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Based on a review of facility policy, documentation, tour, and interview with staff (EMP) it was determined the facility failed to follow their policy to maintain a sanitary environment in the Material Management Department and assure that the medical supplies stored there were stored properly and kept clean for use throughout the hospital.

Findings include:

A review of facility policy "Materials Management Warehouse Storeroom Par Level Area Setup and Storage" last revised October 9, 2015, revealed, "all supplies must be contained in plastic bins... . Supply locations and bins are cleaned on a routine facility determined schedule. ... ."

A tour of the Materials Management Department on April 28, 2017, at 10:30 AM with EMP1, EMP5 and EMP6 revealed two large store rooms that stocked all of the medical supplies used in the facility. Throughout the Department, the metal shelving units with solid shelves and the open storage bins that contained the wrapped medical supplies had a visible film of grey dust and dirt. Also a section of the shelving units contained medical supplies that were not contained in plastic bins and the shelving was covered with visible dust.

An interview conducted on April 28, 2017, at 10:45 AM with EMP1, EMP5 and EMP6 confirmed the presence of a visible film of grey dust and dirt present throughout the Department on the metal shelving units with solid shelves, the open storage bins that contained the wrapped medical supplies for the facility and the area of shelving that contained medical supplies that were not contained in plastic bins. EMP5 also confirmed there was no schedule for cleaning the Department and no documentation of any cleaning in the Department. EMP5 could not determine the last time the Department had been cleaned. EMP6 confirmed that the facility had not followed their "Materials Management Warehouse Storeroom Par Level Area Setup and Storage" policy.

An interview conducted on April 28, 2017, at 11:00 AM with EMP6 revealed that it was the Materials Management Tech's responsibility to clean the Material Management Department, however the tech left unexpectedly in March 2017 and the position was still vacant.
A review of the Personnel file for EMP5 revealed a "Position Description/Competency Based Evaluation" for "Buyer 1" completed June 15, 2016, that revealed an overall rating of "Meets Requirements". Included in the general duties were, "Assists with the oversight of storeroom operations to ensure compliance with hospital policy and department procedures. ... ."

A review of the position description for a "Materials Management Tech" revealed, "Dust, sweep, mop, remove trash and break down cartons in Storeroom. ... ."

A review of the facility's "Environmental Tours Checklist" for the Materials Management Department revealed the last rounding completed May 26, 2016, "Areas are clean and free of offensive odors".? Yes, 1 observation. ... ."

An interview conducted on April 28, 2017, with EMP1 at 2:15 PM revealed that the environmental tours were only completed annually for the Materials Management Department and the most recent, done in May 2016, did not identify any cleanliness issues. Further interview revealed that they had not been aware of the dirt and dust in the Materials Management department and the lack of cleaning there.

A phone interview conducted on May 10, 2017, at 3:00 PM with EMP2 confirmed that the facility had not followed their Materials Management policy.

Based on a review of facility Bylaws, policies, facility documents, tour and interview with staff (EMP), it was determined the Chief Executive Officer (CEO) failed to assure that facility policies were followed for inventory control, infection control and maintaining a clean environment in areas of the facility.

Findings include:

1. A review of the "Advisory Board of Trustee Bylaws", last amended December 20, 2016, revealed, "The CEO shall have the authority to, and be held responsible for, administering the Hospital in all of its activities, subject only to such policies as may be adopted and such orders as may be issued by Corporation. ... . The authority and duties of the CEO shall include responsibility for the following: 6.3(a) Carrying out all policies as established by corporation; ... ."

A review of the facility policy "Inventory Guidelines and Standards Policy" last revised October 9, 2015, revealed, "Inventory control is the responsibility of every Department Manager. ... . It will be the responsibility of Materials Management to assist Department Managers in developing the inventory systems to meet the inventory needs for each department. ... ."

A review of the facility's "Daily Safety Huddle Records" for December 31, 2016, through January 3, 2017, revealed, "January 1, 2017 - Follow Up from Previous Day - Out of yellow isolation gowns. Expected delivery Tuesday (January 3, 2017). ... ."
A review of the Par sheets dated April 28, 2017, for ICU and Telemetry nursing units revealed that ICU's current Par level was five packages of "gowns - isolation cover yellow".

A review of the facility Purchase Orders for yellow isolation gowns revealed orders were placed on December 28, 2016, for five cases of 100 gowns per case, and on December 30, 2016, for seven cases.

An interview conducted on April 28, 2017, with EMP5 at 10:20 AM confirmed they had placed these orders and knew that the order placed on December 30, 2016, would not be delivered until January 3, 2017, because of the New Year's holiday. EMP5 also recalled a shortage of isolation gowns in the hospital from December 31, 2016, to January 2, 2017, and that the Intensive Care Unit's supply of isolation gowns ran out during that time.

An interview conducted on April 28, 2017, at 11:00 AM with EMP6 revealed that, when EMP6 returned to the facility on January 3, 2017, they found that the Materials Management Department's stock of isolation gowns was depleted and they were not sure why. The after hours sign out log did not show any sign out for yellow gowns and they were unable to account for the cases of isolation gowns taken from the Materials Management Department over the long New Year's weekend. EMP6 stated they were not the administrator on call over the New Year's holiday weekend and that EMP2 was. Further interview with EMP6 confirmed that the management staff, which included EMP2, did not follow the policy for inventory control of isolation gowns.

An interview conducted on April 28, 2017, with EMP8 at 1:45 PM revealed that they were not sure when, but that they had directed staff to take isolation gowns from other units, if there was a shortage. EMP8 stated that they were not informed that the ICU was running low on isolation gowns, that the Materials Management Department was out of yellow isolation gowns or that any staff were reusing yellow gowns or not wearing them as required with patients in contact or droplet precautions in the ICU over the New Year's weekend.

A phone interview conducted on May 10, 2017, at 3:00 PM with EMP2 confirmed that they were the Administrator On-Call for the hospital December 31, 2016, to January 3, 2017. EMP2 was off site during that time and did not recall receiving any phone calls regarding lack of isolation gowns and did not know there was an issue during that time. When EMP2 stated they were not briefed about the April 28, 2017, survey findings, the surveyor explained the findings. EMP2 stated that, according to the findings, they would agree that the facility staff had not followed their policies and processes. EMP2 also stated they understood it was their responsibility to assure that the facility staff followed their policies and processes to maintain adequate supplies throughout the hospital.
2. A review of the "Advisory Board of Trustee Bylaws", last amended December 20, 2016, revealed, "The CEO shall have the authority to, and be held responsible for, administering the Hospital in all of its activities, subject only to such policies as may be adopted and such orders as may be issued by Corporation. ... . The authority and duties of the CEO shall include responsibility for the following: 6.3(a) Carrying out all policies as established by corporation; ... ."
An interview conducted on April 28, 2017, at 12:45 PM with EMP9 revealed that they had worked a twelve-hour shift in the ICU on December 31, 2016. They remembered a shortage of yellow isolation gowns that day and the staff "had to use their resources wisely" due to a shortage of isolation gowns in ICU. EMP9 stated that, when they had to provide non-contact patient care to a patient in isolation, they did not don a new yellow gown, just wash their hands and wore gloves. EMP9 confirmed that they had not followed the facility's infection control policies that required a gown be worn each time anyone entered a patient's room who was in contact or droplet precautions.

An interview conducted on April 28, 2017, at 3:30 PM with EMP1 confirmed that staff in ICU did not follow the facility's infection control policies when they entered a patient's room, who was in contact or droplet precautions, without donning a new isolation gown, reusing isolation gowns or entering without an isolation gown.

A phone interview conducted on May 10, 2017, at 3:00 PM revealed that EMP2 agreed the staff had not followed their facility infection control policies that required them to wear isolation gowns when caring for patients in contact and droplet precautions.

3. A review of the Advisory Board of Trustee Bylaws, last amended December 20, 2016, revealed, "The CEO shall have the authority to, and be held responsible for, ... . 6.3(f) Maintaining physical properties in a good state of repair and operating condition;... ."

A review of facility policy "Materials Management Warehouse Storeroom Par Level Area Setup and Storage" last revised October 9, 2015, revealed, "all supplies must be contained in plastic bins... . Supply locations and bins are cleaned on a routine facility determined schedule. ... ."

A tour of the Materials Management department on April 28, 2017, at 10:30 AM with EMP1, EMP5 and EMP6 revealed two large store rooms that stocked all of the medical supplies used in the facility. Throughout the Department, the metal shelving units with solid shelves and the open storage bins that contained the hospital's supply of wrapped medical supplies had a visible film of grey dust and dirt. Also a section of the shelving units in the locked storage area contained medical supplies that were not contained in plastic bins.

An interview conducted on April 28, 2017, at 10:45 AM with EMP1, EMP5 and EMP6 confirmed the presence of the visible film of grey dust and dirt present throughout the Department on the metal shelving units with solid shelves and the open storage bins that contained the wrapped medical supplies for the facility. EMP5 also confirmed that there was no schedule for cleaning the Department and no documentation of any cleaning in the Department. EMP5 could not remember the last time the Department had been cleaned.

An interview conducted on April 28, 2017, at 11:00 AM with EMP6 revealed it was the Materials Management Tech's responsibility to clean the Material Management Department, however the tech resigned unexpectedly in March 2017 and the position was still vacant. Further interview confirmed that the facility had not followed their policy that required the facility set a routine cleaning schedule for Materials Management and assure routine cleaning.

An interview conducted on April 28, 2017, at 2:15 PM with EMP1 revealed that environmental rounding tours were only completed annually for the Materials Management Department and the most recent one done in June 2016 did not identify any cleanliness issues.

A phone interview conducted on May 10, 2017, at 3:00 PM with EMP2 confirmed that they knew about the Materials Management Tech's job vacancy and said they were in the process of interviewing, but did not know when the position would be filled. EMP2 stated that they did not know what responsibilities were on every staff's job description but that they considered it everyone's job to keep the environment clean. EMP2 agreed that the facility had not followed their facility policies and processes. EMP2 also stated they understood that it was their responsibility to assure that the facility staff followed their policies and processes to maintain a clean environment throughout the hospital.

Based on a review of facility policies, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure that staff followed the facility's infection control policies that required the use of isolation gowns for care provided to patients in contact and/or droplet isolation.

Findings include:

A review of facility policy "Infection Control Program" last reviewed March 2016 revealed, "The IC Program develops and implements policies and procedures designed to prevent, reduce, and/or control the transmission of infection as recommended by CDC. This includes Standard & Transmission Based Precautions which includes precautions/ isolation practices and patient room requirements, protective personal equipment, environmental control/housekeeping measures and disease specific controls. Each employee is responsible for practicing hospital wide Infection Control Policy and Procedures. ... ."

A review of facility policy "Standard Precautions/Transmission - Based Precautions" last reviewed February 2016 revealed, "Transmission-based Precautions are for patients known or suspected to be infected by epidemiologically important pathogens, where the mode of transmission is by airborne, droplets or contact (direct/indirect) with an infected host or inanimate objects/environmental surfaces. ... . The following components apply to Standard Precautions:... D. Gowns 1. Wear gowns to protect skin and to prevent soiling of uniform during procedures and patient care activities that are likely to generate splashes, or sprays of blood, body fluids, secretions, or excretions. 2. Remove soiled gown as promptly as possible, using proper technique. ... . Droplet Precautions to be used in conjunction with Standard Precautions - Examples of illness include: ... 1. Invasive Haemophilus Influenza Type disease... Personal Protective Equipment 1. Gowns... . Contact Precautions to be used in conjunction with Standard Precautions - Examples of illness include: ... 1. ... a. Clostridium difficile 7. MDRO (MRSA, VRE, ESBL) ... Personal Protective Equipment 1. Gowns... ."

An interview conducted on April 28, 2017, at 9:50 AM with EMP12 revealed that there were seven patients in the hospital from December 31, 2016, to January 3, 2017, that required isolation gown use for contact and/or droplet precautions and four were in the Intensive Care Unit (ICU) at that time.
A review of the medical records of the four ICU patients who were in contact and/or droplet precautions during, December 31, 2016, to January 3, 2017, revealed:
MR1 patient was admitted December 24, 2016, lab reported Influenza.
MR2 patient was admitted December 29, 2016, lab reported Methicillin Resistant Staph Aureus (MRSA).
MR3 patient was admitted December 27, 2016, lab reported Influenza and MRSA.
MR4 patient was admitted November 21, 2016, lab reported Clostridium Difficile.

An interview conducted on April 28, 2017, at 12:45 PM with EMP9 revealed that they had worked a twelve hour shift in the ICU on December 31, 2016. They remembered a shortage of yellow isolation gowns that day and the staff "had to use their resources wisely" due to a shortage of isolation gowns in ICU. EMP9 stated that, when they had to provide non-contact patient care to a patient in isolation, they did not don a new yellow gown, just wash their hands and wore gloves. EMP9 confirmed that they had not followed the facility's infection control policies that required a gown be worn each time anyone entered a patient's room who was in contact or droplet precautions.

An interview conducted on April 28, 2017, at 1:00PM with EMP10 revealed that they worked day shift in ICU on January 1, 2 and 3, 2017. EMP10 remembered there had been times when there was not an adequate supply of isolation gowns on the unit and they observed nurses reuse isolation gowns for patients in isolation; however they was not sure if it was during that time.

An interview conducted on April 28, 2017, at 3:30 PM with EMP1 confirmed that staff in ICU did not follow the facility's infection control policies when they entered a patient's room, who was in contact or droplet precautions, without donning a new isolation gown, reusing isolation gowns or entering without an isolation gown.

A phone interview conducted on May 8, 2017, at 2:30 PM with EMP16 revealed that they remembered working in ICU December 30, 31, 2016, and January 1, 2017, and were assigned a patient with possible Clostridium-difficile. EMP16 stated that they were forced to enter this patient's room multiple times without wearing an isolation gown to take the patient's vital signs, etc. and also they had to re-use isolation gowns for this patient and other patient's in contact or droplet precautions when assisting other nurses with their patients in similar precautions when direct patient contact was required. EMP16 stated that they hung the used isolation gown inside the patient's room for re-use for that patient. EMP16 stated that, when they assisted with a flu patient, they did not gown and only wore a mask and gloves. EMP16 confirmed that they knew this was not according to the facility's infection control policies, but they had no choice due to the shortage of isolation gowns in the ICU.

A phone interview conducted on May 10, 2017, at 3:00 PM with EMP2 confirmed the staff had not followed the facility infection control policies that required them to wear isolation gowns when caring for patients in contact and droplet precautions.