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Based on facility policy, observations, and interviews, facilty staff members observed during the 1/19/2011 tour of the facility (11:40 AM and 2:00 PM) failed to consistently implement the hospital's hand hygiene and infection control isolation policy/procedures.
Interviews (conducted 1/19/2011) with the family members revealed three family members observed in isolation rooms on tour (Patient Identifier (PI) #'s 3, 8, and 11) did not know the reason for the patient's isolation.
Six employees (Employee Identifier [EI] #'s 16, 11, 12, 25, 26, and 23) observed on tour (1/19/2011) providing care to patients, or transporting patient equipment, failed to follow the hospital's hand hygiene or infection control policy / procedure.
This deficient practice effected eight (8) of twenty (20) sampled patients (PI #'s 3, 8, 11, 20, 16, 13, and 4) and has the potential to effect all patients in the hospital.

Findings Include:
1. Observations/Interviews:
On 1/19/2011 at 11:00 AM, 11:50 AM. at 3:00 PM, and 3:15 PM, the family members at bedside of isolation Patient Identifier (PI) #'s 3, 8, and 11 stated they (family) did not know the reason for the isolation precautions (when questioned by the surveyor).

On 1/19/2011 at 12:10 PM, EI # 16 entered PI # 20's room wearing gloves and carrying a patient therapy equipment for PI# 20, who was not on isolation.

On 1/19/2011 at 2:30 PM, Employee Identifier (EI) # 11, a lab staff member, exited the room of PI#16. When questioned about hand washing, EI #11 states they removed their gloves in the room and used the hand sanitizer in the room. EI #11 stated they did not wash their hands and was observed rubbing hand sanitizer on the palm of the hands for less than 10 seconds, while walking down the hall. A staff member accompanying the surveyor (EI # 1) said this hospital's policy allows staff to use hand sanitizer in place of hand washing when their (staff) hands are not "visibly" soiled.

On 1/19/2011 at 2:40 PM, EI #12 was observed wearing gloves and pressing a key pad to unlock a door. When questioned about wearing the gloves, EI # 12 explained they went to a room to pick up a piece of equipment and brought the equipment back to the locked area to be cleaned.

On 1/19/2011 at 2:50 PM, EI# 24 and EI # 25 were observed to remove and discard their gloves in the isolation room of PI # 4 (a patient being discharged). These staff members applied hand sanitizer to the palms of their hands prior to leaving the room but did not wash their hands before exiting the room.

On 1/19/2011 at 3:00 PM, Patient Identifier (PI) # 8 was preparing for discharge. EI # 23 was observed walking in and out of this isolation room, without washing hands or using hand sanitizer. A family member accompanying PI # 8, stated the patient was "quarantined this morning...is going home this afternoon..."

2. Hospital Policy / Procedures
The hand hygiene policy, effective 8/2009, includes:
"...personnel will follow hand hygiene practices in accordance with current CDC, WHO, and APIC guidelines...

Type of hand hygiene...
Hand Wash
Purpose To remove soil or transient microorganisms
Method Soap and water for 15 seconds
Hand antisepsis
Purpose To remove or destroy transient microorganisms
Method Antimicrobial soap or alcohol based and rub for at least 15 seconds
...Indications for hand hygiene:
1. When hands are visibly dirty or contaminated with blood or other body fluids. Wash with soap and water.
2. Before patient contact (Such as taking a pulse, blood pressure or lifting a patient).
3. After touching wounds or any body surface likely to contain body fluids or microorganism.
4. After contact with inanimate environmental sources likely to be contaminated. Such as blood pressure cuffs and thermometers).
5. After contact with all patient equipment.
6. Before donning and after removing gloves.
7. Before eating and after using the restroom, wash hands with soap and water.
8. Wash hands with soap and water, if exposure to...or other...organisms is suspected or proven...

...D. Alternatives to hand washing:
1. Hospital approved alcohol-based hand rubs or foam may be used for hand hygiene purposes provided hands are not visibly soiled. Alcohol based hand rubs do not remove soil or organic material; therefore if hands are visibly soiled, traditional hand washing with soap (or antimicrobial agent) and water must be done.
2. Apply the proper amount of alcohol based hand rub/foam to hands as per manufacturer's recommendations and rub vigorously covering all parts of hands until hands are dry...Hand antisepsis is achieved by washing hands for 15 seconds, with a surgical scrub or other antimicrobial containing soap. Hand antisepsis can also be achieved by using alcohol-based hand rubs for at least 20 seconds...

...1. Gloves should be used as an adjunct, not a substitute for hand hygiene.
2. Gloves should be changed, and hand hygiene performed after using gloves for contaminated activities.
3. Gloves should be changed when caring for a single patient when moving form one procedure to another. Do not wash gloves.
4. Hands should be washed when the integrity of the glove is in doubt, and between patients.
5. Disposable gloves should be used only once and may not be washed for reuse. Gloves should be disposed of immediately after use.
6. Non-latex glove alternatives will be made available to those individuals with latex allergies/sensitivities.
7. Gloves are not to be worn in patient care areas..."

The " Infection Control " policy revised in April 2005 includes:
" ...five categories of isolation precautions ...Gloves (clean, non-sterile are adequate) must be worn to enter the patient's room. While providing care for the patient, change gloves after having contact with infective material that may contain high concentrations of microorganisms...Gloves will be removed before leaving...room. After glove removal thorough hand washing with antimicrobial soap or waterless antiseptic agent will be done immediately...

I. SPECIFIC PRECAUTIONS FOR ISOLATION PATIENTS ...
Visitors should be instructed on special precautions required before entering the room.

II. HANDWASHING AND GLOVING
A. Hand washing is considered the single most important measure to reduce the risks of transmitting microorganisms from one person to another or from one site to another on the same patient.
Hands must be washed promptly and thoroughly between patient contacts, immediately after removing gloves and after contact with blood, body fluids, secretions, excretions and equipment or articles contaminated by them (see hand washing policy ...)
...B. Gloves are to be worn: to provide a protective barrier and prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes and non-intact skin.
Gloves are worn to reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to the patient during invasive or other patient care procedures that involve touching a patients mucous membranes or non-intact skin.
Gloves are worn to reduce the likelihood that hands of personnel contaminated with microorganisms from a patient or environmental surface can transmit these microorganisms to another patient ...

INITIATION OF ISOLATION PRECAUTIONS
...V. Explain and document purpose of isolation to the patient and significant other..."

3. Corrective Measures
On 1/21/2011, after the surveyor reviewed observation data from the tour hospital staff implemented immediate corrective actions and provided a copy of the following administrative directive/memorandum:
"...Effective immediately, please review the attached Infection Control policy regarding hand hygiene/hand washing ...
All employees in patient care areas (direct and non-direct) must wash hands:
* When visible soiled (dirty)-wash with soap & water.
*Before patient contact.
* After patient contact.
* After contact with patient equipment.
* Before putting on gloves.
*After glove removal.
* Wash with soap and water for patients who have clostridium defficile (no alcohol foam).
Gloves should not be worn for routine patient care...If gloves are to be used...hands should be washed in the patient's room, gloves put on IN THE PATIENT ROOM...gloves are removed before leaving the room and hands washed immediately after removing gloves...all staff to review the...policy...director and management staff will be monitoring compliance..."

This citation is written as a result of the investigation of complaint AL00023687.