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Based on interview and record review, the facility failed to nursing adhered to facility discharge policy and professional nursing standards of practice:

*Two (2) patients were discharged without nursing communicating / providing specific infection prevention discharge information (Patient ID # 1, 8 ).

This deficient practice posed a significant risk for the spread of MDRO and COVID infections to other persons exposed to these patients post-discharge.

Findings included:

TX00492261

Review of the above listed complaint intake showed allegations that Patient ID # 1 was transferred to a nursing home without the hospital communicating the presence of multiple MDRO infections. Allegations included this oversight placed Patient # 1's nursing home roommate, other immunocompromised patients, and staff at risk for at risk for contracting MDRO infections.

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Review of facility policy titled "Discharge Planning," revised date 09/19/2023, showed : Responsible of Nursing included " completes all appropriate paperwork for discharge and/or transfer to post-acute care facility."

Review of Texas Administrative Code (TAC) Title 22: Examining Boards; Part 11: Texas Board of Nursing; Chapter 217- Rule 11: " Standards of Nursing Practice" showed: ...D. Accurately and completely report and document the client's status...".

Patient # 1:

Review of the medical record of Patient # 1 with Staff ID-E, RN/PI Specialist showed he was a 69 year old male admitted on 1/13/2024 .

Record review of facility policy "Infection Prevention & Control Program Plan", date reviewed 1/17/2024 : Table 2: 'Quick Guide for Inpatient Transmission Based Precautions ( Infection/Isolation/ duration) showed 3 columns tabled: 'Suspected / confirmed infection;' 'Isolation (precaution type)'; Discontinue Isolation."

Table 2 was the reference document used when reviewing Patient # 1's medical record / lab results.

On 3/28/2024 the clinical record of Patient # 1 was reviewed with Staff-L, Infection Preventionist. She explained that specific isolation precautions and duration of precautions depended on the bacteria / isolate and date identified. Facility used Table 2 (of facility Infection Control Plan) as a reference to determine precautions and duration of isolation.
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Review of Patient ID # 1's lab specimen culture results showed:

- 1/14/2024: [ sputum culture results]: Acinetobacter calcoaceticus- Acinetobacter- baumannii complex ." This organism is multi-drug resistant."Application of criteria in Table 2 for discontinuation of isolation showed "CONTACT" isolation for this gram negative organisms should be continued.- 1/15/2024 [ right nares culture results]: Methicillin-resistent staphlocossus-aureus PCR : detected. Table 2 showed CONTACT isolation should be continued unless one negative culture or wound is healed.

- 1/27/2024 [ sacral wound culture results]: 3 organisms detected: Klebsiella pneumoniae; Escherichia coli; Proteus mirabilist. All 3 organisms are multi-drug resistant."

- 2/1/2024 [ thigh wound culture results] : 2 organisms: Klebsiella pneumoniae ( multi-drug resistant) ; Enterococcus raffinosus (Vancomycin resistant)

Staff-L , Infection Preventionist, said that based on the MDRO culture results and dates, Patient #1 should have remained on CONTACT precautions post-discharge.
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During interviews conducted on 3/28/2024 on Brazos Tower-6 with three (3) RN staff ID# G, H, I : they described the process for transferring a patient from their unit to a nursing home. Their descriptions were consistent with facility policies. All three (3) RNs said if a patient was transferred with active MDRO infections and required CONTACT precautions post-transfer: this would be included in the verbal report to the nursing home. They all 3 said Contact Precautions and MDRO would be specifically documented.

Additional review of Patient #1's medical record with Staff -E, showed a Nursing Note dated 2/24/2024 at 9:54 AM read: "report called to Mariam RN Supervisor. Complete report done including past medical history, ICU stay..." This documentation did not include mention of the active MDRO infections and the need to for CONTACT Precautions to be continued at the nursing home. This was verified by Staff-E, PI Specialist.


Patient # 8:

Record review on 3/28/2024 of Patient #8's medical record with Staff -E, PI Specialist, showed this patient was admitted on 2/19/2024. Review of his laboratory test results showed he tested positive for COVID on 2/22/2024. He was discharged home on 2/23/2024. Staff-E was unable to locate documentation that Patient # 8 had been provided education or information related to COVID and precautions to follow post-discharge. Staff-E said she would expect COVID education to be included in the "After Visit Summary" and it was not.