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Based on policy review, observation and interview, the nursing staff failed to ensure appropriate infection control precautions were followed with equipment in a patient's room in 1 of 3 observations of isolation rooms, and failed to follow appropriate infection control techniques during 1 of 1 observation of a central line dressing change. (Patient #9)

1. Review of the facility policy "If It's Green, It's Clean, Clean vs. Dirty Non-Critical Medical Devices/Equipment Go-Live March 17, 2017," revealed "Medical Devices/Equipment are either In Use, Dirty or Clean (stored, ready for use). Dirty Equipment *Is cleaned prior to use on next patient or placed in designated dirty storage area/utility room as soon as possible *Any items not identified as clean/ready to use will be cleaned before use..."

An observation on 05/09/2017 at 1430 during an interview with Patient #6 on the Medical Surgical Unit, revealed the patient was sitting in a chair with her left foot elevated. Observation revealed an IV (intravenous) Pole and the IV monitoring equipment positioned between the patient and the bed. Observation revealed the IV pole and the monitoring equipment, were each tagged with a florescent green ribbon.

Interview with Patient #6 during the observation revealed she was on contact precautions for MRSA (Methicillin-resistant Staphylococcus aureus). The patient stated she was being discharged today (05/09/2017).

An Interview on 05/09/2017 at 1440 with the Nurse Manager (NM), revealed the facility had recently implemented a new system called "Green is Clean." Clean equipment was tagged with a green ribbon to indicate it was clean. The NM stated "We should have taken the bands off when we put the equipment in the room."

An interview on 05/11/2017 with the Director of Infection Control (IC), revealed the "Green is Clean" process was new and started "around March 17, 2017." The interview revealed "trying to get everyone on board has not been without challenges..." The Director of IC stated "Staff have been educated and an IV pole or equipment in use would not have a green ribbon. The whole reason for the ribbon is to say it's clean and ready for patient use. We've missed an opportunity to remove that ribbon. Since the process is so new, we still have some educational opportunities."

2. Review of the facility policy "Hand Hygiene" (NH-IC-PH-400, revised Nov, 2014), revealed "...F. Indication for hand hygiene...8. Before donning gloves (sterile and exam). 9. After removing gloves. (Gloves are an adjunct to, not a substitute for hand washing)."

An observation of a central line dressing change on 05/10/2017 at 1630 in ICU, revealed RN #1 removed the dirty dressing, discarded her gloves, and proceeded directly to don sterile gloves. The observation revealed the RN failed to perform hand hygiene after removing the dirty gloves, before donning the sterile gloves.

An interview on 05/10/2017 at 1645 with RN #1, revealed "We can, but don't have to wash hands between glove changes... The policy does not designate we have to perform hand hygiene because it's [the central line dressing change] an aseptic technique."

During an interview on 05/11/2017 with the Director of Infection Control, she stated the facility used "The 5 Points of Hand Hygiene" for the education process. "The nurse should have washed hands between glove changes."

NC00126530