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Based on review of hospital policies, observations during tour, and staff interview the hospital's staff failed to perform hand hygiene to prevent cross-contamination on the Medical/Surgical Floor.

The findings include:

Review of current hospital policy "Hand Hygiene" policy number 8311.530 (last reviewed/revised 11/2011) revealed, "...Hand hygiene is considered the single most important procedure for preventing nosocomial infections. ...Any contact with the patient or the patient's environment could conceivably result in the transfer of microorganisms to the hands. Following standard precautions and avoiding contamination of the hands is essential in helping to prevent the spread of microorganisms. ...B. Indications for hand hygiene: ...4. After contact with inanimate environmental sources likely to be contaminated. ..."

Review of current hospital policy "Bloodborne Pathogen Control Plan" policy number 8311.528 (last reviewed/revised 11/2011), revealed "...Part IV POLICY: Standard Precautions....1. Hands must be throughly washed between all direct contact with patients and after handling soiled or contaminated equipment. ..."

Observation during tour of the Medical-Surgical Floor on 07/10/2012 at 1339 revealed a Nursing Assistant (NA) at the bedside of a patient in room 102. Observation revealed the NA was obtaining the patient's vital signs (blood pressure, pulse, respirations, and temperature) with an automatic vital signs machine (AVSM) on wheels and thermometer. Observation revealed the blood pressure cuff of the AVSM was attached to the patient's upper arm. Observation of the AVSM revealed the blood pressure cuff was not disposable. Observation revealed the NA removed the blood pressure cuff from the patient's arm and exited room 102 with the AVSM and placed the machine in the hallway. Observation revealed the NA ambulated down the hallway and entered into the nourishment room. Observation revealed the NA obtained a Styrofoam cup and used a scoop to obtain ice from the ice machine. Observation revealed the NA placed ice into the cup. Observation revealed the NA obtained Ensure? (a liquid nutritional supplement) from a cabinet. Observation revealed the NA exited the nourishment room and re-entered room 102. Observation revealed at 1343 the NA exited room 102 obtained the AVSM from the hallway and entered room 150. Observation revealed the NA exited room 150 and entered room 148 at 1351 and obtained a pillow. Observation revealed the NA exited room 148 and re-entered room 150 with the pillow. Observation revealed the NA then exited room 150 with the AVSM and plugged the machine into an electrical outlet in the hallway. Observation revealed the NA then entered the nursing station, obtained two patient charts and began documentation in the charts. Observation revealed after the NA completed documentation in the charts, the NA went into an ante-room of the nursing station and performed hand hygiene at a sink. Observation revealed the NA failed to perform hand hygiene when entering and/or exiting rooms 102, 150, 148 and the nourishment room after having direct contact with patients and after contact with inanimate environmental sources likely to be contaminated (i.e. ASVM and thermometer). Observation revealed alcohol based hand rub dispensers mounted to the wall adjacent to the entry doors of rooms 102, 148, 150 and soap/water/sinks available for use. Observation revealed the NA failed to perform hand hygiene per hospital policy.

Interview on 07/11/2012 at 0943 with the Chief Nursing Officer revealed based on the observation "the expectation would be for the NA to at a minimum after contact sanitize their hands or wash their hands afterwards, especially before going into the nourishment room." Interview confirmed the NA failed to follow the hospital's hand hygiene policies.

NC00080557