HospitalInspections.org

Based on observations, Centers for Disease Control (CDC) guidelines for infection prevention, the manufactures direction for use (MDFU) for chlorhexidine gluconate (CHG), facility policies and procedures, facility education document and interviews with staff, it was determined the facility failed to ensure:

1. Staff followed the CDC guidelines and facility policy for hand hygiene.

2. Staff followed the MDFU for CHG.

3. Staff followed aseptic technique for safe injection practices during medication preparation and administration.

4. Staff discarded and did not use patient supplies, possibly contaminated, after contact with the treatment room floor.


This affected medical record (MR) # 2, an unsampled patient, MR # 1, MR # 19, and MR # 20, five of five observations performed, and has the potential to negatively affect all patients treated at the facility.

Findings include:


CDC Health Care Providers February 28, 2024
Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011)
Intravascular Catheter-related Infection (BSI) Prevention Guidelines...
Summary of Recommendations from the Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011).

...2.1. Peripheral Catheters and Midline Catheters
...3. Hand Hygiene and Aseptic Technique

Recommendations for hand hygiene and aseptic technique...
1. Perform hand hygiene procedures, either by washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR). Hand hygiene should be performed before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, repairing, or dressing an Intravascular catheter.
...2. Maintain aseptic technique for the insertion and care of Intravascular catheters...

Policies and Procedures Subject: Hand Hygiene and Fingernails
No number documented.
Issued: 5/25

...When should hand hygiene per performed?
...3. Before, between, and after physical contact with the patient.
4. Before and after handling in-use patient care devices such as Intravascular catheters...
12. After removing gloves.

MDFU ChloraPrep One-Step
2% chlorhexidine gluconate (CHG) and 70 % v/v isopropyl alcohol (IPA)
Patient Preoperative Skin Preparation

...1 milliliter (ml) applicator
Do not Reuse

...Purposes...Antiseptic

...Directions

...hold the applicator with the sponge down. Pinch wings only once to activate...release the antiseptic.

...wet the sponge by pressing the sponge against the treatment area until liquid is visible on the skin completely wet the treatment area with antiseptic...

...use gentle repeated back-and -forth strokes for approximately 30 seconds. Allow the area to air dry for approximately 30 seconds.

...discard the applicator after a single use...

Facility Education Document Titled, Infection Prevention and Control for Clinical Staff
Subject: Safe Injection Practices Aseptic Technique
No number documented.
Expiration Date: 12/6/26.

Safe Injection Practice Aseptic Technique

Medications should be accessed in an aseptic manner

...proper hand hygiene

rubber septum should be disinfected with alcohol and allowed to dry...

1. An observation of care was conducted on 12/3/25 from 10:45 AM to 12:10 PM with Employee Identifier (EI) # 5, Registered Nurse, Outpatient Infusion for intravenous (IV) catheter insertion and IV (Venofer iron supplement) preparation and administration for MR # 2.

EI # 5 failed to perform hand hygiene before initial patient contact, before donning gloves, and inserting MR # 2's IV catheter.

EI # 5 dropped the IV tubing line on the floor during set up. EI # 5 retrieved the IV tubing from the floor and returned the tubing to the infusion table with clean patient supplies.

EI # 5 wiped MR # 2's IV site for three motions using CHG. The IV site was not wet with CHG solution and EI # 5 failed to disinfect the site for thirty seconds per MDFU.

EI # 5 immediately inserted the IV catheter. EI # 5 failed to allow thirty seconds for CHG to dry per MDFU.

EI # 5 wiped the Venofer vial septum with the used CHG swab. EI # 5 failed to disinfect the IV Venofer septum with alcohol prior to inserting the needle during Venofer preparation.

EI # 5 failed to discard and not re-use the CHG applicator.

EI # 5 wiped the 100 ml sodium chloride (normal saline-NS) solution bag injection port with the used CHG swab and added IV Venofer to the NS solution bag.

EI # 5 failed to discard and not re-use the CHG applicator. EI # 5 failed to disinfect the solution bag injection port with alcohol prior to IV Venofer initiation. EI # 5 failed to replace the dropped tubing set and use a sterile IV tubing set.

After cleaning the blood pressure cuff, EI # 5 removed gloves but failed to perform hand hygiene.

On 12/3/25 at 11:20 AM, EI # 5 returned to MR # 2's infusion station for infusion termination, donned gloves, without performing hand hygiene, then flushed the IV tubing/catheter and removed the IV catheter.

An interview was conducted on 12/4/25 at 1:30 PM, with EI # 2, Director of Nursing, and EI # 4, Director of Infection Prevention. EI # 2 and EI # 4 confirmed staff failed to follow accepted infection control practices for hand hygiene/glove use, use only sterile supplies, follow CHG MDFU during IV site preparation, and aseptic technique during IV Venofer preparation and administration.

2. On 12/3/25 at 11:50 AM, an unsampled patient arrived for IV Venofer administration. EI # 5 wiped the IV insertion site with a CHG swab three wipes and not a gentle repeated back and forth strokes for approximately thirty seconds. EI # 5 failed to allow to air dry for thirty seconds before inserting the IV catheter.

EI # 5 failed to disinfect the IV Venofer vial with alcohol prior to inserting the syringe needle during medication preparation. EI # 5 failed to disinfect the injection port on the 100 ml NS solution bag before IV Venofer was instilled.

An interview was conducted on 12/4/25 at 1:30 PM with EI # 2 and EI # 4, who confirmed staff failed to follow accepted infection control practices including CHG MDFU during IV catheter insertion and IV Venofer preparation and administration.



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3. An observation was conducted on 12/3/25 at 11:30 AM with EI # 6, Exercise Physiologist to observe patient care in the outpatient rehab setting.

After obtaining vital signs on MR # 1, EI # 6 cleaned the reusable equipment, removed his/her gloves, and failed to perform hand hygiene. EI # 6, then prepared a cloth for the next patient.

An interview was conducted on 11/4/25 at 1:35 PM with EI # 4, who confirmed the staff failed to follow the CDC guidelines for hand hygiene.




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4. An observation was conducted on 12/3/25 at 12:43 PM with EI # 7, Registered Nurse (RN) to observe patient care in the Emergency Department (ED).

After obtaining vital signs on MR # 19, EI # 7 failed to perform hand hygiene after removing his/her gloves.

An interview was conducted on 12/4/25 at 1:33 PM with EI # 2, who was present during the observation confirmed the staff failed to follow the CDC guidelines for hand hygiene.

5. An observation was conducted on 12/3/25 at 1:19 PM with EI # 8, RN to observe patient care in the ED.

After starting an IV on MR # 20, EI # 8 removed his/her gloves and failed to perform hand hygiene after removing gloves.

An interview was conducted on 12/4/25 at 1:33 PM with EI # 2, who confirmed the staff failed to follow the CDC guidelines for hand hygiene.

Based on Medical Record (MR) review and staff interview it was determined the staff failed to ensure each patient was informed of the patient bill of rights prior to furnishing care.

This affected eight of 20 MR's reviewed to include MR # 4, MR # 13, MR # 19, MR # 20. MR # 3, MR # 5, MR # 17, and MR # 18, and has the potential to affect all patients served by the facility.

Findings include:

1. MR # 4 presented to the Emergency Department (ED) on 12/3/25 with a chief complaint of rash.

Review of the MR revealed no documentation the patient was informed of the patient's rights prior to furnishing care.

An interview was conducted on 12/4/25 at 1:33 PM with EI # 3, Director of Patient Safety, who confirmed there was no documentation MR # 4 was informed regarding the patient bill of rights.



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2. MR # 13 presented to the ED on 7/2/25 with a chief complaint of Anaphylaxis due to Shellfish.

A review of the MR revealed no documentation the patient was informed of the patient's rights prior to furnishing care.

An interview was conducted on 12/4/25 at 1:31 PM with EI # 3, who confirmed there was no documentation MR # 3 was informed regarding the patient bill of rights.


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3. MR # 19 presented to the ED on 12/3/25 with a chief complaint of Back Pain.

Review of the MR revealed no documentation the patient was informed of the patient's rights prior to furnishing care.

An interview was conducted on 12/4/25 at 1:33 PM with EI # 3, who confirmed there was no documentation MR # 19 was informed regarding the patient bill of rights.

4. MR # 20 presented to the ED on 12/3/25 with a chief complaint of Left Genital Labial Abscess.

Review of the MR revealed no documentation the patient was informed of the patient's rights prior to furnishing care.

An interview was conducted on 12/4/25 at 1:31 PM with EI # 3, who confirmed there was no documentation MR # 20 was informed regarding the patient bill of rights


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5. MR # 3 presented to outpatient services on 11/25/25 for a scheduled blood transfusion.

Review of the MR revealed no documentation the patient was informed of the patient's rights prior to furnishing care.

An interview was conducted on 12/4/25 at 1:18 PM with EI # 1, Director, who confirmed there was no documentation MR # 3 was informed regarding the patient bill of rights.


6. MR # 5 presented to the ED on 12/3/2025 with a chief complaint of Elevated Blood Pressure.

Review of the MR revealed no documentation the patient was informed of the patient's rights prior to furnishing care.

An interview was conducted on 12/4/25 at 1:30 PM with EI # 3, who confirmed there was no documentation MR # 5 was informed regarding the patient bill of rights.


7. MR # 17 presented to the ED on 11/5/25 with a chief complaint of a Concussion.

Review of the MR revealed no documentation the patient was informed of the patient's rights prior to furnishing care.

An interview was conducted on 12/4/25 at 1:38 PM with EI # 1, who confirmed there was no documentation MR # 17 was informed regarding the patient bill of rights.


8. MR # 18 presented to the ED on 8/28/25 with a chief complaint of Rectal Bleeding and Lower Gastrointestinal Bleed.

Review of the MR revealed no documentation the patient was informed of the patient's rights prior to furnishing care.

An interview was conducted on 12/4/25 at 1:23 PM with EI # 1, who confirmed there was no documentation MR # 18 was informed regarding the patient bill of rights.