HospitalInspections.org

Based on review of facility policy, observation and interviews with staff (EMP), Holy Spirit Hospital failed to ensure that personnel followed their adopted policy for hand hygiene and injection practices.
Findings Include:
A review on May 29, 2012 of facility policy, " Title: Hand Hygiene" approved January 2012 revealed, " ... POLICY: All personnel are required to practice proper hand hygiene. This is for their protection, as well as for the safety and welfare of the patient. ... B. Decontaminate hands before donning gloves. ... ."
Observation on May 29, 2012, of EMP1 revealed EMP1 changed gloves and donned new gloves numerous times without performing hand hygiene.
Observation on May 30, 2012, of EMP2 and EMP3 revealed EMP2 and EMP3 changed gloves and donned new gloves without performing hand hygiene.
An interview conducted on May 29, 2012, at 11:45 AM and May 30, 2012, at 9:45 AM with EMP4 confirmed EMP1, EMP2 and EMP3 failed to perform hand hygiene before they donned gloves.

A review on May 29, 2012, of facility policy, " Title: IV (intravenous) Push (bolus) Medication" approved July 2011 revealed, "... III. Purpose: To provide guidelines for the administration of IV push (bolus) medications. ... H. Through the existing line: 1. Select the injection port of IV tubing closest to patient, Cleanse with antiseptic ... Infuse the medication ... ."
Observation on May 29, 2012, of EMP1 revealed EMP1 failed to cleanse the IV injection port before administering each medication.
Observation of May 30, 2012, of EMP3 revealed EMP3 failed to cleanse the IV injection port before administering each medication.
An interview conducted on May 29, 2012 at 11:45 AM and May 30, 2012, at 9:45 AM with EMP4 confirmed EMP1 and EMP3 failed to cleanse the injection IV port prior to the administration of each medication.