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Based on observation, interview, record review, and review of the Hand Hygiene Policy, it was determined the facility failed to follow an infection control program for two (2) of ten (10) sampled patients, Patient #2 and #3. Staff failed to disinfect their hands when moving from dirty to clean during a dressing change for Patient #3. In addition, the staff failed to was their hand when leaving an isolation room.

The findings include:

1. Review of the facility's Hand Hygiene Policy, dated August 2012, revealed the purpose of the policy was to remove transient microorganism from hands by following the CDC hand hygiene guidelines. Hand hygiene would be performed before donning and after removal of gloves.

Review of Patient #3's record, revealed the facility admitted the patient on 07/02/14, with diagnoses of Chronic Respiratory Failure, Crohn's Disease, Vancomycin-resistant Enterococcus (VRE) of the Ventilator, Abdominal Wound and a Coccyx Wound.

Observation of Licensed Practical Nurse (LPN) #2, on 08/12/14 at 11:35 PM, revealed LPN #2 donned a gown and gloves, the nurse prepared her supplies and placed a clean garbage bag into Patient #3's garbage can. LPN #2 then removed her gloves and donned a new pair of gloves without washing her hands or utilizing hand sanitizer. The nurse then washed Patient #3's wound. LPN #2 then removed her gloves and donned new gloves without washing her hands or utilizing hand sanitizer. LPN #2 applied Biotin (adhesive foam) to Patient #3's coccyx and cleaned off Patient #3's back with a wet wash cloth. LPN #3, then removed her gloves and washed her hands.

Interview with LPN #2, on 08/12/14 at 3:15 PM, revealed she did not receive hands-on-training in regards to wound dressing changes. LPN #2 stated the Wound Nurse had gone around and done audits of the wound dressing changes. LPN #2 stated she was taught in school that when you remove your gloves, you have to wash your hands or sanitize your hands before donning clean gloves. LPN #2 stated she washed her hands to remove bacteria and germs and to also prevent the spread of infections.

Interview with the Wound Nurse, on 08/13/14 at 2:08 PM, revealed she completed audits of the nurses dressing changes a couple of times a week and turned in the results of the audit to the Chief Clinical Officer (CCO) for review.

Review of LPN #2's aseptic technique of wound care audit, revealed the Wound Nurse had audited LPN #2, on 07/09/14 and her technique was appropriate.

Interview with the Quality Assurance Nurse, on 08/13/14 at 3:05 PM, revealed she knew the staff received training on dressing changes during orientation with the wound nurse and had yearly competencies. The Quality Assurance Nurse stated the Wound Nurse completed audits and spot checked nursing staff. The Quality Assurance Nurse stated LPN #2 should have washed her hands when changing gloves. The Quality Assurance Nurse stated staff washed their hands so that when they remove the dirty gloves, they don't contaminate their knew gloves with their dirty hands.

2. Further review of the Hand Hygiene Policy, dated August 2012, revealed hand gel and instant hand sanitizer may not be used for patients that have C-Diff.

Review of Patient #2's medical record, revealed Patient #2 was admitted with Acute Respiratory Failure, Stoke, Hypercoagulopathy, Aspiration Pneumonia and C-Diff.

Observation of Patients #2's door to his/her room, on 08/12/14 at 11:15 AM, revealed a sign that read "Staff and Visitors wash hands with soap and water, No Alcohol Foam."

Observation of Patient #2's medication pass, on 08/12/14 at 11:05 AM, revealed LPN #2 donned a gown and gloves to help assist LPN #1 verify insulin medication. When LPN #2 finished verifying the medication. LPN #2 removed her gown and gloves and sanitized her hands as she left Patient #2's room.

Interview with LPN #1, on 08/12/14 at 11:15 AM, revealed LPN #2 should have washed her hands. LPN #1 stated they wash their hands to kill the germs and to prevent the spread of C-Diff spores.

Interview with LPN #2, on 08/12/14 at 3:15 PM, revealed she did not recognize the patient had C-Diff and did not notice the sign on the door. LPN #2 stated she was aware that when a patient had C-Diff the staff was to wash their hands.

Interview with the Quality Assurance Nurse, on 08/13/14 at 3;05 PM, revealed when a patient was diagnosed with C-Diff, staff were required to wash their hands and not utilize alcohol because the alcohol did not clean off spores.

Interview with the Corporate Compliance Officer (CCO), on 08/13/14 at 3:23 PM, revealed when a patient was on C-Diff precautions staff were to wash their hands when exiting the patient room.