HospitalInspections.org

Based on observation, staff interviews, and review of facility policies and procedures, it was determined that the facility failed to implement its infection control policy titled "Standard and Transmission-Based Precautions."

Findings include:

Reference: Facility policy titled, "Standard and Transmission-Based Precautions" states, "...Policy...II. Contact Precautions: Contact Precautions, in addition to Standard Precautions, will be used for patients known or suspected to be infected with epidemiologically important microorganisms that can be transmitted by direct contact with the patient or indirect contact with environmental surfaces associated with the patient. ...Guidelines: ...4. Wear gloves and/or gowns as patient care tasks dictate in accordance with Standard Precautions. ..."

1. On 9/10/2020 at 11:53 AM, a tour of the facility was conducted in the presence of Staff #1, #2, #3, #4 and Staff #5 (the Infection Control Preventionist).

a. Patient Room #4 was observed to have a Contact Precautions sign posted outside the room.

(i) Staff #9 was observed entering Patient Room #4 wearing only a mask and goggles. He/she proceeded to pick up the patients incentive spirometer from the floor with his/her bare hands.

(ii) Staff #9 failed to don gloves and a gown when having contact with items associated with a patient on contact precautions.

(iii) The facility "Standard and Transmission-Based Precautions" policy was requested and reviewed. The policy states "...Policy...II. Contact Precautions: Contact Precautions, in addition to Standard Precautions, will be used for patients known or suspected to be infected with epidemiologically important microorganisms that can be transmitted by direct contact with the patient or indirect contact with environmental surfaces associated with the patient. ...Guidelines: ...4. Wear gloves and/or gowns as patient care tasks dictate in accordance with Standard Precautions. ..." Staff #9 failed to don gloves and a gown in accordance with this policy.

2. Upon interview on 9/10/2020 at 12:32 PM, Staff #9 confirmed he/she should have been wearing gloves and a gown, when he/she entered the patients room and picked up the patients incentive spirometer from the floor.