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Based on observation, record review and interview, the facility failed to follow environmental cleaning policies in an effort to minimize the risk of cross-contamination in 1 of 1 inpatient environmental cleaning procedure observed (Room Cleaning).

Findings include:

Review of facility policy "Infection Prevention Guidelines" No. IP-005 revealed "Q. Care of the Environment: 1. Horizontal surfaces (bedside tables, bedrails, bedside equipment, floors) are cleaned daily... 2. Special attention is paid to frequently touched surfaces, especially those in close proximity to the patient. 3. An EPA-approved disinfectant is used for routine cleaning. An appropriate amount of disinfectant is applied to meet the required exposure time."

Review of facility policy "Occupied Isolation Room Cleaning Procedure" No. 7.04 dated 10/1/2017 revealed "4. ...sanitize all patient contact surfaces, including over bed table, bedside table, phone, chairs, low ledges and counter, light switches and door knobs. ...Tips: Clean equipment and return supplies to cart or cleaning closet after use."

Per review of the manufacturer instructions for BruTab 65 Effervescent Disinfectant Tablets for Hospitals and Institutional Use dated 8 April 15: "Prepare a 4311ppm solution; apply to pre-cleaned surface...Allow surface to remain wet for 4 minutes."

On 1/3/2018 at 10:40 AM, Housekeeper G prepared a BruTab solution for cleaning and disinfection of Patient #27's room. Patient #27 was in special contact isolation for C. Difficile infection. Housekeeper G used wet, disposable wipes to wipe down the bedside table and computer keyboard. The wet surfaces were dry within 2 minutes, not wet for 4 minutes. While cleaning the room, Housekeeper G was not observed disinfecting high-touch surfaces such as Patient #27's bedside rails, call light, light switches or door knobs. After disinfecting the bathroom, G opened the door and accessed the housekeeping cart in the hallway without changing gloves used while cleaning the bathroom. G proceeded to obtain additional supplies from the cart without performing glove change or hand hygiene. Housekeeper G brought 2 buckets into Patient #27's room, used for disinfection solution, and when finished placed the buckets back onto the cart in the hallway without wiping down or disinfecting the buckets.

During an interview on 1/3/2018 at 10:50 AM, when asked about disinfecting high-touch surfaces such as bed rails and call light, Housekeeper G stated "I don't usually do that."

During an interview on 1/3/2018 at 3:20 PM, Environmental Services Director J stated "housekeeping staff should be disinfecting all high-touch areas." When asked about accessing the cart in the hall without changing gloves or performing hand hygiene, J stated the staff "should be bringing all supplies into the room with them" to avoid potential for cross-contamination. The manufacturer instructions for wet contact time were reviewed with Director J, J stated "we will have to look into that."

Based on record review and interview, facility staff failed to implement corrective actions for 1 of 1 infection control problem areas identified (Hand Hygiene).

Findings include:

Review of facility policy "Infection Prevention Program" No. IP-003 revealed "I. Monitoring/surveillance activities...are used to set goals for improvement in each area (annual plan). ...9. Hand hygiene and isolation compliance monitoring."

Review of the facility's Infection Prevention Plan 2017 revealed the measurable objective for compliance with hand hygiene as "Consistent greater than 90% compliance with hand hygiene."

During an interview with Infection Preventionist D on 1/3/2018 at 11:00 AM, D stated the facility is monitoring hand hygiene compliance by staff type--Nursing, Provider and Ancillary staff. Quarter 4 2017 aggregate data shows 37% hand hygiene compliance for providers. The facility's hand hygiene observation tool for the Digestive Health department (outpatient endoscopy procedures) reveal providers were compliant with hand hygiene in 50% of observations in September 2017 and in 44% of observations in October 2017. Infection Preventionist D stated the facility uses PDSA (plan, do, study, act) for quality improvement. Per D, Medical Director C offers provider-based education at medical staff meetings, but was unable to provide any evidence of an action plan or implemented interventions in response to the poor compliance rates of hand hygiene among providers.

During an interview on 1/3/2018 at 4:00 PM, Infection Prevention Medical Director C stated "we do know there is a knowledge gap among our healthcare providers [regarding hand hygiene practices]...we are still determining how we are using that information with different groups [of staff]."