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Based on observation, record review and interview the facility failed to ensure infection control practices provided a sanitary environment.

· Soiled linen and soiled patient gowns (not bagged) were observed on the floor in Chute Room "D"

· Soiled linen and soiled gowns (not bagged) were stored in three uncovered large linen bins at the facility's commercial loading and unloading area

· Facility staff did not utilize sufficient personal protective equipment (PPE) during invasive procedures EGD (oral diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract) and a Colonoscopy for patient (P#5)

· Facility staff did not sanitize their hands before and after glove changes during multiple open and closed ulcer treatments to a patient's lower extremities (P#9)

The facility's failure to follow its infection control policies put its patients and staff at risk for potential cross contamination of communicable and infectious diseases.

The findings included:

During observations on 08/17/15 at approximately 2:00 p.m. and on 08/19/15 at approximately 11:20 a.m., soiled linen and soiled patient gowns (not bagged) were observed on the floor in Chute Room "D."

During observations on 08/17/15 at approximately 2:10 p.m. and on 08/19/15 at approximately 11:25 a.m., soiled linen and soiled patient gowns (not bagged) were stored in three separate linen bins at the facility's commercial loading and unloading area. The bins were used to store soiled linen bags and had a combination of bagged and unbagged soiled linen and gowns. The top of the bins were not covered. Each bin had one side that was porously screened exposing the soiled items to staff and others.

Review of the facility's EVS Linen Storage and Handling Procedures with effective date of August 2014 indicated that all soiled linen had to be contained and secured in yellow linen bags. The soiled linen bags had to be stored in a manner to reduce possible cross contamination from communicable and infectious diseases.

During observations on 08/18/15 in the endoscopy suite at approximately 1:00 p.m., a physician (S#42 ) did not utilize a head cover, did not wear a mask, no shoe covers, no eye protection or a face shield during an EGD and a colonoscopy performed on P#5. Other Staff (S#43,# 45 and #46) did not use eye protection or face shields during the invasive procedures. Staff #43 and #45 did not use protective gowns. Staff #45 did not perform hand hygiene when he changed gloves multiple times during the EGD and the colonoscopy procedures. Staff #42, #43, #45 and #46 provided direct patient care and actively participated during both procedures for P#5.

Review of P#5's medical record indicated the patient received Radiofrequency ablation (RFA) of Barrett's esophagus (a procedure that uses a catheter in the esophagus with a special balloon to create a superficial burn that destroys Barrett's esophagus) and a polypectomy (removal of colon polyp). Patient gave consent to procedures which included risks of hemorrhage, perforations that may or may not have required surgery and adverse reactions to sedation.

Review of the facility's Surgical Service Attire policy with effective date June 2015 required for the physician performing procedures in the Endoscopy Suites to utilize a head cover, mask and gown. Shoe covers were recommended if anticipated splashes or spills could occur. Other staff were highly recommended to utilize eye protection and or a face shield and gowns to prevent exposure from potential blood and or bodily fluids. Shoe covers were also recommended if anticipated splashes or spills to the floor could occur.

During an observation on 08/19/15 at approximately 1:30 p.m., Staff (S#48) and Staff (S#49) provided Patient (P#9) multiple open and closed wound care treatments to his lower extremities. S#48 and S#49 did not perform hand hygiene after each glove change during the multiple wound ulcer treatments.

Review of P#9's medical records indicated the patient was on Contact Isolation due to the patient's history of VRE (a type of bacteria that has developed resistance to Vancomycin antibiotics).

Review of the facility's Hand Hygiene policy last revised January 2014 required staff to perform hand hygiene in-part:
· before direct contact with patients
· before donning gloves
· after contact with a patient's intact skin
· after direct contact with patients including contact with body fluids
· contact with mucous membranes or wound dressings
· if moving from a contaminated body site to a clean body site during patient care
· after removing gloves

Interview with Staff (S#3 and S#5) on 08/18/15 at approximately 4:30 p.m. confirmed the observations of infection control deficiencies in the facility's management of their chute system to route yellow soiled linen bags from the multiple levels of the hospital to the lower chute storage rooms and the subsequent storage of any unbagged soiled linen before transport off the facility premises. Staff #3 and #5 recognized facility deficient practices related to Surgical Service Attire requirements and recommendations for physicians and staff during invasive procedures to reduce cross contamination and exposure from potential infectious blood and or bodily fluids. Staff #3 and #5 indicated all staff were required to follow the facility's hand hygiene policies to reduce risks of cross contamination of potential communicable and infectious diseases.

During the Exit Conference on 08/19/15 at approximately 4:00 p.m., facility staff were provided an opportunity to ask questions and provide additional information regarding the deficient practices identified during the survey process. No additional information was given.