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Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure hand hygiene was performed to prevent the spread of infection and/or contain COVID-19 among the patient population. This affected Patient #1, one (1) of six (6) COVID-19 patients observed for infection control practices.

The findings include:

Review of the facility's policy, "Hand Hygiene," policy number 667906, established January 2013 and revised on July 2019, revealed the purpose of the policy was to ensure appropriate health care providers completed hand hygiene to prevent transmission of healthcare associated infections and communicable diseases or conditions. The policy stated hand hygiene was the single most effective deterrent to the spread of infection and was an essential element of safe patient care. Per the policy, hand hygiene must be performed by facility staff before and after direct patient contact, after contact with the patient environment or equipment, when moving from a dirty patient care task to a clean task, prior to an invasive procedure, and before and after glove use.

Observations, on 08/04/2020 at 1:54 PM, showed Registered Nurse (RN) #1 provided direct care to Patient #1. During the observation, RN #1 sanitized her hands with an alcohol solution prior to donning personal protective equipment (PPE) that included a face shield, surgical mask, isolation gown, and exam gloves. Patient #1 was in Droplet Precautions due to an active medical diagnosis of COVID-19. The facility's Infection Preventionist accompanied RN #1 into the patient's room to observe RN #1 administer an antiviral medication through the patient's Peripherally Inserted Central Catheter (PICC), a long, thin tube inserted through a vein in the arm and passed through to the large central veins near the heart used to give medications.

Observations revealed, upon entering Patient #1's room, he/she was sitting on a bedside commode and requested toileting assistance from RN #1. The patient reported he/she just had a bowel movement and needed to be wiped clean before returning to bed. Further observation revealed Patient #1 was able to self-transfer from a seated position on the bedside commode to a standing position. Once in a standing position, RN #1 took a sanitary wipe and cleaned the patient's buttocks. Following the cleaning, Patient #1 proceeded to get back into his/her bed. Further observation revealed immediately following the cleaning of the patient's buttocks, RN #1 removed her soiled gloves and donned a new pair of exam gloves. RN #1 neither washed her hands with soap and water nor used an alcohol-based sanitizer between the change of gloves.

The next observation revealed RN #1 hanging a replacement intravenous (IV) antiviral medication. The nurse did this by disconnecting the previously administered antiviral IV bag from the IV tubing and connecting the new antiviral IV bag to the IV tubing. RN #1 did not wash/sanitize her hands or change gloves prior to connecting the new antiviral medication bag to the patient's IV tubing.

Further observations revealed, after hanging the medication, the IV pump used to infuse the medication through the patient's PICC began to alarm, indicating an occlusion in the PICC line. RN #1 used the patient's call light system/intercom and asked a staff member to bring her a syringe with normal saline to clear the occlusion. While waiting for the saline syringe, RN #1 disposed of the previously infused IV antiviral medication bag into the patient's trash can. Observations revealed the trash can had a lid on it that could be opened via a foot pedal. However, excess incontinence supplies had been stored on top of the lid making the foot pedal inoperative. RN #1 was observed lifting the trash can lid with her gloved hand and placing the used IV bag into the trash can. Further observation revealed RN #1 did not wash/sanitize her hands or change gloves after touching the trash can lid.

The next observations revealed RN #1 received the saline syringe from a staff member at Patient #1's door. RN #1 then disconnected the patient's IV tubing and cleared the occlusion by injecting normal saline from the syringe through the IV line. RN #1 did not wash/sanitize her hands or change gloves prior to infusing the normal saline into the patient's IV line.

Further observations revealed, after ensuring the new antiviral medication was being infused through the patient's PICC, RN #1 removed the patient's bedside commode basin containing urine and feces. The nurse brought the basin to the patient's bathroom and emptied the contents into the toilet. Per observation, RN #1 returned the empty basin and placed it back into the bedside commode. Immediately after this, Patient #1 requested assistance with the covers on his/her bed, and RN #1 pulled up the covers as requested. Further observation revealed RN #1 did not wash/sanitize her hands or change gloves after emptying the bedside commode basin and prior to touching the patient's bed linen.

The next observation revealed RN #1 removed all of her PPE in the patient's room and disposed of the used PPE in a trash can lined with a red biohazard bag. Further observation revealed RN #1 did not wash/sanitize her hands or change gloves after removing the used PPE and prior to exiting Patient #1's room.

Interview with RN #1, on 08/04/2020 at 2:32 PM, in the hallway immediately outside of Patient #1's room, revealed she acknowledged she should have performed hand hygiene after providing toileting assistance, prior to hanging the IV, after touching the trash can, prior to flushing the patient's IV, after touching the bedside commode, after removing the used PPE, and before leaving the patient's room.

Interview with the Infection Preventionist, on 08/04/2020 at 2:47 PM, in the hallway immediately outside of Patient #1's room, revealed she concurred RN #1 failed to perform hand hygiene multiple times while providing direct care to Patient #1.

Further interview with RN #1, on 08/05/2020 at 3:06 PM, revealed she should have performed hand hygiene multiple times and failed to do so because she was distracted with concerns of her other patients' care needs. RN #1 reported her assigned Preceptor had reinforced hand hygiene during Unit Orientation, which she completed on 08/02/2020. RN #1 stated she was aware Patient #1 could have been exposed to additional infectious diseases as a negative outcome of her failure to perform hand hygiene on 08/04/2020.

Further interview with the Infection Preventionist, on 08/06/2020 at 9:45 AM, revealed she had reviewed the facility's Hand Hygiene policy and stated she was not in disagreement with any part of the policy. The Infection Preventionist stated during the observations made of RN #1 providing direct care to Patient #1, on 08/04/2020, the nurse failed to follow the Hand Hygiene policy multiple times, which could have exposed Patient #1 to additional infections.