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I. Based on observation, interview, and document review, the facility failed to ensure maintenance staff cleaned 3 of 3 large ice makers in patient care areas (Med/Surg unit, and PCU) frequently enough to prevent the build-up of slime and lime scale inside the ice machines. The facility identified 3 large ice machines in patient care areas, 23 patients in the Med/Surg unit, and 18 patients in the PCU.

Failure to clean ice machines frequently enough to prevent the build-up of slime and lime scale could potentially result in microorganisms (bacteria, fungi, or viruses) that grew in the ice machines contaminating the ice patients consumed, and potentially causing the patients to develop a life-threatening infection.

Findings include:

1. Review of the policy "DISTRIBUTING ICE ON NURSING UNITS", reviewed 11/11, revealed in part, "Maintenance and cleaning of ice machines: ... Ice machines are periodically serviced and cleaned, as determined by manufacturer's recommendations and prevailing operating conditions."

2. Observations during a tour of the PCU on 8/15/12 at 3:10 PM revealed 1 of 1 large ice machine in the nutrition area of the in-patient floor. Inspection of the inside of the machine revealed a plastic pipe located above the chiller area used to freeze ice. Water flowed from the pipe, over the chiller area, and into a reservoir, where a pump recirculated the water to the pipe above the chiller area. Observation of the pipe above the chiller area revealed that the pipe contained black slime running down the pipe, across the area where water flowed from the pipe, and onto the chiller area. Additional observations showed particulate sediment in the water reservoir, green lime scale on the tube to fill the reservoir, and black slime on the gasket under the lid to the top of the ice machine (all in direct contact with the water used to make ice, or the ice itself). Additionally, the chute that funneled the ice from the manufacturing area to the storage area had black slime on the surface ice slid along.

3. During an interview at the time of the tour, the Infection Preventionist stated maintenance staff members had last cleaned the ice machine on 4/10/12. The Infection Preventionist acknowledged the black slime and lime scale contaminated all the water in the ice machine, and all the ice in the machine had contacted the black slime. They also acknowledged the black slime and lime scale created an unsanitary surface for the ice, and harbored bacteria.

4. Observations during a tour of the Med/Surg Unit on 8/15/12 at 2:30 PM revealed 1 large ice machine located in the kitchen. Observations of the large ice machine in the kitchen revealed a large amount of lime scale on the front right corner, going from the bottom of the ice manufacturing area to about two thirds of the way down the ice containing area (approximately 1-2 feet). Inside the ice manufacturing area, observations revealed black slime on the end of the water tube that filled the water reservoir, in addition to lime scale. The water reservoir contained black particulate sediment.

5. During an interview at the time of the tour, the Infection Preventionist acknowledged the black slime and lime scale on the ice machine. They also acknowledged the black slime and lime scale created an unsanitary surface for the ice, and harbored bacteria.

6. Observations during a tour of the Med/Surg Unit on 8/15/12 at 2:30 PM revealed 1 large ice machine in located in the nutrition room. Observations of the large ice machine in the nutrition room revealed a large amount of lime scale on the outside of the machine. Observations of the inside of the machine revealed black sediment in the water reservoir, and lime scale on the end of the water hose used to fill the water reservoir.

7. During an interview at the time of the tour, the Infection Preventionist acknowledged the sediment and lime scale on the ice machine. They acknowledged the sediment and lime scale created an unsanitary surface for the ice, and harbored bacteria. They stated they knew the maintenance staff cleaned the ice machines regularly, but had not ever personally examined the ice machines to determine if the frequency of cleaning was sufficient to prevent an infection control risk.



II. Based on document review, observation, and staff interview, the facility failed to ensure 2 of 2 nurses (Registered Nurse A and B) in the PCU, observed leaving the room of patients with isolation precautions in place cleansed the medication drawer prior to removing it from the patient's room. The facility identified a census of 18 patients on the PCU, with 3 patients in isolation precautions.

Failure to cleanse the medication drawer prior to removing if from the room of a patient in isolation precautions could potentially result in bacteria from the patient's room attaching to the medication drawer, and potentially spreading to another patient and causing a life-threatening infection.

Findings include:

1. Review of the policy "Transmission Based Precautions", revised 9/10, revealed in part, "Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate... Isolation precautions are designed to prevent transmission of [bacteria, viruses, fungi] by these routes in hospitals..."

2. Review of the policy "MULTIPLE DRUG RESISTANCE ORGANISMS", reviewed 2/11, revealed in part, "Multiple use items ... that need to be used on another patient are wiped down with an [Environmental Protection Agency] approved disinfectant before use on another patient."

3. Observations during the initial tour of the PCU on 8/13/12 at 4:30 PM revealed Registered Nurse (RN) A was standing inside room 216. A sign on the door revealed the patient was on "Contact Precautions", and all staff members in the room needed to wear gloves and a disposable gown when in the room to prevent bacteria from adhering to their clothes, and potentially spreading to another patient. Sitting outside room 216 was a small cart, containing 5 plastic drawers, and a space for an additional drawer. RN A was observed with the additional plastic drawer inside room 216. RN A had placed the plastic drawer on the chair beside the patient's bed, and picked the drawer up prior to leaving the room. Once RN A left the room, they immediately placed the plastic drawer (which contained the patient's medications) into the small cart in the open space. RN A did not disinfect the plastic drawer prior to returning the drawer to the cart.

4. During an interview at the time of the observations, RN A stated they went into room 216 to provide care the to the patient, including to administer medications. RN A stated they took the drawer containing the patient's medications into the room, and set it down on the chair while they administered the medications. They acknowledged the patient was in isolation, which required them to disinfect the drawer prior to returning the drawer to the cart. RN A also acknowledged they failed to disinfect the drawer prior to returning it, which allowed bacteria to spread to other drawers.

5. Observations during the initial tour of the PCU on 8/13/12 at 4:30 PM, revealed RN B was standing inside room 226. A sign on the door revealed the patient was on "Droplet Precautions", and all staff members in the room needed to wear a surgical mask when interacting with patients to prevent patients from coughing bacteria into the air, and the transmitting the bacteria. RN B had placed the plastic medication drawer on the in-room computer table, and administered medications to the patient. RN B then walked out of the room, and placed the plastic medication drawer on the medication cart. RN B failed to disinfect the tray prior to removing the medication tray from the patient's room.

6. During an interview at the time of the observations, RN B stated they went into room 226 to administer medications to the patient. RN B stated they took the drawer into the room, and administered the medications. RN B acknowledged the patient was in isolation, which required them to disinfect the drawer prior to returning it to the cart. RN B also acknowledged they failed to disinfect the drawer prior to returning it, which allowed bacteria to spread to other drawers.



III. Based on document review, observation, and staff interview, the facility failed to ensure 1 of 1 Respiratory Therapist washed their hands with soap and water after leaving the room of a patient in Enteric Precautions in the Critical Care Unit (CCU). The facility staff members identified 1 patient in Enteric Precautions in the CCU, and 3 patients not currently in isolation precautions potentially at risk for transmission of the organism the patient was in isolation precautions to protect against.

Failure to wash their hands with soap and water after leaving a patient's room with Enteric Precautions could potentially result in the staff member failing to remove the infectious particles from their hands, and potentially transmit them to another patient.

Findings include:

1. Review of the policy "Transmission Based Precautions", revised 9/10, revealed in part, "Enteric Contact Precautions ... Hand washing with soap and water MUST take place immediately after glove removal when exiting the room."

2. Observations during the initial tour of the CCU on 8/13/12 at 5:10 PM, revealed Respiratory Technician (RT) C was standing in CCU room 8. A sign on the door revealed the patient was under "Enteric Contact Precautions", and required staff members to wash their hands with soap and water after leaving the room. The sign indicated staff members could not use alcohol based hand foam to clean their hands after leaving the room. RT C walked out of CCU room 8, and applied alcohol based hand foam to their hands, and cleansed their hands with the hand foam. RT C failed to wash their hands with soap and water prior to leaving the room. RT C then walked to the nurses' station, sat down at a computer, and began to chart information in the patient's medical record.

3. During an interview at the time of the observations, RT C acknowledged they failed to use soap and water to cleanse their hands after leaving CCU room 8. RT C also stated facility policy required them to wash their hands with soap and water after leaving a room labeled "Enteric Contact Precautions." RT C acknowledged they worked in all the units of the hospital, and could potentially spread contamination on their hands to all units they visited in the hospital.