HospitalInspections.org

33810


During the revisit survey completed 8/18-8/19/15, non-compliance was determined in the standard level for C0276.

Based on observation, interview and record review the facility failed to ensure that 2 of 4 nurses completed hand hygiene during the preparation and administration of 16 medications. Finding include:

During an observation on 8/18/15 at mid-day, staff member C, RN, prepared and administered patient #15's cefazolin antibiotic (2 grams for reconstitution for intravenous infusion). Staff member C had not completed hand hygiene and worked with ungloved hands. Staff member C popped the sterile cap off the cefazolin bottle, and used a syringe with a blunt needle to remove sterile normal saline from the port of the 100 cc intravenous bag.

During an interview on 8/18/15 at 4:30 p.m., staff member C, stated hand hygiene should be completed before handling medications.

During an observation on 8/19/15 at 10:30 a.m., staff member D, RN, prepared and administered patient #12's Protonix (40 mg/10 ml per through intravenous push). Staff member D had not completed hand hygiene and worked with ungloved hands. Staff member D popped the sterile cap off the Protonix bottle. Staff member D applied and removed exam gloves during the Protonix preparation. Staff member D entered patient #12's room and applied and removed exam gloves to administer the Protonix. Staff member D did not complete hand hygiene prior to starting the medication preparation, twice before applying her gloves, or twice after removing her gloves.

During an observation on 8/19/15 at 9:45 a.m., Staff member D, washed her hands to prepare patient # 9's oral medications (aspirin, folic acid, zoloft, and thiamine). Staff member D administered patient #9's medications and left the room without completing hand hygiene.
Staff member D returned to the nursing station and prepared patient #9's cefepime antibiotic (2 gram for reconstitution for intravenous infusion). Staff member D applied and removed her exam gloves four times during the preparation and administration of the cefepime antibiotic, and exited patient #9's room and did not complete hand hygiene.

During an observation on 8/19/15 at 10:45 a.m., Staff member D, obtained patient # 9's medications from the CERNER system (lovenox 40 mg/0.4 ml injection and duoneb 3 ml).
Staff member D had not completed hand hygiene and worked with ungloved hands.
Staff member D enter patient # 9's room and applied exam gloves and set-up the duoneb for inhalation and administered the lovenox injection subcutaneous into the patient's abdomen. Staff member D removed her gloves and exited the room. No hand hygiene was completed.

During an observation on 8/19/15 at 11:30 a.m., Staff member D, prepared and administered patient # 9's vancomycin antibiotic (1 gram for reconstitution for intravenous infusion). Staff member D completed hand hygiene prior to starting the medication preparation. Staff member D applied and removed exam gloves during the vancomycin preparation. Staff member D entered patient #12's room and applied and removed exam gloves to administer the vancomycin. Staff member D exited patient #9's room and returned with vital sign equipment and assessed the patient's temperature, heart, oxygen saturation, and blood pressure. Staff member D removed patient #9's nasal canula from his nose, and then exited the room with the vital sign equipment and charted in the electronic chart. Twice, staff member D did not complete hand hygiene before applying her gloves, or twice after removing her gloves, and after having direct contact with resident #9's intact skin and inanimate objects in the patient's vicinity.

During an interview on 8/19/15 at 2:55 p.m., staff member D, stated hand hygiene should be completed before you go into a patient's room and when you exit a patient's room, before applying gloves, and after removing gloves. Staff member D stated she probably missed completing hand hygiene a few times today, and that she relied on exam gloves for infection control.

During an interview on 8/19/15 at 4:25 p.m., staff member B, QA Director, stated hand hygiene should be completed before and after medication administration, and before and after removing gloves.

Record review of the facility's policy titled, Hand Hygiene, reflected hand antisepsis should be completed before and after:
-Having direct contact with patients
-Donning exam and sterile gloves
-Removing gloves
-Contact with inanimate objects.