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CHI ST LUKE'S HEALTH BAYLOR COLLEGE OF MEDICINE ME
INFECTION CONTROL SURVEILLANCE, PREVENTION
Tag No.: A0750
Based on record review and observation the facility did not enforce handwashing with nursing staff entering patient room in two hospital areas with two of four staff observed to avoid sources and transmission of infections and communicable diseases.
Findings Include:
Record review of the facility policy "Hand Hygiene: Infection Control (Division), effective February 2022 stated:
Multiple opportunities for hand hygiene may occure during a single are episode. Following are the clinical indications for hand hygiene: upon room/area entry or "wash in" or upon room/area exit or "wash out".
Observation on 09/12/2022 at 1100 of staff (ID #65 ) on cardiovascular ICU was observed multiple times entering patients room (ID# 2,3,4) and not preforming
hand hygiene.
Observation on 09/13/2022 at 1040 of staff (ID #66) on 21 Tower was observed entering patient (ID#11) room and not preforming hand hygiene.
Interview with staff (ID#65,66) during the above incidents, acknowledged they did not perform hand hygiene when entering and leaving patient's rooms.