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HOLY FAMILY MEDICAL CENTER
INFECTION CONTROL PROGRAM
Tag No.: A0749
A. Based on document review, observation and interview, it was determined that for 1 of 1 (E#2) Respiratory Therapist observed on the 3 South nursing unit, the Hospital failed to ensure staff removed their facial masks when leaving one isolation room and prior to entering another.
Findings include:
1. The Hospital policy titled, "Standard Precautions (approved 7/27/17)" was reviewed on 12/11/17. The policy included, " Masks ... are used when it is reasonably anticipated that ... nose, and mouth will be splashed with blood or body fluids."
2. During an observational tour of the 3 South nursing unit on 12/11/17 at 10:10 AM, E#2 was observed leaving room 374 (patient on isolation), walking down the hall, and entering room 386 (patient on isolation) without changing the facial mask.
3. During an interview on 12/11/17 at 10:15 AM, the Manager of 3 South (E#3) stated, "the mask should have been removed when exiting the first room and a new one applied before entering the next room."
B. Based on document review, observation and interview, it was determined that for 1 of 1 (E#11) Dialysis Nurse observed in the Intensive Care Unit (ICU), the Hospital failed to ensure gloves were changed and hand hygiene performed per policy.
Findings include:
1. The Hospital policy titled, "Standard Precautions (approved 7/27/17)" was reviewed on 12/11/17. The policy required, "Gloves are changed after contact with each patient. Perform hand hygiene prior to changing gloves. Change gloves during patient care if going from contaminated site to a clean site..."
2. During an observational tour of the ICU on 12/13/17 at 9:20 AM, E#11 was observed adjusting the dialysis machine, entering information into the computer, using a portable bar code device and returning to adjust the dialysis machine without removing gloves or performing hand hygiene.
3. During an interview on 12/13/17 at 9:30 AM, the Dialysis Team Leader (E#8) stated that E #11 should have changed gloves and performed hand hygiene when going from the dialysis machine to the clean computer.