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Based on observation, interview, and policy review, the facility failed to ensure that staff followed the facility policies for hand hygiene (to wash hands with soap and water or with hand sanitizer) for three patients (#21, #2, #4) of seven hand hygiene observations. The facility failed to ensure that one staff (Staff Z) of one staff observed failed to remove jewelry in the Perioperative (surgical) area. These deficient practices had the potential to increase the risk of infection and cross contamination and placed all patients and personnel at risk for infection. The facility census was seven.

Findings included:

1. Record review of the facility's policy titled, "2011 Perioperative Standards and Recommended Practices," dated 2011, showed directives for staff:
- Not to wear rings in the perioperative area;
- Perform hand hygiene before putting gloves on and after removing gloves; and that
- Wearing gloves would not replace hand hygiene.

Record review of the facility's policy titled, "Standard Precautions," dated 06/26/14, showed the directive for all staff to perform hand hygiene with either soap and water or alcohol-based hand rub for routine decontaminating of hands:
- Before and after direct contact with patients or their environment;
- After removing gloves; and
- When moving from a contaminated body site to a clean body site during patient care.

2. Observation on 02/25/15 at 9:15 AM showed Staff Z, Registered Nurse (RN) and Staff AA, RN, touched Patient #21 and touched the patient's stretcher in positioning him on the operating room table. Staff Z had rings on her gloved hands. Staff Z then assisted Certified Registered Nurse Anesthetist with endotracheal tube insertion (tube placed in airway for breathing during surgical procedure). Staff Z removed her gloves failed to perform hand hygiene and reapplied another pair of gloves. Staff Z placed a urinary catheter (tube placed into patient's bladder to drain urine) into Patient #21.

Staff AA removed gloves after placing Patient #21 on operating room table. Staff AA failed to perform hand hygiene and reapplied gloves. Staff AA opened sterile packages for the scrub nurse.

During an interview on 02/25/15 at 10:25 AM, Staff U, Surgery Manager, confirmed that the perioperative standards required hand hygiene performance when gloves were changed and or reapplied. Staff U confirmed rings were restricted from wear in the perioperative area.

During an interview on 02/25/15 at 2:35 PM, Staff Z stated that she was not aware of facility policy on wearing rings and thought she could wear her wedding ring. Staff Z also stated that she did not always perform hand hygiene after she changed her gloves.

During an interview on 02/25/15 at 2:45 PM, Staff AA stated that she did not perform hand hygiene when she changed gloves during performing care for Patient #21. She stated that she thought she could change gloves and not perform hand hygiene when she cared for the same patient.

3. Observation with concurrent interview on 02/24/15 at 1:30 PM showed Staff F, RN, touched Patient #2's hand to scan (use of a device that reads a bar code on the patient's arm band and then shows the patient's information in the computer) his bracelet and then prepared and administered the patient's medication. Staff F failed to perform hand hygiene after patient contact. Staff F stated that she was less likely to perform hand hygiene, after she scanned the patient, when she just had one medication to administer by mouth.

4. Observation on 02/24/15 at 10:28 AM showed Staff J, Respiratory Therapist, touched Patient #4's skin from the wrist up to the elbow to locate an artery (blood vessel) and draw blood for testing. After touching the patient's contaminated skin with gloved hands and before inserting the needle to draw blood, Staff J failed to perform hand hygiene and put on a clean pair of gloves.

During an interview on 02/24/15 at 10:45 AM, Staff J, stated that she did not know she needed to perform hand hygiene and put on a new pair of gloves after touching the patient's skin and before drawing the blood.

During an interview on 02/24/15 at 10:55 AM, Staff G, RN, Director of Medical/Surgical Services, stated that after Staff J touched the patient's arm to locate a site, she should have performed hand hygiene and put on a new pair of gloves before injecting the needle to draw blood.

During an interview on 02/25/15 at approximately 4:15 PM, Staff SS, Infection Control Officer, confirmed that Staff G should have performed hand hygiene and put on a new pair of gloves after touching the patient's contaminated skin and before drawing the patient's blood.


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