HospitalInspections.org

Based on observations, interview, and a review of the policy and procedure, entitled, "Hand Hygiene", the hospital failed to ensure 1 of 1 dialysis nurses, Registered Nurse(RN) A1, performed hand hygiene after removal of soiled gloves to prevent potential cross contamination in the provision of patient care. After placing blood collection tubes directly on the bedspread of a patient on contact isolations precautions, RN A1 placed the blood tubes on the dialysis machine and used a bare hand to handle/label each tube.

The findings included:

Observations on 4/23/19 between 7:30 AM and 7:52 AM revealed RN A1 in the provision of dialysis care to Patient 8. Observations showed RN A1 failed to perform hand hygiene four times after removal of gloves in the following episodes: after cleaning the patient's right arm access site; after attaching the dialysis lines to the blood lines; after touching and adjusting the blood lines; and after touching the dialysis machine. RN A1 removed the soiled gloves and donned clean gloves without performing hand hygiene.

RN A1 was observed placing blood collection tubes directly on the bedspread of Patient 8 who was on contact isolation precautions. After drawing the blood wearing gloves, RN A1 placed the blood tubes on top of the dialysis machine, removed a soiled glove from one hand, and wrote on some labels and placed the labels on the blood tube touching the blood tubes with a bare hand.
During an interview on 4/23/19 at 8:16 AM, RN A1 was informed of the surveyor's concern related to the lack of hand hygiene after glove removal and potential cross contamination related to the handling of the blood tubes.

On 4/23/19, review of the policy, entitled, "Hand Hygiene", revealed hand hygiene applied to either handwashing or to the use of hand sanitizer. The policy included information that according to the CDC (Centers for Disease Control and Prevention), "The single most important intervention to prevent HAI (Healthcare Associated Infections) is hand hygiene." The policy stated, "The most critical times for performance of hand hygiene are: before and after patient contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; after removing gloves; ...1. Clinical indications for hand hygiene include contact with a patient's intact skin (before and after), before and after an aseptic task, after body fluid exposure risk, after contact with environmental surfaces in the immediate vicinity of patients, after contact with dialysis equipment, after glove removal, and before handling clean supplies...In addition to clinical indications, DCI staff will perform hand hygiene at the following times:...Before reaching into a box of gloves...".

Based on review of the hospital's Emergency Preparedness Program and interview, the hospital failed to ensure all medical providers were trained and tested on the hospital's site specific Emergency Preparedness Program.

The findings are:

Review of the hospital's Emergency Preparedness Program's policies, procedures revealed revealed there was no documentation of a site specific training and testing program for physicians and mid level practitioners. In an interview on 04/23/19 at 3:36 PM, the hospital's Chief Nursing Officer confirmed the hospital's physicians and mid level practitioners participated in a generic emergency preparedness and disaster training and testing program, but did not have a site specific emergency preparedness and disaster training.