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Based on observation of the facility, record review and interview, the facility's Infection Control Officer failed to ensure staff practiced infection control techniques to prevent cross contamination that could potentially result in the spread of infection and communicable diseases among patients and staff. Infection control issues were observed 1 of 2 (ER) emergency carts (#6) and 2 out of 6 employees monitored (#s 63, 66) and in the following:

Finding include:

Review of Policy and Procedure Issued:8/15, Revised 11/15 SOP/INF-017 entitled "Environmental cleaning and disinfection and equipment cleaning and disinfection" reads in part.....Purpose: To provide environmental cleaning and disinfection where patients receive heathcare to prevent the transmission of a microorgansm from patient to patient, from patient to healthcare worker (HCW) and from patients to visitors using evidence-based national guidelines or in the absence of such guidelines, expert consensus to guid infection prevention and control practices throughout the organization. I. Policy: a. Environmental Services (EVS) staff shall follow infection prevention and control procedures applicable to the area he/she is assigned to. e. Infection Preventionist shall: assist EVS Director in evaluation of sanitation practices c. Periodically assess infection prevention and control practices in the EVS deparment. f. Infection Control Commitee: a. Reviews and approves all infection prevention and control poicis and procedures for cleaning walls, floors, windows, bed, furniture, draperies, carpets, was containers, bathroom, equipment, stairs, special care departments and other nonpatient areas.

Review of Policy and Procedure titled: "Hand Hygiene" Issued 1/95 Reviewed/Revised 5/18 SOP/INF-005 reads in part: I. Purpose: To improve hand-hygiene practices of health-care workers (HCW) and to reduce transmission of pathogenic microogranisms to patients and personnel in health-care settings. III. A. Indications for Hand Hygiene 1. Decontaminate hands prior to having direct contact with patients 2. If hands are not visibly soiled, use hospital-approved alcohol-based hand rub for routinely decontaminating hands, except when caring for patients with Clostridium dificile diarrhea 3. Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter 9. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of patients. 10. Decontaminate hands before donning and after removing gloves.

1. Observation of the medical and surgical patient unit on the 2nd floor along with Employee #53 the CNO (Chief Nursing Officer) on 05-22-2018 at 12:40 p.m. revealed in 1 of 2 ER carts #6 was observed to have an accumulation of visible dust on the lateral top shelf along with dust on the suctioin machine and other supplies stored on the cart.

Interview with Employee #53 at 12:45 p.m. on 05-22-2018 stated when asked if the emergency cart was routinely monitored and she stated "yes, it should be, the dates of the drug expiration are on each drawer. When ask about the accumulation of dust CNO replied that is not acceptable and should be cleaned. When ask who was responsible for cleaning the cart she did not respond. When the CNO was asked who was responsible for ensuring the ER cart was cleaned she stated infection control.


2. Observation of the Intensive Care Unit on the 2nd floor along with Employee #53 the CNO (Chief Nursing Officer) on 05-22-2018 at 11:20 a.m. employee #66 was observed donning gloves and wiping down a piece of equipment called "sat to stand patient assist device'. Employee ID #66 was observed removing her containmated gloves and discarding them in the trash. Employee ID #66 did not disinfect or wash her hands after removing dirty gloves, she was then observed with contaminated hands pushing the cleaned equipment down the hallway to the storage area.

Interview with CNO at 11:25 a.m. on 05/22/2018 confirmed that staff are to wash or disinfect hands after removing gloves.

Interview with Employe #66 on 5/22/2018 at 12:50 p.m. confirmed she did clean the patient's "sat to stand" assist device and she stated that she should of disinfected her hands after removing the gloves but she must of forgot.










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Observation on 5/21/2018 at 1210 of the patient care assistance (PCA) (ID #63) entered room patient's (ID #4) room and set up patient's lunch tray. Employee ID # 63 was observed touching and moving patient's articles on the bed side table. Employee # 63 left the room and did not decontaminate hands before or after leaving the patient's ((D #4) room.

Interview on 5/21/2018 at 1220 with PCA (ID # 63), she stated "I should gel in and out".