HospitalInspections.org
Bringing transparency to federal inspections
METROWEST MEDICAL CENTER
INFECTION CONTROL PROGRAM
Tag No.: A0749
Based on observations the Hospital failed to ensure all personnel were compliant with the Hand Hygiene policy and standards of practice.
The Hospital policy titled Hand Hygiene, dated December 2014, indicated that hand hygiene must be performed before donning and after removing gloves.
The Surveyor observed Patient #2 undergo a pain procedure in the Local Ambulatory Room (LAR) #2 room at 11:45 A.M. on 6/15/16. RN #1 changed her gloves twice during the time she assisted with this procedure but failed to perform hand hygiene after she removed her soiled gloves or prior to donning the new pairs of gloves. When RN #1 removed her gloves for the second time she went to the clean dressing cabinet to retrieve dressing materials for Patient #2's procedure site. RN #1 removed her soiled gloved, opened the cabinet and laid the soiled gloves on the shelf alongside the clean dressing materials. RN #1 did not locate the items she sought; she then disposed of the soiled gloves and exited the room without performing hand hygiene.