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Based on observation and interview, the facility failed to follow standard infection control practices during blood glucose procedures for two (#8 and #9) of two patient observations.

The findings included:

Observation on January 6, 2015, at 4:55 p.m., in the unit #6 main activity room, revealed Registered Nurse (RN) #3 donned gloves and performed a blood glucose procedure on patient #8. Continued observation revealed the RN completed the blood glucose procedure, walked to the trash can, placed trash in the trash can, and without removing the dirty gloves or santizing the hands, walked into the smaller adjacent activity room. Further observation revealed the RN spoke to patient #9 and walked back into the main activity room. The RN lifted the trash can lid, looked into the trash can, and reached into a uniform pocket to obtain the key to the trash can lock. The RN unlocked the trash can lid, reached down into the trash can, replaced the lid and lock on the trash can, and walked back into the smaller activity room. Without removing the dirty gloves or sanitizing the hands, the RN obtained a blood specimen from patient #9. Continued observation revealed after completing the blood glucose check, the RN walked back through the main activity room to the nurse's station, unlocked the nurses station door with a key, and then removed the dirty gloves. Further observation revealed the RN failed to change the dirty gloves or sanitize the hands during the entire observation.

Interview with RN #3 on January 6, 2015, at 5:05 p.m., in the Unit 6 Nurses Station, revealed "...did not change my gloves or wash my hands...should have done that..." Further interview revealed "...we go through extensive training about infection control..." Further interview confirmed the RN failed to change the dirty gloves or sanitize the hands during the observation.

Interview with the Associate Superintendent of Quality Management on January 6, 2015, at 5:15 p.m., in the Unit 6 Hallway, confirmed the RN failed to change the dirty gloves or sanitize the hands while providing care for two patients and infection control was not maintained.

Interview with the Director of the Acute Care Nursing Units on January 7, 2015, at 11:50 a.m., in the conference room, confirmed the RN failed to follow infection control practices.