HospitalInspections.org

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Based on observation, policy review and staff interview the hospital staff failed to follow their policy directing staff to clean all non-disposable, non-immersible equipment with the Super Sani wipes before and after each patient use, failed to follow their policy directing staff to follow standard precautions and wear gloves with any manipulation of a urinary catheter system and failed to follow their policy directing staff to wash their hands before and after donning and doffing gloves. Failure of the hospital therapy staff to follow these policies as directed place all patients at risk for the potential infection.

Findings include:

- Observation on 11/16/16 at 12:20pm in the inpatient physical therapy department revealed physical therapy staff members sitting on the beds and chairs used for the patient ' s physical therapy, also standing by counters eating food in this area.

Kara Kent, RN, Nurse Manager explained that the Physical Therapy staff take their lunch break in this area. Kara also explained that the physical therapy department does not schedule patients to be in this area between 12:00pm to 1:00pm.

- Observation on 11/22/2015 at 12:50 PM of the inpatient therapy gym revealed therapy staff sitting around and on the patient therapy beds eating and drinking. Their food and drinks sat on the beds. There were no patients in the gym for therapy at this time. Staff did not wipe down the beds after eating.

- Observation on 11/22/2016 at 1:10 PM revealed therapy staff bringing patients into the gym for therapy. Staff observed placing clean sheet down on the bed for the patient to sit or lie on. A clean pillow case was put on the pillow.

- Observation on 11/22/2015 at 1:20 in the therapy gym revealed physical therapy (PT) student walking with patient #15 around the gym. Patient #15 had a Foley catheter bag (a bag that holds urine that has drained from the bladder through a tube) hanging from the walker. Patient #15 was taken to a bed/table and practiced standing from sitting position several times before being transferred to her wheelchair. There was no sheet on the bed/table. Patient #15 removed the catheter bag from the walker and PT student V hung the bag under the wheelchair. PT student V did not wear gloves when handling the Foley catheter bag.

- Observation on 11/22/2016 at 1:30 in the therapy gym revealed a staff member remove a pillow case from a pillow that was just used by a patient, hand the pillow to another staff member who place a new pillow case on and used the pillow for a different patient. The pillow was not wiped down between patients.

- Observation on 11/22/2016 between 1:15 and 1:30 PM in the therapy gym revealed several staff members wading up the used sheets and pillow case and carrying the used linen up against their clothing to the dirty laundry.

Physical Therapist staff L interviewed on 11/22/2016 at 1:30. S/he is not aware of a policy or protocol on handling Foley catheter bags. S/he said that the catheters bags are not to be dragging on the floor. S/he said that equipment touch by the patients are wiped down with wipes such as slide boards and walkers.

Certified Occupational Therapy Assistant staff W interviewed on 11/22/2016 at 1:40. S/he is not aware of a policy or protocol on handling Foley catheter bags. S/he said the sheets and pillow case act as a barrier on the beds and they are changed between patients.

Policy titled Equipment Cleaning reviewed on 11/22/2016 at 3:15 directed in part ...All non-disposable, non-immersible equipment is to be cleaned after each patient use. A. All non-disposable patient equipment is cleaned with hospital approved cleaning solution after each patient use. B. Any non-disposable is wiped with Super Sani wipes antibacterial cleaner before patient use. C. If the patient has C-Diff bleach wipes will need to be used in addition to the above.

Policy titled Indwelling Urinary Catheter reviewed on 11/22/2016 at 3:30 directed in part ... VI. Proper Techniques for Urinary Catheter Maintenance ... ...C. Use Standard Precautions during any manipulation of the system, including the use of gloves and gowns when appropriate ...

- Random observation on 11/16/16 at 2:35pm on the South unit revealed an RN coming out of the nurse ' s station area with gloved hands carrying equipment to start an Intravenous (IV) catheter on the patient in room 244. The nurse failed to remove those gloves and perform hand hygiene before entering the patient ' s room.

- Observation of Registered Nurse (RN), Staff D on 11/22/2016 at 9:25 AM with gloves on failed to perform hand hygiene in the patients room when gloves were removed after medication administration to patient #12. RN Staff D then put on another pair of gloves.

RN Staff D was interviewed on 11/22/2016 at 9:25 PM confirming it the facility policy is to do hand hygiene between patients.

Review of facility policy titled " Hand Hygiene " on 11/22/2016 at 1:00 PM directed to " ... clean hands after removing gloves ... "

- Observation on 11/16/16 at 2:25pm in patient Billie Bourke ' s room revealed Lynn Shafton, RN performing a dressing change of a skin tear on the patient ' s left forearm. No concerns were identified with the procedure performed by Lynn Shafton, RN.

- Observation on 11/16/11 at 11:20pm in patient Manuel Bruce ' s room revealed Kristina Thompson, RN performing a finger stick blood sugar on the patient. Appropriate hand hygiene and cleaning of the equipment occurred. No concerns were identified.
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