HospitalInspections.org

Based on observation, document review and interviews the facility staff failed to ensure their infection control program was fully implemented disposing of potentially infected waste, staff wore appropriate personal protective equipment (PPE) when interacting with a patient or being near a patient on contact precautions, carried linen away from the body, used equipment to administer medications that could be cleaned between patients and disposed of sterile supplies that were opened and accessed without being used immediately.

The findings include:

On 9/9/14 during the initial tour of the facility with Staff Member #1 the following observations were made:
On the second floor Staff Member #11 was observed exiting room #206 in a yellow gown, mask and gloves with an uncovered urinal containing a liquid brown substance. Staff Member #11 entered the public restroom located adjacent to room #206 and disposed of the contents of the urinal in the toilet. Staff member #11 re-entered room #206. Staff Member #1 stated, "They all know they are supposed to use the hopper for disposing of body fluids."

Staff Member #8 was asked if they needed to empty a urinal, bedpan or emesis basin for a patient on contact precautions were would they empty it. Staff Member #8 stated, "In the bathroom in the hallway. We only have 1 patient room with a bathroom in the room."

In the medication room of the second floor a syringe opened and accessed and available for use was located with other syringes in their sterile wrappers. Also 3 of 3 baskets containing the Accu-chec (blood sugar monitoring equipment) located at the nurses station had opened and accessed but undated test strip containers.

A nurse was observed removing clean linen from the linen cart in the hallway and placing the linen under her arm next to her body. Staff Member #1 approached the nurse who turned around and carried the linen to the soiled utility room.

Room # 206 had 2 patients both on contact isolation. Staff Member #9 was observed coming out of the far side of room #206. In order to exit the room Staff Member #9 had to pass the bed closest to the doorway (bed A). The patient in this bed was observed sitting up on the side of the bed near the foot of the bed conversing with 2 visitors. Staff Member #9 had removed the PPE while still on the far side of room #206 and had to pass within approximately 2 feet of the patient in A bed. Staff Member #1 stated, "She should have waited to remove the PPE once she was near the door. (Name of Patient in A bed) was not 6 feet from the blue line."

Staff Member #3 provided information regarding the blue line. The Blue Safety Zone Project was implemented by the facility in September 2012. The project was based on information in http://capsules.kaiserhealthnews.org/index.php/2011/06/a-hospitals-newest-weapon-against-infection-duct-tape. The project summary stated, "... the CDC research indicating that respiratory infections can travel up to 6 feet when a resident sneezes or coughs thus risking the spread of infection. The blue tape serves as a "safe zone" where health care workers can interact with these isolated patients without donning personal protective equipment." If a staff member needs to interact with a patient or the patient's head is not 6 feet away from the blue line then the required personal protective equipment (PPE) is to be worn per the Infection Prevention and Control Policy and Procedure dated as reviewed on 4/2014.

On the third floor 3 medication carts were observed to have rusting metal trays on the top of the carts. Staff Member #1 explained, "We use those to carry the medications into the patient rooms. They are cleaned with our disinfectant between patients." All of the trays were rusting which would prevent them from being able to be disinfected between use.
In the medication room a 1000 cc bag of 9% Sodium Chloride was opened from the protective outer bag.
(Store IV Bags in Their Overwraps FDA Patient Safety News: Show #22, December 2003: Here's a reminder about the importance of keeping premixed IV bags covered in their plastic overwraps. The Institute for Safe Medication Practices describes
how the protective overwrap serves an important purpose - to control the amount
of water vapor that escapes from an IV solution. When you see water droplets
forming inside a protective overwrap, that's the water vapor moving from the 100
percent humidity within the bag to the lower humidity in the overwrap. Once IV
bags are removed from their overwraps and exposed to room air, the rate of
evaporation increases. And over time, the drug's concentration will increase
because the amount of drug in the bag stays the same while amount of fluid
decreases.)