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Based on review of CDC (Center for Disease Control and Prevention) Guidelines and interview, it was determined the Infection Prevention Nurse failed to control the risk of infection in that designated containers for used disposable or reusable PPE (Protective Personal Equipment) were not in a location that was convenient at the site of removal. The failed practice did not allow facility staff to remove potentially contaminated PPE upon leaving the patients room. The failed practice had to the potential to effect all employees and patients in the facility. Findings Follow:

A. Review of CDC 2007 Guideline for Isolation Precautions titled, "Preventing Transmission of Infectious Agents in Healthcare Settings" updated May 2022, showed designated containers for used disposable or reusable PPE (Personal Protective Equipment) should be placed in a location that is convenient to the site of removal to facilitate disposal and containment of contaminated materials.
B. Review of CDC guidelines provided by Facility, on 08/15/2022 at 1:30 PM "How to Safely Remove Personal Protective Equipment" showed to remove all PPE before exiting the patient room except a respirator, if worn.
C. During interview with Infection Prevention Nurse on 08/15/22 at 1:30 PM, she confirmed the findings in B.
D. During interview with MHT (Mental Health Technician) #1 on 08/15/22 at 11:50 AM, the MHT #1 stated the following:
1) When asked for process when patients test positive, MHT #1 stated, "When a patient test positive, the roommate is tested and if test positive, the room is blocked and both patients are placed in quarantine for 5 days. If the roommate's test is negative, the patient will move into another room and the room is blocked to prevent another patient from being assigned in the second bed."
2) When asked for procedure to enter and exit the patient room, MHT #1 stated, "Putting on the PPE in the storage area and walk down the hallway to the patients quarantined room and when done with the patient care, we walk down the hallway with our PPE still on to the dirty utility room to remove the PPE."
3) When asked to explain the distance for "walking down the hallway" when exiting a quarantined room, MHT #1 stated, "it could be from the room located about 10 feet from the dirty room or it could be the last room, approximately 75 feet for the dirty room."
E. During interview with the Chief Executive Officer and Infection Prevention Nurse on 08/15/22 at 2:30 PM, when Surveyor asked to explain the procedure for donning and doffing of PPE, the CEO and Infection Control Nurse confirmed the findings in D.