HospitalInspections.org

Based on hospital policy and procedure review, observations during tour and staff interview, the hospital's respiratory therapy staff failed to perform hand hygiene prior to administration of respiratory medications in 1 of 2 observed patients (#14).

The findings include:

Review of hospital policy"Hand Hygiene" last revised 03/2019 revealed "PROCESS Hand Hygiene Indications...4. After touching a patient 5. After touching a patient surroundings..."

Observation during tour on 01/15/2020 at 1130 revealed Respiratory Therapist #1(RT#1) performed hand hygiene, placed on gloves, opened area for medication administration of respiratory medication on ventilator circuit and performed patient assessment. Observation revealed the RT #1 continued to administer the medications via ventilator without performing hand hygiene after touching the patient. Observation further revealed RT #1 placed unopened clean supplies in the room without performing hand hygiene or change of gloves.

Interview during observation on 1/15/2020 at 1130 with RT #1 revealed she believed she did not have perform hand hygiene or to change gloves as long as she was careful not to touch the top of tube of medication being administered. Interview revealed she was taught everything in the room was considered "dirty" and always just used a set of gloves for her assessment and medication administration.

Interview with the Infection Control Practioner on 1/15/2020 at 1130 during the observation confirmed hand hygiene should have been performed after touching the patient.

NC00158716; NC00159054; NC00158533; NC00156863; NC00155577; NC00154548; NC00153443