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Based on observations, interviews and record review, the facility failed to provide and maintain a clean and sanitary environment to avoid sources and transmission of infections and communicable diseases as evidenced by failure to properly store ice scoop to prevent contamination of ice consumed by patients in the Emergency Department, by failure to ensure paper towels for drying hands were stored in clean manner, by failure to ensure patient care equipment was free of dust and dirt particles, by failure to ensure medication preparation areas were free of dust and dirt particles; by failure to ensure linens were changed and stretchers were disinfected between patient use in the Emergency Department. The infection control program failed to include appropriate monitoring of housekeeping activities to ensure that the hospital maintains a sanitary environment. The facility failed to implement their Infection Control Program policies and procedures as evidenced by failure to track and trend identified infections; failure to calculate nosocomial infection rates and failure to report the findings to the Infection Control Committee, the Medical Staff Committee and the Governing Body. The cumulative effect of these system failures resulted in the provider's inability to ensure provision of care in a safe and sanitary environment.

Findings:
A surveyor observed ice machine located within the Emergency Department (ED) medication storage/preparation room with ice scoop stored within the ice compartment on 10/20/13 at approximately 11:30am as confirmed by the ED supervisor at the time of the observation. Supervisor stated the ice is used for ED patients. The Supervisor was questioned about the ice scoop handle being in contact with the ice, she removed the scoop and stated "never thought about it."
Observed paper towels used for hand drying stored under handwashing sink in the ED medication storage/preparation room which were removed by director at 11:34am.
Observed horizontal surfaces of medication storage cart, medication refrigerator and ice machine located in the ED medication storage/preparation room to have thick layer of dust and dirt particles as confirmed by the ED director at the time of the observation. Interview with ED revealed medications, to include intramuscular injections and intravenous injections, are prepared in this area.
Observed the cardiac defibrillator and infant incubator housed in Bay 6 in the ED, in the presence of the ED Director, on 10/20/14 at approximately 11:40AM to have visible thick layer of dust. A thick layer of dust was observed on the outside and inside of the infant incubator. The director stated the incubator has not been used recently, but verbalized is available for use for emergency deliveries within the department.
Observed thick layers of visible, in the presence of the ED director, on horizontal surfaces of cardiac monitors, suction canisters and overhead lights in each ED bay area. The ED director stated the ED staff is responsible for ensuring the surfaces of medical equipment and medication room are kept clean and confirmed the presence of excessive dust in patient care areas and on patient care equipment was not acceptable.
On 10/20/14 at approximately 1:00pm, a surveyor observed ED Staff Registered Nurse (RN) placing a top sheet over stretcher after patient had been discharged. The RN failed to wipe the stretcher with a disinfectant and failed to remove the sheet from the stretcher after patient was discharged. In interview with ED director and the RN, at the time of the observation, both stated that emergency room stretchers are wiped down with disinfectant after every 2 or 3 patients; and/or if any visible soiling; otherwise a clean top sheet is placed on the bed.
On 10/21/14 at approximately 11:00am, an interview was conducted with the facility's designated Infection Control Nurse (ICN). The ICN stated all patient equipment, including stretchers, should be cleaned with a disinfectant between patient use and stated was not aware this was not being done. The ICN was unable to demonstrate any ongoing audits/observations were being conducted to ensure staff were implementing the infection control policies and procedures.
The ICN stated she is working on developing a process for tracking and trending infections, but has not yet been developed. The ICN was able to provide documentation of statistical gathering for the 1st quarter of 2014. There is no evidence that the infection control activities for the facility is included in the facility wide QAPI, being presented to Medical Staff or being presented to the Governing Body. The ICN was able to demonstrate reporting of Central Line Associated Blood Stream Infection (CLABSI) infection rate and Catheter Associated Urinary Tract Infection ( CAUI) infection rate to the Center for Medicare and Medicaid Services for 1st and 2nd quarter of 2014, but stated she has not shared this information with the Medical Staff and/or Governing Body.
Review of facility ' s Infection Control Plan, Section III. Titled "Authority/Responsibilities" documents "the Board of Directors receive reports at least quarterly about Infection Control activities. Section III also documents "the Infection Control Nurse makes quarterly reports to the Infection Control Committee that identifies: a. Incident and percentage of nosocomial and community acquired infections b. Categories of suspected wound infections c. Communicable diseases reportable to the Public Health Unit and d. unit statistics for nosocomial infections. Interview with the Infection Control Nurse on 10/21/14 at approximately 11:15am revealed this had not been done.