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Based on observation and interview the facility failed provide and maintain and provide a sanitary environment resulting in the potential for the spread of infectious disease to 818 served by the facility.

See specific A tag:

A-0749 Failure to monitor and conduct active surveillance activities for PPE compliance for staff and visitors for patients on Isolation Precautions; failure to ensure vistors wore PPE while visiting patients on Isolation Precautions; failure to store hazardous waste materials in leak-proof and/or puncture proof containers, failure to store dirty medical devices off the floor.

Based on observation, interview and record review, the Infection Control Officer failed to perform surveillance activities for personal protection equipment (PPE) compliance for staff and visitors; failed to ensure the proper handling/storing of hazardous waste materials and dirty medical equipment was implemented in 2/5 soiled utility rooms observed; failed to ensure visitors donned PPE while visiting 2 patients (#'s 8 and 11) of 3 patients observed on isolation precautions with visitors present, resulting in the potential for transmission of infectious agents for all 818 patients served by the facility. Findings include:

On 9/16/19 at 1400 a tour of the 4th floor nursing units was conducted with Clinical Nurse Director (Staff Z). A red biohazards waste bag was observed on the floor in an upright position. At that time Staff Z was asked to explain if he knew what was in the bag and if the bag should have been stored in a puncture proof or leak proof container. Staff Z said he did not know what was in the bag. He said, "If it's in a red bag it probably should be in a container."

On 9/16/19 at 1430 patient #8 was observed in her room. A sign was posted on the patient's door for Isolation Precautions. An isolation supply cart was observed stationed outside of the patients room. A visitor was observed seated in the patient's room. The visitor was not wearing a gown nor gloves.

On 9/16/19 at 1433, Nurse Supervisor (Staff DD) was asked to explain if staff or visitors were required to wear personal protective equipment (PPE). Staff DD said only if patient activities were being conducted. She said if you don't touch the patient you don't have to wear a gown or gloves. At that time Staff DD confirmed that patient #8's visitor was in the room and not wearing any PPE. Staff DD said we recommend that our visitors wear PPE. She said we educate them. Staff DD was asked to provide evidence that documented the current visitor for patient #8 had been instructed on contact isolation based precautions requirements. At that time Staff DD said I don't have anything.

On 9/16/19 at 1500 a tour of the 5th floor nursing unit was conducted with Nursing Supervisor (Staff AA). There were 2 medical equipment pumps observed on the floor in the soiled utility room. There was signs posted on the wall for staff to store the soiled equipment on the shelves. At that time Staff AA confirmed the medical pumps should have not been stored on the floor.

On 9/19/19 at 1015 a review of the Infection Control Program was conducted with the Director of Infection Control (Staff O) and the following was revealed at that time:

1. A review of Infection Control surveillance logs, surveillance activity data collection, and infection control committee minutes were reviewed for January 2019 through August 2019. At that time, Staff O was queried regarding data collection for auditing staff and visitors for PPE compliance. Staff O said, "We only do PPE audits if we have a 'C-diff' (clostridium difficile infection found in the intestine) trigger." She said I don't have any audits for PPE." She said, "We probably haven't done those in over year. She said, "We normally don't track those."

2. Staff O was queried regarding as to why patient #8 was on contact precautions. Staff O explained the patient was on precautions due to diagnosis of vancomycin resistant enterococci infection (VRE). When queried as to if visitors should be wearing PPE when in the room with a patient who was on contact precautions, Staff O confirmed that all staff and visitors should wear PPE.

3. Staff O was queried regarding the observations of the storage and handling of hazardous waste and soiled medical equipment. Staff O said she had been informed of the concerns. She said she could not confirm what was in the red hazardous waste bag. She said however, nothing should have been stored directly on the floor.

On 9/19/19 at 1345 an interview was conducted with the Director of Accreditation (Staff A).
When asked to explain if she was aware of the Infection Control Preventionist lack of surveillance activities for monitoring and auditing for compliance with PPE for staff and visitors she said she was not. She said I will follow up with the Infection Control Preventionist.

Staff A said she was aware of the concerns regarding visitors not being required to wear PPE. She said our policy is to recommend that they (visitors) do.

Staff A said she was aware of the concerns regarding the storage of hazardous waste in red bags stored on the floor. She confirmed whatever was in the bag had since been disposed of properly. Staff A said she felt that soiled medical devices stored on the floor in the soiled utility room was more of a safety hazard rather than an infection control concern. However, Staff A offered no further explanation when as to explain why signs were posted in 5 observed soiled utility rooms for staff to store soiled medical equipment on the shelves.

A review of the facility's Infection Control Policy titled, "Contact Precautions (CP)/Contact Precautions Diarrheal (CP-D)", last revised on 11/18 documented:
II. Definitions:
Specific disease/condition requiring CP/CP-D and duration of precautions:
Antibiotic-resistant microorganisms. Contact Precautions. Refer to Exhibit A.
III. Policy Standards, Procedures/Actions:
6. Gloves shall be worn upon entry to the patient room. Gloves are not suitable for hand hygiene. Gloves must not be worn outside any patient's room or treatment area. Gloves shall be used once and discarded after use.
7. Long-sleeved gowns shall be worn upon entry to the patient room. Gowns shall be used once and discarded after use. Do not wear gown outside of patient's room or a treatment area.
12. Patient/Family/Visitors:
a. Education-Clinical staff shall explain the precautions to the patient and/or family/visitors and provide them with the appropriate patient education sheets (i.e.-patients with MRSA should be given both the Contact Precautions for Antibiotic-Resistant Bacteria and MRSA sheets).
b. Hand hygiene-Family/Visitors shall be instructed to wash their hands or use alcohol based handrub whenever exiting the room. When visiting a patient in CP-D, hands must be washed with antimicrobial soap, alcohol based handrub shall not be use.
c. Barriers-For their protection, it is recommended that all family/visitors wear gloves and a gown if they will be participating in patient care activities. Gowns and gloves must be removed prior to leaving the room. Family/visitors must perform hand hygiene whenever leaving the patient room and immediately after performing patient care activities... Family/visitors visiting a patient in Contact Precautions or Contact Precautions Diarrheal may not go to the nourishment room or Child Life areas.

A review of the facility's "Regulated Medical Waste Management Policy and Procedure, last revised on 08/2019 documented:
C. Containers
Regulated medical waste may be placed in red bags, biohazard-labeled plastic bags, sharps container, fiber drums, biohazard boxes, or biohazard buckets.
Cultures and stocks of material contaminated with infectious agents must be placed in puncture-resistant containers. Other regulated medical waste such as liquid body fluids, semi-liquid body fluids, and pathological waste must be placed in containers that are closable, impervious to moisture, and constructed to contain all contents and prevent leakage of fluids. Containers must have sufficient strength to resist ripping, tearing, breaking, or bursting under normal conditions of usage or handling.
E. Handling
Standard precautions including protective clothing and equipment shall be used at all times when handling materials that may be contaminated with regulated medical waste (RMW).








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Upon entering the medical intensive care unit (ICU) on 9/17/2019 at 1257, room D6824 was observed to have a "contact precaution" sign hanging on the door frame. Inside the room, Patient #11 was observed sitting on the bed. A female visitor was also in the room, setting up the bedside table and the patient's lunch for him, touching the patient and bed with her hands and clothing. The female visitor was not wearing any type of personal protective equipment (PPE).

Staff A was queried as to if the visitor should be wearing PPE while the patient was considered to be in contact precautions to which she stated, "Only if they are assisting with the care of the patient." Staff A was then queried as to if adjusting the bedside table, setting up lunch, and touching the patient and bed was considered "care of the patient" to which she stated it was not.

Staff O was queried on 9/18/2019 at 1130 as to why Patient #11 was in contact precautions to which she stated that there was a previous diagnosis of respiratory methicillin resistant staphylococcus auerus (MRSA) from 3/2019. She also stated that a previous diagnosis of MRSA would trigger automatic precautions until the patient could be thoroughly evaluated. After a thorough evaluation, the precautions could be lifted by any of the Infection Preventionist Team except for the analysts. Staff O further stated Patient #11 was no longer on contact precautions. When queried as to if visitors should be wearing PPE when in a room with a patient who is on contact precautions, Staff O agreed that visitors should be wearing PPE.