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Based on observations, interviews and document review, it was determined the hospital staff failed to a) utilize infection control methods that prevent and control the transmission of infection within the hospital by contaminating clean supplies and incorrectly handling contaminated linen and b) develop and implement a procedure for visual monitoring and/or verification of negative pressure rooms.

The findings include:

a) Failure to follow infection control practices

Review of hospital policy "Hand Hygiene" effective 02/2025 indicates hand hygiene should be performed before touching a patient, before a clean procedure, after contact with bodily fluid occurred or possible risk was present, after touching a patient and after touching patient surroundings.

Review of CDC "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings" last updated September 2024 reveals under Personal Protective Equipment "Gowns IV.B.3.a. Wear a gown, that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and patient-care activities when contact with blood, body fluids, secretions, or excretions is anticipated" https://www.cdc.gov/infection-control/media/pdfs/Guideline-Isolation-H.pdf retrieved March 21, 2025 12:33 PM

During observations on March 17, 2025, the surveyor noted the following breaks in infection control practice by staff providing care to a patients while in the ED:

Patient #2's shoes were placed on the counter adjacent to a hand washing sink and below clean supplies. Clean supplies were placed next to the Patient's shoes creating potential for contamination.

When providing care for a patient whose ostomy bag had leaked the contents on the patient and bed linens, Staff #16 when cleaning the patient, changing their brief, and changing bed linens on more than one occasion accessed clean supplies (gloves and linens) while wearing contaminated gloves.

Staff #16 failed to wear PPE to protect their clothing when providing care to a patient with a known risk for exposure to bodily fluids.
When placing soiled linens in the hamper, Staff #16 carried linens against their body contaminating their clothing, identification badge and a stethoscope worn around their neck. After removing dirty gloves, Staff #16 failed to perform hand hygiene before donning clean gloves.

Staff #16 failed to clean the stethoscope after leaving Exam room 8 and before entering Exam room 7.

While in room 7, Staff #16 failed to perform hand hygiene after removing dirty gloves and before accessing clean supplies.

The surveyor noted Staff #16's stethoscope fall to the floor. The stethoscope was not cleaned prior to Staff #16 entering Exam room 4.

On March 18, 2025, Staff #19 was observed to carry the drawer, from the medication storage unit, into Patient #5's room to administer medications. The storage unit was potentially contaminating when the drawer was returned to the unit without any disinfection.

During the patient care observation periods on March 17th and 18th, multiple staff members were noted to enter patient area and donning gloves before performing hand hygiene, potentially contaminating the glove supply.

b, Failure to visually monitor/verify negative pressure rooms

Review of hospital policy "Isolation Procedures" effective 02/2025 indicates patients requiring airborne isolation should be placed in an airborne infection isolation room (AIIR), in the event a patient is admitted to an AIIR, the AIIR will be turned on and "verified" for negative pressure, and staff or maintenance will check the negative pressure monitor daily for all patient's in AIIR.

Review of CDC (Centers for Disease Control and Prevention) guidance reveals under V.D.2 Patient Placement "V.D.2.a.iii. Whenever an AIIR is in use for a patient on Airborne Precautions, monitor air pressure daily with visual indicators (e.g., smoke tubes, flutter strips), regardless of the presence of differential pressure sensing devices (e.g., manometers)." https://www.cdc.gov/infection-control/media/pdfs/Guideline-Isolation-H.pdf retrieved March 21, 2025 at 11:44 AM.

During review of airborne isolation protocols it was determined that the hospital was relying solely on the pressure alarm to verify the AIIR (airborne infection isolation room) or negative pressure isolation system was working properly. Interviews with hospital staff on March 17, 2025 and March 18, 2025 indicate there is no protocol in place to verify the AIIR room is working correctly other than the pressure alarm and staff had not been trained to perform a manual visual check of the system as recommended by the CDC.

Staff #3 and Staff #4 explained on March 18, 2025 at 1:00 PM during the discussion of observation findings that the expectation is that staff would only access clean supplies with clean hands or clean gloves; soiled linen should not be carried in a way that could contaminate staff clothing; the medication "drawer" should not be taken to the patient's room; hand hygiene is expected between glove changes and when entering and leaving the patient's room.

Staff #3 and Staff #4 indicated during an interview on March 18, 2025 at 1:00 PM that they were unaware of a need to perform a visual check to validate the negative pressure room is working and were unable to provide a date when the AIIR rooms were used for true airborne isolation. There are two AIIR rooms in the hospital, one in the emergency department and one in the intensive care unit.