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Based on observation, interview and document review, the facility failed to ensure appropriate infection control practices were implemented while performing a terminal cleaning of 1 of 1 (P1) patient room following discharge from the facility.

Findings include:

During interview with the infection preventionist (IP) on 6/24/19 at 12:55 p.m., the IP stated P1 had hospitalized for treatment for disseminated Shingles (Chicken pox virus re-activated that is widespread), but had recently been discharged. Observation revealed a sign outside P1's room indicating the need for infection control precautions required while P1 was a patient including; mask, gown, and gloves. According to the IP, once P1 had been discharged, staff would need to follow contact precautions with the use of gown and gloves for cleaning of the room.

Observation was made on 6/24/19, beginning at 1:16 p.m. of housekeeping (HS)-A wearing gloves, but no gown while cleaning P1's room. At 1:16 p.m., HS-A walked out of the open door of room 1105 wearing the same gloves used to clean the room, carrying a red biohazard bag. HS-A crossed the hall, wearing his gloves and touched the keyed locked door and handle to open the soiled utility door. HS-A placed the biohazard bag into the covered container, turned and walked out of the soiled utility room back into P1's room without removing the soiled gloves. At 1:18 p.m., HS-A was observed to be wearing the same gloves and no gown, and grabbed a ladder to take down the room divider curtain. When HS-A put the contaminated linens into a red biohazard bag and once again, transported the linens out of P1's room, across the hall to the soiled utility room. HS-A once again touched the key pad to enter the soiled utility room while wearing his contaminated gloves, disposed of the linen, walked back across the hall and entered P1's vacated room again. HS-A continued to wear the same contaminated gloves with no gown and picked up a food dish from P1's room. HS-A left P1's room with the dishware and brought it to the kitchenette area, where it was placed onto a common soiled dishware cart. HS-A was observed to have again had to touch the the door entry of the kitchenette, while continuing to using the same unchanged gloves and no gown.
(3) 1:20 p.m., HS-A returned to P1's room wearing the same contaminated gloves and no gown and picked up P1's isolation trash can and transported it to the tub room for disinfection. HS-A wore the same gloves and no gown through this process. Upon return, HS-A verified he did not change his gloves and the trash can had been disinfected before it was taken from the room and transported to the tub room. HS-A identified he thought all precautions had been removed 3 days prior, and that P1 had no longer been under airborne precautions at the time of discharge. However, according to interview with the hospital's IP, precautions remained in place until P1 was discharged.
At 1:23 p.m., HS-A re-entered P1's room to finish terminal cleaning. HS-A proceeded to put on new gloves but no gown and took a cloth from a bucket sitting on the counter in P1's room containing the disinfectant. HS-A picked up the pillow from the bed and wiped it off with the disinfectant and continued on to the sofa. Once completed, HS-A tossed the contaminated cloth on the floor beside the sink. HS-A then proceeded into P1's bathroom and returned caring a walker, and wiped it with a disposable sanitizing cloth. Without changing gloves, HS-A returned to the bathroom, obtained a soiled bed pan, and carried the uncovered bedpan outside the room, to the soiled utility room. HS-A again gained access to the room wearing the soiled gloves, touched the keyed entry touch pad and entered the soiled utility room. HS-A then took the soiled bed pan to the sink, rinsed and then placed on the counter beside the sink and returned to the house keeping cart. At 1:30 p.m., HS-A identified he removed his contaminated gloves but failed to perform any hand hygiene. HS-A stated he sometimes washed his hands after removing gloves but not always. HS-A indicated he would wash his hands at a later time when he clocked out from work.

The IP was interviewed on 6/24/19 at 1:40 p.m., about expectations of staff for use of appropriate infection control precautions. The IP again verified that although P1 had been discharged, the precautions should have remained in effect until P1's room had been terminally cleaned.

On 6/24/19 at 1:53 p.m., the director of nursing (DON) stated staff were to perform hand hygiene before applying and after removing gloves. In addition, the DON stated staff should follow appropriate isolation precautions based on need, identified by nursing staff or policy.

Review of the August 2018, Infection Control Policy, indicated all staff were to wear gloves and appropriate personal protective equipment (PPE) as indicated by the Centers for Disease Control and Prevention (CDC) related to transmission-based and standard precautions.