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Based on observation, record review, and interview the facility failed to ensure staff follow their infection control policy for the appropriate use of gloves; handwashing after removing gloves and ;
safe handling of soiled linen to prevent cross contamination.

This failed practice had the potential to adversely affect staff and patients in the operating room department. Citing (3) random observations in the operation Room department.

Findings:

Observation on 4/17/2015 at 9:20 am in the Operating Room Department revealed Staff (V) wearing one hand of glove while taking specimens from the operating room to the Laboratory. Staff (K) Infection Control Nurse asked the staff why he was wearing one hand of glove, he removed the hand of glove and continued with the specimen in his ungloved hands.

Observation on 4/17/2015 at 9:45 am in the recovery room area revealed Staff (G) came out of the operating room into the recovery room suite wearing a pair of gloves. Staff (G) used her gloved hands to place her phone in her pocket and handled other personal items while wearing the gloves.
Staff (Q ) was observed on 4/17/2015 at 10:00 am in the operating room suite cleaning the floor with mop . The staff replaced the mop on a cleaning cart removed her gloves and did not wash/sanitize her hands after removing the gloves.
Observation on 4/17/2015 at 10:25 am in the operating room suite revealed Staff (P) was observed carrying a bag of soiled linen from an operating room to the biohazard room. The staff was not wearing gloves while handling the bag of soiled linen.

During an interview on 4/17/2015 at 11:30 am with the Infection Control Director, she stated staff should not leave the operating room with gloves on nor should staff wear one hand of glove for any task that require wearing gloves. She stated gloves should be worn when transporting or handling contaminated linen or specimen.

Review of the facility's infection control policy/ procedure dated March 27, 2014 gave the following information:

"Wear gloves (clean non-sterile gloves are adequate) for anticipated hand contact with blood, secretions, excretions, mucous membranes, contaminated items,

nonintact skin, and any moist body substance of all patients.
2. Gloves should be changed prior to contact with another patient and/or between procedures on the same patient, after contact with material(s) that may contain high concentration of microorganisms. Remove glove promptly after use.
3. Perform hand hygiene with either soap/ water or alcohol hand sanitizer".