HospitalInspections.org

Based on observation and interview the Infection Control Officer failed to enforce the hand hygiene policy in 6 of 6 staff observed, failed to enforce infection control policy for 28 day expiration date on multi-dose vials in 1 of 1 multi-dose vials observed, and failed to enforce sanitation of multi-use/single-use patient equipment in 2 of 2 patients observed.

On 9/28/2011 at 9:30 AM in the outpatient wound care center, staff #5, who was the physician for the morning clinic, washed his hands and placed gloves on them. He palpated the patient's wound. He removed the gauze over the wound to visualize the open wound and manipulated the wound margins. He then opened a cloth case and removed the hand held doppler. The podiatrist auscultated the patient's pedal pulses with the hand-held doppler. The podiatrist did not change his gloves or use gel for hand hygien during the assessment of the wound and obtaining the doppler unit from the cloth case.

On 9/28/2011 at 10:00 in the Intensive Care Unit (ICU), Staff #1 was observed entering Patient #1 ICU room for morning medication. The RN did not wash her hands or use hand gel prior to entering the room. Gel hand sanitizer was not outside the door. A sink was visible inside the patient's room. The RN gave morning medications by mouth and accessed the intravenous (IV) tubing twice to administer medications and did not use hand gel nor did she wash her hands.

On 9/28/2011 at 11:00 AM on 3rd floor hospice/medical surgical unit, staff #4 was observed to set up morning medicatios for a patient. Staff #4 entered the room, set her medications down, and used hand gel. Upon exiting the room, staff #4 did not use hand gel.

On 9/28/2011 at 11:45 AM, Staff #11 was observed during preparation and administration of an epidural for and obstetrical patient. Staff #11 was observed entering the patient's room and did not wash his hands and did not use hand gel. He placed sterile gloves on and performed the spinal procedure. Upon removing his gloves he placed the dressing over the epidural site and proceeded to administer the anesthetic. Staff #11 exited the room and did not use hand gel or wash his hands once his gloves were removed.

On 9/29/2011 at 11:00 AM on the 3rd floor hospice/medical surgical unit, Staff #2 was observed entering a contact isolation room without using hand gel. Hand gel was available at the door. Staff #3 was not observed using hand gel upon exiting the room.

On 9/29/2011 at 11:20 AM, staff #3 was observed entering a contact isolation room without using hand gel. Hand gel was available at the door. Staff #3 did not use gel upon exiting the room.

On 9/28/2011 at 10:00 AM in the surgery suite, the Certified Registered Nurse Anesthetist (CRNA) failed to date a multi-dose bottle. The bottle was opened by the CRNA, a partial dose was removed from the bottle and the bottle was locked back into the medication cart without a dated label. The patient was positioned on the surgery table.

On 9/28/2011 at 12:00 PM, staff #4 was observed to obtain a disposable blood pressure cuff which was attached to a monitor and attempted to obtain a blood pressure on a patient. The monitor did not register and the disposable cuff was exchanged for a cloth cuff. The cloth cuff was used to obtain a blood pressure and was not sanitized before or after it was used on the patient to obtain the blood pressure reading.

On 9/29/2011 at 11:20 AM, staff #3 was observed with gloved hands to pick up a glucometer and enter a contact isolation room. Upon exiting, staff #6 did not was his hands with soap and water or use hand gel and did not wipe down the glucometer after use.

Based on record review, and interview, the facility failed to maintain a log of infections identified through employee health services.

Findings include:

Review of infection control/employee health policies revealed no process for tracking employee illness. No call-in logs (employees who call-in with illness) and no epidemiologic data relating to employee illness was found.

During an interview on 9/28/11 at 10:00pm in the conference room, staff #10 confirmed that no employee illness data was being collected.