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Based on observations, interviews, policies and procedures review, the facility failed to ensure that all licensed nurses who provide services in the hospital adhered to the policies and procedures to promote patient safety and utilize appropriate measures to prevent and control hospital acquired infections (HAIs). This deficient practice also increased the risk of a medication error and compromised the safety of 1 of 4 Sampled Patients (SP). SP#2

Findings include:

Observations were conducted on 10/19/2023 at 10:40 AM on 2-Hope (Stepdown unit), along with Surveyor #2. Registered Nurse 1 (RN1) was observed administering several medications to SP#2. While administering the medications to SP#2, RN1 answered the phone with her gloves on and after ending the call, RN1 resumed administering the medications to SP#2 without changing her gloves or performing hand hygiene.

During a follow-up interview conducted on 10/19/2023 at 11:07 AM, RN1 acknowledged answering the phone during the medication administration process to SP#2 and not performing hand hygiene or changing her gloves after ending the call.

During an interview conducted on 10/19/2023 at approximately 12:05 PM- 12:10 PM, the Assistant Vice President of Nursing and 2-Hope Nursing Supervisor acknowledged that RN 1 did not follow the Infection Control Standards of Practice while administering medications to SP#2.

A review of the facility's policies and procedures revealed Policy No.: BHM-580.00, Policy Title: Infection Prevention and Control Program: Scope of Service, Last revised 07/22/2022 which included but wasn't limited to:

PROCEDURES TO ENSURE COMPLIANCE:
2. Performance of ongoing surveillance activities as described in the annual infection Prevention and Control Plan.
3. Oversee observations of established infection control practices. Non-compliance is reported to appropriate authorities for follow-up.

Infection Prevention and Control Plan 2023 documented:
I. Planning

B. Shared Responsibilities for the Infection Prevention and Control Program
3. Healthcare Worker Responsibilities:

All healthcare workers of the organization will:
a) Adhere to hand hygiene guidelines.
b) Adhere to policies for the prevention and control of infections.

Further review of the facility's policies and procedures revealed Policy No.: BHSF-10000-66416-00006, Policy Title: Hand Hygiene, Last revised 11/16/2022 which included but wasn't limited to:

POLICY: Effective hand hygiene practices shall be followed by all employees, licensed independent practitioners, volunteers, students, contract workers and vendors at all Facility Florida Entities.

PROCEDURES TO ENSURE COMPLIANCE:

1. Indications for Hand Hygiene
a. Use an alcohol-based hand rub if hands are not visibly soiled as the preferred means for routine hand antisepsis in all clinical situations listed below. If an alcohol-based hand rub is not available, wash hands with soap and water:

vii. After contact with inanimate surfaces and objects (including medical equipment) in the immediate vicinity of the patient.

d. Before handling medication or preparing food perform hand hygiene using an alcohol based hand rub or wash hands with soap and water.

The facility failed to ensure that RN1 followed Infection Control Standards of Practice.