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.

Based on document review, observation and interview with staff it was determined the facility's infection control leadership failed to audit hand hygiene practices to prevent transmission of disease for all patients. The facility implemented an electronic hand hygiene monitoring system and did not support it with direct observation to ensure it was functioning as designed before relying on the system. This failure created the potential hand hygiene opportunities would be missed, causing harm to all patients.

Findings include:

Review of Infection Control Meeting Minutes for December 2021 and January 2022 revealed the meetings focused on electronic system data. The only areas addressing direct observation of hand hygiene were the Neonatal Intensive Care Unit, the Introspective Unit, and the Emergency Department.

Review of a document titled "Infection Control Risk Assessment Year 2021" revealed it lists hand hygiene as a high risk priority.

Review of documents showing compliance with hand hygiene (according to electronic surveillance) for Units 8, 9 and 10 Southeast, for December 2021 through January 2022, revealed all units experienced declines in hand hygiene compliance.

Review of a policy titled "WVUH (West Virginia University Hospital) Infection Control Plan," reviewed 6/19 revealed: "West Virginia University Hospital Infection Control (IC) Program ... Intervenes directly to prevent transmission of infectious diseases."

Review of a policy titled "Hand Hygiene," revised 5/17 revealed: "A. Hand Hygiene is the single most important means of reducing the risks of transmitting microorganisms from one person to another or from one site to another on the same patient. B. In order to minimize the incidence of Healthcare Acquired Infection (HAI) at WVUH and Ambulatory Clinics and promote patient, staff and visitor safety, all employees and all healthcare professionals ... will comply with hand hygiene procedures."

Observation conducted 2/15/22 at 4:00 p.m. on Unit 7 Northeast revealed the following:

a. Clinical associate (CA) #1 was not wearing their electronic hand hygiene badge and stated it was in their locker.

b. Travel nurse #1 was not wearing their electronic hand hygiene badge and stated they did not know anything about the electronic hand hygiene system and was never issued a badge.

c. CA #2 was not wearing their electronic hand hygiene badge and stated, "I had a badge, but I threw it in the trash four (4) months ago. I was in a patient room and it wouldn't stop beeping. Nobody ever said anything, and they never gave me another one."

Observation conducted 2/15/22 at 4:45 p.m. on Unit 9 East revealed the following:

a. Registered Nurse (RN) #1 was not wearing their electronic hand hygiene badge and stated they did not know anything about the electronic hand hygiene system and did not have an electronic system badge.

b. RN #2 was not wearing their electronic hand hygiene badge and stated they had an electronic badge and thought it was in their pocket. RN #2 then checked and determined he/she was not wearing or carrying it.

An interview was conducted with the Manager of the Department of Infection Control (MDIC) on 2/15/22 at 9:10 a.m. The Chief of Infectious Disease, the Specialty Care Nurse with Infection Control and the Infection Preventionist Registered Nurse (IPRN) were present. The MDIC stated the facility is still rolling out a hand hygiene reporting system. He/she stated they have had problems getting someone from the contractor that is installing the electronic reporting system to come in to complete setting up the system due to the fact that they will not enter a room where a COVID patient is actively being cared for. He/she stated they placed sensors on patient beds to alert staff they have to sanitize their hands within a certain period of time when they are caring for a patient. Both the MDIC and the IPRN stated Units 8 and 9 Southeast "may not have beacons set-up by the electronic hand hygiene contractor yet."

A phone interview was conducted with the MDIC on 2/16/22 at 8:55 a.m. He/she stated the electronic hand hygiene system was done as a trial on the Intensive Care Units in mid 2019, but the COVID epidemic occurred before they could adequately set the system up. He/she stated staff badges (which were required to implement the system) were distributed in January and February 2021. He/she stated the system was installed hospital-wide by March 2021. He/she stated the learning process then began and adjustments of hand hygiene locations and beacons were adjusted. He/she stated they have never stopped learning from the system, but by July/August 2021 the facility was using the electronic system full-fledged. He/she stated only three (3) areas of the hospital (the Neonatal Intensive Care Unit, the Perioperative area and the Emergency Department) were still doing secret shoppers (staff doing direct observation audits of hand hygiene). He/she stated those areas were using secret shoppers because beacons could not be placed on stretchers or incubators. He/she stated leadership was discussing results obtained from the electronic system in their meetings. He/she stated secret shopper audits for the entire facility were not being discussed, because that data was not being collected. During the phone interview the survey findings were discussed and the MDIC concurred the findings were concerning, and not using secret shoppers in all patient care areas creates the potential hand hygiene opportunities are being missed.