HospitalInspections.org

Based on observation, interview and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards when staff failed to:
- Perform a sterile dressing change for two patients (#2 and #21) of two observed.
- Date and initial one wound dressing (#2) of two observed.
- Perform hand hygiene before and after glove use, after retrieving and administering medication for one patient (#21) of eight observed.
- Remove three particle shedding products from the Gastrointestinal laboratory (GI lab).
- Remove rust (reddish brown bacteria that may contribute to hospital-associated infections) from the Cesarean Section Operating Room (C-section OR).
- Remove rust from Operating Room (OR) #1.
- Clean, remove rust and particle shedding items from the Central Sterile processing rooms.
- Remove rust, dirt and oil build up from the kitchen area.
- Maintain three staff members' hair in a hair net and remove earrings in the kitchen area.
These failed practices had the potential to expose all patients, visitors and staff to cross- contamination and increased the potential to spread infection. The Medical Surgical Unit census was 14 and the Geropsyciatric Unit census was nine for a total facility census of 23.

Findings included:

1. Observation on 05/16/23 at 10:20 AM, showed Staff A, Licensed Practical Nurse (LPN), changed Patient #2's wound dressing. Staff A removed the old dressing (undated and unsigned) from the wound, removed gloves, washed hands and applied new gloves. Staff A, then used tweezers to remove the old packing and used the same contaminated tweezers to place new packing into the patient's wound.

During an interview on 05/16/23 at 10:48 AM, Staff A, LPN, stated they should have used a new pair of tweezers to pack the wound.

During an interview on 05/18/23 at 1:55 PM, Staff R, Registered Nurse (RN), Infection Control Preventionist (ICP), stated each dressing should have a date with staff initials on the dressing and Staff A should have used a clean pair of tweezers to pack the wound.

2. Observation on 05/17/23 at 8:25 AM, showed Staff K, Surgeon, prepared Patient #21 for a wound vac (vacuum-assisted therapy used to help wounds heal) dressing change:
- Staff K failed to remove the patient's breakfast tray from the over-the-bed table or disinfect the table's surface before Staff K placed the wound vac supplies on the table.
- Staff K failed to move and place the over-the-bed table in a position that Staff K would not have to reach behind him to retrieve supplies needed to clean, apply a dressing and the wound vac to the patient's opened wound.
- Staff K placed several supplies on the patient's bed without a barrier between the bed linen and supplies.
- Staff K removed the old dressing and removed gloves, however, Staff K failed to perform hand hygiene before Staff K re-gloved.
- Staff K cleansed the patient's wound and wearing the same gloves worn to clean the wound, Staff K retrieved additional supplies from the wash basin located on the counter next to the sink that contained additional supplies.
- Wearing the same gloves, Staff K applied the wound vac foam into the patient's opened wound. - After Staff K applied the foam into the patient's opened wound, wearing the same gloves, Staff K retrieved additional supplies from the wash basin.

During an interview on 05/17/23 at 8:53 AM, Staff K, Surgeon, stated:
- He received hand hygiene training yearly on-line.
- Hand hygiene needed to be performed every time:
- After touching a patient;
- After touching anything dirty, for example, wound dressings;
- Before going into a patient's room and upon exiting a patient's room; and
- After glove removal and before re-gloving.

Observation on 05/17/23 at 8:25 AM, showed Staff M, RN, put on gloves, however, Staff M failed to perform hand hygiene before gloving. Staff M removed gloves, however, Staff M failed to perform hand hygiene after glove removal and before Staff K retrieved medication and administered oral pain medication to Patient #21.

During an interview on 05/18/23 at 2:04 PM, Staff R, RN, ICP, stated staff was expected to:
- Remove a patient's breakfast tray off the over-the-bed table and disinfect the surface of the table before placing supplies on the over-the-bed table.
- Move the over-the-bed table closer to them so staff did not have to continue to reach behind them to retrieve supplies.
- Perform hand hygiene after glove removal and before re-gloving.
- Remove gloves, perform hand hygiene and re-glove before staff retrieved additional supplies from the container with supplies.
- Perform hand hygiene after glove removal and before retrieval and administration of medications to patients.
- Follow the facility's policy and procedures for infection control prevention including hand hygiene practice.

3. Observation on 05/17/23 at 8:00 AM, in the Cesarean Section Operating Room, showed the bottom of a stool rusted and a surgical equipment cart bottom rusted.

Observation on 05/17/23 at 8:15 AM, in Operating Room #1, showed two surgical equipment carts with bottoms rusted and rust on rollers for one trash cart.

Observation on 05/17/23 at 8:30 AM, in the Central Sterile decontamination room, showed:
- An unclean floor;
- One cart with rusted wheels;
- Three rust spots on the cabinets;
- An air vent screen stained and discolored with drainage; and
- Three paper labels (particle shedding) attached to three tanks.

Observation on 05/17/23 at 9:00 AM, in the Central Sterile clean room, showed:
- One surgical equipment cart with rusted wheels;
- The inside of two steam sterilizers with rust colored streaks;
- Insulation (particle shedding material) exposed and attached to the pipes leading to two sterilizers;
- Two rusted levers attached to the pipes of two sterilizers.

During an interview on 05/17/23 at 9:16 AM, Staff C, Surgical Technician, stated that she was responsible for the Central Sterile rooms and she should have noticed these problem areas and contacted maintenance.

Observation on 05/17/23 at 1:34 PM, in the GI lab, showed two papers and one calendar (particle shedding material) hanging on the wall in the procedure room. These products would prevent terminally cleaning the lab that increased the risk of cross-contamination.

4. Review of the facility's policy titled, "Central Sterilizing Terminal Cleaning," dated 06/2018, showed that housekeeping were to perform terminal cleaning on the central sterile areas nightly.

Review of the facility's cleaning logs for the ORs and Central Sterile, showed that they have been completed for the last three months.

During an interview on 05/18/23 at 1:55 PM, Staff R, RN, ICP, stated that:
- They toured the ORs twice per year;
- Staff should have removed all particle shedding items (paper, rust and insulation); and
- They expected staff to contact the manager to order machine maintenance on the steamers;

5. Observation on 05/18/23 at 2:00 PM, in the kitchen, showed:
- Oil residue build up on kitchen fryer #1.
- Floor around the stove showed a large amount of dirt.
- Rust (reddish brown bacteria that contributes to hospital-associated infections) and dirt around the wheels of the two steamers.
- Inside the lower hot box, the grills were discolored and rusted.
- Oil residue build up on kitchen fryer #2 in the service area.
- Trash can with unclean wheels in the service area.
- A rusted hood above the dishwasher.
- Staff T, Cook, failed to keep hair in hair net.
- Staff U, Kitchen staff member, failed to keep hair in hair net and failed to remove earrings.
- Staff V, Kitchen staff member, failed to keep hair in hair net.

Review of the weekly cleaning logs for the last three months, showed that they were incomplete.

Review of the monthly cleaning logs for the last three months, showed that they were incomplete.

Review of the facility's policy titled, "Food/Nutrition - Uniform Dress Code - E006," undated, showed that all associates working with food should wear a hair restraint and should not wear any jewelry other than a plain wedding band or medical alert jewelry when on duty.

Review of the facility's policy titled, "Food/Nutrition - Area and Equipment Cleaning - F014," undated, showed that management should assign weekly and special cleaning to be completely daily.

During an interview on 05/18/23 at 3:15 PM, Staff W, Director of Dietary Services, stated the staff performed monthly deep cleanings and they were aware of the rusted hood.

During an interview on 05/18/23 at 1:55 PM, Staff R, RN, ICP, stated they expected dietary to complete daily and monthly cleaning logs and the rusted items removed.



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