HospitalInspections.org

Based on review of policies, review of medical records, observations and interviews with staff, the facility failed to demonstrate proper infection control practices by failing to perform proper hand hygiene during administration of infusion of blood in 2 of 2 observations. (Patients #20 and #21).

The findings include:

Review of policy titled "Hand Hygiene" with revision date of November 15, 2021, revealed "1. SCOPE/PURPOSE: The purpose of this policy is to assist in reducing the risk of transmission of infections to team members, patients, and visitors. Hand hygiene is the single most effective way to prevent the spread of organisms and potential infections. II. ...Hand hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, antiseptic hand rub (i.e., alcohol-based hand sanitizer including foam or gel) E. Indication for Hand Hygiene: 1. Before entering and exiting a patient's room... 3. Before and after each patient contact... 8. After contact with a source of microorganisms (body fluids and substances, mucous membranes, non-intact skin, an inanimate object, that are likely to be contaminated) ...10. Before donning (putting on) gloves and other personal protective equipment (PPE). 11. After doffing (removing) gloves and other PPE. (Gloves are an adjunct to, not a substitute for hand hygiene) ...14. After any suspected contamination."

1. Open medical record review on 05/03/2023 of Patient #21 revealed a 53 year old female with a diagnosis of anemia (low blood count) with a physician order to administer two units of PRBCs.

Observation on 05/03/2023 at 0830 through 0904 on campus A revealed RN #1 assigned to Patient #21. Observation at 0834 revealed RN #1 donning gloves and performing vital signs. Vital signs were obtained, and gloves were removed. Observation revealed gloves were donned prior to blood retrieved by RN #1 from the blood bank. Observation revealed RN #1 removed those gloves at the patient's bedside and donned new pair of gloves. RN #1 removed bag of blood from the biohazard bag, double checked blood unit numbers, scanned Patient #21's arm band, verified patient's name and date of birth and removed gloves. RN #1 donned new gloves and scanned blood bar code entered information in the bedside portable computer and spiked the blood with the IV (intravenous) tubing. Observation did not reveal hand hygiene with the use of hand sanitizer or hand washing was performed during the observation period of RN #1 donning and doffing gloves while in contact with the blood on Patient #21.

Interview on 05/03/2023 at 0904 with RN #1 revealed hand washing was done at the sink near the desk. Interview revealed RN #1 did not use hand sanitizer or hand soap at the sink during the observation. Interview revealed policy was not followed.

Interview on 05/03/2023 at 0904 with DON #2 revealed no hand hygiene was observed during the blood administration. Interview revealed policy was not followed. Interview revealed hand sanitizer was available for use by the staff.

Interview on 05/05/2023 at 1000 with Infection Control Director (IP #3) revealed hand hygiene should have been performed during the blood administration. "Hand hygiene is our best defense to prevent infection." The interview revealed policy was not followed during the administration of blood.

2. Open medical record review on 05/04/2023 revealed a 72 year old female admitted to Campus B on 05/03/2023 for new diagnosis of Leukemia. Review of orders revealed "05/03 transfuse 1 (one) unit of PRBC."

Observation on 05/03/2023 at 1330 revealed RN #4 was observed donning gloves after blood arrived to Patient #20's room. Observation revealed RN #4 typed on the computer keyboard then spiked the blood bag with the IV tubing, without changing gloves and performing hand hygiene.

Observation revealed dispensers of hand sanitizier and hand soap were available in the Patient 20's room.

Interview on 05/03/2023 at 1400 with RN #4 revealed gloves should have been removed after using computer, performed hand hygiene and donned new gloves before spiking blood bag.

Interview on 05/03/2023 at 1400 with Manager #4 revealed policy was not followed. Interview revealed RN #4 should have removed used gloves and performed hand hygiene before spiking blood bag.

Interview on 05/05/2023 at 1000 with Infection Control Director (IP #3) revealed hand hygiene should have been performed during the blood administration. "Hand hygiene is our best defense to prevent infection". The interview revealed policy was not followed during the administration of blood.

NC00201438; NC00201144; NC00200377; NC00200027; NC00197775; NC00194487; NC00196597; NC00197949; NC00194943; NC00200542