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Based on observation, interview, and record review, the facility failed to exercise procedures for preventing and controlling the transmission of infections on 1 of 6 (Unit 8) inpatient psychiatric units. This failure resulted in:
1) Placement of soiled towels in the hallway; and
2) Breach in glove protocol during the removal of soiled towels from the hallway.

Findings included:

During a tour of unit 8 (a general psychiatric unit) on December 15, 2020 at 9:45am, the following was observed:

On the floor against the wall of the hallway of patient rooms 807 - 813 were two (2) piles of soiled towels. At the far end of the hallway was a female staff member (Staff F) pushing a small linen cart. It was noted that she was wearing one (1) glove on her right hand. She initially stepped away from her linen cart, leaving the cart unattended. She moved toward the nearest pile of towels which was halfway down the hallway. She was told by Staff B to bring her cart with her. Staff F stepped back to the cart and pulled it down the hallway. She collected the towels with the gloved hand, depositing them into the linen cart. She used her left ungloved hand to keep her braided hair pulled back. After she picked up the two piles of soiled towels, she returned to the far end of the hallway to exit the unit.

In an interview with Staff F on December 15, 2020 at 9:50am, she stated she was a Mental Health Technician [MHT] and not a member of the housekeeping staff. While we were talking she folded her hands by placed her ungloved left hand on top of the back of her gloved right hand. When this action was brought to her attention, she quickly unfolded her hands. She stated she was supposed to have on two (2) gloves.

In an interview with Staff B on December 15, 2020 at 9:45am, she stated Staff F should have been wearing two (2) gloves when handling soiled towels. She also stated the towels were not supposed to be outside of the patient's rooms on the hallway floor, adding that she thought the patients had placed the towels in the hallway. She acknowledged the need for training of staff and patients.

Record review of the policy, "Handling Clean and Soiled Linen," last reviewed 12/27/2019, showed:
"Purpose: To prevent the spread of infection and reduce the possibility of linen contamination
...Soiled Linen Policy: ...
3. Non-infectious soiled linen may be collected in the house-keeping cart without bagging it when the cart is directly outside the patient's room.
4. All linen must be either bagged or collected into the housekeeper's cart directly outside the patient's room before transport."

Record review of the policy, "Hand Hygiene," last reviewed 12/27/2019, showed:
"Purpose: To emphasize the use of hand hygiene to minimize the acquisition of or transmission of pathogens ...
4. Personnel shall wear gloves when in contact with blood or other potentially infectious materials, mucous membranes ...
Gloves:
1. To be in compliance with OSHA healthcare requirements, healthcare workers must wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin will occur."