Observations:
Based on facility documentation, observation, and employee (EMP) interview, it was determined the facility failed to follow their policy for hand hygiene.
Findings included:
Review of "Hand Hygiene Policy" revised 2012, References: CDC Guidelines; AORN (Association of PeriOperative Registered Nurses) Recommended Practices, revealed "2010 Policy Statement: Appropriate hand hygiene, based on CDC Guidelines will be implemented within the Surgery Center. ... Procedures: I. Indications for hand washing and hand antisepsis: ... G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient ..."
Observation on December 5, 2023, at 11:00 AM in operating room 1 revealed, employee EMP1 dropped an item on the floor and retrieved it. EMP1 did not change gloves or apply hand sanitizer. Further observation revealed EMP1 wiped their nose and touched an item containing blood. EMP1 did not change gloves or apply hand sanitizer.
An interview conducted on December 5, 2023, at 12:00 PM with EMP2 confirmed the expectation of hand hygiene and the adherence to the facility policy was not followed.
| | Plan of Correction - To be completed: 01/31/2024
The individual identified is part of the credentialed medical staff. Re-education on our Hand Hygiene Policy was performed immediately with the identified individual. Beginning in January 2024, this medical staff member will be the subject of random hand hygiene surveys conducted by the Clinical Director or designee over a 3-month period with a minimum of 2 random surveys conducted per month. If issues are noted the individual will be re-educated and the random surveys extended for an additional 3-month period. If no issues are identified during a consecutive 3-month period, the medical staff member will be considered hand hygiene proficient and be required to complete hand hygiene re-education annually thereafter.
Hand hygiene education is included in the center's annual employee and medical staff competency re-education conducted every January. The 2024 re-education will be coordinated by the Clinical Director or designee and be completed by January 31, 2024. Employees or credentialed medical staff members that have not completed the had hygiene education by January 31, 2024 will not be permitted to provide patient care until the education is complete.
Random monthly hand hygiene surveys will be conducted by the Clinical Director or designee to ensure proper hand hygiene practices are being followed. Any employees or medical staff members who are not conducting proper hand hygiene will receive immediate re-education. If the behavior persists, employees will be placed on corrective action plans and medical staff members will receive a written letter requiring that the deficiency be corrected immediately. The survey results will be reported quarterly during the infection control meeting held simultaneously with the Quality Assurance and Performance Improvement (QAPI) meeting. The infection control committee will assess and modify the action plan as needed to ensure continued compliance.
Documentation of any corrective action taken will be reported to the Board of Managers.
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