Our Hospice of South Central Indiana Inc.

“Based on observation, record review, and interview, the agency failed to ensure staff followed manufacturer’s guidelines for appropriate disinfection of equipment to prevent cross-contamination and ensure safety of staff and patients for 3 of 4 SN home visits (Patient #2, #3, #4) and failed to ensure staff followed standard precautions to prevent the transmission of infections and communicable diseases for 2 of 2 Hospice Aide home visits in the inpatient unit (Patient #5, #7). Findings include: 1. A 12/21/2023 policy titled Healthcare Bag Technique indicated, but was not limited to, “Reusable equipment will be cleaned with the appropriate disinfectant after each use and before being returned to the healthcare bag.” 2. A review of a procedure titled “Catheter and Perineal Care,” indicated but was not limited to: “When peri care and/or catheter care is complete, remove the under pad or towels. Remove your gloves and perform hand hygiene…” 3. A review of the manufacturer’s guidelines and directions for use listed on the container was provided by RN 1 on 04/23/2025 at 9:38 AM. The manufacturer’s instructions for use indicated Clorox Wipes should be used to clean and disinfect hard, nonporous surfaces. Wipe surface; use enough wipes for treated surface to remain visibly wet for 4 minutes, let surface dry. 4. During a home visit on 04/23/2025 at 9:00 AM with Patient #2, RN 1 disinfected vital sign equipment (blood pressure cuff, stethoscope, oxygen saturation device, thermometer) after use with Clorox Disposable Wipes. RN 1 did not ensure each item remained wet for four (4) minutes then allowed to air dry before putting equipment away into the clean part of the bag per manufacturer’s instructions. This surveyor observed RN 1 clean the vital sign equipment again at the employee’s vehicle, but RN 1 failed to ensure each item remained wet for four minutes. Interview with RN 1 indicated they clean equipment again once it’s placed in the employee’s vehicle. 5. During a home visit on 04/23/2025 at 12:58 PM with Patient #4, RN 2 disinfected vital sign equipment (blood pressure cuff, stethoscope, oxygen saturation device, thermometer) and a reusable bag barrier after use with Clorox Disposable Wipes. RN 2 did not ensure each item remained wet for four (4) minutes then allowed to air dry before putting equipment away into the clean part of the bag per manufacturer’s instructions. Interview with RN 2 indicated receiving training to wipe surfaces, then let surface dry for four (4) minutes, and did not know that there was a 4 minute wet time when using the Clorox Wipes. RN 2 indicated not keeping the vital sign equipment or reusable bag barrier wet for 4 minutes after use with Patient #4. 6. During a home visit with Patient #3 on 04/23/2025 at 2:00 PM, RN 3 cleaned soiled equipment (oxygen sensor, thermometer, stethoscope, and manual blood pressure cuff) with Clorox Disposable Wipes. The RN failed to ensure the surface of the equipment remained wet for four (4) minutes when disinfecting. Interview with RN 3 indicated agency staff was not educated on the manufacturer’s guidelines to follow, listed on the Clorox Disposable wipes container, including the wet time for disinfection. 7. During a home visit on 04/24/2025 at 10:28 AM, Hospice Aide 1 performed catheter and peri care to Patient #7. Hospice Aide 1 repositioned patient, changed linens, adjusted pillows, applied lip moisturizer, and performed oral care without removing gloves and performing hand hygiene following catheter/peri care. Interview with Hospice Aide 1 indicated needing to change gloves and perform hand hygiene following peri care/catheter care, then continue to provide other care for patient. 8. During a home visit on 04/24/2025 at 10:41 AM, Hospice Aide 2 (trainee) performed peri care to Patient #5. Hospice Aide 2 repositioned patient and provided oral care without removing gloves or performing hand hygiene following peri care. Interview with Hospice Aide 1 (trainer) indicated needing to change gloves and perform hand hygiene before touching a clean area. 9. During an interview on 04/25/2025 at 3:30 PM, the Manager of Clinical Compliance indicated staff should follow manufacturer’s instructions on the Clorox Disposable Wipes and make sure surface wet time is four (4) minutes. She indicated staff will be reeducated on this topic.”