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Based on observation, interview and policy review, the hospital failed to ensure staff followed the hand hygiene policy when caring for 12 patients (#1, #2, #5, #7, #8, #9, #10, #11, #15, #19, #26 and #27) of 24 patients observed. This failure increased the risk of hospital-acquired infection for all patients admitted to the hospital. The hospital census was 207.

Findings included:

Review of the hospital's policy titled, "Hand Hygiene," dated 04/09/21, showed that infection prevention interventions included changing gloves during patient care if moving from a contaminated body site to a clean body site. Indications for hand antisepsis were before and after direct contact with patient's, after contact with a patient's intact skin, body fluids or excretions, mucous membranes, non-intact skin, dressing changes, if moving from a contaminated-body site to a clean-body site and after removing gloves.

Review of the hospital's policy titled, "Standard and Transmission Based Precautions," dated 08/2022, showed that clean gloves must be put on just before touching mucous membranes and non-intact skin. Gloves were to be changed between tasks and procedures on the same patient, and after contact with material that may contain a high concentration of microorganism. Gloves were to be removed promptly after use, before touching non-contaminated items and surface. Gloves were not to be worn while speaking on the telephone.

Observation on 06/13/23 at 8:30 AM, in the Intensive Care Unit (ICU, Intensive Care Unit (ICU, a unit where critically ill patients are cared for), showed Staff V, RN, failed to remove her gloves and perform hand hygiene prior to opening a dressing change kit after removing a dressing from Patient #11. Staff V, RN, then placed sterile gloves over dirty gloves prior to cleaning a peripherally inserted central catheter (PICC line, a flexible tube inserted into an arm, leg or neck vein to infuse fluids, blood products, and medications, or to withdraw blood for testing) site for Patient #11. Staff V, RN, failed to remove her gloves and perform hand hygiene prior to answering her phone, while caring for Patient #11.

Observation on 06/12/23 at 3:00 PM, in the Progressive Care Unit (PCU, a telemetry [remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen] monitored unit that provides care for adult patients requiring continuous cardiac monitoring) showed Staff H, Registered Nurse (RN), failed to remove her gloves and perform hand hygiene after removing two soiled dressings while performing a dressing change on Patient #2.

Observation on 06/12/23 at 3:05 PM, in the Neonatal Intensive Care Unit (NICU, unit for premature and ill newborns) showed Staff E, RN, failed to perform hand hygiene prior to putting on her gloves and after removing her gloves while caring for Patient #1.

Observation on 06/12/23 at 3:22 PM, in the NICU, showed Staff F, RN, failed to perform hand hygiene after removing her gloves and prior to answering her phone, while caring for Patient #1.

Observation on 06/12/23 at 3:43 PM, in the PCU, showed Staff J, RN, failed to perform hand hygiene after removing her gloves while performing catheter care and catheter removal for Patient #5.

Observation on 06/13/23 at 8:30 AM, in the PCU, showed Staff EE, RN Manager, failed to perform hand hygiene between gloves changes when she discontinued Patient #19's IV. Patient #19 was in an isolation room.

Observation on 06/13/23 at 8:25 AM, on the fifth floor, showed Staff N, RN, failed to perform hand hygiene after removing his gloves, while administering medications for Patient #7.

Observation on 06/13/23 at 9:08 AM, on the fifth floor, showed Staff P, RN, failed to perform hand hygiene after removing her gloves and retrieving supplies from a drawer, while administering medications for Patient #8.

Observation on 06/13/23 at 9:32 AM, on the sixth floor, showed Staff R, RN, failed to perform hand hygiene prior to putting on her gloves, while administering medications to Patient #9.

Observation on 06/13/23 at 9:50 AM, on the fifth floor, showed Staff S, Patient Care Technician (PCT), failed to remove her gloves and perform hand hygiene after providing catheter care, and prior to touching Patient #10's bed covers.

Observation on 06/13/23 at 10:50 AM, on the sixth floor, showed Staff CC, RN, failed to perform hand hygiene after removing her gloves while caring for Patient #15. Staff CC, RN, failed to remove her gloves and perform hand hygiene prior to retrieving supplies from a drawer while caring for Patient #15.

Observation on 06/13/23 at 1:15 PM, on the sixth floor, showed Staff OO, RN, failed to remove his gloves and perform hand hygiene after attempting to start an intravenous (IV, in the vein) line for Patient #26, and prior to moving the bed out of the room.

Observation on 06/13/23 at 1:35 PM, on the sixth floor, showed Staff T, RN, failed to remove his gloves and perform hand hygiene after cleaning the bedside table, and before performing a dressing change for Patient #27.

During an interview on 06/12/23 at 3:15 PM, Staff H, RN, stated that she should have changed her gloves after removing Patient #2's dressings.

During a group interview on 06/13/23 at 1:20 PM, Staff A, ACNO; Staff K, CNO; and Staff O, RN, Telemetry Director, stated that hand hygiene should be performed after glove removal and prior to putting on gloves.

During an interview on 06/13/23 at 2:58 PM, Staff NN, RN, Infection Prevention Manager, stated that hand hygiene should be performed prior to putting on gloves and after removing gloves.



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