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Based on observation, interview, and policy review, the hospital failed to ensure that staff performed hand hygiene during the care of eight patients (#12, #13, #14, #15, #24, #25, #27, and #29) of 11 patients observed and failed to label intravenous (IV, in the vein) tubing with an expiration date for five patients (#11, #12, #14, #15, and #27) of five patients observed.

These failed practices had the potential to expose all patients, visitors and staff to cross contamination (germs that are spread from one person or surface to another). The hospital census was 12 including swing beds.

Findings included:

1. Review of the hospital policy titled, "Hand Hygiene," dated 12/09/18, directed staff to wash their hands with soap and water or cleanse with an alcohol-based waterless hand sanitizer:
- Between all patient contacts;
- Before medication preparation;
- Before application and after removal of gloves; and
- After contact with inanimate objects in the immediate vicinity of the patient, such as medical equipment, furniture, linens, etc.

Observation on 03/09/20 at 3:40 PM, showed Staff C, Registered Nurse (RN), failed to perform hand hygiene before she put on her gloves, when she cared for for Patient #12 and Patient #15, who were cohorted (patients who are in the same room and have a similar diagnosis).

Observation on 03/09/20 at 3:45 PM, showed Staff C, RN, failed to perform hand hygiene after she cared for Patient #12 and before she cared for Patient #15.

Observation on 03/10/20 at 8:52 AM, showed Staff L, Licensed Practical Nurse (LPN), failed to perform hand hygiene before he put on his gloves, during medication administration for Patient #24.

Observation on 03/10/20 at 9:05 AM, showed Staff L, LPN, failed to perform hand hygiene before he put on his gloves, during medication administration for Patient #25.

Observation on 03/10/20 at 10:00 AM, showed Staff L, LPN, failed to perform hand hygiene after he removed his gloves, during medication preparation for Patient #12.

Observation on 03/10/20 at 10:03 AM, showed Staff L, LPN, failed to perform hand hygiene before he put on is gloves, when he cared for Patient #12 and Patient #15, who were cohorted.

During an interview on 03/10/20 at 2:47 PM, Staff L, LPN stated that hand hygiene should be performed before you went into a patient's room, when you left a patient's room, between patients, and when you removed your gloves.

Observation on 03/10/20 at 3:30 PM, showed Staff D, Certified Respiratory Technician, failed to perform hand hygiene upon entrance and exit from Emergency Department (ED) Patient #29's room, with the same gloves in place.

Observation on 03/10/20 at 3:30 PM, showed Staff GG, Paramedic, Certified Respiratory Technician, failed to perform hand hygiene during entrance and exit from ED Patient #29's room, with the same gloves in place.
During an interview on 03/11/20 at 9:00 AM, Staff A, ED Director, stated that hand hygiene should be performed upon entering and exiting a patient's room, even during an emergency situation.

Observation on 03/10/20 at 10:12 AM, showed Staff W, LPN, failed to perform hand hygiene before she put on her gloves, during medication administration for Patient #27.

Observation on 03/10/20 at 9:34 AM, showed Staff W, LPN, failed to perform hand hygiene before she prepared medication for Patient #14.

Observation on 03/10/20 at 10:55 AM, showed Staff Y, RN, failed to perform hand hygiene before she put on her gloves and provided care for Patient #13.

During an interview on 03/10/20 at 4:00 PM, Staff K, Acute Care Services Director, stated that hand hygiene should be performed before you put on gloves and after you removed gloves.

During an interview on 03/10/20 at 4:32 PM, Staff BB, RN, Infection Control Nurse, stated that hand hygiene should be performed before you went in a patient's room, when you left a patient's room, before you put on gloves, and after you removed gloves.

During a telephone interview on 03/12/20 at 12:00 PM. Staff JJ, Chief Nursing Officer (CNO), stated that hand hygiene should be performed before you entered a patient's room, when you left a patient's room, and before you put on gloves or when gloves were removed. She stated that included the ED during an emergency situation.

2. Review of the hospital policy titled, "Intravenous Infusion," dated 01/17/19, directed staff to change IV tubing every 96 hours, label tubing with date and time changed, and include that information in the nurse's notes.

Observation on 03/09/20 at 3:40 PM, showed no label on two IV antibiotic tubing's for Patient #15.

Observation on 03/10/20 at 10:00 AM, showed no label on the IV tubing for Patient #12.

Observation on 03/10/20 at 10:00 AM, showed a label on the IV antibiotic tubing with an expiration date of 03/08/20, that had not been changed, for Patient #12.

Observation on 03/10/20 at 10:03 AM, showed no label on two IV antibiotic tubing for Patient #15.

Observation on 03/10/20 at 10:12 AM, showed no label on the IV tubing for Patient #27.

Observation on 03/10/20 at 10:39 AM, showed no label on the IV tubing for Patient #14.

Observation on 03/09/20 at 3:30 PM, showed no label on the IV tubing for Patient #11.

During an interview on 03/10/20 at 2:47 PM, Staff L, LPN, stated that IV tubing should be labeled with an expiration date and should be changed every four days.

During an interview on 03/10/20 at 4:00 PM, Staff K, Acute Care Services Director, stated that IV tubing should be labeled with an expiration date.

During an interview on 03/10/20 at 4:32 PM, Staff BB, RN, Infection Control Nurse, stated that IV tubing should be labeled with an expiration date.

During a telephone interview on 03/12/20 at 12:00 PM, Staff JJ, CNO, stated that IV tubing should be labeled with an expiration date.




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