HospitalInspections.org

Based on observation, staff interview, and policy review it was determined the hospital failed to ensure infection control practices were followed as it pertains to wearing gloves during vascular access procedures in the operating room. This affected one of one surgical patient observed (Patient # 11) during the surgical procedure. The total sample size was 11. The census at the time of the survey was 548.

Findings include:

Patient # 11 was observed during his/her surgical procedure on 07/02/13. At 8:59 AM the anesthetist performed a "timeout" procedure and then immediately began to administer anesthesia induction medications. The anesthetist administered Fentanyl 75 milligrams, Lidocaine 100 milligrams and Propofol 150 milligrams, through individual vials, without wearing gloves. While these medications were being administered, the anesthetist handled his/her phone, clipped it back on his/her waistband and continued to administer the medications through the patient's intravenous catheter. The surveyor did not observe the anesthetist perform hand hygiene at anytime during the medication administration or the phone call. At 9:07 AM after the medications were administered, the anesthetist was observed to have gloves on.

Interview with Staff H , the registered nurse director of surgical services who accompanied the surveyor, on 07/02/13 at 09:06 AM confirmed the anesthetist should have had gloves on.

Review of the hospital's Infection Control policy and procedure manual was completed on 07/02/13. Review of the policy revealed "gloves shall be worn when performing vascular access procedures...".

Review of the hospital's Patient Care Standards of Practice policy was completed on 07/02/13. Review of the policy revealed, "If pushing medication through an existing IV line, perform hand hygiene and don gloves".

These findings were confirmed with Staff I on 07/02/13 at 2:00 PM.