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Based on record review and interview the facility failed to ensure implementation of infection control policies, failed to maintain sanitation techniques in all facility personnel and failed to monitor handwashing of the Emergency Room (ER) staff for 1 of 5 patients' records reviewed. (Patient #1)

The findings included:

Review of the clinical record of patient #1 (16 year old) revealed that the patient had been to the facility every other day X 7 days as follows:
On 3-6-10 the diagnosis was made of pilonidal cyst. The cyst was incised, drained of a large amount of foul smelling pus and packed with nu-gauze. The patient had no fever. The wound was gram stained. The results were gram + cocci in clusters with mixed gram + flora. A prescription for Bactrim and Vicodin was provided.
On 3-8-10 the packing was removed and replaced. There was no fever. The patient was to continue with the antibiotics.
On 3-10-10 the packing was removed and replaced. There was no fever. The patient was to continue with the antibiotics.
On 3-12-10 the packing was removed and replaced. There was no fever. The patient was to continue with the antibiotics.
On 3-14-10 the packing was removed and replaced. There was no fever. The patient was to continue with the antibiotics.
On 3-16-10 the packing was removed and replaced. There was no fever. The antibiotics ended and were not renewed.

Interview on 3-18-10 at 8:55 am with the patient's mother in the ER revealed that on the 3-14-10 visit she observed the physician's assistant (PA) on duty discard the old packing and place the new packing with the same gloves. The PA did not wash his hands before entering the patient area. Once the wound was opened and the packing removed, the PA knocked over the trash can, righted it, put the dirty dressing in the can and then came to the patient with the clean packing. The complainant called the facility after she left with the patient and spoke with a supervisor. She was asked to return to the ER and see the physician on duty to have the contaminated packing changed if needed.

Review of the complaint documented by the supervisor on 3-14-10 revealed that the complaint was sent to Risk Management. The supervisor documented that the PA did not deny that he had omitted hand washing, and he said that the procedure was not supposed to be sterile.

Review of the current facility policy for Hand Hygiene revealed that the hands were to be decontaminated before having direct contact with patients; decontaminate hands after contact with body fluids; decontaminate hands after removing gloves. Included in the policy are the 5 moments for hand hygiene. They are before touching a patient, before a clean or aseptic procedure, after a body fluid exposure risk, after touching a patient and after touching patient's surroundings.