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BEAVER DAM COMMUNITY HOSPITAL 707 S UNIVERSITY AVE BEAVER DAM, WI 53916 Aug. 25, 2015
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, record review and interview, staff at this facility failed to follow P/P and maintain an environment free from potential contaminants during patient care in 3 out of 8 patient observations of care (Pt. # 1, 3, 5)

Findings include:

In an interview with ICP P and Clinical Quality Lead Q on 8/24/2015 at 2:40 PM regarding standards of practice for staff at this facility, ICP P identified the CDC and Clinical Quality Lead Q identified AORN as expected standards of practice for staff to follow.

The CDC guidelines can be found in the website: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm

AORN recommendations (2012):
Hair coverings should cover facial hair, sideburns, and the nape of the neck. Perioperative nurses can help minimize the risk of surgical site infections by covering head and facial hair, which prevents skin squames and hair shed from the scalp from falling onto the sterile field. Skull caps are not recommended because they do not completely cover the wearer ' s hair and skin; they fail to cover the side hair above and in front of the ears and the hair at the nape of the neck.

Observations in OR:
The following observations in OR took place on 8/24/2015 during Pt. #1's total knee surgery.
At 10:35 AM RN F and RN G were noted to be wearing cloth surgical caps. RN F and G's ears were exposed and RN G's hair was not covered at the nape of the neck, noted to be touching the outside of the cover jacket.
At 10:47 AM RN F removed gloves (worn to assist in holding Pt. #1 during spinal block injection) and opened the foley catheter supply package. No HH. RN F then proceeded to apply sterile gloves and insert the foley catheter.
At 10:48 AM RN G removed gloves to leave the OR suite for supplies. No HH.
At 10:50 AM RN F removed the sterile gloves after the foley catheter insertion and went to a cabinet to retrieve a blue towel. No HH. RN F then proceeded to assist with positioning of the catheter tubing and Pt. #1 for the surgical procedure.

These observations were discussed with and confirmed per interview with OR Dir E on 8/25/2015 at 9:35 AM. RN G stated that RN G is new and will need some guidance for attire.

The facility's policy titled, "OR Attire," # OP-007-13, dated 2-2013 was reviewed on 8/25/2015 at 12:35 PM. The policy states in part, "Disposable scrub hats or surgical hoods that completely cover all possible head and facial hair are to be worn by all personnel entering the OR restrictive area."

Observation on the Medical floor:
On 8/25/2015 at 7:30 AM an observation of LPN O doing a bedside blood glucose test on Pt. #3 was completed. After completing the procedure LPN O wore the same gloves to clean the equipment as worn during the procedure.

This finding was discussed in interview with Dir of Inpt Svcs B on 8/25/2015 at 7:50 AM, who stated, "[LPN O] should have changed gloves before cleaning the equipment."





Per review of facility policy titled Hand Hygiene, #IC-009-12, dated 3/12, stated in part under B. Decontaminate hands with either soap and water or alcohol based hand gel: 1. Before having direct contact with patients. 2. Before and after applying sterile gloves used to insert indwelling urinary catheters, peripheral vascular catheters or other devices that require aseptic technique. 4. After contact with patient's intact skin (e.g., when taking a blood pressure or lifting a patient). 8. Immediately upon removing gloves worn for any purpose.

Per review of facility policy titled Standard Infection Prevention and Control Practices, #IC-001-12, dated 1/12, stated in part under E. Supplies and Equipment 2. Reusable items (blood pressure cuffs, otoscopes, etc.) are cleaned when visibly soiled or after contact with potentially infectious materials with a hospital grade disinfectant.

Per review of facility policy titled Medication Administration, #PC-280-14, dated 5/2014, stated in part under Procedure C. Rubber Topped Vial 1. Cleanse rubber top with antiseptic wash.

Observations in the ED:
Per observation on 8/24/15 at 10:40 AM of Emergency Department (ED) in room Trauma C, Medical Doctor (MD) J was in the room completing an assessment on pt. #5, including a lung and heart assessment with a stethoscope. MD J finished assessment, removed gloves and placed stethoscope around neck and MD J left the room at 10:41 AM without completing hand hygiene or cleaning the stethoscope. At 10:42 AM, MD J re-entered the room, reviewed vital signs and left the room at 10:44 AM without completing any hand hygiene upon entering or leaving the room.

On 8/24/15 at 10:45 AM, standing outside the trauma C ED room, while chest x-rays were being completed on pt. #5, an interview with Director of Emergency Department (Dir of ED) I occurred how MD J had not completed any hand hygiene despite touching the patient, entering the room, or leaving the room several times throughout the treatment of pt. #5. Dir of ED I agreed that MD J had not completed any hand hygiene.

On 8/24/15 at 10:50 AM, observed Dir of ED I approach MD J from behind the curtain in trauma C ED room and remind MD J to complete hand hygiene. At 10:52 AM, MD J completed hand hygiene prior to leaving the room.

On 8/24/15 at 11:02 AM in trauma C ED room, observed Emergency Department Registered Nurse (ED RN) K preparing to draw up medication (Lasix) from a vial. ED RN K removed the cover from the vial and used a syringe to draw up the medication without cleansing the rubber top of the vial.

On 8/24/15 at 11:10 AM in trauma C ED room, observed Laboratory Technician (Lab tech) L obtained blood samples from pt. #5, Lab tech L then left the room (with the same gloves on used to draw the blood) holding the tube of blood.

On 8/24/15 at 11:14 AM in trauma C ED room, observed ED RN M obtain a urine sample from pt. #5's foley catheter. ED RN M removed gloves, and completed hand hygiene. ED RN M then labeled the urine specimen, placed the specimen in a plastic bag, placed call light within reach of patient and walked out of the room without completing hand hygiene.

On 8/24/15 at 11:30 AM, an interview was completed with Dir of ED I and the above findings were shared. Dir of ED I agreed that there were missed opportunities when hand hygiene should have been completed during the observations completed in the trauma C ED room. Dir of ED I also stated in an interview on 8/25/15 at 1:15 PM, that the rubber stopper needs to be cleaned on the vial prior to drawing up medications and that tubes of blood should be placed in a plastic bag when being transported out of the patient room.