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Based on interview, record review and the "Surveillance, Prevention and Control of Infections Plan" the Infection Control Program failed to investigate an (fungal) infection in 1 (SP#1) out of 4 sample patients (SP).


Findings include:

Review of SP#1 History and Physical dated 08/04/2018 at 12:01AM revealed Physical Exam: Skin - Skin is warm and dry. No rash noted. Patient is not diaphoretic. No erythema. No pallor.


Review of SP#1 Nursing Integumentary Assessment dated 08/04/2018 at 10:15 AM revealed Skin color pale; skin Cool, dry; skin integrity with abrasion; location: bilateral upper and lower extremities.

Review of SP#1 Nursing Integumentary Assessment dated 10/05/2018 at 8:10 AM revealed skin condition/temperature is warm, dry; skin integrity with abrasion; location: Left elbow.

Review of SP#1 Nursing Integumentary Assessment dated 10/15/2018 at 8:00 PM revealed skin condition/temperature is warm, dry; skin integrity with abrasion, and bruising; location: left elbow fungal infection

Review of SP#1 Susceptibility Preliminary Report revealed date received: 10/17/2018; Source: wound drainage from left elbow. Results of Antifungal Susceptibility Testing 10/23/2018.

Review of SP#1 medication report revealed patient received antifungal medications from 08/03/2018 - 12/05/2018 infection.


Review of SP#1 Consult from the Infectious Disease physician dated 10/24/2018 at 11:51 PM revealed consult is to give recommendations regarding Rhizopus wound infection. Respiratory: Positive for cough, Skin: Dry. There is ecchymosis. There is shallow skin ulcer in Left elbow, no erythema or no discharge. The Microbiology - 10/0618: Microbiology: Wound culture: Rhizopus species, and 10/13/2018: Chest CAT Scan: Large cavitary lesion, and 10/20/2018: Wound culture (Lip): Rhizopus species. Assessment and Plan: Invasive fungal infection Rhizopus isolated from left elbow wound infection. Ground glass opacity and cavitary lesion in lung, likely due to Rhizopus. Patient has disseminated Rhizopus infection with suspected lung involvement and biopsy/culture proven Rhizopus on left elbow ulcer and lip lesion.

Review of SP#1 Inpatient Wound Care Nursing Consult Note: Initial Evaluation dated 10/24/2018 at 12:56 PM revealed Wound Etiology: Fungal; General Appearance: Wound developed after traumatic small cut. Wound Culture reports Rhizopus species.

Review of SP#1 Dermatology Consult dated 10/26/2018 at 8:15 PM revealed that patient found to have rhizopus from left elbow wound and lip culture with suspected pulmonary involvement.

Review of SP#1 Cardiothoracic Surgery Consult dated 11/15/2018 at 7:51 PM revealed that patient hospital course has been complicated by a rhizopus infection of the elbow and a CAT scan chest showing bilateral cavitary lesions in the right upper lobe and left lower lobe.

Review of sample patient (SP) #1 Expiration Summary dated 12/06/2018 at 4:14PM revealed Admit Date: 08/03/2018 and Expiration Date: 12/06/2018.
Expiration Diagnosis included Infection of skin and subcutaneous tissue due to fungus, Fungal pneumonia and Infection due to rhizopus. Later patient was found to have an infected wound in the elbow, wound culture grew Rhizopus and patient was treated. Patient was found to have 2 cavitary lesions in right upper lobe and left lower lobe. Patient underwent bronchoscopy and was positive for Rhizopus on October 16, 2018. On November 25, 2018, patient developed altered mental status, lethargy and acute kidney injury. Patient was found to be hypoxic and was transferred to the Medical Intensive Care Unit (MICU) for further management.

Review of "Surveillance, Prevention and Control of Infections Plan", dated January 2018 revealed the infection prevention and control plan includes but is not limited to define activities to minimize, reduce or eliminate the risks of infection based upon the needs of the population.

Interview with Infection Control Practitioner on 03/06/2019 at 12:39 PM revealed that there was no Analysis for SP#1. States the Infection Control Department does not follow fungal infections. If there is a positive culture, will follow the Center for Disease Control Skin Infection guidelines.

Interview with Infection Control Physician on 03/06/2019 at 2:42 PM via telephone revealed that a Rhizopus infection is treated with antifungals and if needed debridement or surgery because the infection can affect other parts of the body. No isolation is required.

Interview with Infection Control Practitioner on 03/07/2019 at 9:35 AM revealed the department receives notification of all positive cultures but if the culture is not one that is tracked, the infection will be followed by infectious disease unless there is an outbreak. When there is an outbreak, an investigation is done.

Interview with the Director of Infection Control and the Infection Control Practitioner on 03/07/2019 at 12:48 PM revealed that infections are considered hospital acquired if they meet criteria 3 days after admission. Stated SP#1 wound culture that resulted greater than three days after admission was positive for a Rhizopus infection and was not identified as a hospital acquired infection.

Interview with Senior Risk Manager on 03/07/2019 at 9:45AM revealed that there are no incident reports for hospital acquired infections for this facility for the time period of 08/2018 - present. There was no incident report related to skin issues for SP#1.
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Interview with Senior Risk Manager on 03/07/2019 at 10:36AM revealed that an incident report is not completed if a new skin issue is found upon reassessment, unless the skin issue is a pressure ulcer. An incident report would be completed if a patient had an injury that resulted in a skin issue.