HospitalInspections.org

Based on observation , interview and record review, the facility failed to ensure current infection control standards of practice were enforced in one (1) of two (2) patient care areas observed. (intermediate care)



Findings include:

Observation on 3/1/2017 at 10:30 AM in the intermediate care unit revealed sign posted on patient's (ID#5) hospital room door stating contact precautions. Phlebotomist (ID# 65) was observed performing blood draw on patient (ID#5) with gloves on as the only form of personal protective equipment (PPE). Charge Nurse for the unit (ID# 58), at the time of observation, notified phlebotomist (ID# 65) that the patient was on contact isolation and that she needed to be wearing a gown when in contact with the patient. Phlebotomist (ID#65) completed procedure in progress, left the patient room, labeled specimen tubes, documented information on clip board, then removed gloves and sanitized hands.

Interview with phlebotomist (ID# 65) at the time of observation revealed that she did not see the contact isolation sign on the patient's door. She acknowledged that she broke protocol and that she should have had a gown on, and removed her contaminated gloves before documentation of information.

Record review of facility policy titled: Isolation Procedure with publication date of 02/10/2017 revealed the following information:

1. PURPOSE:
Contact Precautions are designed to prevent transmission of highly transmissible or epidemiologically important microorganisms. All diseases or conditions in this category are spread primarily by direct or indirect contact with the patient and/ or environment.

2. PROCESS:
A.Gloves- wear gloves before entering the room; clean non-sterile are adequate for contact with blood, fluids, secretions, excretions and contaminated items. Change gloves after contact with infective material. Remove gloves before leaving the room. If sterile procedure is performed, sterile gloves need to be worn. Wash or sanitize hands after glove removal.

B. Gowns- wear gown before entering the room. A clean non-sterile is adequate to protect skin and prevent soiling of clothing from contact with the patient's environment, or during procedures and patient care activities that are likely to result in splashing or spraying of blood or other body fluids. Discard gown just before leaving the room.

C. Hand washing- wash or sanitize hands before and immediately after removing PPE. After glove removal and sanitizing hands, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room to avoid transfer of microorganisms to other patients or environments.