HospitalInspections.org

Based on record review, observation, and interview the facility staff failed to remove surgical masks after completion of case in 4 of 4 staff (RN M, RN N MD O, and MD P) observed and staff failed to perform hand hygiene with removal of gloves in 1 of 9 staff (CP R) observed. This deficiency has the potential to provide cross contamination to other patients, staff, and visitors.

Findings Include:

Per review of policy titled Surgical Services Infection Control Guidelines, no policy number, dated 12/2013 stated on page 10, 2. H. Masks should be removed carefully by handling only the ties, and they should be discarded immediately after use. 2. I. Masks should not be saved by hanging them around the neck or tucking them into a pocket for future use.

Per review of policy titled Infection Prevention and Control Manual, no policy number, dated 12/2013 stated on page 5, II. A. 3. Decontaminate hands in the following circumstances, whether or not gloves are worn; f. after removing gloves.

Per observation on 6/15/2015 at 2:10 PM numerous staff member brought a pt. up to room 310 from the surgery department. Staff MD O and MD P were observed sitting behind the nurses station and walking in the hallways with masks hanging around their necks. MD O and MD P left the unit with masks hanging around neck. Staff RN M and RN O were observed standing at the nursing unit desk and walking in the halls with masks around their neck. RN M and RN O removed masks when asked why they were left hanging around necks. Findings were shared with Executive Director of Patient Care (EDPC) T at time of observation.

Per observation on 6/17/2015 at 1:10 PM of Care Partner (CP) R completing a blood sugar check on pt. #11 in room W1109. CP R put on gloves entered pt. room and scanned bracelet of patient, walked back out to entry way of room, removed gloves and grabbed new gloves without the benefit of performing hand hygiene. Finding was shared with Executive Director of Patient Care (EDPC) T at time of observation.

Per interview with Infection Control Nurse I and J on 6/17/2015 at 12:10 PM, ICN I stated that "staff is aware that masks are single use and should be removing them immediately and performing hand hygiene." ICN I also stated "staff should be completing hand hygiene any times gloves are removed".