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MAINEHEALTH MAINE MEDICAL CENTER
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on document reviews, interviews and observations, the hospital failed to ensure nursing staff wore personal protective equipment during the care of a patient on isolation status for one (1) out of one (1) patients observed in a room with precautions on Unit R5 (Patient #11).
Findings:
The hospital's policy titled, "Drug Resistant Organism Precautions", last revised 02/2023 states in part, " ... Gloves are indicated for all healthcare workers prior entry into room. Change gloves after contact with infective material. Remove gloves before leaving the patient's room ... ." "...Gowns are indicated for all healthcare workers prior entry into room. Remove gown before leaving the patient's environment ...".
A booklet the hospital provides to patients titled, "The Patient Care Partnership: Understanding Expectations, Rights, and Responsibilities", dated 10/2022 states in part, " ...What to expect during your hospital stay: High quality hospital care. A clean and safe environment ... ."
Certified Nursing Assistant ("CNA") #1's Learning Management System transcript was reviewed, and showed that he completed, "2023 MMC EOC Infection Prevention Training for Clinical Staff" on 01/18/2024.
CNA #1's Competency Based Orientation Tool was reviewed and was signed by his preceptor on 01/18/2024, indicating that he was able to independently, " ... Demonstrate appropriate use of and disposal of personal protective equipment ... ."
On 3/4/2024 at 12:41 PM, surveyors observed a sign on Patient #11's door indicating Drug Resistant Organism ("DRO") precautions are required, including, " ... Staff must wear gown and gloves before entering room ... ."
This observation revealed the following:
- CNA #1 was observed in Patient #11's room at the foot of the bed; and
- CNA #1 was not wearing any personal protective equipment.
On 3/4/2024 at 12:41 PM, CNA #1 acknowledged to the surveyors that he should have been wearing personal protective equipment while in the room.
CNA #1's failure to follow DRO precautions subsequently placed all other patients and/or staff he came into contact with that day at risk of potential exposure to Drug Resistant Organisms.
SUPERVISION OF CONTRACT STAFF
Tag No.: A0398
Based on document reviews, interviews and observations, the hospital failed to ensure nursing staff followed the hospital's Drug Resistant Organism Precautions policy for one (1) of one (1) patients observed in a room with precautions on Unit R5 (Patient #11).
Findings:
The hospital's policy titled, "Drug Resistant Organism Precautions", last revised 02/2023 states in part, " ... Gloves are indicated for all healthcare workers prior entry into room. Change gloves after contact with infective material. Remove gloves before leaving the patient's room ... ." "...Gowns are indicated for all healthcare workers prior entry into room. Remove gown before leaving the patient's environment ...".
On 3/4/2024 at 12:41 PM, surveyors observed a sign on Patient #11's door indicating Drug Resistant Organism Precautions ("DRO") are required, including, " ... Staff must wear gown and gloves before entering room ... ."
This observation revealed the following:
- Certified Nursing Assistant ("CNA") #1 was observed in Patient #11's room at the foot of the bed; and
- CNA #1 was not wearing any personal protective equipment.
On 3/4/2024 at 12:41 PM, CNA #1 acknowledged to the surveyors that he should have been wearing personal protective equipment while in the room.