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A. Based on two (2) of two (2) observations of hand hygiene, staff interviews and document review on 10/14/2021, it was determined that the facility failed to implement its policy and procedure for Hand Hygiene and adhere to professionally acceptable standards of practice for glove use.

Finding include:

Reference #1: Facility policy titled, "Hand Hygiene and Skin Antisepsis" states, " ...Decontaminate Hands and Alcohol Hand Sanitizer: ...7. Before donning and after removing gloves. ...HAND HYGIENE TECHNIQUES ...1. Vigorously rub together all surfaces of lathered hands for at least 20 seconds.

Reference #2: CDC Personal Protective Equipment: Questions and Answers Updated Apr. 9, 2021, https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirator-use-faq.html, states, "...Is double gloving necessary when caring for suspected or confirmed COVID-19 patients in healthcare settings? CDC guidance: does not recommend double gloves when providing care to suspected or confirmed 2019-COVID patients. ..."

1. During observation of facility staff cleaning a designated COVID-19 patient room in the Intensive Care Unit, in the presence of Staff #1, the following was observed:

a. At 10:30 AM, Staff #10 removed his/her gloves, grabbed two (2) trash bags filled with soiled items, stepped out of the room, and took the (2) trash bags to the dirty utility room. Staff #10 then walked to a handwashing sink and washed his/her hands with soap and water for approximately seven (7) seconds and not 20 seconds. This is not in accordance with facility policy.

b. The above finding was confirmed with Staff #1 at 10:45 AM.

2. During a tour of the designated at the COVID-19 Unit, 2 East, in the presence of Staff #1, the following was observed:

a. At 12:35 PM, Staff #12 was walking out of Room #2001. Staff #12 then removed his/her gloves. After glove removal, it was observed that Staff #12 had another pair of gloves on his/her hands. Staff #12 did not remove this pair of gloves. While wearing the same gloves, Staff #12 obtained hand sanitizer from the dispenser located on the wall and sanitized his/her gloves.

b. During interview at 12:35 PM, Staff #12 stated, "we sanitize our first set of gloves, then wear a second set of gloves over the first gloves."

c. At 1:00 PM, Staff #12 was walked into Room #2001 with gloves on. At 1:05 PM, Staff #12 walked out of Room #2001 and into Room #2002 without performing hand hygiene.

d. At approximately 1:07 PM, Staff #12 walked out of Room #2002 and into Room #2032 without performing hand hygiene.

e. Staff #12 walked of Room #2032 and down the hall to the nurse's station with same gloves on and started typing on the computer keyboard.

f. During interview, Staff #15 (COVID Unit Manager) stated, "The whole Unit is a COVID Unit, there is COVID everywhere so why do we need to change gloves?" Staff #15 also stated that staff on the COVID-19 Unit wear double gloves. Staff #15 stated that the first set of gloves is treated as the skin and therefore the first gloves are disinfected before applying a second set of gloves.

3. During interview, at 2:30 PM, Staff #1, Staff #2 and Staff #15 stated that the facility policy does not match the facility process for hand hygiene.


B. Based on one (1) of one (1) observation of Environmental Services (EVS) staff, staff interview and document review on 10/14/2021 it was determined that the facility failed to ensure its Personal Appearance and Uniform Policy was implemented.

Findings include:

Reference: The facility document titled, "Personal Appearance and Uniform" states, " ...7/ Jewelry, other than a plain wedding band or medic alert jewelry is strictly prohibited. Medical Alert Jewelry is permitted, however, must be worn as a necklace under the uniform or as an ankle bracelet. ..."

1. During a tour of the Emergency Department (ED) at 10:05 AM, Staff #7 (EVS Staff #7) was observed wearing more than six (6) bracelets on his/her wrist.

a. During interview at 10:10 AM, Staff #7 stated that the facility allows EVS staff to wear jewelry when on duty.

b. During interview, at 12:15 AM, Staff #16 (EVS Director) stated that EVS staff is not permitted to wear jewelry when on duty.

2. The above findings were confirmed with Staff #1, Staff #2 and Staff #15 at 2:45 PM.