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Based on observation, interview, and record review, the facility failed to ensure housekeeping staff (F and G) followed their policies and procedures for terminal room cleaning; failed to provide evidence of houskeeping education and compentency; failed to develop an infection control policy for clean linen handling; failed to ensure staff donned personal protection equipment (PPE) for patient on contact isolation precautions; and failed to implement bed bug detection protocol per policy/procedure, resulting in the increased potential for the spread of infections for all patients served by the facility. Findings include:

See specific tags
A-0749- Failure to monitor, evaluate and conduct active surveillance activities performed by contract housekeeping/environmental staff, Failure to don PPE for transmission precautions.
Failure to follow policy/protocol for bed bug detection.
A-0756- Failure to develop a policy/procedure for clean linen handling, Failure to provide evidence of houskeeping education and compentency in infection control.

Based on observations, interviews and record review, the Infection Control Officer (ICO) failed ensure 2 of 2 housekeeping staff (F and G) followed their policies and procedures for terminal room cleaning; failed to provide evidence of housekeeping education and competency; failed to ensure staff donned personal protection equipment (PPE) for 1 patient (#2) on contact isolation precautions; and failed to implement bed bug detection protocol per policy/procedure for 1 (#2) of 3 patients reviewed for bedbugs, resulting in the increased potential for the spread of infections for all patients served by the facility. Findings include:

On 6/19/17 at approximately 0930 a tour of the 4th floor nursing unit was conducted while accompanied by the Interim Chief Nursing Officer (CNO) (Staff B), Facilities Supervisor (Staff C) and the Facilities Manager (Staff D). The 4th floor Clinical Manager (Staff E) accompanied the surveyors and facility staff during the tour at 0945. When queried regarding patient discharges Staff E explained room 450/451 (one room that was a semi-private room) was vacant and awaiting housekeeping staff to perform terminal room cleaning. According to Staff E the patient that was discharged had been on Contact Isolation Precautions and had just been discharged.

On 6/19/17 at approximately 0940 housekeeping staff F and G were observed for terminal room cleaning for room 450/451. Bleach wipes were protocol for terminal room cleaning according to housekeeping Staff F. Staff F was overheard as she said, "We don't have any bleach wipes. I'll have to go to the supply room." Staff F left the floor to obtain bleach wipes. At that time Staff G was queried regarding his employment. He said he had worked for the company for 3 weeks. When asked if he had been trained by the facility he said, "No." He said they told me what I would be doing. When asked if he was still in orientation he said "No". He explained that the company that he worked for had talked to him about different products for cleaning.

While waiting for Staff F to return to the unit with bleach wipes the surveyors accompanied Staff G to the janitors closet on the 4th floor. Staff G explained there were no bleach wipes in the janitors closet. Staff F returned to the 4th floor after approximately 15 minutes with one container of bleach wipes.

Staff F and G were observed as the donned PPE and proceeded with terminal cleaning for room 450/451 on 6/19/17 at 0945. There was one bed in the room. There was an upright wing chair and a recliner chair. There was a bathroom with a shower. There was a air compressor pump stored on the upright wing chair. There was an Intravenous (IV) pump and pole. There were wall adapters for oxygen and suction delivery. There were 2 night stands. There was a phone on each night stand. The overhead light cords were touching the floor. The phone extension cords were long and curled on the floor. There was one overbed tray. The overhead light for bed 450 were turned upward toward the ceiling. Staff F and G were overheard as they said to each other did you clean this or I cleaned that already as they proceeded with cleaning the room. Staff F was observed as she cleaned the upright wing chair. She cleaned the back of the chair and the arms of the chair. The air compressor pump in the wing chair were not touched nor cleaned. Staff F was observed as she cleaned the IV pump and pole. Staff F was observed as she cleaned the base and hand set of the corded phone. Staff F did not clean the extension of the phone cord that was curled and lying on the unclean floor. Staff F was observed as she used a bleach wipe to clean the surfaces of the shower chair and bedside commode that were stored in the shower.

Staff G was observed as he performed terminal cleaning for room 450/451. Staff G worked from the distant part of the room cleaning surface areas with a bleach wipe. Staff G was observed as he cleaned the telephone base and headset with a bleach wipe for bed 451. Staff G did not clean the extension cord of the phone that was curled and lying on the unclean floor. Staff G was observed as he wrapped the dirty phone cord over and around the wall oxygen adapter. Neither staff member turned on the overhead lights for bed 450 the lights were dim as both staff F and G performed terminal cleaning. Neither staff member dusted the or checked the wall vents, ceiling vents, or window blind rods. The overhead light extension cords were cleaned however, the bottom of the cords were laid curled on the dirty floor after cleaning.

Staff F left the room to obtain clean linen (sheets, pillowcase and a blanket) for the bed. Staff F returned to the room with the clean linen. The clean linen came into contact with to the dirty air compressor pump. Staff F was observed as she made the bed up with the contaminated linen.

At that time when queried regarding the aforementioned concerns Staff F said "I didn't know the linen was that close." When asked to explain why she placed the linen on the chair where a dirty air compressor pump was stored. Staff F stated, "We don't clean those pumps. The Patient Care Technician's (PCA's) are suppose to clean those." She said the pump still has a tag on it that means that it is clean. The tag was dated cleaned on 6/15/17 (4 days prior).

Staff E was queried regarding the cleaning of the air pump compressor, IV pole and IV pump, Bedside commode (BSC) and shower chair on 6/19/17 at approximately 1030. Staff E explained the housekeeping staff were responsible for removing the BSC and cleaning and tagging it with a label with the date that it was cleaned. Staff E explained the IV pole and IV pump should have been removed by the nursing staff. Staff E said housekeeping should have removed the air compressor pump for cleaning.

At that time the CNO was overheard as she said "This room needs to be cleaned again." The surveyor observed the bed being stripped by another housekeeping staff member.

There was no evidence observed or documented that identified bed bugs were on the nursing unit or in patient rooms. Electronic and paper ledgers were reviewed for repairs and/or reports of pests or insects.

On 6/19/17 at approximately 1100 a tour of the Emergency Department was conducted with Staff B and Assistant ED Nurse Manager Staff (L). When queried the Staff L explained patient (#2) had presented to the ED via ambulance and had since been admitted to the 5th floor under contact isolation precautions for bed bugs. Staff L explained the patient had come in on the previous evening and was transferred prior to the 0700 day shift on 6/19/17. According to Staff L the patient was given a shower and her belonging would have went up with her to her room.
Per record review on 6/19/17 at 1115, patient #2 was a 42 year old female who presented to the ED via ambulance on 6/18/17 at 1951. The ED nurses assessment dated 6/19/17 at 0045 documented that the patient's skin was intact.
Per provider history and physical dated 6/19/2017 (no time indicated) documented bedbugs were noted by nursing staff upon the patient's presentation to the ED. Per the provider's examination there were multiple excoriations present that were consistent with bug bites.
The provider prescribed permethrin secondary to the bedbugs.

At that time Staff L was queried regarding the policy/procedure for bedbug management. Staff L stated, "The patient was given a shower. Her personal belongings were double bagged and sent with her up to the floor." When asked to explain if the patient's clothes were laundered or held for safe keeping until discharge. Staff L repeated no her clothing would be with her.

On 6/19/17 at approximately 1130 a tour of the 5 th floor nursing station was conducted with Staff B and the 5th floor Clinical Nurse Manager Staff N. Patient #2's call light was illuminated above the entry door. A sign with Contact Isolation precautions was posted. Nurse Assistant Staff M was observed as she entered the patient's room without donning any PPE. Nurse Assistant Q was observed in the hallway with disposable mid-calf shoe covers on her feet.
Staff Q was observed as she entered patient #2's room without donning any gloves or a gown.

On 6/19/17 at approximately 1150 Staff N was queried regarding the type of precautions that were in place for patient #2. Staff N stated, "She's (#2) on contact precautions. Staff should wear gowns and gloves." When further queried regarding the observation of seeing Nurse Assistant Q wearing disposable shoe covers near the nurses station, Staff N stated, "That's not good. They should have been disposed of in the patient's room."

Staff Q was queried regarding her wearing disposable shoe covers near the nurses station. She stated, "The box on the patient's door was empty. When I went to get a new box I put them on before I got to her room. When asked to explain if that was the policy, Staff Q offered no further explanation.

On 6/19/17 at approximately 1330 an interview was conducted with the Infection Control Officer Manager Staff R. When queried regarding the aforementioned observations of staff performance and breaks in infection control protocol Staff R said Environmental Services is contracted out. They were responsible for their employees. She said that was her understanding. Staff R said their managers attend our meetings. The managers report to us any concerns. When asked to provide evidence that documented the Environmental Services staff were performing surveillance activities and audits. Staff R stated, I wouldn't be responsible for that."
When queried regarding bedbug policy/procedure Staff R explained if a bed bug was found on a patient or in their belongings the staff member who observed would have been responsible for securing the bug and having the bug tested to determine if the bug was a bedbug or not. Staff R explained to her knowledge it had been a while since an incident of a bedbug had been reported to her department. Staff R said "a bedbug is not considered an infection."

On 6/19/17 at 1500 a review of incident/accidents and complaints and grievance reports was conducted with Staff B. There was 1 incidents related to bed bugs. Patient #3 was a 53 year old male who presented to the ED on 5/4/17 at 2330. The patient lived in a group home prior to his admission to the hospital. Bedbugs were found in the patient's personal belongs. A bug sample was tested and the results were positive for a bedbug on 5/5/17. The patient's belongings were secured in a holding area for the family to pick up as the patient awaited placement into a local behavioral health facility.

On 6/20/17 at 0915 a review of personnel files was conducted with Staff B. There was no evidence that documented housekeeping Staff F or G were trained, observed or evaluated for housekeeping duty requirements. There was a blank packet of teaching materials for environmental services that included pre and post test questions.

Environmental Director Staff K was interviewed on 6/20/17 at approximately 1000. Staff K explained all training was conducted off site. When asked to provide evidence of competency of job duties, performance evaluation and/or audits for Staff F and G's work performance Staff K explained pre and post environmental test were taken by all staff. However, Staff K did not provide evidence that documented Staff F and G were competent in the housekeeping roles. There was no evidence that documented how Staff F or G scored or their pre or post testing. When asked to provide evidence that Staff F and G had been monitored or audited regarding their work performance. Staff K said "I have hundreds of audits they are electronic." However, Staff K did not provide the surveyor with any documents prior to the survey exit.

A review of the Environmental Services Contract dated 4/24/2017 documented:
"...9. (name of company) shall train all department employees in the performance of their respective duties...11. (name of company) will supply all housekeeping chemicals and cleaning supplies needed to provide proper housekeeping..."

On 6/19/17 a review of the facility's policy number EVS 107, titled "Isolation Room: Terminal cleaning, dated 1/1/2017 documented:
"4. Policy 4.1 The cleaning and disinfection of surfaces touched by patients, healthcare staff and visitors...5.12.3 Perform high dusting with a microfiber high duster; be sure to check high wall vents using a stool if necessary. Dust curtain rods. Tops of doors and recessed lights. Ceiling vents..5.12.7...with disinfectant clean the nurse call device and cord, and the TV remote..."

A review of the facility's "Bedbugs/Insect Infestation Management" policy number INF21 dated 8/20/15 documented:
5.1.2....If a bug is found, either on the patient or during inspection, it should be tested. Collect bug in a specimen container, obtain an order for a 'bug ID', and sent ti to Laboratory Microbiology for identification...5.1.5.Initiate/Maintain Contact Precautions until observation indicates no further presence of bugs..."

Based on observation, interview and record review, the Chief Executive Officer (CEO), medical staff and the Chief Nursing Officer (CNO) failed to develop a policy for clean linen handling, resulting in the potential for the spread of infections for all patient served by the facility. Findings include:

On 6/19/17 at approximately 1130 Housekeeping Staff F was observed as she performed terminal room cleaning for room 450/451. An air compressor pump was observed in an upright arm chair. Staff F cleaned the back and the arms of the chair, she cleaned around the air pump compressor. However, Staff F did not remove the air compressor pump to clean the remainder of the chair, nor did she clean the air pump compressor. Staff F was observed as she returned to the room with clean linen (sheets, pillowcase and a blanket) and placed the linen on the chair. The clean linen came into contact with to the dirty air compressor pump. Staff F was observed as she made the bed up with the contaminated linen.

At that time when queried regarding the aforementioned concerns Staff F said I didn't know the linen was that close. When asked to explain why she placed the linen on the chair where a dirty air compressor pump was stored. Staff F stated, "We don't clean those pumps. The Patient Care Technician's (PCA's) are suppose to clean those."

On 6/19/17 at approximately 1530 an interview was conducted with the Interim Chief Nursing Officer (Staff B) and the Director of the Infection Control Program Staff R.
When asked to provide a policy for the handling of clean linen. Staff R explained it was the responsibility of the Environmental Services Department (EVS) to have a policy on handling linen.

When further queried regarding if only EVS handled clean linen in the facility Staff B stated no nursing staff would also handle linen. Staff B confirmed there should be a policy. She explained she would check for a policy.

On 6/20/17 at approximately 0930 when asked to provide a copy of the policy for handling clean linen Staff B stated, "I looked we don't have one."

On 6/20/17 at approximately 0940 the Director of Environmental Services (Staff K) was queried regarding a policy for clean linen handling. Staff K stated, "There is not one. I was asked if I had one. I don't."

A review of the Environmental Services Contract dated 4/24/2017 documented:
"...9. (name of company) will be responsible for providing and maintaining the applicable training used in training department employees...".