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Based on observation, document review and interview, in one (1) of four (4) Nursing Units toured, the facility did not ensure that medications were secured.

This presence of medications left unattended and not secured, places patients at risk for potential harm.

Findings include:

Observations during a tour of the facility's 4 North's Nurses' Station on 02/02/18 at 2:30PM identified one (1) unattended WOW (Workstation On Wheels) which housed five (5) unlocked medication drawers.

On interview during the tour, Staff W (Nurse Manager) confirmed the findings and stated the drawers should be locked.

The facility's Policy and Procedure titled "Location, Storage and Procurement of Medications ..." last revised 06/2018, states: "Medication WOWs are placed in the locked position to ensure that drawers are closed and medications secured when unattended."
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Based on observation, document review and interview the facility failed to ensure that outdated drugs were not available for patient use.
Specifically, in one (1) of three (3) observations expired medication was not removed from the medication room.

This may have placed patients at risk for receiving expired medications.

Findings includes:

Observations on 01/31/18 during a tour of the 3 North - 2 Telemetry Unit between 12:10PM and 1:30PM identified two (2) multi-dose containers in the Medication Room with expired Beyond-Use Dates (BUD). One (1) was a bottle of Geri-Lanta on a shelf with a BUD of 01/28/18, and the second was a bottle of Vancomycin Hydrochloride in the medication refrigerator with a BUD of 01/02/18. This was confirmed with Staff J (Clinical Nurse Manager).

Per interview at the time of the observation, Staff J stated that the Charge Nurse is responsible for checking for expired medications and that the expired medications found should not have been in the Medication Room.

The facility's Policy and Procedure titled "Medication Management...Expiration Dates of Multi-Dose Vials & Other Medication", last revised 05/12, stated: "After a multi-use bottle is first opened or punctured, the bottle is labeled with the expiration date, usually 28 days from opening...Unusable medication may be discarded or returned to the pharmacy..."
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Based on observation, document review and interview, the facility failed to implement the hospital's infection control program.
Specifically, the facility failed to:
(a) follow current Infection Control standards for cleaning patient care areas and equipment,
(b) perform appropriate hand hygiene or hand washing,
(c) wear Personnel Protective Equipment (PPE) consistent with facility Policy, and
(d) educate patients, visitors, or caregivers about infections to reduce transmission.

This failure may place patients and staff at increased risk for the transmission of infections and communicable diseases.

Findings include:

See tag A749
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Based on observation, document review and interview, the facility failed to ensure that staff failed to: (a) follow current Infection Control standards for cleaning patient care areas and equipment, (b) perform appropriate hand hygiene or hand washing, (c) wear PPE (Personnel Protective Equipment) consistent with facility Policy, and (d) educate patients, visitors, or caregivers about infections to reduce transmission.

These Infection Control breaches place all patients at risk for exposure to infectious diseases.

Findings related to (a) include:

(a)(1)
During a tour between 12:15PM and 1:45PM on 01/31/18, Staff B (Housekeeper) was observed terminally cleaning a contact isolation patient's room in the Medical Intensive Care Unit. Staff B saturated the floor by spraying it with a large amount of germicidal solution labeled "A 456". Staff B then spread the solution with a clean mop head leaving the floor wet.

When asked, at the time of observation, Staff B stated that she cleans all floors with his germicidal solution (A 456). When questioned if the solution was used to clean the patients' rooms on enteric precautions (enhanced isolation to prevent the transmission of infections that survive in the external environment for long periods of time) for Clostridium Difficile (C Diff) or Candida Auris (C Auris), the member answered, "yes." When asked if the solution was a sporicidal (cleaning chemical used to kill spores), the staff member stated that it was a "germicidal, not a disinfectant."

Per interview with Staff A (Director of Environmental Services) and Staff C (Assistant Director of Environmental Services) on 01/31/18 at 1:15PM, both stated that all floors, including Isolation Rooms, are cleaned with "A 456" which is a germicidal, not a sporicidal, and confirmed that this included Isolation Rooms with enteric precautions for C Diff and C Auris.

The facility's "Product Specification Document" for "A 456 Disinfectant Cleaner" dated 04/25/11, described the following information: "A 456 ... is a concentrated disinfectant cleaner that is effective against a broad spectrum of bacteria ..., is a virucidal ... a fungicidal and inhibits mold and mildew ..." but it does not include that it is effective against Clostridium Difficile (C Diff) spores.

The facility's Policy and Procedure titled "Isolation Room Terminal Cleaning - Precautions [for] (Airborne, Contact and Droplet)", last revised 04/17/17, stated the following: "all high touch areas ... are to be cleaned a second time with the facility approved bleach solution and allowed to air dry". The Policy did not include cleaning the floors with a sporicidal (bleach) as required by current CDC (Centers for Diseases Control) Guidelines.


(a)(2)
Observations on 02/02/18 during a tour of the 4 North-1 Nursing Unit between 2:30PM and 3:15PM identified the following: the bathroom of Patient Room #437, designated for patients on C. Auris Isolation Precautions reported to have been terminally cleaned and is ready for the next patient. On observation, the bathroom was noted to be unkempt and was being used for storage. It contained a visibly dust laden wheelchair, an open half full bag of patient diapers, a walker and a covered commode. The floor of the bathroom was covered with dust, discarded paper and small particles of debris.

During this same tour, observations of the floor along the wall border and corner areas of the hallway shower room, used to store clean linen carts, was noted to be dust laden and covered with unknown particles.

Additionally, the Unit's hallway Bath / Shower Room, designated for patient use, had broken wall tiles. The floor appeared dirty and a grey film covered a metal plate in the floor, a square bracket and the emergency call bell lying on the floor next to discarded trash (open straw and paper cover.)

Staff W (4 North Nurse Manager) confirmed these findings at the time of the tour and observations.

The facility's Policy and Procedure titled "Patient / Resident Rooms and Special Care Areas" approved as of July 2015, states the following: "Dust mop the floor ... Be sure to dust mop ...in the bathroom. Move whatever is possible ... Wring out a mop in a bucket of germicidal solution and begin mopping the floor ... #22 Mop the restroom floor ... #24 Report any needed repairs".

(a)(3)
Observations during a tour of the 3 North-2 Telemetry Unit on 01/31/18 between 12:10PM and 1:30PM with Staff I (Director of Nursing Education) and Staff J (Clinical Nurse Manager), of Staff Dd (Housekeeper) terminally cleaning a room in PPE was identified by Staff J as an Isolation Room. However, the Contact Precautions sign was removed prior to the room being terminally cleaned.

Upon interview, both Staff I and Staff J confirmed that the sign should remain posted until the room is completely cleaned.

The facility's Policy and Procedure titled: "Isolation Room Terminal Cleaning - Precautions [for] (Airborne, Contact and Droplet)", last revised 04/17/17 stated the following: "The sign will remain on the door and removed when the terminal cleaning has been completed."

(a)(4)
Observations during a tour of 4 North on 02/01/18 at 2:45PM with Staff X (Laundry Aide), Staff V (Director of the Linen Department) and Staff W (4 North Nurse Manager) identified the following: four (4) empty linen hampers with clean replacement bags were stored in the 4 North 1 & 2 shared Dirty Utility Room with six (6) full linen hampers containing soiled laundry.

All the full hampers were touching each other and one (1) open hamper with a clean replacement bag was touching a soiled full hamper. There was no identification on the hampers indicating which linens had come out of an Isolation Room.

On interview at the time of the observation, Staff X (Laundry Aide) stated that another Laundry Aide is responsible for coming up to the Unit, removing the full bags, and then replacing the bag with a clean one, "but we do not clean the hampers".

Staff W stated that the Nursing Assistant on the Unit would wipe down the hamper with a Super Sani-Cloth germicidal disposable wipe before putting it into the Dirty Utility Room.

However, both Staff X and Staff V were unsure who was responsible to clean the hamper once it was removed from the Dirty Utility Room and placed in the hallway outside the Patient Rooms.

The facility's Guidelines titled "Low Level Disinfection" last revised 06/2017, stated the following: "Nursing staff [are] to clean non-critical items as indicated below ... isolation linen carts ... frequency - end if each shift ... [with] Micro-Kill Bleach [wipes] ...", but it lacked instruction on cleaning linen hampers taken from the Dirty Utility Room.

(a)(5)
Additional observations on 02/01/18 at 3:00PM with Staff Members X, V and W identified the following: clean linen was being stored in a shower room located in the hallway of 4 North-1. The Storage Area housed both a large tall plastic framed [Delivery] cart with light blue mesh cover and a short plastic framed [Unit] cart with a solid dark blue cover.

On interview at the time of the observation Staff X (Laundry Aide) stated that the clean laundry supplies are brought up to each Unit on the tall [Delivery] carts and the Nursing Staff places the linen on the smaller [Unit] carts which are then placed outside patient rooms in the hallway.

If the Nurses need linens in the evening they call the Department and the tall [Delivery] carts are brought down to be refilled. However, the linen on the Candida Auris side of this Unit (4 North-1) is discarded. "It is never brought down because it might be contaminated."

Staff V (Director of the Linen Department) stated that the tall mesh covered [delivery] carts are brought down daily to the Clean Laundry Area and are exchanged for a clean filled [Delivery] cart. In the evening the tall [Delivery] carts are brought down and refilled. Staff V was unsure if the tall [Delivery] cart from the Candida Auris side of 4 North was being cleaned before leaving the Nursing Unit.

The facility's Policy and Procedure titled "Laundry / Linen Department - General Environmental Procedures", last revised 10/10/16, states the following: "all clean linen carts are to be used only for their intended purposes and are washed regularly ... all soiled linen carts are washed weekly with a germicidal solution" but there is no specific instruction for cleaning the tall [Delivery] cart from the Candida Auris side of 4 North after the staff has discarded the linen before bringing the cart back to the Clean Linen Area for exchange.

(a)(6)
Observations in the facility's Operating Room (OR) Suite during a tour between 11:00AM and 2:00PM on 02/01/18, identified the following in OR #1:

Staff P (Housekeeper) did not completely remove OR table cushions from the OR table when wiping. Staff P wiped the tops and bottoms of the cushions on the right side of the OR table, raised them slightly to wipe underneath, but did not remove the cushions completely off the table. Staff P did not allow the required contact time for the cleaning agent as per the manufacturer's instructions before replacing the wet cushions onto the wet OR table. Staff P repeated the same process on the left side of the OR table, without completely removing the cushions and allowing sufficient contact time for the cleaning agent. These findings were confirmed with Staff M (Assistant Head Nurse) at the time of observation.

The label on the cleaning agent product used by the hospital was titled: "Super Sani-Cloth Bleach Germicidal Wipe", and listed a contact time of four (4) minutes for disinfection.

The facility's Policy and Procedure titled "Environment of Care Guidelines for Operating Room", last reviewed 07/15, states: "...The OR bed is cleaned and all surfaces and mattress pads are wiped with an approved hospital grade disinfectant. Particular attention is given to all surfaces of the OR bed, mattress and positioning aids where contamination with blood or body fluids may have occurred ..." This Policy lacked direction on the complete removal of the OR table cushions for cleaning and the required contact time of the cleaning agent.

The EVS (Environmental Services) Policy and Procedure titled "Surgical / Invasive Areas and Delivery Rooms - Between Cases", last revised 07/15, states: "Use a solution-dampened cloth and damp dust: light, table, furniture fixtures and horizontal ledges," but did not match the current practice, lacked direction for the complete removal of the OR table cushions for cleaning and the appropriate contact time for the cleaning agent.

These findings were discussed with Staff A (Director of Environmental Services) and Staff C (Assistant Director of Environmental Services) on 02/02/18 at 9:20AM. They acknowledged this finding and stated the expectation of the Environmental Services (EVS) Staff is to remove all cushions from the OR table and allow the cleaning agent to dry for the recommended time.

(a)(7)
Observations in the facility's OR Suite during a tour between 11:00AM and 2:00PM on 02/01/18, identified the following in OR #1: Staff P (Housekeeper) performed high dusting of OR lamps over a recently-cleaned OR table. This was confirmed with Staff M (Assistant Head Nurse) at the time of observation.

The facility's Policy and Procedure titled "Environment of Care Guidelines for Operating Room", last reviewed 07/15, stated: "Using appropriate disinfectant and a clean cloth, damp dust all lights and vertical surfaces of all furniture and fixtures in the room ...," but lacked direction of the appropriate order of high-dusting to ensure high dusting was not performed over cleaned equipment.

The EVS Policy and Procedure titled "High Dusting", last reviewed on 07/15, stated "Never dust over patients, residents or other people," but also lacked direction of the appropriate order of high-dusting.

The High Dusting Training Class Outline dated 03/29/17 also lacked direction of the appropriate order of high dusting.

These findings were discussed with Staff A (Director of Environmental Services) and Staff C (Assistant Director of Environmental Services) on 02/02/18 at 9:20AM. They acknowledged this finding and stated that high dusting should have been performed prior to the cleaning of the OR table, and that the Policies and Training did not specify the appropriate order of the high-dusting procedure.

(a)(8)
Observations in the facility's OR Suite during a tour between 11:00AM and 2:00PM on 02/01/18, identified the following in OR #1: While mopping, Staff P (Housekeeper) failed to move the OR table and Staff O (OR Technician) failed to move the suction and anesthesia machines to allow mopping of the floor underneath the equipment. Also, while mopping, Staff P (Housekeeper) utilized the same mop to wipe two (2) foot-stools before continuing to mop the OR floor. These findings were confirmed with Staff M (Assistant Head Nurse) at the time of observation.

The facility's Policy and Procedure titled "Environment of Care Guidelines for Operating Room", last reviewed 07/15, stated: "...Move furniture as necessary ... The OR bed is moved to the periphery of the room so that access is gained to the center of the room for cleaning. Move all furniture to the other side of the room and repeat the previous steps on the newly exposed floor area ..." This Policy lacked specific direction as to what equipment should be moved and by whom, and instructions to utilize mop on floor surfaces only.

The EVS Policy and Procedure titled "Surgical / Invasive Areas and Delivery Rooms - Between Cases", last revised 07/15, stated: "...Wet mop the entire floor ... start with the area around the operating room or delivery table ..." This Policy also lacked specific direction for staff to move equipment for mopping.

The Damp Mopping Training Class Outline dated 03/29/17, stated: "For rooms, mop the perimeter of the room or area. Beginning at the door or perimeter of area, mop all edges and baseboards, and around any item you are unable to move. When the perimeter is done, start damp mopping at the far corner of the room, using figure 8 strokes by moving backwards towards the doorway. Remember to clean behind doors, under beds and furniture." This Training contradicted the previous Policy and did not specify what equipment should be moved and by whom.

These findings were discussed with Staff A (Director of Environmental Services) and Staff C (Assistant Director of Environmental Services) on 02/02/18 at 9:20AM. They acknowledged these findings and stated that all portable equipment should have been moved and the floor underneath mopped. Staff A stated the portable patient-care equipment was to be moved by the OR Technician, while any portable non-patient care equipment is moved by the EVS Staff, although this was not specified in either Policy presented. Staff Members A and C stated it was inappropriate for Staff P (Housekeeper) to have utilized the same mop to wipe the foot stools, adding, "Mops are only to be used on floors, nothing else." Staff Members A and C acknowledged that the Policies and Procedures did not match the facility's current OR cleaning practices nor adequately directed the staff to the appropriate OR cleaning procedures.


Findings related to (b) include:

(b)(1)
Observations in the facility's 4 North-1 Medical / Surgical Unit, on 02/02/18 at approximately 3:00PM, identified that Staff Aa, (Registered Nurse) exited Patient #13's room, who is on Contact and Enteric Precautions, without performing hand washing.

This was observed in presence of Staff I (Director of Nursing Education) who confirmed on interview that the Enteric Precaution sign directed staff to wash hands with soap and water after exiting the room.

The facility's Policy and Procedure titled "Contact Isolation" last revised 01/18, stated the following: "Hands must be washed and decontaminated after touching the patient or potentially contaminated articles ... and after removing gloves."


(b)(2)
Observations in the facility's OR Suite during a tour between 11:00AM and 2:00PM on 02/01/18, identified the following in OR #1: Staff O (OR Technician) and Staff P (Housekeeper) changed disposable gloves multiple times during the OR cleaning process, but failed to perform hand hygiene between glove changes. These findings were confirmed with Staff M (Assistant Head Nurse) at the time of observation.

The facility's Policy and Procedure titled: "Guidelines for Hand Hygiene", dated 04/05/16 stated: "...If hands are not visibly soiled, alcohol-based hand rub will be used for routinely decontaminating hands ... after removing gloves ... However, the use of gloves does not eliminate the need for hand hygiene ... remove gloves promptly after use ... decontaminate hands after removing gloves."

The facility's Policy and Procedure titled "Environment of Care Guidelines for Operating Room", last reviewed 07/15, states: "Clean, non-sterile gloves should be worn when touching blood, body fluids, secretions, excretions and contaminated items. Change gloves between tasks and patient procedures." This Policy did not direct staff to perform hand hygiene after glove changes.

These findings were discussed with Staff A (Director of Environmental Services) and Staff C (Assistant Director of Environmental Services) on 02/02/18 at 9:20AM. They acknowledged these findings and stated that staff are expected to perform hand hygiene after each glove removal. Staff A stated that although staff are taught to "go to the sink to use water and soap after five (5) to six (6) glove changes, the expectation is for them to use the sanitizer whenever they remove their gloves."


Findings related to (c) include:

(c)(1)
Observations in the facility's 3 North-2 Telemetry Unit, during a tour between 10:45AM and 12:30PM on 02/01/18 identified Staff Y (Respiratory Therapist) exit a Droplet Precaution Room, remove his face mask, put the dirty mask in his lab coat pocket and without performing hand hygiene, exit the floor via the staircase. This was observed in the presence of Staff I (Director of Nursing Education) who confirmed that Staff Y should have discarded his used PPE and performed hand hygiene.

The facility's Policy and Procedure titled "Droplet Precautions", last revised 01/18 stated the following: "Masks should be discarded after exiting the room ... Hands must be washed / degermed after touching the patient or potentially contaminated articles..."

(c)(2)
Observations in the facility's Central Sterile Department during a tour between 10:30AM and 12:15PM on 02/02/18 identified that Staff Cc (Central Service Technician) was in the Preparation Room with a face mask under her chin. This was observed in presence of Staff I (Director of Nursing Education) and Staff Bb (Central Supply Manager).

During an interview with Staff Bb on 02/02/18 at approximately 11:10AM, the staff member indicated that Staff Cc is required to wear the mask because she declined the flu shot and should always be wearing it appropriately while on duty.

The facility's Policy and Procedure titled "Prevention of Influenza Transmission by Personnel", last revised 08/17 stated the following: "...unvaccinated 'Personnel'... to wear a surgical mask where patients may be present ... when 'Personnel' share a surface that comes in contact with a patient (equipment-to-patient contact)."

(c)(3)
Observations in the facility's OR Suite on 02/01/18 at 12:1PM identified the following in OR #4:

During a surgical procedure on Patient #7, Staff T (Surgeon) and Staff U (Resident) were observed with hair slipping out along the sides and back of their disposable bouffant head covers. Staff Members T and U were unable to re-adjust their head covers during the surgical procedure. Staff M (Head Nurse) informed Staff Q (Circulating Nurse) to assist in re-adjusting Staff T's and U's head covers. Shortly after Staff T's and Staff U's caps were re-adjusted, their hair began to slip out from their head covers once again.

Per interview with Staff M at the time of observation, Staff M stated that this is often a problem with the staff who have longer hair. She stated the disposable bouffant head covers are not always strong enough to hold the hair back completely and the hair may become exposed during a procedure.

The facility's Policy and Procedure titled "Environment of Care Guidelines for Operating Room", last reviewed 07/15, stated: "If indicated, a head cover and beard cover shall be worn to fully cover hair and head and face ... disposable bouffant and hood-style covers are preferred."


Findings related to (d) include:

Observations in the facility's 2 North Medical / Surgical Unit during a tour between 10:45AM and 12:30PM on 02/01/18 identified that Patient #10 was on Airborne Precautions and had a visitor (wife) in the room with a mask on. Review of the patient's Electronic Medical Record (EMR) revealed no evidence that the patient and/or the patient representative received Education on Isolation Precautions and that both patient and wife did not speak English. The findings were confirmed with Staff K (Clinical Nurse Manager) in the presence of Staff I (Director of Nursing Education).

During an interview with Staff K (Clinical Nurse Manager) on 02/01/18 at approximately 12:15PM, she indicated that the patient and family member were not educated on PPE use and Hand Hygiene.

The facility's Policy and Procedure titled "Airborne Precautions Pulmonary Tuberculosis", last revised 01/18 stated the following: "Visitors should be kept to a minimum; the Nursing Service should instruct visitors on the necessity for adherence to Isolation procedures."