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Based on observations, interviews, and document review, the facility staff failed to ensure staff members adhered to their hand hygiene policy, cleaned equipment between patients, stored clean linen so it was protected from contamination, and did not store corrugated boxes in patient care areas.

The findings include:

During the survey conducted 3/10/2020 through 3/12/2020, observations were made on the Second Floor, 3 North, ICU, 4 North and South, Sterile Processing Department (SPD) and linen storage areas.

On 3/11/2020 at approximately 2:00 P.M., the clean laundry storage area was observed and contained partially covered linens stored in a room and hallway. In the room, there were approximately 8 to 9 large storage bins. The ceiling over the bins had approximately three (3) large and three (3) small water stains on the ceiling tiles. The air exchange system was dusty. Staff Member #9 stated during the tour, "The ceiling tiles were not that way in January when we made rounds."

On 3/11/2020 at approximately 3:05 P.M. during a tour of 4 North, Staff Member #13 was observed leaving room #457 where the patient was on contact precautions. After exiting the room, Staff Member #13 was observed pushing a TPR (temperature, pulse and respirations) machine down the hallway without cleaning the machine. Staff Member #13 stopped, walked backwards, reached into room #457, took out cleaning wipes, and began to clean the machine. When asked what was the process to be followed after using equipment in a patient's room, Staff Member #13 stated "To clean it. But I ran out of wipes." It was noted that a container of disinfecting wipes was hanging on the hallway wall just outside the door.

While on 4 North, Staff Member #12 was observed at approximately 3:20 P.M. leaving room #455 and walking into the next room without performing hand hygiene. Staff Member #12 walked out of the room, performed hand hygiene and walked on. During the tour, Staff Member #11 identified Staff Member #12 as a physician.

On 3/12/2020 at approximately 11:00 A.M., Staff Members #19 and #20 were observed leaving room #215 on the 2nd floor. Staff Member #19 performed hand hygiene immediately on exiting the room. Staff Member #20 did not. Staff Member #14 re-educated Staff Member #20 on hand hygiene.

At approximately 11:30 A.M. on 3/12/2020, the ICU was toured. In patient room #16, approximately 6 corrugated boxes were noted stored on a cart inside the unoccupied room. The boxes had original shipping labels. Staff Member #1 stated, "We have discussed corrugated boxes numerous times and they know not to store them in the patients rooms."

A tour of 3 North was conducted on 3/12/2020 at approximately 12 noon. During the tour, two (2) staff members (Staff Members #16 and #17) were observed exiting room #355 and walking toward room #357.
Staff Member #16 was observed pushing a computer cart while entering information from a glucometer into the computer and placing the glucometer in its storage box. Staff Member #16 then proceeded to use personal hand sanitizer removed from their clothing pocket to perform hand hygiene. Staff Member #16 failed to use an Infection Control Committee approved hand sanitizer per facility policy. Staff Member #16 did not clean the glucometer prior to returning it to its case.
After exiting room #355, Staff Member #17 was observed pushing a TPR machine. Staff Member #17 did not clean the TPR machine after removing it from room #355. Prior to entering room #357, Staff Member's #1 and #15 were asked to intervene. Staff Member #1 spoke to Staff Members #16 and #17 but they continued into the room. Staff Member #16 proceeded to check the patient's blood glucose.

Staff Member #6 was made aware of the occurrence with Staff Member's #16 and #17 by Staff Member #1 at approximately 12:30 P.M. on 3/12/2020. Staff Member #6 stated at the exit conference (approximately 2:00 P.M. on 3/12/2020), "I can assure you, they know how and when to clean equipment now."

The facility policies and procedures were reviewed on 3/12/2020 at approximately 10:00 A.M. and revealed:
Handling, Storage and Cleaning of Equipment and Supplies (Review date of 11/12/17) which noted on Page 1, Section II Patient Care Equipment Cleaning and Low Level Disinfection, Letter A: "After patient use,...will be wiped with hospital approved disposable disinfectant wipe before ...or use on another patient".

Standard Precautions (Review date 11/28/17) which noted on Page 1 Section I. Hand Hygiene, Letter A: "Wash hands after contact with blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Perform hand hygiene immediately after gloves are removed, between patient contact, and when otherwise indicated to avoid transfer of microorganism to other patients or environments...".

Hand Hygiene (Review date 1/17) Page 2 Section titled: Selection and Approval of Hand Hygiene Products: "All hand hygiene and hand moisturizing products will be approved through the authority of the Infection Prevention Committees...".
Indications for Hand Hygiene: Section A. The World Health Organization Five Moments for Hand Hygiene are as follows #5. "After Contact with Patient Surroundings-Clean your hands after touching any object or furniture in the patient's immediate surroundings, when leaving-even if the patient has not been touched."

According to the USAF Guidelines:
External shipping cartons/boxes are considered to be "dirty" because they have been exposed to unknown and potentially high microbial contamination. Also, cardboard shipping boxes serve as generators and reservoirs for dust and can potentially house vectors such as
roaches. Distribution Statement A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 11-007, 26 October 2010.