HospitalInspections.org

Based on observation, policy review, job description review and staff interview, it was determined that for 3 of 6 patient observations (Patient #'s 2, 3 and 7), staff failed to follow the hospital's infection control policies. Findings include:

The hospital job description entitled "Infection Preventionist" stated, "...ensures regulatory compliance for...education and practice standards...assures compliance with...regulations..."

The hospital policy entitled "Standard Precautions" stated, "...Personal protective equipment (PPE)...Gloves are worn when it is expected that contact with blood or body fluids may occur...Gloves are removed after contact with a patient...Patient-care equipment that may be contaminated with blood or body fluids are handled in a manner that prevents...exposures...and transfer of microorganisms to other patients and environments..."

The hospital policy entitled "Transmission-Based Precautions" stated, "...Contact precautions are used for patients...that represent an increased risk for contact transmission and for those with multidrug-resistant organism (MDRO) infection...Gloves are donned upon entry...A gown is donned upon entry into the room or cubicle...Gown is removed and hands are cleaned before leaving the patient-care environment...When common use of equipment for multiple patients is unavoidable, such equipment is cleansed and disinfected before use on another patient..."

A. On 8/7/14 at 10:28 AM, the following was observed during the care of Patient #7 provided by registered nurse (RN) A in the emergency department (ED):

- exited Room #18 wearing PPE/gloves
- walked to nurses' station carrying paperwork- placed paperwork on the nurses' counter
- touched inanimate objects in the area
- removed gloves
- sanitized hands
Interview with RN A on 8/7/14 at 10:29 AM revealed that he/she did not remove gloves after providing direct patient care in Room #18.

Director of Emergency Services A, present at the time of observation, confirmed this finding on 8/7/14 at 10:29 AM.

B. On 8/7/14 at 10:30 AM, a "Contact Precautions" sign which stated, "anyone entering this room must wear: gloves...gown..." was observed outside ED Room #16. On 8/7/14 at 10:31 AM, the following was observed in ED Room #16 during the care of Patient #2 provided by Phlebotomist A:

- Phlebotomist A was in Room #16 without a gown
- phlebotomy basket, which contained phlebotomy supplies and Patient #2's specimen, was on bedside table
- removed gloves
- sanitized hands
- exited Room #16 with phlebotomy basket

Interview with Phlebotomist A on 8/7/14 at 10:43 AM confirmed the following:

- he/she was not aware of the contact precautions protocol implemented for Patient #2
- the phlebotomy basket should not have been taken into a room identified as requiring contact precautions

On 8/7/14 at 12:26 PM, Director of Emergency Services A, present at the time of observation, confirmed these findings.

C. On 8/7/14 at 10:55 AM, a "Contact Precautions" sign which stated, "anyone entering this room must wear: gloves...gown..." was observed outside ED Trauma Room A. On 8/7/14 at 10:56 AM, the following was observed in Trauma Room A during the care of Patient #3:

Scribe A:
- entered room without gloves
- entered information on computer keyboard

Scribe A failed to:
- don gloves prior to entering Trauma Room A

On 8/7/14 at 10:57 AM, Director of Emergency Services A, present at the time of observation, confirmed this finding.

D. On 8/7/14 at 11:05 AM, a "Contact Precautions" sign which stated, "anyone entering this room must wear: gloves...gown..." was observed outside ED Trauma Room A. On 8/7/14 at 11:06 AM, the following was observed outside Trauma Room A after Physician A provided care to Patient #3:

- exited Trauma Room A wearing yellow gown
- walked to nurses' station
- removed yellow gown
- returned to Trauma Room A carrying gown in hands

Physician A failed to:
- remove gown prior to exiting room

On 8/7/14 at 11:06 AM, Performance Improvement Analyst A, present at the time of observation, confirmed this finding.

During an interview with Infection Preventionist A on 8/7/14 between 3:09 PM and 3:38 PM, the observations and findings were discussed. Infection Preventionist A confirmed that RN A, Phlebotomist A, Scribe A and Physician A failed to adhere to the hospital's infection control policies for standard and contact precautions.