HospitalInspections.org

Based on observations, staff interviews, and policy review, the facility's infection control officer did not ensure there was a system in place for controlling infections and communicable diseases of patients and personnel.

Findings include:

1) Observation made on 8/1/12 at 11:20 A.M. noted 3 staff and surveyor donning personal protective equipment (PPE; gown, mask, gloves) before entering the room of Patient #5 in "Contact Isolation". Direct care staff did a blood glucose test for the patient. Upon completion of the test, staff placed the test strip on a paper towel next to the sink counter. Staff then removed gown and mask and took the test strip outside of the room. No observation was made of staff removing gloves and washing hands. After placing strip in the glucometer for a blood sugar reading, staff removed gloves. No hand sanitizing was observed. Interview with the Infection Control Officer revealed staff should have removed gloves before exiting the patient's room and washed hands. Review of the facility's policy on "Guidelines for Isolation Precautions" was done. Under Procedure for Standard Precautions; Hand Hygiene: "After touching blood, body fluids, secretions, excretions, contaminated items; immediately after removing gloves; between patient contacts".


2) On 8/1/12 at 11:40 A.M. observation was made of a staff standing next to Patient #5's bed without wearing appropriate PPE such as a gown or mask. A sign posted outside of the patient's door "Contact Isolation" along with disposable mask, gown, and gloves was available. Interview with licensed nurse prior to entering the room revealed the staff working with the patient was the wound nurse doing a dressing change. Queried nurse regarding the reason the patient was in isolation was due to MRSA (methicillin-resistant staphylococcus aureus) to the wound in his left hand. Upon entering the patient's room observed staff finishing a dressing change to the patient's left hand. At the completion of the dressing change the staff discarded the soiled dressings. Interview with staff regarding why she was not wearing appropriate PPE while doing a dressing change revealed that she should have been wearing PPE. Review of the facility's policy on "Guidelines for Isolation Precautions" noted under "Transmission - Based Precautions are used in addition to providing Standard Precautions and these include: Contact ..." "A dedicated isolation cart is placed outside the patient's room that contains personal protective equipment for staff such as gloves, gown, masks or N95 respirators".




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3) Observation on the morning of 7/31/12 at 9:18 A.M. in one of the Operating Room (OR) suites had the nurse anesthetist taking the cap off a vial of sodium chloride. Without wiping the rubber septum with alcohol, he pierced the septum with a needle to withdraw the sodium chloride into the syringe. Interview with the Director of Surgical Services on the morning of 8/1/12 confirmed that the rubber septum was to be wiped with alcohol prior to piercing the septum with the needle.

4) On the morning of 7/31/12 in one of the OR suites, the nurse anesthetist was observed inserting an endotracheal tube into a patient with his bare hands. He was not gloved. Interview on the morning of 8/1/12 with the Director of Surgical Services confirmed that the nurse anesthetist should have been wearing gloves during this procedure. The facility policy titled Personal Protective Equipment noted "wear gloves whenever there is an opportunity for hand contact with blood, blood products, mucous membranes, non-intact skin, other potentially infectious materials or contaminated items and surfaces".

5) On the morning of 7/31/12 after surgery had been completed, the surgical department staff was observed cleaning the OR suite. A staff person dropped a clean cloth on the unclean floor. She picked up the cloth, sprayed it with the cleaning solution and proceeded to wipe down the anesthesia cart with that cloth.