HospitalInspections.org

Based on observation, policy and document review and staff interview, it was determined that for 3 of 8 patient care observations (Patient #'s 6, 14 and 15) in the sample, staff failed to follow the hospital's infection control policies. Findings included:

The hospital policy entitled "Hand Washing/Alcohol Hand Sanitizer Procedure" stated, "...follows the Centers for Disease Control and Prevention's Handwashing Guidelines...Key Elements: 5 Moments for Hand Hygiene...use an alcohol-based hand rub for routinely decontaminating hands...When entering and/or leaving the patient room...Before and after having direct contact with patient's intact skin..."

The related hospital document entitled "5 Moments of Hand Hygiene" stated, "...When entering or Leaving a Patients Room...Before donning gloves & (and) After removing gloves ...Before and after Patient Contact...After contact with patient surroundings."

1. Patient #6

During an observation in the Emergency Department Triage area on 9/9/20 between 11:20 AM and 11:30 AM, the following technique was observed by Employee #1:
- wearing gloves, approached Patient #6, who was seated in wheelchair in hallway outside of Exam Room/Bay #'s 3 and 4
- touched Patient #6's shoulder/arm and wheelchair
- removed gloves, donned new gloves
- walked into Exam Room #3, touched equipment in room
- exited Exam Room #3
- removed gloves
- donned new gloves

Employee #1 failed to perform hand hygiene:
- before and after direct patient contact
- after contact with patient surroundings
- before donning and after removing gloves

These findings were confirmed by Employee #1 on 9/9/20 at 11:29 AM.

Accreditation Coordinator A, present and witness to this observation, confirmed the employee's practice was not in accordance with hospital infection control policies/procedures.

2. Patient #'s 14 and 15

The hospital policy entitled "Infection Prevention Policy - Hemodialysis #28" stated, "...Each dialysis station is considered the patient's room for infection prevention purposes..."

During an observation in the Dialysis Center on 9/9/20 at 1:05 PM, the following technique was observed during patient care, provided by registered nurse (RN) A:
- exited nurse station holding patient chart
- entered Station #4 and placed chart on Patient #15's bedside tray
- exited Station #4 and entered Station #3
- touched Patient #14's dialysis machine and the adjacent keyboard/screen located in Station #3
- exited Station #3
- removed gloves
- entered nurses station and touched keyboard of medication dispensing machine
- removed intravenous (IV) medication bag from cabinet drawer of medication dispensing machine
- exited nurses station
- entered Station #4 and placed IV medication on Patient #15's tray

RN A failed to perform hand hygiene:
- when entering/leaving patient dialysis station
- after removing gloves
- after contact with patient surroundings

These findings were confirmed with RN A on 9/9/20 at 1:10 PM.

During an interview on 9/9/20 at 1:15 PM, Dialysis Nurse Manager A confirmed that RN A's practice was not in accordance with hospital infection control policies/procedures.