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The Hospital reported a census of 137 patients. Based on observations, policy/document review and staff interview the infection control officer/committee failed to ensure two environmental service (housekeeping) staff followed the hospital's hand hygiene policy. Non-compliance with these requirements has the potential to adversely affect all patients at the hospital.

Findings include:

- Hospital policy titled "Hand Hygiene" reviewed on 6/5/12 at 3:00pm instructed staff "...all personnel will use the hand-hygiene techniques as set forth ...The CDC (Centers for Disease and Prevention Control) has recommended...to use non-antimicrobial soap and water, or an alcohol based hand rub ...always after removing gloves ..." .

Observations conducted on 6/5/12 from 2:25pm to 3:30pm of staff E, Housekeeping as they terminally cleaned room #608 post-discharge of a patient revealed the following:

1. Staff E arrived at room #608 already wearing a pair of disposable patient care gloves.

2. Staff E positioned their cleaning cart just outside the room. They entered the room and bagged up the trash from several trash containers. They placed the bag of trash in the cleaning cart's trash receptacle.

3. Staff E re-entered the room wearing the same pair of disposable gloves. They bagged up the linens and then placed the bag of linens in the dirty linen closet.

4. Staff E wearing the same pair of disposable gloves obtained a clean cloth rag from their cleaning cart. Staff E explained they had soaked the cloth with "Dispatch" disinfectant.

5. Staff E began to clean the patient room. Staff E started with the patient bed and cleaned all of the flat surfaces in the room (i.e., bedside dresser, the over-the-bed table). While staff E cleaned they stated they had a "cold". Observations of staff E as they cleaned revealed staff E coughed and did not cover their mouth, coughed onto their scrub jacket sleeve and coughed onto their gloves.

6. Staff E continued to wear the same pair of disposable gloves as they cleaned the bathroom.

7. Once staff E completed the bathroom, they exited room #608 and proceeded up the hall to the clean linen closet. Staff E wore the used pair of disposable gloves into the clean linen closet and picked up clean linens to re-make the bed.

8. Staff E made the bed up in room #608 and then mopped the room floor.

9. Staff E exited the room wearing the same pair of disposable gloves and pushed their cleaning cart up the hallway. Staff E did not remove their used disposable gloves or do hand hygiene.

Observations on 6/6/12 at 10:45am to 11:30am of staff F, housekeeping staff as they cleaned room #504 post-discharge of a patient revealed the following:

1. Staff F arrived to clean room #504 wearing a pair of disposable patient care gloves.

2. Staff F positioned their cleaning cart just outside the room. They entered the room and bagged up the trash from several trash containers. They placed the bag of trash in the cleaning cart's trash receptacle.

3. Staff F re-entered the room wearing the same pair disposable of gloves. They bagged up the linens and then placed the bag of linens in the dirty linen closet.

4. Staff F went to their cleaning cart picked up a feather duster and dusted the room. They completed the dusting. Staff F went back to the cleaning cart and wrung out a cloth that was soaked with "Dispatch" disinfectant and began to clean the call light cords.

5. Staff F stopped and went out of the room to their cleaning cart. Staff F changed their disposable gloves (no hand hygiene) and cleaned the bed, chairs and pillows.

6. Staff F ran out of clean cloth rags on their cart. They exited the room with their used disposable gloves on and went to the housekeeping closet. Staff F returned to room #504. They applied clean disposable gloves (no hand hygiene) and cleaned the bathroom.

7. Staff F completed the room. They exited the room wearing a pair of disposable gloves and pushed their cleaning cart to the dirty utility room where they put dirty equipment and the bagged trash. After staff F placed items in the dirty utility room they changed their disposable gloves (no hand hygiene).

Staff A interviewed on 6/6/12 at 11:30am verified staff E and F failed to follow hospital policy regarding hand hygiene.

The Hospital reported a census of 137 patients. Based on observations, policy/document review and staff interview the infection control officer failed to ensure environmental services (housekeeping) staff used disinfectants in accordance with manufacturer's direction for use and failed to ensure licensed staff disinfected the access diaphragm of medication vials prior to drawing up medications in syringes. Non-compliance with these requirements has the potential to adversely affect all patients at the hospital.

Findings include:

- Observations conducted on 6/5/12 from 2:25pm to 3:30pm of staff E, Housekeeping as they terminally cleaned room #608 post-discharge of a patient revealed the following:

1. Staff E arrived at room #608 already wearing a pair of disposable patient care gloves.

2. Staff E positioned their cleaning cart just outside the room. They entered the room and bagged up the trash from several trash containers. They placed the bag of trash in the cleaning cart's trash receptacle.

3. Staff E re-entered the room wearing the same pair of disposable gloves. They bagged up the linens and then placed the bag of linens in the dirty linen closet.

4. Staff E wearing the same pair of disposable gloves obtained a clean cloth rag from their cleaning cart. Staff E explained they had soaked the cloth with "Dispatch" disinfectant.

5. Staff E began to clean the patient room. Staff E started with the patient bed and cleaned all flat surfaces in the room (i.e., bedside dresser, the over-the-bed table). The mattress on the patient bed stayed visibly wet one minute. The bedside dresser, the over the bed table, the chairs and all other flat surfaces failed to stay visibly wet for one minute.

6. Staff E proceeded to clean the patient bathroom. They started with the toilet. Staff E dumped a solution into the water in the toilet bowl. Staff E explained the solution was a disinfectant called "Crew". Staff E swished the water and "Crew" solution around in the toilet bowl then promptly flushed the toilet.

7. Once staff E completed the bathroom, they exited room #608 and proceeded up the hall to the clean linen closet. Staff E wore the used pair of disposable gloves into the clean linen closet and picked up clean linens to re-make the bed.

8. Staff E made the bed up in room #608 and then mopped the room floor. Staff E stated they could not recall the name of the cleaning product they used on the floor.

9. Staff E exited the room wearing the same pair of disposable gloves and pushed their cleaning cart up the hallway. Staff E did not remove their used disposable gloves or do hand hygiene.

Staff A, Infection Control Officer interviewed on 6/5/12 at 4:00pm provided for review the manufacturer's directions for use on "Dispatch" and "Crew" chemicals.

Review of the manufacturer's direction for use for "Dispatch" instructed staff the following:

1. Dispatch a ready-to-use cleaner disinfectant, cleans and disinfects environmental surfaces and medical equipment.

2. Use in one step on hard non-porous surfaces.

3. Dispatch with bleach kills multi-drug resistant organisms in just one minute and Clostridium difficile spores in five minutes.

Review of the manufacturer's direction for use for "Crew" bowl and bathroom disinfectant cleaner directed staff to:

1. To disinfect toilet bowls use swab applicator.

2. Remove the water from the bowl by forcing water over the trap.

3. Press swab applicator against side of bowl to remove excess water. Apply one ounce of "Crew" cleaner to the swab applicator, cloth, mop, sponge or directly to surface.

4. Swab entire surface area especially under the rim.

5. Treated surfaces must remain wet for 10 minutes, Rinse thoroughly.

- Observations on 6/6/12 at 10:45am to 11:30am of staff F, housekeeping staff as they cleaned room #504 post-discharge of a patient revealed the following:

1. Staff F arrived to clean room #504 wearing a pair of disposable patient care gloves.

2. Staff F positioned their cleaning cart just outside the room. They entered the room and bagged up the trash from several trash containers. They placed the bag of trash in the cleaning cart's trash receptacle.

3. Staff F re-entered the room wearing the same pair disposable of gloves. They bagged up the linens and then placed the bag of linens in the dirty linen closet.

4. Staff F went to their cleaning cart picked up a feather duster and dusted the room. They completed the dusting. Staff F went back to the cleaning cart and wrung out a cloth that was soaked with "Dispatch" disinfectant and began to clean the call light cords.

5. Staff F stopped and went out of the room to their cleaning cart. Staff F changed their disposable gloves (no hand hygiene) and cleaned the bed, chairs and pillows.

6. Staff F ran out of clean cloth rags on their cart. They exited the room with their used disposable gloves on and went to the housekeeping closet. Staff F returned to room #504. They applied clean disposable gloves (no hand hygiene).

7. Staff F took a bottle of "Dispatch" cleaner disinfectant. They poured the "Dispatch" directly into the toilet bowl, swished it around and immediately flushed the toilet.

8. Staff F completed the room. They exited the room wearing a pair of disposable gloves and pushed their cleaning cart to the dirty utility room where they put dirty equipment and the bagged trash. After staff F placed items in the dirty utility room they changed their disposable gloves (no hand hygiene).

Staff A interviewed on 6/6/12 at 11:30am verified staff E and F failed to follow manufacturer's direction for use when they used hospital disinfecting products.

The manufacturer's direction for use for Virex one-step disinfectant cleaner and deodorant reviewed on 6/5/12 instructed staff in health care settings to:

1. Thoroughly clean blood and body fluids from surfaces and objects before application of Virex. Allow surfaced cleaned to remain wet for 10 minutes then air dry to achieve disinfection. Change cloth, sponges or towels frequently to avoid recontamination of areas cleaned. For disinfection, all surfaces must remain wet for 10 minutes.

- The 2011 Perioperative Standards and Recommended Practices (AORN) provided by the hospital on 6/6/12 as the hospital's standards for environmental cleaning stated, "a safe, clean environment should be reestablished after each surgical procedure. Routine cleaning and disinfection reduces the amounts of dust, organic debris, and microbial load in the environment. Following scientifically based recommendations for cleaning and disinfection practices in health care organizations helps to reduce infections associated with contaminated items. Many studies have documented that failure to comply with scientifically based recommendations has led to infection outbreaks ".

11. a Operating rooms should be cleaned after each surgical or invasive procedure with a lint-free or microfiber cloth moistened with a detergent/disinfectant and water.

11.b.1 Nonporous surfaces such as mattress covers, pneumatic tourniquet cuffs, blood
pressure cuffs and other patient equipment should be cleaned and disinfected with an EPA-registered hospital disinfectant between patient use.

Observations on 6/5/12 at 11:15am of nursing staff G, H, I and K cleaning OR (operating room) 3 after a surgery which left blood pooled on the floor near the OR table and splattered on the foot of one instrument stand revealed staff failed to follow the manufacturer's guidelines for cleaning/disinfection with Virex. Nursing staff wiped all equipment surfaces with clothes wet with Virex but failed to keep the surfaces wet the required 10 minutes. Staff failed to preclean the blood spatters and pool prior to wiping the surfaces with Virex as required by the manufacturer.

Nursing staff G, H, I, and K interviewed on 6/5/12 at 11:30am were all unaware of the manufacturer's requirement for surfaces to remain wet with the product Virex for 10 minutes.

- Review of the 7/30/2009 APIC (Association for Professionals in Infection Control and Epidemiology) Position Paper titled "Safe Injection, Infusion and Medication practice in Health Care" reviewed on 6/6/12 at 2:00pm directed under medication vials " ...cleanse the access diaphragm of vials using friction and 70% alcohol or other antiseptic. Allow to dry before inserting a device into the vial ...".

Observations on 6/5/12 at 10:16am in Interventional Radiology revealed registered nurse staff D prepared medications for a patient undergoing a heart catheterization. Staff D held in their hand a vial of Versed and flipped off the plastic protective cap. Staff D immediately inserted a sterile needle connected to a sterile syringe and withdrew the medication. Staff D failed to clean the access diaphragm of the medication vial with an antiseptic prior to inserting the needle.

Observations on 6/5/11 at 11:00am of staff G, a CRNA (Certified Registered Nurse Anesthetist) preparing medications for a surgery revealed staff G failed to clean the access diaphragm of the medication vial with an antiseptic prior to inserting a needle to withdraw the following medications: Lidocaine (local anesthetic agent), Propofol (agent used for induction of general anesthesia), and Zemuron (a neuromuscular blocking agent used in surgery)

Staff A, Infection Control Officer interviewed on 6/6/12 at 9:00am stated the plastic cap covering the access diaphragm was a dust cover and the diaphragm was not sterile. Staff A verified licensed staff failed to disinfect the access diaphragm of medication vials.