HospitalInspections.org

Based on observations, staff interviews, and review of the facility's policy & procedures for Isolation Precautions: Protective Environment Precautions Procedure-Florida, the facility failed: 1) to don required Personal Protective Equipment (PPE) while performing patient care for 3 of 8 patients (#5, #6, #8); 2) Failed to perform hand hygiene for 1 of 8 patients (#6). Failure to observe infection control practices may result in patients developing nosocomial infections.


The findings include:


On 01/16/20 at 9:20 AM, a tour was conducted of the Intensive Care Unit (ICU) located on the 4th Floor.


1A. On 01/16/20 at 2:30 PM, observed two lab technicians in Isolation Room 406. Patient #6 was admitted on 12/28/19 to rule out stroke. Observed one lab technician in the room drawing blood, who was wearing a gown and gloves as required, according to the signage on the door. A 2nd lab technician was standing at the threshold of the door, not wearing a gown or gloves. First lab technician that was wearing the PPE handed the blood tubes with the specimen over to the 2nd lab technician not wearing any of the required PPE. The 2nd lab technician that was not wearing the required PPE then proceeded to place the specimens on a cart with other specimens.


On 01/16/20 at 2:31 PM, interview conducted with the Nurse Manager who was present at time of observation. The Nurse Manager stated that she observed both lab technicians and they should have been wearing the required PPE. Nurse Manager instructed the lab technician who was not wearing any PPE to don the required PPE.


Record review of the Electronic Medical Record (EMR) revealed Patient #6 was admitted on 12/28/19 to rule out stroke. Patient #6 had a swab of nares done on 12/30/19 for culture. The culture result was positive for Methicillin-resistant Staphylococcus Aureus (MRSA) in nares. Patient #6 was placed on Contact Isolation per MD order dated 12/30/19. Record review also revealed a bronchoalveolar lavage collected on 01/21/20, resulting in a positive for Klebsiella PNA. Record review showed another bronchoalveolar lavage collected on 02/2/20 resulting in a positive for gram negative bacillus.


The Centers for Disease Control (CDC) states, "In healthcare facilities, such as a hospital or nursing home, MRSA can cause severe problems including: Bloodstream infections, pneumonia (PNA), surgical site infections, sepsis, and death. MRSA is usually spread by direct contact with an infected wound or from contaminated hands, usually those of healthcare providers." "Healthcare Settings." Https://Www.Cdc.Gov/Mrsa/Healthcare/Index.Html, 2019, www.cdc.gov/mrsa/healthcare/index.html


1B. On 01/16/20 at 9:45 AM, observed Employee C, RN, in Isolation Room 404 wearing a face mask but no gloves. Patient #5 was admitted on 11/18/19 for post-transplant respiratory infections. Per MD order dated 12/18/19, Patient #5 was placed on droplet isolation. On 11/24/19 bronchial wash culture was positive for yeast. There was signage on the door to indicate patient was on droplet isolation. Review of facility's policy and procedures on Isolation Precautions: Droplet Precaution Procedure - Florida, mask and gloves are mandatory upon entering the room and must be removed upon exiting the room.


On 01/16/20 at 9:48 AM, interview was conducted with Employee C, RN. She stated that the patient was immunocompromised and did not have an infection. When asked why she was not wearing gloves, she stated that she forgot. Review of the physician's order in the medical record revealed a droplet isolation order dated 12/18/19.


1C. On 01/16/20 at 2:40 PM, observed Employee F, RN, not wearing gloves in isolation Room 432. Patient #8 was post-lung transplant on 09/27/16 and admitted on 01/09/20 for an Operating Room procedure of the prostate. Patient was on Contact Isolation per MD order dated 01/11/20. Patient had a positive blood culture result on 01/11/20, which was a positive showing gram-negative bacilli. A urine culture collected on 01/09/20 resulted positive for Klebsiella.


On 01/16/20 at 2:45PM, interview conducted with Employee F, RN, who stated that he was not wearing the proper required PPE because he was not going to be in the patient's room long. He stated that the patient was a transplant patient, which was why he was on isolation. Review of the physician's orders in the medical record revealed Patient #8 was on Contact Isolation for gram negative bacilli.


2. On 01/16/20 at 9:30 AM, observed Employee B, Patient Care Technician (PCT), who did not wash hands nor use hand sanitizer upon entering Room 406, (#6). Review of the facility's policy on Isolation Precautions: Protective Environment Precautions Procedure - Florida, stated that all healthcare workers were to perform hand hygiene upon room entry and exit.


On 01/16/20 at 9:32 AM, an interview with Employee B, PCT, confirmed that she did not wash her hands nor use hand sanitizer before entering the room. She stated that the patient was on isolation for Methicillin-resistant Staphylococcus Aureus (MRSA.) Record review of the physician's orders revealed that Patient #6 was positive for MRSA in nares and was placed on contact isolation per MD order dated 12/30/19. Patient #6 was also positive for Klebsiella PNA on 01/21/20, and positive for gram negative bacillus on 02/02/20.

Review of the facility policy Isolation Precautions: Protective Environment Precautions Procedure - Florida stated that all healthcare workers were to perform hand hygiene upon room entry and exit.


Interview conducted with the Interim Director of Infection Control on 02/03/20 at 2:00 PM, who stated that surveillance of PPE usage was conducted weekly by an infection control nurse. When asked for documentation from the surveillance, she stated that there was not a form or checklist that was utilized. She also stated that she could not provide any documentation that surveillance had been conducted.