HospitalInspections.org

Based on observation and document review, it was determined that facility staff failed to ensure methods for preventing and controlling the transmission of infections during two (2) infection control observations.

The findings include:

On April 7, 2021 between 1:00 p.m. and 2:00 p.m., "diabetic protocol" was observed on unit 6 A.

At 1:20 p.m., Staff Member # 13 was observed assisting Patient # 12 with a blood sugar check and insulin administration. Staff Member # 13 donned clean gloves and prepared insulin. Staff Member # 13 picked up a pen from the nursing station counter and documented in Patient # 12's notebook while wearing dirty gloves. Staff Member # 13 removed the dirty gloves and failed to perform hand hygiene. Staff Member # 13 picked up the dirty pen from the nursing station with dirty hands and documented on the medication administration record (MAR). Staff Member # 13 failed to clean and disinfect the dirty pen and the nursing station counter.

At 1:40 p.m., Staff Member # 13 was observed assisting Patient # 13 with a blood sugar check and insulin administration. Staff Member # 13 donned clean gloves and prepared insulin. Staff Member # 13 touched face mask with dirty gloves. Staff Member # 13 failed to change mask after touching. Staff Member # 13 then removed dirty gloves and placed the dirty gloves on the nursing station counter. Staff Member # 13 picked up the dirty pen with bare hands and documented on MAR. Staff Member # 13 then picked up the dirty gloves from the nursing station counter and placed in the trash. Staff Member # 13 failed to perform hand hygiene or clean and disinfect the dirty pen and the nursing station counter.

On April 7, 2021, a review of the facility policy titled "Infection Control" with Staff Member # 16 revealed "Hand hygiene should be performed after glove removal. Contaminated surfaces should be cleaned and disinfected."

According to the Center for Disease Control (CDC) guidelines "Masks are worn to help stop droplets from being spread by the person wearing the mask. They also keep splashes or sprays from reaching the mouth and nose of the person wearing the mask. The mask should fully cover the nose, mouth and chin to prevent fluid penetration. The front of the mask should not be touched. If the front of the mask is touched, hand hygiene should be performed or the mask should be changed.

The findings were discussed with Staff Members # 1, # 2, # 3 and # 4 during the exit interview on April 8, 2021 at 2:30 p.m.