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Based on a review of facility documents and staff interviews (EMP), it was determined that the facility failed to ensure staff documented pertinent and complete information for two of two indwelling catheters (MR9 and MR10).

Findings include:

Review of "Management of Indwelling, Intermittent (Straight) and External Urinary Catheter Insertion, Care and Necessity" dated April 15, 2015, revealed, "...1. It is the policy of UPMC to promote safe and effective insertion of indwelling, intermittent straight and application of external urinary catheters...With a physician's order present, the registered nurse, licensed practical nurse, nurse intern may perform the insertion of the indwelling or intermittent catheter as directed by a nurse...II Purpose...Provide appropriate indications for inserting indwelling and intermittent urinary catheters...IV. General Information for Indwelling Catheter Insertion...A physician's order is required..."

1. Observation of the Pediatric Intensive Care Unit (PICU) located on the fifth floor, on January 12, 2016, at approximately 10:15 AM revealed that EMP20 was observed entering the room and emptying the indwelling catheter of MR9. Review of MR9 revealed that that there was no order for the indwelling catheter. EMP37 confirmed that there was documentation that the catheter for MR9 was inserted on January 11, 2016 at 2:00 PM.
2. Observation of the PICU, fifth floor, on January 12, 2016, at approximately 10:20 AM revealed another patient, MR10, with an indwelling catheter in place. Review of MR10 revealed that the urinary catheter was inserted on January 10, 2016, at 8PM. Continued review of MR10 confirmed that there was no order for the indwelling catheter.
Interview with EMP37 at the time of the observations and medical record reviewers confirmed that there was no order for the urinary catheters for MR9 or MR10.

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility staff failed to follow the established policy and procedure for proper cleaning methods, and failed to ensure a sanitary environment was maintained to minimize health hazards for the protection of both patients and employees.

Findings include:

Review of Policy HS-IC0604, "OSHA Bloodborne Pathogen Standard Exposure Control Plan," dated July 9, 2015 revealed, " ... IV...F. ENVIRONMENTAL SERVICES DEPARTMENT (ESD) - Maintaining the hospital in a clean and sanitary condition ... important part of the Bloodborne Pathogen Compliance Program. Employees must follow certain procedures for cleaning and decontaminating the environment, equipment and work surfaces.... All pails, bins, cans and other receptacles ... inspected, cleaned and decontaminated ..."

Review of facility policy and procedure on January 11, 2016, at approximately 1:00 PM revealed, "...Discharge Room Cleaning Procedure...Date Reviewed: 2/1/2014...Procedure: 3. High dust, beginning at the entranceway and working around the room in a circle. High dust horizontal surfaces above shoulder height starting opposite the restroom. If a patient is still present, never dust above a patient/resident. High dust surfaces in the restroom. 4. Using germicidal cleaner and a micro fiber clean cloth, sanitize all patient contact surfaces, starting with the bed. wife the tope an sides of the mattress. Beginning at the head of the bed, fold mattress in half and clean the underside of the mattress, springs and frame...Clean the head of the bed, moving to the bed rails and the bed controls, then the foot of the bed and opposite side bed rails. Proceed to clean overbed table, bedside table, phone, chairs, low ledges and count, light switches and door knobs...10. Remove gloves and wash hands..."

Review of facility policy and procedure on January 11, 2016, at approximately 1:00 PM revealed, "...Emergency Room Cleaning...Date Reviewed: 2/1/2014...Procedure...3. Follow enhanced Discharge Cleaning Procedures from 5.02 and the EVS Policy and Procedure Manual and follow approved hand hygiene protocols..."

1. Observation of an Environmental Services staff member on January 11, 2016, at approximately 10:30 AM revealed that EMP11 was observed cleaning Exam Room #1 in the Emergency Department. EMP11 cleaned the sink, table, foot stool, trash receptacle, red bag trash lid and side surfaces of the trash receptacles and then proceeded to the cords of the blood pressure and pulse ox machines. EMP11 then cleaned the metal bedside stand, which is used to set up the clean field when a blood culture or specimen is obtained. EMP11 continued around the room and then cleaned the bottom of the bedside table, the top of the bedside table, the pillows and the bed. EMP11 cleaned all of the above items with the same cloth. EMP6 was present during this observation and confirmed that this was not the correct order for cleaning.
At approximately 11:15 AM on January 11, 2016, EMP11 was observed cleaning room #8. The employee again cleaned the items in the same order witnessed earlier in exam room #1 [foot stool, trash lid, red trash lid and sides, blood pressure cuff and cords, patient's call and television remote and then the patient's bed pillows and bed. The cleaning was completed with the same cloth.

2. Observation of a room cleaning was observed on January 13, 2016, between 11:20 and 11:35 AM. EMP23 was observed cleaning a room on the NICU after the patient was discharged. EMP23 was observed washing the sink, then the blood pressure cuff, and later the patient's call/light control. These items were cleaned in the order mentioned with the same cloth.
3. Observations in ladies rest room off the main lobby on January 11, 2016 at approximately 8:30 AM revealed toilet paper on the floor in two stalls, several paper towels on the floor by the hand washing station, over flowing trash bins and water puddles on the counters of the hand washing stations.

4. Observations in the stair well between the third and fourth floor on January 12, 2016, revealed several clumps of "bluish-gray colored" material on the steps and in the corner of the landings on the third floor and fourth floor. There was also what appeared to be a pretzel nugget by the pipe in the corner of the fourth floor landing. Several "dust bunnies" and small pieces of paper and debris were also observed in the stair wells between the fifth and sixth floors as well on January 12, 2016.

5. Observation of the cafeteria on January 13, 2016, at approximately 11:45 AM revealed a dirty wall behind the trash receptacle located to the right of the doors leading to the outside courtyard. The wall behind the trash receptacle was observed with drip marks from the trash height to the floor. The baseboard ledge behind the trash receptacle evidenced an accumulation of dust and debris. The same was noted behind the trash located to the right of the doors that exit to the outside courtyard and behind another trash can on the other side of cafeteria. Heating registers were noted with dust and debris. In another area of the dining room, there was a large decorative picture that had multiple thick drip marks. The drip marks/splashes continued to the wall on either side of the picture. EMP7 confirmed these findings at the time of the observations.

Based on review of facility documents, direct observation, and staff interviews (EMP), it was determined that facility failed to ensure the appropriate use of personal protective equipment (PPE) and hand hygiene practice for two of four surgical procedures observed.

Findings include:

Review of the "UPMC Physician Services Division Bloodborne Pathogen Exposure Control Plan," no date, revealed "Appendix C" in which procedures were identified requiring routine use of hand hygiene, gloves and mask/eye covering. Review "Appendix C" revealed, "PROCEDURES
insertion peripheral venous catheters
insertion invasive CVP catheters
insertion arteriole catheters
insertion epidural catheters; spinal catheters for regional catheters for regional anesthesia insertion catheters for caudal anesthesia
insertion naso/oral gastric tubes
insertion endo tubes."

Review of Policy # 2.02, "Maintenance of Surgical Asepsis," reviewed/revised September 2013 revealed, "II. POLICY: ... An aseptic technique should be implemented during any invasive procedure that bypasses the body's natural defenses. ..."

Review of Policy HS-ORD0010, "Dress Code in the Operating Room," dated February 27, 2015, revealed, "IV. PROCEDURE: ... D. MASK AND EYEWEAR 1. All individuals must wear a single-use surgical mask in areas where open sterile supplies or scrubbed persons are located. ... . 2. ... should change mask between patients ... . 3. Surgical masks should be removed and discarded when leaving the semi restricted areas. Masks should not be worn hanging down from the neck or placed into the pockets. ... b) Hand hygiene should be performed after removal of masks. ... G. PERSONAL PROTECTIVE EQUIPMENT (PPE) 1. ... PPE (gloves, gowns, masks, eyewear, shoe covers, and disposable head covers) is available ... . 2. PPE must be used to cover the personnel's skin, eyes, and mucous membranes any time there is a risk of touching, splashing, or spraying of blood, body fluids, secretions, and excretions ... ."

Review of Policy HS-IC0615, "Hand Hygiene," dated July 9, 2015, revealed, "III. PURPOSE: ... . Hand hygiene is the single most important strategy to reduce the risk of transmitting organisms from one person to another or from one site to another site on the same patient. Cleaning hands promptly and thoroughly between patient contact and after contact with blood, body fluids, secretions, equipment and potentially contaminated surfaces is an important strategy for preventing healthcare associated and occupational infections. IV. DEFINITIONS:
· Health Care Personnel refers to all employees, faculty, temporary workers, trainees, volunteers, students and vendors regardless of employer that provide care to patients. This includes staff that provide services to or work in any UPMC facilities.
· Direct Patient Contact ... anyone who has contact with a patient and/or their environment.
· Indirect Patient Contact ... anyone who has contact with a common area or equipment which patients may have had contact (corridors, waiting area in ancillary areas, common areas, etc.)
· Hand Hygiene - Performing handwashing, antiseptic handwash, alcohol based handrub, surgical hand hygiene/antisepsis
· ... .
· WHO Patient Zone - contains ... patient and ... immediate surroundings. ... typically includes ... intact skin of patient and all inanimate surfaces that are touched by or in direct physical contact with the patient ... bed rails, bedside table, bed linens, infusion tubing and other medical equipment. ... surfaces frequently touched by HCWs ( while caring for patients ... monitors, knobs and buttons, trash and linen bins, and other 'high frequency' touch surfaces.
· ... .
· WHO Critical Sites - are associated with infection risks. ... can either correspond to body sites or medical devices. Critical sites either 1.) pre-exist as natural orifices such as mouth and eyes, 2.) occur accidently ... wounds or pressure ulcers; 3.) ... care associated ... injection sites, vascular catheter hubs, drainage bags and bloody linen.
V. PROCEDURES: A. Indications for hand hygiene - In most cases, either a waterless antiseptic product or handwashing with soap and water may be used for hand hygiene. Hand hygiene is performed utilizing the ... WHO five moments of hand hygiene ...: 1. Before touching a patient (or patient zone); 2. Before clean/aseptic procedure (critical sites); 3. After body fluid exposure risk; 4. After touching a patient; 5. After touching patient surroundings (patient zone). ... . B. Gloves
- Hand hygiene must be performed prior to donning gloves when ... being worn for interaction with a patient and/or patient zone;
- ... must be worn for contact precautions and when ... anticipated body fluid exposure risk;
- When wearing gloves, hand hygiene must be performed between glove changing and gloves should be changed during patient care when performing a clean or aseptic procedure (critical sites);
- Remove gloves and perform hand hygiene after contact with a patient, after contact with ... patient zone, and after potential contact with blood/body fluids ( i.e. blood spill);
- ... ;
- Do not wear the same pair of gloves for the care of more than one patient.
- GLOVES DO NOT REPLACE THE NEED FOR HAND HYGIENE. ... . E. Compliance - All staff are encouraged and expected to stop and remind ... staff... to perform hand hygiene ... . F. Oversight for Physicians - Non-compliant physicians will be referred to local Medical Leadership (or designee) ... . VII. REVIEW & EVALUATION - All staff including physicians will continue to have their hand hygiene monitored. ... results of this monitoring will be reported periodically to Hospital Leadership, and Infection Control Committee, and ... . "

Review of Policy Number 106, "Anesthesia Hand Hygiene Safety Precautions in the Operating Room," revised August 2015 revealed, "... 21. Anesthesia providers will follow the hospital policy regarding hand antisepsis. ... to reduce both transient flora and resident flora ( policy 100.57). ..."

Review of Policy HS-IC0604, "OSHA Bloodborne Pathogen Standard Exposure Control Plan," dated July 9, 2015 revealed, " ... IV. METHODS OF COMPLIANCE ... . E. PERSONAL PROTECTIVE EQUIPMENT (PPE) ... Examples of PPE ... Gloves, Gowns/Aprons, Face shields, masks, eye protection; Ventilation devices/pocket masks/mouthpieces; Fluid resistant laboratory coats; Shoe covers/boots; Safety glasses with solid side shields/goggles; Hoods/surgical caps ... . 1. Gloves (latex/nitrile) or other materials approved by Infection Prevention and Control, a. At a minimum, gloves must be used where there is reasonable anticipation of employee hand contact with blood or other potentially infectious material (OPIM), mucous membranes, or non-intact skin when performing vascular access procedures and when handling contaminated surfaces or items. b. ... are for single use only. ... . c. Hand hygiene must occur as soon as feasible after gloves are removed. d. Gloves must be changed between patients or during the care of a single patient when moving from a contaminated area to a clean body site. ... . 2. Protective Clothing (gowns, aprons, laboratory coats, similar outer garments, boots or shoe covers, etc. ) a. Must be worn when ... potential for splashing, spraying or splattering of blood or OPIM into eyes, mouth, or other mucous membrane. b. Must be worn whenever potential exposure to the body is anticipated. 3. Face protection (masks, goggles, face shields, etc.) a. Must be worn when ... potential for splashing, spraying or splattering of blood or OPIM into eyes, mouth, or other mucous membrane. ... . "

1. Observations in Operating Room (OR) #5 on January 12, 2016, between 11:20 AM and 12:30 PM revealed after the patient was placed on the operative table and anesthesia was administered via face mask by EMP39, an intravenous (IV) intra-catheter was placed by EMP40. After starting the IV, EMP40 removed the gloves, failed to perform hand hygiene and donned a fresh pair of gloves. EMP40 administered several IV medications, again removed the gloves but failed to perform hand hygiene and typed on the computer. After completing the documentation, EMP40 was observed removing the combination face mask/eye shield, placing it on the nape of the neck, performing hand hygiene and exiting OR#5 without removing and discarding the face mask/shield. While both EMP39 and EMP40 were observed performing hand hygiene upon entering the OR and donning gloves, EMP39 was observed wearing the same pair of gloves throughout both of the patient ' s procedures. EMP39 was observed applying EKG pads to the patient's chest, connecting the leads to the cardiac monitor, clipping the pulse oximeter on the patient's left index finger, positioning the patient, administering oxygen and anesthesia via face mask, inserting an endotracheal tube, administering intravenous medications, adjusting the dials on the anesthesia machine periodically throughout the procedures and documenting in the eRecord without changing gloves or performing hand hygiene between tasks. EMP39 was observed suctioning the patient at the end of the procedure, removing the gloves after suctioning but failed to perform hand hygiene before donning a fresh pair of gloves to administer IV medications to awaken the patient from the anesthesia. EMP39 also failed to change gloves and perform hand hygiene before suctioning the patient and removing the endotracheal tube.

At approximately 12:03 PM, EMP40 re-entered OR#5 wearing gloves and face/eye shield combo mask, spoke with EMP39 and typed something on the computer. EMP40 removed the gloves after typing on the computer but failed to perform hand hygiene. EMP39 was observed speaking with EMP40 and was again observed typing on the computer without gloves and failed to perform hand hygiene after typing on the computer. EMP40 was then observed to flip the combo face/eye shield mask over the shoulder and without removing and discarding the mask/shield exited the room. (EMP40 was observed twice exiting OR#5 without removing the surgical mask and discarding it.)

On January 12, 2016 at 12:35 PM, EMP26 confirmed that the two staff members (EMP39 and EMP40) should have performed hand hygiene in between glove changes during the procedures in OR#5 and that EMP39 should have changed gloves between tasks and not just at the beginning and end of the procedures. EMP39 and EMP40 failed to perform hand hygiene according to the OR and hospital wide facility policies.

On January 13, 2016 at approximately 10:30 AM, EMP5 confirmed that hand hygiene in the OR has improved but Anesthesia continues to require reminders to do hand hygiene between glove changes and to remove and discard their masks before exiting the room. QAPI data was reviewed with EMP5, which showed the OR Anesthesia Department's hand hygiene compliance improved from 50% to 87%. EMP5 further stated, the Chief of Anesthesia and Director of the Operating Room will continue to conduct frequent spot checks of staff and are enforcing progressive disciplinary actions against the providers that continue to be non-compliant with hand hygiene and PPE. EMP5 stated, "We continue targeting these providers. There will be another in-service for all employees as well as special training sessions focused on the Anesthesia department."