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Based on observation, interview, record review, and policy review the facility failed to ensure hand hygiene was completed as necessary to prevent contamination of an open wound for one Patient (P) 8 during one of one dressing change observed.

Observation of one of two meal services on the 2nd floor Medical Surgical Unit (MSU) revealed two of three Certified Nurse Aides (CNA's) passing meal trays to patients that failed to perform hand hygiene between serving patients. This occurred during the meal service of four of 12 patients. Failure to perform hand hygiene before leaving one patient room and entering a second patient room has the potential to spread infection.

Findings include:

1. Review of a physician progress note found in the electronic medical record, (EMR), under Physician Notes found diagnoses identified for P8 of diabetes, acute osteomyelitis of left 2nd and 3rd toe, and a left foot second toe diabetic ulcer.

A physician's order for P8 located under the Physician's Orders in the EMR directed intravenous antibiotic therapy for 6 weeks for the osteomyelitis of the 2nd and 3rd toe. The order for treatment for P8 included a "Nursing Wound Order," dated 02/22/20 at 5:49 PM, for the toe on the left foot, "Change daily. Cleanse with NS [normal saline], pat dry, apply xeroform gauze and secure with Coban (a self-adherent wrap used to secure wound dressings)."

Observation of the dressing change by Registered Nurse (RN) 6 on 02/24/20 at 2:15 PM showed the RN to wash his/her hands and put clean gloves on. The RN removed the soiled dressing from P8's left foot. The nurse then picked up the clean syringes filled with normal saline (NS) and administered the NS to the open areas on the end of P8's left foot large toe. The RN took off his/her dirty gloves and put another pair of clean gloves on without using a hand sanitizing agent or washing his/her hands. RN6 then cut a piece of sterile impregnated gauze wound dressing, picking it up with her gloved hand, and placed over the open areas of the left foot large toe. The left foot was wrapped with a self-adherent cohesive bandage. RN6 removed her gloves and washed her hands.

Interview of RN6 on 02/24/20 at 2:40 PM, outside of P8's room on the 2nd floor of the MSU, verified he/she failed to clean or sanitize his/her hands after removing the dirty dressing and cleaning the open wound. RN6 stated that he/she should have washed her hands when he/she changed his/her gloves before continuing with the dressing change.

A review of the dressing change observation for P8 was completed with the hospital Infection Control (IC) nurse on 02/24/20 at 3:00 PM in the conference room located in the C building of the hospital. The IC nursed stated that it would be the expectation the nurse would change gloves between removing a dirty dressing and wash his/her hands and put on clean gloves before cleaning the wound and applying the clean dressing.

2. Observation of meal service on 02/24/20 at 12:05 PM on the 2nd floor MSU showed CNA7 and CNA8 passing patients trays. CNA8 picked up a tray off the cart and walked into room 203 moved the resident bedside (BS) table in place in front of the patient and placed his/her meal tray on the BS table removed the lid from the plate, laid it on the table and walked out of the room. CNA8 did not wash his/her hands or use hand sanitizer to cleanse his/her hands. CNA 8 picked up another meal tray off the cart and walked into room 204. CNA 8 moved the resident's walker and moved personal items on the bedside table and placed the meal tray on the BS table and walked out of the room without washing or sanitizing his/her hands. CNA8 walked into the nurses station and sat down at the desk.

Further observation of meal service on 2nd floor MSU showed CNA7 at 12:07 PM picked up a meal tray off the cart and walked into room 210. CNA7 moved the patients walker and BS table and placed the tray on the BS table and walked out of the room. CNA7 did not wash her hands or use hand sanitizer. CNA7 walked back to the meal cart and removed a second meal tray for room 207 marked as an isolation room. The tray was placed on top of the dressing cart while the CNA put on a gown, mask, and gloves picked up the tray and placed the tray on the patients BS table. The CNA sanitized her hands after leaving the room.

Interview of CNA7 on 02/24/20 at 12:13 PM outside of room 207 on the MSU verified he/she failed to wash or sanitize his/her hands during meal tray delivery to rooms 210 then to 207.

Interview of CNA8 on 02/24/20 at the nurses station on 2nd floor at 12:15 PM verified he/she failed to cleanse his/her hands between delivery of meal trays to room 203 and 204.

The failure of the two CNA's to cleanse their hands was verified by the Utilization Review Nurse present during meal delivery service on the 2nd floor of the MSU on 02/24/20. He/she verified CNA7 and CNA8 failed to wash or sanitize their hands between tray delivery to rooms 203, 204, 210 then 207.

A review of the meal observation was conducted with the IC nurse in the conference room at 3:00 PM on 02/24/20. The IC nurse stated that hand hygiene must be completed between patients during the service of meal trays.

Review of the hospital policy, "Hand Hygiene," dated 10/22/03, ...3. Indications for hand hygiene: i. Decontaminate hands after contact with a patient's intact skin, i.e. taking a pulse, blood pressure or lifting a patient. ii. Decontaminate hands after contact with body fluids or excretions, mucus membranes, non-intact skin, or wound dressing, as long as hands are not visibly soiled. iii. Decontaminate hands if moving from a contaminated body site to a clean body site during patient care. iv. Decontaminate hands after contact with inanimate objects, including equipment, in the immediate vicinity of the patient. ..."