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Based on review of facility policy, medical record review, observation, and interview, the facility failed to ensure proper hand hygiene was performed during the disinfection process of a treatment room for one of three rooms reviewed.

The findings included:

Review of the facility policy #J011 Standard Precautions review date 1/16, revealed "...standard precautions involves...use of gloves...reasonably anticipated that contact with blood, body fluids, secretions...contaminated items and soiled surfaces could occur...Change gloves between tasks and procedures after contact with material that may contain a high concentration of microorganisms...Remove gloves promptly after use; before touching non-contaminated items and environmental surfaces...and wash hands immediately to avoid transfer of microorganisms to other patients or environments..."

Observation of Licensed Practical Nurse (LPN) #1 cleaning treatment room #1 between patients on 8/24/16 at 2:00 PM revealed the LPN entered the room, donned gloves, removed the sheet and pillow case from the stretcher; and carried the linens across and down the hall to the soiled utility room. Continued observation revealed the LPN opened the door to the soiled utility room with the elbow; stepped on the foot pedal to open the linen hamper; placed the linens in the hamper; and returned to the treatment room #1. Continued observation revealed the LPN entered treatment room #1 without removing the gloves; removed several disinfectant wipes from the canister; cleaned the stretcher mattress and side rails; and continued to wipe the surfaces of the stretcher. Continued observation revealed the LPN removed and disposed of the gloves, donned clean gloves without cleansing or washing the hands; obtained several disinfectant wipes and cleaned the chair, counter, tray table, scissors, computer key board, and mouse. Continued observation revealed after the dry time had been obtained patient #1 was assisted into treatment room # 1 via wheelchair.

Interview with the Director of Clinical Programs on 8/24/16 at 3:30 PM, in the hallway, confirmed the LPN failed to follow policy when the LPN failed to remove the gloves after transporting the soiled linens to the soiled utility room; and failed to cleanse the hands after removing gloves and prior to application of clean gloves while disinfecting the treatment room.