|Survey Date: 3/30/2010|
Regulation Title: IC-WEAR GLOVES/HAND HYGIENE
Regulation Description: Wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station.
Based on observations, staff interview and review of the facility's policies and procedures, the facility personnel failed to perform adequate hand hygiene while performing patient care. This failure created the potential for contaminant transmission.
The findings were:
The facility's policy and procedure #1-05-01 entitled, "Infection Control for Dialysis Facilities," revised on September 2009, stated the following in pertinent part: "Hand hygiene is to be performed upon entering the facility, prior to gloving, after removal of gloves, after contamination with blood or other infectious material, after patient and dialysis delivery system contact, between patients even if the contact is casual, before touching clean areas such as supplies and before leaving the patient care area."
The following observations were made on 3/29/10 from approximately 1:00 p.m. to 1:30 p.m. A staff member was observed to be cleaning and setting up a dialysis machine for the next patient. An adjacent machine had alarms that were sounding and the staff member silenced the alarm without changing gloves. After silencing the machine, the staff member changed gloves and walked to the reuse room to get a new dialyzer. The staff member connected the new dialyzer and again changed gloves. There was no hand washing observed in between the changing of three pairs of gloves.
An observation was made on 3/30/10 at approximately 10:55 a.m. of a staff member on the treatment floor doing patient care that changed gloves without washing hands or using a hand sanitizer.
The observations made on 3/29/10 were brought to the attention of a staff educator on 3/30/10 at approximately 8:00 a.m. The educator stated that hand hygiene is stressed during training and in-house audits are periodically performed.
Facility Plan of Correction:
On 4-7-2010, the teammates were in-serviced on policy 1-05-01”Infection Control for Dialysis Facilities” with emphasis on proper handwashing, sanitizing after each glove removal, etc. Weekly infection control spot checks will be performed for 6 weeks, then bi-monthly for 8 weeks, then monthly ongoing by the Facility Administrator to ensure that all teammates are following policy and procedure
Continue monthly infection control audits by a member of the nursing staff and results reviewed with Facility Administrator. When teammates are identified not to be following policy and procedure, they will be immediately corrected and disciplinary action taken as necessary. Result of audits will be reviewed in CQI with the Medical Director and addressed as necessary. FA is responsible for ongoing compliance with POC.