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Based on observation, interview and record review the facility failed to follow their policy to initiate, review and prioritize problems specific to the patient on an ongoing basis; failed to update the plan of care to reflect changes in the patient's needs to prevent the development of pressure sores (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction); and failed to prevent the worsening of pressure sores for one (Patient #22) of five patients at high risk. The facility census was 94.

Findings included:

Record review of Patient #22's medical chart revealed the patient was admitted to the facility on 4/17/10 after falling at home which resulted in a fractured right leg. The patient's past medical history revealed in part a diagnosis of Chronic obstructive pulmonary disease (a lung disease which makes it difficult to breath), Degenerative Joint Disease (involved degradation of joints with symptoms which may include joint pain, tenderness, stiffness, and locking) and a right total hip replacement in 1993 with a revision surgery in 2003.

Record review of the patient's admission assessment on 4/17/10 at 8:48 p.m. revealed the patient had no skin breakdown other than a left elbow skin tear .

Record review of the admission care plan dated 4/17/10 revealed the care plan included Activity Intolerance, High Fall Risk, Impaired Mobility, Pain, Impaired Skin Integrity. The care plan did not include individualized problems, interventions. and goals or timelines.

On 4/20/10 at 9:30 a.m. the Physical Assessment Shift documentation revealed (in part) the patient developed "Right heel redness".

Record review revealed no update in the care plan to include the right heel redness or interventions, goals or timelines.

On 4/22/10 at 9:00 p.m., the Physical Assessment documentation revealed the following:
- Right heel with redness, blanchable/elevated; (skin returns to normal color after being depressed)
- Left medical coccyx (tailbone) with Stage II pressure ulcer (partial thickness skin loss - usually presenting as an abrasion, blister, or shallow crater), length 0.8 cm(centimeter) by width 0.7 cm, reddened, no drainage, wound edges regular, wound bed greatest portion red granulation, dressing type thin duoderm;
- Right Coccyx with Stage I pressure ulcer (persistent redness), length 0.4 cm, width 0.3 cm, reddened and well approximated, no drainage, dressing type thin duoderm, dressing status dry and intact, wound bed greatest portion blanched/dull.
" Hospital Acquired Pressure Ulcer this Admission - yes "

Record review of the care plan revealed no mention of pressure sores; interventions; goals or timelines.

The Discharge Summary dated 4/23/10 revealed the patient was discharged to the Skilled Nursing Unit with the following skin assessment (in part):
- Skin Risk Assessment Score 13 indicating Moderate Risk;
- right heel pressure ulcer (Deep Tissue Injury length 0.6 cm x 0.1 cm, width 1.0 cm x 1.4 cm);
- Left (no further description) pressure ulcer (Deep Tissue Injury length 0.5 cm, width 0.5 cm), dressing type Duoderm;
- Right Buttock pressure ulcer (Deep Tissue Injury length 0.5 cm, width 0.5 cm) dressing type Duoderm

On 4/24/10, the patient was re-admitted to the hospital.
Record review of the patient's Physical Assessment Admission dated 4/24/10 at 2:45 p.m. revealed the following information:
" Skin Risk Assessment Score of 14 indicating Moderate Risk, Skin Assessment Posterior Buttock, Problem Comment RED, Wound Assessment Posterior Buttock
Wound type RED, Wound Assessment - Right heel, Wound Type - SNF (skilled nursing facility) RN (Registered Nurse) reports red, Dressing Intact - Not viewed " .

Record review of the Wound/Pressure Ulcer Assessment dated 4/24/10 at 8:00 p.m. revealed the following information:
- Skin Assessment Right Heel, Problem - Redness, Problem Comment 2 x 2 cm;
- Skin Assessment Posterior Left Buttock, Problem - Redness, Problem Comment 11 x 9 Area - Blanchable;
- Skin Assessment Right Posterior Buttock, Problem - Redness, Problem Comment 8 x 5 cm - Blanchable;
" Hospital Acquired Pressure Ulcer This Admission - yes "
Conditions that Affect Wound Care - Mobility/Turning Limitations, Nutritional Status
Skin Preventative Care - Extremity Elevated, Heel Protectors, Incontinence Management, Turn/Reposition schedule Q (every) 2 hour turns, Hill Rom Specialty Low Bed.

Record review of the care plan revealed no mention of pressure sores; interventions; goals or timelines.

On 5/4/10, the patient was transferred from the acute care hospital to skilled nursing.

On 5/20/10, the patient was transferred back to the acute care hospital for possible surgical debridement of the pressure ulcer. The ulcer was full thickness and there were ulcerations on the left gluteal region and some eschar on the right that needed to be debrided (surgically removed). The ulcer was at least Stage III with the central portion and Stage II laterally with surrounding erythema (redness).

Record review of the care plan revealed no mention of pressure sores; interventions; goals or timelines.

On 5/27/10, a consult for surgical debridement of the pressure ulcer was completed. The surgical debridement was completed on 6/7/10 along with a colostomy to help prevent the soiling of the pressure sore.

Record review of the care plan revealed no update to reflect the pressure sores, interventions, goals or timelines, the debridement and/or treatment or the colostomy and care.

Record review of the facilities policy titled DOCUMENTATION OF PATIENT CARE NS-234 page 3 of 7 revised 1/10 in part revealed the following:
Patient Plan of Care
1. An initial Plan of Care is generated from the admission history and assessment for each patient. This Plan of Care is individualized, addressing identified patient needs.
2. c. Any Problems that are identified by any discipline as a result of an initial assessment or from subsequent reassessments.
3. The nurse will review and prioritize problems a minimum of every 24 hours.
a. Reassessment of the Plan of Care should include the following:
2. Review of the Plan of Care and any changes to the plan; as well as the interventions necessary to reflect changes in the patient's needs.
3. Prioritization of the patient's problems/goals, and interventions as appropriate.
4. Consideration of the patient's progress or lack of progress toward meeting the expected outcome(s), the effectiveness of interventions and the continued needs of the patient.
4. Ongoing revision of the patient Plan of Care may occur at any time. This may be done by adding additional problems, outcomes, and/or interventions to the Plan of Care ...
5. Implementation of the Plan of Care is necessary to achieve desired outcomes.

Based on interview, record review and facility policy review, the facility failed to develop comprehensive individualized care plans with measurable goals and interventions for five (Patient ' s #14, 17, 18, 21 and 23) of five; (Patient #14) regarding pain related to a fracture, dementia and constipation, (Patient #17 and #18) regarding impaired skin integrity and pain, (Patient #21) regarding impaired skin integrity and diabetes, and (Patient #23) regarding diarrhea. The facility census was 94.

Findings included:

1. Record review of the medical chart of Patient #14 revealed the patient was admitted to the facility on 6/7/10 for complaints of pain after a fall. Record review of the History & Physical Examination dated 6/7/10 in part revealed the following information:
IMPRESSION
- Left pelvic superior and inferior ramus (a group of four bones in front of the pelvis) fractures as well as sacral ala (large triangular bone at the base of the spine) fracture on the left side.
- Frontal lobe dementia with propensity toward falls.
- Chronic constipation
PLAN
- For chronic pain control we will plan on Duragesic patches (a narcotic pain medicine which is imbedded in a patch applied to the skin) for a duration of 4 to 6 weeks as she is unlikely to be able to reliably ask for pain medication at the appropriate times.
- Anticonstipation measures

Record review of the Patient's Plan of Care - Additional Problems/Interventions dated 6/8/10 in part revealed the following:

- Staff did not include in the Care Plan measurable goals, interventions or time tables related to the patient's need for Duragesic patches to control pain due to the patient's impaired cognition and inability to appropriately ask for pain medications.
- Staff did not include in the Care Plan measurable goals, interventions or time tables related to the patient's need for anticonstipation measures due to the patient's history of chronic constipation.
- Staff did not include in the Care Plan measurable goals, interventions or time tables related to the patient's impaired cognition related to dementia and high risk for falls.

During an interview on 6/8/10 at 1:45 p.m. the Nurse Manager F stated that she would expect pain, measures to prevent constipation and impaired cognition to be on the care plan with individualized interventions and she confirmed they were not.

2. Record review of the medical chart of Patient #17 revealed the patient was admitted to the facility on 6/6/10 for complaints of pain after a fall at home which resulted in a fracture of the left hip.

Record review of the History and Physical Examination dated 6/7/10 in part revealed the following information:
ASSESSMENT
- Subcapital fracture of the left femoral neck (hip fracture)
- Elevated blood pressure
PLAN
- We will have an Orthopedic consultation with physician for a left hemiarthroplasty (a surgical procedure which replaces one half of the joint with an artificial surface and leaves the other in its natural state).
- Follow her blood pressure closely. Some of that is probably elevated slight due to the pain.

Record review of the Physician's Orders dated 6/6 (no year) and (no time) in part revealed the following information:
- Morphine ( a narcotic pain medication) 2-4 mg Intravenously (IV) [by vein] q (every) 1 hour prn (as needed)

Record review of an Order by the Physician's Assistant Y dated 6/8/10 at 8:40 a.m. in part revealed the following information:

Record review of the patients Plan of Care - Additional Problems/Interventions dated 6/7/10 in part revealed the following:
- Staff did not include in the Care Plan measurable goals, interventions or time tables related to the patient's impaired skin integrity related to left hip incisions.
- Staff did not include in the Care Plan measurable goals, interventions or time tables related to the patient's pain related to the fracture of the left hip.
- Staff did not include in the Care Plan measurable goals, interventions or time tables related to the patient's elevated blood pressure.

During an interview on 6/8/10 at 2:55 p.m. Nurse Manager F stated after reviewing the Care Plan, " the expectation would be to see pain and impaired skin integrity addressed on the care plan and they were not " .

3. Record review of the medical chart of Patient #18 revealed the patient was admitted to the facility on 6/5/10 for complaints of pain related to fracture of the right femur (thigh bone) and inferior pubic rami.

Record review of the patients Plan of Care - Additional Problems/Interventions dated 6/6/10 in part revealed the following:
- Staff did not include in the Care Plan measurable goals, interventions or time tables related to the patient's impaired skin integrity related to the right femur incisions.
- Staff did not include in the Care Plan measurable goals, interventions or time tables related to the patient's pain related to the fracture of the proximal right femur and superior pubic rami..

4. Record review of the medical chart of Patient #21 revealed the patient was admitted to the facility on 6/5/10 for non healing ulcers of the lower extremities.

Record review of the History & Physical Examination dated 6/5/10 in part revealed the following information:

CHIEF COMPLAINT
Peripheral vascular disease (a condition of the blood vessels that leads to narrowing and hardening of the arteries that supply the legs and feet), non healing leg ulcers (wounds or open sores that will not heal or keep returning).
PHYSICAL EXAMINATION
EXTREMITIES: Decreased blood flow about the lower extremities. Ulcer present on the right heel with dressing -------- and mood presently and also in the left lateral (outside) aspect there is an ulcer with dressing in place in ------- mode.
SKIN: Ulcer present on the right heel and left foot.
ASSESSMENT/PLAN
1. Nonhealing ulcers bilateral feet. Will continue local care of the wound with debridement (medical removal of dead, damaged or infected tissue) and treatment.
6. Diabetes, uncontrolled. Will continue to monitor glucose(sugar) before meals and at bedtime and will adjust her insulin (a medication) dosage.

Record review of the Physician's Orders dated 6/6/10 at 11:20 a.m. in part revealed the following information:
" Pt to f/u with wound care center for cont. of his/her R (right) foot wound tx (treatment).
Wet - dry with NS (Normal Saline) [a salt water solution] BID (two times a day) till pt is seen by wound care center.
Pillows 1-2 under B (bilateral) legs
No pressure to B (bilateral) heels "

Record review of the patients Plan of Care - Additional Problems/Interventions dated 6/5/10 in part revealed the following:
- Staff did not include in the Care Plan measurable goals, interventions or time tables related to the patient's impaired skin integrity.

5. Record review of the medical chart of Patient #22 revealed the patient was admitted to the facility on 4/17/10 with a right distal femoral fracture (fracture of lower right leg).

Record review of the History and Physical Examination/Discharge Progress Note dated 5/20/10 revealed in part the following information:
Impression
1. Septicemia - Stenotrophomonas maltophilia (an uncommon bacteria and human infection)
2. Presacral decubiti (bedsore on the tailbone)
Plan
4. Continue IV Levaquin for now.

Record review of the patients Plan of Care - Additional Problems/Interventions dated 6/6/10 in part revealed the following:
- Staff did not include in the Care Plan measurable goals, interventions or time tables related to the patient ' s pressure sores or the septicemia (infection throughout the body).

6. Record review of the medical chart of Patient #23 revealed the patient was admitted to the facility on 6/1/10 for complaints of diarrhea.

Record review of the History and Physical Examination dated 6/2/10 in part revealed the following information:

HISTORY OF PRESENT ILLNESS:
...he started to have diarrhea again, 3-4 days ago, 4-5 episodes, associated with some black colored stools and some times bright red blood. ...was found to have C-difficile (Clostridium difficile is a bacteria) infection. ...started on Flagyl and Vancomycin (antibiotic drugs).
LABORATORY:
C-diff is positive.
ASSESSMENT AND PLAN:
C-difficile infection. History of recurrence. We will start the patient on Flagyl, IV fluids and monitor electrolytes.

Record review of the patients Plan of Care - Additional Problems/Interventions dated 6/2-6/10 in part revealed the following:
- Staff did not include in the Care Plan measurable goals, interventions or time tables related to the patient's diarrhea or C-difficile infection.

During an interview on 6/9/10 at 10:55 a.m. Nurse Educator K stated that care plan training for new hires is done during orientation. During a system change in the last 2 years, the Nurse Educator talked with the 2 East staff about selecting appropriate problems for the patients. He/she stated monitoring was done for a short time but no documentation was done on the monitoring and stated there is no yearly re-education.

Record review of the Nursing Service Policy and Procedure NS-234 revised 1/10 in part revealed the following information:
Patient Plan of Care
1. An initial Plan of Care is generated from the admission history and assessment for each patient. This Plan of Care is individualized, addressing identified patient needs.
2. All Plans of Care contain:
c. Any Problems that are identified by any discipline as a result of an initial assessment or from subsequent assessments.
3. The nurse will review and prioritize problems a minimum of every 24 hours.
a. Reassessment of the Plan of Care should include the following:
1. Consideration of the biophysical, psychosocial, environmental, nutritional, self-care, educational and discharge planning factors affecting the patient's care needs.
2. Review of the Plan of Care and any changes to the plan; as well as the interventions necessary to reflect changes in the patient' needs.
3. Prioritization of the patient's problems/goals, and interventions as appropriate.
4. Consideration of the patient's progress or lack of progress toward meeting the expected outcome(s), the effectiveness of interventions and the continued needs of the patient.
5. Ongoing revision of the patient Plan of Care may occur at any time.

Record review of the facility policy DOCUMENTATION OF PATIENT CARE NS-234 revised 1/10 in part revealed the following information:
PATIENT PLAN OF CARE
1. An initial Plan of Care is generated from the admission history and assessment for each patient. This Plan of Care is individualized, addressing identified patient needs.
2. All Plans of Care contain:
C. Any Problems that are identified by any discipline as a result of an initial assessment or from subsequent reassessments.
3. The nurse will review and prioritize problems a minimum of every 24 hours.
a. Reassessment of the Plan of Care should include the following:
1. Consideration of the biophysical, psychosocial, environmental, nutritional, self-care, educational, and discharge planning factors affecting the patient's care needs.
2. Review of the Plan of Care and any changes to the plan; as well as the interventions necessary to reflect changes in the patient's needs.
3. Prioritization of the patient's problems/goals, and interventions as appropriate.
4. Consideration of the patient's progress or lack of progress toward meeting the expected outcome(s), the effectiveness of interventions and the continued needs of the patient.
4. Ongoing revision of the patient Plan of Care may occur at any time. This may be done by adding additional problems, outcomes, and/or intervention to the Plan of Care through the Process Plans routine.
5. Implementation of the Plan of Care is necessary to achieve desired outcomes.


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Based on observation, interview, record and policy review the facility failed to ensure staff follow the physician ' s order when giving medication by tube instead of by mouth for one (Patient #22) of four patients observed.

Findings Included:

1. Record review of Patient #22's medical record revealed the patient was admitted to the facility on 4/17/10 for a fractured leg.

Observation on 6/9/10 at 9:15 a.m. revealed Registered Nurse J crushed medications and administered the medications through the Percutaneous Gastrostomy (PEG) tube (a tube inserted into the patient ' s stomach).

Record review of the medication orders dated from 5/22/10 to 6/7/10 revealed the medications were ordered PO (to be given by mouth).

Record review dated 6/2/10 at 9:11 a.m. revealed an order had been given by the Physician's Assistant as follows:

-Switch as many meds as possible to liquid; may crush other meds and give all through PEG tube.

During an interview on 6/9/10 at approximately 10:10 a.m. (after reviewing the medical chart, the physician's orders and checking the electronic record), Nurse Manager F stated that the order had not been communicated through the system as it should have been.

Record review of the facility's Policy and Procedure Guidelines for Giving Medications NS-202 revised 3/09 in part revealed the following information:
Planning:
2. Check accuracy and completeness of each MAR (medication administration record) with prescriber's written medication order. Check client's name, drug name and dosage, route of administration and time for administration. Compare MAR with medication label.

Based on interview and record review the facility failed to ensure the Medical staff authenticate physician's orders by either not sighing, and/or dating and/or timing in five (Patient ' s #17, 18, 21, 22 and 23) of five in-patients charts reviewed. The facility census was 94.

Findings Included:

1. Record review of Patient #17's medical chart in part revealed the patient was admitted to the facility on 6/6/10 with a fractured hip.
-Record review of Post-Procedure Medication Continuation Physician Order dated 6/7/10 revealed no date or time of authentication by the physician.
-Record review of the Physician's Orders dated 6/6/no year revealed no time of the physicians authentication.
-Record review of the verbal order dated 6/6/no year revealed no authentication of signature, date or time.
-Record review of the Deep Vein Thrombus (DVT) [blood clots] dated 6/8/10 at 8:45 p.m. with a risk score of 5 (High Risk) revealed no authentication of physicians signature, date or time.

2. Record review of the medical chart of Patient # 18 revealed in part the patient was admitted to the facility for a fractured right hip.
-Record review of the Post-Procedure Medication Continuation Physician Order dated 6/6/10 revealed no date or time of authentication by the physician.
-Record review of the Post Anesthesia Care Unit (PACU) [care for patients who are recovering from anesthesia] Orders dated 6/6/10 revealed no time of authentication by the physician.
-Record review of the Admission'/Discharge Medication Continuation Physician Order dated 6/5/10 revealed no date or time of the authentication by the physician.
-Record review of the Physician's Orders dated 6/5/10 revealed no time of authentication by the physician.

3. Record review of the medical chart for Patient # 21 revealed the patient was admitted to the facility on 6/4/10 for non healing ulcers of the lower extremities.
-Record review of the Physician's Orders dated 6/5/10 at 12:27 p.m. revealed no authentication including signature, date or time by the physician.
-Record review of the verbal order for Admission'/Discharge Medication Continuation Physician Order dated 6/4/10 revealed no authentication of signature, date or time by the physician.

4. Record review of the medical chart of Patient #22 revealed the patient was admitted to the facility on 4/17/10 for a broken leg.
-Record review of the Physician's Orders dated 5/20/10 10:10 p.m. revealed no authentication including signature, date or time of the DVT Prevention Orders.
-Record review of the Physicians's Orders Hold TF; RT to eval (evaluation). t (sic) tx; CXR (chest x ray) revealed no date or time of authentication.
-Record review of the Post-Procedure Medication Continuation Physician Order dated 5/21/10 at 12:38 a.m. revealed no date and time of authentication.
-Record review of the Physician's Orders dated 5/29/10 revealed no time of authentication
-Record review of the Physician's Orders dated 6/5/10 and 6/9/10 revealed no time of authentication.

5. Record review of the medical chart of Patient #23 revealed the patient was admitted to the facility on 6/1/10 for diarrhea and Clostridium Difficile (C-diff) infection (a bacteria in the stool).
-Record review of the Physician's Orders dated 6/8/ (no year)
-Record review of the Admission/Discharge Medication Continuation Physician Order dated 6/1/10 revealed no authentication of date or time by the physician.

During an interview on 6/8/10 at 2:55 p.m. Nurse Manager F stated all orders should be signed, dated and timed by the physician.

Record review of the Medication Safety Policy 112-180-28 effective date 3/16/10 in part revealed the following information:

I. All Medication Orders
The following are elements of a complete medication order:
-Date and time
-The physician must sign the scripted order immediately, otherwise it is a verbal order.

Based on observation and interview the facility failed to ensure staff follow the facility policies when staff did not cleanse their hands when entering and/or leaving the patient's room, after removing gloves and when administering oral medications; and failed to apply gloves while aspirating, flushing and administering medications through a PEG tube (Percutaneous endoscopic gastrostomy )and when administering oral medications. The facility census was 94.
Findings included:

Observation on 6/8/10 at 3:03 PM revealed Staff P, Patient Care Technician (PCT) failed to wash or sanitize hands before, between, or after he/she:
-walked into a semi-private room and assisted the patient in bed A to the bathroom;
-touched the patient's visitors back;
-turned off the patient call light;
-touched the patient in bed B on the hand;
-left the room.
At 3:07 PM, PCT P failed to wash or sanitize hands when he/she:
-re-entered the room;
-assisted the patient in bed A from the bathroom back to bed;
-picked up a chair and removed it from the room.

Observation on 6/8/10 at 3:12 PM showed Staff Q, PCT, failed to wash or sanitize hands before, between, or after he/she:
-entered room 138 and turned off the call light;
-touched the patient's arm;
-entered room 130 and placed gloves on to dump urine;
-picked up the patient's gown and exited the room with the same gloves on;
-touched the dirty linen door handle and entered with the same gloves;
-exits the dirty utility room with gloves on and returned to room 130;
-picked up the patient's water pitcher, left room, and returned with filled water pitcher, gloves still on.

Observation on 6/8/10 at 3:32 PM showed signs posted on patient doors which stated, "Wash your hands before and after touching patients".

During an interview on 6/8/10 at 3:23, Staff Q, PCT stated he/she does not always wash hands between patients. The PCT stated he/she does not wash hands between patients when completing vital signs. The PCT also stated they carry linen out of the room with gloves on because they don't have dirty linen bags in the patient rooms.

During an interview on 6/8/10 at 3:42 PM, Staff P, PCT stated he/she does not always wash hands between patients when completing vital signs.

Observation on 6/9/10 at 8:40 a.m. revealed Registered Nurse (RN) I donned gloves to administer oral medications to the patient. The medications were administered and the RN removed the gloves and left the room. No handwashing with soap and water or hand cleanser was observed prior to gloving, following the removal of gloves and/or prior to leaving the patient ' s room.

Observation on 6/9/10 at 8:55 a.m. revealed RN I entered the patient's room without donning the required Personal Protection Equipment (PPE) of gloves, gown and mask as required for a patient on contact isolation with a diagnosis of Clostridium-difficile (a harmful bacteria in stool that is easily spread by contact).

Observation on 6/9/10 at 9:00 AM showed Staff Y, RN did not wash hands prior to administering medications to Patient #25.

Observation on 6/9/10 at 9:05 a.m. revealed RN J left the patient's room after administering medications without cleansing his/her hands with soap and water or hand cleanser.

Observation on 6/9/10 at 9:15 a.m. revealed RN J reentered the patient's room without cleansing his/her hands with soap and water or hand cleanser. The RN then proceeded, without wearing gloves, to lift the split 4x4 guaze which covered the insertion site of the Percutaneous endoscopic gastrostomy (PEG) tube ( a tube placed in the stomach) and was observed to have scant serous (pale yellow and transparent) drainage. He/she then administered a subcutaneous injection( an injection into the layer of skin directly below the skin) of Lovenox (an anticoagulant drug to help prevent blood clots); and put water from the faucet into a graduated container; and aspirated (drew up) fluid from the PEG tube. He/she removed the plunger and poured water in the tube. The crushed medications were then instilled per the PEG tube. No gloves were worn.

During an interview on 6/9/10 at 1:05 p.m. Occupational Health and Safety L stated that the expectation would be all staff would wash their hands with soap and water or hand cleanser when entering and leaving a patents's room and to wear gloves when handling anything which might splash such as a Percutaneous Endoscopy Gastrostomy (PEG) tube (a tube which is placed into a patient stomach).

Record review of the Infection Control Policy Regarding Hand Hygiene IC-A-9 date approved 6/04 in part revealed the following information: Policy Regarding Hand Hygiene, Opportunities for Hand Hygiene
All personnel are encouraged to decontaminate their hands periodically throughout their shift. In addition to traditional hand washing with antimicrobial soap and water, the Center for Disease Control (CDC) recommends the use of alcohol-based hand rubs.
I. Decontaminate hands at the following times:
d. Before gloving and after gloving
e. Before and after contact with patient's intact skin
f. Contact with environmental surfaces in the immediate vicinity of patients.
G. Before and after each patient contact
h. After handling contaminated objects
i. Before handling medications
II. Always wash hands with soap and water when hands are visibly soiled or exposed to blood and body fluids.

Record review of the Infection Control, Placement of Patients on "Isolation Precautions" revised 7/01 in part revealed the following information:
Policy Statement
This manual, "Guidelines for Isolation Precautions in Hospital," has been adopted by the Infection Control Committee and approved by the Medical Staff of Lake Regional Health System for use as the official guide for isolation procedures.
Purpose
To provide a workable guide to the hospital staff for the care of patients with potentially communicable diseases and to protect patients with diminished resistance to infection from unnecessary exposure to a potentially contaminated environment.

Record Review of the Clinical Nursing Skills & Techniques 6th edition which was provided by the facility in part states the following information: Equipment: Disposable gloves
Planning
5. Apply clean gloves
14. Remove gloves. Perform hand hygiene


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