HospitalInspections.org

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on review of facility policy, observation and interview with facility administrative staff, it was determined Employee Identifier (EI) # 2, Registered Nurse (RN) failed to follow the facility policy for hand washing. This affected Patient Identifier (PI) # I and had the potential to negatively affect all patients served by this facility.

Findings include:


Policy/Procedure Title: Hand Hygiene
Review/Revised Date(s): 5/13

" Purpose: To reduce the risk of transmission of infection by appropriate hand hygiene.
To ensure compliance with the current CDC (Centers for Disease Control) hand hygiene guidelines.

Policy: Hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections... Although antiseptics and other hand hygiene agents do not sterilize the skin, they can reduce microbial contamination depending on the type and the amount of contamination, the agency used, the presence of residual activity and the hand hygiene technique followed.

G. Decontaminate hands after contact with body fluids or excretions...

I. Decontaminate hands after contact with an inanimate objects (including medical equipment) in the vicinity if the patient.

J. Decontaminate hands after removing gloves...

II. Handwashing

When hands are visibly dirty or contaminated or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water.

A. Turn on water...

B. Moisten hands with soap and water and make a heavy lather.

C. Wash well under running water...

D. Rinse hands well under running water.

E. Turn off faucet with paper towel and discard.

F. Dry hands with a clean paper towel and discard.


On 7/16/14 at 10:50 AM, the surveyor observed EI # 2, RN provide wound care for PI # 1. During this observation, the surveyor observed EI # 2 washed her hands at the patient's sink with soap and water. EI # 2 turned the faucet off with her wet hands. There were no paper towels in the patient's room. EI # 2 allowed her hands to air dry, opened a new sterile Normal Saline bottle, then donned clean gloves. EI # 2 removed the dressing and steri-strips to PI # 2's wrist wound which contained bloody drainage. EI # 2 removed her gloves and donned clean gloves. EI # 2 did not perform hand hygiene after removal of the soiled dressing and gloves and before donning clean gloves. EI # 2 cleaned the patient's wound with Normal Saline, then removed her gloves. EI # 2 did not perform hand hygiene. EI # 2 opened new steri-strips, donned clean gloves, applied the steri-strips. EI # 2 removed her gloves, applied 4 by 4 gauze, Kerlix and secured the dressing with tape. EI # 2 washed her hands at the patient's sink with soap and water and turned the faucet off with her wet hands.


EI # 2 failed to use a paper towel to turn the faucet off after washing her hands with soap and water. EI # 2 failed to perform hand hygiene after removal of dirty gloves and before donning clean gloves. EI # 2 also failed to wear gloves during the application of 4 by 4 gauze.

An interview was conducted on 7/17/14 at 2:00 PM with EI # 1, Director of Nurses, who verified EI # 2 failed to follow acceptable procedure for wound care and hand washing.



Tonya Blankenship, RN
Jackie Asher, RN




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