HospitalInspections.org

The hospital reported a census of 30 patients and twenty-one patients were included in the survey sample with 11 patients with wounds. Based on observation, document review and staff interview the infection control officer failed to ensure staff followed nationally recognized infection prevention and control precautions such as current CDC guidelines and recommendations, and hospital policies for infection control to prevent possible HAI (healthcare acquired infection) for two of two patients who received dressing changes from two of two staff members (Registered Nurses B and C) observed providing patient care (patient #'s 3 and 21).

Findings include:

- The hospital policy titled "Hand Hygiene", reviewed on 6/12/13 at 8:00am, directs staff to perform hand hygiene after removing gloves.

- Patient #3's wound care, observed on 6/10/13 at 1:30pm revealed staff B applied a pair of protective gloves and removed the soiled dressing. Staff B removed the gloves, applied another pair, cleansed the wound and applied a clean dressing. Staff B failed to perform hand hygiene after removing the soiled gloves.

- Patient #21's wound care, observed on 6/11/13 at 1:20pm, revealed staff B and C preparing for the dressing change.

Staff B applied protective gloves and removed the soiled wound-vac dressing (promotes healing by applying a vacuum through a special sealed dressing), and placed the soiled dressing in the trash can instead of biohazard trash. Staff B removed the protective gloves and applied another pair of gloves without performing hand hygiene. Staff B took photographs of the wound, removed the gloves and applied another pair of gloves without performing hand hygiene. Staff B removed the protective gloves, applied another pair without performing hand hygiene and applied a clean dressing. Staff B removed the gloves and applied another pair of protective gloves without performing hand hygiene to complete the dressing change.

Staff C put on protective gloves and assisted staff B apply the wound vac dressings. Staff C removed their gloves and applied another pair of gloves without performing hand hygeine. Staff C ocntinued to assist with the dressing change.

Staff B removed the wound vac canister from the machine, and placed the canister containing body fluids in the regular trash instead of a biohazard container. Staff B and C continued to use the trash can placing additional items contaminated with bodily fluids to be discarded in the trash. A few minutes later, staff B reached into the trash can to retrieve the wound vac canister to place the canister in a separate plastic bag.

Staff B removed the protective gloves and performed hand hygiene at completion of the dressing change.

- Infection control officer D, interviewed on 6/12/13 at 2:30pm confirmed the Hospital's policy to perform hand hygiene after removing gloves. Staff D acknowledged staff should not place contaminated dressings and wound vac canisters in an open trash can in the patient's room then retrieve the contaminated items placed in trash cans since this would create a potential for cross contamination and the possibility of a HAI.