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Based on observation, record review and interview, the facility failed to implement its policy and procedure to conduct surveillance of infection in the facility, the facility failed to implement its policy and procedure to ensure facility's staff wash, sanitize hands after direct contact with patients during provision of care and services, failed to ensure linen used by the facility is laundered by the facility or by a contracted service and failed to ensure staff present in the operating room wear head gear that covers the entire head in 2 of 8 patients observed . Patient #s 16 and 18.

Findings:

Review on 08/27/2015 of the Facility's Infection Control Log and Surveillance Report revealed documentation which indicated the most current surveillance of infection conducted in the facility was dated April 2015.

Interview on 08/27/2015 at 8:08 a.m with the Facility's Infection Control Personnel, revealed she had resigned from the facility for approximately 3 months and during that time there was no one assigned to the position, so surveillance of facility's infections was not done. She stated " I am trying to catch up. "

Review of the Facility's current Policy and Procedure # 45, on Infection Control Program directs staff as follows : "There is a hospital -wide infection control program that is monitored by a multi-disciplinary committee of medical staff. This is the Infection control committee and shall meet at least quarterly to review, approve and direct the activity of Infection control within the hospital "

Review of the Facility's Health and Safety meeting dated January 21, 2015 revealed documentation which indicated that the infection control data was presented to the committee on January 2015. There was no further indication that there was involvement by the infection control committee.

Review of the Facility's Policy and Procedure on Infection Control Standard Precaution, directs staff as follows: " Handwashing - Hands are to be washed after touching blood, body fluids, secretions excretions or other contaminated items, whether or not gloves have been worn. Hands must be washed immediately after removal of gloves between patient contact and when otherwise indicated. This will help prevent transmission of microorganisms."

Patient #16
On 08/26/2015 at 10:43 a.m, Physical Therapist Assistant (A) was observed in the out- patient physical therapy suite. The Physical Therapist Assistant was observed manipulating and providing range of motion to Patient # 16's arms. During the procedure, the Physical Therapist Assistant used her ungloved hands to manipulate and provide range of motion to the patient's arm /hands. After completing the procedure, the Physical Therapist Assistant did not wash or sanitize her contaminated hands. She then walked over to the cabinet which stored patients ' clinical records and removed the patient's clinical record. She did not wash or sanitize her contaminated hands.

During an interview on 08/26/2015 at 10.50 a.m, the Surveyor notified Physical Therapist Assistant (A) that she did not wash/sanitize her contaminated hands after providing care to the patient.
She stated " I washed my hands before touching the patient."

Laundering of Facility's Linen
Observation on 08/26/2015 at 10.52 a.m in the facility's physical therapy suite, revealed stacks of heating pads covers were observed stored on a rack in the suite.

During an interview on 08/26/15 at 11.54 a.m with Physical Therapist Assistant (A), the Surveyor asked the Physical Therapist Assistant how are the heating pads covers laundered after patient usage. The Physical Therapist Assistant (A) said the heating pad covers are laundered at staff's private residence.


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Patient #18
On 08/26/2015 at 11.10 a.m., Surgical Nurse Director (B) was observed in the intake/ pre-operative room. The Surgical Nurse Director (B) was observed inserting peripheral intravenous needle to left arm of Patient #18. During the procedure, the Surgical Nurse Director (B) failed the insertion. The Surgical Nurse Director did not remove her contaminated gloves that she had used to cannulate the patient's left arm and wash/sanitize her hands prior to her re-inserting the peripheral intravenous needle to the patient's right hand. After completing the procedure, Surgical Nurse Director (B) did not wash or sanitize her contaminated hands. She then opened the patient's clinical records and started her documentation. She did not wash or sanitize her contaminated hands.

During an interview on 08/26/2015 at 12.05 p.m., the Surveyor notified Surgical Nurse Director (B) that she did not wash/sanitize her contaminated hands in-between the procedure and after providing care to the Patient. She stated "I did not know that I am supposed to do that."

Nurse Anesthetist (H)
On 08/26/2015 at 12:25 p.m. Nurse Anesthetist (H) was observed in the main operating room. The Nurse Anesthetist was observed providing anesthesia for a Laparoscopic abdominal procedure. During the procedure, Nurse Anesthetist (H) was wearing a head cap that did not cover the back of the head, exposing the remaining hair of his head.

During an interview on 08/26/2015 at 01.15 p.m., the Surveyor notified Surgical Director of Nursing (B) inside the operating room that Nurse Anesthetist (H) was wearing a head cap that exposed his hair at the back of his head. She stated " I will let him know after the procedure."

Based on observation, record review and interview, the facility failed to implement its policy and procedure related to staff members who provide direct patient care to patients competency assessment, in 2 of 7 staff members observed . Surgical Nurse Director (B) and Registered Nurse (E)

Findings:

Surgical Nurse Director (B)
On 08/26/2015 at 11.10 a.m., Surgical Nurse Director (B) was observed in the intake/ pre-operative room. The Surgical Nurse Director (B) was observed inserting peripheral intravenous needle to left arm of Patient #18. During the procedure, Surgical Nurse Director (B) failed the insertion. The Surgical Nurse Director did not remove her contaminated gloves that she had used to cannulate the patient's left arm and wash/sanitize her hands prior to her re-inserting the peripheral intravenous needle to the patient's right hand. After completing the procedure, the Surgical Nurse Director (B) did not wash or sanitize her contaminated hands. She then opened the patient's clinical records and started her documentation. She did not wash or sanitize her contaminated hands.

Personnel File of the Surgical Nurse Director (B) was reviewed on 08/27/2015. It revealed that her date of hire was 06/18/2007. There was no orientation, and no current competency records noted in the record.

Registered Nurse (E)
On 08/26/2015 at 13.20 a.m., Surgical Registered Nurse (E) was observed in the operating Room functioning as a circulating nurse to an ongoing surgical laparoscopic abdominal procedure.

Personnel File of Registered Nurse (E) reviewed on 08/27/2015, revealed that her date of hire was 02/25/2015 as an Obstetrics Nurse. There was no evidence of orientation, or current competency records noted for the Surgical Services.

During an interview on 08/28/2015 at 11:50 a.m. with the Assistant Director of Nursing (D), the Surveyor notified her of missing competency records of Surgical Nurse Director and Registered Nurse (B). She said "This is the only one we've got in their personnel records. The Surgical Nurse Director told me that she was supposed to give that nurse (Registered Nurse B) the checklist, and she's not sure if it was returned back already."

Review of the Facility current Policy titled "Orientation/Competency Verification of Nurses and other Personnel Providing Nursing Care. Effective September 1, 2002 stated "All nurses and other personnel who provide nursing care will be oriented to the areas in the hospital in which they will be expected to perform. Page 1: Initial Orientation will be accomplished by the nurses and other personnel who provide nursing care through completion of a competency checklist within 90 days of employment. The competency checklist will be maintained in the personnel file"