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Based on observation, interview and record review the facility failed to administer medications within the accepted standard of 30 minutes before and 30 minutes after the prescribed medication administration times affecting all of the patients in the facility. The facility also failed to include the standard of practice in the nursing administration policies and procedures. The patient census at the time of survey was 85.

Findings included:

1. Observation on 09/08/10 at 7:30 a.m. in the medication room on the third floor revealed that Staff C, RN, procured medications for Patients #2, 3 and 5 for scheduled administration times 8:00 a.m. through 10:00 a.m.

During an interview on 09/08/10 at 7:30 a.m. in the medication room on the third floor, Staff C, RN, stated medications could be administered to patients one hour before until one hour after the scheduled medication administration times printed on the MAR (Medication Administration Record) so he/she could give the 10:00 a.m. medications beginning at 9:00 a.m.

Record review of the PATIENT CARE DEPARTMENT PATIENT CARE PROCEDURE MANUAL titled MEDICATIONS, ADMINISTRATION OF dated 01/19/10 reference number: 100-123, page 2, on 09/08/10 at 9:00 a.m. revealed, in part, the following:

MEDICATION ADMINISTRATION TIMES

2. Medications ordered around the clock, e.g., Q6, Q8, etc. can be given in a window of one (1) hour before or one (1) hour after time due.
3. Ordered medication should be administered within two (2) hours after the initial order is written.

During an interview on 09/08/10 with Staff A, Vice President, Patient Care Administration and Staff B, Ph.D., Pharmacy Director acknowledged the accepted standard of practice for medication administration was 30 minutes before and 30 minutes after stated medication administration times recorded on the MAR and that their current policies, procedures, and nursing practices did not follow this accepted standard.

Based on observation, record review and interview the facility failed to follow the CDC (Centers for Disease Control and Prevention) Guidelines of hand hygiene by not using hand hygiene after glove removal or in between glove changes and failed to use hand hygiene during patient care for four patients (#2,3,4,5) of four patients observed. The facility census at the time of survey was 85.

Findings included:

1. Record review of the Guideline for Hand Hygiene in Health-Care Settings Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force dated October 25, 2002 / 51(RR16);1-44, reveals, in part, " Although recent studies indicate that improvements have been made in the quality of gloves (366), hands should be decontaminated or washed after removing gloves (8,50,58,321,361).
Recommendations
1. Indications for handwashing and hand antisepsis
A. When hands are visibly dirty or contaminated with proteinaceous material 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 (IA) (66).
B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C--J (IA) (74,93,166,169,283,294,312,398). Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items 1C--J (IB) (69-71,74).
C. Decontaminate hands before having direct contact with patients (IB) (68,400).
D. Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter (IB) (401,402).
E. Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure (IB) (25,403).
F. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient) (IB) (25,45,48,68).
G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled (IA) (400).
H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care (II) (25,53).
I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient (II) (46,53,54).
J. Decontaminate hands after removing gloves (IB) (50,58,321).

Gloving Policies
CDC has recommended that HCWs wear gloves to 1) reduce the risk of personnel acquiring infections from patients, 2) prevent health-care worker flora from being transmitted to patients, and 3) reduce transient contamination of the hands of personnel by flora that can be transmitted from one patient to another (354). Before the emergence of the acquired immunodeficiency syndrome (AIDS) epidemic, gloves were worn primarily by personnel caring for patients colonized or infected with certain pathogens or by personnel exposed to patients with a high risk of hepatitis B. Since 1987, a dramatic increase in glove use has occurred in an effort to prevent transmission of HIV and other bloodborne pathogens from patients to HCWs (355 ). The Occupational Safety and Health Administration (OSHA) mandates that gloves be worn during all patient-care activities that may involve exposure to blood or body fluids that may be contaminated with blood (356).
The effectiveness of gloves in preventing contamination of HCWs' hands has been confirmed in several clinical studies (45,51,58). One study found that HCWs who wore gloves during patient contact contaminated their hands with an average of only 3 CFUs per minute of patient care, compared with 16 CFUs per minute for those not wearing gloves (51). Two other studies, involving personnel caring for patients with C. difficile or VRE, revealed that wearing gloves prevented hand contamination among the majority of personnel having direct contact with patients (45,58). Wearing gloves also prevented personnel from acquiring VRE on their hands when touching contaminated environmental surfaces (58). Preventing heavy contamination of the hands is considered important, because handwashing or hand antisepsis may not remove all potential pathogens when hands are heavily contaminated (25,111).
Several studies provide evidence that wearing gloves can help reduce transmission of pathogens in health-care settings. In a prospective controlled trial that required personnel to routinely wear vinyl gloves when handling any body substances, the incidence of C. difficile diarrhea among patients decreased from 7.7 cases/1,000 patient discharges before the intervention to 1.5 cases/1,000 discharges during the intervention (226). The prevalence of asymptomatic C. difficile carriage also decreased substantially on "glove" wards, but not on control wards. In intensive-care units where VRE or MRSA have been epidemic, requiring all HCWs to wear gloves to care for all patients in the unit (i.e., universal glove use) likely has helped control outbreaks (357,358).
2. Record review of CAPITAL REGION MEDICAL CENTER INFECTION CONTROL/EMPLOYEE HEALTH MANUAL titled Exposure Control Plan and Standard Precautions, Policy: Article 4, Section B, Number 1 last revised 06/2009 revealed, in part:
Contact Precautions - Use for patients known or suspected to be infected with microorganisms transmitted by direct contact with the patient (hand or skin-to-skin contact) or indirect contact (touching) with environmental surfaces or patient-care items.

Example Diseases: MRSA, VRE, C. Diff, Scabies, RSV

2. Wear gloves upon entrance to room and at all times, change gloves after contact with infective material (fecal material, wound drainage).
3. Wash hands with soap or alcohol based rinseless agent upon leaving the room taking care not to touch environmental surfaces.
7. Use additional precautions for preventing the spread of MRSA and vancomycin resistance (refer to MRSA and Vancomycin Resistant Enterococcus policies).

PERSONAL PROTECTIVE EQUIPMENT (PPE)

Gloves - shall be worn when contact with blood, mucous membranes, non-intact skin or other potentially infectious materials is likely. Gloves must be removed and replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when the barrier properties are compromised. With the exception of reusable utlity gloves, gloves should never be washed or decontaminated for reuse. Gloves must be worn when performing venipuncture or vascular access procedures and when handling or touching items or surfaces that are contaminated.

3. Observation on 09/08/10 at 7:50 a.m. showed Staff C, RN, enter the room of Patient #5. Staff C did not perform hand hygiene upon entering room and proceeded to touch the cup, straw, juice carton, and utensils on the patient ' s breakfast tray. Staff C performed hand hygiene before leaving the room.

4. Observation on 09/08/10 at 8:00 a.m. showed Staff C, RN, enter the room of Patient #2. Staff C performed hand hygiene upon entering the room; nurse administered medication to the patient but exited the patient ' s room without performing hand hygiene.

5. Observation on 09/08/10 at 8:10 a.m. showed Staff C, RN, enter the room of Patient #3. Staff C explained Patient #3 was suspected of having MRSA (Methicillin-resistant Staphylococcus aureus is a bacterium (bacteria) responsible for several difficult-to-treat infections in humans) in he/she ' s leg wound. A contact isolation sign was posted outside of the patient ' s room. Staff C performed hand hygiene upon entering the room but did not don gloves. Staff C began to administer oral medications but the patient ' s water receptacle was empty. Staff C left the room without performing hand hygiene, then went to the sink outside the patient ' s room and returned to the room with a full cup of water and did not perform hand hygiene. Staff C proceeded to give the oral medication, returned to the portable computer in the room and typed on the keyboard, picked up the IV (intravenous - within the vein) medication, walked over and touched the patient ' s clothes, bare arm, and IV portal (opening), hung the bag of medication and attached it to the IV line. Staff C washed her hands and exited the room with the portable computer.

6. Observation on 09/08/10 at 10:30 a.m. revealed Staff F, RN, Wound Care Nurse and Staff G, LPN, enter the room of Patient #4 and perform hand hygiene and don gloves in preparation of wound care on the patient ' s thigh attaching a wound vac (Negative pressure wound therapy (NPWT), also known as topical negative pressure, sub-atmospheric pressure dressings or vacuum sealing technique, is a therapeutic technique used to promote healing in acute or chronic wounds, fight infection and enhance healing). Staff F removed old bandage with bloody drainage and sponge (used to absorb drainage and keep the wound bed dry) within the wound that upon removal emitted a foul odor. Staff F irrigated the wound with saline water and patted it dry with clean gauze pads and proceeded to measure the wound. Staff F then removed her gloves - but did not perform hand hygiene - and donned a new pair of gloves to apply the clean bandages for the wound vac.

In an interview with Staff A, RN, MSN, Vice President, Patient Care Administration on 09/08/10 at 11:00 a.m. it was stated that Staff F, RN, Wound Care Nurse is the only wound nurse that circulates throughout the hospital performing wound care.

Record review of the current patient work load for Staff F revealed she is currently performing patient care for 35 patients with wounds of the 85 patients in the hospital at the time of survey.

7. During an interview on 09/07/10 at 1:35 p.m. with Staff A, RN, MSN, Vice President, Patient Care Administration and Staff E, RN, BSN, CIC-ICN, it was stated that Nursing Services adheres to CDC Guidelines.