HospitalInspections.org

Based on observations and interviews, the CAH failed to ensure the physical environment was maintained for the safety of the patients. This deficient practice is evidenced by failing to ensure the call bell feature worked on the patient's beds for 19 of 21 beds in the in-patient/swing-bed rooms.
Findings:

1) Observations on 08/15/2022 at 10:00 a.m. revealed 19 of 21 patient's hospital beds were equipped with a nurse call function on the patient's bed. Further observation revealed this nurse call functions on the beds were not connected to the call bell system and were non-functioning.

In an interview on 08/16/2022 at 10:30 a.m., S1DON confirmed the call bell feature on 19 of 21 patient's beds were non-functioning.

Based on policy/procedure review, observations and interviews, the CAH failed to maintain a clean and sanitary environment to avoid sources and transmission of infection as evidenced by 1) storing clean and dirty patient use equipment together and 2) failing to ensure staff sanitized their hands and changed gloves between the dirty and clean aspects of a dressing change.
Findings:

1) Review of the facility's policy EOC 9.0 titled, "Clean Equipment" revealed in part: 2. Once equipment is cleaned a clear plastic bag or a tag will be placed over the equipment. For bedside commodes, a sanitary strip will be placed over the seat.

Observation on 08/15/2022 at 10:00 a.m. of room a, which was being used as a clean utility/patient equipment room, revealed 1 uncovered infusion pump and 2 bedside toilets without sanitary strips stored alongside of clean equipment.

In an interview on 08/15/2022 at 10:05 a.m., S2RNIC confirmed the clean and dirty patient equipment was stored together in room a.

2) Review of the facility's policy IC1.2 titled, "Universal Precautions and Standard Precautions" revealed in part: Gloves shall be changed between tasks and procedures on the same patient after contact with material that may contain high concentrations of microorganisms. Wash hands immediately after gloves are removed. Change gloves between tasks and procedures on the same patient.

Observation of wound care for Patient #3 on 08/16/2022 at 1:20 p.m. revealed RN3 and LPN4 did not sanitize or wash their hands between glove changes after removing the soiled dressings and applying the new dressings on the patient's heels.

In an interview on 08/16/2022 at 3:15 p.m., S2RNIC acknowledged staff should wash or sanitize their hands between the dirty and clean aspects of a dressing change.