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Based on observation, interview and record review, the facility failed to provide a sanitary environment to avoid sources and transmission of infections in 1 of 4 sampled patients. Patient # 4
.

Findings:

Observation on 10/2/2013 at 11:45 AM revealed that Staff A is going to perform a wound dressing change on Patient # 4. Staff A gathered all dressing supplies and places them over a bedside table with a barrier. Staff A closed the door for privacy; she washed her hands and explained the process to the patient. Staff A log rolled the patient to expose the wound on the left buttocks. Staff A donned 3 gloves on her right hand and 3 gloves on her left hand. Staff A removed the old dressing from the left buttocks. Staff A removed and discarded the outer layer of gloves from both hands. Staff A proceeded to cleanse the wound with gauze saturated with normal saline in a circular motion, and then pat dry. Staff A removed and discarded second layer of gloves from both hands. Staff applied and dated a new clean dressing and covered the wound. Staff A removed and discarded the third layer of gloves from both hands and proceeded to wash her hands.

Interview with Staff A on 10/2/2013 at 12:00 PM revealed and stated when asked why she wore 3 gloves per hand, Staff A replied; "because you need 3 gloves changes when you do a dressing change, I have been doing this way for years". Staff A stated that she learned this way through the wound association. When asked to provide a copy of the wound associations standard of dressing changes, Staff A and the RN Supervisor searched through the Internet for 15-20 minutes and were unable to provide documentation.

Interview with the Hospitals Infection Control Preventionist on 10/2/2013 at 1:10 PM revealed and stated that she performs wound dressing competency checks with the nurses but have not observed Staff A. She stated that the hospital does not have an infection control policy specific to wound dressing changes.
Review of the facility wound assessment, prevention and documentation policy and procedure did not reveal specific dressing change policy. Review of the facility Infection Prevention and Control Surveillance with effective date of October 2012 revealed on page 1 of 5 under Roles and Responsibilities: The Infection Preventionist is responsible for coordinating and carrying out the functions of the Infection Prevention Surveillance Program. On Page 4 of 5 under letter J reads: The Infection Preventionist collects and reviews data to determine Healthcare Associated Infections.