HospitalInspections.org

Based on observation, review of policy and procedure, Centers for Disease Control Standards and interview, the facility failed to ensure staff performed hand hygiene per practice standards in 1 of 1 nursing care observations. This had the potential to affect all patients served by the facility.


Findings include:


Centers for Disease Control (CDC)
cdc.gov

" Hand Hygiene in Healthcare Settings

Hand Hygiene Basics
Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings)..."

Policy and Procedure:
Subject: Intravenous Therapy
Revised October 2013

" Policy:
I. Registered Nurses... may perform the following:
A. Begin an intravenous (IV) infusion...
Procedure:
I. Venipuncture...
F. Select appropriate IV catheter/device
G. Wash hands...
M. Prepare the skin with antiseptic provided in IV start kit and allow to air dry for approximately 30 seconds. Put on gloves. Do not touch site with finger unless you prep finger with Betadine."




30952

During an observation of care 10/21/14 at 9:50 AM in the Day Surgery Department, Employee Identifier (EI) # 1, Registered Nurse, was starting an intravenous (IV). EI # 1 performed hand hygiene using hand sanitizer and donned gloves. EI # 1 verified the correct patient, scanned the patients bracelet, charted on the bedside computer, then hung the IV solution on the IV pole. EI # 1 removed his/her gloves and laid the gloves on the bedside table. EI # 1 did not perform hand hygiene after glove removal.

EI # 1 spiked the IV bag, primed the IV tubing with solution, opened the IV start kit and applied the tourniquet to the patient's left arm. EI # 1 then removed his/her gloves. EI # 1 did not perform hand hygiene after glove removal.


In a 10/21/14 9:55 AM interview with EI # 2, Surgery Services Department Manager, the above observations were confirmed.

Based on observation, review of policy and procedures and interview it was determined Employee Identifier # 3, Respiratory Therapist failed to remove her gloves after touching a contaminated service and continued to perform ventilator care without changing gloves and performing hand hygiene.



Findings include:

Policy and Procedure
Subject: Standard Blood and Body Fluid Precautions
" Policy: Standard refers to a system of infection control which assumes that every direct contact with body fluids is potentially infectious...
Personal Protective Equipment (PPE) are barriers designed to prevent employees from having direct contact with blood or other potentially infectious materials. Examples include gloves... Contaminated personal protective equipment must be removed immediately upon leaving the work area and may not be worn into non-contaminated areas i.e., nursing stations, lounge, cafeteria.

Patient contact, not involving blood/body fluids, or contact with items not contaminated with such, does not require the use of protective barriers."

Observation of care was conducted on 10/21/14 at 10:20 AM with Employee Identifier (EI) # 3, Respiratory Therapists. EI # 3 was providing a breathing treatment to a Medical Record (MR) # 10. MR # 10 was a ventilator patient in the intensive care unit. EI # 3 entered MR # 10's room and donned gloves. EI # 3 then dropped an alcohol pad on the floor and picked the alcohol pad up and placed it in the trash.

EI # 3 began resetting the ventilator settings, administering the Duoneb breathing treatment, performing lavage and suctioning of the tracheal tube and examined the inside of MR # 10's mouth with the same pair of gloves used to pick up the alcohol pad from the floor.

An interview was conducted on 10/22/14 at 7:00 AM with EI # 5, Chief Nursing Officer who verified EI # 3 should have removed the gloves and performed hand hygiene after picking the alcohol pad up off the floor.

An interview was conducted on 10/22/14 at 9:00 AM with EI # 4, Infection Control Manager who verified EI # 3 should have removed the gloves and performed hand hygiene after picking the alcohol pad up off the floor.