HospitalInspections.org

Based on observation, interview, record review, and facility policy review, the facility failed to ensure an effective infection control program was maintained to ensure infections and communicable diseases were controlled for one of ten patients (Patient #4). Patient #4 was admitted to the hospital with a physician's order for sterile dressings to be applied to the patient's left foot. However, facility staff failed to follow established guidelines to ensure a dressing to Patient #4's left foot was applied using sterile technique on 12/17/13.

The findings include:

A review of the facility's Infection Control policy (no date) revealed infections would be prevented through implementation of methods to prevent transmission of infectious agents and to reduce risks for device-related and procedure-related infections. Review of the procedure for "Changing Surgical Dressings" (no date) revealed staff was to put on disposable gloves and remove the soiled dressing. The procedure revealed after removal of the soiled dressing staff was to apply sterile gloves and use "sterile" technique to clean the wound. Continued review of the procedure revealed after the wound had been cleaned sterile technique would continue to be maintained through the use of sterile gloves to apply the appropriate dressing to the wound.

According to the facility's Hand washing policy (no date) staff should perform hand washing when moving from a contaminated body site (e.g., soiled wound/dressing) to a clean body site (e.g., clean wound/sterile dressing) during patient care.

Review of the Contact Isolation policy (dated 1997) revealed unwashed hands were the most frequent cause of pathogen transfer resulting in Healthcare Associated Infections. The policy further included gloves should be changed when caring for a patient to prevent cross-contamination from one patient site to another.

Review of the medical record revealed on 12/06/13, Patient #4 underwent amputation of the second toe of the left foot due to gangrene and cellulitis. A culture of the wound on Patient #4's second toe of the left foot was obtained on 10/06/13 and revealed a light growth of staph aureus was present in the wound. Documentation revealed Patient #4 signed out of the hospital on 12/07/13 against medical advice. Patient #4 was readmitted to the hospital on 12/08/13 with an abscess of the wound on the left foot, which required incision and drainage, and the patient was placed in Contact Isolation. Review of the physician orders dated 12/10/13 revealed staff was to provide sterile wound care to the patient's left foot.

Patient #4 was observed on 12/17/13 at 9:30 AM lying in bed in a private room with a dressing intact to the left foot. A "contact precaution" sign was posted on the door and staff was observed to utilize personal protective equipment when entering the patient's room. An observation of the patient's wound and treatment on the left foot was conducted on 12/17/13 at 10:10 AM. Licensed Practical Nurse (LPN) #1 was observed to perform hand washing and put on a disposable gown prior to entering the patient's room. Patient #4 was observed to be lying on the bed with no dressing in place on the left foot. The LPN put on sterile gloves and cleaned the open wound with sterile water and "4 X 4" gauze. LPN #1 obtained sterile dressing supplies and proceeded to touch the sterile dressing with the gloved hand used to cleanse the wound, cut a section of the sterile dressing, and placed the sterile dressing over the wound on the patient's left foot without washing her hands or changing gloves.

Interview conducted with LPN #1 on 12/17/13 at 11:00 AM, revealed the LPN was aware the wound care to the wound on Patient #4's left foot was to be performed using sterile technique. The LPN stated she should have changed gloves and performed hand washing after she had cleaned the patient's wound. LPN #1 further stated she had received training on sterile dressing procedures.

Interview with the Infection Control Coordinator on 12/17/13 at 12:25 PM, revealed staff received training related to sterile technique and wound care during orientation and "at least" annually. The Infection Control Coordinator stated the nurse managers for each hospital unit were responsible to observe staff to determine competency with skills, including sterile dressing changes, annually and stated the nurse managers had not reported any problems to the Infection Control Coordinator. The Infection Control Coordinator confirmed the nurse should have changed gloves and washed his/her hands prior to touching the sterile dressing.