HospitalInspections.org

Based on random observations, staff interviews, and review of CDC guidelines, it was determined the facility failed to ensure Operating Room (OR) staff adhere to CDC guidelines regarding hand hygiene and glove use.

Findings include:

Reference: CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf) pages 50-51 states, "... It may be necessary to change gloves during the care of a single patient to prevent cross-contamination of body sites. It also may be necessary to change gloves if the patient interaction also involves touching portable computer keyboards or other mobile equipment that is transported from room to room. ... Gloves that are removed properly will prevent hand contamination. Hand hygiene following glove removal further ensures that the hands will not carry potentially infectious material that might have penetrated through unrecognized tears or that could contaminate the hands during glove removal."

1. During a tour of the OR Suite on 7/20/21, the following was observed:

a. At 12:20 PM, Staff #20 was observed exiting the OR supply storage room wearing gloves. He/she then entered an OR while wearing the same gloves.

(i) Staff #20 failed to doff his/her gloves or perform hand hygiene prior to entering the OR supply storage room or the OR.

b. At 12:41 PM, Staff #21 was observed exiting an OR while wearing gloves. While wearing the same gloves, Staff #21 entered the OR supply storage room, retrieved supplies, exited the OR supply storage room, and re-entered the OR.

(i) Staff #21 failed to doff his/her gloves or perform hand hygiene prior to entering the OR supply storage room or the OR.

2. Staff #1, Staff #2, and Staff #7, and Staff #14 confirmed the above findings on 7/21/21 at 3:30 PM.