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Based on policy review, observation and interview the hospital failed to ensure that the infection control officer implemented an effective system for controlling infections and communicable diseases of patients and personnel as evidenced by:

1) failure to ensure hand hygiene was implemented according to hospital policy for 2 (S11Dietary, S12RN) of 10 staff members observed performing patient care;

2) failure to ensure PPE (personal protective equipment) was donned appropriately as evidenced by S9DialysisRN failing to snap her gown closed while holding pressure on a patient's bleeding dialysis shunt;

3) failure to ensure a sanitary physical environment was maintained.

Findings:

Review of the hospital policy titled "Infection Control and Prevention Plan", effective January 2014 revealed the following:
2. Purpose:
A.The purpose of the Infection Control and Prevention Plan is to identify infections and reduce the risk of disease acquisition and transmission through the introduction of preventive measures.
B.The goals of the plan include recommendation and implementation of risk reduction practices by integrating principles of infection prevention and control into all direct and indirect standards of practice.
3. Scope of Service:
? Developing and implementing infection control and prevention measures and education initiatives related to healthcare personnel; including all hospital and ambulatory staff, contract workers (e.g. agency nurses, housekeeping staff, etcetera) and volunteers.
? Consulting and advising on decontamination, sanitation, and environmental disinfection with Dietary and Environmental Services
? Maintaining a sanitary physical environment
F. Roles and Responsibilities:
Healthcare worker responsibilities: All healthcare workers of the organization will: adhere to standard precautions including hand hygiene guidelines and disease transmission based precautions.
Priorities and Goals:
A. Prevent and Reduce the Risk of Infections:
Identifying and preventing the occurrences of healthcare-associated infections by pursuing sound infection control and prevention practices such as standard precautions (hand hygiene and use of personal protective equipment), aseptic technique, environmental sanitation, and isolation of patients as needed.

1) Failure to ensure hand hygiene was implemented according to the hospital ' s Infection Control and Prevention policy:

On 12/9/14 at 9:30 a.m. an observation was made of S12RN performing patient care during a cesarean section delivery. She was observed inserting a Foley urinary catheter. She removed her gloves after performing the catheterization, gathered the used supplies bare handed and discarded them in the trash. S12RN failed to perform hand hygiene after removing her gloves and prior to donning a new pair of gloves. S12RN performed multiple (4) glove changes and was never observed performing hand hygiene.

On 12/10/14 at 12:10 p.m. an observation was made of S11Dietary delivering lunch trays to patients in the Adult ICU unit. She was observed entering room #5 with the patient's tray. She touched the doorframe and the patient's bedside table. S11Dietary failed to perform hand hygiene both prior to entering the patient's room and upon exiting the patient's room. S11Dietary was then observed entering room #8, delivering that patient's lunch tray. She touched the door and the patient's bedside table. S11Dietary again failed to perform hand hygiene prior to and upon exiting the patient's room. She was also observed delivering a lunch tray to room #9. S11Dietary touched the bedside table and the patient's plate. She failed to perform hand hygiene before entering the patient's room and upon exiting the patient ' s room.

In an interview on 12/10/14 at 12:15 p.m. with S2DirectorNICU, she confirmed S11Dietary had not performed hand hygiene prior to entering/exiting patient rooms #5, #8, and #9. S2DirectorNICU agreed failure to perform hand hygiene before entering patient rooms and exiting patient rooms was an infection control breach. She also confirmed performance of multiple glove changes without performing hand hygiene before and in-between donning gloves were also an infection control breach.

2) Failure to ensure PPE was donned appropriately while providing care to a dialysis patient.

On 12/10/14 at 2:45 p.m. an observation was made of S9DialysisRN holding pressure on a patient's dialysis shunt which had been bleeding. Further observation revealed S9DialysisRN's gown was not snapped and was open across the front.

In an interview on 12/10/14 at 2:50 p.m., S6Infection Control confirmed S9DialysisRN's gown should have been snapped closed while holding pressure on the patient's bleeding dialysis shunt.

3) Failure to ensure a sanitary physical environment was maintained.

On 12/10/14 at 12:15 p.m. a tour was conducted of the Adult ICU. The following observations were made during the tour: ICU staff was using a toilet, in a designated clean storage area, for disposal (flushing) of urine from catheter collection bags and sticky brownish substances were noted on the shelves and inside the door of the nourishment refrigerator.

On 12/10/14 at 1:05 p.m. a tour was conducted of the ED (Emergency Department). The following observations were made during the tour: a green gelatinous substance was noted under the mattress of the bed in the psychiatric observation room and a heavy coating of dust was also noted on the wall in the observation room; a suction canister was noted to have 450 cc (cubic centimeters) of cloudy liquid in ED Trauma Room 2 (a room that was reported by the head nurse as ready for occupancy).

In an interview on 12/10/14 at 2:55 p.m., S6Infection Control confirmed the above mentioned findings in the Adult ICU and ED were breaches in infection control practices.