HospitalInspections.org

Based on observation, interview, record review and policy review, the facility failed to ensure staff followed infection control polices by:
- Inappropriate hand hygiene (to wash hands with soap and water or use hand sanitizer) for two patients (#16 and #7) of 12 patients observed;
- Inappropriate glove changes during tracheostomy (trach, incision in the neck, into the windpipe to remove an obstruction for breathing) care for one patient (#14) of one observed;
- Not gowning when necessary in the Operating Room (OR) for one patient (#27) of one observed;
- Not removing gowns appropriately when caring for two patients (#4 and #5) of 12 patients observed;
- Not cleansing a nebulizer (a device that produces medication into a fine spray to be inhaled) for one patient (#3) of one patient observed; and
- Wearing jewelry that was not covered by three staff (DD, CC, and GG) of five staff members observed.
- The facility also failed to maintain smooth and easily cleanable surfaces of metal hinges in the medication servers (a cabinet with a fold down door used to store and prep medications in a patient's room) in 69 of 73 patient rooms.
These failed practices of not following established policies and procedures to prevent the spread of infection had the potential to cause harm by healthcare associated infections for all patients. The facility census was 41.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene (to wash hands with soap and water or hand sanitize)," dated 05/2015, showed the directive for staff to perform hand hygiene after removal of gloves.

Record review of the facility's policy titled, "Bloodborne Pathogen Exposure Control Plan," dated 02/2014, showed the directive for staff to wear appropriate protective clothing which included gowns when there was possible occupational exposure situations.

2. Observation with concurrent interview on 11/17/15 at 9:50 AM showed Staff K, Environmental Services (EVS) in Patient #16's room. Staff K had gloves on and removed the right glove, put on a new glove, and wiped off a tub that held a toilet brush. A few minutes later, she had gloves on and removed the left glove and cleaned a mop handle. She failed to perform hand hygiene after she removed her gloves each time. Staff K stated that she should have performed hand hygiene after she removed her gloves and probably did not do it because she was nervous.

3. Record review of Patient #7's History and Physical (H&P) showed she had Methicillin-Resistant Staphylococcus Aureus (MRSA,a bacteria that is resistant to most antibiotics) Pseudomonas aeruginosa (bacteria frequently found in wounds) in her wound on her rectal (area where bowel movements are expelled) area.

Observation with concurrent interview on 11/17/15 at 10:30 AM showed Staff N, Restorative Aide, in Patient #7's room. The room had a sign on the outside of the door that read contact isolation and instructed all who entered to perform hand hygiene between glove changes, must where a gown and gloves (Personal Protective Equipment, PPE, gown and gloves worn to prevent spread of germs). A phone rang; she removed her gloves, took the cell phone from her pocket, talked, put the phone back in her pocket, then removed her gown and performed hand hygiene. She failed to perform hand hygiene when she removed her gloves and contaminated her uniform and phone by using it in a contact isolation room with hands that had not been cleaned. Staff N stated that she failed to perform hand hygiene because she forgot due to the phone call.

4. During an interview on 11/18/15 at 8:47 AM, Staff DD, OR Manager, stated that Patient #27 was in contact isolation (also known as contact precautions, specific measures taken to prevent the spread of highly contagious, or difficult to treat infections) on the nursing unit.

Observation in the OR on 11/18/15 at 9:05 AM showed Staff DD with no gown on while she cleansed Patient #27's abdomen prior to the beginning of the surgical case.

During an interview on 11/18/15 at 1:05 PM, Staff DD stated that she failed to realize she had removed her gown prior to cleansing the patient.

5. Record review of the facility's policy titled, "Donning and Doffing (put on and remove) PPE," dated 05/2015, showed facility staff direction that the front and sleeves of the gown were contaminated, to unfasten ties with ungloved hands and pull away from the neck and shoulders, touching only the inside of the gown.

6. During an interview on 11/17/15 at 2:27 PM, Staff G, Registered Nurse (RN), stated that Patient #4 was on contact precautions for Clostridium difficile (C. diff, a highly contagious infection which causes severe diarrhea.)

During an observation on 11/17/15 at 9:45 AM, Staff H, Registered Respiratory Therapist (RRT), assisted with the care of Patient #4, who was on contact precautions for C. diff after patient care was completed, Staff H removed his gloves, grabbed the front of his contaminated protective gown with his bare hands and removed the gown.

During an interview on 11/17/15 at 1:20 PM, Staff H stated that he usually removed his gown by grabbing the front with his gloved hands and then removed the gown and gloves together, but he forgot because he was nervous

7. Record review of Patient #5's laboratory results dated 09/17/15, showed the patient was positive for MRSA.

During an observation on 11/17/15 at 10:00 AM, Staff I, Physician, examined Patient #5, who was on contact precautions for MRSA. After examination, Staff I removed her gloves, grabbed the front of her contaminated protective gown with her bare hands and removed the gown.

8. Record review of the facility's policy titled, "Tracheostomy Care," dated 02/2012, showed facility staff direction that after the soiled dressing was removed to remove gloves, perform hand hygiene, and put on clean gloves.

9. Observation with concurrent interview on 11/17/15 at 1:20 PM in Patient #14's room showed Staff H, RRT, removed the soiled dressing from the trach site and cleansed the area. Staff H failed to remove his gloves, perform hand hygiene, and put on clean gloves after he removed the soiled dressing. Staff H stated that he usually removed his gloves, performed hand hygiene, and put on clean gloves and just forgot because he was nervous.

10. Record review of the facility's policy titled, "Dress Code," dated 10/2014, showed facility staff direction not to wear dangling, loose, or protruding jewelry.

11. During an interview on 11/18/15 at 9:45 AM, Staff DD, stated that the facility followed Association of Operating Room Nurses (AORN) guidelines.

Record review AORN guidelines titled, "2014 Perioperative Standards and Recommended Practices," revised 10/2010, showed that jewelry including earrings, necklaces, watches, and bracelets that cannot be contained or con¿fined within the surgical attire should not be worn. Jewelry that cannot be confined within the surgical attire should be removed before entry into the semi-restricted and restricted areas.

12. Observation on 11/18/15 at 8:55 AM in the OR with Patient #27 showed three staff wearing surgical caps exposing their ears. Staff DD had two stud earrings (small piece, that protrudes, but does not dangle, of jewelry worn through a hole in the earlobe) in both ears and a necklace of beads, Staff CC, Surgical Assistant had one stud earring in each ear, and Staff GG, RN had round earrings that dangled down and were in the shape of a circle.

During an interview on 11/18/15 at 11:05 AM, Staff DD stated that all jewelry must be covered in the OR.

13. Record review of the facility's policy titled, "Nebulizer Therapy," dated 08/2013, showed facility staff direction to rinse nebulizer cups after treatment with sterile or distilled water and allow it to dry on a paper towel in a safe place.

14. Observation with concurrent interview on 11/17/15 at 2:30 PM in Patient #3's room showed Staff Z, RRT, administer a nebulizer treatment and then put the nebulizer device back into a plastic bag. Staff Z stated that they were instructed not to clean the nebulizer out, but to place it back into the plastic bag.

During an interview on 11/18/15 at 2:05 PM, Staff AA, Director of Respiratory, stated that she expected the respiratory therapists to remove any extra medication from the nebulizer device after a treatment was completed and place it back in a plastic bag. She did not expect the staff to wash the nebulizer device between treatments. Staff AA stated that she was not aware of the staff directive in the policy.
The facility's policy directed staff wash the nebulizer cup after each treatment.

15. Observation on 11/18/15 at 9:30 AM showed rusted and pitted hinges on the medication server cabinets in patient rooms 304-306, 308, 310-343 on third floor, 101-105 the 100 hallway on the second floor, 207-212, 214, 216 and 220-245 on the second floor.

During an interview on 11/18/15 at 11:00 AM, Staff OO Operations Manager stated that the cleaning solution was highly corrosive and had caused the hinges to rust. Staff OO stated there was not a written policy or plan to replace the rusted hinges.

16. During an interview on 11/19/15 at 9:20 AM, Staff SS, Infection Preventionist, stated that rusty hinges in the patient rooms were not a cleanable surface and could harbor bacteria that could be transmitted to patients and cause infections. She stated that she expected the staff to:
- Perform hand hygiene after removal of gloves;
- Not to use personal cell phone or reach in pocket when wearing an isolation gown;
- Remove gloves, perform hand hygiene, and put on clean gloves after removal of a soiled trach dressing;
- Wear an isolation gown in the Operating Room when cleansing a patient who was on contact isolation; and
- Not wear dangling earrings, but the facility's policy did not address jewelry in the Operating Room.
The AORN guidelines showed jewelry that cannot be contained or con¿fined within the surgical attire should not be worn.















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