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Based on staff interview and policy review, the hospital failed to ensure the adherence to infection control policies and procedures by hospital personnel for one of 255 staff assigned to the Neonatal Intensive Care Unit (Staff B). This had the potential to affect all patients in the Neonatal Intensive Care Unit (NICU). The NICU census was 76 patients.

Findings include:

Interview with Staff A on 02/27/23 at 4:02 PM revealed the person that stocked the linens (Staff B) in the NICU had a sore on the palm of her left hand that was very small. Staff A was told that Staff B said she still washed her hands. On 02/16/23, Staff B and Staff A called Employee Health about the sore on her hand. Employee Health stated that since it was not work related Staff B needed to see her primary care physician (PCP). Staff B saw her PCP on 02/16/23. The PCP wrote a note for her to return to work. On 02/17/23, Staff B brought the note to the Director of NICU and she was sent home again. Since the policy referenced being seen by Employee Health Services and due to the vague note from her PCP that said she could return to work the facility felt that she should be evaluated by Employee Health. Employee Health saw her on 02/21/23, which was on Tuesday. A nasal polymerase chain reaction (PCR) was done to test for Methicillin-resistant Staphylococcus aureus (MRSA) on 02/21/23 and was negative on 02/22/23. The employee was off of work until 02/22/23 and her first day back to work was on 02/23/23.

Interview with Staff B on 02/28/23 at 8:34 AM revealed she only worked in the NICU unit and had done so for 19 years. She stated she folded baby clothes and took dirty clothes down to the basement. She stated that she or someone else would bring up the clean baby clothes. Staff B further revealed that she has had the sore since the last part of December 2022. She stated the sore was bleeding a lot and she would put a Band-Aid on it, but still washed her hands. When she would get home she would take the Band-Aid off. She stated she did not report the sore to anyone at work and she was not sure how she got the sore. On 02/16/23 after she arrived at work, Staff A told her to go and see Staff J to have the sore looked at. She stated Staff J told her it was a blister and that she could return to work on Friday, 02/17/23, but Staff A told her to stay home. She was home the rest of the week and on 02/21/23 Staff A and Staff D told her to go to Employee Health and they swabbed her nose. She stated she did not see the results but Staff D told her it was negative. Staff B revealed she wore gloves when she wiped down surfaces but was not wearing a Band-Aid at this time.

Interview with Staff C on 02/28/23 at 9:20 AM revealed she talked to a charge nurse on a Friday about a sore that Staff B had at the base of her ring finger of the left hand. She stated that the charge told her to go to Staff A and report it. She stated that Staff B told her that she had gone to the emergency room (ER) for a sore on her ring finger because it would not stop bleeding and Staff B told her that it had been draining. Staff C stated when she saw the sore it was not covered and it was pink. When Staff C spoke with Staff A she told her she felt like she needed to pass it along and Staff A thanked her. Staff C further revealed that she was aware of the policy and procedure that stated that a sore was to be reported and that staff could not work. Staff C revealed she learned this from education received from the facility.

Review of the policy and procedure titled, Hand Hygiene/Artificial nails, reviewed/revised date 07/2021, revealed health care workers with open wounds, sores, or infections on their hands cannot work in a position where hand hygiene is necessary. These workers must be evaluated by the appropriate ProMedica provided employee health services.