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Based on policy and procedure review, observation and interview, it was determined the facility failed to identify and control infections in that the Infection Control Nurse was not aware of the laundry's contingency plan, that the plan was implemented for approximately 15 - 17 days before Infection Control was aware of it, and that there were no policies and procedures detailing the following:

1. Protective measures necessary to protect staff, vehicles, and the public utilizing the laundry mat.
2. The actual processing of the laundry to include checking water temperature, bleach and detergent amounts, and usage.
3. The length of time the contingency plan was allowed to be utilized before more permanent measures were executed.
4. The clinical individuals who should have been immediately notified to mitigate risks to patients, staff and their families, and the public.
The failed practice had the potential to allow cross contamination and the spread of infection to patients, employees and their families, and the general public that used the local laundry mat. Findings follow:

A. Review of the policy and procedure titled "Facility Laundry Written Contingency Plan," received on 09/20/18 showed if the facility was unable to meet the demands of its laundry, the dirty laundry was to be taken to the local laundry washing facility by the Laundry Operator. Review of the policy and procedure did not outline any protective measures staff should take to protect the transport vehicle, the laundry mat and its equipment; no instructions on checking the water temperature, how much bleach to use, if any special detergent was to be used; and no timeline for how long the process was to be used before more permanent measures were to be put in place.

B. The CNO (Chief Nursing Officer) stated during an interview at 11:30 AM on 09/20/18 that she became aware the facility laundry was taken to the local laundry mat a day or two prior to the Infection Control Committee Meeting on 09/13/18.

C. The Infection Control Nurse (ICN) was asked during an interview at 1:40 PM on 09/20/18, if she was aware that the facility's laundry was being taken down to the local laundry mat. The ICN stated no, she became aware of it a day or two prior to the Infection Control Committee Meeting on 09/13/18.

D. Review of the email timeline and corresponding emails received from the Controller at 12:45 PM on 09/20/18 showed the facility obtained a quote to replace the washer on 09/06/18, a quote to repair the machine on 09/07/18, and started to obtain quotes from other vendors on 09/12/18 for a new machine. The email timeline also showed the facility began to obtain quotes to outsource the laundry on 09/13/18.


Based on manufacturer's guidelines and interview, it was determined the facility failed to prevent and control the spread of infection in that the Quality Control Procedure to check the Cidex OPA test strips was not performed at the opening of each new bottle. Failure to perform the Quality Control Procedure each time a new bottle of strips were opened did not ensure the accuracy of the strips. Findings follow:

A. Review of the Cidex OPA test strips package insert, received from the Infection Control Nurse at 10:05 AM on 09/21/18, showed a Quality Control Procedure was to be performed at the opening of each new bottle of strips.

B. Review of the policy and procedure titled "Endoscopy Department Cleaning of Endoscopic Scopes," received from the Infection Control Nurse at 10:10 AM on 09/21/18, showed no evidence the Quality Control Procedure was performed.

C. During an interview with the Infection Control Nurse at 10:10 AM on 09/21/18, she stated she did not know the Quality Control Procedure had to be performed and it had not been done.


Based on policy and procedure review and interview, it was determined the facility failed to ensure laundry staff and their uniforms were protected from contamination when sorting, handling and delivering dirty and soiled laundry. Failure to ensure staff wore protective apparel when handling dirty and soiled laundry had the potential for cross contamination of uniforms, staff family, and clean laundry. The failed practice had the potential to affect all staff handling dirty and soiled laundry, their families, and patients. Findings follow:

A. Review of the policy and procedure titled "Infection Control for Laundry," received on 09/20/18, showed a smock and gloves were to be worn by laundry personnel when removing soiled laundry from the laundry cart.

B. Review of the policy and procedure titled "Washing Machine Operation," received at 10:30 AM on 09/20/18, showed prior to unloading clean laundry from the washer to the dryer, protective attire used for soiled linen was to be removed.

C. Review of the River Valley Medical Center (RVMC) 2018 Annual Health and Safety Training, received 09/20/18, showed the following; "ALL used laundry is considered contaminated therefore Standard Precautions are used. All used linen should be placed in clear plastic bags and secured before placing in the laundry hamper. Use PPE (Personal Protective Equipment) as appropriate when handling contaminated linen."

D. Review of the River Valley Medical Center (RVMC) 2018 Annual Health and Safety Training, received 09/20/18, showed the following listed as PPE: gloves, gowns -repellant and impervious, face shield, masks, protective eyewear, and ventilation devices.

E. Housekeeper #1 was asked during an interview at 11:50 AM on 09/20/18, what kind of protection they utilized in handling the laundry in and out of the bags, the car, the cart, and the machines. Housekeeper #1 stated the only protection they used was gloves, nothing to protect their clothing or face, and utilized nothing but Lysol spray to protect the interior of the transport vehicle.

F. Housekeeper #2 was asked during an interview at 12:10 PM on 09/20/18, if she was utilizing any protective equipment when handling the laundry and she stated she wore gloves. Housekeeper #2 was asked if she wore any water-proof gown, apron or anything and she stated no, just gloves. Housekeeper #2 was asked if she placed anything down in the back of her SUV to protect the carpet prior to putting the laundry in it and she stated no, they just sprayed it with Lysol.


Based on policy and procedure review and interview, it was determined the facility failed to identify and control the spread of infections in that it failed to develop a policy and procedure for transporting dirty and clean laundry in an employee/private vehicle. Failure to develop policy and procedures detailing how dirty and clean laundry were to be handled to prevent the spread of infection had the potential for the spread of infection to employees and their families. The failed practice had the potential to affect all employees and their families who used their personal vehicles to transport facility laundry. Findings follow:

A. Review of the policy and procedure titled "Facility Laundry Written Contingency Plan," received on 09/20/18 showed if the facility was unable to meet the demands of its laundry, the dirty laundry was to be taken to the local laundry washing facility by the Laundry Operator.

B. Review of the policy and procedure showed no mechanism which directed staff how to protect the employee/private vehicle from possible contamination.

C. Housekeeper #1 was asked during an interview at 11:50 AM on 09/20/18, what kind of protection they utilized in handling the laundry in and out of the bags and the car. Housekeeper #1 stated the only protection they used was gloves, nothing to protect their clothing or face, and utilized nothing but Lysol spray to protect the interior of the transport vehicle.

D. Housekeeper #2 was asked during an interview at 12:10 PM on 09/20/18, if she placed anything down in the back of her SUV to protect the carpet prior to putting the laundry in it and she stated no, they just sprayed it with Lysol.



Based on policy and procedure review, observations and interview, it was determined the facility failed to identify and control the spread of infections in that is failed to develop and implement a policy and procedure for laundering the facility's linen at a public laundry mat. Failure to develop and implement policies and procedures detailing how the laundry mat water was tested to ensure it was at the required temperature, how much bleach was to be used in each load, how to prevent leakage or dripping in the event a bag containing laundry was ripped and how the laundry mat's carts and washers were to be cleaned before and after use did not ensure the laundry was free of hospital microbial bioburden and did not ensure the safety of the persons who utilized the laundry mat and its equipment for their personal laundry. The failed practice had the potential to affect all hospital patients utilizing the linens, and all persons utilizing the laundry mat since 08/26/18. Findings follow:

A. Review of the policy and procedure titled "Facility Laundry Written Contingency Plan," received on 09/20/18 showed if the facility was unable to meet the demands of its laundry, the dirty laundry was to be taken to the local laundry washing facility by the Laundry Operator.

B. Review of the policy and procedure showed no mechanism which directed staff how the water at the local laundry mat was to be tested, how much bleach was to be used in each load, how to safeguard the laundry mat's carts and flooring in the event a plastic bag was ripped and then leaked or dripped, and how the carts and washers were to be cleaned before and after the use.

C. During an interview at 11:50 AM on 09/20/18 Housekeeper #1 was asked how much bleach was used in each load at the laundry mat. Housekeeper #1 stated she "just poured bleach in until it was full." Housekeeper #1 was asked how the bags containing the dirty laundry was taken from the vehicle to the laundry mat and Housekeeper #1 stated the laundry mat's carts were used. Housekeeper #1 was asked if the carts were cleaned before or after using them and Housekeeper #1 stated no. Housekeeper #1 was asked if she knew what the temperature of the water at the laundry mat was and she stated no, but knew the water temperature was supposed to be 160 degrees.

D. During an interview at 12:10 on 09/20/18 Housekeeper #2 was asked if they laid any barrier in the back of the private vehicle or in the bottom of the laundry mat's carts to protect both and prevent any leaking or dripping on the floor. Housekeeper #2 stated no, that was not done.