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Based on policy review, observation and interviews, the hospital failed to ensure the infection control officer implemented a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:
1) failure to ensure hand hygiene was performed after each glove change while staff was performing wound care for 1(#4) of 1 patient observed for wound care from a total patient sample of 5 (#1-#5);

2) failure to ensure a Housekeeping staff member changed gloves and hand hygiene was performed when moving from a dirty task to a clean task while cleaning contact isolation patients' (#R1, #R2) rooms for 2 of 2 observations of S4HK performing housekeeping duties; and

3) failure to ensure proper positioning of patient catheter bags to reduce the risk of urinary tract infections (catheter bag containing urine was placed on the foot of the patient's bed above the level of the bladder) for 1(#4) of 1 patient observed with an indwelling Foley catheter from a total patient sample of 5 (#1- #5).

Findings:

1)Failure to ensure hand hygiene was performed after each glove change while staff was performing wound care.

Review of the hospital policy tiled, "Hand Hygiene" Policy Number: IC- 8, revealed in part:
Policy: Hand hygiene is an important measure in reducing healthcare associated infection rates. It is achieved by cleansing hands with soap, warm water and friction or with alcohol based hand rubs.
Purpose: To remove transient microorganisms from the hands.
Procedure: 1. Hand hygiene to be performed at a minimum: B. Before and after patient contact. C. Before applying gloves and after removing gloves. D. Before performing a clean/aseptic procedure, E. After exposure to body fluids, F. After touching patient surroundings.

On 03/24/2021 at 9:08 a.m. an observation was conducted of S1LPN performing Patient #4's wound care. S1LPN was observed removing the dressing from the patient's left elbow. S1LPN removed her gloves after discarding the soiled dressing and donned a new pair of gloves to cleanse and dress the wound. S1LPN failed to perform hand hygiene after glove removal, prior to donning clean gloves. S1LPN was then observed removing the dressing from the patient's right elbow, discarding the soiled dressing, and removing her gloves. S1LPN donned a new pair of gloves to cleanse and dress the wound but failed to perform hand hygiene after glove removal, prior to donning clean gloves. S1LPN then moved on to removing the dressing from the patient's sacral wound. S1LPN removed the soiled dressing, discarding it, removed her gloves, and donned a new pair of gloves to cleanse the sacral wound in preparation for applying the wound vac. S1LPN failed to perform hand hygiene after glove removal, prior to donning clean gloves.

On 03/24/2021 at 10:00 a.m. an interview was conducted with S3QA regarding the hand hygiene breaches observed during wound care. S3QA confirmed hand hygiene is to be performed prior to donning gloves and after glove removal.

2) Failure to ensure a Housekeeping staff member changed gloves and hand hygiene was performed when moving from a dirty task to a clean task while cleaning contact isolation patients' rooms.

On 03/24/2021 at 9:32 a.m. an observation was conducted of S4HK cleaning contact isolation patients' rooms. S4HK was observed gathering the trash bag from Patient #R1's room (Room "a"). Patient #R1's room had signage indicating the patient was on contact isolation (patient was on contact isolation for MRSA and VRE). S4HK brought the trash bag out of the patient's room and discarded it in the rolling garbage bin by pushing it down into the bin with her gloved hands. S4HK then wet a cloth with a cleaning solution, with the same gloves on, entered Patient #R1's room, and proceeded to wipe down the patient's bedside table. S4HK exited the patient's room, removed her gown and gloves and donned a new gown and gloves without performing hand hygiene after removing her gown and gloves. S4HK then entered Patient #R2's room (Room "b"). Patient #R2's room also had signage indicating the patient was on contact isolation (patient was on contact isolation for VRE). S4HK brought the trash bag out of the patient's room, discarded it in the rolling garbage bin, and failed to change her gloves after handling the trash bag. S4HK then wet a cloth with a cleaning solution, with the same gloves on, entered Patient #R2's room, and proceeded to wipe down Patient #R2's bedside table.

On 03/24/2021 at 10:10 a.m. an interview was conducted with S3QA regarding the hand hygiene breaches and cross-contamination observed when S4HK was cleaning contact isolation Patient #R1 and #R2's rooms. S3QA confirmed hand hygiene is to be performed prior to donning gloves and after glove removal. She also confirmed gloves should be changed when moving between clean and dirty tasks.

3) Failure to ensure proper positioning of patient catheter bags to reduce the risk of urinary tract infections - catheter bag containing urine was placed on the foot of the patient's bed above the level of the bladder.

According to the CDC Guidelines for Preventing Catheter Associated Urinary Tract Infections the urine collection bag should be placed below the level of the bladder to ensure proper drainage of urine.

On 03/24/2021 at 9:08 a.m. an observation was conducted of S1LPN performing Patient #4's wound care. S1LPN was assisted by S2CNA. During the observation S2CNA was observed placing Patient #4's catheter urine collection bag on the foot of the bed. The bag contained urine and it was approximately ¾ full. The foot of Patient #4's bed was elevated resulting in the catheter collection bag being positioned above the level of the patient's bladder.

On 03/24/2021 at 10:00 a.m. an interview was conducted with S3QA regarding the position of Patient #4's catheter bag on the foot of the patient's bed. She acknowledged Patient #4's catheter bag should not have been placed on the patient's bed.