Observations:
Based on observation, review of facility policies and procedures, and interview with staff (EMP), it was determined the facility failed to follow its facility policies for infection control practices related to hand hygiene and soiled instrument transportation.
Finding include:
1)Observation on May 9, 2024, at 10:18 AM in pre-operative holding room, revealed EMP3 removed gloves after preparing medication for patient and did not perform hand hygiene. Further observation revealed EMP3 preparing a liquid mouth wash solution, for patient administration, without gloves on. Additional observation revealed EMP3 handing small, plastic medicine cup containing oral medications to patient without performing hand hygiene or donning gloves. Continued observation revealed EMP3 holding plastic basin for patient to spit out mouthwash in, without wearing gloves.
Observation on May 9, 2024, at 10:21 AM, in pre-operative holding room, revealed EMP2 enter room without preforming hand hygiene. Continued observation revealed EMP2 listening to patient's heart and lung without performing hand hygiene before touching patient.
Observation on May 9, 2024, at 10:33 AM, in pre-operative holding room, revealed OTH1 entered room without performing hand hygiene. Further observation revealed OTH1 marking patient's face for procedure without performing hand hygiene before or after touching patient.
Review on May 9, 2024, of facility policy and procedure, " Standard Precautions for Infection Control Practices " , revised March 4, 2024, revealed " ...Employees should routinely use appropriate barrier precautions to prevent skin and mucus membrane exposure when in contact with blood or other body fluids. Gloves should be worn for touching blood and body fluids, mucus membranes, or broken skin of all patients, for handling items or surfaces soiled with blood or body fluids... "
Review on May 9, 2024, of facility policy and procedure, " Hand Hygiene " , revised March 4, 2024, revealed " ...Clean hands before and after routine patient care activities, including entering and exiting the patient care environment and after hand-contaminating activities. Clean hands before handling medication ... Glove use does not replace the need for hand hygiene ... "
Interview on May 9, 2023, at 10:33 AM, with EMP3 confirmed above findings.
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2)Observation on May 9, 2024, at 1:28 PM, in operating room one after procedure was completed, revealed two metal basins and two surgical light handles used during procedure stacked up on metal table, not enclosed or covered.
Review on May 8, 2024, of facility policy and procedure, " Instrument Care, Disinfection, Sterilization and Storage " , revised March 6, 2024, revealed " ...Transport instruments in a closed container or enclosed cart that is labeled with a biohazard legend ... "
Interview on May 8, 2024, at 11:19 AM, with EMP1 revealed that when the procedure is completed, EMP1 will spray soiled instruments with pre-cleansing spray and carry the instrument tray down the hallway to the soiled room. Further interview with EMP1 confirmed that EMP1 does not cover the soiled instruments with a wrap or place them in a closed container prior to leaving the operating room to transport instruments to soiled room for reprocessing.
| | Plan of Correction - To be completed: 06/26/2024
1)The staff had an immediate in-service on Monday 5/20/24 on the importance of hand hygiene and doffing gloves. The center will do weekly hand hygiene audits for one-two employees randomly on any given day the administrator and/or Director of Nursing chooses. The Director of nursing, who is also the infection control officer will also be chosen at random for the audits. The audit will be conducted weekly for one month then bi-monthly the following month and then ongoing once a month. If the employee fails to pass any part of the hand hygiene audit corrective action and education will be taken immediately. The employee will then be re-audited randomly the following week until error/s have been corrected. The results will be reported to the Medical Director and Governing Body and included in the material reviewed at the Infection Control, Patient Safety and Quality Assurance meeting quarterly. Ways to improve staff practices will be discussed at these meetings and presented to the Governing Body at the quarterly Medical Advisory Board meetings for review and Analysis.
2)A biohazard transport bin has been ordered and will arrive in the office by 5/31/24. The staff will have an Inservice including a visual demonstration on how to properly transport instruments from the Operating Room. Educational materials will be provided. In the meantime, the instruments will be covered with a wrap when leaving the OR and going to the dirty room. Once the biohazard transport bin arrives that will be used when transporting the instruments to the dirty room. Use of the transport bin will be audited. The audit will take place weekly for one month and then bi-monthly the following month then monthly for up to 6 months. After 6 months the audit will take place quarterly to ensure ongoing compliance. The audit will be performed by the Director of Nursing who is also the Infection Control Officer. The results will be reported to the Medical Director and Governing Body and included in the material reviewed at the Infection Control, Patient Safety and Quality Assurance meeting quarterly. Ways to improve staff practices will be discussed at these meetings and presented to the Governing Body at the quarterly Medical Advisory Board meetings for review and Analysis. This plan of correction is the responsibility of the Director of Nursing and the Administrator.
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