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.

Based on document review, observation, and interview, it was determined that for 4 of 6 staff (E#3, E#12, E#14, and E#15) observed performing tasks in the OR (Operating Room) and SPD (Sterile Processing Department), the Hospital failed to ensure that hand hygiene was performed after glove removal as part of the infection prevention and control program.

Findings include:

1. The Hospital's procedure reference titled, "Hand Hygiene" (dated 8/20/2021), was reviewed on 9/14/2021, and required, "Using an alcohol-based hand rub is appropriate for decontaminating hands... after removing gloves..."

2. An observational tour of the OR (Operating Room) Area was conducted on 9/13/2021, between approximately 11:00 AM and 12:25 PM.
- At approximately 11:05 AM, a Certified Surgical Technician (E#3) was observed in OR#11 with gloved hands, handling a cart of soiled instruments. E#3 covered the cart and then pushed it to the elevator to be sent down for reprocessing. After placing the cart in the elevator, E#3 removed the gloves and did not perform hand hygiene before touching objects in the environment and entering a clean supply room by touching the door handle.
- At approximately 11:23 AM, OR#9 was being cleaned for the next case, following a surgical procedure. At approximately 11:25 AM, an Anesthesia Aide (E#14) was observed wiping down the anesthesia equipment and cart with gloved hands. E#14 removed the gloves after cleaning, then went to setup clean equipment/supplies for the next case without first performing hand hygiene. At approximately 11:29 AM, an OR Support Assistant (E#15) had wiped down equipment and began mopping the floor with gloved hands. E#15 handed the the mop over to another staff member and then changed gloves without performing hand hygiene.

3. An observational tour of the SPD's decontamination room was conducted on 9/13/2021, at approximately 1:20 PM. An Instrument Technician II (E#12) was observed cleaning soiled instruments with a detergent solution in the sink. After E#12 moved the tray of instruments to the rinse sink, E#12 removed the top layer of gloves and had another pair underneath. E#12 retrieved a new pair from a clean cabinet and put the new pair of gloves over the bottom pair of gloves without performing hand hygiene. E#12 then went to rinse the cleaned instruments.

4. An interview was conducted with E#12 on 9/13/2021, at approximately 1:41 PM. E#12 stated that E#12 changes gloves in between cleaning and rinsing to prevent cross contamination. When asked if hand hygiene needed to be done after removing glvoes, E#12 responded, "I've got gloves underneath, and they stay dry so I just put a new one on."

5. An interview was conducted with the OR Director (E#1) on 9/13/2021, at approximately 2:25 PM. E#1 stated that staff are expected to perform hand hygiene after removing gloves. E#1 stated that double gloving does not eliminate the need to perform hand hygiene after glove removal.