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A. Based on document review, observational tour, and interview, it was determined, for 12 of approximately 40 staff and physicians observed, (MD #1, 3, 4, 5, 6, 9, & 19 and E # 5, 6, 7, 9, & 10), the hospital failed to ensure staff adherence to personal protective equipment (PPE) in accordance with Hospital policy.

Findings include:

1. On 4/9/15 at 10:30 AM, hospital policy entitled, "General Infection Control Policy for the Operating and Recovery Room (Surgical) Suites", revised August 2013, was reviewed. The policy required, "6. Hair a. All head and facial hair (including beards, sideburns, and necklines) must be completely covered and contained in lint-free hats or hoods while in the restricted areas... 7. Surgical masks or particulate respirators must be worn in the operating room during a case and when open sterile items and equipment are present... Masks shall be... properly placed to prevent venting at the sides. They shall not be left hanging around the neck..."

2. On 4/6/15 between 9:30 AM and 10:40 AM, an observational tour was conducted in the Center for Care and Discovery (CCD) peri-operative area on the 6th floor with the director of regulatory compliance (E #1) and assistant operation room (OR) director (E #2). The following events were observed during the tour and were witnessed by E #1 & 2:

- At 9:44 AM, in the OR corridor, an anesthesia visiting scholar physician (MD #1) wore a dangling mask from his neck.

- At 10:08 AM, in OR suite 1, two perfussionist's (E #5 & 6) caps failed to cover approximately 3 inches of hair at the back of the head, while a surgical case was in progress.

- At 10:09 AM, at OR suite 5, a perfussionist (E #7) entered the suite holding on an untied mask, while a surgical case was in progress.

- At 10:11 AM, at OR suite 7, an anesthesia resident (MD #3) entered the suite with his beard partially exposed and partially covered by a face mask, while a surgical case was in progress.

3. On 4/7/15 between 7:00 AM and 9:15 AM, a second observational tour was conducted in the CCD peri-operative area on the 6th floor with the Lead Infection Control Practitioner (E #3). The following events were observed in OR suite 8, where sterile surgical instruments were open, and were witnessed by E #3:

- At 7:24 AM, a physician assistant (E #9) entered the suite holding a mask to his face and then tied the mask.

- At 7:30 AM, a 5th year resident physician (MD #4) entered the suite holding a mask to his face and then tied the mask.

- At 7:46 AM, 2 anesthesiologists (MD #5 & 6) entered the suite, with a patient (Pt. #1), holding untied masks to their faces and then tied the masks.

- At 8:10 AM, an OR nursing manager (E #10) entered the suite holding a mask to her face and then left.

- At 8:19 AM, an anesthesiologist (MD #9) entered the suite wearing a skull cap with approximately 3 inches of hair protruding from the back.

4. On 4/9/15 at 9:55 AM, an observational tour was conducted in the Duchossois, 3E, Pain Management Center, with E #3. At 10:00 AM, a physician (MD #19) was performing an epidural procedure for Pt. #8. MD #19's mask did not cover her nose.

5. On 4/7/15 at 8:15 AM, an interview was conducted with E #3. E #3 stated masks should be tied before entering the OR suite and not left hanging around the neck.

6. On 4/7/15 at approximately 4:00 PM an interview was conducted with the Infection Control Director E #2. E #2 stated the infection control group is attempting to encourage the surgeons wear bouffant hair covers in place of skull caps.

B. Based on document review, observational tour and interview, it was determined, for 7 of approximately 40 physicians and staff observed, (MD #7, 8, & 12 and E #8, 9, 12, & 16), the hospital failed to ensure staff adherence to hand hygiene in accordance with Hospital policy.

Findings include:

1. On 4/9/15 at 10:30 AM, hospital policy entitled, "Hand Hygiene (Including Care of Hands), Antiseptics and Skin Preparation", revised June 2013, was reviewed. The policy required, "A. 3. Decontaminated hands before having direct patient contact... 7. Decontaminated hands after removing gloves..."

2. On 4/7/15 between 7:00 AM and 9:15 AM, an observational tour was conducted in the Center for Care and Discovery (CCD) peri-operative area on the 6th floor with the Lead Infection Control Practitioner (E #3) The following events were observed in OR suite 8, where sterile surgical instruments were open, and were witnessed by E #3:

- At 7:16 AM, a registered nurse (RN) (E #8), picked up an indicator tag and cup lid from the floor, did not disinfect his hands, and failed to disinfect her hands prior to opening sterile trays.

- At 7:26 AM, a physician assistant (E #9), half leaning and half sitting on the OR table, put on shoe covers, and did not disinfect his hands.

- At 7:51 AM, a resident physician (MD #7) inserted a Foley catheter for Pt. #1, removed the gloves but did not disinfect his hands.

- At 8:00 AM, a surgeon (MD #8), prepped Pt. #1's right leg, changed gloves without disinfecting his hand and then prepped Pt. #1's left leg.

- At 8:18 AM, a RN (E #12), picked up a drape from the floor with gloved hands, did not change gloves or disinfect her hands, and continued performing circulating duties.

3. On 4/8/15 between 9:00 AM and 10:30 AM, an observational tour was conducted in Mitchell 6SE, Infusion Therapy Unit, with E #3 and the following were observed:

- An infusion therapy nurse (E #16) prepared a morphine injection for Pt. #5, removed her gloves, did not disinfect her hands, used a computer, and put on new gloves to administer the morphine.

- A physician (MD #12), wearing gloves, completed a skin preparation for Pt. #5's bone marrow procedure. After the prep, MD #12 removed his gloves, did not disinfect his hands, and donned sterile gloves prior to the procedure.

4. On 4/7/15 and 4/8/17, during the observational tours, interviews and discussion was conducted with the Lead Infection Control Practitioner (E #3), who witnessed the findings. E #3 stated the hospital infection control staff constantly reinforce hand hygiene practice.

C. Based on observational tour and interview, it was determined, for 1 of 2 respiratory therapist (E #14) transporting a patient, the hospital failed to ensure contaminated supplies were not placed with clean supplies.

Findings include:

1. On 4/7/15 at 1:40 PM, an observational tour was conducted in the post anesthesia recovery area on the CCD 6th floor. Pt. #3 was in room C 27, in contact isolation, awaiting transport to an in-patient room. A respiratory therapist (E #14), knocked a clean cover gown to the floor, picked it up and placed it back with the clean cover gowns, instead of disposing of it.

2. On 4/7/15 at 1:40 PM, during the observational tour, an interview was conducted with the Lead Infection Control Practitioner (E #3), who witnessed the finding. E #3 stated the cover gown should have been disposed of.

D. Based on document review, observational tour, and interview, it was determined, for 3 of approximately 40 staff and physicians observed, (MD #14, 15, & 16), the hospital failed to ensure protective gowns were worn in isolation rooms, to decrease the potential for patient and staff contamination.

Findings include:

1. On 4/9/15 at 10:15 AM, hospital policy entitled, "Isolation", revised June 2012, was reviewed. The policy required, "IV. A. Contact Precautions. 4. Gowns and gloves are required prior to entry into patient's room or cubical."

2. On 4/8/15 at 10:50 AM, a Contact Precaution placard on the doors of rooms 39 and 40 in the medical intensive care unit (10N) in the Center for Care and Discovery (CCD) building was reviewed. The placards included, "gowns required".

3. On 4/8/15 at 10:50 AM, an observational tour was conducted in CCD, 10N, with the Lead Infection Control Practitioner (E #3). The following events were observed during the tour and were witnessed by E #3:

4. At 10:55 AM, a first year intern physician (MD #14) was not wearing a protective gown in room 40, a contact isolation room for rule out pneumonia (Pt. #6). MD #14 left the room, but returned and reentered room 40 at 11:18 AM, without donning a cover gown.

5. At 11:05 AM, a fellow physician (MD #16) entered room 39, a contact isolation room (Pt. #7), not wearing a gown. MD #16 set up for a triple lumen procedure and performed Pt. #7's skin preparation without wearing a protective gown. At 11:10 AM, MD #16 donned a sterile gown, completed the triple lumen catheter procedure, removed the gown, and exited room 39 at 10:50 AM.

6. A resident physician (MD #15), entered room 39 to assist MD #16 at approximately 11:06 AM, without wearing a gown.

7. On 4/8/15 at 11:45 AM, during the observational tour, an interview was conducted with E #3, who witnessed the findings. E #3 stated physicians should wear gowns in contact isolation room.

E. Based on observational tour and interview, it was determined, for 1 of approximately 40 staff and physicians observed, (MD #16 ), the hospital failed to ensure Hospital surfaces were not contaminated with blood.

Findings include:

1. On 4/8/15 at 10:50 AM, an observational tour was conducted in Center for Care and Discovery (CCD) 10N with the Lead Infection Control Practitioner (E #3). The following event was observed during the tour and were witnessed by E #3:

2. At 11:05 AM, a fellow physician (MD #16) entered room 39, a contact isolation room (Pt. #7), and performed a triple lumen procedure. During the procedure, MD #16's gloves became blood stained. At 11:45 AM, having completed the procedure, MD #16 moved the Pt. #7's bed and intravenous stand while wearing the same bloody gloves. Thus contaminating the bed and intravenous stand.

3. On 4/8/15, during the observational tour, an interview was conducted with E #3. E #3 stated room furnishings and equipment should not be touched with bloody gloves.

F. Based on document review, observational tour, and interview, it was determined, for 1 of 1 patient room cleaning procedure observed, the hospital failed to ensure bleach solution was used, per policy.

Findings include:

1. On 4/9/15 at 11:10 AM, hospital policy entitled, "Environmental Cleaning and Disinfection", revised August 2013, was reviewed. The policy required, "VII. A... At discharge, all reusable equipment in the room must be cleaned and disinfected before it is removed with a 1:10 dilution of bleach Dispatch Hospital Cleaner with Bleach unless contraindicated by the manufacturer."

2. On 4/9/15 at 10:30 AM, a discharge room cleaning (E #18) was observed in the Mitchell building, 4SE, room 412. The environmental service worker (E #18) used SaniMaster solution for cleaning (does not contain bleach and is not as effective for killing germs), instead of Dispatch.

4. On 4/19/15 at 10:30 AM, an interview was conducted with E #18. E #18 stated that Dispatch is used on isolation room and SaniMaster on non isolation rooms.