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Based on observation, interview, and record review, the facility failed to ensure the Infection Control Plan - Hand Hygiene Policy, was being followed by all staff.

This deficient practice had the likelihood to cause harm in all patients.

Findings Include:

1. Observation made 3/24/20 in the Emergency Room at 10:15 a.m.

A non-clinical staff member observed entering the room of a patient in the emergency room. This staff member did not use the provided alcohol-based hand sanitizer outside of this room prior to entering the room. A few minutes later the door to the room opened and the same non-clinical staff member exited the patient room and did not use the provided alcohol-based hand sanitizer outside of this room. The staff member failed to follow the facility's Infection Control Plan for proper hand hygiene.

2. Observation made 3/24/20 in the Emergency Room at 10:15 a.m.

A clinical staff member observed entering the room of a patient in the emergency room. This staff member did not use the provided alcohol-based hand sanitizer outside of this room prior to entering the room. A few minutes later the door to the room opened and the same non-clinical staff member exited the patient room and did not use the provided alcohol-based hand sanitizer outside of this room. The staff member failed to follow the facility's Infection Control Plan for proper hand hygiene.

Observations were confirmed by staff # 2 and staff # 7. Education was provided to the staff member at the time of observation by staff # 2.

3. Observation made 3/24/20 in the Intensive Care Unit at 11:00 a.m.

A clinical staff member was observed exiting a patient's room without using the provided alcohol-based hand sanitizer outside of this room. The staff member then entered a clean utility area and returned to the patient's room with supplies. The staff member did not use the provided alcohol-based hand sanitizer outside of this room. The staff member placed the patient's clothes in a patient belongings bag. The staff member then exited the patient's room without using the provided alcohol-based hand sanitizer outside of this room. The staff member failed to follow the facility's Infection Control Plan for proper hand hygiene.

The observation was confirmed with staff # 2 and staff # 9 at the time of observation. Education was provided to the staff member at the time of observation by staff # 2.

A review of the facility policy titled "Hand-Hygiene Guidelines," with a latest review date of 11/09/2015, revealed section titled "Policy- Hand hygiene (hand washing with soap and water or with the use of alcohol-based hand sanitizer) before and after patient contact and after contact with the immediate patient care environment .....Immediately after touching a patient, contaminated items or surfaces, or removing gloves. After touching items or surfaces in the immediate patient care environment, even if you didn't touch the patient. Upon leaving patient's room, even if you only touched patient care equipment or other surfaces."