Eventide Hospice

“Based on record review, policy and procedure review, the observation of the provision of cares, and staff interview, 4 of 4 staff (Staff D, E, F, and G) observed during the provision of cares to 4 of 4 patients (Patient 1, 2, 3, and 4) failed to perform appropriate hand hygiene, glove use, cleaning of multiple-patient equipment, and/or use of clean bag technique according to the agency policies and procedures to prevent the potential of cross contamination and home care acquired infections. The total sample size was 19. The census was 136. A. Review of the agency policy and procedure titled, Hand Hygiene, Policy No. 6-006.1, reviewed 11/24, revealed staff are to sanitize hands with soap and water or an alcohol-based hand rub, before having direct contact with patients, after contact with a patient’s intact skin, when moving from contaminated body site to clean body site during patient care, after contact with inanimate objects in the immediate vicinity of the patient, and after removing gloves. B. Review of the agency policy and procedure titled, Bag Technique, Policy No. 6-013.1 revised 11/18, revealed: 1.Hand washing supplies are to be removed from the supply bag and left at the sink at the start of the visit. 2.Hand washing is to be completed prior to opening the supply bag, supplies are to be removed from the supply bag after hand washing, when the visit is completed, reusable equipment was to be cleaned using alcohol, soap and water, or other appropriate solution, hands washed, and supplies returned to the bag. 3.Laptop, tablet, or other documentation device are to be cleaned using alcohol, or sanitizing wipe prior to returning equipment to the supply bag at the end of the visit. 4.The policy does not provide instruction to staff for the sanitization of equipment such as cell phones that are not returned to a supply bag. C. Review of clinical records revealed: 1.Patient 1’s Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update, dated 11/5/24, included orders for Social Worker (SW) 2 times per month and 3 as needed visits to assist patient/family with coping, companionship, and support. 2.Patient 2’s Hospice Recertification Plan of Care Update for the certification period of 10/7/24 thru 12/5/24, included orders for Home Health Aide (HHA) 2 times a week for 8 weeks, then 1 time a week for 1 week, for assistance with personal cares, hygiene, and activities of daily living (ADLs). 3.Patient 3’s Hospice Certification and Plan of Care for the certification period of 9/25/24 thru 12/23/24, included orders Skilled Nurse (SN) 2 times per week for 13 weeks, then 1 time a week for 1 week, and 3 as needed visits for patient evaluations and assessments. 4.Patient 4’s Hospice Certification and Plan of Care for the certification period of 10/2/24 through 12/30/24, included orders for SN 2 times per week for 13 weeks, then 1 time a week for 1 week, and 3 as needed visits for patient evaluations and assessments. D. The observation of the provision of SW services on 11/18/24 at 10:25 AM by Staff-D (SW) to Patient 1, revealed the SW failed to sanitize the cell phone used during the visit to assist the patient with speaking to a family member and prior to placing the cell phone in [gender] pocket after completing the visit with the patient. E. The observation of the provision of HHA services on 11/18/24 at 12:28 PM by Staff-E to Patient 2, revealed the HHA failed to have hand sanitizer available for use during the bed bath process until provided by the SN (Staff- GG) and failed to perform hand hygiene once hand sanitizer available for use: 1.After cleansing the patient’s body (dirty task) and prior to applying clean gloves to apply lotion (clean task) on the patient on three occasions 2.After cleansing the patient’s back and removing gloves and prior to leaving the room to obtain clean bed supplies. 3.After changing pillowcase soiled with wound drainage and prior to applying a clean pillowcase. F. The observation of the provision of SN services on 11/21/24 at 10:20 AM by Staff-F to Patient 3, revealed the SN failed to sanitize hands after completing assessment and storing used equipment in dirty supply bag and prior to enter clean supply bag to retrieve a devotional book, and failed to sanitize hands prior to returning the devotional book back to the clean supply bag. G. The observation of the provision of SN services on 11/21/24 at 1:20 PM by Staff-G to Patient 4, revealed the SN failed to sanitize hands after completing patient assessment and prior to entering bag to remove sanitizer wipes. H. During an interview on 11/21/24 at 3:30 PM, the Administrator and Director of Clinical Services (DCS)- B & DCS-C confirmed staff D, E, F, G failed to perform appropriate hand hygiene, glove use, cleaning of multiple-patient equipment, and/or use of clean bag technique during the provision of cares, according to the agency policies and procedures, to prevent the potential of cross contamination and home care acquired infections.”