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Based on observation, interview, record review and policy review it was determined the facility failed to follow an infection control program for three (3) of ten (10) sampled patients. Patients #5, #6 and #10. The facility failed to ensure the staff members were washing their hands between glove changes. One (1) staff member was found to triple glove and peal each glove after each task was completed without washing his hands.

The findings include:

Review of the Hand Hygiene policy, Infection Prevention and Control Practices, dated 06/2011, revealed hand antisepsis was achieved through the use of antimicrobial hand sanitizer and handwashing was achieved through the use of antimicrobial soap and water. Hand hygiene would be performed after the removal of gloves.

Review of the Application of Dressings and Compresses, revised 10/14/97, revealed the purpose was to provide dry aseptic or sterile dressings for promotion of healing a wound in a non contaminated environment. The purpose was also to prevent the development or spread of an infection from an infected site. The Procedure revealed that after removal of the old dressing staff were to place the old dressing in a plastic bag with the now dirty gloves and wash their hands, then apply new set of gloves.

Observation of a skin assessment performed on Patient (PT) #6, by Licensed Practical Nurse (LPN) #1, on 06/28/12 at 3:48 PM, revealed LPN #1 removed an old dressing from PT #6, and changed her gloves. She then sprayed wound cleaner on the wound of PT #6. LPN #1 then changed gloves and attached clean tubing and sponge to the wound and placed the patient onto his/her left side. No hand washing was observed between glove changes.

Interview with LPN #1, on 06/28/12 at 3:48 PM, revealed she was not taught to wash her hands in between glove changes especially if she was working on the same wound. She was taught hand washing was not needed if you did not leave the patients side.

Observation of a Sterile Dressing Change performed on PT #10 by Registered Nurse (RN) #1, on 06/28/12 at 4:11 PM, revealed RN #1 put on sterile gloves and removed the old dressing from PT #10. RN #1 then removed her old gloves and then placed new sterile gloves on and tucked a 4x4 in the wound of PT #10.

Interview with RN #1, on 06/28/12 at 4:11 PM, revealed she was taught to never leave the sterile field. RN #1 stated that once she removed the dirty gloves she always placed on a new set of sterile gloves. RN #1 was aware if she left the sterile field she would contaminate the sterile field. Additional interview with RN #1, on 06/28/12 at 4:47 PM, revealed once she observed the policy on hand hygiene she agreed she was performing the dressing changes wrong. RN #1 stated she was aware she should wash her hands after glove removal so that germs would not be transferred back to the patient.

Observation, on 07/02/12 at 11:35 AM, revealed LPN #2 performed a dressing change on Patient #5. LPN #2 was wearing gloves and removed the dressing from the wound on the coccyx and placed the dirty dressing on the barrier pad on the bed. He then removed his gloves and without washing his hands he donned another pair of gloves and sprayed the wound with wound cleaner and then laid the bottle of wound cleaner on the barrier pad with the dirty dressing. The nozzle of the wound spray touched the dirty dressing. LPN #2 sprayed saline into the wound and used a gauze dressing to absorb the saline. Without removing his gloves he went to a cabinet and removed a tube of ointment. He then changed his gloves and applied new gloves without washing his hands. LPN #2 applied the ointment with his gloved fingers, picked up the tube and replaced the cap and laid the tube of ointment on the barrier pad that contained the soiled dressing. Without removing his gloves he reached and obtained more dressing supplies from a container sitting on the window sill. LPN #2 saturated a roll of gauze with saline, changed his gloves without washing his hands, packed the wound with the roll of gauze and then taped a dry dressing in place to cover the wound. He left the room and came back with more dressing supplies. LPN #2 applied three pairs of gloves and proceeded to remove a dressing from the patient ' s thigh. Once the dressing was removed he removed one pair of gloves and started to clean the wound with wound cleaner.

Interview with LPN #2, on 07/02/12 at 2:20 PM, revealed he never washed his hands between glove changes. He stated he was aware the hospital policy included washing hands after removing gloves but felt that referred to when a procedure was completed. He stated that he normally did not double up on gloves but was overwhelmed with the Patient #5's extensive wounds. He was unaware that he left a dirty dressing lying on the barrier pad and contaminated the wound cleaner spray bottle. He stated the concern with not using proper hand washing and the contamination of supplies was the possibility of the patient having continuous infections due to re-infecting the wound with contaminated supplies.

Interview with the Quality Control Monitor Manager, on 07/02/12 at 3:13 PM, revealed there was no actual observations of dressing changes being conducted to monitor policy compliance. She stated the hospital promotes proper handwashing by education. She stated it was not acceptable to put on multiple pairs of gloves during a dressing change due to the possibility of contaminating the wound.

Interview with the Unit Supervisor, on 07/02/12 at 3:27 PM, revealed there was a huge concern if staff did not recognize the need to wash their hands between glove changes and she was appalled to think that a nurse would put on multiple pairs of gloves to prevent changing gloves during a procedure. She stated there was not a system to monitor the technique of dressing changes.

Interview with the Chief Clinical Officer, on 07/02/12 at 3:40 PM, revealed there are competency check offs that are done at the time of hire and annually that included handwashing techniques and wound care. There was currently no system to have an observation check off. She stated she felt like it was a system issue for all of Kindred since it was not being done.