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Based on observation and interview the facility's Director of the Food Services failed to establish and maintain a sanitary environment in the kitchen, affecting the facility census and multiple staff. The facility census was 358.

Findings included:

1. Observations in the kitchen on 06/04/13 at 3:00 PM through 3:55 PM showed the following:
-Scraps of paper, plastic lids, caps and unidentifiable trash debris accumulated in the drain pit, or sump of a cart washer machine.
-Accumulated blackened grease residues pooled in corners of the base inside of a deep fryer cabinet on the fry cook line that served the cafeteria showed it receives a thorough cleaning infrequently.

2. During interviews on 06/04/13 at 3:55 PM, Staff AAAA, Sous Chef, stated that the inside cabinet of the deep fat fryers were not cleaned on a regular basis. He stated that the general kitchen cleaning policies did not specify or dedicate a procedure to cleaning the interior cabinet below the burners. It was assumed that the general cleaning process would include the interior cabinet. During an interview on the same date and time, Staff LLL, Director of Food Services, acknowledged that the accumulated grease deposits on the bottom shelf of the deep fryers should be part of every cleaning the piece of equipment receives. Staff LLL stated that kitchen staff were assigned to clean up their work areas, which included the kitchen floors. Staff AAAA stated that kitchen staff do not access or clean the drain pit around the cart washing machine, but he thought Housekeeping Services was supposed to do that. Staff BBBB, Director of Environmental Services (Housekeeping), stated in the same interview that housekeeping staff have never been assigned to clean the drain pit around the cart wash machine.

3. During an interview on 06/05/13 at 1:40 PM, Staff YYY, Infection Control Coordinator, stated that the facility complied with the Centers for Disease Control and Prevention (CDC) Guidelines for infection control. She stated that infection control was not regularly monitored in the kitchen area. She stated that all facility departments such as dietary are reviewed twice yearly for infection control issues by there are no current processes for monitoring in those departments.




27029

Based on observation and interview, the facility failed to preserve the general cleanliness of the receiving dock area to ensure good sanitation practices were followed to discourage nesting of pests and vermin. (Loose trash, food and fluid residues provide nesting and living quarters for rodents, cockroaches, flies, ants, spiders and other common household nuisance pests that are common carriers of disease and infectious agents.) The facility census was 358.

Findings included:

1. Observation on 06/05/13 at 4:30 PM in a service area located off of the facility's loading dock, showed scraps and pieces of Styrofoam packing material, plastic wrap, and pieces of cardboard around two trash compactors and an open topped roll-off container (partially filled with dry construction debris). Several pieces of unidentified paper and plastic trash littered the area and were stuck under the lift mechanism under an adjustable loading ramp located off of the left side of the dock area.

2. During an interview 06/05/13 at 4:30 PM, Staff JJJ, Director of Building Services stated that there was no formal policy, procedure or regular schedule for cleaning the dock area and driveway. He stated that they usually tried to keep the trash picked up and clean the area when they noticed it was dirty.

Based on observation, interview, and policy review, the facility Infection Control Officer failed to identify, investigate and ensure staff followed the facility infection control policies and applicable Centers for Disease Control (CDC) guidelines in relation to:
- Proper use of personal protective equipment (PPE) for care of five patients (#13, #51, #52, #53, and #64) of eight patients observed for care with PPE.
- Proper hand hygiene during care of 10 patients (#2,#7,#16, #17, #18, #19, #23, #32, #52, and #64) of 18 patients observed receiving care;
- Provision of clean environment for medication set up for one patient (#4) of one patient receiving medication by injection (placing medication under patient's skin with a needle); and
- Proper maintenance of surfaces in patient rooms on 6100 unit and 8200 unit.
These deficient practices increased the risk of cross contamination and spread of infection to all patients and staff in the facility. The facility census was 358.

Findings included:

1. Review of the 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings showed:
Indirect contact transmission. Indirect transmission involves the transfer of an infectious agent through a contaminated intermediate object or person. In the absence of a point-source outbreak, it is difficult to determine how indirect transmission occurs. However, extensive evidence cited in the Guideline for Hand Hygiene in Health-Care Settings suggests that the contaminated hands of healthcare personnel are important contributors to indirect contact transmission. Examples of opportunities for indirect contact transmission include:
- Hands of healthcare personnel may transmit pathogens after touching an infected or colonized body site on one patient or a contaminated inanimate object, if hand hygiene is not performed before touching another patient.
- Patient-care devices (e.g., electronic thermometers, glucose monitoring devices, telephones) may transmit pathogens if devices contaminated with blood or body fluids are shared between patients without cleaning and disinfecting between patients.
- Clothing, uniforms, laboratory coats, or isolation gowns used as PPE, may become contaminated with potential pathogens (an agent that causes disease) after care of a patient colonized or infected with an infectious agent.

Record review of the facility's policy titled, "Standard Precautions and Isolation Guidelines" revised on 07/09/09, showed direction for facility staff to:
- Apply a gown as personal protective equipment (PPE) when entering the environment of a patient on contact precautions (precautions put in place to prevent the spread of infection from an infected patient to other patients), overlap the gown in the back to cover clothing, and secure it.
- Put on gloves, making sure that cuffs of gown are covered.
- Contact transmission is the most important and frequent mode of transmission of nosocomial (hospital acquired) infections. Contact transmission can be divided into two (2) subgroups: direct contact, and indirect contact.
- Direct Contact - involves a direct body surface-to-body surface contact and physical transfer of micro-organisms to a susceptible host from an infected or colonized person, such as occurs when a person performs other patient care activities that required direct personal contact.
- Indirect Contact - hands that are not washed and gloves that are not changed between patients or tasks.
- Dedicate the use of non-critical items such as stethoscopes, disposable blood pressure cuffs and/or electric thermometers for this patient only. Items that cannot be designated should be wiped thoroughly between use using hospital approved disinfectant.

2. Observation on 06/03/13 at 1:55 PM on the 7th floor West Medical Unit showed Staff M, Nursing Assistant, in Patient #13's room. Patient #13 was in contact isolation. Staff M's PPE gown was not tied at the waist and was not covering her clothing in the back.

During an interview at 06/03/13 at 2:00 PM, Staff M stated, "I usually tie my gown."

3. Observation on 06/03/13 at 2:10 PM, on the 8th floor Oncology Unit, showed Staff W, MD (Medical Doctor), put on PPE gown and gloves and entered Patient #64's room without performing hand hygiene. Patient #64 was in contact isolation and Staff W's gown was not tied at the waist. Staff W used the bedside computer, then started to remove his personal stethoscope from around his neck (replaced his stethoscope around his neck) then used the stethoscope that was in the patient's room to listen to the patient's lungs. He then removed the PPE and exited the room.

During an interview on 06/03/13 at 2:28 PM Staff W, MD, stated that he was not aware that he did not tie his gown at the waist, but stated that he knows he should have. He stated that he will do better with this in the future.

4. Observation on 06/05/13 at 10:09 AM showed Staff UUU, RN (Registered Nurse), and Staff VVV, RN, in the Dialysis Unit at Patient #51's bedside who was undergoing a dialysis treatment. Staff VVV was wearing full PPE but Staff UUU was wearing none. Staff UUU then put on PPE but did not tie the PPE gown at the waist allowing the ties to touch inanimate objects as well as the patient's bed and dialysis machine. Staff UUU removed the PPE and put on new PPE to care for Patient #52 but failed to tie the PPE gown. She moved the patient's bed and the ties were touching her shoes, the floor and the patient's bed and her back and clothing were exposed allowing the PPE gown to fall at her sides. She removed the PPE and sat at the desk and used the computer. She got up from the desk and put on gloves but did not perform hand hygiene. She gave Staff VVV a bottle of Dialysate (a solution of purified water with an electrolyte which is salts and minerals that can conduct electrical impulses in the body composition similar to blood), she removed her gloves but did not perform hand hygiene.

During an interview on 06/05/13 at 10:32 AM, Staff WWW, Dialysis Trainee (learning to care for patients undergoing Dialysis treatment), stated that Staff VVV was precepting (teaching or instructing) Staff UUU. She stated that she observed Staff UUU without PPE when at Patient #51's bedside during dialysis. She stated that she also observed that Staff UUU did not tie her PPE gown and the ties were touching the floor. Staff WWW stated that Staff VVV should have corrected trainee, Staff UUU.

5. Observation on 06/05/13 at 11:00 AM in the Intensive Care Unit showed Staff XXX, RN, performing tracheostomy (an artificial opening in the throat) care on Patient #53. Patient #53 was in contact isolation. Staff XXX put on PPE gown and gloves. During the procedure, Staff XXX removed the gloves and put on sterile gloves but failed to pull one glove over the cuff of the PPE gown, leaving her skin exposed at the wrist.

6. During an interview on 06/05/13 at 1:40 PM, Staff YYY, Infection Control Coordinator, stated that the facility complied with CDC Guidelines for infection control. She stated that hand hygiene was monitored but procedures were not monitored for glove or PPE use.

7. Record review of the facility's policy titled, "Standard Precautions and Isolation Guidelines" revised on 07/09/09, showed direction for facility staff to:
- Hands must be washed as soon as possible after gloves are removed.
- HANDWASHING: The single most important means of preventing infections.
- Inanimate objects in the environment that have become contaminated are also potential sources of infection.

Record review of the facility's policy titled, "Hand Washing/Hand Hygiene" revised on 03/03/11, showed direction for facility staff to wash hands with soap and water or an alcohol-based hand rub:
- After touching a patient;
- After touching a patient's surroundings; and
- After removing gloves.

8. Observation on 06/03/13 at 2:00 PM showed Staff F, RN, assist Patient #2 up in bed. Staff F administered a medication to Patient #2. Staff F failed to perform hand hygiene between assisting the patient up in bed and medication administration. She also failed to perform hand hygiene when entering Patient #2's room.

During an interview 06/03/13 at approximately 2:15 PM Staff F stated that she should have done hand hygiene when she entered the patient's room and before giving the patient her medication.

9. Observation on 06/03/13 at 2:10 PM, on the 8th floor Oncology Unit, showed Staff W, MD, performed a physical exam on Patient #7. Staff W entered the patient's room, put on gloves and removed the bed linens, exposing the patient's legs. He touched each side of a non-dressed leg wound on the lower left leg. He proceeded to pull the bed linens up to the patient's chest, removed his gloves and placed them into a trash can and left the room without performing hand hygiene. He then proceeded to chart on his laptop at the nurses' desk.

During an interview on 06/03/13 at 2:28 PM Staff W, MD, stated that he sanitized his hands after leaving Patient #7's room.

10. Observation on 06/03/13 at 3:10 PM on the 7th floor West Medical Unit showed Staff O, RN, performed wound care on Patient #16's sacral area. Staff O put on gloves to cleanse the wound, removed the gloves, and failed to wash her hands before putting on new gloves to apply barrier ointment to the wound.

During an interview on 06/04/13 at 9:25 AM, Staff O stated that she was not aware of the facility policy to wash her hands between glove changes.

11. Observation on 06/04/13 at 1:45 PM on the 6th floor West Surgical Stepdown Unit showed Staff ZZ, RN, performed wound care on Patient #32's lower extremities. Staff ZZ put on gloves, removed the old dressings, cleansed the wounds, and then touched the patient's shoulder and linens with the soiled gloves.

During an interview at 06/04/13 at 2:00 PM, Staff ZZ stated that she should have removed the soiled gloves and washed her hands before touching the patient and the linens.

12. Observation on 06/04/13 at 8:50 AM in the Emergency Department (ED) showed Staff X, RN, preparing to administer an intravenous (IV or into the vein ) line into Patient #19's arm. Staff X had put on gloves but removed her right glove and reached for some supplies with her bare hand. She then put a clean glove on her right hand without performing hand hygiene and continued with the procedure.

13. Observation on 06/04/13 at 9:03 AM in the ED showed Staff X, RN, enter Patient #17's room. She took the patient's blood pressure and set up IV supplies on the bed-side table. Staff X put on gloves without performing hand hygiene and started the IV, removed her gloves and performed hand hygiene. She then got the IV tubing and supplies ready to attach to the medication and then put on gloves without performing hand hygiene. She removed the right glove and used the computer without performing hand hygiene. She took a telephone out of her pocket and talked on the phone then replaced the telephone into her pocket. She put on another glove on the right hand, without performing hand hygiene, and attached the IV line to the patient. She removed both gloves and did not perform hand hygiene until after she programmed the IV pump and removed the blood pressure cuff from the patient's arm.

14. Observation on 06/04/13 at 9:34 AM in the ED showed Staff Y, RN, enter Patient #18's room. She put on gloves without performing hand hygiene and applied EKG (electrocardiogram, a test that checks for problems with the electrical activity of the heart) tabs to the bare chest of the patient and then applied the EKG lines to the tabs. She used the computer while twice touching the patient's arm to check the spelling of his name and his birth date. Staff Y exited the room with the soiled gloves on and then removed and discarded the gloves without performing hand hygiene. She re-entered the room and washed her hands with soap and water but there were no paper towels to dry her hands so with her wet hands she opened drawers until she found a hospital gown and used it dry her hands. With her bare hands, she prepared to insert an IV into the patient's arm by getting supplies out of a drawer and putting them on the patient's bed side table. She sat down at the patient's bed, put on gloves without performing hand hygiene. She removed the left glove to palpate (feel) for the patient's vein and replaced the same glove and inserted the IV into the patient's arm.

15. During concurrent interviews on 06/04/13 at 10:00 AM, Staff D, ED Nurse Manager, and Staff E, Director of ED, stated that the expectations would be to perform hand hygiene before putting on, after removing and between glove changes. They also stated that CDC Guidelines require hand hygiene when moving from inanimate objects (e.g. computer keyboard, supplies, etc.) to touching the patient. The ED had 43 patients at the time of observations and patient care needs did not allow interviews with Staff X or Y.

16. Observation on 06/04/13 at 10:43 AM in the Surgical Intensive Care Unit (SICU) showed Staff JJ, RN, preparing to start an IV on Patient #23. She put on gloves and attempted to start an IV but could not find a vein so she removed the IV and held the bleeding site with gauze. She then removed her gloves, did not perform hand hygiene, took some tape out of a drawer and taped the gauze to the patients arm. She put on new gloves and threw away the contaminated supplies from the failed IV attempt but also picked up the unopened IV supplies and placed them back in the supply area still wearing the same soiled gloves.

17. Observation on 06/04/13 at 10:58 AM in the SICU showed Staff GG, RN, and Staff HH, RN, preparing to administer blood to Patient #23. Staff HH used the computer and Staff GG, instructed Staff HH to put on gloves and spike (insert a piece of sharp plastic) the bag containing blood. Staff HH put on gloves without performing hand hygiene. Staff HH removed the gloves without performing hand hygiene and programmed the IV pump. Staff GG put on gloves without performing hand hygiene and emptied the trash into a red bag (red bags are commonly used in facility's as a caution that it contains contaminated or potentially hazardous or infectious medical waste) container. She then removed her gloves and did not perform hand hygiene. Staff HH then administered medication to Patient #23. Staff GG did not perform hand hygiene and put on gloves. She then opened a drawer and removed supplies, touched the patient's bare arm, touched the patient's medication, then touched the patient's bare hand.

During an interview on 06/04/13 at 11:20 AM, Staff GG stated that she was training Staff HH.

During an interview on 06/05/13 at 9:50 AM, Staff GG stated that she was so concerned about precepting Staff HH that she forgot about the hand hygiene but knew that she should perform hand hygiene between glove changes and between inanimate objects and patient care.

During an interview on 06/05/13 at 10:00 AM, Staff HH stated that she was just nervous and tried to do everything right and didn't even think about hand hygiene.

18. Observation on 06/03/13 at 2:40 PM Staff G, RN, placed a needle and syringe on the lid of the soiled linen cart in Patient #4's room. Staff G proceeded to prepare medication for injection from the lid of the soiled linen cart. Staff G then administered an injection of medication to Patient #4.

During an interview on 06/03/13 at 3:10 PM, Staff G stated that she should have set-up the medication on the work shelf in the corner of the patient's room. Staff G stated that the lid to the soiled linen cart posed a risk of contamination for the patient.

19. During an interview on 06/04/13 at 10:00 AM, Staff A, RN, Director of Nursing Resources, stated that providing a clean environment for medication preparation was just basic nursing practice.

20. Observation on 06/03/13 at 2:15 PM through 4:00 PM showed on the 8200 unit patient rooms #8214, #8216 and #8104 missing large chips and splinters of wood veneer from the hinged edge of entrance doors, which exposed vulnerable unfinished rough wood surfaces up to two inches square that were no longer sealed or easily cleanable.

Further observation on 6100 unit showed several of the entrance doors to patient rooms had once been repaired with a 30 inch high flush metal corner guard applied to a routed area. The metal corner guards on the entrance doors to patient rooms #6102, #6114, #6118, and #6122 were missing and exposed the unfinished routed wood with glue residue-rough surfaces which were no longer sealed or easily cleanable.

During interviews on 06/03/13 at 2:15 PM through 4:00 PM, Staff JJJ, Director of Building Services stated that the areas were in disrepair because there may be future renovation however, there was no current plan for work in the area. He stated that no work orders had been submitted for repairs.



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