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Based on observations, interviews, policy, and record reviews, the facility failed to identify practices to control infections and communicable diseases of patients and personnel for 2 patients at the facility. (Patient #11 and Patient #28)

Findings include:

1) On 6/14/2016 at 9:39 A.M., Licensed Nurse #1 (LN #1) was observed doing a medication pass to Patient (Pt.) #28 who was scheduled to receive a dose of Heparin SQ and Cephazolin IVP. With donned gloves LN #1 raised Pt. #28's hospital gown and pinched Pt. #28's abdomen. With the other hand LN #1 did an alcohol wipe to the raised abdominal area and injected the heparin dose into Pt. #28's abdomen. LN #1 discarded the used syringe into a sharps container hanging from the patient's wall near the foot of the bed. LN #1 then walked to the medication cart parked near the foot of Pt. #28's bed. LN #1 took a syringe from the medication cart, walked back to the right of the patient's bedside. Using the same gloved hands LN #1 felt for and took the IV line in the patient's right forearm. LN #1 stopped, walked back to the medication cart to pick up a small packet containing a light blue cap and walked back to the patient's bedside. LN #1 then lifted the IV line to prepare the IV port; and proceeded to administer the antibiotic by intravenous push into the patient's IV line over a period of 3 minutes. After the observation LN #1 was asked about glove change and hand sanitizing between medication administration. LN #1 shared "I guess I should have changed gloves".

2) On 6/14/2016 a medical record review found Pt. #11 was admitted with sepsis, anasarca, CHF, history of necrotizing fasciitis to right lower leg cellulitis MRSA. Contact isolation was started upon admission on 6/9/2016. At 12 noon on the same day LN #2 was observed doing a dressing change to Pt. #11. Also present during the observation was the Charge Nurse for the unit. After donning personal protective equipment for contact isolation LN #2 walked into the patient's room and placed the dressing change supplies on a table located in the corner of Pt. #11's room. Next to the left of the patient's bed was the patient's overbed table on which a lunch tray sat with food dishes already opened. With gloved hands LN #2 dragged a large trash can close to the foot of Pt. #11's bed, removed the worn gloves and donned a clean pair of gloves. No observation was made of staff hand sanitizing between glove change. After cleaning the wound LN #2 changed gloves and donned new gloves, failing to hand sanitize between the glove change. All together 5 glove changes and 2 hand sanitizing activities were performed by LN #2 from the start to end of the dressing change procedure. At the end of the dressing change LN #2 asked the patient if the lunch tray was done and ready for removal from the room. Outside of the patient's room LN #2 was asked about the policy for hand sanitizing between glove changes. The Charge Nurse shared only if hands are visibly soiled.

A review of the facility's Hand-Hygiene Policy states: "3. INDICATIONS FOR HAND HYGIENE. 3.2 If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described below. 3.2.4 After contact with a patients's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient). 3.2.8. After removing gloves."

On 6/17/2016 an interview was held with the Infection Control Senior Coordinator (IC). When the medication observation and dressing change observation were described to the IC, the IC affirmed when touching patient's skin gloves should be changed. The IC also affirmed anytime there is glove change there should be hand sanitizing.