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Based on observation, interview and policy review, the hospital failed to ensure they followed infection prevention policies when staff failed to:
- Perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) and change gloves while administering medications and touching inanimate objects for 10 patients (#3, #7, #8, #9, #10, #17, #18, #19, #26, and #27) of 15 patients observed. (A-749)
- Prepare a clean work surface or provide barriers prior to performing patient care for eight patients (#2, #3, #7, #10, #13, #14, #27, and #30) of 18 patients observed. (A-749)
- Label intravenous (IV, in the vein) accesses for 10 patients (#1, #3, #8, #9, #12, #13, #14, #25, #27, and #29) of 18 patients observed. (A-749)

These failures had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The hospital census was 90.

The severity and cumulative effects of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs and resulted in the hospital's failure to ensure quality health care and safety. Refer to A-749 for details.

Based on observation, interview and policy review, the hospital failed to ensure they followed infection prevention policies when staff failed to:
- Perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) and change gloves while administering medications and touching inanimate objects (not alive, for example computer keyboard, medical equipment, medical bed, etc.) for 10 patients (#3, #7, #8, #9, #10, #17, #18, #19, #26, and #27) of 15 patients observed.
- Prepare a clean work surface or provide barriers prior to performing patient care for eight patients (#2, #3, #7, #10, #13, #14, #27, and #30) of 18 patients observed.
- Label intravenous (IV, in the vein) accesses for 10 patients (#1, #3, #8, #9, #12, #13, #14, #25, #27, and #29) of 18 patients observed.

These failures had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The hospital census was 90.

Findings included:

Review of the hospital's policy titled, "Hand Hygiene," dated 12/20/21, showed the directive for staff to perform hand hygiene with alcohol-based hand rub:
- When entering or exiting the patient's environmental threshold;
- Before and after direct patient care;
- After contact with patient's intact skin;
- When moving from a contaminated body site to a clean body site during patient care; and
- After contact with inanimate objects, including medical equipment in the immediate vicinity of the patient.

Although requested, the hospital failed to provide a policy specifically related to the use of gloves.

Observation on 08/02/23 at 9:29 AM showed Staff PP, Registered Nurse (RN), failed to perform hand hygiene between sterile glove changes while accessing the Port-A-Cath (a small medical appliance installed beneath the skin in the chest region and connects the port to a vein and is used to administer medications and draw blood) of Patient #26.

Observation on 07/31/23 at 3:55 PM showed Staff N, Licensed Practical Nurse (LPN), failed to perform hand hygiene and glove changes after touching the computer and before opening medications, administering medications, and checking Patient #3's blood sugar.

Observation on 08/01/23 at 8:30 AM showed Staff U, RN, failed to perform hand hygiene and glove changes after touching the side rail of the bed, before pulling a drain out, and placing a new dressing over the open drain site for Patient #7.

Observation on 08/01/23 at 8:43 AM showed Staff V, RN, failed to perform hand hygiene between glove changes three times when administering medications to Patient #8 after:
- Touching the computer and scanning medications;
- Taking the patient's blood pressure; and
- Picking up medication off the floor.

Observation and concurrent interview on 08/01/23 at 9:35 AM showed Staff T, RN, failed to perform hand hygiene after touching the computer and before opening and administering medications for Patient #9. He said that staff was encouraged to use gloves when administering medications but that it was a clean procedure.

Observation on 08/01/23 at 9:54 AM showed Staff Y, RN, failed to perform hand hygiene after touching the computer and before she opened and administered medications for Patient #10.

Observation on 08/01/23 at 2:10 PM showed Staff HH, RN, failed to perform hand hygiene after touching the computer keyboard and barcode scanner and before opening medications for Patient #17. Staff HH also failed to perform hand hygiene and apply gloves before intravenous push (to manually administer a dose of medication through a tube into a vein) of normal saline (solution made of salt and water) in Patient #17's saline lock (a thin flexible tube placed into a vein used for fluid or medication or nutrition administration).

Observation on 08/01/23 at 2:00 PM showed Staff HH, RN, failed to perform hand hygiene after touching the computer keyboard and barcode scanner and before opening medications for Patient #18.

Observation on 08/01/23 at 2:20 PM showed Staff II, Certified Respiratory Therapist (CRT), failed to perform hand hygiene between changing gloves while performing tracheostomy (an opening created in the neck in order to place a tube into a person's windpipe that allows air to enter the lungs) care for Patient #19.

Observation on 08/02/23 at 8:40 AM showed Staff JJ, LPN, failed to perform hand hygiene and glove changes after touching the computer and before she opened and administered medications to Patient #27.

During an interview on 07/31/23 at 4:02 PM, Staff N, LPN, stated that she would have normally performed hand hygiene and changed her gloves after touching the computer and before she provided patient care.

During an interview on 08/01/23 at 8:37 AM, Staff U, RN, stated that she usually would not have changed gloves or performed hand hygiene during a drain removal because it was a clean procedure. She stated that she did not remember touching the side rail of the bed before she removed the drain.

During an interview on 08/01/23 at 8:55 AM, Staff V, RN, stated that she forgot to do hand hygiene in between glove changes.

During an interview on 08/01/23 at 2:20 PM, Staff HH, RN, stated that the hospital did not have a policy requiring the use of gloves during medication administration.

During an interview on 08/01/23 at 2:35 PM, Staff II, CRT, stated he did not perform hand hygiene between every glove change because "it was not really needed during that part of the process."

Although requested, the hospital failed to provide a policy related the use of barriers or clean work surfaces.

Observation on 07/31/23 at 3:25 PM showed Staff L, Wound Care Nurse, used Patient #2's bed for wound vacuum assisted closure (wound VAC, a device that decreases air pressure on a wound to help it heal more quickly) supplies without a barrier.

Observation on 07/31/23 at 3:55 PM showed Staff N, LPN, used Patient #3's bed for the glucometer (device that measures blood sugar levels) and supplies without a barrier. Staff N prepared medications on the computer table before she cleaned the surface or placed a barrier down.

Observation on 08/01/23 at 8:30 AM showed Staff U, RN, used Patient #7's bed for drain removal supplies without a barrier.

Observation on 08/01/23 at 9:54 AM showed Staff Y, RN, used Patient #10's computer table and prepared medications without cleaning the surface or placing a barrier down.

Observation on 08/01/23 at 10:40 AM showed Staff EE, RN, used Patient #13's bed for the glucometer and supplies without a barrier.

Observation on 08/01/23 at 11:02 AM showed Staff CC, RN, used Patient #14's dirty over bed table for the glucometer and supplies then moved them to the bed without a barrier.

Observation on 08/02/23 at 8:40 AM showed Staff JJ, RN, used Patient #27's computer table and prepared medications without cleaning the surface or placing a barrier down.

Observation on 08/20/23 at 9:34 AM showed Staff LL, LPN, used Patient #30's counter to prepare IV medications without cleaning the surface or placing a barrier down.

During an interview on 07/31/23 at 3:50 PM, Staff L, Wound Care Nurse, stated that it was a clean procedure, but could see the potential for contamination by using the patient's bed for supplies.

During an interview on 08/01/23 at 8:37 AM, Staff U, RN, stated that she should have placed the drain removal supplies on the over bed table rather than the patient's bed.

During an interview on 08/01/23 at 10:45 AM, Staff EE, RN, stated that he should have placed the glucometer on the cleaned over bed table instead of the patient's bed.

During an interview on 08/01/23 at 11:07 AM, Staff CC, RN, stated that she should have cleaned the over bed table to use instead of the bed. She stated that, "It should not contaminate supplies just because they were laid on the bed."

During an interview on 08/02/23 at 9:40 AM, Staff LL, LPN, stated that she usually would clean the counter before she placed IV supplies down and prepared medications for administration.

Review of the hospital's document titled, "Peripheral IV Catheter (small flexible tube) Insertion," dated 09/2020, showed the directive for staff to label the site with a date, time, and initials of the nurse inserting.

Observation on 07/31/23 at 3:05 PM showed that Patient #1's IV dressing was not dated, timed or initialed.

Observation on 07/31/23 at 3:55 PM showed that Patient #3's IV dressing was not dated, timed or initialed.

Observation on 08/01/23 at 8:43 AM showed that Patient #8 had two IV dressings not dated, timed or initialed.

Observation on 08/01/23 at 9:35 AM showed that Patient #9's IV dressing was not dated, timed or initialed.

Observation on 08/01/23 at 10:25 AM showed that Patient #12's IV dressing was not dated, timed or initialed.

Observation on 08/01/23 at 10:40 AM showed that Patient #13's IV dressing was not dated, timed or initialed.

Observation on 08/01/23 at 10:52 AM showed that Patient #14's IV dressing was not dated, timed or initialed.

Observation on 08/02/23 at 8:50 AM showed Patient #25's IV dressing was not dated, timed or initialed.

Observation on 08/02/23 at 8:40 AM showed that Patient #27's IV dressing was not dated, timed or initialed.

Observation on 08/02/23 at 9:18 AM showed that Patient #29's IV dressing was not dated, timed or initialed.

During an interview on 07/31/23 at 3:15 PM, Staff J, Clinical Staff Leader, stated that IV dressings were to have been dated, timed and initialed.

During an interview on 08/01/23 at 8:55 AM, Staff V, RN, stated that IV dressings were to have been dated, timed and initialed.

During an interview on 08/01/23 at 10:25 AM, Staff BB, RN, stated that IV dressings were to have been dated, timed and initialed.

During an interview on 08/02/23 at 8:35 AM, Staff B, Patient Safety Officer, stated that IV dressings were to have been dated, timed and initialed.

During an interview on 08/02/23 at 10:30 AM, Staff G, Infection Preventionist, stated that she would have expected staff to have changed gloves with performing hand hygiene and after touching inanimate objects. She stated that she expected that a table or counter was cleaned to use for supplies or medication administration and a barrier placed down on the bed if used. IV dressings were to have been dated, timed and initialed when the IV was started.


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