The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

HARRISON MEDICAL CENTER 2520 CHERRY AVENUE BREMERTON, WA 98310 Nov. 19, 2020
VIOLATION: INFECTION CONTROL LOG Tag No: A0750
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Item #1 Terminal Cleaning Procedures

Based on observation, document review, and interview, the hospital failed to ensure that staff used effective infection control measures to avoid sources and transmission of infection during terminal cleaning procedures.

Failure to maintain a clean and sanitary environment places patients, staff, and visitors at increased risk of exposure to harmful microorganisms.

Finding included:

1. Document review of the hospital's policy titled, "Isolation Patient Room Daily and Terminal Cleaning, 8021.00," PolicyStat ID: 6, reviewed 09/20, showed that staff are to use a clean cloth with approved disinfectant for cleaning each surface, ex. 1 micro fiber cloth for bed, 1 micro fiber cloth for overbed table, 1 micro fiber cloth for bedside table, etc., and that staff are to clean and sanitize all surfaces; ceiling, walls, furniture, equipment, TV, etc.

Document review of the hospital's policy titled, "Perioperative Sanitation and Cleaning Procedure," PolicyStat ID: 66, reviewed 01/19, showed that Operating Room (OR) Terminal Cleaning includes cleaning/disinfection of all surfaces, furniture, and equipment.

2. On 11/18/20 from 3:10 PM to 5:10 PM, an Environmental Services (EVS) Supervisor (Staff #603), Investigator #8, and Investigator #6 observed the isolation patient terminal cleaning of Patient Room #2209 by an EVS staff member (Staff #604). The observation showed:

a. Patient Room #2209 was designed for double occupancy; however, the terminal cleaning followed the discharge of a single patient treated under Airborne Precautions for COVID-19;

b. while dusting and disinfecting the walls, Staff #604 did not bring the mop head completely to the ceiling line, leaving a strip of approximately 2 - 5 inches of un-sanitized wall surface around the perimeter of the room;

c. the ceiling surface was not dusted or disinfected;

d. neither of the two ceiling mounted televisions were dusted or disinfected;

e. accumulated dust between both television ceiling mounts and their cable conduits was not removed;

f. the window blinds were not cleaned or disinfected;

g. while cleaning the patient bed (isolation patient), Staff #604 removed the un-sanitized foot board and placed it on the sanitized surface of the mattress. The mattress was not re-sanitized after the foot board was replaced;

h. while wiping an overbed table, Staff #604 allowed the cloth to contact the floor and then used the same cloth to wipe a patient bed hand-control, a patient phone, a bed side table, the surface of the 2nd patient bed, a bed side chair, a stethoscope, and a cardiac monitor;

i. the 2nd patient bed was not terminally cleaned;

j. using a new wiping cloth, Staff #604 wiped a bed side commode, the exposed surfaces of a Slipp (patient transfer device) tote, and the 2nd overbed table;

k. both bedside chair seats had cracked vinyl upholstery that exposed the underlying cloth and padding (absorbent and uncleanable surface);

l. an unlaminated paper sign was taped to the inside of the bathroom door (absorbent and uncleanable surface);

m. the disinfected patient call button in the bathroom was placed on the floor next to the toilet;

n. Staff #604 removed her gloves without performing hand-hygiene prior to collecting clean linens;

o. Staff #604 removed a bag of trash from the room and began to make-up the bed without changing gloves or performing hand-hygiene.

3. At 5:10 PM, Investigator #8 and Investigator #6 interviewed Staff #604 about the hospital's isolation-patient room terminal cleaning procedures. Staff #604 stated that she was not aware that she should have terminally cleaned the "unused" bed or that the wiping cloth should not be used for multiple surfaces. Staff #604 stated that she thought she had cleaned the walls all the way to the ceiling and that she should have dusted and disinfected the televisions.

4. On 11/18/20 between 5:40 PM and 8:00 PM, the EVS Supervisor (Staff #605), the evening EVS Supervisor (Staff #607), Investigator #8, and Investigator #6 observed the terminal cleaning of Operating Room #5 by an EVS staff member (Staff #606). The observation showed:

a. while wiping a Mayo stand (a movable stand that holds surgical supplies), Staff #606 allowed the wiping cloth to contact the floor and then used the same cloth to wipe a 2-basin stand and a 2nd Mayo stand before replacing the cloth;

b. the underside of 3 of 3 interlocking surgical step stools were not cleaned or disinfected;

c. trash and linen bags were not removed to disinfect all surfaces of the frames and the waste basket;

d. Staff #606 removed her gloves without performing hand hygiene prior to collecting clean linens;

e. a smart speaker was not cleaned or disinfected.

5. At 8:00 PM, Investigator #8 and Investigator #6 interviewed Staff #605 about the hospital's process for the OR terminal cleaning procedure. Staff #605 stated that wiping cloths should not be used after contact with the floor and that Staff #606 should have sanitized her hands after removing gloves and before collecting clean linens. Staff #605 stated that all surfaces of waste baskets and bag frames should be disinfected. Staff #605 stated he did not know how a smart speaker should be sanitized.

Item #2 Hand Hygiene

Based on observation, document review, and interview, the hospital failed to ensure that hospital staff performed hand hygiene (HH) according to hospital procedure and accepted standards of practice.

Failure to perform effective hand hygiene and glove changes places patient and staff at increased risk of exposure to pathogens.

Findings included:

1. Document review of the hospital policy titled, "Hand Hygiene Policy," policy number 931.00, revised 09/2020, showed that staff must perform hand hygiene upon entering and leaving a patient room, after direct contact with a patient, after removing gloves, and after removing personal protective equipment (PPE) including gloves.

2. On 11/18/20 at 11:25 AM, Investigator #5 and the Director of Critical Care (Staff #501) inspected the hospital's Intensive Care Unit (ICU). Investigator #5 observed a Respiratory Therapist (Staff #502) exit a patient room, doff his gloves, and then enter a different patient room. Staff #502 failed to perform hand hygiene after doffing gloves and before entering a patient room.

3. At the time of the observation, Staff #501 confirmed the finding and stated that the staff member should have performed hand hygiene.

4. On 11/18/20 at 11:35 AM, during inspection of the hospital's ICU, Investigator #5 observed a Registered Nurse (Staff #503) transport a patient to an inpatient ICU room. The patient was admitted for the treatment of COVID-19 and was in Aerosol Precautions. Investigator #5 observed Staff #503 doff her gloves, remove her soiled N95 mask, adjust paperwork on a counter, retrieve a new mask from a table, and then don the new mask. Staff #503 failed to perform hand hygiene at each hand hygiene opportunity; after doffing gloves, after doffing her used N95, after exiting the patient room, and prior to donning a clean mask.

5. At the time of the observation, Staff #501 verified the finding, and stated that the nurse had not followed hospital policy for hand hygiene.
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