0750 findings 1, 2, 3).

2. One of one Ultrasound (specialized imaging machine that uses sound waves to produce image within the body) Technician (UST) did not demonstrate the appropriate technique to disinfect the ultrasound machine and its probes; did not follow manufacturer's IFU for contact time and was not trained on cleaning of the ultrasound equipment after each patient use. (Refer to A-0750 finding 4).

3. One of one EVS Staff (EVS 4) did not follow infection control standards in cleaning a room occupied by Patient 43 (Bed A) and previously occupied by Patient 44 (Bed B). (Refer to A-0750 finding 5).

4. The hospital did not follow current infection control standards of practice when patient toilets were cleaned using the same soiled toilet bowl brush for up to five days without rinsing, disinfecting or disposing of the soiled toilet bowl brush. (Refer to A-0750 finding 6).

5. The EVS Department disinfecting chemicals were not reviewed to ensure the EVS disinfecting chemicals were EPA (Environmental Protection Agency- registered cleaning products- means a product should do what the label says and should not pose an unreasonable hazard to a person's health) certified and approved by the Infection Control Committee (ICC) prior to EVS staff using the disinfectant chemical solution in the hospital;. (Refer to A-0750 finding 7).

6. The hospital did not develop EVS Policies and Procedures (P&P) that followed National Infection Control Guidelines and failed to ensure the ICC reviewed and approved EVS P&P prior to the P&P implementation. (Refer to A-0750 finding 8).

7. The hospital did not perform effective contact tracing (involves identifying people who have an infectious disease and who they came in contact with and working with them to prevent the spread of disease), exposure risk assessments, training, and reporting to the local health department to maintain an effective infection prevention and control program to reduce the risk of transmission of COVID-19 (a serious respiratory illness caused by a virus which is the cause of a current worldwide pandemic [prevalent over a whole country or the world]). (Refer to A-0750 finding 9).

8. One of 45 patients (Pt 42) contracted COVID while in the hospital and the hospital did not conduct an investigation to determine the source of the infection. (Refer to A-0750 finding 10).

9. One of one Sterile Processing Department Technician (SPDT) did not follow AAMI (Association for the Advancement of Medical Instruments- professional standards the hospital follows) standards and manufacturer's IFUs of channel brushes (long-handled nylon brushes used to clean devices with spaces) and steel brushes (tooth brush style cleaning brush made of steel bristles) in the performance of decontamination (removal of dangerous substances or germs from an area, object, or person) area (a room used to clean and disinfect reusable patient surgical instruments) of surgical instruments sets (instruments from different patient surgeries) when the SPDT used the same channel brush and steel brush for multiple surgical tray sets. (Refer to A-0750 finding 11).

10. The Environmental Services (EVS) Department disinfecting chemicals were not reviewed to ensure the EVS disinfecting chemicals were EPA (Environmental Protection Agency- registered cleaning products- means a product should do what the label says and should not pose an unreasonable hazard to a person's health) certified and approved by the Infection Control Committee (ICC) prior to EVS staff using the disinfectant chemical solution in the hospital. (Refer to A-0772, finding 1).

11. The hospital did not develop Environmental Services (EVS) (P&P) that followed nationally recognized Infection Control Guidelines and failed to ensure the ICC reviewed and approved EVS P&P prior to the P&P implementation. (Refer to A-0772, finding 2).

Because of the serious potential harm to all patients, staff and visitors related to not ensuring a sanitary environment and the serious potential and actual harm of the spread of COVID-19 related to not having a surveillance program to avoid infections, an Immediate Jeopardy (IJ) situation was called with the Chief Nursing Officer (CNO), Director of Four North (D 4), Accreditation Manager (AM), and the Infection Prevention Director (IPD), on 10/9/20 at 7:29 p.m. under A750 CFR 482.42(a)(3). The CNO was provided the IJ template which documented the immediate actions necessary to address the IJ situation. The CNO was provided an explanation to submit an acceptable Action Plan to address the IJ situation. Version 3 of the Action Plan was acceptable on 10/12/20. The following items were listed on the Action Plan and validated by the survey team: All EVS staff completed competency of cleaning and disinfecting environmental surfaces, policies and procedures were reviewed and approved by the Infection Prevention Committee, Occupational Health staff were trained on contact tracing to identify COVID 19 exposures and to investigate risks of transmission. All items of the Action Plan were validated through observations, interview, and record review and the IJ was removed with the CNO in attendance on 10/16/20 at 2:57 p.m.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and responsible manner.

Based on interview and record review, the hospital failed to ensure one of 45 patients (Pt 25) was free from verbal abuse and failed to have a written procedure for investigating verbal abuse when Registered Nurse (RN) 1 did not report Pt 25's allegation of verbal abuse.

This failure violated Pt 25's right to be free from verbal abuse, resulted in Pt 25 to feel upset and for allegations of verbal abuse to not to be reported and investigated by the hospital.

Findings:

During a telephone interview on 9/30/20, at 2:30 p.m., with Pt 25, Pt 25 stated she was admitted to the General Acute Care Hospital (GACH) on 8/17/20 and was diagnosed with Coronavirus (Covid-19- a serious respiratory illness caused by a virus which is the cause of a current worldwide pandemic [prevalent over a whole country or the world]). Pt 25 stated, "I had the worst experience in the [Intensive Care Unit (ICU)]. A traveling nurse called me fat, that I couldn't do anything. She's just mean and talking crap about me ... I wanted to get suctioned (removing secretions from a patient with an artificial airway in place and is used to clear retained or excessive lower respiratory tract secretions in patients who are unable to do so for themselves) and she didn't want to suction me. I was so upset. I informed [RN 1] about the incident and I wrote it down on a piece of paper because I couldn't talk at that time. I had a tracheostomy (is a surgically created opening in the windpipe (trachea) that provides an alternative airway for breathing). I was really sick."

During an interview on 9/30/20, at 4:29 p.m., with RN 1, RN 1 stated she was familiar with Pt 25 and she took care of her while Pt 25 was in the ICU. RN 1 stated Pt 25 wrote down on a piece of paper an RN on the night shift called her fat and did not want to assist her with care. RN 1 stated Pt 25 was really upset about the situation. RN 1 stated she reported the incident to the Charge Nurse (CN), " ... [CN ICU] gave me the assurance [Pt 25] will not be assigned to the nurse and I left it with that..."

During an interview on 10/1/20, at 10:32 a.m., with CN ICU, CN ICU stated RN 1 did not inform her of Pt's 25 allegation of verbal abuse by another RN. CN ICU stated RN 1 should have reported it to her and should have filled an online report regarding Pt 1's allegation of verbal abuse so that an investigation could be conducted.

During an interview on 10/2/20, at 9:47 a.m., with the Patient Safety Officer (PSO), the PSO stated Pt 25's allegation was considered verbal misconduct. The PSO stated the facility had a policy and procedure on physical abuse and assault. The PSO stated there were different kinds of abuse and one form of abuse was verbal abuse. The PSO stated any abuse allegation verbalized by patients needed to be reported and investigated. The PSO stated, " ...We don't define it as verbal assault, but we don't ignore it. That's why that complaint goes to the director to follow up. They have to follow up on that allegation ... It would be something that should be reported. We have an electronic reporting that is real time. It goes to Patient Safety Officers, Director of the Unit and the Management Unit ... Every complaint needs a follow through and resolution. We don't ignore those ..."

During a concurrent interview and record review, on 10/7/20 at 3 p.m. with the Patient Safety Officer (PSO), the PSO stated the various forms of abuse were verbal, sexual, physical, neglect, and assault. The PSO stated verbal abuse can be described as unprofessional conduct and degrading (cause people to feel that they or other people have no value and do not have the respect or good opinion of others) the patient or whoever an individual is speaking to. The PSO reviewed the hospital's P&P titled, "Reporting of Allegations of Patient Neglect or Physical or Sexual Abuse or Assault" dated 1/23/19 and stated the policy is specific to patient neglect, physical abuse, sexual abuse, and/or assault. The PSO stated the hospital's policy did not address verbal abuse.

During a concurrent interview and record review, on 10/19/20 at 1:15 p.m., with the Chief Nursing Officer (CNO), the CNO stated she was informed there were allegations a nurse had called Pt 25 fat, told her she stunk, and made comments that should could not do anything for herself. The CNO stated the hospital's policy and procedure regarding abuse addresses actual assault. The CNO stated the hospital did not have a policy specific to verbal abuse, instead it would follow under standard of conduct or the hospital's complaint and grievance policy.

During a review of the hospital's policy and procedure (P&P) titled, "Reporting of Allegations of Patient Neglect or Physical or Sexual Abuse or Assault" dated 1/23/19, the P&P did not address verbal abuse.

During a review of the hospital's document untitled, that was provided as the hospital's standard of conduct training guide, the document did not address verbal abuse.

During a review of the hospital's P&P titled, "Patient Complaint and Grievances" dated 2/26/20, the P&P did not address verbal abuse.


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Based on observation, interview and record review, the hospital failed to ensure licensed nurses adhered to the hospital's policies and procedures when:

1. One of 45 patients (Pt 32) was not turned every two hours to prevent pressure ulcer injury (damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure) per the hospital's policy and procedure titled, "Pressure Injury Prevention and Management Policy"; and

2. Three of six emergency crash carts (set of trays/drawers/shelves on wheels used in hospitals for transportation and dispensing of emergency medication/equipment at site of medical/surgical emergency for life support protocols to potentially save someone's life) (Crash Carts B, C and D) in the Emergency Department (ED) were not checked by licensed nurses for completeness and equipment function per the hospital's policy and procedure titled, "Crash Carts- Cleaning, Checking, and Restocking Procedure".

These failures had the potential to result in not providing the necessary nursing interventions to maintain skin integrity for further skin breakdown and harm of Pt 32 and could possibly lead to worsening of the's pressure ulcer; and for equipment to malfunction (not work properly) in the ED in the event of an emergency.

Findings:

1. During a review of Pt 32's clinical record, dated 9/27/20 at 8:15 p.m., the "Incision/Wound Description" indicated Pt 32 had a pressure injury to the sacrum (triangular bone in the lower back). The "Adult ADL [activities of daily living]" flowsheet indicated nursing staff did not turn or change Pt 32's position on 9/28/20 from 8:25 a.m. to 4:23 p.m.

During an interview on 10/14/20, at 11:40 a.m., with the Director of the 1st Floor Medical Unit (D 6), D 6 stated there was no indication of position change or turning of Pt 32 every two hours. D 6 stated the staff should have documented Pt 32's turning position every two hours. D 6 stated it was important to turn Pt 32 every two hours to take pressure off Pt 32's skin injury and prevent further skin breakdown of the sacrum.

The hospital's policy and procedure (P&P) titled, "Pressure Injury Prevention and Management Policy" dated 5/27/20, the P&P indicated, " ...Purpose: To ensure timely identification, assessment and treatment for patients that are at risk or have pressure injury present on admission ...Braden Pressure Reduction Measure ...Turn patients at least every 2 hours ..."

2. During a concurrent observation, interview, and record review on 9/29/20, at 10:50 a.m., in the ED with the ED Director (D 5), the documentation log for Crash Cart B was reviewed and the log dated 9/12/2020 and 9/16/2020 did not have documentation it was checked for completeness and equipment function. D 5 stated it was the Licensed Nurse's responsibility to check the crash cart once a day every night shift to ensure the equipment's are working.

During a concurrent observation, interview, and record review on 9/29/20, at 10:52 a.m., in the ED with D 5, the documentation log for Crash Cart D was reviewed and the log dated 9/26/2020 did not have documentation it was checked for completeness and equipment function. D 5 stated Licensed Nurse during the night shift should have ensure the log was completed and checked for equipment function and it was not done.

During a concurrent observation, interview, and record review on 9/29/20 at 10:56 a.m., in the ED with D 5, the documentation log for Crash Cart C was reviewed and the log dated 9/11/2020 and 9/12/2020 did not have documentation it was checked for completeness and equipment function. D 5 stated it was very important to check the crash cart once a day every night shift to make sure the equipment's are functioning in the event of an emergency.

During a review of the hospital's P&P titled, "Crash Carts- Cleaning, Checking, and Restocking Procedure" dated 5/27/20, the P&P indicated, "Purpose: To assure cart and supplies required for immediate, emergency patient care are in place at all times and in usable condition ... Frequency ... Once every 24 hours, the checklist will be reviewed for completeness and equipment function ... Checking Process ... Daily log is updated with new lock number and expiration date ... 2. Manual testing of the defibrillator will be done daily and logged appropriately ... "

Based on observations, interviews, and record review, the hospital failed to ensure there was an active hospital-wide program for the surveillance, prevention, and control of Healthcare Associated Infections (HAIs-infection that develops as a result of medical care while in the hospital) such as Coronavirus (COVID 19-a serious respiratory illness caused by a virus which is the cause of a current worldwide pandemic [prevalent over a whole country or the world]) and other communicable (a disease capable of being transmitted, by any means, from one person to another) diseases when:

1. Environmental Services (EVS) staff did not follow various disinfectant's (a chemical solution used to sanitize [to make clean] surfaces and devices and approved to destroy bacteria and viruses) manufacturer's instructions for use (IFU) of contact time (time the disinfectant needs to stay wet on surface in order to work) when disinfecting the hospital's environmental surfaces. (Refer to A-0750 findings 1, 2, 3).

2. One of one Ultrasound (specialized imaging machine that uses sound waves to produce image within the body) Technician (UST) did not demonstrate the appropriate technique to disinfect the ultrasound machine and its probes; did not follow manufacturer's IFU for contact time and was not trained on cleaning of the ultrasound equipment after each patient use. (Refer to A-0750 finding 4).

3. One of one EVS Staff (EVS 4) did not follow infection control standards in cleaning a room occupied by Patient 43 (Bed A) and previously occupied by Patient 44 (Bed B). (Refer to A-0750 finding 5).

4. The hospital did not follow current infection control standards of practice when patient toilets were cleaned using the same soiled toilet bowl brush for up to five days without rinsing, disinfecting or disposing of the soiled toilet bowl brush. (Refer to A-0750 finding 6).

5. The hospital did not ensure Environmental Services Department disinfecting chemicals solutions were reviewed to ensure the EVS disinfecting chemicals were EPA (Environmental Protection Agency- registered cleaning products- means a product should do what the label says and should not pose an unreasonable hazard to a person's health) and approved by the Infection Control Committee (ICC) prior to EVS staff using the disinfectant chemical solution in the hospital. (Refer to A-0750 finding 7).

6. The hospital did not develop EVS Policies and Procedures (P&P) that followed National Infection Control Guidelines and failed to ensure the ICC reviewed and approved EVS P&P prior to the P&P implementation. (Refer to A-0750 finding 8).

7. The hospital did not perform effective contact tracing (involves identifying people who have an infectious disease and who they came in contact with and working with them to prevent the spread of disease), exposure risk assessments, training, and reporting to maintain an effective infection prevention and control program to reduce the risk of transmission for COVID-19. (Refer to A-0750 finding 9).

8. One of 45 patients (Pt 42) contracted COVID while in the hospital and the hospital did not conduct an investigation to determine the source of the infection. (Refer to A-0750 finding 10).

9. One of one Sterile Processing Department Technician (SPDT) did not follow AAMI (Association for the Advancement of Medical Instruments- professional standards the hospital follows) standards and manufacturer's IFUs of channel brushes (long-handled nylon brushes used to clean devices with spaces) and steel brushes (tooth brush style cleaning brush made of steel bristles) in the performance of decontamination (removal of dangerous substances or germs from an area, object, or person) area (a room used to clean and disinfect reusable patient surgical instruments) of surgical instruments sets (instruments from different patient surgeries) when the SPDT used the same channel brush and steel brush for multiple surgical tray sets. (Refer to A-0750 finding 11).

10. The hospital did not ensure the Environmental Services Department disinfecting (clean an object, especially with a chemical, in order to destroy bacteria) chemicals solutions were reviewed for EPA (Environmental Protection Agency- registered cleaning products- means a product should do what the label says and should not pose an unreasonable hazard to a person's health) and approved by the Infection Control Committee (ICC) prior to EVS staff using the disinfectant chemical solution in the hospital. (Refer to A-0772, finding 1).

11. The hospital did not develop Environmental Services (EVS) (P&P) that followed nationally recognized Infection Control Guidelines and failed to ensure the ICC reviewed and approved EVS P&P prior to the P&P implementation. (Refer to A-0772, finding 2).

Because of the serious potential harm to all patients, staff and visitors related to not ensuring a sanitary environment and the serious potential and actual harm of the spread of COVID-19 related to not having a surveillance program to avoid infections an Immediate Jeopardy (IJ) situation was called with the Chief Nursing Officer (CNO), Director of Four North (D 4), Accreditation Manager (AM), and the Infection Prevention Director (IPD), on 10/9/20 at 7:29 p.m. under A750 CFR 482.42(a)(3). The CNO was provided the IJ template which documented the immediate actions necessary to address the IJ situation. The CNO was provided an explanation to submit an acceptable Action Plan to address the IJ situation. Version 3 of the Action Plan was acceptable on 10/12/20. The following items were listed on the Action Plan and validated by the survey team: All EVS staff completed competency of cleaning and disinfecting environmental surfaces, policies and procedures were reviewed and approved by the Infection Prevention Committee, Occupational Health staff were trained on contact tracing to identify COVID 19 exposures and to investigate risks of transmission. All items of the Action Plan were validated through observations, interview, and record review and the IJ was removed with the CNO in attendance on 10/16/20 at 2:57 p.m.

The cumulative effects of these systemic problems resulted in the hospital's inability to provide an effective hospital wide infection control program with patient care in a safe and effective manner in accordance with the §482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs.

(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)
§482.42(a)(3) The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and
Interpretive Guidelines §482.42(a)(3)

Based on observation, interview and record review, the hospital's infection control program failed to ensure a clean and sanitary environment throughout the hospital and failed to ensure an infection prevention and control program that included surveillance and prevention of Coronavirus (COVID-19-a serious respiratory illness caused by a virus which is the cause of a current worldwide pandemic [prevalent over a whole country or the world) infections when:

1. Two of two EVS (Environmental Services) staff (EVS 1 and 2) did not follow a disinfectant's (a chemical solution used to sanitize [to make clean] surfaces and devices and approved to destroy bacteria and viruses) manufacturer's instructions for use (IFU) of contact time (time the disinfectant needs to stay wet on surface in order to work) when sanitizing surfaces in the Emergency Department (ED);

2. One of one EVS staff (EVS 4) did not follow manufacturer's IFU of contact time when she used [brand name] disinfectant to sanitize surfaces in a patient's restroom and did not follow infection control standards when she used the same cloth for various surfaces;

3. One of one EVS staff (EVS 3) did not disinfect an IV (intravenous-into the vein) pole and infusion pump (medical device that delivers fluids into patients' body) from a discharged patient's room before it was returned to a room that was cleaned and disinfected in preparation for a new patient;

4. One of one Ultrasound (specialized imaging machine that uses sound waves to produce image within the body) Technician (UST) did not demonstrate the appropriate technique to disinfect the ultrasound machine and its probes; did not follow manufacturer's IFU for contact time and was not trained on cleaning of the ultrasound equipment after each patient use;

5. One of one EVS Staff (EVS 4) did not follow infection control standards in cleaning a room occupied by Patient 43 (Bed A) and previously occupied by Patient 44 (Bed B). EVS 4 did not change the sweep and mop pads to clean the toilet and bedroom floors, did not sanitize hands nor change gloves throughout the cleaning process, and did not properly dispose of soiled pillows and soiled items and trash into the trash container;

6. The hospital did not follow current infection control standards of practice when patient toilets were cleaned using the same soiled toilet bowl brush for up to five days without rinsing, disinfecting or disposing of the soiled toilet bowl brush;

7. The Environmental Services (EVS) Department disinfecting chemicals were not reviewed to ensure the EVS disinfecting chemicals were EPA (Environmental Protection Agency- registered cleaning products- means a product should do what the label says and should not pose an unreasonable hazard to a person's health) certified and approved by the Infection Control Committee (ICC) prior to EVS staff using the disinfectant chemical solution in the hospital;

8. The hospital did not develop EVS Policies and Procedures (P&P) that followed National Infection Control Guidelines and failed to ensure the ICC reviewed and approved EVS P&P prior to the P&P implementation;

9. The hospital did not perform effective contact tracing (involves identifying people who have an infectious disease and who they came in contact with and working with them to prevent the spread of disease), exposure risk assessments, training, and reporting to maintain an effective infection prevention and control program to reduce the risk of transmission for COVID-19;

10. One of 45 patients (Pt 42) contracted COVID while in the hospital and the hospital did not conduct an investigation to determine the source of the infection;

11. One of one Sterile Processing Department Technician (SPDT) did not follow AAMI (Association for the Advancement of Medical Instruments- professional standards the hospital follows) standards and manufacturer's instructions for use (IFUs) of channel brushes (long-handled nylon brushes used to clean devices with spaces) and steel brushes (tooth brush style cleaning brush made of steel bristles) in the performance of decontamination (removal of dangerous substances or germs from an area, object, or person) area (a room used to clean and disinfect reusable patient surgical instruments) of surgical instruments sets (instruments from different patient surgeries) when the SPDT used the same channel brush and steel brush for multiple surgical tray sets;

12. One of one Registered Nurse (RN 6) demonstrated double gloving (putting on two pairs of gloves) technique, she removed the outer gloves, touched a doorknob, removed her N95 respirator (respiratory protective device designed to achieve a very close facial fit that protects the wearer from inhaling particles) and put on a new mask while wearing the inner gloves;

13. A Medical Doctor (MD) did not perform hand hygiene after he removed his gloves while in the ante room (a small room between areas of contamination and treatment areas to isolate workspace from patient space). The MD proceeded to touch surfaces and put on a new pair of gloves and did not perform hand hygiene;

14. One of two Registered Nurse (RN 4) had patient contact with gloved hands, touched environmental surfaces (refers to the patient or patient's surroundings) with the gloved hands, and returned to the patient to remove their intravenous (IV - directly into the vein) catheter (thin, flexible tube that can put fluids into your body) with the same pair of gloves;

15. An MD wore an isolation gown (a protective article used by medical personnel to avoid exposure to blood, body fluids, and other infectious [likely to spread infection] materials, or to protect patients from infection) while at the nurse's station;

16. Three of three patients' (Pts 14, 22, 23) rooms had disposable isolation gowns that were hanging inside or outside of the room;

17. The ED stored "clean" and "dirty" equipment/items in a designated soiled utility storage room; and

18. One of one Unit Coordinators (UC) in the ED did not wear a surgical mask that covered her nose and mouth.

These failures resulted in the risk for cross contamination (inadvertent transfer of germs from one surface or person to another) and transmission of disease, including but not limited to COVID-19 to 375 patients, staff, and visitors in the hospital.

Because of the serious potential harm to all patients, staff and visitors related to not ensuring a sanitary environment and the serious potential and actual harm of the spread of COVID-19 related to not having a surveillance program to avoid infections an Immediate Jeopardy (IJ) situation was called with the Chief Nursing Officer (CNO), Director of Four North (D 4), Accreditation Manager (AM), and the Infection Prevention Director (IPD), on 10/9/20 at 7:29 p.m. under A750 CFR 482.42(a)(3). The CNO was provided the IJ template which documented the immediate actions necessary to address the IJ situation. The CNO was provided an explanation to submit an acceptable Action Plan to address the IJ situation. Version 3 of the Action Plan was acceptable on 10/12/20. The following items were listed on the Action Plan and validated by the survey team: All EVS staff completed competency of cleaning and disinfecting environmental surfaces, policies and procedures were reviewed and approved by the Infection Prevention Committee, Occupational Health staff were trained on contact tracing to identify COVID 19 exposures and to investigate risks of transmission. All items of the Action Plan were validated through observations, interview, and record review and the IJ was removed with the CNO in attendance on 10/16/20 at 2:57 p.m.

Findings:

1. During an observation on 9/29/20, at 11:04 a.m., in the ED admitting lobby, EVS 2 wiped the chairs with a disinfectant solution [bleach] and EVS 1 started wiping the chairs dry after 30 seconds.

During an interview on 9/29/20, at 11:07 a.m., with EVS 2, EVS 2 stated the disinfectant solution of bleach should be left wet on the surface for three minutes and EVS 1 should have not wiped it dry after 30 seconds. EVS 2 stated the importance of the leaving the disinfectant on the surface for three minutes was to ensure everybody was safe and to kill the germs on the surface. EVS 2 stated there were a lot of patients and it was very busy therefore she could not leave the disinfectant for the directed time of three minutes.

During an interview on 9/29/20, at 11:15 a.m., with EVS 1, EVS 1 stated she was aware the bleach solution should have been left wet for three minutes before wiping it dry. EVS 1 stated the purpose of leaving the bleach solution wet for three minutes was to ensure all microorganisms were killed and to prevent the transmission of infectious diseases such as COVID-19.

During a review of the [brand name] disinfectant manufacturer's IFU, dated 2020, indicated, "...Using [brand name] Germicidal (substance or agent that destroys harmful virus or bacteria) Bleach Against SARS-CoV-2 (coronavirus)...Instructions for SARS-CoV-2...Contact time used to kill SARS-CoV-2...5 minutes...Instructions for hard, nonporous surface disinfection...3. Allow solution to contact surface for at least 5 minutes..."

2. During an observation and concurrent interview, on 9/30/20, at 12:05 p.m., in a patient's room in 4 South (Hospital Unit), EVS 4 wiped the patient's sink once with a cloth that contained [brand name] disinfectant. After EVS 4 wiped the sink, she proceeded to the toilet and wiped the toilet bowl with the same towel. EVS 4 stated she used the same cloth to wipe the sink and the toilet. EVS 4 touched the sink and stated it was dry.

During an interview on 9/30/20, at 2:44 p.m., with EVS 4, EVS 4 stated she did not keep the sink surface area wet for 10 minutes.

During a review of the [brand name] disinfectant manufacturer's IFU, dated 2016, indicated, " ...This product can be applied by mop, sponge cloth, disposable cloth ... Change cloth sponge wipes or towels frequently to avoid redeposition of soil. For disinfection, surfaces must remain wet for 10 minutes ..."

3. During a concurrent observation and interview on 9/29/20, at 3:21 p.m., with the Director of Two South (D 1), in the hallway, a licensed nurse went inside Room 214, room of a discharged patient, and took the IV pole and infusion pump out of the room and removed the IV set (tubing connect to a bag of IV solution) and drip (plastic bag containing fluids). EVS 3 did not clean and disinfect the IV pole and infusion pump after the licensed nurse removed the IV set and drip. EVS 3 returned the IV pole with the infusion pump that was not disinfected back inside the room that was cleaned and disinfected. D 1 stated staff should have cleaned and disinfected the IV pole and IV infusion pump before it was placed back inside a cleaned room.

During an interview on 10/8/20, at 1:30 p.m., with the IPD, the IPD stated the EVS staff was responsible for disinfecting the IV pole and infusion pump. The IPD stated an IV pole with the infusion pump should be disinfected prior to bringing it back into a room that has been cleaned and disinfected. The IPD stated if used equipment was brought back into a "clean" room, the room was required to be cleaned again.

During a review of the hospital document titled, "Patient Room," undated, indicated, " ...[name of vendor] 10 Step Cleaning Process ....Patient Room Module ...Purpose ...To maintain clean and hygienic (maintaining health and preventing disease) stretchers, I.V. poles, and wheelchairs ...Process ...Wipe all surfaces with germicidal solution ..."

During a review of the hospital's policy and procedure (P&P) titled, "Standard Precaution Policy," dated 5/27/20, the P&P indicated, " ...Purpose: Standard Precaution were developed by the CDC (Centers for Disease and Control and Prevention) as the minimum infection control practices to prevent the spread of infection to both patients and healthcare workers .... E. Medical equipment cleaning ... ... properly clean and disinfect .... reusable equipment using a hospital-grade disinfectant before re-use ..."

4. During a concurrent observation and interview on 10/2/20, at 12:25 p.m., with the UST, in the ultrasound room, UST was asked to demonstrate how she cleaned and disinfected the ultrasound machine and ultrasound probe in between patient use. The UST wiped the ultrasound machine probe with a disinfectant wipe that was stored in a container with a gray top and let it dry for 37 seconds. The UST wiped the ultrasound machine horizontal touch board with a disinfectant wipe that was stored in a container with a purple top and let it dry for 37 seconds. The UST was unable to demonstrate and verbalize the contact time of the gray top wipes and the purple top wipes per the manufacture's IFU. The UST stated she was newly hired, that she started two months ago and was never trained on the contact time of the wipes for cleaning and disinfection of the ultrasound machine and probe. The UST stated, "What is contact time? I just wipe it extra. I do not know the [contact time]. You just have to let [the Ultrasound Machine] dry and re-wipe it after patient use."

During an interview on 10/2/20, at 12:40 p.m., with the IPD, the IPD stated the expectation was for USTs to be trained and follow the manufacturer's IFU of the gray and purple top disinfectants. The IPD stated the UST should have followed the manufacturer's IFU for proper cleaning and disinfection of the US machine and probes.

During an interview on 10/7/20, at 3:35 p.m., with the Director of Diagnostic Imaging (D 4), D 4 stated the process of USTs was to clean the equipment surfaces and probes with a disinfectant after each use. D 4 stated staff were supposed to use the disinfectant with the gray top, that has a three-minute contact time. D 4 stated staff were expected to follow the manufacture's IFU regarding contact time because there could be organisms (germs, bacteria, or virus) on the equipment and probe. D 4 stated the disinfectant's IFU indicated in or to kill organisms, the equipment and probe needed to be cleaned per manufacturer's IFU.

During an interview on 10/8/20, at 1:30 p.m., with the IPD, the IPD stated contact time meant when the individual used a disinfecting agent on surfaces, the item needed to stay wet on the surface for the directed time listed on the manufacture's IFU. The IPD stated this was important because the contact time is required to destroy microorganisms (germs, bacteria, or virus). The IPD stated staff should assure anytime they disinfect a surface, they always maintain the contact time. The IPD stated if the staff do not maintain the contact time, the risk would be transmission (process of passing something from one person or place to another) of organisms that is on the surface or equipment may be picked up by staff or patients of acquiring the organisms.

During a review of [brand name of disinfectant] [gray top product] IFU, dated 2019, indicated, "...GENERAL GUIDELINES FOR USE ... [brand name] germicidal (destroying germs) disposable wipes.... 4. Allow treated surface to remain wet for three minutes. Let air dry ... 5. Do not reuse towelette. ..... use on hard, nonporous environmental surfaces ..."

During a review of [brand name of disinfectant] [purple top product] IFU, dated 2019, indicated, "...GENERAL GUIDELINES FOR USE ... [brand name] germicidal disposable wipes... 4. Allow treated surface to remain wet for two minutes. Let air dry ... 5. Do not reuse towelette. ..... use on hard, nonporous environmental surfaces ..."

5. During a concurrent observation and interview on 10/8/20 at 10:03 a.m., of room cleaning in Unit 2 South and interviews with the Environmental Services Director (EVSD), Chief Financial Officer (CFO), and Accreditation Manager (AM), a large dark gray color trash container halfway filled with trash was parked in the hallway in front of Pt 43's room. Pt 43 was awake and sat on the edge of his bed (Bed A). There were two (2) hampers placed against the wall at the foot part of Pt 43's bed; one for soiled linens and the other for trash. Bed B was vacant. EVS 4 wore blue gloves and walked around Bed B which was already stripped (the bedsheets had been removed from the bed). A white pillow with visible brown-color spots was on the floor next to the bathroom door. The floor between Bed A and Bed B had off-white and brown debris/substances and bits of {paper} towels/tissues. EVSD stated, "Bed B is a discharge cleaning (meaning the process of cleaning and disinfecting the room or patient zone after the patient is discharged or transferred. It includes removal of material and significant reduction and elimination of microbial (bacteria causing disease) contamination)."

Beginning at 10:05 a.m., EVS 4 performed the following cleaning steps:

At 10:07 a.m., EVS 4 took pieces of disinfectant wipes (DW) from a container and wiped the over-bed table and its stand and left it to air dry. EVS 4 did not remove or change gloves and did not wash or sanitize hands.

At 10:10 a.m., EVS 4 took pieces of DW and wiped the entire outer surface of the blue mattress and left the mattress to air dry.

At 10:11 a.m. to 10:12 a.m., EVS 4 wiped the metal bed frames and the step control and left these to air dry. EVS 4 did not remove or change gloves and did not wash or sanitize hands.

At 10:13 a.m., EVS 4 picked up the soiled pillow from the floor, walked to the door and tossed the soiled pillow into the trash container. Dust particles floated in the air, three feet away from EVSD, AM, and the CFO. EVS 4 did not remove or change gloves and did not wash or sanitize hands.

At 10:15 a.m., when asked to describe the standard for disposal of soiled items such as pillows, the EVSD stated, "Soiled disposable pillows should be placed inside a plastic bag and immediately thrown away in the soiled linen/trash room ... It should not have been left on the floor."

At 10:20 a.m., still wearing the same soiled gloves, EVS came out of Pt 43's room and retrieved a mop from her cart which was parked outside the room. EVS 4 placed a dry pad into the mop-head. She went back to the room, went inside the toilet and swept the floor. With the same mop, EVS swept the bedroom floor, moved the 2 hampers away from the wall, swept this area and all the way across Pt 43's foot part of the bed. EVS 4 then scooped the dirt and debris with a dustpan and lifted the dustpan into the trash container. Dust particles floated in the air, three feet away from the EVSD, AM, and the CFO. EVS 4 did not remove or change gloves and did not wash or sanitize hands. At 10:23 a.m., the EVSD stated, "The mop head/pad should have been changed after sweeping the bathroom ... A new pad should have been used to sweep the bedroom floor ... She should have removed her gloves, washed her hands, and put new gloves on."

At 10:25 a.m., EVS 4 retrieved and prepared a "wet mop" from her cart, went back to the room, went inside the toilet, and mopped the floor. With the same mop, EVS 4 mopped the bedroom floor. EVS 4 again moved chairs and hampers and over bed table with her soiled gloves. After EVS 4 was done mopping, she came out of the room and took her gloves off. EVS 4 did not sanitize her hands with an alcohol based hand rub or wash her hands.

At 10:30 a.m., EVS 4 was asked when was the last time she had training regarding infection control techniques and processes pertinent to room cleaning and disinfection, EVS 4 stated, "This morning (10/8/20) ... They taught us about proper gowning and proper (use of) [face] shields." At 10:35 a.m., EVSD informed EVS 4 that she did not follow proper steps in cleaning a "discharge" room. EVSD then instructed EVS 4 to clean the room all over again.

During a concurrent interview and record review with the EVSD and the EVS Vendor (EVSV) on 10/8/20 at 4 p.m., EVSD stated he had spoken with EVS 4 who realized she had failed to change her gloves, wash/sanitize her hands, put wet floor signs, and to not use one mop to sweep or clean the toilet and the bedroom. EVSV stated, "EVS 4 is the same one who was involved in the fiasco last week ...did not know the dwell [contact] time ..." A review of the hospital document titled, "Training Guide-10 Step Cleaning" (A guide EVS staff follow when cleaning patients' room), the document did not include specific steps on how to clean an occupied and/or discharged room, when to change gloves, when to perform hand sanitizing/handwashing techniques, how to properly use and disposal of mops used to clean the toilet floor and bedroom, and how to safely dispose of soiled pillows, soiled items, and trash.

During review of article published by the Centers for Disease Control and Prevention (CDC) {https://www.cdc.gov/hai/pdfs/resource-limited/environmental-cleaning-RLS-H.pdfCDC}, CDC listed the following Best Practices for Environmental Cleaning in Healthcare Facilities: " ...Terminal or discharge cleaning of inpatient areas, which occurs after the patient is discharged/transferred, includes the patient zone and the wider patient care area and aims to remove organic material and significantly reduce and eliminate microbial contamination to ensure that there is no transfer of microorganisms to the next patient ... Contaminated hands or gloves will also continue to spread microorganisms around the environment ... Contaminated hands or gloves of healthcare personnel, caretakers and visitors can also contaminate environmental Surfaces ... Proper hand hygiene and environmental cleaning can prevent transfer of microorganisms to healthcare personnel, caretakers, and visitors and to susceptible patients ... Toilets in patient care areas (private or shared among patients and visitors have high patient exposure (i.e., high-touch surfaces) and are frequently contaminated. Therefore, they pose a higher risk of pathogen transmission than in general patient areas ..."

6. During a concurrent observation and interview on 10/9/20 at 1:18 p.m. through 1:56 p.m. with EVS 16, in patient room 308, on the Telemetry Unit (a unit in a hospital where patients are under continuous electronic monitoring), EVS 16 took a white two compartment caddy (a storage item) from the housekeeping cart, walked in the patient bathroom and began cleaning the toilet. EVS 16 poured the (brand name) liquid multi (many) surface toilet bowl cleaner solution into the toilet bowl and began wiping the inside of the toilet bowl using a brown/gray stained, fabric cotton ball toilet brush. EVS 16 finished the toilet cleaning and tapped the toilet bowl brush on the edge of the toilet a couple times to remove excess toilet bowl water. EVS 16 placed the toilet brush back into the white two-compartment white caddy holder without rinsing or disinfecting the brush. EVS 16 placed the white caddy back into the housekeeping cart. The two-compartment white caddy holder had brown colored residue on the inside base where the toilet brush was kept. EVS 16 finished cleaning patient room 308 and proceeded to clean the next patient room. At 1:40 p.m., EVS 16 took the white two compartment caddy from the housekeeping cart. The two-compartment caddy had on one side a bottle of (name brand) multi surface toilet bowl cleaner and in the second compartment holder a brown/gray stained, fabric cotton ball toilet brush. This was the same soiled, stained toilet brush used in patient room 308. EVS 16 poured the multi surface toilet bowl cleaner in the toilet and began cleaning the inside of the toilet using the same soiled toilet brush. After EVS 16 finished cleaning the inside of the toilet, she tapped the soiled toilet brush on the edge of the toilet to remove excess toilet water and placed the toilet brush back into the white two compartment caddy. EVS 16 placed the caddy back into the housekeeping cart. EVS 16 was asked to comment on the practice of re-using soiled toilet brushes she stated, " ...I never, we never rinse, clean or disinfect the toilet bowl brushes. I use the same brush in all patient rooms and all the hospital toilets. We all do. We (EVS staff) use the same brush all day long ..." EVS 16 stated the toilet bowl brushes were disposed of every five to seven days depending on condition of the toilet brush. EVS 16 stated, "... Honestly, we (EVS staff) never rinse the toilet brush off and I actually never throw them away ... [EVSV] told us to use it [toilet brush] for as long as we could. I don't think we have enough (meaning the number of toilet brushes) to throw it [toilet brush] away at the end of every day." EVS 16 stated the EVS Department used the same toilet brush in patient isolation (identified, contagious infection precaution) rooms. EVS 16 stated, "We use the same process, we are supposed to use the brush only once in those (isolation) rooms, but we do not have enough to only use once. I'm just being honest."

During a concurrent observation and interview on 10/9/20 at 2:05 p.m., with EVS 17, on Three North Medical Surgical floor, patient room 101, EVS 17 took out a white two compartment caddy from the housekeeping cart and proceeded to the patient bathroom. EVS 17 poured (brand name) multi surface toilet bowl cleaner in the toilet bowl, took the brown stained fabric cotton ball toilet brush and cleaned the inside of the toilet bowl. Once EVS 17 finished cleaning the inside of the toilet, she submerged the toilet brush in the toilet water, tapped the brush on the border of the toilet to get the excess toilet water off the brush. EVS 17 placed the soiled toilet brush back into the white caddy and then placed the white two compartment caddy with the soiled toilet bowl brush back in the housekeeping cart. EVS 17 was asked about the practice of re-using toilet brushes she stated, "We use the toilet water to rinse the toilet bowl brushes after we clean the toilet. We are supposed to throw them out after five to seven days ...isolation room ...We should be throwing the toilet brush out after cleaning an isolation room, but honestly I am not sure if we are doing that because we may not have enough toilet brushes."

During a concurrent observation and interview on 10/9/20 at 3 p.m., in the EVS supply storage room, with EVSV, EVSV stated the hospital had a total of 12 toilet bowl brushes (for 394 patient beds) in the supply room, EVSV stated, "I have some extra [toilet bowl brushes] in the housekeeping closets."

During a concurrent observation and interview on 10/9/20 at 3:12 p.m. in the housekeeping supply room with EVS 18, she was asked about the process of re-using toilet brushes, EVS 18 stated, " ...I have never replaced one [toilet bowl brush]. We use the same brush to clean all toilets." EVS 18 stated she was educated to re-use toilet bowl brushes by EVSV.

During a concurrent observation and interview on 10/9/20 at 3:13 p.m., in three additional housekeeping supply closets, EVSV checked for extra toilet bowl brushes and found seven brushes. After the search, EVSV stated he had a total of 19 toilet bowl brushes. EVSV stated the hospital had 40 housekeeping carts in use at any given time within the hospital. EVSV stated he would not have enough toilet bowl brushes to replace each soiled brush in the 40 housekeeping carts and patient isolation rooms.

During a concurrent interview and record review on 10/9/20 at 3:35 p.m., with the lead EVS floor supervisor (EVS 5), she was asked about her assigned supervisory duties and the process of re-using toilet bowl brushes. EVS 5 stated, "I really do not have time to supervise, they [ EVSV] assign me to a floor, so I am also a housekeeper. I also have to finish my job ... I am available if one of the [EVS] staff needs supplies or something from [EVS], but I really do not have time to check on any of the housekeepers." EVS 5 stated the process of re-using toilet bowl brushes was to use the same toilet bowl brush for a week and then throw the brush away, " ...Every five to seven days." EVS 5 stated, "We do not rinse or disinfect the toilet bowl brushes. We use the same toilet bowl brush in all the hospital toilets ... Isolation rooms ... we should not use that same toilet brush in any other toilet, but I do not know if we are really doing that. I do not have time to check. [EVSV] is the one that told us to use the same brush for a week [five to seven days] then throw it out." EVS 5 reviewed the EVS policies and procedures and stated, she did not know if the EVS department had a policy and procedure that would direct the staff on the current infection control standards of practice when re-using toilet bowl brushes. EVS 5 stated, "I have never seen one [policy and procedure]."

During a concurrent interview and record review on 10/9/20 at 4 p.m., with EVSV, he reviewed the EVS policies and procedures and stated, "There are no policies about the use/sanitation/rinsing/re-use of toilet bowl brushes, or when cleaning toilets... not here, not anywhere!!" EVSV stated the EVS process used when cleaning hospital toilet was, "The chemical disinfectant is inside the container [white two compartment caddy]. EVS staff cleans inside the toilet bowl from top, above the water line, inside the rim, then to the base. After the bowl is cleaned, the toilet brush is not rinsed but is returned into the container which has the same chemical disinfectant." EVSV stated, when cleaning an isolation room, the brush should have been thrown away. EVSV stated, if the bathroom was not in an isolation room, the toilet bowl brush was disposed of after five days. EVSV stated he was in the hospital supervising the staff four out of seven days a week. EVSV stated he did not know if toilet brushes used in isolation rooms were thrown out after the one-time use. EVSV stated he did not know how many patient rooms were under isolation precautions. EVSV stated that was not something he looked at. EVSV stated EVS 5 was the lead housekeeping floor supervisor. EVSV stated, he was aware that EVS 5 did not have time to perform her supervisory duties. EVSV stated, "We have had to use her like this (assigned additional housekeeper duties) since the beginning of the year." EVSV stated toilet bowl brushes were made of polyester (manmade fiber) shaving fabric. EVSV stated using the same soiled toilet brush without rinsing or disinfecting the brush for up to five to seven days would not pose a risk for contamination and or spread of infection. EVSV stated, "None. None whatsoever. The toilet is flushed, the water goes down. There is absolutely no risk for infection... I have been doing this for 20 years. I went to [name of hospital] for a two week training in the 80's. I completed a 12-module in the training [80's] for room cleaning, and there was nothing! nothing about toilet bowl cleaners [rinsing or disinfecting toilet bowel brushes]."The EVSV indicated EVS department did not have policies and procedures for toilet bowl cleaning and for the re-use of toilet brush. EVSV stated the P&Ps that were being used by the EVS department were not following hospital guidelines, did not have ICC review or approval dates and did not reflect the hospital adopted of the policy, its implementation and or nationally recognized guidelines. EVSV stated he did not know if the EVS polices were approved by the ICC prior to the implementation of the policies. EVSV stated the unapproved policies have been in effect in the hospital for over a year. EVSV reviewed four employee training files and stated the EVS employee files do not contain specific infection prevention training for toilet cleaning and re-use of toilet bowl brushes. EVSV stated he gave the direction of re-using soiled infectious toilet bowl brushes for five days. EVSV stated he educated the EVS staff on not needing to be rinsed or disinfected toilet bowl brushes after each use. EVSV stated he has used the same practice since the 80's without any problems and that is the process that he educated the EVS staff to use.

During a review of the manufacturer's instructions for use of the "(brand name) 204W little dipper toilet bowl mop (brush), undated indicated, "Disposable [toilet bowel brush], soft mop head ...one-time use ..."

During a concurrent interview and record review with the IPD on 10/9/20 at 4:40 p.m

(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)
§482.42(c)(2) Standard: Leadership responsibilities
(2) The infection preventionist(s)/infection control professional(s) is responsible for:
(i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines.
Interpretive Guidelines §482.42(c)(2)(i)

Based on interviews and record review, the hospital failed to ensure the Infection Control Committee (ICC) reviewed and implemented hospital-wide infection surveillance, prevention, and control policies and procedures when:

1. The hospital did not ensure the Environmental Services (EVS) Department disinfecting (clean an object, especially with a chemical, in order to destroy bacteria) chemicals were not reviewed to ensure the EVS disinfecting chemicals were EPA (Environmental Protection Agency- registered cleaning products- means a product should do what the label says and should not pose an unreasonable hazard to a person's health) certified and approved by the Infection Control Committee (ICC) prior to EVS staff using the disinfectant chemical solution in the hospital; and

2. The hospital did not develop EVS Policies and Procedures (P&P) that followed nationally recognized Infection Control Guidelines and failed to ensure the ICC reviewed and approved EVS P&P prior to the P&P implementation.

These failures resulted in the lack of surveillance of the EVS department by the ICC which resulted in the risk for cross contamination (inadvertent transfer of germs from one surface or person to another) and transmission of diseases to 375 patients, staff, and visitors.

Findings:

1. During a concurrent interview and record review with the Infection Prevention Director (IPD), on 10/9/20 at 4:40 p.m., the Infection Control Committee minutes from February, April, May, June, July and September of 2020 were reviewed. The IPD stated, "I will save you time, the Infection Control Committee did not review and or approve EVS disinfecting products and did not review or approve EVS policies and procedures" to ensure the disinfecting products were EPA rated. The IPD stated the EVS vendor company provided services for the hospital for over one year and the hospital infection control committee had not reviewed or approved the EVS disinfection agents and P&P and they should have done that.

During an interview with the Chief Financial Officer (CFO) (supervisor for EVS Vendor) on 10/9/20 at 4:56 p.m., the CFO stated the expectation for the EVS contracted vendor was to ensure that all environmental services department's chemicals and policies and procedures were reviewed and approved by the Infection control committee and the Governing Body and they were not.

2. During a concurrent interview and record review on 10/9/20 at 4 p.m., with the Environmental Services Vendor (EVSV), EVSV reviewed the EVS P&Ps for toilet bowl cleaning and re-use toilet brush national guidelines and was unable to find reference to National EVS Infection Control Guidelines on the policies. The EVSV stated the P&Ps were not formatted as policies, not dated, and did not reflect the hospital policy implementation and or nationally recognized guidelines. The EVSV stated he did not know if the EVS polices were approved by the ICC prior to the implementation of the policies. The EVSV stated the unapproved policies have been in effect in the hospital for over a year.

During an interview with the CFO (supervisor for EVSV) on 10/9/20 at 4:56 p.m., the CFO stated the hospital expectation for the EVS contracted vendor was to ensure the policies and procedures used current National Infection Control standards and were reviewed and approved by the infection control committee and the Governing Body prior to the implementation and they were not.

During a review of the EVS P&P titled, "Procedure 1.03: Infection prevention and Control" dated 10/1/19, indicated, "Infection Prevention and Control is to prevent the spread of infections to patients, visitors and staff. The spread of infection can be controlled by ...cleaning and disinfection of the environment and patient care equipment ...Cleaning ... The hospital environment, however, demands more than just the removal of waste, soil and dust. Disinfection is the necessary process of destroying harmful microorganisms ... Disinfectants and germicide should be carefully selected and approved by the Infection Control Committee ...Products used in cleaning ...must always be in stock ...The Director of the housekeeping is often member of the hospital's Infection Prevention and Control Committee The Committee monitors the infection control program ...Housekeeping cleaning procedures and products are reviewed and approved periodically by the committee. Although procedures and products are designated to reduce the threat of infection, the infection Control Committee may recommend changes based on local experience and evidenced based national guidelines ..."