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A. Based on document review and interview, it was determined for 1 of 2 (Pt. #7) patients sampled, that were in airborne isolation, the Hospital failed to conduct daily negative pressure meter tests in the isolation rooms, to ensure the negative pressure in the rooms was operating efficiently.

Findings include:

1. Hospital policy entitled, "Isolation/Negative Pressure Rooms," (initiated 12/1/2001) required, "Testing and PM's [preventative maintenance]... Daily... Facilities Management will perform the negative pressure meter test to make sure that the room is working properly. The daily negative pressure meter test will be done until the patient is taken out of isolation precautions or is discharged."

2. The partial electronic clinical record of Pt. #7 was reviewed on 03/10/16 at approximately 2:00 P.M. This was a 75-year-old admitted on 10/23/15 with a diagnosis of hyponatremia (low sodium level in the blood). The clinical record included documentation that airborne isolation in room C132 was initiated for Pt. #7 on 10/26/15 at 3:43 P.M. and an acid fast bacillus stain and culture (test for tuberculosis[TB]) was collected. The record further noted that airborne isolation was discontinued at 4:00 P.M. on 10/28/15.

3. The Hospital's "Isolation Room Smoke check"(manual monitoring of negative pressure isolation rooms) and "Metasys"(online monitoring system for negative pressure isolation rooms) documentation was reviewed on 03/09/16 and 03/10/16 respectively. The documentation lacked evidence that the negative pressure for room C132 was monitored on 10/27/15 and 10/28/15 while Pt. #7 was in airborne isolation.

4. An interview was conducted with the Infection Prevention Manager (E#9) on 03/10/16 at approximately 1:30 P.M., who reviewed Pt. #7's microbiology results simultaneously. E#9 stated she did not see negative pressure monitoring for isolation room C132 for 10/27/15 and 10/28/15, while Pt. #7 was in airborne isolation.


B. Based on observation, interview, and document review, it was determined that for 2 of 5 (E#1 and E#2), staff observed in the Neonatal Intensive Care Unit (NICU), the Hospital failed to ensure proper hand hygiene and personal protective equipment (PPE) in accordance with policy. This potentially affected 20 infants on census on 03/08/16.

Findings include:

1. On 03/08/16 at approximately 11:07 A.M., during a tour of the NICU, E#1(registered nurse [RN]) left the bedside of an infant, carrying a feeding syringe in ungloved hands. She disposed of the syringe into a red waste can, an then proceeded to a centrally located desktop computer and pulled out pen and paper, without performing hand hygiene.

2. An interview was conducted with E#1 on 03/08/16 at approximately 11:08 A.M., when E#1 stated that the syringe was a feeding syringe used to check the feeding tube placement (possibility of contact with abdominal fluid contents).

3. Hospital policy entitled, "Gavage Feeding in the NICU" (initiated 8/26/2010) required, "C... Perform hand hygiene and don gloves... Verify the NG/OG tube placement..."

4. Hospital policy entitled, "Hand Washing Technique and Nail Care" (initiated August 1976) was reviewed on 3/8/16, and required, "Routine hand-washing: this can be done in one of two ways: Using soap and water; vigorous friction is to be done for 30 seconds..."

5. On 03/08/16 at approximately 11:45 A.M., in the NICU, E#2 (respiratory therapist) entered the NICU and went to the sink to wash her hands for 10 seconds.

6. An interview was conducted with E#2 on 03/08/16 at approximately 11:45 A.M. regarding how long she had washed her hands. E#2 stated, "I think I washed for 30 seconds because I sang the happy birthday song. I was trying to hurry so I could speak to you."


C. Based on document review and interview, it was determined the Hospital failed to ensure policies governing infection control practices were updated and revised as needed. This potentially affected all patients, staff, and visitors of the Hospital.

Findings include:

1. Hospital policy entitled, "Equipment Cleaning," (initiation date 02/01/1988) was reviewed on 03/09 and 03/10/16. The policy required, "NICU[neonatal intensive care unit] Equipment... IV pumps... Breast milk refrigerators and freezers... feeding prep areas... cribs... infant weighing scales... current cleaning practice... Cavi wipes/spray... isolettes... current cleaning practice... Cavicide wipes."

2. On 03/08/16 from approximately 10:00 A.M. - 11:45 A.M. a tour of the NICU was conducted. No Cavi wipes/spray/Cavicide was available to use for cleaning equipment. However, hydrogen peroxide wipes were available for use.

3. An interview was conducted on 03/09/16 at approximately 11:30 A.M. with E#9, the Infection Prevention Manager, who stated the practice was changed to start using hydrogen peroxide instead of Cavicide, but the policy has not been revised.

4. Hospital policy entitled, "Isolation/Negative Pressure Rooms," (initiated 12/1/2001) required, "Testing and PM's [preventative maintenance]... Daily... Facilities Management will perform the negative pressure meter test to make sure that the room is working properly. The daily negative pressure meter test will be done until the patient is taken out of isolation precautions or is discharged."

5. The Hospital's "Isolation Room Smoke check"(manual monitoring of negative pressure isolation rooms) and "Metasys"(online monitoring system for negative pressure isolation rooms) documentation was reviewed on 03/09/16 and 03/10/16 respectively. The documentation was not representative of policy requirements, i.e. performing a daily negative pressure meter test.

6. In an interview with the Hospital's Facility Manager (E#10), on 03/10/16 at approximately 3:40 P.M. E#10 stated that the practice for checking negative pressure in isolation rooms had changed back and forth, but he thought he had updated the policy.

D. Based on document review and interview, it was determined that for 1 of 2 sterilization loads on September 16, 2015 and on October 20, 2015, The Hospital failed to ensure biological test results were documented. This potentially affected the patient recipients of the instruments from the two loads on the above noted dates.

Findings include:

1. Hospital policy entitled, "Biological Monitoring of Sterilizers- Sterile Processing Department," (initiated 4/8/2011) required, "... Place BI in incubator and record activation time in logbook... Record results at conclusion of incubation period (24 hours)..."

2. The sterilizer logs for steam and Sterrad machines were reviewed on 03/11/16 at 2:00 P.M., for the months of September, October, November, and December 2015. The Sterrad sterilizer logs lacked documentation of one load (Sterrad 8) on September 16, 2015 at 10:40 A.M. and one load (Sterrad 12) on October 20, 2015 at 3:00 P.M.

3. An interview was conducted on 03/11/16 at approximately 2:30 P.M. with E#11, the OR Manager. E#11 stated that staff are supposed to document the biological [bio] result as soon as it is read. He stated that he believes the person mistakenly documented the negative result on the control result, even though it was a bio test on one of the dates in question. This is why he says, both the control (positive) and the bio result should be documented daily for consistency.


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E. Based on document review, observation, and interview, it was determined that for 4 of 12 (E #4, 5, 6, & 7) staff observed in the operating room (OR), the Hospital failed to ensure staff adherence to surgical attire policy.

Findings include:

1. The Hospital policy titled, "Surgical Attire-Restricted and Semi-Restricted Procedural Areas" (initiated 3/06), required, "...All personnel should cover head and facial hair, including side-burns and the nape of the neck, when in the semi-restricted and restricted areas."

2. During observation of the surgical department on 3/10/16 between 6:45 and 9:30 AM the following was observed:

-A Registered Nurse (E #4) had strands of hair, approximately 2 inches, outside of the cap below both ears.
- A Physician (E #5) had approximately 2 inches of hair exposed on the back of the head below the head cover.
- A Certified Registered Nurse Anesthetist (CRNA- E #6) had strands of hair exposed at the nape of the neck.
-A nurse orientee (E #7) had hair exposed around the temple area.

3. The above findings were discussed with (E#9) the Infection Preventionist (IP) and the E#11, the OR Manager during an interview on 3/10/16 at approximately 9:30 AM, each stating that all hair should be covered. The IP stated all clinical policies are reviewed annually.


F. Based on document review, observation, and interview, it was determined that for 1 of 2 (E #6) staff observed preparing medication in the operating room (OR) 6, the Hospital failed to ensure staff followed aseptic technique during medication preparation.

Findings include:

1. The Hospital policy titled, "Expiration Date Labeling" (initiated 2/10/82) required, "Purpose-To establish safe handling usage...of single dose and multi-dose vial...Procedure: Any entry into a vial should follow proper aseptic technique. Vial Tops should be scrubbed with 70 % alcohol prior to each entry. Ten (10) seconds of contact time is required to ensure bactericidal action."

2. During observation of the preparation of operating room (OR) 6, on 3/10/16 at approximately 8:00 AM, E # 6 Certified Registered Nurse Anesthetist (CRNA) was observed preparing injectable medications. E #6 opened 2 vials of medication and inserted a needle attached to a syringe to draw up the medication from each of the vials, without scrubbing the vial top with alcohol.

3. The above finding was discussed with E#9 the Infection Preventionist (IP) during an interview on 3/10/16 at approximately 9:30 AM,who stated that the vial tops should be scrubbed with alcohol after removing the plastic cap and before drawing the medication.


G. Based on observation, document review and interview, it was determined that for 1 of 1 (E #8) observed in a droplet isolation room, the Hospital failed to ensure staff adherence to isolation policy. This potentially affected all patients on the Medical Surgical/Cancer Care Unit.

Findings include:

1. During an observational tour of the Medical Surgical/Cancer Care Unit on 3/10/16 at approximately 11:00 AM, E #8 (Registered Nurse) entered a droplet isolation room wearing a mask and performed hand hygiene before entry. E #8, after conversing with the patient, removed her mask, performed hand hygiene, began to step out of the room, and then stepped back inside the room and continued to talk to the patient, without wearing a mask.

2. The Hospital policy titled, "Isolation Placement for Patients" (initiated 1/1/02) required, "Droplet Precaution...when a patient is know or suspected to be infected with microorganisms that are transmitted by large particle droplets...These droplets can be generated when a person talks, sneezes or coughs...Precaution Guideline... Droplet...Mask: Yes-for contact within 3-5 feet of the patient."

3. The above finding was discussed with E#12, the Unit Manager and E#13 the Accreditation and Regulatory Compliance Officer during an interview on 3/10/16 at approximately 11:30 AM. The Unit Manager stated that the threshold for removing the mask would be the door and the Regulatory Compliance officer acknowledged that the nurse was in the room too long without a mask.

Based on document review and interview, it was determined that for 1 of 3 (Z#1) volunteers' files reviewed, the Hospital failed to ensure infection control education and training. This potentially affected all infants admitted to the neonatal intensive care unit (NICU) and their families.

Findings include:

1. On 03/09/16 the volunteer file for (Z#1), a NICU volunteer was reviewed, and included a volunteer application dated 05/21/07. The file lacked documentation of infection control education and training.

2. On 03/09/16, E#3 provided a "Position Performance Plan - NICU Volunteer, Family Birth Center" for Z#1's position. The "Plan" included, "Position Performance Area/Expectations: Volunteer greets and directs patients and visitors to their respective destinations. Continuously checks patient and family preferences/needs... Fold Linens. Assists staff with projects, as needed. Office work... Put together infant charts for NICU Follow-up Clinic..."

3. An interview was conducted with E#3 (administrative assistant for patient support services) on 03/09/16 at approximately 2:20 P.M. E#3 stated there was no documentation available for V#1 to indicate infection control education and training.