HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to ensure that staff performed hand hygiene as indicated by hospital policy (Item 1), failed to ensure that staff appropriately wore personal protective equipment when working in isolation rooms (Item 2), failed to ensure that staff followed aseptic technique when inserting foley catheters (Item 3), and failed to ensure that expired dialysis supplies and disinfectants were not available for use (Item 4).

Failure to properly implement and comply with infection control policies and procedures places patients and staff at risk of infection.

Findings included:

Item #1 - Hand Hygiene

1. Document review of the hospital policy titled, "Hand Hygiene, Nail Length, Artificial Nails," policy number 8150463, effective 04/18, showed that staff should perform hand hygiene after removing sterile or non-sterile gloves.

2. On 10/05/20 from 2:32 PM to 3:15 PM, Investigator #2 observed a discharge cleaning of patient room 3016. During the procedure, the investigator observed a housekeeper (Staff #201) change gloves without performing hand hygiene on seven separate opportunities.

3. The Investigator discussed the observations with a quality analyst (Staff #202) who stated that staff should perform hand hygiene after removing gloves.

Item #2 - Transmission-Based Precautions

1. Document review of the hospital policy titled, "Transmission Based Isolation Precautions," policy number 8101662, effective 04/17, showed that staff entering contact precaution isolation rooms should wear an isolation gown.

2. On 10/5/20 at 1:44 PM, Investigator #2 toured the medical surgical floor of the hospital. During the tour, the investigator observed a physical therapist (Staff #203) performing patient care in a room for a patient requiring contact precautions. Staff #203 was not wearing an isolation gown while performing patient care.

3. During the observation, the investigator confirmed the observation of the lack of proper personal protective equipment with a quality analyst (Staff #202).

Item #3 - Foley Catheter Aseptic Technique

Reference: Bard Medical SureStep (Trademark) Foley Tray System "Foley Catheter Insertion & Removal Sample Procedure; " http://surestep.bardmedical.com/media/675892/ud-surestep-insertion-removal-procedure.pdf: "Attach the water-filled syringe to the inflation port ... Use syringe with the green plunger to deposit lubricant into tray ... Remove catheter from wrap and place catheter in lubricant ... Prepare patient with povidone-iodine sticks ...Proceed with catheterization."

1. Document review showed that the hospital policy titled, "Catheter Associated Urinary Tract Infection Prevention," policy ID 8101774, approved 07/19, showed that trained personnel should insert urinary catheters using aseptic technique and in accordance with the manufacturer's recommendations.

2. On 10/06/20 at 10:25 AM, Investigator #11 observed hospital operating room staff prepare a patient (Patient #1101) for childbirth by cesarean delivery (a procedure used to deliver a baby through incisions in the abdomen and uterus). During the preparation for delivery, a registered nurse (RN) (Staff #1101) placed a foley catheter (a drainage tube placed into the bladder to collect urine) in Patient #1101. Before inserting the catheter, the RN prepared the patient for the procedure by cleaning her vaginal area with povidone-iodine swabs. The RN used her left hand to separate the labia and her right hand to swab. The RN then used both hands to attach the water filled syringe to the inflation port, remove the catheter wrap, lubricate the catheter, and proceed with insertion. The RN did not remove her gloves, perform hand hygiene, and don new sterile gloves before touching the sterile supplies with her contaminated (left) hand, thereby breaking aseptic technique.

3. Immediately following the procedure, Investigator #11 discussed the observation with the Quality Program Coordinator (Staff #1102), and she agreed that the RN failed to follow the correct process and use aseptic technique during the catheter insertion process.

Item #4 - Expired Supplies

1. Review of the DaVita Inc. Hospital Services Policy and Procedure, #1, titled, "Acid Concentrates" policy #7-06-03, revised 04/18, showed that upon opening acid concentrate containers, staff were to label the container with the date opened and their initials. The policy showed that open containers must be used within 30 days after opening, and unopened acid concentrate containers must be used prior to the manufacturer's expiration date on the label.

2. On 10/05/20 at 2:30 PM, Investigator #11 inspected the hospital's dialysis storage room with the Quality Program Coordinator (Staff #1102). The observation showed:

a. One partially filled container of Naturalyte Dialysate acid concentrate marked with an opened date of "10-3 @ 08:00."

b. Two partial containers of Naturalyte Dialysate acid concentrate labeled "Biomed," with no label of the open date or staff initials.

c. Two unopened boxes of Naturalyte 4,000 bicarbonate with an expiration date of 04/20.

d. Four containers of Minncare HD disinfectant labeled, "Do Not Use Expired," with expiration dates 02/19, 05/19, 01/22/20, and 09/10/20.

3. At the time of the observation, Investigator #11 interviewed Staff #1102 who confirmed the findings of the expired supplies.