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LINCOLN MEDICAL & MENTAL HEALTH CENTER
INFECTION CONTROL PROGRAM
Tag No.: A0749
Based on observations, document review and interview in one (1) eight (8) hand hygiene observations conducted, it was noted that a member of the nursing staff failed to implement the facility's policy and procedures for hand hygiene (Staff #A).
Findings include:
The facility policy and procedure titled "Hand Hygiene" last revised August 8, 2017 states: "The facility incorporates the World Health Organization's Five (5) Moments of Hand Hygiene around patient care activities ... All healthcare workers are expected to perform hand hygiene during the 5 moments, before donning, and after doffing gloves." The five moments are defined as follow: "before every contact with a patient; before any procedure and between different procedures for the same patient; after a body fluid exposure risk; after every patient contact; after contact with the patient environment."
During a tour of the Emergency Department on 8/03/2020 at 10:50 AM, Staff A with gloved hands was seen caring for a patient in a cubicle. Staff A, while wearing the dirty gloves left the patient's bedside and she went to the nursing station where she picked up some clean supplies and was observed touching the monitor and reviewing some data while wearing the same pair of contaminated gloves. Staff A returned to the patient's bedside wearing the same dirty gloves and continued to care for the patient. Staff A returned to the nursing station with the same dirty gloves, she removed the gloves and discarded them in a garbage bin. Staff A then went directly to a computer an began using it.
Staff A did not remove her gloves and perform hand hygiene after caring for a patient and before she touched clean supplies. Staff A did not perform hand hygiene and don a new glove before she returned to care for the patient. Lastly, Staff A did not doff her gloves and perform hand hygiene immediately after patient contact and before she returned to the nursing station and touched the computer.
These observations were made in the presence of Staff B, Nursing Supervisor, who confirmed findings.