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16655 SOUTHWEST FREEWAY

SUGAR LAND, TX 77479

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on observation and interview, the facility failed to uphold their policy related to handwashing to ensure patients (ID #8,9, 10) receive care in a safe setting.

Findings include:

Review of facility policy titled "Hand Hygiene and Artificial Nails" revised 04/08/2021 stated:
Appropriate hand hygiene practice is the single most important factor in preventing the transmission of pathogens. Procedure: Hand Hygiene is indicated upon entering a patient's room, even if patient contact is not anticipated.

Observation on 12/06/2022 at 1100 in the medical intensive care unit revealed two staff members (staff ID #60, 62) and one visitor going in and out of patient rooms (ID # 8,9,10) without gelling in and out.

Interview on 12/06/2022 at 1130 with the quality manager (staff ID# 51), confirmed that staff did not follow the facility policy and did not gel in and out when entering and leaving patient's (ID #8,9,10) room.