HospitalInspections.org

15036

A. Based on observation, interview, policy review, and job description review, the provider failed to ensure two of five observed environment services (EVS) aides (CC and DD) performed daily room and terminal cleaning (deep clean of a room between patients) of isolation rooms in a sanitary manner to prevent cross-contamination to other areas of the hospital. Findings include:

1a. Observation on 7/12/22 at 10:30 a.m. of EVS aide CC revealed:
*She was outside of patient 21's room and was beginning to put on personal protective equipment (PPE).
*There was a contact isolation sign posted outside that room.
*She:
-Was wearing a mask, put on an isolation gown, and then clean gloves.
-Entered the contaminated room carrying a tub of disinfectant wipes and a roll of plastic trash can liners.
-Started cleaning the bathroom using disinfectant wipes and then cleaned the overbed table while picking up the patient's water container, juice glass, and Kleenex box.
-Exited the room wearing the PPE and placed the tub of disinfectant wipes and roll of plastic trash can liners on top of the clean PPE cart.
-Retrieved a mop handle and mop pad from the housekeeping cart and reentered the room.
-Swept debris (crackers, food crumbs, dust, and soiled Kleenex tissue) with the mop into the hallway outside the room entrance, and retrieved a clean mop pad from the housekeeping cart.
-Reentered the room, mopped the floor, exited the room wearing PPE, and touched the door jam with her gloved hands.
-With those soiled gloves she took a dust pan off of the housekeeping cart to pick up the debris off the floor.
-Returned the mop handle and dustpan to the housekeeping cart.
-Took the tub of disinfectant wipes and roll of plastic trash bags from on top of the PPE cart and put them back onto the housekeeping cart.
--The PPE cart was not disinfected.
-Removed the isolation gown and put it in a trash bag from the room, used hand gel and wiped excess off with a cloth, put on clean gloves, carried the trash to the soiled utility room, punched in the door code, and disposed of the trash.
-Had not removed the contaminated gloves.
-Returned to the housekeeping cart, pushed it down the hallway, knocked on room 105's door (a non-isolation room), did not enter because staff were in the room with the patient.
-Proceeded to push the cart down towards the nursing station.

Review of patient 21's medical record revealed:
*She had been admitted on 7/2/22.
*On 7/2/22 she was placed on contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) in her wound.
-MRSA is a bacteria that is resistant to several antibiotics.
*A 6/27/22 culture report showed prevotella bivia at her Hickman catheter site (type of intravenous catheter).
-A type of bacteria normally found with a pelvic inflammatory disease.

b. Observation on 7/12/22 at 11:40 a.m. of EVS aide CC revealed:
*She was wearing gloves and had stationed the housekeeping cart outside patient 19's room.
*There was no patient in the room. A sign outside the room indicated it had been used for a patient on contact precautions.
*Without putting on an isolation gown, she entered the room and removed the bed linen.
*Without disinfecting the lap tray and posey box (a plastic box), she brought them out of the contaminated room and placed them on top of the clean PPE cart.
*She placed a disposable chair alarm belt on top of the PPE cart along with the other equipment.
*She reentered the room and continued the cleaning process.

Review of patient 19's medical record revealed she:
*Had been admitted on 6/24/22 and discharged on 7/12/22.
*Was placed on contact precautions for a urinary infection due to Vancomycin-resistant Enterococci (VRE) microorganism.
-VRE is a bacteria that is resistant to several antibiotics.

Observation and interview on 7/12/22 at 12:20 p.m. with physical therapy director EE confirmed:
*The lap tray and posey box were still on top of the PPE cart.
*Those items should have been disinfected prior to being brought out of the room.
*The chair alarm belt should have been discarded.

c. Observation on 7/12/22 at 11:55 a.m. of EVS aide DD revealed:
*He stationed the housekeeping cart outside patient 20's room.
*A sign outside the room indicted the patient was on contact precautions.
*Without performing hand hygiene, he retrieved a clean gown and gloves out of the PPE cart, put on the PPE, entered the room, and then shortly exited the room.
*He only removed the isolation gown.
*Without removing the contaminated gloves, he entered patient 19's room to assist EVS CC with terminal cleaning.
*Without disinfecting the Stryker mattress pump he removed it from the room and set it up against the PPE cart outside of patient 20's room.
*He reentered patient 19's room and continued to assist with the terminal room cleaning.

2. Interview on 7/12/22 at 11:50 a.m. with EVS manager BB revealed:
*He was responsible for managing the environmental services staff.
*The patient in room 140 (patient 19) had been discharged and staff were terminally cleaning that room.
*If there was an isolation cart outside the room and the patient was in the room staff should have gowned up before entering.
*He was not sure what staff should have worn when terminally cleaning a room and would have to ask the infection control nurse.
*He later stated when the patient had been discharged, staff did not have to gown up to terminally clean a room.
*Staff should have disinfected any equipment before it was brought out of the room.

Interview on 7/12/22 at 12:00 p.m. with infection preventionist AA and EVS manager BB revealed:
*Infection preventionist AA was not sure what PPE staff should have worn when terminally cleaning an isolation room and would need to review the policy.
*Equipment could have been brought out of the isolation room before disinfecting if it was disinfected before storage.
*Infection preventionist AA was responsible for training EVS staff on cleaning products, PPE usage, and infection control.

Interview on 7/13/22 at 9:20 a.m. with EVS aides CC and DD revealed:
*During their orientation they had been taught to start cleaning from cleanest to dirtiest, how to use the gear and equipment, and about the cleaning supplies.
*To clean everything in general and take out equipment.
*They had a refresher training on 7/12/22 and was taught:
-To wash hands after coming out of rooms and before going to another place, clean everything, and use new gloves.
-To wash their hands, put on gloves, mask already on, and for special rooms use N-95 masks.
-Remember to take off all PPE to prevent the spread of infection.
-Any equipment left in a patient's room had to be cleaned before it was taken out of the room.
-To wear a gown when cleaning.
-EVS CC had double gloved during the cleaning process and would have removed one pair as needed.
-If they had questions to contact their supervisor or infection control nurse.

Review of the EVS aide job description revealed:
*EVS aides were responsible for maintaining a clean, sanitary, and safe environment in all areas of the hospital in accordance with the company's standards, local, state and federal regulations.
*Responsibilities and tasks included but not limited to:
*Performing "routine and isolation cleaning procedures according to infection control standards."
*Understands and institutes standards for cleanliness and sanitation.

B. Based on observation, interview, and record review, the provider failed to ensure environmental services (EVS) manager (BB) was fully trained to the role and responsibilities for the environmental services department. Findings include:

1. Interview with the EVS manager BB on 7/12/22 at 4:16 p.m. revealed:
*His training included reading policies and watching an infection control video.
*There was no hands-on precepted training for his role.
*He inspected patient rooms after staff had cleaned to ensure cleanliness.
*He had not documented his inspections of the rooms and had no process to document those inspections.
*He had not observed staff cleaning rooms.
*For terminal room cleaning there was a discharge cleaning checklist in English.
-The checklist had not been translated to Spanish, was not available to all staff, and
available for staff who only spoke/read Spanish, therefore, was not used.

Interview on 7/13/22 at 10:17 a.m. with regional director of facilities management regarding EVS manager BB training revealed:
*EVS BB was responsible for purchasing and environmental services.
-He had been promoted into those dual roles.
-He had first started out managing the environmental services contract.
-EVS staff were contracted because they could not hire personnel for the position.
-The current staff was hospital employees.
-He and two other corporate staff had rotated every other week to assist him with both of those management positions.
-He had discussed training with him but had not provided hands-on precepted training for the EVS roles and responsibilities.
*He had:
-Completed an initial competency form for him and had given that form to human resources.
-Not maintained a copy of that competency.
*He agreed the infection preventionist and EVS manager should have worked collaboratively together on protocols for the EVS aides.

Review of EVS BB's personnel file revealed:
*He was promoted to the role of EVS manager on 11/28/21.
*There was no initial competency form on file in his record.
*There was no documentation from other corporate staff verifying training had been provided to him on his roles and responsibilities as the EVS manager.
*No previous oversight for housekeeping services was listed on his application.
*He had completed online training for his job description for environmental services manager on 11/30/21.
*He had an associate degree in business management.

Review of the Environmental Services Manager job description revealed:
*The manager was responsible for maintaining housekeeping and laundry services; and ensuring a safe, sanitary, and clean environment for patients, visitors, and employees.
*The manager provided direct supervision and guidance to environmental services and laundry staff.
*His roles and responsibilities included but were not limited to:
-Collaboration with nursing and admissions to ensure patient rooms were ready for patient arrivals.
-Performance of routine and isolation cleaning procedures, floor care, and distribution of linen.
-Meeting position requirements and performing essential functions.
*Minimum position qualifications included:
-Bachelor's degree or a minimum of five plus years of experience.
-Previous housekeeping experience was required.

Review of the provider's 2/24/22 Terminal Room Cleaning policy revealed:
*"It is the responsibility of the CEO [chief executive officer] to ensure that terminal room cleaning is done according to evidence-based standards as outlined in the "Practice Guidance for Healthcare Environmental Cleaning"
*"Terminal cleaning and disinfecting of rooms shall occur at discharge, transfer from one room to another, and at the discontinuation of precautions."

Review of the provider's 2/24/22 Standard and Transmission-Based Precautions policy revealed:
*All patient blood and body fluids will be considered potentially infectious.
*"Transmission-based precaution measures will be utilized as appropriate when an infectious agent is known or suspected to be present in a patient."
*Hand hygiene should have been performed:
-Before beginning work, upon entering a patient room/environment, with each new task, and upon exit from the room or at task completion before approaching a new patient.
*Contact precautions:
-Was used in addition to Standard Precautions for patients known or suspected to be infected with epidemiologically important microorganisms that can be transmitted by direct contact with the patient or indirect contact with environmental surfaces associated with the patient.
-"Use Contact Precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment."
-Contact Precautions will be posted according to the type of infectious organisms listed per CDC known to be spread by contact.
--"Posting will be made by medical order, the Infection Preventionist, or any nurse in charge."
*"Equipment:
1. PPE Container: gloves, gowns, masks, cleaning wipes, and information cards.
2. Patient care items to [be] dedicated to individual use: BP [blood pressure] cuff, stethoscope. Clean after precautions stopped."
*Guidelines:
"2. Place Contact Precaution sign on the door and ensure PPE is available for staff, patient, and visitor use.
3. Perform appropriate hand hygiene upon entering and leaving patient room and as otherwise needed during patient care."
4. Wear gloves and/or gowns as patient care tasks dictate.
"5. Soiled equipment:
A. Any disposable articles are to be placed in a large waste disposal barrel in the room.
B. All equipment belonging to [the] patient such as wheelchair, IV poles, [and] feeding pumps, will be cleaned in the room upon discharge or at termination of precautions.
C. Any rental equipment must be cleaned in the room prior to removal."

According to the Centers for Disease Control (CDC) and Prevention website at https://www.cdc.gov/mrsa/community/index.html:
-MRSA is a bacteria resistant to several antibiotics.
-All staff should have been trained on prevention practices, such as hand hygiene, PPE use, Standard Precautions, Contact Precautions, and environmental cleaning and disinfection.
-Facilities should routinely audit and conduct competency-based assessments for core infection control practices.
-Facilities should ensure adherence to hand hygiene and isolation precautions.
-Facilities should ensure adequacy of room cleaning and environmental services.

Review of the CDC website at https://www.cdc.gov/hai/organisms/vre/vre.html:
VRE can spread from one person to another through contact with contaminated surfaces or equipment or through person-to-person spread, often via contaminated hands. It is not spread through the air by coughing or sneezing.