HospitalInspections.org

46123

Based on observations, policy and procedure review and staff interview the facility failed to ensure that 3 of 7 observations (Patients 21, 22, 23) that Registered Nurses (RNs) followed the hand hygiene policy and procedure with intravenous (IV) medications and blood transfusions. This failed practice has the potential to affect all patients. The census at entrance was 472.
Findings include:
A. Observations
- On 3/23/2022 at 10:50 AM observed RN-B prepare IV medication administration for patient #21. IV Thiamine 500mg in 50mL of sodium chloride 0.9% infused every 8 hours over 30 minutes was prepared by RN-B. RN-B was in patient #21's room with gloved hands. RN-B left patient room to retrieve a supply from nurse server and returned to room without performing hand hygiene and re-gloving. RN-B then continued with medication administration.

- On 3/24/2022 at 11:00 AM observed RN-C prepare IV medication administration for patient # 22. IV Insulin regular in 0.9 sodium chloride 100units/100mL (1unit/1mL) continuous infusion was prepared by RN-C. RN-C was in patient #22's room after medication was prepared gloved hands. RN-C left patient room to retrieve a supply from nurse server and returned to room without hand hygiene and re-gloving. RN-C then continued with medication administration.

- On 3/28/2022 at 2:52 PM observed RN-D prepare blood for transfusion for patient #23. Order for red blood cell transfusion of 2 units to be infused at a rate of 75-125mL per hour. Blood was prepared for transfusion by RN-D in patient room. RN-D had hands gloved. RN-D then pulled trash can across the room with gloved hand while blood tubing was primed. RN-D then pulled trash can back across room with gloved hand. RN-D did not remove gloves and perform hand hygiene after touching trash can. RN-D then touched patient to connect blood tubing and IV pump to initiate transfusion with gloved hands.

B. Policy and Procedure
- Review of the policy and procedure Hand Hygiene last reviewed 1/22 indicates that hand hygiene be performed after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. The policy also indicated that gloves do not take the place of hand hygiene measures.

C. Interview
- On 3/29/2022 at 2:05 PM interview with Accreditation Coordinator RN-A confirmed that staff RN-B and RN-C performing medication administration for patients #21 and #22 left patients rooms while gloved and did not perform hand hygiene or re-glove after re-entering patients rooms. RN-A also confirmed RN-D performing blood transfusion for patient #23 was gloved and touched the trash can in patient room twice and continued with blood transfusion without performing hand hygiene and re-gloving.