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Based on observation and interview, the facility failed to maintain infection control techniques as evidenced by staff performing invasive procedures without appropriate glove changes, increasing the potential risk for contamination and infection for 2 (#R1, #R3) of 3 (#R1, #R2, #R3) patients observed receiving invasive procedures.
Findings:

Patient #R1
On 01/17/17 at 10:30 a.m., observation revealed S6Lab Tech Student obtained a blood culture from patient #R1's left arm while wearing gloves. After performing the procedure, she did not remove the contaminated gloves and clean her hands. She was then observed to handle clean supplies (gauze, needles, blood tubes) on the rolling lab cart and touch the hand-held computer with the same gloved hands. S5Lab Tech was in the room observing the student during this procedure.

On 01/18/17 at 3:00 p.m., interview with S1CEO and S2CNO confirmed that the lab student should have been supervised by the hospital's lab tech properly. They further confirmed the above breach in infection control.

Patient #R3
On 01/18/17 at 10:40AM, observation revealed S7RN donned gown and gloves (patient on contact isolation precautions) and removed an old intravenous (IV) dressing and catheter from the left arm of patient #R3. After performing the procedure, he did not remove the contaminated gloves. S7RN then opened packages containing an IV start kit and syringe for flushing and connected the syringe to the catheter. S7RN proceeded to open an alcohol swab, cleanse an area on the left arm of patient #R3, and insert the IV catheter into the left arm site of patient #R3. Interview with S7RN at this time revealed he was not aware of the need to change gloves during this procedure.

On 01/18/17 at 10:50AM, interview with S10Coordinator of Care for Medical/Surgical Unit confirmed that aseptic technique was not followed and that gloves should be changed after removing a dirty dressing before inserting a new IV catheter.

On 01/18/17 at 3:00 p.m., interview with S1CEO and S2CNO confirmed that gloves should be changed when going from dirty to clean procedures. They further confirmed the above breach in infection control.




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