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Based on observation, interviews with a patient family member, staff and record review, the hospital failed to provide and maintain a sanitary environment by ensuring there was consistent, active and effective monitoring and surveillance of housekeeping staff performance in their required duties specifically related to cleaning and disinfecting objects and environmental surfaces in patient care areas and utilizing cleaners and disinfectants in accordance with manufacturer's instructions and hospital policies and procedures. Findings include:

1. Per observations on 12/29/15 of hospital staff's testing of the concentration level of the disinfecting solution Oxivir (a disinfecting hydrogen peroxide solution) used throughout the hospital for inpatient care areas (excluding isolation rooms), the staff member failed to follow the hospital procedure "Disinfectant Chemical Testing" (#048), effective 12/2008; the failure to assure adequate disinfection of patient units created the potential risk for patient HAIs (Healthcare Associated Infections). Per review, the test policy/procedure stated: "1. Insert testing paper ...for 1 second for Oxivir., 2. Compare the color of the paper (strip) after 120 seconds on the dispenser for the Oxivir strips to determine the PPM (Parts Per Million). This procedure stated that the purpose of the test was to ensure that the disinfectant used in the bucket emersion system remains within acceptable efficacy range of 2500 PPM for Oxivir.

On 12/29/15 at 11:50 AM on the Shepardson 4 unit, Lead Housekeeper #1 demonstrated the process for testing of the Oxivir solution. The Lead put the test strip, taken from his/her pocket, into the floor housekeeper's bucket containing disinfecting solution and microfiber cloths. When the surveyor asked to see the dispenser bottle to review the directions, the Lead did not have a bottle to use to compare the color of the test strip with the corresponding PPM on the chart on the test strip bottle. A bottle was retrieved from the housekeeping office and the test redone. At the surveyor's request, a timer was used for accuracy, the bottle stated that the reading should be done at exactly 120 seconds. The color on the strip showed between 1000 and 2000 PPM at 120 seconds. Next, the disinfecting solution in the unit Command Center* was tested and showed a level of 2000 PPM. Both of these readings were less then the policy's required 2500 PPM level required for disinfection. (The manufacturer's written information provided by the Assistant Environmental Services Manager later the same day, confirmed that the reading should be at 2500 PPM for disinfection of surfaces). Subsequent readings were taken immediately after in 3 other unit Command Center* locations within inpatient units. One other unit Command Center* solution tested at between 500 and 1000 PPM. The 2 other units tested read at 2500 PPM; thus, 2 of 4 patient care units tested failed to meet the required 2500 PPM for the disinfectant solution used to clean the inpatient units.

The failure to follow the hospital's procedure was confirmed after the observations with the Lead Housekeeper doing the testing and the Assistant Manager of Environmental Services present for the testing. The Lead confirmed that their usual practice did not include the timing of the reading at exactly 120 seconds and did not compare the color of the strip to the dispenser color chart to determine the PPM of the solution being tested. S/he usually carried the strips in a tube in his/her pocket to complete the tests on all units s/he was in charge of that day. S/he stated that the color of the test strip was supposed to be brown. Per observation of the bottle color chart, there were 3 different colors that were brown, at different saturations, thus using memory to determine an accurate reading was not reliable. Lead Housekeeper #1 was responsible for the daily testing of Oxivir disinfecting solution on 8 units. The recorded results reviewed on the logs provided for review showed acceptable readings of 2500 PPM for the month of December, 2015 on all 8 units. The Assistant Manager of Environmental Services stated that s/he did not conduct audits of the Lead Housekeepers' performance of duties and was unaware of the deviation from the written procedure. S/he did state that the housekeeping supervisors were responsible for observations of entire cleaning processes by housekeepers and they report to him//her. There was no previous awareness of any problem with these processes.

*The 1.5 gallon Command Center* is a push button system which dispenses ready-to-use product accurately and consistently and the manufacturer reports it is effective against Healthcare Associated Infections (HAIs/infections that a patient can contract while receiving medical treatment or surgical condition) to include Norovirus, Hepatitis B & C, MRSA (Methicillin-resistant Staphylococcus infection) and VRE (Vancomycin-Resistant Enterococci).

2. Per observations on 8 inpatient units during the 2 days of survey (12/28/15 - 12/29/15), housekeeping staff failed to follow the hospital's infection prevention related protocols regarding procedures for setting up the carts for use on the units related to the disinfecting solution and use of microfiber cloths used for routine cleaning of inpatient areas. Per interviews with 4 housekeepers on 4 units, all stated that they keep the microfiber cloths in the bucket of disinfecting solution. The same process was seen as described on the 8 units observed during the survey.
Regarding the use of the cleaning cloths for each patient room, including bathroom cleaning, all 4 housekeepers interviewed gave different responses to how to clean the patient room and bathroom and when to change cleaning cloths during the process. One housekeeper stated that 1 cloth could be used to clean both the patient room and the bathroom. Other staff stated that they would use 1 cleaning cloth for the patient room and another for the bathroom. Later, the Assistant Manager of Environmental Services confirmed that housekeepers should be using multiple cloths to clean each area and should always use a new cleaning cloth when starting the bathroom cleaning, using about 3 - 4 cloths for the entire bathroom cleaning procedure.

Per interview with the Assistant Manager of Environmental Services at 10 AM on 12/29/15, regarding cleaning of inpatient units, the Assistant Manager stated that the observations seen of the cloths all placed in the solution bucket at once was in violation of hospital practice. The microfiber cleaning cloths should be stored covered and dry on the housekeeping carts. The cleaning solution should be taken from the Command Center* in the housekeeping closet obtaining the precise measured amounts of required disinfecting solution mixed with water. The solution should be drawn into the blue buckets and covered and placed on the cart at the start of the shift. The cloths should not be placed into the disinfecting solution until each one is needed for use, per interview. The Assistant Manager confirmed that storing the cloths in the disinfecting solution was against hospital practice and could possibly affect the efficacy of the disinfectant, especially when not covered and exposed to air (as observed).

3. During a tour of Surgical Intensive Care Unit (SICU) on 12/28/15 at 11:35 AM accompanied by the Director of Critical Care Services and SICU nurse manager and assistant nurse manager the following was observed in SICU rooms #7& #14 and the Pediatric ICU room #22, all identified as ready for patient occupancy and previously cleaned by Environmental Services housekeepers:
a. Patient room #7, tubing attached to a wall mounted suction canister was noted to be soiled both internally and externally; also there was a brown substance on the dial of a wall monitor.
b. Patient room #14, a soiled wet wash cloth was left in a wall compartment identified as a dialysis drain. A brown substance was noted on the wall cardiac monitor which was confirmed and cleaned by the nurse manager.
c. At 11:53 AM while touring the Pediatric ICU, in room #22 soiled suction equipment, including canister and tubing was observed. The suction equipment is used for patients by nursing and respiratory therapy staff and equipment is disposed of after individual patient use. The nurse manager confirmed that upon discharge of a patient from SICU or Pediatric ICU both housekeeping staff and assigned Licensed Nursing Assistant (LNA) would play a role in preparing the room for a new admission. Housekeeping conducts the cleaning and the LNA would replace supplies in each patient room to include the removal of all suction equipment. It is the expectation all used disposable tubing and equipment would be removed during the cleaning of each discharged patient room.
4. The following observations of the inpatient environment (including Baird 4, 5 and 6) showed areas that were not maintained in a clean and sanitary manner:

a. Shower room #1 - sign on door stated "Clean", observed white material on floor drain, (1 cm. by 1 cm.), tape stuck on the floor, measuring 14 cm. in length, plastic cup on the floor, black hair tie on the floor.
Shower room #2 - soiled wall shelf
Shower room #3 - cleaning staff interviewed confirmed that they do not routinely remove all
stored items from the shower floor prior to cleaning the room, (incomplete cleaning)

b. Patient room #1 - shelf in bathroom over sink visibly soiled after daily cleaning had taken place.

5. Per telephone interview on 12/21/15 a family member of a patient hospitalized on McClure 5 observed a housekeeper enter the family member's hospital room on 11/9/15 at 1:30 PM and, using only one cloth, proceeded to wipe the patient's bathroom door handle on both the outside and inside; the housekeeper using the same cloth cleaned the outside of the toilet seat, under the toilet seat and then wiped the inside rim of the toilet bowl. With the same cloth, the housekeeper then wiped down the entire bathroom sink. The family member stated s/he yelled at the housekeeper and a nurse who was in the room caring for the other patient who shared the room, thanked the family member for bringing the improper infection control procedures s/he observed to the housekeeper's attention. On 11/10/15 the office for Patient & Family Advocacy was contacted by the family member regarding the observations made on 11/9/15 but could not recall the individual who noted his/her concerns but was assured the Director of Housekeeping would be informed. Per interview on the afternoon of 12/29/15 the Director of Facilities Management and the Assistant Manager for Environmental Services denied being informed of the incident.

Per interview at 2:40 PM on 12/29/15 the Director of Facilities Management and the Assistant Manager for Environmental Services agreed hospital-wide training and re-education of housekeeping staff was imperative to ensure appropriate compliance with hospital policies and procedures and maintaining and monitoring of correct infection control practices. Presently newly hired housekeepers receive 1 week of training which includes a hospital mandatory training and housekeeping training by the Environmental Service educator and lab simulation followed by 1 week assignment of working with an experienced housekeeper. Per review, Disinfection, Sterilization and Antisepsis: Principles, Practices, Current Issues, and New Research proceedings from the Association for Professional in Infection Control and Epidemiology (APIC) June /2006 Stated: page 86, "Members of house-keeping staff play a key role in the routine decontamination of environmental surfaces. The cadre in most healthcare facilities is perhaps the least skilled and trained....This creates another weak-link in the system and thus undermines the entire process of infection prevention and control....a higher level of training of house-keeping staff with regard to proper storage of concentrates of microbicidal activity, preparing their use-dilutions properly...." was deemed necessary.

On 12/29/15, the Manager of Infection Prevention was interviewed regarding the hospital's ongoing surveillance processes to assure a safe and sanitary environment. The main task for surveillance is for monitoring for HAIs. There are multiple groups involved in monitoring and managing of areas including isolation processes, rounding of all areas of the hospital. The groups include the Infection Control Committee, the Environment of Care Committee, the Infection Prevention Advocacy Group and others. The Manager stated that routine hospital wide environmental surveillance auditing takes place 2 times annually. There is a follow up process to address all findings, with a triage rating system to address the critical findings within one day, for example. It was also noted that the general hospital orientation for new employees, which would include newly hired housekeepers, receive an Infection Control in-service that is approximately 20 minutes. Ongoing Infection Control education would continue for new hires as applicable within their designated assigned departments.

Although there was no evidence of an increase in patient HAIs on the units observed and per review of inpatient medical records, the potential risk was increased by housekeeping staff's failure to adhere to hospital procedures regarding cleaning of inpatient areas and the failure of supervisory staff's auditing processes to identify the deficient practice to assure the maintenance of a safe and sanitary hospital environment.