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CITRUS MEMORIAL HOSPITAL 502 W HIGHLAND BLVD INVERNESS, FL 34452 Nov. 29, 2012
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, record reviews, and interviews, the facility failed for 2 of 3 patients (# 5, # 6) to follow accepted infection control practices during blood specimen collection procedure and in the cleaning of equipment in the Emergency Department.
Findings:
1.) A tour and observation of the Emergency Department was conducted on 11/28/2012 at 11:04 AM with the Emergency Department Manager. Two staff persons were observed in the hallway, one was an Environmental Services Worker (EVS) floor tech and the other was a Paramedic at 11:18 AM. The Paramedic was observed actively cleaning a patient bed. During the observation, the Paramedic was observed utilizing a blue reusable cloth which was used to clean both the mattress and the pillow without changing the clothes between tasks (bed mattress to pillow). The Paramedic was dressed in scrubs with no personal protective measures observed.

An interview was conducted with the Emergency Department Manager, EVS floor tech and Paramedic at 11:21 AM specific to the process of cleaning the bedding. The EVS floor tech confirmed along with the Emergency Department Manager at that time different cleaning cloths would be utilized depending on who would be cleaning the bedding. It was also confirmed a changing of the cloths would be completed so that the mattress and the pillow would not be cleaned utilizing the same cloth.

An interview was conducted with the Environmental Services Director at 11:52 AM where the policies and procedures for the terminal or standard cleaning of beds in the Emergency Department were requested. A follow-up interview on 11/18/2012 at 12:14 PM confirmed the standard practice is for the EVS workers assigned to the Emergency Department are the persons who would generally be responsible for the cleaning. It was confirmed in this situation, a Paramedic volunteered to assist in the cleaning of the equipment when observed completing the process inappropriately.

A review of the policies and procedures revealed in policy #EVS-H-G #2 Cleaning Mattresses: " Mattresses are cleaned on a discharge basis with an approved germicide. The mattresses are a special type in which they are constructed using foam rubber for the interior. A removable nylon cover makes up the portion of the mattress that the patient rest on. This cover is impermeable to fluids. The other half of the mattress is made of a tough and durable plastic. All personnel will wear gloves and follow universal precautions regarding personal protective equipment when cleaning or handling mattresses prior to cleaning.

Stretcher type mattresses are cleaned by nursing after patient use and routinely cleaned by Environmental Service staff.

Normal Procedure:
Dust mattress using a disposable dusting cloth.
Wipe down entire outer mattress using an approved germicide. "

A review of 6 policies provided by the Environmental Services Director on 11/28/2012, each involving cleaning and disinfecting of patient rooms, equipment and areas, fail to identify how the patient pillow is to be handled, cleaned and sanitized between patient use. "





2.) An observation of a patient blood draw was conducted on 11/28/2012 at 11: 45 AM on Patient # 4, Staff # 1. The staff person prepared all venipuncture kits and tubes outside the patient's room. Staff #1 knocked on door before entering room, identified patient's name and date of birth. Staff #1 identified accuracy of ID bracelet. Explained the purpose of the blood draw to the patient. Staff #1 donned on a pair of gloves, applied tourniquet to left upper forearm, cleaned area with alcohol, used a butterfly needle with one attempt, and collected 4 ml of blood in a tube. A small gauze dressing applied over venipuncture site and covered with tape. Staff #1 applied pressure for approximately 2-3 seconds on the left antecubital area. Staff #1 wrote her initial and time of draw on a pre-printed patients name and attached label to the tube. Removed and disposed contaminated gloves. Staff used hand sanitizer in patients ' room and exited room.
Observation on 11/28/2012 at 11:50 AM revealed Staff # 1 failed to wash her hands after removing the contaminated gloves and before leaving Patient # 4 room. Staff # 1 used hand sanitizer from the wall before exiting room. Observed Staff # 1 proceeded to Patient # 5 room to perform another blood draw.
Observation of blood draws on 11/28/2012 at 11:55 AM on Patient # 5. Staff #1 knocked on door before entering room, identified patients ' name and date of birth. Staff identified accuracy of ID bracelet. Explained the purpose of the blood draw to the patient. Staff # 1 donned on a pair of gloves, applied tourniquet to left upper forearm, cleaned area with alcohol, used a butterfly needle with one attempt, and collected 4 ml of blood in a tube. A small gauze dressing is applied and covered with tape. Staff #1 applied pressure for approximately 2-3 seconds on the left antecubital area. Staff #1 wrote her initial and time of draw on a pre-printed patients name and attached label to the tube. Staff #1 removed contaminated gloves and used hand sanitizer from the wall in patients ' room and exited room.
Observation of blood draws on 11/28/2012 at 12:25 PM on Patient # 6 by Staff # 1, Clinical Lab assistant. Staff knocked on door before entering room, identified patients ' name and date of birth. Staff identified accuracy of ID bracelet. Explained the purpose of the blood draw to the patient. Staff # 1 donned on a pair of gloves and applied tourniquet to right upper forearm, cleaned right antecubital area with alcohol, used a butterfly needle with one attempt, and collected 8 ml of blood in 2 tubes. Small gauze dressing applied and covered with tape. Staff # 1 applied pressure for approximately 2-3 seconds on the right antecubital area. Staff # 1 wrote her initial and time of draw on a pre-printed patients name and attached label to each tube. Staff used hand sanitizer from wall and exited room.
Observation on 11/28/2012 at 12:30 PM, Staff # 1 failed to wash her hands after removing the contaminated gloves and before leaving the Patient # 6 room.
Interview with Staff # 1 on 11/28/2012 at 12:32 PM revealed and concurred that she did not wash her hands before leaving Patient # 5 and # 6 rooms and between patients ' blood draw procedure. She stated that she used the hand sanitizer from the wall.
Interview with Staff # 2 on 11/28/2012 at 12:35PM concurred and confirmed through observation and subsequent interview that Staff # 1 failed to wash her hands after removing her contaminated gloves
Review of hospitals policy and procedure on Fundamentals of Standard and Transmission - Based Precautions, Appendix (CDC-2007), Effective Date of July 1, 2010, page 3 of 9 revealed " hand washing is cited as the single most important measure to reduce the transmission of infectious agents in healthcare settings. Washing hands as promptly and thoroughly as possible between patient contacts and after contacts with blood-body fluids, secretions and equipment or articles contaminated by them is an important component of infection control and isolation precautions. Gloves must be changed between patient contacts and hands should be washed after gloves are removed. Wearing gloves does not replace the need for hand washing, because gloves may have small inapparent defects or may be torn during use, and hands can become contaminated during removal of gloves".