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Based on observation, document review and interview the facility failed to monitor and provide a sanitary environment and ensure that it had an active program for the prevention, control and investigation of infections and communicable diseases.
Findings include:

On 6/20/13 at approximately 1000 during a tour of the unit 3L the environmental services person was observed cleaning room # L312, in which the patient was in contact precautions, the environmental service personnel had no gown on while in the room, then came out of room with gloves on and touched the cleaning cart with the contaminated gloves still on. While continuing to tour the unit, a physician resident in patient room #L328 in which the patient was in contact precautions, was doing a patient assessment with no gloves on and a gown only partially on without being tied closed.

On 6/20/13 at approximately 1300 during policy and procedure review it was found in the policy titled, "Precautions: Infectious Diseases", states under II Contact Precautions, D, "Gowns and gloves are worn UPON ENTERING THE ROOM. Gloves are changed after contact with infective material before going to another task. Gowns and gloves are removed before leaving the patient's room. Gowns are single use only."

Based on document review and interview the facility failed to ensure that a program for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was completed. This has the potential for spread of infection and disease to patients and personnel.

Findings include:

On 6/20/13 at approximately 1330 during a review of infection control documents, i.e., hand washing percentages, which per March documentation was at "33% compliance", infection control meeting minutes for 5/2013 showed that "the Clostridium Difficile (c-diff) rates in 5/2013 continued to be elevated and to investigate the relationship between hand hygiene percentages and elevated c-diff rates.." The 2013 Infection Control Program description documentation was noted to be from the previous year, 2011/2012. When the Infection Preventionist, staff B, was asked for documentation for the current year, 2013, none could be provided.

On 6/20/13 at approximately 1415 during an interview with the Infection Preventionist, staff B, it was asked if the facility had an Infection Control Program description for the current year 2012-2013, in which the Infection Preventionist replied, "No."

Based on document review and interview the facility failed to ensure that problems identified by the infection control officer were addressed by the quality committee and that corrective action in the problem areas were implemented.
Findings include:

On 6/20/13 at approximately 1430, when asked if the infection control meeting minutes were reviewed by the facility's quality committee, the Infection Preventionist, staff B, and staff D responded by saying, "No, they only go through the Culture of Safety Steering Committee." When queried about the lack of initiating a plan for improvement of hand washing compliance, that had been discussed in infection control meeting minutes for February, March, April and May of 2013, the Infection Preventionist, staff B, responded that, "We are working on it."