HospitalInspections.org

Based on observation, interview, and policy review, the provider failed to ensure hand hygiene and glove use by one of one licensed practical nurse (LPN) K and one of one registered nurse (RN) D was followed during a colonoscopy procedure for one of one sampled patient (25). Findings include:

1. Observation on 5/2/23 from 9:28 a.m. through 10:06 a.m. with LPN K during a colonoscopy procedure for patient 25 revealed:
*At 9:43 a.m. the gastroenterologist had requested a smaller endoscope to replace the endoscope he was currently using for the patient.
*LPN K removed the used endoscope and handed it off to an unidentified endoscope processor.
*She removed her soiled gloves and then:
-Used hand sanitizer to cleanse her hands and waved her hands in the air to dry them.
-Applied one clean glove and had difficulty getting her remaining hand into the second clean glove.
-She opened the end of the second glove, put it up to her mouth, and blew air from her lungs into the glove.
-She then applied the remaining second glove to her hand.
*With those same gloved hands she:
-Assembled the smaller endoscope and flushed it with sterile water.
-Applied lubricant to the endoscope.
-Handed the endoscope to the gastroenterologist.
-Pushed on the patient's exposed stomach to assist with the endoscope's advancement through the colon.
*Without removing those gloves she picked up a sterile biopsy forcep and inserted the forcep into the opening of the endoscope to remove colon polyps.

Interview on 5/3/23 at 1:00 p.m. with LPN K regarding her hand hygiene and glove use during the above procedure revealed:
*She agreed there were some missed opportunities for hand hygiene and glove use.
*Stated she should not have blown air into a clean glove but had done that to quickly apply the glove.
*"It is not a good reason for a shortcut."

Interview on 5/3/23 at 3:30 p.m. with infection preventionist RN C regarding the above observation and interview with LPN K revealed:
*She thought hand hygiene audits were being performed in the procedure rooms.
-She was unsure which procedures were being audited.
*She had a spreadsheet of staff who had been audited for hand hygiene and glove use.
-LPN K was not located on the audit spreadsheet as having been audited for hand hygiene and glove use.
*She stated it was not an acceptable practice to blow air into a glove before applying the glove to the hand.



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2. Observation on 5/2/23 of registered nurse (RN) D during the colonoscopy procedure for patient 25 revealed:
*At 9:50 a.m. she removed her gloves and then:
-Applied a new pair of clean gloves without performing hand hygiene.
-Assisted with obtaining a pediatric colon scope.
-Removed her gloves and without performing hand hygiene applied another pair of clean gloves.

Interview on 5/3/23 at 12:55 p.m. with RN D regarding her hand hygiene and glove use revealed:
*She was not aware that hand hygiene was required before applying a new pair of gloves.

Interview on 5/3/23 at 4:10 p.m. with infection preventionist RN C regarding the observation and interview with RN D revealed:
*She agreed that hand hygiene should have been performed before applying gloves and after the removal of gloves.
*Staff had been under the impression that hand hygiene had not needed to be completed before applying gloves.

Interview on 5/4/23 at 11:45 a.m. with director of nursing B regarding the above observations and interviews revealed:
*She had been aware of the observations and interviews.
*The staff had spoken to her about those observations and interviews.
*There had been a staff member who was performing audits in the endoscopy area and had left employment six months ago.
*They had not found a replacement to continue the audits for the past six months.

Review of the provider's December 2022 Hand Hygiene policy revealed:
*Indications for hand washing and alcohol-based hand rub use:
-Cleanse hands before applying gloves.
-Cleanse hands after removing gloves.
*"H. Monument Health Observes and monitors hand hygiene compliance..."
-"4. Observations within a unit are conducted weekly or monthly across all shifts and on all days of the week proportional to the number of individuals who touch patients or who touch items that will be used by patients on duty for that shift."
-"5. Observations are conducted to capture a representative sample of the different roles of individuals who touch patients or who touch items that will be used by patients (e.g., nurses, physicians, techs, environmental services workers)."
*"I. Other Aspects of Hand Hygiene"
-"4. Change gloves during patient/resident care if moving from a contaminated body site to a clean body site and perform hand hygiene."
-"5. Replace contaminated, torn, or punctured gloves as soon as practical. If there is any doubt that a glove's ability to function as a barrier is compromised, the gloves should be replaced."