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Based on observations, interviews and record reviews, the hospital failed to ensure the infection control officer maintained an effective system for identifying, reporting, investigating, and controlling of infections and communicable diseases of patients and personnel, as evidenced by:
1) failing to ensure correct isolation precautions were put in place as evidenced by no implementation of "contact precautions" for 1 (#7) of 2 (#7, #8) patients identified for "contact precautions";
2) failing to ensure that staff adhered to infection control practices for the cleaning/disinfecting of patient multi use handheld glucometers;
3) failing to ensure that surgical services were provided in accordance with acceptable professional standards of practice by failing to ensure that surgical instrument trays were available in a quantity that was commensurate with the hospital's expected daily procedure volume, as evidenced by the hospital's routine use of IUSS (Immediate Use Steam Sterilization)(Flash Sterilization) of surgical instrument trays for surgical procedures; and
4) failing to ensure that staff (S28CRNA (Certified Registered Nurse Anesthetist), S29MD (Medical Doctor), S30RN( Registered Nurse) )in the surgical/obstetrical operating room suites followed acceptable professional standards of practice by observations of staff wearing their surgical masks hanging down from the neck and an observation of staff (S27CST (Certified Scrub Technician)) not using proper sterile technique when donning sterile surgical attire before a surgical procedure for 1 of 1 patient's (#1) surgical procedure observed.

Findings:
1) failing to ensure correct isolation precautions were put in place as evidenced by no implementation of "contact precautions" for 1 (#7) of 2 (#7, #8) patients identified for "contact precautions";

A review of the hospital policy, titled, "Nursing Administration: Infectious Patient..", provided by S2 ICDir (Infection Control Director) as the most current, revealed in part: Standard precautions will be followed in accordance with CDC (Centers for Disease Control) guidelines for all patients entering the hospital. Transmission based Isolation Precautions shall be implemented as soon as the need for each precaution is determined.

A review of Patient #7's medical record revealed in part: the patient was admitted on 2/06/15 with diagnoses of bronchitis, persistent cough and positive for influenza. Patient #7 was placed on isolation "droplet precautions" on 2/06/15. On 2/08/15 Patient #7 presented with explosive diarrhea, weakness, and with some blood in stool. The patient's physician ordered a C-diff culture on 2/08/15 to rule out a possible Clostridium-difficile (C-diff) infection. A further review of Patient #7's medical record revealed no physician order for "contact precautions" for Patient #7 for the possible C-diff infection.

An observation of Patient #7's room on 2/11/15 at 3:30 p.m. revealed signage on the patient's door indicating that Patient #7 was on "droplet precautions" for positive influenza. There was no signage noted on Patient #7's room door on 2/11/15 at 3:30 p.m. indicating that Patient #7 was also on "contact precautions" for a possible C-diff infection. S39RT (Respiratory Therapist) was observed entering Patient #7's room to perform a respiratory treatment on Patient #7, as ordered by the patient's physician. S39RT was observed donning the appropriate PPE (personnel protective equipment) to include a mask prior to entering Patient #7's room.

In an interview on 2/11/15 at 3:35 p.m. with S35RN and S19RN (Nurse Manager), S35RN indicated that she was the nurse caring for Patient #7 on 2/11/15. S35RN and S19RN indicated that Patient #7 was on "contact precautions" and that the patient's door should have had signage on it indicating that Patient #7 was also on "contact precautions" for possible C-diff. S19RN indicated that she was not sure why Patient #7's door signage did not have signage for both "droplet and contact" precautions.

In an interview on 2/12/15 at 11:40 a.m. with S39RT she indicated that Patient #7 was only on "droplet precautions" due to a positive influenza. S39RT indicated that she was not aware that Patient #7 was also on "contact precautions" as there was no signage on Patient #7's door indicating that Patient #7 was also on "contact precautions" for a possible C-diff infection. S39RT indicated that after she removed her PPE on 2/11/15 she sanitized her hands. S39RT further indicated that she would have washed her hands with soap and water after she removed her PPE on 2/11/15, if the signage on Patient #7's door indicated that he was also on "contact precautions" for a possible C-diff infection, since hand washing with soap and water was required after caring for patients with C-diff "contact precautions".

In an interview on 2/12/15 at 12:00 p.m. with S2 ICDir she indicated that "contact precautions" should also have been implemented on Patient #7 on 2/08/15 after the patient was suspected of having a C-diff infection. S2 ICDir indicated that the physician should have ordered "contact precautions" on Patient #7 when he ordered the C-diff culture. S2 ICDir further indicated that nursing did not need a physician order to initiate "contact precautions" for a patient suspected of having a C-diff infection and that "contact precautions" should have been initiated on Patient #7 on 2/08/15.

2) failing to ensure that staff adhered to infection control practices for the cleaning/disinfecting of patient multi use handheld glucometers;

A review of the hospital policy titled, "Nursing Administration: Glucose Monitoring - Device Cleaning and Disinfecting" as provided by S2 ICDir, as the most current. revealed in part: Point of care device cleaning and disinfecting procedure.... handheld testing devices should be disinfected after each patient use. These disinfecting procedures apply to devices that use fingerstick samples and where the device or meter is near or next to the patient.

In an interview on 2/10/15 at 4:00 p.m. with S21RN (Medical-Surgical Manager) she was asked about the cleaning/disinfecting of the handheld glucometer devices. S21RN indicated the handheld glucometer devices were required to be cleaned daily. She further indicated that the handheld glucometer devices would be cleaned/disinfected after patient use only if it was soiled.

In an interview on 2/10/15 at 4:15 p.m. with S19RN (Nurse Manager) she was asked about the cleaning/disinfecting of the handheld glucometer devices. S19RN indicated that the handheld glucometer devices were cleaned daily by the night nurse, as one of her night responsibilities. She further indicated that the handheld glucometer devices would not be routinely cleaned/disinfected after each patient use.

In an interview on 2/11/15 at 10:45 a.m. with S2 ICDir she was made aware of the interviews with S21RN and S19RN regarding the cleaning/disinfecting of the handheld glucometer devices. S2 ICDir indicated that the Infection Control policy indicated that the handheld glucometer devices should be cleaned/disinfected after each patient use.

3) failing to ensure that surgical services were provided in accordance with acceptable professional standards of practice by failing to ensure that surgical instrument trays were available in a quantity that was commensurate with the hospital's expected daily procedure volume, as evidenced by the hospital's routine use of IUSS (Immediate Use Steam Sterilization)(Flash Sterilization) of surgical instrument trays for surgical procedures;

A review of the AORN (Association of periOperative Registered Nurses) Perioperative Standards and Recommended Practices, 2013 edition - Recommended Practice for Sterilization revealed in part: IUSS should not be used as a substitute for sufficient instrument inventory in order to minimize the patient risk for SSI's (surgical site infections).

A review of the hospital policy titled, "Sterilization; IUSS", as provided by S11RN (Surgical Services Director) as the most current, revealed that IUSS would be kept to a minimum and would be used only in necessary critical situations.... in the instance of urgent or emergency situations.

A review of the hospital policy titled, "Infection Control; IUSS", as provided by S2 ICDir as the most current, revealed that IUSS should be used in emergency situations only.

A review of the hospital's infection control data (as provided by S2 ICDir) that was collected by the Surgical Services Department on the number of IUSS loads run by the Surgical Services Department each year from 2007 to 2014 revealed: in 2007 there were 1155 loads, in 2008 there were 1040 loads, in 2009 there were 710 loads, in 2010 there were 634 loads, in 2011 there were 947 loads, in 2012 there were 1048 loads, in 2013 there were 710 loads and in 2014 there were 432 loads.

A review of the IUSS log for Sterilizer #1 revealed the following:
On 2/04/15, the nasal instrument set was IUSSed with the reason for the IUSS noted as "quick turnaround" time between cases.
On 2/09/15, a sterile retractor was dropped and had to be IUSSed (There was no notation on the IUSS log as to whether the retractor was a "one of a kind item" ).
On 2/10/15, orthopedic drill batteries were IUSSed with the reason for the IUSS noted as "quick turnaround" time between cases.

A review of the IUSS log for Sterilizer #4 revealed the following:
On 2/03/15, an unsterile retractor was IUSSed with the reason for the IUSS noted as "quick turnaround" time between cases and on the same day (for another patient surgical procedure) an unidentified instrument was brought in by a medical representative and the instrument had to be IUSSed. (There was no notation as to why the instrument was not sterile prior to the surgical procedure).
On 2/09/15, an unsterile laparoscopic instrument had to be IUSSed for a patient's procedure. (There was no notation as to why the instrument was not sterile prior to the the surgical procedure).
On 2/10/15, an orthopedic cement gun, orthopedic prosthetic trail sizes, and orthopedic drill batteries were IUSSed (on 2 different patient procedures) with the reason for the IUSS noted as "quick turnaround" time between cases.

A review of the IUSS log for Sterilizer #5 revealed the following:
On 2/05/15, the ENT (Ear, Nose and Throat) instrument set was IUSSed 2 (two) times (for 2 different patients) with the reason for the IUSS noted as "quick turnaround" between cases.

In an interview on 2/11/15 at 4:10 p.m. with S11RN and S32RN of the Surgical Services Department they were asked about the use of IUSS in the Surgical Services Department. A review of the hospital's infection control data collected by the Surgical Services Department on the number of IUSS loads run by the Surgical Services Department each year from 2007 to 2014 and the IUSS log sheets from February 2015 were reviewed with S11RN and S32RN. They indicated that they have been attempting to reduce IUSS use to "minimal use" over the years by educating the staff, monitoring the use of IUSS, and increasing inventory for capital budget items. S11RN and S32RN indicated that IUSS was mainly used on heavy orthopedic surgery days, eye surgery days, some ENT surgery days and bariatric surgery days when there was not enough time between surgical procedures and/or enough instruments to process the instruments by the preferred method of sterilization (in accordance with acceptable AORN professional standards of practice). S11RN and S32RN indicated that the hospital's Surgical Services Department followed the AORN Perioperative Standards and Recommended Practices.

In an interview on 2/12/15 at 12:10 p.m. with S2 ICDir she was asked about the use of IUSS in the Surgical Services Department. A review of the hospital's infection control data (as provided by S2 ICDir) that was collected by the Surgical Services Department on the number of IUSS loads run by the Surgical Services Department each year from 2007 to 2014 was reviewed with S2 ICDir. S2 ICDir indicated that the hospital's monthly average of IUSS from January 2013 to December 2014 had ranged from 30.1% to 6.5% with only 6 months being less than the corporate benchmark of 10%. She indicated that the hospital attempted to stay below the corporate IUSS monthly average of 10%. S2 ICDir further indicated that IUSS use should be minimal (as indicated in their Infection Control policy). S2 ICDir indicated that the hospital's Surgical Services Department followed AORN Perioperative Standards and Recommended Practices.

4) failing to ensure that staff (S28CRNA, S29MD, S30RN) in the surgical/obstetrical operating room suites followed acceptable professional standards of practice by observations of staff wearing their surgical masks hanging down from the neck and an observation of staff (S27CST) not using proper sterile technique when donning sterile surgical attire before a surgical procedure for 1 of 1 patient's (#1) surgical procedure observed.

A review of the AORN (Association of periOperative Registered Nurses) Perioperative Standards and Recommended Practices, 2013 edition - Recommended Practice for Surgical Attire revealed in part: Surgical masks should not be worn hanging down from the neck. Surgical masks are intended to contain and filter droplets from the nasopharynx. The filter portion of the surgical mask harbors bacteria collected from the nasopharyngeal airway and should not be worn hanging from the neck. Surgical masks should be tied securely and discarded after each procedure or when soiled.

A review of the AORN (Association of periOperative Registered Nurses) Perioperative Standards and Recommended Practices, 2013 edition - Recommended Practice for Sterile Technique revealed in part: Perioperative personnel should use sterile technique when donning and wearing sterile surgical gowns. Implementing sterile technique when donning and wearing sterile surgical gowns reduces the risk of contaminating the sterile field during set-up and thereby reduces the risk of wound contamination and SSIs (surgical site infections) that may result from direct contact of the surgical team members' skin or clothing with the sterile surgical field.

An observation on 2/11/15 from 6:35 a.m. to 6:50 a.m. in the restricted area of the surgical/obstetrical operating room suite revealed S27CST setting up the sterile surgical field, prior to Patient #1's surgical procedure, without having her sterile surgical gown (after donning her sterile surgical gown) properly secured (tied) in the back. The sterile surgical gown was observed open (unsecured) in the back and semi-hanging off her shoulders until S28CRNA entered the surgical/obstetrical operating room suite and properly secured (tied) her sterile surgical gown.

An observation on 2/11/15 from 6:50 a.m. to 7:00 a.m. in the semi-restricted area of the surgical/obstetrical operating room revealed S28CRNA, S29MD, and S30RN with their surgical masks worn hanging down from the neck.

In an interview on 2/11/15 at 10:45 a.m with S9RN (Obstetrical Manager) and S2 ICDir they were informed of the above observations in the surgical/obstetrical operating room area and suite. S9RN and S2 ICDir indicated that the staff (S27CST, S28CRNA, S29MD, S30RN) were not adhering to the hospital's infection control policies. S9RN and S2 ICDir further indicated that the hospital followed the AORN Perioperative Standards and Recommended Practices for all surgical/obstetrical operating room areas and suites.

Based on interviews, observations and record reviews, the hospital 1) failed to ensure that surgical services were provided in accordance with acceptable professional standards of practice by failing to ensure that surgical instrument trays were available in a quantity that was commensurate with the hospital's expected daily procedure volume, as evidenced by the hospital's routine use of IUSS (Immediate Use Steam Sterilization)(Flash Sterilization) of surgical instrument trays for surgical procedures; and 2) failed to ensure that staff (S28CRNA, S29MD, S30RN) in the surgical/obstetrical operating room suites followed acceptable professional standards of practice by observations of staff wearing their surgical masks hanging down from the neck and an observation of staff (S27CST) not using proper sterile technique when donning sterile surgical attire before a surgical procedure for 1 of 1 patient's (#1) surgical procedure observed.

Findings:
1) failed to ensure that surgical services were provided in accordance with acceptable professional standards of practice by failing to ensure that surgical instrument trays were available in a quantity that was commensurate with the hospital's expected daily procedure volume, as evidenced by the hospital's routine use of IUSS (Immediate Use Steam Sterilization)(Flash Sterilization) of surgical instrument trays for surgical procedures;

A review of the AORN (Association of periOperative Registered Nurses) Perioperative Standards and Recommended Practices, 2013 edition - Recommended Practice for Sterilization revealed in part: IUSS should not be used as a substitute for sufficient instrument inventory in order to minimize the patient risk for SSI's (surgical site infections).

A review of the hospital policy titled, "Sterilization; IUSS", as provided by S11RN (Surgical Services Director) as the most current, revealed that IUSS would be kept to a minimum and would be used only in necessary critical situations.... in the instance of urgent or emergency situations.

A review of the hospital policy titled, "Infection Control; IUSS", as provided by S2 ICDir as the most current, revealed that IUSS should be used in emergency situations only.

A review of the hospital's infection control data (as provided by S2 ICDir) that was collected by the Surgical Services Department on the number of IUSS loads run by the Surgical Services Department each year from 2007 to 2014 revealed: in 2007 there were 1155 loads, in 2008 there were 1040 loads, in 2009 there were 710 loads, in 2010 there were 634 loads, in 2011 there were 947 loads, in 2012 there were 1048 loads, in 2013 there were 710 loads and in 2014 there were 432 loads.

A review of the IUSS log for Sterilizer #1 revealed the following:
On 2/04/15, the nasal instrument set was IUSSed with the reason for the IUSS noted as "quick turnaround" time between cases.
On 2/09/15, a sterile retractor was dropped and had to be IUSSed (There was no notation on the IUSS log as to whether the retractor was a "one of a kind item" ).
On 2/10/15, orthopedic drill batteries were IUSSed with the reason for the IUSS noted as "quick turnaround" time between cases.

A review of the IUSS log for Sterilizer #4 revealed the following:
On 2/03/15, an unsterile retractor was IUSSed with the reason for the IUSS noted as "quick turnaround" time between cases and on the same day (for another patient surgical procedure) an unidentified instrument was brought in by a medical representative and the instrument had to be IUSSed. (There was no notation as to why the instrument was not sterile prior to the surgical procedure).
On 2/09/15, an unsterile laparoscopic instrument had to be IUSSed for a patient's procedure. (There was no notation as to why the instrument was not sterile prior to the the surgical procedure).
On 2/10/15, an orthopedic cement gun, orthopedic prosthetic trail sizes, and orthopedic drill batteries were IUSSed (on 2 different patient procedures) with the reason for the IUSS noted as "quick turnaround" time between cases.

A review of the IUSS log for Sterilizer #5 revealed the following:
On 2/05/15, the ENT (Ear, Nose and Throat) instrument set was IUSSed 2 (two) times (for 2 different patients) with the reason for the IUSS noted as "quick turnaround" between cases.

In an interview on 2/11/15 at 4:10 p.m. with S11RN and S32RN of the Surgical Services Department they were asked about the use of IUSS in the Surgical Services Department. A review of the hospital's infection control data collected by the Surgical Services Department on the number of IUSS loads run by the Surgical Services Department each year from 2007 to 2014 and the IUSS log sheets from February 2015 were reviewed with S11RN and S32RN. They indicated that they have been attempting to reduce IUSS use to "minimal use" over the years by educating the staff, monitoring the use of IUSS, and increasing inventory for capital budget items. S11RN and S32RN indicated that IUSS was mainly used on heavy orthopedic surgery days, eye surgery days, some ENT surgery days and bariatric surgery days when there was not enough time between surgical procedures and/or enough instruments to process the instruments by the preferred method of sterilization (in accordance with acceptable AORN professional standards of practice). S11RN and S32RN indicated that the hospital's Surgical Services Department followed the AORN Perioperative Standards and Recommended Practices.

In an interview on 2/12/15 at 12:10 p.m. with S2 ICDir she was asked about the use of IUSS in the Surgical Services Department. A review of the hospital's infection control data (as provided by S2 ICDir) that was collected by the Surgical Services Department on the number of IUSS loads run by the Surgical Services Department each year from 2007 to 2014 was reviewed with S2 ICDir. S2 ICDir indicated that the hospital's monthly average of IUSS from January 2013 to December 2014 had ranged from 30.1% to 6.5% with only 6 months being less than the corporate benchmark of 10%. She indicated that the hospital attempted to stay below the corporate IUSS monthly average of 10%. S2 ICDir further indicated that IUSS use should be minimal (as indicated in their Infection Control policy). S2 ICDir indicated that the hospital's Surgical Services Department followed AORN Perioperative Standards and Recommended Practices.

2) failed to ensure that staff (S28CRNA, S29MD, S30RN) in the surgical/obstetrical operating room suites followed acceptable professional standards of practice by observations of staff wearing their surgical masks hanging down from the neck and an observation of staff (S27CST) not using proper sterile technique when donning sterile surgical attire before a surgical procedure for 1 of 1 patient's (#1) surgical procedure observed.

A review of the AORN (Association of periOperative Registered Nurses) Perioperative Standards and Recommended Practices, 2013 edition - Recommended Practice for Surgical Attire revealed in part: Surgical masks should not be worn hanging down from the neck. Surgical masks are intended to contain and filter droplets from the nasopharynx. The filter portion of the surgical mask harbors bacteria collected from the nasopharyngeal airway and should not be worn hanging from the neck. Surgical masks should be tied securely and discarded after each procedure or when soiled.

A review of the AORN (Association of periOperative Registered Nurses) Perioperative Standards and Recommended Practices, 2013 edition - Recommended Practice for Sterile Technique revealed in part: Perioperative personnel should use sterile technique when donning and wearing sterile surgical gowns. Implementing sterile technique when donning and wearing sterile surgical gowns reduces the risk of contaminating the sterile field during set-up and thereby reduces the risk of wound contamination and SSIs (surgical site infections) that may result from direct contact of the surgical team members' skin or clothing with the sterile surgical field.

An observation on 2/11/15 from 6:35 a.m. to 6:50 a.m. in the restricted area of the surgical/obstetrical operating room suite revealed S27CST setting up the sterile surgical field, prior to Patient #1's surgical procedure, without having her sterile surgical gown (after donning her sterile surgical gown) properly secured (tied) in the back. The sterile surgical gown was observed open (unsecured) in the back and semi-hanging off her shoulders until S28CRNA entered the surgical/obstetrical operating room suite and properly secured (tied) her sterile surgical gown.

An observation on 2/11/15 from 6:50 a.m. to 7:00 a.m. in the semi-restricted area of the surgical/obstetrical operating room revealed S28CRNA, S29MD, and S30RN with their surgical masks worn hanging down from the neck.

In an interview on 2/11/15 at 10:45 a.m with S9RN (Obstetrical Manager) and S2 ICDir they were informed of the above observations in the surgical/obstetrical operating room area and suite. S9RN and S2 ICDir indicated that the staff (S27CST, S28CRNA, S29MD, S30RN) were not adhering to the hospital's infection control policies. S9RN and S2 ICDir further indicated that the hospital followed the AORN Perioperative Standards and Recommended Practices for all surgical/obstetrical operating room areas and suites.