HospitalInspections.org

Based on observation, interview and policy review, the facility failed to:
- Change gloves and perform hand hygiene for three patients (#3, #4 and #12) of six patients observed for appropriate glove use and hand hygiene.
- Wear gloves for the administration of injectable medication for one patient (#1) of one patient observed for injectable medication administration.
- Ensure all hair was contained in a hairnet while in the kitchen area for one staff (T) of three staff observed in the kitchen.
These failures increased the risk of hospital-acquired infection for all patients admitted to the facility. The facility census was 24.

Findings included:

1. Review of the facility policy titled, "Hand Hygiene," dated 01/2018, showed that following proper hand hygiene is the single most effective technique for preventing the spread of infections and that hand hygiene shall be performed after contact with a patient's intact skin, after removing gloves, if moving from a contaminated body site to a clean body site during patient care and after contact with inanimate (not alive, for example, computer keyboard, computer mouse, bed etc.) objects in the immediate vicinity of the patient.

Observation on 10/15/18 at 4:00 PM, showed Staff B, Registered Nurse (RN), picked Patient #5's urine collection bag off the floor and hung it on the bed with gloved hands. Staff B then proceeded to touch the patient's Intravenous (IV, in the vein) pump (a machine used for controlling the rate of medication/fluids administered to patients) with her soiled gloves.

During an interview on 10/15/18 at 4:15 PM, Staff B stated that she should have removed her soiled gloves after she touched the urinary collection bag, performed hand hygiene and applied clean gloves before she touched the IV pump.

Observation on 10/16/18 at 9:32 AM, showed Staff Q, Licensed Practical Nurse (LPN), entered Patient #3's room to remove his IV catheter (small flexible tube inserted into a vein through the skin do deliver medications or fluids into the bloodstream). Staff Q put on gloves, moved a trash with her gloved hands, and removed the IV catheter with the same gloves.

During an interview on 10/16/18 at 9:45 AM, Staff Q, LPN, stated that she should have removed her gloves after she touched the trash can, performed hand hygiene and put on another pair of gloves before she removed the patient's IV.

Observation on 10/16/18 at 9:35 AM, in the ED, showed Staff D, RN, entered Patient #12's room to insert a urinary catheter (a small flexible tube inserted into the body through an opening of the urinary tract to drain urine). Staff D applied gloves, repositioned the patient's legs with her gloved hands and opened the sterile urinary catheter package with the contaminated gloves.

2. Review of the facility document titled, "Medication Administration: Intramuscular Injection - CE," published 05/2018, showed the directive that staff should wear gloves when administering intramuscular (IM, in the muscle) injections (a method of delivering medications with a needle placed through the skin).

Observation on 10/15/18 at 3:45 PM, showed Staff B, RN, entered Patient #1's room to administer a pneumonia (infection of the lungs) vaccine (a medication that is administered into a muscle to help protect against pneumonia). Staff B did not put on gloves when she administered the vaccine into the patient's arm. When Staff B removed the needle from the patient's arm, a small amount of blood seeped from the injection site.

During an interview on 10/18/18 at 9:58 AM, Staff B, RN, stated that she should have worn gloves when she administered the pneumonia vaccine to Patient #1.

3. Review of the facility's policy titled, "Food Safety & Requirements," dated 08/17/16, showed that hair restraints must cover hair to prevent contact with exposed food and other kitchen items.

Observation on 10/16/18 at 12:50 PM in the kitchen, showed Staff T, Diet Clerk, without her hair contained in her hairnet.

During concurrent interviews on 10/16/18 at 1:00 PM, Staff U, Executive Chef, stated that all hair must be covered when in the kitchen. Staff T stated that she was unaware that her hair was not contained in her hairnet.

During an interview on 10/18/18 at 1:00 PM, Staff KK, Infection Preventionist, stated that:
- All hair should be contained under hair nets in dietary (includes the kitchen).
- Gloves should be changed and hands cleansed between tasks, after contact with the patient and before the next task is performed.
- Gloves should be worn when injections were administered and when IV catheters were removed. .






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