HospitalInspections.org

Based on observations, review of facility documents and interviews with staff (EMP), it was determined that the facility failed to ensure the appropriate use of personal protective equipment (PPE) in the restricted areas with open sterile supplies or at the surgical field and proper handwashing prior to entry of patient room.

Findings include:

Review on April 27, 2015 of facility policy"Surgical Attire in the Operating Room," dated October 22, 2014, revealed "...Personnel will cover head with a disposable hat provided by the hospital. ...Facial hair, including sideburns and necklines, will be covered in restricted areas with open sterile supplies or at the surgical field. ..."

Observations on April 28, 2015, in the main and outpatient operating rooms revealed that physicians, anesthetists, registered nurses and surgical technicians had their neckline hair and/or sideburns outside the skull cap and/or disposable hat while in the operating room with open sterile supplies or at the surgical field.

Interview on April 28, 2015, between 9:00 AM to 11:00 AM, with EMP12 confirmed that many of the operating room personnel had their hair exposed while in the main and outpatient operating rooms with open sterile supplies or at the surgical field.

Review on April 27, 2015, of facility policy "Hand Hygiene," dated December 26, 2014, revealed " ... St. Mary Medical Center follows the Centers for Disease Control guidelines on hand hygiene. ... Hands are washed in the following situations: 1. Before and after all patient contact and after contact with the patient's environment ... "

Review on April 27, 2015, of facility policy "Transmission-based Precautions," dated August 10, 2014, revealed " ... Contact Precautions ... 4. Gloves, Gown and Hand Hygiene a. Wash hands before and after all contact with the patient or the patient's environment and before donning and removing gloves. ... "

Observation on April 27, 2015, at 1:20 PM, revealed that EMP3 entered patient Room 1017 and failed to perform hand hygiene. There was a sign posted at the door requiring hand hygiene prior to entry and after exiting the room.

Interview on April 27, 2015, with EMP5 confirmed that the physician failed to perform hand hygiene.

Observation on April 28, 2015, at 7:48 AM, revealed that EMP7 entered patient Room 177 and failed to perform hand hygiene and don gloves. The physician auscultated the patient heart and or lung sounds. There was a sign posted at the door that required hand hygiene prior to entry and after exiting the room. The patient was on contact precautions.

Interview on April 27, 2015, with EMP5 confirmed that the physician failed to follow contact precautions.

Based on observation, review of facility policy, review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure their policy was followed for one patient who received Aerosol Therapy (MR11 ).

Findings include:

Review of facility policy "Hand-Held Nebulizer Procedure," dated March 28, 2014, revealed " ...Post treatment ... Rinse patient's mouthpiece. The nebulizer cup should be emptied after each use, rinsed with sterile water and place in a designated bag at the patient's bedside. ... "

Review on April 27, 2015, of MR11 revealed that the patient was to receive DuoNeb (Combination medication of Albuterol and Ipratropium) four times daily.
Observation on April 27, 2015, at 1:50 PM of the Aerosol Therapy provided by EMP4 to MR11 revealed that EMP4 failed to rinse the nebulizer cup after the treatment was completed.
Interview on April 27, 2015, at 2:20 PM, with EMP4 confirmed that the nebulizer cup was not rinsed with sterile water after the treatment to MR11.