HospitalInspections.org

Based on policy review, observation and interview, the hospital failed to ensure infection control measures were followed by 1 of 1 (RN #1) nurses observed performing patient care in the hemodialysis unit.

The findings included:

1. Review of the hospital's "Hand Hygiene - Non Surgical" policy revised 11/2021 revealed, "...Hands are decontaminated before and after patient contact...when visibly soiled, after touching objects or surfaces likely to be contaminated with microorganisms or hospital pathogens (example: hair, face, clothing, diapers, or keyboards) and before invasive procedures...Hand hygiene should immediately follow removal of gloves.

Observations in the dialysis unit on 10/23/2023 beginning at 3:16 PM revealed Patient #4 was resting on the hospital bed with his Central Venous Catheter (CVC) hubs visible on a moisture proof barrier. Registered Nurse (RN) #1 donned gloves without performing hand hygiene and removed the old dressing from the CVC site, removed his gloves and discarded the old dressing and gloves in the waste bin. Without performing hand hygiene, RN #1 donned new gloves and cleaned the CVC hubs with an alcohol swab, attached syringes to each hub, then cleaned the CVC insertion site with antiseptic swabs. RN #1 removed his gloves, donned new gloves without performing hand hygiene and applied a new dressing to the CVC insertion site, reached into the pocket of his uniform, took out a marker and wrote the date, time, and his initials on the patient's CVC dressing. RN #1 removed his gloves, donned new gloves without performing hand hygiene and finished setting up the dialysis machine for the patient's hemodialysis treatment. RN #1 opened the supply cabinet, then obtained the clip board and had the patient sign a consent form for the treatment. RN #1 laid the clipboard down, removed his gloves, then donned new gloves without performing hand hygiene. RN #1 went back to the supply cabinet, opened the door with his gloved hands and gathered an alcohol swab, picked up the dialysis tubing and proceeded to attach the tubing to the patient's CVC port. RN #1 then walked back to the supply cabinet and obtained another alcohol swab, cleaned the 2nd CVC hub and attached the dialysis tubing. RN #1 entered data into the dialysis machine then removed his gloves and continued entering data into the dialysis machine. Without performing hand hygiene, RN #1 donned new gloves, opened the clamps on the dialysis tubing and started the treatment.

RN #1 failed to perform hand hygiene before providing patient care and after removing and donning new gloves repeatedly.

In an interview on 10/23/2023 at 3:57 PM, the Patient Safety Director stated hand hygiene should be performed, "Before they [staff] enter the patient's room, before providing patient care, before donning gloves, after donning gloves, and when exiting the patient room."