HospitalInspections.org

Based on observation and record review, the facility failed to ensure that medical staff perform hand hygiene (primary measure for reducing the risk of spreading infection among patients by hand washing with soap and water or using alcohol-based hand rubs) prior to entering the patient room and upon exiting the patient room for 1 (P (patient) P12) of 12 (P1-P12) patients.
This failed practice is likely to lead to the spread of infections to patients, serious injury, or death to all patients in the facility.

The findings are:

A. Record review of the facility's policy titled "Hand Hygiene" "Last Revised 01/2021; Expires 01/2024" revealed:

1. "1. Specific Indications for Hand Hygiene in Health Care Settings for Health Care Personnel (including but not limited to): A. Before entering a patient room and after exiting a patient room, regardless of patient contact." In other words, hand hygiene (either washing hands with soap and water, using alcohol-based hand rub, or both) must be performed by all healthcare personnel before entering a patient room and after exiting a patient room, regardless of patient contact.

2. "B. Handwashing With Soap And Water" "i. Hands must be washed with soap and water ..." (to remove germs, dirt and other unwanted material. One may use alcohol-based hand rubs as well.)

3. "C. Hand Hygiene Technique Using Alcohol-based Sanitizers (alcohol-based hand rub)" "i. Decontaminating (remove germs) hands with the approved alcohol-based sanitizing agents (waterless) ..." (One may wash hands with soap and water as needed.)

B. During an observation of the Medical Surgical unit on 01/22/2024, at 3:15 pm, an unidentified staff member entered patient P12 room number 307, walked up to the patient, spoke with the patient, exited the room without performing hand hygiene. Staff returned to the room with an object, and exited the room a second time without performing hand hygiene.