HospitalInspections.org

Based on 8 of 8 observations (2 of 2 wound care,1 of 1 trach care, and 5 of 5 blood sugar checks) interview with staff (A&F) and review of policy the hospital failed to ensure all staff were educated in infection control. This has the potential to affect the total hospital census of 36 patients.

Findings include:

Facility policy #051-39-029.2 entitled; "Hand Hygiene" with a revision date of 09/2007 governs infection control. It defines "Decontaminate hands. To reduce bacterial counts on hands by performing antiseptic hand rub or antiseptic handwash." Under "Indications for hand washing and hand antisepsis" is listed: "9. Decontaminate hands after removing gloves."

Patient #3; On 04/03/13 at 2:40 PM, RN E was observed providing wound care for pt. #3, dressing changes to wounds on #3's left foot and knee. After donning gloves RN E removed scissors from a bedside dresser and laid them on a dirty overbed table RN E proceeded to clean half of the overbed table to lay out clean supplies then removed her gloves without cleaning hands. RN E contaminated a new pair of gloves by placing them on the dirty overbed table before putting them on. RN E then proceeded to remove soiled dressing from the foot wound and reapply a clean dressing while wearing the same pair of gloves. By wearing the contaminated gloves and using contaminated scissors to cut clean gauze RN E potentially contaminated the new dressing. Wearing the same previously contaminated gloves RN E proceeded to remove the dressing from the knee wound and redress it with clean dakin's (an antiseptic solution) soaked gauze.

Patient #7; On 04/02/13 at 4:00 PM, Registered Nurse (RN) D was observed providing wound care for pt. #7. After donning gloves D removed pt. #7's soiled dressings from an open hip wound, removed gloves and donned a clean pair of gloves without cleaning her hands. RN then proceeded to lay out 7's dirty bed sheets and remove soiled dressings from a second leg wound. RN D proceeded to open additional packages of sterile gauze with contaminated hands. While securing the dressings RN D asked pt. #7 to hold them in place without assuring the cleanliness of pt. #7's hands.

Patient #11; On 04/03/13 at 9:25 AM, Respiratory Therapist (RT) C was observed providing routine tracheostomy care for pt. #11. After donning gloves and cleaning a work surface RT C doffed her gloves and proceeded to don a new pair without cleaning her hands. RT C proceeded with cares with potentially contaminated hands.

Per interview with QA manager A on 04/03/13 at 1:00 PM staff are expected to clean hands when removing gloves between glove changes.


The following observations were made the morning of 04/03/13, starting at 11:00 AM; CNA F went from room to room obtaining patients' blood sugars using the same glucometer. CNA F began in room 309 and obtained pt. #12's blood sugar, after using the glucometer she did not clean it but placed it directly in her pocket. CNA F proceeded to room 307 where pt. #10 was on contact isolation precautions, she proceeded to use the glucometer without cleaning it and when finished returned it to her pocket without cleaning. CNA F then proceeded to room 303 to get pt. #13's blood sugar, she again neglected to clean the glucometer both before and after use. The next stop was in room 301 where pt. #9 was on contact isolation precautions, again CNA F neglected to clean the same glucometer before or after use and placed it back in her pocket. Finally CNA F used the same dirty glucometer to obtain pt. #14's blood sugar in room 311.
At 12:15 PM on 04/03/13 CNA F was interviewed, she stated the glucometer is supposed to be cleaned between patients as she was trained during her orientation. She stated she had been employed since 06/12/12 and had been trained by another CNA.
At 1:00 PM on 04/03/13 QA manager A stated she would expect staff to clean the glucometer from patient to patient.