| 76 |
HATLEY HEALTH CARE INC |
15023 |
300 MEDICAL CENTER DRIVE |
CLANTON |
AL |
35045 |
2017-03-16 |
314 |
D |
0 |
1 |
4ZQH11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, medical record reviews and a review of a facility document titled, Hand Hygiene Table, the facility failed to ensure Employee Identifier (EI) #1, a Registered Nurse (RN) washed her hands and changed gloves after cleaning the wound of Resident Identifier (RI) #3 and before continuing with RI #3's wound care. EI #1 further failed to ensure she washed her hands and changed gloves when she performed wound care on RI #10's multiple wounds. This deficient practice affected RI #3 and RI #10, two of three residents observed for wound care. Findings Include: A review of an undated facility document titled, Hand Hygiene Table, revealed hand hygiene should be performed using .Either Antimicrobial Soap and Water or Alcohol Based Hand Rub . After handling items potentially contaminated with blood, body fluids, secretions, or excretions . When during resident care, moving from a contaminated body site to a clean site . 1) RI #3 was admitted to the facility on [DATE]. RI #3's physician orders [REDACTED]. On 3/15/2017 at 11:46 a.m., EI #1, the RN/Wound Care Nurse, was observed performing wound care on the Stage 2 pressure ulcer on RI #3's sacrum. EI #1 washed her hands and applied gloves then removed the dirty dressing from RI #3's sacrum. EI #1 then ungloved and washed her hands and applied clean gloves. EI #1 then cleansed the wound with saline soaked gauze. EI #1 did not change gloves and wash hands after cleaning the wound. EI #1 then proceeded to cut the [MEDICATION NAME] gauze with sterile scissors and transferred it to the wound using sterile tweezers and secured it in place using gloved fingers; then covered the wound with the [MEDICATION NAME] Border dressing. On 3/16/2017 at 2:33 p.m. and interview was conducted with EI #1, the RN who performed the wound care on RI #3. EI #1 was asked when should gloves be changed and hands washed during wound care. EI #1 responded, prior to touching the old dressing, prior to cleaning the wound, and then prior to changing the dressing (before applying the new dressing). When EI #1 was asked if she washed her hands and changed her gloves after cleaning the wound of RI #3 and prior to applying the clean dressing, EI #1 replied, she thought she did, but was nervous. EI #1 further explained the potential harm in not washing the hands and changing gloves after cleaning the wound and before continuing with wound treatment could result in contamination of the wound, because you are going from a dirty to a clean area. On 3/16/2017 at 3:02 p.m. an interview was conducted with EI #2, the Infection Control Nurse. EI #2 was asked when during wound care should gloves be changed and hand hygiene performed. EI #2 explained, before starting wound care and anytime during wound care when going from dirty to clean. When asked if it was an acceptable practice to clean a dirty wound with hand held gauze and then, without changing gloves and washing hands, continue to apply the clean dressing, EI #2 responded, no. EI #2 further explained the harm in doing so could result in the spreading of bacteria. 2) RI #10 was admitted to the facility on [DATE]. RI #10's physician orders [REDACTED]. The RN/Wound Care Nurse, EI #1, was observed providing wound treatment to RI #10 on 3/15/2017 at 2:30 PM. EI #1 washed her hands and applied gloves before cleaning and measuring the area to RI #10's right buttock. Without removing her gloves and washing her hands, EI #1 then cleaned and measured the area to RI #10's left buttock. EI #1 was interviewed on 3/16/2017 at 2:42 PM. EI #1 was asked what should be done after cleaning one open wound before cleaning the second open wound. EI #1 stated to remove gloves and wash hands to avoid cross contamination. When asked why she had not removed her gloves and washed her hands between wound treatments, she stated she forgot. |
2020-09-01 |