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The hospital reported a census of 94 patients. Based on observation, policy review, and staff interview the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control practices for one of two observed medication pass through a gastric tube, six of six observed outdated bottles of disinfection solution, one of one observed cleaning of a discharged patient"s room during tour of the Adult Treatment Center (ATC) on 7/9/12.

Findings include:

- The hospital's Infection Control Prevention and Control Program Scope of Service reviewed on 7/11/12 at 4:15pm directed "...provides for education, surveillance, reporting, response and monitoring in regard to infection, sanitary practices and techniques or methods to assure a safe and healthful environment for patients, staff and visitors..."

Staff H, Licensed Practical Nurse (LPN), observed on 7/10/12 at 9:15am provided patient #12 with a medication pass via a gastric feeding tube (g-tube) (a tube inserted through a small incision in the abdomen into the stomach used for long-term nutrition). Staff H entered patient #12's room after performing hand hygiene and applied gloves. Staff H removed the feeding tube from the g-tube, covered the feeding tube tip with a cover and allowed the feeding tube to fall to the floor. Staff H assessed the patency of the g-tube then provided the medications with a catheter syringe. Staff H flushed the g-tube with water, picked up the feeding tube from the floor, removed the cover and reapplied the feeding tube to the g-tube.

Staff H, LPN, interviewed on 7/10/12 at 9:35am indicated since the cover on the tip of the feeding tube touched the floor they thought that is would be alright to use the feeding tube that fell on the floor.

Administrative staff J, interviewed on 7/10/12 at 12:45pm acknowledged they would expect staff to discard any supplies or equipment that falls on the floor.

- The manufacturer's guidelines for "FreQuency 256" reviewed on 7/11/12 at 12:20pm directed, " ...this product when diluted...remains effective for up to 30 days..."

- Observation on 7/9/12 at 1:05pm in the triage intake room on the north unit revealed a locked cabinet in the bathroom. The locked cabinet contained a spray bottle labeled "FreQuency 256" lacked a mixing date of the "FreQuency 256" or an expiration date.

- Observation on 7/9/12 at 1:20pm in the triage intake exam room on the north unit revealed three spray bottles labeled "FreQuency 256". The spray bottles lacked a mixing date of the "FreQuency 256" or an expiration date.

- Observation on 7/9/12 at 1:40pm in classrooms #2 and #3 on the north unit revealed a locked cabinet. The locked cabinet contained a spray bottle labeled "FreQuency 256" lacked a mixing date of the "FreQuency 256" or an expiration date.

- Observation on 7/9/12 at 4:15pm in the triage intake exam room on the north unit revealed a staff member cleaning the shower with "Frequency 256". The spray bottle labeled "FreQuency 256" lacked a mixing date of the "FreQuency 256" or an expiration date.

Staff C, Environmental Services staff, interviewed on 7/9/12 at 2:00pm acknowledged staff dilutes the "FreQuency 256" and they do not date when the spray bottles are mixed or an expiration date.


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- The Hospital's policy titled, "Termination Cleaning of A Patient Room" reviewed on 7/11/12 at 2:15pm lacked directions for the use of the disinfectants FreQuency 256 and 2DBX6.

- Review of the manufacturer's guidelines for the use of the FreQuency 256 disinfectant cleaner on 7/11/12 at 12:30pm directed, ...For disinfection, all surfaces must remain wet for 10 minutes."

- Review of the manufacturer's guidelines for the use of the 2DBX6-disinfectant spray cleaner on 7/11/12 at 12:30pm directed,...Spray 2 to 3 seconds or until entire surface is wet. Allow to remain at least 10 minutes..."

- Observation of staff C on 7/11/12 between 11:05am to 11:45am cleaning room C-14 on the Crisis Stabilization Unit (CSU), a discharged patient room, revealed staff C applied FreQuency 256 disinfectant to the bathroom sink, shower walls, and entire toilet. Staff C then wiped the surfaces with a dry cloth. Staff C applied FreQuency 256 disinfectant to the desk area, book shelve, and closet shelves, wiping them with a cloth wet with a solution of FreQuency 256 disinfectant. Staff C applied FreQuency 256 to all surfaces of two mattress and immediately wiped them with a dry cloth. All of the surfaces wet with FreQuency 256 remained wet for 15 seconds to six minutes not the required 10 minutes for total disinfection.

After drying the surfaces of the mattress staff C applied 2DBX6-Disinfectant to all surfaces of the mattress. The surfaces remained wet for five minutes not the required 10 minutes for disinfection.

Staff C interviewed on 7/11/12 at 11:45am revealed they lacked knowledge of the manufacturer's guidelines that the surfaces must remain wet for 10 minutes to achieve disinfection.


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- During tour of the ATC unit, on 7/1912 at 2:03pm, a housekeeping room contained one container of Purell Hand Sanitizer, which expired on 9/2010. Licensed staff B, LPN, interviewed on 7/9/12 at 2:03pm states this bottle was a "new bottle."

On 7/9/12 at 2:50pm the nursing station on the Crisis Stabilization Unit (CSU) contained a container of Purell Hand Sanitizer, which expired on 9/2010. Licensed nirse A interviewed on 7/9/12 at 2:50pm stated this bottle of hand sanitzer had been in the dispensing unit of this nurses station since the last bottle started leaking; 3 - 4 months ago. Nurse A verified they put this bottle of hand sanitizer in the dispenser themselves at the time and failed to look at the expiration date.