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Based on observations, policy review, and staff interviews, the ACH ' s administrative staff failed to ensure the hospital ' s nursing staff adhered to pertinent policies and procedures of the hospital for 2 of 3 patients in which the survey team observed patient care. Failure to adhere to policies and procedures set forth by the hospital ' s administrative staff could result in the provision of reduced quality of care, the proliferation of nosocomial (hospital-acquired) or iatrogenic (treatment-related) infections, and an increased risk of adverse outcomes, which could include a deterioration in health, disability, or death. The ACH identified an average of 116 patients receiving nursing services in an inpatient setting per day.

Findings include:

1. Review of 05/2022 "Standard Precautions" revealed in part: "Standard precautions must be consistently used for all patients regardless of their diagnosis or presumed infection status . . . Standard Precautions apply to: . . . Blood. All body fluids (including other potentially infectious material (OBIM)), secretions, and excretions (except sweat) regardless of whether or not they contain visible blood. Non-intact skin. Mucous Membranes."

2. Review of 09/2022 "Hand Hygiene" policy revealed in part: "Hand hygiene is performed: Before and after contact with a patient . . . Before moving from work on a soiled body site to a clean body site on the same patient . . . After contact with blood, bodily fluids, excretions, mucous membranes, non-intact skin, wound dressings, or visibly soiled surfaces . . ."

3. Review of 04/2024 "Sterile and Disposable Supplies- Storage and Handling" policy revealed in part: "Storage: C. Supplies are not stored on floors, window sills, or areas other than designated shelving, counters, or carts . . . F. In-room supply storage. Clean supplies are stored in patient rooms in a manner where contamination cannot occur. Hand hygiene is performed before accessing in-room supply cupboards or carts to ensure handles and cart locks remain clean."

4. On 7/15/24 at 3:00 PM, observation of a wound cleaning and dressing procedure revealed the following:

a. Staff CC (Clinical Wound Specialist (CWS), Registered Nurse (RN)), assisted by Staff DD (CWS, RN), removed bilateral soiled wound dressings from Patient #21 ' s feet, evaluated the wound sites for signs and symptoms of infection, collected measurements of the respective wounds, topically cleansed the wound sites, and reapplied clean dressings to both feet.

b. Subsequent to physical contact between Staff CC ' s gloves and the patient ' s skin on and adjacent to the wound sites, Staff CC retrieved medical supplies improperly stored in their front shirt pocket, which included dual-purpose cotton-tipped applicators/measurement instruments.

c. During this process, Staff CC failed to remove the contaminated gloves, practice appropriate hand hygiene, and replace gloves prior to handling the medical supplies-including supplies intended for other patients. Additionally, Staff CC failed to properly discard the potentially contaminated supplies. This presented an opportunity for transmission of infectious agents from the patient ' s open wound to the aforementioned supplies, as well as potential transmission of disease to subsequent wound patients via said contaminated supplies.

d. Staff CC placed the unsanitized exterior of the retrieved applicator package on the patient ' s wound to collect measurements, presenting an opportunity for the transmission of infectious agents from the unsanitized package to the patient ' s open wound.

5. During an interview on 7/18/24 at 11:10 AM, Staff OO (Infection Prevention Coordinator) reported Staff CC ' s (CWS, RN) practice of storing medical supplies in their pockets did not adhere to the 04/2024 "Sterile and Disposable Supplies- Storage and Handling" policy, which allows for storage of supplies in designated locations only. Additionally, Staff OO confirmed Staff CC ' s failure to change gloves and practice hand hygiene in between touching a soiled body site or surface and a clean body site or surface did not adhere to the 09/2022 "Hand Hygiene" policy mandating such.

6. During an interview on 7/18/24 at 11:45 AM, Staff DD (RN) confirmed the hospital ' s policies and procedures requirement for replacing gloves and practicing proper hand hygiene when alternating between clean and dirty body sites and surfaces.

7. On 7/18/24 at 9:00 AM, observation of a peripheral intravenous (IV) cannula assessment and removal revealed the following:

a. Staff NN failed to perform hand hygiene prior to donning gloves, thereby introducing potential contamination to the gloves, as well as any items handled with the gloves.

b. Staff NN (CWS, RN) palpated Patient #23 ' s left IV site, flushed the IV saline lock to evaluate its patency and integrity, removed the IV site dressing, saline lock, and IV cannula upon identifying compromise of the IV, and applied manual pressure to the IV site to promote clotting upon removal.

c. Staff NN failed to replace gloves when alternating between physical contact with the patient and physical contact with unsanitized surfaces-including a supply closet handle, supplies within the supply closet, and Staff NN ' s mobile phone-introducing opportunities for the spread of infectious agents between the patient, externally contaminated supplies and devices, and subsequent patients.

d. Upon removal of the IV, Staff NN performed hand hygiene and utilized paper towels to close the sink faucet; however, Staff NN then recontaminated their hands by crumbling the contaminated paper towels together in their hands prior to disposal.

8. During an interview on 7/18/24 at 11:10 AM, Staff OO (Infection Prevention Coordinator) reported Staff NN ' s failure to change gloves and practice hand hygiene in between touching a soiled body site or surface and a clean body site or surface did not adhere to the 09/2022 "Hand Hygiene" policy mandating such.

9. During an interview on 7/18/24 at 1:00 PM, Staff NN (RN) voiced acknowledgment of their failure to follow acceptable standards of nursing practice and hospital policies and procedures requiring the replacement of gloves and proper hand hygiene when alternating between tasks involving contact with potentially contaminated surfaces and body sites.

10. During an interview on 7/17/24 at 3:00 PM, Staff CC (CWS, RN) acknowledged their routine wound care procedure included retrieving supplies improperly stored in their front shirt pocket while wearing soiled gloves and without replacing said gloves or practicing proper hand hygiene. Staff CC revealed the hospital employs one full-time CWS and two part-time CWS who collectively treat approximately 15 to 20 wound patients per day. As the only full-time CWS, Staff CC estimates that they perform approximately 80 percent of wound care services-with the remaining 20 percent completed by two part-time CWSs-whereas nursing staff throughout the hospital perform IV cannulation and IV care as needed. Due to uncertainty regarding the frequency in which the aforementioned policy violations have occurred, however, the full extent and effects of the identified deficient practices can not be precisely delineated.