The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

FRANCISCAN HEALTH INDIANAPOLIS 8111 S EMERSON AVE INDIANAPOLIS, IN 46237 June 30, 2020
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on document review, observation, and interview the facility failed to follow hand hygiene policy for one drive through testing site.

Findings include:

1. Policy/procedure review: Review of facility policy, Infection Prevention Hospital Wide Personnel Hand Hygiene Policy, last reviewed 01/29/2020, indicated the following. Wash hands before donning gloves and immediately after removal of gloves.

2. Observation: On observation of 6/30/2020, at approximately 10:30 am, in the parking lot of facility the following was observed. An open structure with a roof where vehicles were lined up waiting. N8 (Registered Nurse) is observed getting a nasopharyngeal swab from a patient. N8 has on two pairs of gloves. The first pair of gloves is removed. The second pair of gloves N8 cleans with hand sanitizer. Another pair of gloves are placed over the hand sanitized gloves. N8 goes to the next patient and collect their specimen.


3. Interview: On 06/30/2020, at approximately 1:36 pm, with N2 (Registered Nurse/Emergency Department) confirmed the following. Issue with Registered Nurses using two pairs of gloves had been previously addressed. Nurse removes top glove, sanitizes bottom glove and adds a new glove in between patients.