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Based on observation, interview, and record review, the hospital failed to post an accurate listing of medications for one of three emergency crash carts found in the Emergency Department (ED). This failure could place hospital patients at risk for adverse outcomes, and a potential delay of treatment during a medical emergency.

Findings:

During a concurrent observation, interview, and review, on 1/24/23, at 12:32 PM, in the ED, with the hospital Pharmacy Manager (PM), the medication content list outside of a pediatric crash cart was reviewed for accuracy. The medication content list indicated, no Dextrose (a type of sugar) injectable syringe. When the crash cart was opened, there were Dextrose 2.5 gm (gram-unit of weight measurement) per 10 ml (milliliter-unit of volume measurement) syringe and a Dextrose 25 gm per 50 ml injectable syringe.

During an interview on 1/24/23, at 12:35 PM, with PM, PM acknowledged there was a couple of discrepancies between the list of medications posted outside of the crash cart, and the emergency medications stored in it.

During a review of the hospital's policy and procedure (P&P) titled, "Medication Inspection," dated 6/2003, the P&P indicated, "The Pharmacist will perform the monthly inspection of all drug storage areas in the hospital. . .b. When discrepancies are identified, a report is made to the supervisor of the area and the Chief Nursing Officer stipulating the corrections needed."

Based on observation, interview, and record review, the hospital failed to ensure a clean and orderly physical environment in the Radiology Department (RD). This failure had the potential to put patients and staff at risk for harm.

Findings:

During a concurrent observation and interview on 1/24/23, at 12 PM, between the Radiology Manager (RM) office and the bathroom, with RM, the radiology ceiling was missing six tiles. The missing areas were patched with pieces of wood and left unopened. RM stated, there was a leak from the rain since last winter (January 2022), and RM put in a ticket (repair order) for the maintenance department. RM stated, after patching the holes, she did not hear anything back anymore as to when it (ceiling) will be repaired.

During a concurrent observation and interview on 1/24/23, at 12:15 PM, in RD, the wall beneath the unopened ceiling was noted with bubbling of the peeling paint. RM stated, "The water leak from the rain seeped through the wall all the way to the floor. We placed towels on the floor and replaced it every five hours to keep the floor dry." RM stated, there could be a potential of mold accumulating under the walls and the ceiling.

During an interview on 1/26/23, at 9:15 AM, with Director of Maintenance (DM), DM stated, "We had older roof and it had leaks. It came through to the couple areas, the 12" (inch) X 12" tiles in the nurses' station, radiology, and a spot in medical records. When the ceiling gets wet, it would have molds, so I removed the ceiling tiles and patched it for days. The particular leak was difficult to find, and the leak started last winter. We obviously did not patch it yet."

During a review of the hospital's policy and procedures (P&P) titled, "Plant Operations and Maintenance Policy," dated 5/2009, the P&P indicated, "The maintenance and operation of all facility buildings, grounds, plant components, utilities, sanitary systems, refrigeration units, HVAC, internal communications, file alarm systems, roads and parking lots, and plant security are the primary responsibilities essential in the plant operations and maintenance program.
Where authorized, responsibilities will include repairs, alteration and minor construction and remodeling related to maintenance. . ."

Based on observation, interview, and record review, the hospital failed to meet the regulatory requirements for the Condition of Participation (COP) on CFR 485.640 Infection Prevention & Control & Antibiotic Stewardship Program as evidenced by the following:

1. Ensure infection control practices were implemented in accordance with nationally recognized infection control and prevention guidelines. This failure had the potential to transmit COVID-19 (a highly infectious respiratory illness caused by the Coronavirus) or other infectious diseases. (Refer to 1206)

2. Effectively conduct infection prevention surveillance activities (collection and analysis of data) on hand hygiene. This failure resulted in the hospital's inability to have measurable data to improve patient health outcomes, reduce the incidences of infections, and the inability to identify, address, and correct departures from nationally recognized infection control practices. (Refer to 1208)

3. Ensure the Infection Preventionist (IP) had the training and skills to facilitate the Infection Control Program in collaboration with the hospital's multidisciplinary team. This failure had the potential to result in an ineffective Infection Control Program, which could potentially result in increase infection in the hospital's patients. (Refer to 1297).

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure an effective system-wide infection control program thus resulting in the hospital's inability to provide an environment which was free from the transmission of infections and communicable diseases.

Based on observation, interview, and record review, the facility failed to follow nationally recognized infection control and prevention practices when:

1. The clean bedside commodes in the Emergency Department (ED) were stored inside the dirty utility room, in very close proximity to the Hopper (used for disposal of waste, urine, blood and/or body fluids).

2. Emergency water were stored on the floor.

3. Five of five gallons drinking water were stored on the floor in the ED.

4. Six boxes of tubular net bandages used for dressing wounds or fractures [broken bones] were exposed and mixed in with orthopedic (related to the treatment of injuries or disorders of the bones and muscles) equipment filled with blackish, grayish particles and stored among unclean and unused items on a shelf in the ED.

5. The Foley catheter (a tube that helps urine drain from the bladder) urine drainage bag for one of one patient (Patient 19) was kept hanging low on the foot of the bedrail and the urine bag was touching the floor.

6. Three staff members, Registered Nurse (RN) 1, RN 2, and Housekeeping (HSK) 1, did not perform hand hygiene.

7. A nursing staff (RN 2) and a physician (MD) 1 were not knowledgeable about the proper sequence of donning (putting on) and doffing (taking off) of Personal Protective Equipment (PPE-refers to gowns, masks, gloves, goggles, face shields to protect the wearer from infection or injury) prior to entering a COVID-19 positive room in the Acute Care.

8. Contaminated N95 (a type of mask used to filter approximately 95% of particles in the air) masks and face shields were stored on the wall and behind the door in the PPE room in the Acute Care and a used face shield was left hanging by the oxygen flowmeter (a device that measures the flow of oxygen to the patient) in the Operating Room (OR) .

9. RN 1 was not knowledgeable about the process of disinfecting a contaminated or used face shield and the contact time of the bleach wipe.

10. RN 2 delivered the meal tray in an unsanitary manner for one of one COVID-19 positive patient (Patient 19) by using the patient's restroom as an entryway.

11. Intravenous (IV, within the vein) fluids, and other surgical supplies and biologicals were expired in Surgery Department (SD).

12. The transport containers for contaminated/soiled instruments were not the proper biohazard containers.

13. Autoclaved (process of killing bacteria and other germs using direct steam) instruments were not dated and labeled, and improperly packaged.

14. Sterile instruments were mixed in with unclean items in a three-tiered instrument cart in Central Processing Room.

15. Clean gowns were hanging across from the hopper in the decontamination room in SD.

16. No handwashing sink in the decontamination room in SD.

These failures had the potential to transmit COVID-19 or other infectious diseases to patients, staff, and visitors.

Findings:

1. During a concurrent observation and interview on 1/24/23, at 11:05 AM, in the ED dirty utility room, two clean bedside commodes were stored to the right of the hopper. RN 3 stated, "The hopper is actively used. That's where we dispose urine, human waste, blood/body fluids. Space is very limited here. The facility does not really have a place to store these items."

During a review of the hospital's policy and procedure (P&P) titled, "Infection Prevention and Control Exposure Control Plan," dated 6/2017, the P&P indicated," Clean and Dirty Supplies:There are separate designated locations for clean and dirty supplies for each patient care unit and department. It is the patient care unit and departmental responsibility that all clean and dirty supply areas are kept neat and orderly. . ."

During a review of the Center for Disease Control and Prevention (CDC) Guidelines, dated 9/11/19, the Guideline indicated, "Splashes may occur when water flow hits the contaminated drain cover or when a toilet or hopper is flushed. Splashes can lead to dissemination of Multidrug-Resistant Organisms (MDRO-bacteria that have become resistant to certain antibiotic) containing droplets, which in turn may contaminate the local environment or the skin of nearby healthcare personnel and patients."

2. During a concurrent observation and interview on 1/24/23, at 11:15 AM, in the ED, with the Director of Maintenance (DM), four plastic containers filled with emergency water were piled on top of each other on the floor and one plastic container filled with a gallon of water was stored on the floor. DM stated, "We (the facility) need a platform to store them on."

3. During a concurrent observation and interview on 1/24/23, at 11:20 AM, in the ED lounge, with Emergency Room Technician (ERT) 1, five of five gallons of drinking water (used to placed in a water dispenser), were stored on the floor, underneath a table. ERT 1 verified the findings and stated, that should not be on the floor.

4. During a concurrent observation and interview on 1/24/23, at 11:23 AM, in the ED, with ERT 1, on the shelf was a cast cutter, electric cords, scissors, pliers, that had blackish, grayish particles with several boxes of opened and exposed tubular net bandages, also with grayish particles. ERT 1 stated, the hospital has not used the orthopedic equipment for years. No one has touched this equipment, and they really need to be stored away. They are just collecting dust.

During a review of the hospital's policy and procedure (P&P) titled, "Infection Prevention and Control Exposure Control Plan," dated 6/2017, the P&P indicated," Clean and Dirty Supplies: There are separate designated locations for clean and dirty supplies for each patient care unit and department. It is the patient care unit and departmental responsibility that all clean and dirty supply areas are kept neat and orderly. . ."

5. During a concurrent observation and interview on 1/24/23, at 1:50 PM, in Patient 20's room, with RN 1, Patient 20's Foley catheter was hanging on the foot bedrail that was down. The Foley catheter was hanging low and touching the floor. RN 1 stated, "There is no other way I could hang the Foley catheter." RN 1 exited Patient 20's room, and left the Foley catheter where it was resting on the floor.

During a review of the CDC Healthcare Infection Control Practice Advisory Committee Article titled, "Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, updated 6/6/19, the Guidelines indicated, "Current best practices require that urinary drainage tubing not rest on the floor, as contamination of collection tubing or drainage bag is associated with an increased risk of Catheter Associated Urinary Tract Infection (CAUTI) due to migration of organisms up the tubing to the patient. . .III. Proper techniques for Urinary Catheter Maintenance: B.2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor."

6. During a concurrent observation and interview on 1/24/23, at 12:02 PM, in Acute Care hallway, with RN 1, RN 1 took a meal tray from the meal cart in the hallway without performing hand hygiene, and delivered it to Patient 16's room. Again without performing hand hygiene after coming out of Patient 16's room, RN 1 went to the meal cart, took another meal tray, and delivered the meal tray to Patient 21's room.

During a concurrent observation and interview on 1/24/23, at 12:20 PM, with RN 2, RN 2 removed her used N95 mask, and without performing hand hygiene, RN 2 opened the PPE cart and grabbed a new N95 mask. RN 2 stated, "I did not wash my hands."

During a concurrent observation and interview on 1/24/23, at 2:27 PM, with RN 1, RN 1 gathered the three used N95 masks and face shields hanging on the wall with her bare hands and did not perform hand hygiene after touching the contaminated masks and face shields. RN 1 stated, "I don't know who these masks and face shield belong. It's been here for couple of weeks now." RN 1 stated, "I did not wash my hands."

During a concurrent observation and interview on 1/25/23, at 9:42 AM, in the main lobby, with HSK 1, HSK 1 was cleaning and disinfecting the counter with wipes soaked in Microkill (a disinfectant) solution with gloves on. HSK 1 removed his gloves, but did not perform hand hygiene, and proceeded to push the housekeeping cart outside. HSK 1 acknowledged and stated he should have washed his hands.

During a review of the hospital's policy and procedure (P&P) titled, "Hand Hygiene," dated 3/12/21, the P&P indicated, "A. Hand hygiene is the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: 1. During the delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient/resident to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. . .4. Examples when to perform hand hygiene: b. When entering and exiting a patient/resident's room. . . f. Before and after eating or handling food. g. Before and after assisting a patient/resident with meals. . .Before applying and after removing gloves, gowns, masks, etc."

7. During a concurrent observation on 1/24/23, at 12:20 PM, in Acute Care hallway and PPE room, RN 2 took Patient 19's meal tray from the meal cart in the hallway. RN 2 carried Patient 19's meal tray inside the PPE room. Without performing hand hygiene, RN 2 first removed her N95 mask and put on a new N95 mask. RN 2 did not perform a user-seal check (a procedure that is performed to confirm that a tight-fitting respirator is adequately sealed against the face). RN 2 put on her gown, and then her gloves. Without using a face shield, RN 2 entered the shared bathroom carrying the meal tray of Resident 19 in one hand. The meal tray touched the bathroom door, and the milk carton touched the bathroom wall as RN 2 was entering the restroom to deliver the meal tray for Resident 19. After delivering the meal tray, RN 2 exited Patient 19's room using the bathroom. With gloves on, RN 2 removed the contaminated gloves, and did not perform hand hygiene. RN 2 removed her isolation gown, without rolling it away from her body, which cross-contaminated her uniform scrub. RN 2 removed her N95 mask, and without washing her hands, opened the PPE cart and grabbed a new N95 mask and put it on. RN 2 did not disinfect the bathroom door knob as she touched it with her dirty gloves before and after entering the restroom.

During an interview on 1/24/23, at 2:04 PM, with RN 2, RN 2 stated, "I have been here since February of 2022, and I have not had an infection control training. I don't remember it being discussed in Orientation. RN 2 stated, "I know I did not perform hand hygiene, did not wear full PPE. Since I wear glasses, I thought I did not have to wear a face shield."

During an observation on 1/24/23, at 2:15 PM, in the PPE room, MD 1 put on his PPE prior to entering a COVID -19 positive room. MD 1 removed his used surgical mask and put it inside his pant pocket. Without performing hand hygiene, MD 1 put on the gown, N95 mask, and gloves. MD 1 did not perform a user-seal check. MD 1 grabbed a face shield behind the door. MD 1 stated, "this is where I put my faceshield just in case I have to return to see Patient 19 again. MD 1 entered Patient 19's room using the bathroom door entry. After coming from Patient 19's room, MD 1 returned the used face shield and hung it behind the door without disinfecting the faceshield, and without performing hand hygiene.

During a review of the hospital's policy and procedure (P&P) titled, "Transmission-Based/Expanded Precautions," dated 3/2010, the P&P indicated, "Personal Protective Equipment (PPE): Assuming that all patients are potentially infected or colonized, HCW (healthcare workers) must create barriers and use respirators to protect mucous membranes, skin and clothing from contact with these infectious agents. . . A. Gloves: . . .Whenever gloves are changed, hand hygiene will be practiced before donning a clean pair of gloves. The integrity of the glove may be compromised even if not visible to the eye. Gloves will never take the place of handwashing. . .B. Isolation Gowns: . . 3. Gowns will be removed in the patient's room. The outer side of the gown should be rolled inward to prevent contaminating the HCW's uniform. It will be discarded in a designated container. . ."

During a review of the Centers for Disease Control and Prevention (CDC) Guidelines, titled, "Sequence for Putting On Personal Protective Equipment," dated 10/21/21, the Guideline indicated, "Gown, Mask, Face shield, and Gloves."

During a review of CDC Guidelines titled, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," dated 6/19/20, the Guidelines indicated, "Filtering Facepiece Respirators (FFR) Including N95 Respirators: FFR users should also perform a user seal check to ensure proper fit each time an FFR is used."

8. During a concurrent observation and interview on 1/24/23, at 2:04 PM, inside the PPE Room, with RN 2, there were two N95 masks hanging on the wall, and one N95 mask hanging at the back of the entry door. One faceshield was hanging on the wall and one faceshield was hanging at the back of the entry door. RN 2 stated, "I don't know who those masks belong to. They have been there, left over from the COVID. I don't know if the staff reuse N95 masks."

During an concurrent observation and interview on 1/24/23, at 2:27 PM, with RN 1, inside the PPE Room, RN 1 stated, "I don't know who these masks and faceshield belong. It's been here for couple of weeks now."

During a concurrent observation and interview on 1/25/23, at 2:11 PM, in the Gastrointestinal (GI - refers to stomach and intestines) Suite with Licensed Vocational Nurse (LVN) 1, a used face shield was hanging over the oxygen flowmeter. LVN 1 stated, she did not know who it belongs to, and that it should have been discarded.

During a review of the hospital's policy and procedure (P&P) titled, "Transmission-Based /Expanded Precautions," dated 3/2010, the P&P indicated, "Expanded Precautions: B. Droplet Precaution: 3. Masked will not be worn outside the patient's room once care of the patient has been initiated. Masks should be disposed of in the patient's room. C. Airborne Infection Isolation Room (AIIR). . .4. N95 respirators are to be discarded after use."

9. During a concurrent observation and interview on 1/24/23, at 2:30 PM, in the PPE Room, with RN 1, seven patient belonging bags were hanging on the wall. RN 1 stated, those bags contain staffs' used face shields. RN 1 stated, they reuse face shields. RN 1 pulled one of the patient belonging bags, which has her face shield. RN 1 demonstrated how to disinfect the face shield but wiped down the face shield starting from the outside first (dirty side) then to the inside (clean side) of the face shield. RN 1 used a bleach wipe to disinfect, but RN 1 was not familiar with the contact time of the bleach wipe used. RN 1 stated, "one to two minutes."

During a review of the "SaniCloth Bleach Wipe" manufacturing recommendation, [undated], the label indicated,"Treated surface must remain visibly wet for a full four (4) minutes. Use additional wipe(s) if needed to assure continuous four minute wet contact time."

During a review of the CDC Guidelines titled, "Eyewear Recommendation: Face Shield Disinfection," dated 4/8/20, the Guidelines indicated, "1. While wearing gloves, carefully wipe the inside, followed by the outside of the face shield or goggles, using a clean cloth saturated with a neutral detergent solution or cleaner wipe. 2. Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA-registered hospital disinfectant solution. 3. Wipe the outside of face shield or goggles with clean water or alcohol to remove residue. 4. Fully air dry or use clean absorbent towel. 5. Remove gloves and perform hand hygiene."

10. During a concurrent observation and interview on 1/24/23, at 12:07 PM, RN 2 brought Patient 19's meal tray into the PPE room. After donning PPE, RN 2 entered the patient's restroom carrying the meal tray. RN 2 stated, "The former Infection Preventionist (IP) advised us to go through the restroom and not the main entrance door because Patient 16 was in a negative pressure room (the air pressure inside the room is lower than the air pressure outside the room. This means that when the door is opened, potentially contaminated air or other dangerous particles from inside the room will not flow outside into non-contaminated areas).

During an interview on 1/24/23, at 3:05 PM, with DM, DM stated, "The facility does not have a true negative pressure room. HEPA (high efficiency particulate air-(removes 99.97% - 99.99% of airborne particles) filters have been placed inside patient rooms that require isolation. Air from the corridor is sucked inside the room. With HEPA Filter, air from the room cannot escape to the outdoor. There is no reason why the nurses cannot enter through the main patient door...that is not a policy; it may be a nursing process."

During a review of the "Guidelines for Environmental Infection Control in Health-Care Facilities," dated 7/2019, the Guidelines indicated, "Filtration, the physical removal of particulates from air, is the first step in achieving acceptable indoor air quality. Filtration is the primary means of cleaning the air. Air from toilet rooms or other soiled areas is usually exhausted directly to the atmosphere through a separate duct exhaust system. Air from rooms housing tuberculosis patients is exhausted to the outside if possible, or passed through a HEPA filter before recirculation."

11. During a concurrent observation and interview on 1/25/23, at 2:25 PM, in Surgery Room, with LVN 1 and Certified Registered Nurse Anesthetist (CRNA) 1, a box of biopsy valve was undated. LVN 1 stated, there must be a received date and the product expires five years from the receipt date. One biopsy valve had an expiration date of 7/2017, and two biopsy valves had an expiration date of 7/2014. Inside the cabinet was a water bottle used for irrigation with an expiration date of 4/20/15. There were two bags of Lactated Ringers (intravenous fluids), with expiration dates of 12/2020 and 9/2020. One resolution clip (intended for hemostasis [control bleeding], with an expiration date of 1/7/23. LVN 1 and CRNA 1 verified the findings.

During a review of the "Association of periOperative Registered Nurses (AORN) Guidelines for periOperative Practice," dated 2019, the Guidelines indicated, "Items that have an expiration date should not be used after the date has passed."

12. During a concurrent observation and interview on 1/25/23, at 2:30 PM, in Surgery Room, with LVN 1 and CRNA 1, two large white plastic containers without lids were noted. The lids were stored in the bottom of a cart and the lids had a biohazard plastic bags affixed to the middle portion of the lid. LVN 1 stated, these are the containers we use to transport soiled/contaminated instruments to the decontamination room. LVN 1 acknowledged the plastic containers and stated, "These containers were not the usual biohazard containers that were red in color with visible biohazard labels, and puncture resistant. We should change these containers. The bottom portion of the containers are not labeled and could potentially be used for something else."

During a review of the "AORN Guidelines for periOperative Practice," dated 2019, the Guidelines indicated, "Soiled instruments must be transported to the decontamination room in a closed container or enclosed transport cart. The container or cart must be leak proof, puncture resistant, large enough to contain all contents, and labeled with an orange or orange red label containing a biohazard legend. Transporting soiled instruments in a manner that prevents exposing personnel to bloodborne pathogens and other potentially infectious materials is OSHA requirement. Labeling the transport containment device communicates to others that the contents are potentially infectious."

13. During a concurrent observation and interview on 1/25/23, at 2:45 PM, in Central Processing Room, with LVN 1 and CRNA 1, the following hinged instruments were noted: needle drivers, and three packages of lahey clamps (used for grasping or blunt dissection) were closed when sterilized. LVN 1 verified the findings and stated, the packages of lahey clamps and the needle driver were not dated, or labeled when sterilized.

During a review of the "AORN Guidelines for periOperative Practice," dated 2019, the Guidelines indicated, "Items to be sterilized should be placed in the package or tray in an open or unlocked position. The open or unlocked position facilitates sterilizant contact of all surfaces of the item. . .Packages should be labeled before sterilization. . .Package label information allows items to be identified or retrieved in the event of a sterilization processing error or equipment malfunction. Package labels should be visible and remain securely fixed to the packaged throughout processing, storage, and distribution to the point of use."

14. During a concurrent observation and interview on 1/25/23, at 3:18 PM, in Central Processing Room, with LVN 1 and CRNA 1, sterile instruments were mixed in with unclean, open packages of gauze and sponges in a plastic bucket. LVN 1 verified the findings and stated sterile items cannot be stored with unclean supplies.

During a review of the "AORN Guidelines for periOperative Practice," dated 2019, the Guidelines indicated, "Sterile items should be protected from contamination, damage, or tampering. . .Sterile package should be stored in a manner that protects the integrity of the sterile barrier."

15. During a concurrent observation and interview on 1/25/23, at 3:30 PM, in the Decontamination Room, with LVN 1 and CRNA 1, four cloth gowns were hanging across from the hopper. LVN 1 stated, those gowns were used when the staff had to go out of the decontamination room. LVN 1 stated, usually housekeeping comes and replaces those gowns but LVN 1 did not know when they were last washed and replaced. CRNA 1 stated, the distance from the hopper to the gowns were approximately three to four square feet. LVN 1 stated, the hopper is where staff dispose body fluids, and other infectious wastes.

During a review of the Center for Disease Control and Prevention (CDC) Guidelines, dated 9/11/19, the Guideline indicated, "Splashes may occur when water flow hits the contaminated drain cover or when a toilet or hopper is flushed. Splashes can lead to dissemination of Multidrug-Resistant Organisms(MDRO-bacteria that have become resistant to certain antibiotic) containing droplets, which in turn may contaminate the local environment or the skin of nearby healthcare personnel and patients."

16. During a concurrent observation and interview on 1/25/23, at 3:35 PM, in the Decontamination Room, with LVN 1 and CRNA 1, two sinks were noted, One single sink with no division was labeled dirty and the other single sink with no division was labeled clean. LVN 1 stated, there used to be a plastic barrier in between the two sinks but not here now. LVN 1 stated, the dirty sink was used to clean the scopes and dirty instruments, and the other sink was used for rinsing the scopes and the instruments. Handwashing was done in the clean sink where the instruments were rinsed. LVN 1 and CRNA 1 verified there was no designated handwashing sink in the Decontamination Room.

During a review of the "Association of periOperative Registered Nurses (AORN) Guidelines for PeriOperative Practice," dated 2019, the Guidelines indicated: "Hand washing stations. . .should be provided in the decontamination room and the clean work room, when endoscope processing activities will occur in a single room, hand washing station should be provided in the decontamination area. . . Hand washing sinks should not be used to clean flexible endoscopes. Cleaning endoscopes in hand washing sinks could contaminate the sink, faucet, and hands of personnel subsequently washed in the same sink. . .Decontamination sinks should not be used for hand washing."

Based on interview and record review, the hospital failed to ensure surveillance infection activities for handwashing were conducted with consistency, data collected, analyzed, tracked and trended, and actions implemented. This failure had the potential to negatively impact process outcomes and patient care.

Findings:

During an interview on 1/25/23, at 3:11 PM, with Infection Preventionist (IP), IP stated, the hospital's infection surveillance activities were conducted on handwashing, monitoring of urinary catheter infections, and on issues observed during environmental rounds.

During a concurrent interview and record review, on 1/25/23, at 3:15 PM, with IP, the Healthcare Associated Infection Program Adherence Monitoring on Hand Hygiene, dated 11/17/22 and 11/22/22, conducted in the Emergency Department, were reviewed. The hand hygiene monitoring record, dated 11/17/22, indicated, nine staff members in the ED, including a physician, were observed. and the adherence rate was 73%. The record did not indicate what actions were taken to correct staff non-compliance. The hand hygiene monitoring record, dated 11/22/22, indicated, "six staff members in the ED were observed and the adherence rate was 80%. IP stated, there was no other infection control surveillance activities on handwashing performed in the ED. The raw data collected was not analyzed, acted upon, tracked and trended.

During a concurrent interview and record review, on 1/25/23, at 3:25 PM, with IP, the Healthcare Associated Infection Program Adherence Monitoring on Hand Hygiene, dated 11/17/22 and 11/22/22, conducted in the the Acute Care, were reviewed. The hand hygiene monitoring record, dated 11/17/22, indicated, 11 staff members in Acute Care were observed, and the adherence rate was 88%. The hand washing monitoring record, dated 11/22/22, indicated, Four staff members in Acute Care were observed, and the adherence rate was 86%. The records did not indicate what actions were taken to correct staff compliance. IP stated, staff will be provided more education and more opportunities on handwashing. IP verified the data collected was not analyzed, acted upon, tracked and trended.

During a review of the hospital's policy and procedure (P&P) titled, "Hand Hygiene Program," dated 4/2017, the P&P indicated, "1. The hospital will provide knowledge to staff by developing standards with emphasis on organizational knowledge of proper hand hygiene. . .a. Educate all new employees about the importance of hand hygiene. . .b. Annual reinforcement to existing staff about the importance of hand hygiene will be provided at staff member's annual evaluation and during Annual Skills Fair c. Re-education will also be provided at time of hand hygiene compliance monitoring with those staff observed to be out of compliance."

During a review of the hospital's policy and procedure (P&P) titled, "Surveillance Program Plan," dated 01/2020, the P&P indicated, "Documentation of quality healthcare includes documentation of the outcomes of care. Surveillance is a comprehensive method of measuring outcomes and related processes of care, analyzing the data, and providing information to members of the healthcare team to assist in improving outcomes. Surveillance is an essential element component of effective clinical programs designed to reduce the frequency of adverse events such as infection or injury. . .Hand Hygiene: a Compliance by Healthcare Personnel. . .b. Compliance is compared to hand hygiene opportunities observed and hand hygiene opportunities performed. c. Focused observations will occur in areas of most noted noncompliance. d. Ongoing education will be provided."

Based on interview and record review, the hospital failed to ensure the Infection Preventionist (IP) had the training and skills to facilitate the Infection Control Program in collaboration with the hospital's multidisciplinary team. This failure had the potential to result in an ineffective Infection Control Program, which could potentially result in increase infection in the hospital's patients.

Findings:

During an interview on 1/24/23, at 2:40 PM, with IP, IP stated he's new to the hospital and has only been working for the last three months. IP stated, he is a registered nurse but has not done any specialized training on infection control. "I am just learning the day-to-day reporting and acclimating to the position." IP stated, he has one year to complete infection control training. IP stated, he received his infection control training regarding daily reporting from the hospital's former IP. IP was unable to verbalize what nationally recognized organization the hospital follows to guide them with their infection control implementation.

During a review of the "Infection Preventionist Position Description/Performance Evaluation," dated 4/7/22, the job description indicated, "The Infection Preventionist is responsible for the overall direction of the Infection Prevention and Control Program (IPCP). This includes planning, developing, directing, implementing, and evaluating infection prevention within the healthcare district and it's (sic) associated facilities. The IP is responsible for the effective direction, management and operation of the infection prevention and control department, including education of hospital personnel. . ."

Based on observation, interview, and record review, the hospital failed to review and update its emergency preparedness. This was evidenced by the failure to address all elements of a complete emergency preparedness plan.

Findings:

During an interview and record review, on 1/26/23, at 8:45 AM, with Director of Maintenance (DM), the "Emergency Preparedness Plan (EPP)," dated 2019, was reviewed. The EPP indicated, 2019 was the date of the last review by the Disaster Committee. DM stated, "The 2019 emergency preparedness plan is already old."

During a review of the hospital's policy and procedure (P&P) titled, Emergency Preparedness Plan," dated 9/2010, the P&P indicated, " The overall authority and direction of the hospital's emergency preparedness plan rests with the Chief Executive Officer. In the absence of the CEO, the Administrator on call or the house supervisor on duty will be incharge during a disaster. . .C. Annual Evaluation: 1 The Safety Officer is responsible for performing the annual evaluation of the Emergency Preparedness Program. 2. The annual evaluation is presented to the Disaster Committee by the end of the first quarter of each year. The disaster committee reviews and approves the report. Their deliberations and actions are recorded in the minutes. 3. Once the review is finalized, the Safety Officer is responsible for implementing the recommendations in the report as part of the performance improvement process."