HospitalInspections.org

Based on document review, observation and interview, the Infection Control Committee (ICC) failed to ensure a safe and healthful environment was maintained to minimize infection exposure and risk for patients, health care workers and visitors in the hospital for two occurrences.

Findings include:

1. Review of the Infection Control Plan 2020 (approved 1-20) indicated the following: "The scope of infection prevention and control activities extends to all direct inpatient and outpatient services, ancillary services, support services, in-service education, and employee health."

2. Review of the policy/procedure Cleaning of an Occupied Room (approved 1-18) indicated the following: "Occupied patient rooms are cleaned and disinfected daily by an Environmental Services Tech ..."

3. Review of facility administrative documentation indicated a concern was reported to the facility on 6-22-20 indicating a patient's room (410) was not cleaned during the 6/11-14/20 stay, the wall-mounted, alcohol-based hand sanitizer dispensers located in the immediate vicinity of the patient's room were out of sanitizer, and the public bathroom associated with the nursing unit 4A was not cleaned and restocked with paper towels over the weekend.

4. Review of the EVS daily unit assignment documentation for 6/13-14/20 confirmed no EVS personnel was assigned to the 4A nursing unit to provide occupied room cleaning or sanitation services for the immediate environment of care on the Saturday or Sunday associated with the allegations.

5. On 6-24-20 at 1020 and 1030 hours, the Director of EVS A4 confirmed that no EVS personnel were assigned to the 4A nursing unit on 6/13-14/20. Staff A4 indicated the alcohol-based hand sanitizer refills are a proprietary product and have been in short supply since the staff began working on 6-1-20. Staff A4 confirmed they were responsible for ordering the refills from the health care system warehouse and confirmed their orders were not being filled as requested. Staff A4 was requested to provide documentation indicating the hand sanitizer refill orders were placed and not filled as requested by the system warehouse prior to the patient's date of admission on 6-11-20 and no other documentation was provided prior to exit.

6. During a tour of the 4A nursing unit on 6-24-20 at 1335 hours, in the company of the Quality Manager A2, the Infection Prevention Manager A3, and staff A4, the four wall-mounted, alcohol-based hand sanitizer dispensers located next to the doors of rooms 409, 410, 411 and 412 (currently occupied by a patient) were observed to be out of sanitizer product and no handwashing sink or other containers of hand sanitizer were observed in the vicinity of the 4 patient rooms or on the countertop of the adjacent nursing station. At the time of the observation, two medical staff exited from room 411 and looked around the immediate area for a wall-mounted dispenser containing hand sanitizer (or a hand sink) to perform hand hygiene, observed none, gestured and walked briskly out of the area and view of the surveyor.

7. On 6-24-20 at 1335 hours, staff A2, A3 and A4 confirmed the above.

Based on document review and interview, the infection preventionist(s)/infection control professional(s) failed to ensure competency validation documentation was maintained for cleaning and disinfecting in the restricted surgical environment for 4 environmental services (EVS) personnel (EV23, EV24, EV25 & EV26).

Finding include:

1. Review of the policy/procedure Infection Control Plan 2020 (approved 1-20) indicated the following: "Services...[include]...3. Development and implementation of infection control policies and control measures in accordance with current evidence-based recommendations. 4. Assistance with maintaining compliance with current guidelines, regulatory, and accreditation requirements. 5. Evaluation of risks for the acquisition and transmission of infectious agents on an ongoing basis and implementation of prevention and control measures. 6. Provision of educational services (formal & informal) to hospital staff..."

2. Review of the undated document titled Competency Validation Checklist: Surgical/Procedure Room Terminal/Cycle Cleaning Practices (Surgical/Procedure Room Cleaning) provided with the facility policy 4.02.22 Procedure for Operating Room Cleaning (revised 4-19) indicated a process for assessing staff competency by a qualified evaluator.

3. Review of the personnel files for four EVS staff (EV23, EV24, EV25 & EV26) assigned to provide terminal cleaning and disinfecting services in the surgical services department lacked a signed copy of the Competency Validation Checklist or other competency documentation indicating the EVS staff were observed by a qualified staff (eg., surgical services educator) while demonstrating proficiency in terminal OR cleaning skills to ensure the cleaning and disinfecting services were performed in a safe and effective manner.

4. On 6-24-20 at 1655 hours, staff A3 and the Director of EVS A4 confirmed the above and confirmed no additional documentation of competency validation for staff EV23, EV24, EV25 and EV26 was available.