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Based on observation, interviews with patient(s) and staff, and record reviews, the hospital failed to assure that there was consistent, active and effective monitoring and surveillance of housekeeping and nursing staff related to their required job responsibilities in assuring a safe and sanitary environment and adherence to aseptic technique during patient care. (Patients #1 and #11)

a). 1. During observation of administration of an IM (intramuscular) injection to Patient #11, the Staff Nurse (#2) failed to perform hand hygiene after removing soiled gloves and prior to donning new gloves.

2. .After observation of I.V. (intravenous) medication administration to Patient #11, Staff Nurse #2 removed his/her gloves and without performing hand hygiene, proceeded to remove an empty bag of intravenous (IV) antibiotic solution and placed it on his/her COW (computer on wheels); s/he then left the room and went down the hall with the COW and the used IV set up. S/he entered the medication room and obtained medications to be administered to Patient #11 and returned to the patient's room. The Staff Nurse did not wash or sanitize his/her hands upon returning to the room and donning a new pair of gloves.
Staff Nurse #2 failed to perform hand antisepsis at multiple required times during the 2 observations stated above.

b.) Per observations on the Medical Surgical Unit (West), Staff Nurse #1 violated the hospital policy regarding "Hand Antisepsis"while performing a dressing change for Patient #1. The Staff Nurse donned gloves and then, with the gloved hands proceeded to touch the Patient's arm, the bed controller, and the Patient's right hip. The Staff Nurse then removed the old dressing from the Patient's right hip and with the same gloves, s/he proceeded to pull down the Patient's gown over his/her legs. The Staff Nurse then threw away the soiled dressing and then removed his/her gloves. Without washing his/her hands, the Staff Nurse put a pillow in between the Patient's legs, touched the Patient's legs and arm. The nurse then proceeded to leave the room with soiled linen in his/her hands. Per interview at approximately 2:00 PM on 10/31/16, the Staff Nurse confirmed that s/he did not wash his/her hands immediately after removing gloves.

Per review, the hospital's policy/procedure entitled "Hand Hygiene", rev. 5/5/16, stated under B. Indications for hand antisepsis......, 2. After contact with a patient's skin/surroundings, 7. following contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient, 8. "ALWAYS after removing gloves, and 9. When leaving the patient's room..


c.) During observation on 10/31/16 at 1:44 PM, the housekeeper was doing a post discharge cleaning of room 264 West. There was a commode in the room and the seat cover had a paper wrap on it. The housekeeper cleaned all around the commode, but did not clean the commode and s/he stated that, "it is a clean commode because the patient hasn't used it." When inquired how s/he knew that it was clean, s/he indicated that the tape seal would have been broken if it had been used. After observing him/her disinfecting the bed pillows with the disinfectant Oxivir, s/he placed the pillows directly on the commode that s/he had not cleaned. Per review, the hospital policy "Cleaning of Non Critical Care Items, effective 10/17/16, stated under 'Commodes', standard, clean "Daily, if visibly soiled and at discharge". The housekeeping staff failed to follow hospital policy/procedure for cleaning of the commode.

d.) During observation of post discharge room cleaning on the East medical unit (RM 207 E), the housekeeper failed to clean all of the identified areas included in the hospital's policy/procedure "Routine Patient, Ancillary and Discharge Room Cleaning. The following observations did not comply with facility procedure:
1. Blood pressure cuffs (total of 3) were cleaned on one side with sanitizing wipe and then turned over and placed against the housekeeper's clothing and wiped on the other side, thus recontaminating the cuff.
2. Areas not cleaned included - wastebasket, baseboards, white wall mounted alarm boxes, a bag containing a gaitbelt was placed on a soiled bed and put in the wall rack without wiping the bag, a bag containing a clean bed alarm was placed on the soiled bed and fell out of the bag approximately 3 inches, when the bag was picked up for wiping, the alarm fell into the bag and was not recleaned before placing on a clean chair; the wall mounted suction equipment was not wiped.
Additionally, the brush used for dusting the room was matted, with visible gray soiling in the fibers. When asked what the process was for obtaining new dusters, the housekeeper was not aware of how this was determined. During interview later in the day, the Director of Housekeeping services stated that the dusters should be replaced when they become matted and appear soiled and that the housekeepers determine when this is needed.
Refer to the policy/procedure: "Routine Patient, Ancillary and Discharge Room Cleaning".

e.) Per staff interview, the hospital failed to assure adherence to manufacturer's recommendations regarding routine monitoring and testing of 2 disinfecting solutions used to maintain a clean and sanitary environment throughout the hospital. Per review of the manufacturer's written testing recommendations (Diversey, Inc.) information includes: "Frequency: Diversey recommends facilities test dispensing systems whenever a concentrated bottle if disinfectant is changed or at least monthly, depending on the frequency of use." Method: Diversey recommends that facilities use disinfectant test/indicator strips to determine the accuracy of the disinfectant solution."
When discussing the use of disinfectants in the hospital, it was revealed that the hospital had not initiated it's own system, per manufacturer's recommendations, for monitoring and testing of the two disinfectant solutions referred to, Oxivir Five 16 and Virex II 256. During interview, the Director of Housekeeping confirmed that s/he was not previously aware of the recommendations to conduct regular testing of the disinfectant solutions, per the manufacturer S/He stated that they believed that since the salesman from the company did audits at approximately quarterly intervals, that testing was sufficient. Per review, the last time the solution had been tested (by the salesman) was during May, 2016. The test strips were obtained by the hospital during the survey and observed tests were within required levels.