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Based on observation, interview, and record review the facility failed to ensure effective implementation of its infection control policies.

Two (2) direct care patient staff failed to perform hand hygiene per facility infection control policy when providing wound care to Patient #11.

Findings include:

TX # 00181662

Observation on 09-16-13 at 1:00 p.m. revealed Patient # 11 lying in bed in the Intensive Care Unit. He was verbally unresponsive and breathing via ET tube connected to a mechanical ventilator. Patient # 11 had an indwelling catheter draining clear yellow urine to bedside drainage.

Interview with Registered Nurse (RN) Staff ID # 57 at the time of observation, she stated Patient # 11 had a Stage IV sacral pressure ulcer that was positive for Methicillin Resistant Staphylococcus Aureus (MRSA). Patient # 11 was currently on Contact Precautions due to the MRSA infection.

Continued observation at this time revealed RN/ID # 57 donned gown and exam gloves. Tech ID # 59 assisted in patient positioning and wound care process.

Patient # 11 was turned to his right side; a large amount of loose feces was noted on his buttocks. RN ID # 57 cleansed the patient ' s buttocks area, tucked the soiled wipes under the disposable pad. RN / ID # 57 then changed gloves and failed to sanitize her hands prior to donning a new pair of gloves. She then removed the visibly soiled dressing from Patient # 11 ' s sacral pressure ulcer. Again, RN/ID # 57 changed gloves and failed to perform hand hygiene prior to donning a clean pair of gloves. RN/ID # 57 changed her gloves three (3) additional times and did not sanitize her hands between any of the glove changes.

Further observation revealed Tech # 59 removed the feces-soiled wipes and disposable pad from under Patient # 11 and discarded them in the trash. Tech # 59 changed her gloves and failed to sanitize her hands prior to donning clean gloves. She then proceeded to reposition the patient, including touching his ET tube and vent circuit tubing.

During an interview immediately following the procedure, RN/ ID # 57 stated she was aware she changed her gloves much more frequently than was necessary. RN # 57 acknowledged she should have sanitized her hands between glove changes, especially after cleaning the feces and also after removing the soiled dressing.

During an interview immediately following the procedure, Tech # 59 stated she was not aware of the facility policy regarding hand hygiene between glove changes. She went on to say it would be difficult to do this, as the hand sanitizer dispenser was located in the hallway, away from the bedside.

Interview on 09-16-13 at 1: 45 p.m. with the Chief Nursing Officer (CNO) she stated the facility policy required hand hygiene between glove changes, especially when moving form a contaminated area to a clean area.

Review of facility policy titled " Hand Hygiene, " dated 03/09, read: "Introduction: Effective Hand Hygiene is considered the basis for an effective Infection Control Program. Research has indicated that Hand Hygiene Compliance is based upon: Effective education ....vigilance and accountability ....Policy: ...When (to perform hand hygiene): Between patient care activities within the same episode of care; when moving from high contamination patient care activities to cleaner activities; if moving from a contaminated body site to a less contaminated body site ...Between glove changes and after removing gloves. After any contact with body fluids, dressings, patient linen ... "