HospitalInspections.org

Based on record review, observation and interview the facility failed to follow their policy related to patients' rights to receive care in a safe setting. The facility failed to enforce the Infection Prevention and Control policy with multiple staff, including housekeeping and family.

The findings include:

Record review of the facility's "Infection Prevention and Control Program" dated 06/20/2023, stated:
Patients, visitors, and family members will be educated regarding infection Prevention and Control Practices as needed. Patients, family members and visitors may be provided fact sheets, pamphlets and other printed material that may include information on the rationale for precautions, risks to household members, room assignments for transmission-based precautions purposes, explanation about the use of PPE by the HCWs and directions for use of such equipment to family members and visitors.

Observation on 07/26/2024 at 1130,the facility failed to enforce the hand hygiene policy with multiple staff (ID #55, 56, 57, 58) who were not sanitizing their hands when going to multiple rooms to care for patients (ID# 3, 6).

Visitors were found in patients' (ID#8) room without a mask or gown with MDRO (multi-drug resistant organism). Housekeeper was also found in the same room (ID#8) removing her gown after cleaning the room of debris but remained in the room without a gown and mask to continue cleaning.

Interview on 07/26/2024 at 1145 with staff (ID #54), who was present during observation and stated we have really worked on this issue.