HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of nine patients. Based on observation, staff interview, and policy review the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control practices for one of one observed dressing change.

Findings include:

- The CAH's policy "Handwashing" reviewed on 5/30/12 at 2:00pm directed "...hands will be washed before and after patient contact, before putting on gloves and after removing gloves, after contact with inanimate objects including medical equipment in the immediate vicinity of the patient..." The CAH's policy "Waterless Hand Antiseptic" reviewed on 5/30/12 at 2:00pm directed "Hand antiseptic will be used in addition to hand washing when hands are not visibly soiled..."

- The CAH's policy "Performing a Wound Assessment" reviewed on 5/30/12 at 2:00pm directed "...Protective equipment: clean gloves, gown, and goggles if splash/spray risk exists ..."

- Staff C, observed on 5/29/12 between 10:35am and 11:30am provided patient #5 with a dressing change to wounds on the left buttocks, left elbow, and left shoulder. Staff C entered patient #5's room performed hand hygiene, put on gloves and a gown (the only "protective" equipment). Staff C removed a soiled dressing from the left buttock exposing a wound approximately 1 inch by 3/4 inch. The wound appeared pink. Staff G failed to removed their soiled gloves and cleaned the wound with a 4X4 gauze and spray CarraKleans (a wound cleaning agent). Staff C removed their gloves, performed hand hygiene, and reapplied clean gloves. Staff C applied a clean dressing. Staff C then removed a soiled dressing from a small wound on the left buttock, failed to change their soiled gloves and cleaned the wound with a 4X4 gauze and spray CarraKleans. Staff C removed their gloves, failed to perform hand hygiene and reapply a clean pair of gloves. Staff C then applied a clean dressing to the wound. Staff C removed their gloves, performed hand hygiene, and reapplied clean gloves.

Staff C removed a soiled dressing from patient #5's left elbow, remove their soiled gloves, failed to perform hand hygiene, and cut a dressing for the elbow. Staff C reapplied clean gloves and cleaned the wound with a 4X4 and spray CarraKleans. Staff C placed a clean dressing to the left elbow, removed their gloves, and failed to perform hand hygiene.

Staff C repositioned patient #5 then performed hand hygiene, and reapplied clean gloves. Staff C removed a soiled dressing from two wounds on the left shoulder, failed to change their soiled gloves and cleaned the wound with a 4X4 gauze and spray CarraKleans. Staff C removed their gloves, performed hand hygiene, and reapplied gloves. Staff C applied a clean dressing to the two wounds on the left shoulder.

Staff C, interviewed on 5/29/12 at 11:30am, acknowledged they failed to performed hand hygiene with each glove change.

Administrative staff A interviewed on 5/30/12 at 2:15pm acknowledged staff should wear face protection when performing a dressing change when using spray cleaner.

Staff B interviewed on 5/30/12 at 2:15pm acknowledged the facility held training on proper wound care. Staff B acknowledged they failed to start surveillance of staff performing wound care.