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ST CATHERINE OF SIENA HOSPITAL 50 ROUTE 25A SMITHTOWN, NY 11787 Oct. 28, 2020
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, document review and interview, facility staff did not adhere to acceptable standards of infection control practices for: (A) Hand hygiene; (B) Clean linen processing; (C) Air vent cleaning; and (D) Terminal cleaning of patient rooms.

These lapses in infection prevention placed patients, visitors and staff at increased risk for infection.

Findings pertinent to A:
During observations in the facility's Intensive Care Unit on 10/22/20 at 10:45AM, Staff O (Registered Nurse) was observed administering intravenous (IV) medications to Patient #11 [a patient on Contact and Droplet Isolation Precautions].

The staff member removed her contaminated gloves twice during the process and without performing hand hygiene, retrieved new gloves from a box located in the patient's room and donned them.

Per interview of Staff O at the time of observation, Staff O stated that she did not think it was necessary to perform hand hygiene in between glove changes because she was using her nursing judgment by deciding to change them.

On 10/22/20 at 11:45AM, Staff J (Housekeeper) was observed removing soiled linens from the 2 North Unit. During four separate observations, Staff J removed his dirty gloves after removing the soiled linens from the carts, applied alcohol-based hand sanitizer, rubbed his hands and without allowing them to dry completely, retrieved new gloves from a box and donned them.

Per interview of Staff J at the time of the observation, Staff J acknowledged this finding.

Similar failures to perform hand hygiene prior to donning gloves or after removing contaminated gloves was observed for Staff members L (Registered Nurse), M (Patient Care Associate) and N (Registered Nurse).

These observations were made in the presence of Staff H (Director of Infection Prevention/ Control) and Staff I (Director of Environmental Services) who confirmed the findings.

The facility policy and procedure titled "Hand Hygiene," last reviewed January 2019, directed staff to do the following: "If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands in all other clinical situations described ...decontaminate hands before donning and after removing gloves ...when decontaminating with an alcohol-based waterless antiseptic, apply a "dime" size amount of product to palm of one hand and rub hands together briskly, covering all surfaces of hands and fingers, until the hands are dry."

Findings pertinent B:
The facility policy and procedure titled "Handling Clean Laundry and Linen" last revised 2/2/2019, contained the following statement: "Clean linen should be wrapped in impervious bags, or similar protection at the processing site, and should remain wrapped until it is ready for use ...linen should be stored in a manner that will prevent it from contamination ...exchange carts (that are covered) should be used to deliver linen to patient areas ...as well as protect it against airborne contamination ...clean linen should be ...stocked away in the appropriate storage carts ...to protect it from dust, soil and airborne contamination, as well as water."

On 10/22/20 at 12:15PM during observations of the facility's Linen Processing Area, four (4) carts with linen considered clean were observed uncovered, exposed to the elements and in hallways near the loading docks used for the on-loading and off-loading of various types of equipment and supplies.

Per interview of Staff H (Director of Infection Prevention/ Control) and Staff I (Director of Environmental Services) at the time of this observation, both confirmed that the "clean linen" carts should have been covered.

Findings pertinent C:
Observations in the facility's 2 North Unit on 10/22/20 at 1:35PM identified the following:
The air vent in room 222 was observed soiled, with a black residue.
The air vent in room 227 was observed with dust/residue.

These observations were made in the presence of Staff H and Staff I, who confirmed the findings.

The facility policy and procedure titled "Discharge Room/Bed Cleaning Procedures," last revised 12/11/18, directed Housekeeping staff to "Look at the vent to see if it is dusty. Wipe the exterior of the vent and surrounding areas with a microfiber dust cloth, if needed use cleaning solution to remove dirt."

Findings pertinent D:
Observations of the Terminal Cleaning of patient room #237 on the 2 North Unit on 10/22/20 at 1:20PM identified the following:

Staff K (Housekeeper) entered the room and proceeded to clean the chair, closet, bed, equipment in the room and bathroom without performing high dusting or cleaning of the walls during the terminal clean.

During cleaning of the chair, Staff K cleaned the arms, legs and then the top of the chair with the same cleaning wipe.

Staff K cleaned the call bell starting with the area used by patients [the most contaminated] to the wall [the least contaminated]. Staff K then placed the call bell on the hooks of an IV pole attached to the bed without cleaning the hooks.

During cleaning of the bed, she cleaned the base of the bed, then the upper parts of the foot of the bed, with the same cleaning wipe.

During cleaning of the patient bathroom, Staff K cleaned the toilet seat, bowl, support rails, upper parts of the toilet, sink, faucets and bathroom mirror. Then without changing her contaminated gloves, she retrieved a bottle of glass cleaner and additional cleaning wipes from her cart.

After using the supplies [glass cleaner and cleaning wipes], she placed the supplies onto her cleaning cart without cleaning the outside of the items contaminating her cleaning cart and the items located near them.

During interview of Staff H and Staff I, at the time of these observations, both acknowledged the findings.

During interview of Staff K at the time of observation, when asked if she was to have performed high dusting during terminal cleaning, Staff K confirmed that yes, she was supposed to have performed high dusting.

The facility policy and procedure titled "Terminal Cleaning Procedure for Isolation Rooms," last revised 4/10/2019, and the facility's training materials dated 2018, both lacked specific guidance directing housekeeping staff to terminally clean a patient's room from the least contaminated areas to the more contaminated areas.