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The hospital reported a census of 30 patients. Based on medical record review, policy/procedure review, and staff interview the hospital failed to ensure the provider signed, dated, and timed verbal/telephone orders promptly for two of three medical records reviewed with restraints (patients #8 and #11).

Findings include:

- Patient #8's medical record reviewed on 2/8/16 revealed an admission date of 1/20/16 from an acute care hospital with diagnoses of post-operative infection in chest and ventilator dependent. The medical record review revealed the staff received a telephone order from the physician to initiate the use of left and right upper extremity restraints on 1/23/16 at 1:00am and again on 2/3/16 at 3:10pm. The physician failed to sign the telephone orders for the use of the restraints.

- Patient #11's medical record reviewed on 2/8/16 revealed an admission date of 1/26/16 with diagnoses of chronic respiratory failure and cerebral vascular accident (CVA-stroke). The medical record review revealed the staff received a telephone order from the physician to initiate left and right upper extremity wrist restraints on 2/8/16 at 6:15am. The physician failed to sign the telephone order for the use of the restraints.

Charge nurse, registered nurse (RN) staff T interviewed on 2/9/16 at 3:11pm acknowledged the lack of the physician's signature on the telephone order for the use of restraints. Staff T explained the physician is to sign the telephone orders within 24 hours.

- The hospital's policy/procedure titled "RESTRAINTS AND SECLUSION " reviewed on 2/9/16 directed "...A written order... is entered into the patient's medical record on a daily basis when restraint use is clinically appropriate ..."

The hospital reported a census of 30 patients. Based on observations, policy/procedure reviews, manufacturer's guidelines review, and staff interviews, the hospital's infection control officer failed to ensure hospital personnel followed basic infection control practices for one of one observed dressing change (patient #27, registered nurse (RN) Staff H), one of one observed discharged patient's room cleaning (patient #22, Housekeeper Staff K), three of three observed medication administrations (patient #29-RN Staff Z; patient #23, RN Staff C; and patient #2, RN Staff C), five of five observed glucometer (blood sugar analyzer) tests (patient #7, RN Staff E; patient #25, RN Staff F; patient #25, RN Staff F; patient #33, RN Staff H; patient #27, RN Staff H), and seven of seven observed uses of personal protective equipment (PPE) (patient #30, CNA Staff Q; patient #32, RN Staff E; patient #30, unidentified advanced practice registered nurse (APRN) staff;. patient #30, unidentified CNA Staff; patient #31, Respiratory Therapy Staff AA; patient #31, RN Staff I; and patient #21, RN Staff J). These deficient practices placed patients at risk for cross contamination and hospital-acquired infections.

Findings include:

- Observation on 2/8/16 at 12:15pm revealed RN staff E performing a blood sugar check on patient #7. Staff E applied gloves and picked up the glucometer and supplies to perform a blood sugar check. Staff E entered the patient's room and performed the blood sugar check. She walked out of the room and went straight to the medication cart that also has a computer on top of it and removed her gloves. She failed to perform hand hygiene after she removed her gloves and proceeded to document the blood sugar results on the computer keyboard with her dirty hands. She then put the glucometer, which had not been disinfected after it had been in patient #7's room, in a drawer of the medication cart. She failed to disinfect the keyboard after typing on it with her dirty hands.

- Observation on 2/8/15 at 2:15pm of medication administration revealed RN staff Z retrieving a vial of Ativan (a sedative) from the medication cart and drawing it up into a syringe. Staff Z failed to disinfect the rubber stopper on the vial of medication before drawing the medication up into a syringe. Staff Z applied gloves and entered patient #29's room. Staff Z failed to perform hand hygiene prior to donning gloves.

- Observation on 2/9/16 at 9:30am of medication administration by RN staff C revealed they entered patient #23's room and applied gloves. Staff C failed to perform hand hygiene before they applied gloves. Staff C checked the patient's arm band and walked to the medication cart in the hallway to call the pharmacist because the right dose of medication was not available. Staff C failed to remove her gloves and perform hand hygiene when leaving a patient's room. She then reentered the patient's room with the same dirty gloves on and flushed their IV with normal saline and performed oral care for the patient.

- Observation on 2/9/16 at 9:50am of medication administration by RN staff C revealed they entered patient #23's room and applied gloves. Staff C failed to perform hand hygiene before they applied gloves. She checked the patient's armband and then exited the patient's room. Staff C failed to remove her gloves and perform hand hygiene when leaving a patient's room. Wearing the unclean gloves, she removed a saline flush from the medication cart and an IV bag of antibiotic and went back into patient #23's room and flushed the IV port and hung the IV antibiotic with the same contaminated gloves.

- Observation on 2/10/16 at 7:50am of a blood sugar test on a patient in contact isolation (Contact isolation precautions-used for infections, diseases, or germs that are spread by touching the patient or items in the room (examples: MRSA (Methicillin Resistant Staphylococcus Aureus-an antibiotic resistant bacteria responsible for several difficult to treat infections), VRE (vancomycin resistant enterococcus- a bacterial strain resistant to the antibiotic vancomycin), diarrheal illnesses, open wounds, RSV(respiratory syncytial virus-causes an illness that usually resembles a moderate to severe cold and is very contagious) by RN staff F revealed they applied gloves and a gown and entered patient #25's room with the bar code reader (a handheld device used to scan a patient's armband for identification and medication administration purposes). She failed to perform hand hygiene prior to applying gloves. She went to the medication cart that was positioned just outside the entrance to the patient's room and set the bar code reader on top of the cart. She failed to remove her gloves and gown before leaving the room and failed to disinfect the bar code reader before placing on top of the cart. She retrieved the glucometer and supplies to perform a blood sugar off the top of the medication cart and went back in the patient's room and set the glucometer on the bedside cabinet without a barrier underneath it. She performed the blood sugar test and came to the door of the room where the medication cart was and placed the now contaminated glucometer on top of the medication cart. She failed to remove her gloves and gown and perform hand hygiene before leaving the room and failed to disinfect the glucometer machine. Using her unclean gloved hands, Staff F then used the computer attached to the medication cart to document the patient's blood sugar reading.


RN Staff F interviewed on 2/10/16 at 7:50am acknowledged that the patient was in contact isolation and all equipment brought into that room needed to be disinfected after use. She also acknowledged that she needed to remove her gown and gloves when exiting the room and perform hand hygiene in between.

- Observation on 2/11/16 at 7:55am of a blood sugar test on a patient in contact isolation revealed RN staff F in patient #25's room wearing a gown and gloves. Staff F came to the door way of the room to the medication cart and typed on the computer keyboard without removing her gloves and gown and performing hand hygiene. She proceeded back into the room to perform the blood sugar test setting the glucometer on bedside cabinet without placing a barrier underneath it. She came back to the doorway afterwards placing the contaminated contaminated glucometer on the medication cart without disinfecting it and again typing on the computer keyboard without removing her dirty gloves and performing hand hygiene. Staff F failed to remove the gown and gloves before coming to doorway to document in the computer and failed to disinfect the glucometer.

- Observation on 2/11/16 at 8:15am of blood sugar test revealed RN Staff H, wearing gloves, placed the glucometer on patient #33's over the bed table without a barrier underneath it. Staff H performed the blood sugar test and then placed the contaminated glucometer on a clip board that was on the medication cart and removed her gloves. She failed to disinfect the glucometer or perform hand hygiene after she removed her gloves. She then placed the contaminated glucometer in a clean drawer in the medication cart and typed on the computer keyboard. Staff H failed to perform hand hygiene after removing gloves and failed to disinfect the computer keyboard after use with dirty hands.

- Observation on 2/11/16 at 8:45am of a blood sugar test revealed RN staff H, wearing gloves, retrieved the glucometer and blood sugar testing supplies from the medication cart and entered patient #27's room. Staff H placed the glucometer on the over bed table without a barrrier underneath it and performed the blood sugar test. Staff H exited the room and with the same dirty gloves on documented the results of the blood sugar test using the computer keyboard. Staff H failed to remove her gloves and perform hand hygiene when leaving a patient's room and failed to disinfect the keyboard after using unclean gloved hands to type on it. She retrieved insulin from the medication cart and drew up the insulin in a syringe with her unclean gloved hands. She reentered the patient's room and gave the insulin injection.

- Observation on 2/11/16 at 11:30am of a wound dressing change in patient #27's room revealed an unidentified staff assisting RN staff H (wearing gloves) to position the patient in bed. RN Staff H removed her gloves and applied clean gloves but failed to perform hand hygiene in between glove changes. Then, she performed a dressing change to patient #27's wound.

- Certified Nurse Aide (CNA) Staff Q observed on 2/8/2016 at 9:00 AM revealed Staff Q failed to have gloves on while in a patient #30's room with contact precautions. Staff Q was writing on the patient's white board.

Staff Q interviewed on 2/8/2016 at 9:05 AM acknowledged she should have had gloves on while in patient's room.

- RN Staff E observed on 2/8/2016 at 9:15 AM revealed Staff E failed to have a gown on while in patient #32's room with contact precautions. Staff E was assisting with the patient's care.

Registered Nurse, Director of Quality Management, Staff A interviewed on 2/8/2016 at 9:17 AM acknowledged Staff E should have been wearing a gown when performing patient care.

- Observation on 2/9/16 at 9:04am of an unidentified Advance Practice Registered Nurse (APRN) revealed the APRN entered patient #30's contact isolation room with gloves and gown on. The APRN failed to tie the gown in the back exposing the back of their clothes. When they leaned forward to assess the patient, the gown fell forward exposing the front of their clothes against the patient's bed. The APRN failed to wear the gown in a manner which their clothing was not exposed to possible contamination.

- Observation on 2/9/16 at 9:15am an unidentified Certified Nurse Aide (CNA) entered patient #30's isolation room with a gown on that the CNA failed to tie in the back exposing the back and sides of their uniform. They entered the patient's room without gloving and obtain gloves when in the patient's room. The CNA failed to perform hand hygien prior to donning gloves, failed to apply gloves prior to entering the room, and failed to wear the gown in a manner which their clothing was not exposed to possible contamination.

- Observation on 2/10/16 at 1:20pm of a Respiratory Therapist (RT) (wearing a gown and gloves) revealed them wheeling a medication cart to patient #31's room who was in contact isolation. They parked the medication cart in the doorway of the room and entered the room assisting the patient to sit up. The RT came back to the medication cart to document on the computer keyboard wearing his dirty gloves and removed a medication from the medication cart to give the patient a breathing treatment. The RT failed to remove the contaminated gown and gloves after assisting the patient and before typing on the keyboard and retrieving the medication from the medication cart. The RT failed to disinfect the keyboard after he typed on it with contaminated gloves.

- Observation on 2/11/16 at 8:00am revealed RN staff I (wearing a gown and gloves)coming from inside patient #31's room to the medication cart in the door way. Patient #31 was in contact isolation. RN Staff I was observed typing on the computer keyboard wearing the contaminated gloves and gown. She failed to remove her gloves, perform hand hygiene before leaving the room, and disinfect the computer keyboard after use with her unclean gloved hands.

Staff I, RN interviewed on 2/11/16 at 8:00am explained they did the patient's vital signs and needed to document them in the medical record.

- Observation on 2/11/16 at 8:35am of RN staff J standing in the door way of patient #21's room at the medication cart. Patient #21 was on contact isolation precautions. RN Staff J had a gown and gloves on and was typing on the computer keyboard that is on the medication cart. Staff J failed to remove the contaminated gown and gloves and perform hand hygiene before leaving the room and documenting on the computer keyboard.

RN Staff J interviewed on 2/11/16 at 8:35am explained she had taken the vital signs of the patient and was documenting them into the computer.

Staff A, RN, Director of Quality Management, Staff A interviewed 2/10/16 at 4:45pm acknowledged the hospital was aware of the hand hygiene concerns and lack of following isolation protocols.

- The hospital's policy/procedure titled, "Hand Hygiene" reviewed on 2/8/16 directed "...When...before donning either sterile or non-sterile gloves ...between glove changes and after removing gloves... "

- The hospital's policy/procedure titled, "Equipment Cleaning" reviewed on 2/8/16 directed "...when not possible (weights, glucose monitoring, EKG, certain respiratory equipment, etc.) a sleeve device will be used or the equipment will be disinfected after use by the clinical staff, immediately after use ..."

- The hospital's policy/procedure titled, "Contact/Contact Enteric Precautions" reviewed on 2/9/16 directed, "...Gowns should be worn when soiling will be likely to occur or when contact with the patient or environmental surfaces that have been contaminated will occur ...Hand hygiene with alcohol-based cleanser must be performed upon entering and leaving the room ...Non-sterile gloves are to be worn by persons having direct contact with the patient and the environment. Gloves must be removed before leaving the room ...all equipment that needs to be "shared" will be disinfected between patients ..."

- The hospital's policy/procedure titled, "Standard Precautions" reviewed on 2/8/16 directed "...gloves will be changed after every patient contact ...gloves must be removed before one leaves the room or work area ...principles from working clean to dirty must be followed ...to put the gown on, close the gown securely so the back is completely covered and tie both waist and neck strings ... "

- Observation on 2/10/16 between 1:25pm to 2:52pm of the cleaning of discharged patient #22's room. Housekeeper staff K (with gloves on) cleaned the bathroom shower and surfaces with a spray disinfectant "Crew". They sprayed the inside of the commode and using a toilet bowl mop swabbed the inside of the commode after two minutes. Then, they removed their gloves and applied clean gloves. Staff K failed to perform hand hygiene between glove changes. Next, Staff K used a microfiber mop wet with "Neutral Cleaner" (an all-purpose cleaner for use as daily/general floor cleaner) to wipe the outside and inside of the closet. Then, they took a clean cloth and sprayed it with the "Neutral Cleaner" and wiped the window sill, shades, and bedside table with the same cloth. Staff K removed their gloves and applied clean gloves again. Staff K failed to perform hand hygiene between glove changes. Staff K failed to follow the manufacturer's guidelines for the use of the "Crew" disinfectant that states the surfaces must remain wet for 10 minutes to disinfect and used the "Neutral Cleaner" which is not a disinfectant to clean some surfaces in the room.

Staff K, housekeeper interviewed on 2/10/15 between 1:25pm to 2:52pm acknowledged she was unaware of the proper procedure for the use of the "Crew" disinfectant, and thought that the "Neutral Cleaner" was also a disinfectant.

Staff D, Director of Environmental Services interviewed on 2/10/16 at 3:30pm explained that all of the housekeepers cleaning carts have a procedure on how to clean the rooms, acknowledged the "Crew" disinfectant must remain wet on the surfaces for ten minutes to disinfectant, and the "Neutral Cleaner" is not a disinfectant and is used only to clean the floors.

- The hospital' s policy/procedure titled, "Checkout Cleaning" reviewed on 2/10/16 directed "...wipe furniture and fixtures with disinfectant solution ...sanitize toilet bowl ...pour bowl cleaner on swab and clean toilet bowl being sure to get under the rim ... "

- The manufacturer's guidelines for "Crew" disinfectant reviewed on 2/10/16 directed "...for toilet bowls/urinals ...empty bowl and apply and apply solution to exposed surfaces and swab thoroughly. Allow to remain for ten minutes then flush ... "

- The manufacturer's guidelines for "Neutral Cleaner" reviewed on 2/10/16 directed "...all purpose, natural pH cleaner for use as daily/general floor cleaner.

- Registered Nurse, Director of Quality Management, Staff A interviewed on 2/11/2016 at 9:00 AM indicated the Infection Control Nurse is on vacation. Staff A reviewed the Infection control plan. Staff A indicated they just started to use secret shoppers (unknown staff members sent to different departments to identify infection control breeches by hospital personnel) for surveillance of breeches in infection control. Staff A indicated the Infection control nurse had been doing monthly hand hygiene surveillances.