567.1 Principle
The ASF shall have a sanitary environment, properly constructed,
equipped and maintained to protect surgical patients and ASF personnel from
cross-infection and to protect the health and safety of patients.
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Observations:
Based on review of facility policy, observations, and interview with staff (EMP), it was determined that the facility failed to follow their policy and procedures for hand hygiene and exposure control program.
Findings include:
On February 19. 2025, review of facility policy "Hand Hygiene" dated October 4, 2024, revealed "POLICY It is the policy of UPMC to reduce the risk of transmission of pathogens and incidence of healthcare acquired infections by promoting and monitoring compliance with hand hygiene guidelines using guidance from the World Health Organization ' s (WHO), Your
Five Moments for Hand Hygiene and the Center for Disease Control and Prevention
(CDC). PURPOSE Effective hand hygiene removes transient microorganisms, dirt and organic material from the hands and decreases the risk of cross contamination to patients, patient care equipment and the environment. Hand hygiene is the single most important strategy to reduce the risk of transmitting organisms from one person to another or from one site to another on the same patient. Cleaning hands promptly and thoroughly between patient contact and after contact with blood, body fluids, secretions, excretions, equipment, and potentially contaminated surfaces is an important strategy for preventing healthcare associated and occupational infections. DEFINITIONS Direct Patient Contact refers to anyone who has contact with a patient and/or their environment. Indirect Patient Contact refers to anyone who has contact with a common area or equipment which patients may have had contact (corridors, waiting areas in ancillary areas, common areas, etc.) ... WHO Patient Zone - contains the patient and his/her immediate surroundings. This typically includes the intact skin of the patient and all inanimate surfaces that are touched by or in direct physical contact with the patient such as the bed rails, bedside table, bed linen, infusion tubing and other medical equipment. It further contains surfaces frequently touched by HCWs while caring for the patient such as monitors, knobs and buttons, trash and linen bins, and other 'high frequency ' touch surfaces. PROCEDURES Indications for hand hygiene: In most cases, either an alcohol-based hand sanitizer or handwashing with soap and water may be used for hand hygiene. Hand hygiene is performed when entering and exiting a patient room (area) along with the World Health Organization's (WHO) five moments of hand hygiene. The five moments are:1. Before touching a patient (or patient zone) 2. Before clean/aseptic procedure (critical sites) 3. After body fluid exposure risk 4. After touching a patient 5. After touching patient surroundings (patient zone) ... Gloves - GLOVES DO NOT REPLACE THE NEED FOR HAND HYGIENE. Hand hygiene must be performed prior to donning gloves when gloves are being worn for interaction with a patient and/or patient zone. Hand hygiene must be performed after removing gloves when gloves are being worn for interaction with a patient and/or patient zone and patient surroundings. Remove gloves, clean hands and don a fresh pair of gloves when caring for a patient that requires moving from a dirty site to a clean site. i.e. after caring for a draining wound to changing a central line dressing. Do not wear the same pair of gloves between patients."
1. Observation on February 19, 2025, EMP2, in the preoperative area retrieved patient from waiting room area without performing hand hygiene prior to contact with patient. EMP2 weighed patient, escorted patient to Pre-Op Bay 7 (G) assisted patient in getting set up on stretcher provided patient instructions and everything needed for changing, touched stretcher side rails, and items in bay area. EMP2 closed bay curtain leaving patient to dress and proceeded to document. EMP2 did not perform hand hygiene after contact with patient/patient zone with weighing, assisting patient in bay or closing bay curtain. After documenting EMP2 went back into bay area to assist patient did not perform hand hygiene prior to coming in contact with patient when returning into bay.
2. Observation on February 19, 2025, EMP3 entered bay pre-op bay 7 (G) to assist EMP2 with IV insertion. EMP3 did not perform hand hygiene before donning gloves and coming in direct contact with patient skin.
3. Observation on February 19, 2025, EMP4 entered bay 3 (C) was in direct contact with patient, stretcher, items in bay, patient shoes and then came out of area to chart. EMP4 was not observed performing hand hygiene prior to entering bay area nor performing hand hygiene after direct contact with patient/patient zone prior to charting outside of bay.
4. Observation on February 19, 2025, EMP4 donned gloves at pre-op nurses station to prepare medication. EMP4 did not perform hand hygiene prior to donning or when doffing gloves. EMP4 donned gloves and entered bay 3 (C) to clean surgical site with betadine sponge. EMP4 did not perform hand hygiene prior to donning gloves nor when doffing gloves after cleaning patient skin.
5. Observation on February 19, 2025, EMP5 entered PACU bay 10 came in direct contact with patient post-surgical site skin area. EMP5 did not perform hand hygiene prior to contact with patient. EMP5 left bay 10 after coming in direct contact with patient skin and opened supply cabinet retrieved a supply used for multiple patients. EMP5 did not perform hand hygiene after coming in contact with patient/patient zone prior to getting clean supplies. EMP5 returned to bay 10 came in direct contact with patient skin/patient zone then left bay to chart at nurse ' s station. EMP5 did not perform hand hygiene prior to direct contact with patient nor after contact with patient skin/patient zone.
Interview with EMP1 on February 19, 2025, EMP1 confirmed hand hygiene policy was not followed by EMP2, EMP3, EMP4 or EMP5.
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Based on review of facility documents, observation, and employee (EMP)
interview it was determined the facility failed to ensure instruments/equipment are being cleaned and disinfected properly to protect the health and safety of patients according to manufacture guidelines.
Findings include:
On February 19, 2025, review of "Bio-Zyme G Directions for use" reveal "Enzyme cleaning solution preparation: For manual, automatic, and ultrasonic applications add 1/2 fl. oz (3.9 ml per liter) of Bio-Zyme G per gallon of water."
Interview with EMP6 on February 19, 2025, EMP6 confirmed the facility uses two (2) pumps of the Bio-Zyme G enzymatic cleaner in five gallons of water. EMP6 also confirmed to get five gallons of water no measuring tool is used, but the water in the sink is filled using the eyeball method.
Observation noted on February 19, 2025, EMP6 deposited two pumps of Bio-Zyme G enzymatic cleaner into a measuring cup totaling two ounces of cleaner. Per manufacturer guidelines five gallons of water should have 2 1/2 fl oz.
Interview with EMP1 on February 19, 2025, EMP1 confirmed the facility was not adhering to the manufacturer's guidelines.
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Based on a review of facility policy, observations, and interview with staff (EMP), it was determined that the facility failed to follow the recognized standards of infection control to prevent cross-infection and a clean environment for patient care.
On February 19, 2025, review of facility policy "Dress Code" dated July 30.2024, revealed
"POLICY- It is the policy of UPMC that personal appearance reflects overall cleanliness, good grooming and hygiene, and professional identity. These guidelines were developed in
careful consideration of employee and patient safety, infection control and public image.
Exceptions to this policy may be made based on verified medical and religious needs. ... D. Guidelines for Staff Members with Direct Patient Care and/or Uniform Requirements ... 4. In consideration for infection control and patient safety: ... f) Artificial nails are prohibited for staff who have direct patient contact, who prepare instruments for sterile procedures or who prepare sterile pharmaceuticals, or who have contact with a patient's environment.
The definition of artificial fingernails includes, but is not limited to, acrylic nails, all overlays, tips, bonding, extensions, tapes, inlays, and wraps."
1) On February 19, 2025, observation of EMP2 fingernails it was noted EMP2 had colored artificial nail bonding.
2) On February 19, 2025, observation of EMP7 fingernails it was noted EMP7 had colored artificial nail bonding with spacing between end of product and cuticle where the nail had grown out.
Interview with EMP1 on February 19, 2025, EMP1 confirmed the above findings.
| | Plan of Correction - To be completed: 03/17/2025
Immediately after the survey, EMP2, EMP3, EMP4, & EMP5 that were identified as being noncompliant, were counseled on expectations related to proper nail grooming per dress code policy.
The UPMC policy that addresses hand hygiene was reviewed with staff during morning huddles held on February 24 – March 7, 2025, and will be reinforced during the staff meeting scheduled for March 6, 2025. Specifically, per system policy HS-IC0615 Hand Hygiene, the triggers to perform hand hygiene were highlighted including the following: when entering or exiting a patient room (area), before donning and after doffing gloves, before touching a patient (or patient zone), before clean/aseptic procedure (critical sites), after body fluid exposure risk, after touching a patient, and after touching patient surroundings (patient zone).
Immediately after the survey, EMP6 who was identified as being noncompliant was counseled on expectations related to the proper cleaning solution preparation as determined by the product MIFU.
The leaders reviewed the manufacturer instructions for use (MIFU) for the Bio-Zyme G Enzymatic Cleaner.
To support the ability to prepare the mixture accurately, a graduated cylinder was purchased to measure the enzymatic cleaner concentrate, and a water level indicator was installed in the sink to accurately measure the volume of water. An informational sign was posted in CSSD providing directions for preparing the solution. An in-service for all technicians who are responsible to disinfect the instruments was held on March 5, 2025, to review the new process.
Immediately after the survey, EMP2 & EMP7 that were identified as being noncompliant were counseled on expectations related to proper nail grooming per dress code policy.
The UPMC policies that define operating room dress code were reviewed with staff during morning huddles held on February 24 – March 7, 2025, and will be reinforced during the staff meeting scheduled for March 6, 2025. As stated in policy, HS-OR0010 Dress Code in the Operating Room and Sterile Processing Department, scrubbed personnel should not wear nail polish. The UPMC system policy HS-HR0714 Dress Code prohibits artificial nails for staff who have direct patient contact, who prepare instruments for sterile procedures or who prepare sterile pharmaceuticals, or who have contact with a patient's environment. The definition of artificial fingernails includes, but is not limited to, acrylic nails, all overlays, tips, bondings, extensions, tapes, inlays, and wraps.
The ambulatory surgery center leader or designee will perform 30 audits per month of staff interactions with patients to evaluate compliance with the hand hygiene guidelines. Any employee that is noncompliant will receive additional education and coaching.
The ambulatory surgery center leader or designee will perform 10 audits per month to confirm compliance with preparing the Bio-Zyme G enzymatic cleaner mixture per manufacturer instructions for use (MIFU). Any employee that is noncompliant will receive additional education and coaching.
The ambulatory surgery center leader or designee will perform 30 audits of surgical attire per month. Any employee that is noncompliant will receive additional education and coaching.
Audits will be performed monthly until 100% compliance is achieved for 3 consecutive months.
Results of the audits will be reported to the Director, Surgical Services monthly for the duration of the action plan.
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