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Based on observation, interview, and record review the facility failed to implement an effective system to control the transmission of infections and communicable disease. The facility failed to ensure:

* A Registered Nurse (RN) utilized appropriate hand hygiene prior to inserting an intravenous (IV) catheter on 2 sampled patients (Patient # 5, # 6).

*Two (2) RNs donned appropriate personal protective equipment (PPE) when providing direct care to a patient on Contact Isolation Precautions (Patient # 5)

* Operating room (OR) surfaces and equipment were maintained in a manner to allow appropriate cleaning and disinfecting.

* OR staff donned appropriate hair covering during surgery (Patient # 4).

* Linen was stored and transported in a manner to prevent contamination.

Findings include:

TX # 00218662

Hand Hygiene:

Patient # 6:

Observation in the Day Surgery Unit on 08-07-15 at 9:50 a.m. RN # 6 prepared to insert an IV catheter into Patient # 6 prior to her surgery. RN # 6 failed to perform hand hygiene prior to donning gloves. RN # 6 proceeded to insert the IV catheter into Patient #6's left hand.

He was unable to open the Biohazard sharps container. RN # 6 left the room while wearing the contaminated exam gloves. He went into an empty patient room and opened the biohazard container and disposed of the IV catheter needle. RN # 6 was still wearing the contaminated gloves.

Patient # 5:

Observation in the Day Surgery Unit on 08-07-15 at 12:30 p.m. RN # 6 prepared to insert an IV catheter into Patient # 5 prior to her surgery. RN # 6 failed to perform hand hygiene prior to donning gloves. RN # 5 proceeded to insert the IV catheter into Patient #5's left hand.

Interview immediately after this observation with Quality Manager # 4, she stated hand hygiene is required before / after donning gloves and before an invasive procedure.

Review of facility policy titled "Hand Hygiene," revised date 12/13, read: " ...Procedure...ll. Hand Hygiene is indicated:...before donning gloves...when inserting peripheral vascular catheters...

PPE : Contact Precautions

Observation in the Day Surgery Unit on 08-07-15 at 12:20 p.m. RN # 6 entered Patient# 5's room to investigate a sounding alarm ( bed alarm). RN # 6 remained in the room to insert an IV catheter. Further observation revealed a sign posted on the outside of Patient #5's room that read "CONTACT PRECAUTIONS."

RN # 7 entered the room to assist RN # 6 with repositioning the patient. She donned gloves and came into contact with Patient # 5's bed linen when repositioning her.

During an interview with RN # 7 when she exited the room, she was asked if she was aware this patient was on Contact precautions? RN #7 then observed the sign on Patient # 5's door and said "I did not see the sign; I should have been wearing a gown."

Interview on 08-07-15 at 12: 35 p.m. with RN # 6 while he remained in Patient # 5's room, he was asked if he was aware this patient was on Contact Precautions? RN # 6 said "Yes, she is on Contact precautions for MRSA (Methicillin-Resistant Staphylococcus Aureus) of the wound." RN #6 was not wearing a gown. After he exited the room, RN # 6 was asked by the unit manager to change his scrubs and wear appropriate PPE when caring for patients placed on Contact Precautions.

Review of facility policy titled "Isolation Plan," revised date 12/13, read: "... Fundamentals of Transmission-Based Precautions:...B. Contact Precautions:...3. Personal Protective Equipment:...b. Gowns will be worn whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environment surfaces..or equipment in close proximity to the patient..."

OR Surfaces and Equipment: Cleaning & Disinfecting:

Observation on 08-07-15 at 1:00 p.m. in OR # 3 revealed one of the walls had non-intact drywall/sheetrock. In addition, the paint around the OR door frame was peeled and chipped in multiple areas.

Further observation in OR # 3 revealed an IV pole stand and an equipment cart with rust on the bases.

The non-intact wall and the rusted areas were not able to be appropriately cleaned and disinfected.

Review of facility policy titled "Operating Room Cleaning Checklist,"undated, read: The Operating Room should be cleaned before the first case of the day, between each case and at the end of the day Terminal cleaning...Terminal cleaning: 1. Disinfect all of the following...b.push plates and door handles..l. All furniture & equipment...2. Spot clean walls..." Review of facility "Surgery Rooms Terminal Cleaning Log Sheet," read: "...4. High dust ( damp-disinfect) vents and equipment...6. Wash disinfect walls, ledges...13. Inspect work area...and report anything in need of repair.."

Hair Covering in OR

Observation on 08-07-15 at 1:00 p.m. in OR # 3 revealed OR preparing Patient # 4 for a "excision of soft tissue mass and bone-left hallux." Patient # 4 was given general anesthesia.

Observation of three (3) male OR personnel in the room: Surgeon DPM # 9; MD anesthesiologist #11; and MD anesthesiologist (resident) # 10 revealed they were not wearing acceptable hair coverings. All three were wearing skull caps with hair visible and uncovered at the nape of the neck. Two of the 3 had beards that were not covered,

Review of facility policy titled Surgical Attire in the Operating Room,"revised date 05/13, read: " Policy: All personnel entering the restricted areas of the surgical suites must be in proper OR attire...All possible head and facial hair including sideburns and neckline must be covered in the semi-restricted and restricted areas of the surgical suite..."

Review of correspondence (regarding OR Attire) from Region VI. CMS (Centers for Medicare & Medicaid) dated 04-24-14, read: "...Head coverings should completely cover the hair, scalp, and facial hair. Skull caps are not permissible since it fails to contain the side hair above and in front of the ears and hair at the nape of the neck..."

Storage and Transport of Linen:

Observation in the Day Surgery Unit on 08-07-15 at 9:10 a.m. revealed an uncovered pillow and patient gown stored on top of a rolling linen cart. Continued observation revealed a wire cart on wheels that contained multiple patient gowns. This cart was covered with a bedsheet and located in a high traffic area easily accessible to visitors. Interview at the time of observation with manager RN # 14, she stated this linen could be contaminated as the bedsheet was not impermeable.

Continued observation in the Day Surgery Unit on 08-07-15 at 9:20 a.m. revealed RN # 7 holding a stack of clean linen directly against her scrub uniform as she entered a patient's room. Interview at the time of observation with manager RN # 14, she stated linen should not be held against RNs uniform as it becomes contaminated. RN # 14 said she would speak to this nurse regarding this practice.

Review of facility policy titled "Infection Control-Linen Service," revised date 03/05, read: " V."...An extra supply of linen should be stored on shelves in clean linen room on nursling unit. Linen should not be stored on bottom shelves and shelving units must have solid bottoms..."