HospitalInspections.org

Based on observation, policy and procedures and staff interviews it was determined the facility failed to avoid sources and transmission of infections by compromised hand hygiene and PPE.

Findings include:

On 03/08/2021 at 12:30 PM observed the wound nurse come out of a room without gloves and set down camera and what appeared to be an accu-check machine. Wound care nurse wiped down the accu-check machine, keys and camera and set it back down on her papers on top of the wound cart where it was originally placed. No 3-minute wet time noted on the equipment used in contact isolation room, no hand hygiene noted.

On 03/09/2021 at 7:15 AM, a tour was conducted on 2 North with escort of the Director of Clinical Services (DCS). At 7:25 AM observed a wound cart in front of room 247 at the doorway. Observed the wound care nurse coming out of room without doing any type of hand hygiene or change of dirty gloves. She proceeded to push the wound cart a little away from the door way and opened the top drawer of the cart and reached inside, and withdrawing a measuring tape. Then went back into room without proper hand hygiene performed and with the same gloves donned.

On 03/09/2021 at 7:52 AM, a tour was conducted on 2 south with escort of the DCS, observed a Certified Nursing Assistant (CNA) coming out of room 203 (contact isolation room) with gloves on. The CNA went to the breakfast cart and opened the door and grabbed a food tray and placed it on top of the cart and proceeded to touch other breakfast trays inside of the cart before shutting the door of the cart, he then took the tray off the top of the breakfast cart and went into room 202(Contact isolation room). Did not observe the tech doing hand hygiene nor removal of gloves when he came out of one room and went into another.

On 03/09/2021 at 8:00 AM, during a tour of the Intensive Care Unit (ICU) observed a Respiratory Therapist (RT) with gloves on in room ICU 6 (contact isolation) proceed to go to RT cart outside of ICU 6 room and reach his dirty gloved hands into a bag hanging on the back of the cart and withdrew 2 line neb treatment tubing from the bag. 7-line neb treatment tubing noted left in the bag. Then went back into the room without changing gloves or doing hand hygiene.

Policy and Procedure title, " Hand Hygiene", Policy # H-IC 02-006, Dated: 06/2018
All staff and persons will perform hand hygiene before entering and leaving the patient's room every time .... After touching a patient's surroundings/ environment .... Between patients ....

Policy and Procedure tile, "Donning and Doffing Personal protective Equipment"
Policy # H-IC 02-009
Dated: 06/2019
This procedure establishes guidelines for Donning and doffing Personal Protective Equipment (PPE). PPE is utilized to reduce the risk of transmission and/or prevent the transmission of pathogenic organisms from patient to health care worker and from health care worker to patient...

Tour completed with the Director Clinical Services who observed and confirmed above findings.