Water outlet flushing records were not quarterly, 6 monthly and consistently completed in the Renal Dialysis annual actions. Domestic Supervisors On going Weekly Unit. Water flushing records should be Check water flushing and Checklist checked regularly by supervisory staff to maintain records as per ensure that hospital policy in this regard is policy. implemented. 8 Transmission- Based Precautions 8.1 Transmission-based precautions were Increase awareness on IPC Link Nurse Group On going Environmental not fully implemented at the time of this Guideline for Correct Use of CN/MM’s Hygiene inspection on Medical 3 Ward. Some Personal Protective Audits staff did not put on plastic aprons Equipment during Clinical reviewed by before entering isolation rooms to Work Practices. Available on HSAG remove meal trays which is not in line Q Pulse. with hospital isolation policy. A door to IPC Link Liaison nurse on Staff Nurses/Midwives, an occupied isolation room in the Renal each ward/department HCA’s Dialysis Unit was ajar at the time of Adherence to IPC Policies Domestic Services inspection. Review communication Catering Staff. process in relation to Support Staff isolation cleaning All LUH staff requirements Isolation room doors must be closed as per patient risk assessment Hand Hygiene 9 Project Manager HSE Estates Hand Hygiene Sinks 9.1 Clinical hand wash sinks in On going As per Clinical hand wash sinks in the Renal Facilities Manager, higher risk clinical areas will refurbishment Dialysis Unit were not compliant with Maintenance Manager, be prioritized for plans. Health Building Note (HBN) 00-10 Part GM replacement as per HIQA Audits C: Sanitary Assemblies standards. There IPCT refurbishment plan -RDU
Water outlet flushing records were not consistently completed in the Renal Dialysis Unit. Water flushing records should be checked regularly by supervisory staff to ensure that hospital policy in this regard is implemented. quarterly, 6 monthly and annual actions. Check water flushing and maintain records as per policy. Domestic Supervisors On going Weekly Checklist 8 Transmission- Based Precautions 8.1 Transmission-based precautions were not fully implemented at the time of this inspection on Medical 3 Ward. Some staff did not put on plastic aprons before entering isolation rooms to remove meal trays which is not in line with hospital isolation policy. A door to an occupied isolation room in the Renal Dialysis Unit was ajar at the time of inspection. Increase awareness on Guideline for Correct Use of Personal Protective Equipment during Clinical Work Practices. Available on Q Pulse. IPC Link Liaison nurse on each ward/department Adherence to IPC Policies Review communication process in relation to isolation cleaning requirements Isolation room doors must be closed as per patient risk assessment IPC Link Nurse Group CN/MM’s Staff Nurses/Midwives, HCA’s Domestic Services Catering Staff. Support Staff All LUH staff On going Environmental Hygiene Audits reviewed by HSAG 9 Hand Hygiene 9.1 Hand Hygiene Sinks Clinical hand wash sinks in the Renal Dialysis Unit were not compliant with Health Building Note (HBN) 00-10 Part C: Sanitary Assemblies standards. There Clinical hand wash sinks in higher risk clinical areas will be prioritized for replacement as per refurbishment plan -RDU Project Manager HSE Estates Facilities Manager, Maintenance Manager, GM IPCT On going As per refurbishment plans. HIQA Audits