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Based on observation, interview and record review, the facility failed to:

1. Verify that a qualified person was held accountable for the facility's Infection Control Program. (Refer to A-748)

2. Follow sanitary environment practices with regard to maintaining clean water spouts in the Intensive Care Unit (ICU). (Refer to A-749)

3. Screen visitors and staff members for possible Covid-19 infection upon entering the facility. (Refer to A-749)

4. Ensure qualified staff for the Infection Prevention and Control program. (Refer to A 748)

5. Maintain a safe and sanitary environment to prevent the transmission of infections and communicable diseases. (Refer to A 749)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality care in a safe environment.


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Based on interview and record review, the facility failed to verify that a qualified person was held accountable for the facility's Infection Control Program. Without this leadership, the goals of this Program may not be met placing all staff and patients at risk for contracting communicable diseasee and infections.

Findings:

During an interview with the Coordinator on 7/31/2020 at 9:30 AM, the Coordinator stated that the position of Infection Control Director (person responsible for ensuring goals of the facility's infection control plan are met) had been vacated for some time. She continued on to say that the Associate Chief Nursing Officer (ACNO) was not available this week; the Chief Nursing Officer (CNO) was not in the facility to answer questions due to illness.

The Director Emergency Services concurrently emphasized that the Infection Control (IC) Coordinator was not available today to answer questions regarding the facility's Infection Control Program and the IC Coordinator was substituting for the position of Infection Control Director.

A record review of the job description and qualifications required for the position of Infection Control Director indicated that the Infection Control Director is responsible for implementing effective infection control policies guided by principles set forth by the Centers for Disease Control and Prevention (CDC), Joint Commission (Hospital Accreditation Organization), OSHA (Occupational Safety and Health Administration), and other regulatory agencies. The facility's goals and direction of the Performance Improvement Plan must be met through the actions of the Infection Control Director. The document asserts that the following licenses and certifications must be met: Registered Nurse license in the state of California with a bachelor's degree in Nursing or bachelor's degree in Microbiology or Epidemiology; certification of Infection Control is required.

A review of the job description and qualifications required for the position of Infection Control Coordinator showed that the Infection Control Coordinator is responsible for organizational tasks, evaluating infection control in the hospital, and other duties as assigned by the Infection Control Director. The following licenses or certifications and experience is required: high school diploma, hospital experience, certification in infection control at least within 18 months from the date of hire. There was no documented evidence of the IC Coordinator possessing certification in infection control.

On August 5, 2020 at 12:41 p.m., during interview with Infection Control Coordinator (ICC - staff who keeps records and prepares reports for the Infection Control Practitioner), ICC stated the Infection Control Practitioner (ICP), (an staff person in additional to the Infection Control Director responsible for infection control practices within the facility), was on medical leave from February 2020 to March 2020, and during that time, the records for the lab results were not reviewed and reported to the NHSN. The ICC stated the ICP resigned in July 2020 and the lab reports for the NHSN had not been done because nobody has asked for those records. The ICC stated the hospital administration was notified of this situation.

On August 5, 2020 at 2:30 p.m., during interview the Director of Human Resources (DHR), stated he did not have the personnel file of the ICP because after the ICP terminated employment on June 12, 2020, the ICP's personnel file was sent to the corporate office.

On August 5, 2020 at 3 p.m., during concurrent interview with Human Resources Manager (HRM) and record review of ICC's personnel file, the HRM stated the ICC's job description, dated May 4, 2018, indicated the ICC reported to the Infection Control Practitioner and required that the applicant have certification in Infection Control, at the time of hire, or within 18 months of hire.

Concurrently, HRM stated the ICC, currently, does not have certification in Infection Control.


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Based on observation, interview, and record review the facility failed to:

1. Follow sanitary environment practices with regard to maintaining clean water spouts in the Intensive Care Unit (ICU).

2. Screen visitors and staff members for possible Covid-19 infection upon entering the facility.

3. Have emergency pull cords in common use areas (Restrooms) that can not be cleaned.

4. Not store items in patient care area in Corrugated cardboard boxes.

5. Keep equipment clean and free of soilage and tape/residue.

6. Keep hand sanitizers full and available for use.

7. Keep sinks free of mineral deposits and soilage/residue. Keep patient care items clean and free of damage.

These practices may lead to the spread of infection within the facility.

Findings:

1. During a tour of the facility's 2 Tower ICU on 7/31/2020 at 10:10, accompanied by the Director of ICU/Telemetry, there were white deposits on the spout of the faucet over the sink in the 'Soiled Utility' room.

At that time, the Director of ICU/Telemetry acknowledged the deposits and stated she would attend to cleaning the faucet as soon as possible.

The Centers for Disease Control and Prevention (CDC) indicates that common use points in patient care areas are sinks, faucets, aerators, showers, toilets, and eye wash stations. The potential for these devices serving as reservoirs of disease causing organisms has been documented. Surfaces and aerosol production by these tools have been associated with a risk of production of bacterial colonizations and infections, including Legionnaires disease, especially where immunocompromised patients are present. (https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html

2. Upon entry to the facility on 7/31/2020 at 9:25 AM, Security was stationed behind a counter in the lobby of the main entrance. Security asked the surveyors if he could take their temperatures; the surveyors accepted and temperatures were not elevated. When asked if there would be any further questioning regarding signs and symptoms of possible Covid-19 infection, e.g., sudden sore throat cough, shortness of breath, or recent exposure to Covid-19 infection, Security stated that there would be no further assessment after he took surveyors' temperatures.

During a conversation with the Director of Emergency Services on 7/31/2020 at 10:00 AM, the Director of Emergency Services stated that before entering the facility all persons should be screened for temperature and signs and symptoms of respiratory distress such as cough, shortness of breath, and sore throat.

A review of the San Gabriel Valley Medical Center 'Infection Control Manual - Pandemic Influenza Plan' (Revised 6/11/2020), the facility will use the definitions provided by the Centers for Disease Control and Prevention (CDC) to identify the novel strain pandemic influenza [Covid-19] by the following:

· Acute onset of respiratory illness
· Fever greater than 100.4 [degrees Fahrenheit] which may be present in the elderly
· Cough or respiratory distress: Sore throat, joint pain, muscle pain/exhaustion, diarrhea, vomiting, abdominal pain, conjunctivitis (pink eye)

Review of this document indicated these were the identifiers of possible Covid-19 infection. However, there was no mention of who was responsible for monitoring these indicators.

3. On August 4, 2020 at 1:34 p.m., during initial tour of the emergency department, with the Associate Chief Nursing Officer (ACNO), the Director of Emergency Services (DED), and the Director of Pharmacy Services (DPS), two patient bathrooms were observed with emergency pull-cords made of twine (strong thread that is made of permeable material that cannot be disinfected).

Concurrently, the DED stated the pull-cords could not be properly disinfected because they were made of materials that could not be disinfected after use.

During the tour of the emergency department with the ACNO, the DED, and the DPS, the ice machine in the clean utility room was observed with mineral deposits. The gastric tube tack box was observed with tape and tape residue, and soiled feeding pumps were stored in a bin adjacent to clean supplies and equipment.

Concurrently, the DED stated the ice machine is cleaned daily by housekeeping and monthly by the maintenance department.

On August 4, 2020 at 2:09 p.m., during the tour of the emergency department's medication room, with the Associate ACNO, the DED, and the DPS, the following items were observed:
1. Two intravenous (IV) carts, stocked with needles and syringes inside, were observed with tape and tape residue and soiled with brown spots.
2. Pill crusher equipment was visibly soiled.
3. Four corrugated boxes of supplies were observed.
4. A Glucometer (machine to check blood sugar) was soiled with blood stains and tape residue.

Concurrently, the DPS stated the pill crusher should be cleaned before use and the DED stated the glucometer should be cleaned and disinfected after each use.

4. On August 5, 2020 at 9:44 a.m., during a tour of the 5th floor with the DPS and the Director of ICU (DICU), four corrugated boxes of cleaning supplies were observed in the clean utility room.

Concurrently, the DPS stated there should not be any corrugated boxes in patient care areas.

5. On August 5, 2020 at 10:15 a.m., during a tour of the 4th floor with the DPS and the DICU, the medication refrigerator in the medication room was observed with tape and tape residue and the freezer portion was observed soiled with brown spots.

Concurrently, the DPS stated the refrigerator needed to be cleaned and the tape with tape residue removed and cleaned.

6. On August 5, 2020 at 10:28 a.m., during a tour of the 3rd floor with the DED, the DPS and the DICU, room #309 was observed with an empty alcohol-based hand rub (ABHR - hand sanitizer) dispenser.

Concurrently, the DED stated she will call housekeeping to fill the ABHR dispenser.

During the tour of the 3rd floor, corrugated boxes were observed in the medication room.

Concurrently, the DPH stated there should not be corrugated boxes in the patient care area.

7. On August 5, 2020 at 11:00 a.m., during a tour of the Labor and Delivery (L&D) operating room, with the Director of Maternal-Child Health (MCHD), the scrub sinks were observed with mineral deposits and tape residue.

Concurrently, the MCHD stated that housekeeping cleans the scrub sinks daily but did not remove the mineral deposits on the sinks.

Afterwards, at 11:19 a.m., in L&D, the following items were observed:
1. A supply cart with corrugated boxes of medical supplies.
2. Transport incubator's mattress with multiple tears and holes.

During the tour and observation the MCHD stated she didn't know there were corrugated boxes in the patient care area and didn't know the incubator mattress had holes and tears.

A review of Infection Control policy, "Cleaning Products and Equipment", dated March 2019, indicated the following:
1. Medical equipment used, in a patient room or that came into contact with the patient or his environment, will be cleaned and disinfected.
2. Glucometer to be cleaned and disinfected with disinfecting wipes after each use by the nursing department.
3. Medication refrigerators will be cleaned weekly and as needed by the nursing departments.
4. Ice machines will be cleaned daily by housekeeping and monthly by the facilities department.
5. Medication carts will be cleaned by nursing department when visibly soiled with disinfecting wipes.


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