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936 SHARPE HOSPITAL ROAD

WESTON, WV 26452

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on clinical record review, observation, interview and document review it was revealed the facility failed to provide care in a safe setting. The facility failed to ensure patients who have Clostridium Difficile (C-diff) use private bathrooms which are cleaned after every bowel movement. This failure creates the potential of spread of C-diff to other patients, causing serious harm from contracting this infectious disease, which can be fatal.

Findings include:

Review of clinical records revealed patient #2 is a sixty-seven (67) year-old with a diagnosis of bipolar I disorder. On 12/22/21 they were diagnosed with C-diff. They were placed in a seclusion room on a unit with a bathroom next door to isolate them.

A tour was conducted of eight (8) units on 1/19/22 from approximately 1:00 p.m. to 3:30 p.m. Six (6) out of eight (8) units had single seclusion rooms with a hallway bathroom next door. On five (5) of those units the door next to the seclusion room was locked. On one (1) unit (unit E1) the bathroom next door to the seclusion room was unlocked and standing open.

An interview was conducted on 1/19/22 at approximately 8:50 a.m. with the Infection Control Director (ICD). The ICD stated they were not aware of any situation where a C-diff patient would be using a hallway shared bathroom. The ICD concurred that the bathroom of a patient with C-diff should be cleaned according to facility policy. In reference to a patient with C-diff using a shared bathroom, they stated in part, "If that were to happen, I would be jumping stiff legged." She would be angry.

An interview was conducted on 1/19/22 at approximately 12:35 p.m. with the Registered Nurse (RN) charge nurse on units N 2 and 3 (these are a combined unit). The charge nurse stated the bathroom of a patient with C-diff would be cleaned when visibly soiled. Otherwise it would be cleaned by housekeeping once daily unless the patient with C-diff refused to leave their room. In that case, the patient would be escorted from their room after three (3) days and the bathroom would be cleaned.

An interview was conducted on 1/19/22 at approximately 1:00 p.m. with the Nurse Manager (NM) on unit E1. The NM stated when the seclusion room is used as an isolation room for a patient with C-diff, the bathroom is cleaned frequently but they were not sure if it is done after every bowel movement.

An interview was conducted on 1/19/22 at approximately 1:45 p.m. with the RN charge nurse on unit G2. The charge nurse stated a patient with C-diff might be placed in the seclusion room for isolation. The bathroom next to the seclusion room is always left unlocked when a patient is in the seclusion room. This would be true even if the patient had C-diff. The bathroom would be cleaned on the same schedule as the other patient bathrooms unless it was visibly soiled.

An interview was conducted on 1/19/22 at approximately 2:30 p.m. with the Lead Nurse on unit N1. They stated a patient with C-diff would be moved to their room with the anteroom and their bathroom would be cleaned by nursing staff if visibly soiled. Otherwise housekeeping would clean it daily.

Review of a document titled, "Clostridium Difficile Management," effective date 7/2/19, revealed, "The Charge Nurse will notify Housekeeping daily of the C. Diff or suspected C Diff. diagnosis for them to use only hypochlorite disinfectant to clean this patient area. The patient's room will be cleaned twice a day and the bathroom cleaned with hypochlorite disinfectant after each loose stool."

SUPERVISION OF CONTRACT STAFF

Tag No.: A0398

Based on clinical record review, observation, interview and document review it was revealed the facility failed to ensure nursing staff followed policies and procedures. The facility failed to ensure nursing staff assigned patients with Clostridium Difficile (C-diff) to rooms with anterooms. The facility failed to ensure nursing staff were placing patients in rooms with their own private bathrooms and failed to ensure those bathrooms were cleaned after every bowel movement. These failures create the potential for harm to all patients from spread of this highly infectious and potentially fatal disease.

Findings include:

Review of clinical records revealed patient #2 is a sixty-seven (67) year-old with a diagnosis of bipolar I disorder. On 12/22/21 patient #2 was diagnosed with C-diff. They were placed in a seclusion room to isolate them.

A tour was conducted of eight (8) units on 1/19/22 from approximately 1:00 p.m. to 3:30 p.m.. Six (6) out of eight (8) units had seclusion rooms with a hallway bathroom next door. On five (5) of those units the door next to the seclusion room was locked. On one (1) unit (unit E1) the bathroom next door to the seclusion room was unlocked and standing open.

An interview was conducted on 1/19/22 at approximately 8:50 a.m. with the Infection Control Director (ICD). The ICD stated they were not aware of any situation where a C-diff patient would be using a hallway shared bathroom. They stated in part, "If that were to happen, I would be jumping stiff legged." They would be angry. The ICD stated two (2) units have rooms with anterooms. Two (2) patients who had C-diff recently, including patient #2, were not placed in an anteroom "because the house was too full." When questioned if patients who had no infections would be moved out of the anterooms to make room for a patient with C-diff, the ICD responded, "No." The State surveyor discussed the facility policy and procedure which states patients with C-diff are to be placed in an isolation room with an anteroom. The ICD concurred this did not always happen. The ICD stated, "In the perfect world ... the C-diff policy would be followed."

An interview was conducted on 1/19/22 at approximately 10:40 a.m. with the Nurse Manager (NM) on unit E2. The NM stated an uninfected patient occupying their room with an anteroom would not have their room switched with a patient with C-diff so the patient with C-diff could be in the room with the anteroom.

An interview was conducted on 1/19/22 with the Registered Nurse (RN) charge nurse on unit E1 at approximately 10:50 a.m. The charge nurse stated they have never known of a patient with C-diff being switched with n non-infectious patient so they could be in the room with an anteroom.

An interview was conducted on 1/19/22 at approximately 12:35 p.m. with the RN charge nurse on unit N 2 and 3 (these are a combined unit). They stated it would be "unlikely" a patient with C-diff would be moved into the room with an anteroom. The bathroom of a patient with C-diff would be cleaned when visibly soiled. Otherwise it would be cleaned by housekeeping once daily unless the patient with C-diff refused to leave their room. In that case, the patient would be escorted from their room after three (3) days and the bathroom would be cleaned.

A follow-up interview was conducted on 1/19/22 at approximately 1:00 p.m. with the NM on unit E1. The NM stated when the seclusion room is used as an isolation room for a patient with C-diff, the bathroom is cleaned frequently but they were not sure if it is done after every bowel movement.

An interview was conducted on 1/19/22 at approximately 1:45 p.m. with the RN charge nurse of unit G2. The charge nurse stated a patient with C-diff might be placed in the seclusion room for isolation. The bathroom next to the seclusion room is always left unlocked when a patient is in the seclusion room. This would be true even if the patient had C-diff. This bathroom would be cleaned on the same schedule as the other patient bathrooms unless it was visibly soiled.

An interview was conducted on 1/19/22 at approximately 2:30 p.m. with the Lead Nurse on unit N1. They stated a patient with C-diff would be moved to the room with the anteroom and their bathroom would be cleaned by nursing staff if visibly soiled. Otherwise housekeeping would clean it daily.

Review of a document titled, "Clostridium Difficile Management," effective date 7/2/19, revealed, "Any patient with a positive C. Diff. diagnosis will be placed on Contact Precautions in an Isolation Room with an anteroom to enable staff members to perform hand hygiene when entering and exiting the room ...The Charge Nurse will notify Housekeeping daily of the C. Diff or suspected C Diff. diagnosis for them to use only hypochlorite disinfectant to clean this patient area. The patient's room will be cleaned twice a day and the bathroom cleaned with hypochlorite disinfectant after each loose stool."

IC PROFESSIONAL ADHERENCE TO POLICIES

Tag No.: A0776

Based on interview it was revealed the facility failed to ensure the Infection Control Director (ICD) was monitoring the care of patients with Clostridium Difficile (C-diff). This failure creates the potential of harm to all patients from the spread of this potentially fatal disease.

Findings include:

Review of clinical records revealed patient #2 is a sixty-seven (67) year-old with a diagnosis of bipolar I disorder. On 12/22/21 patient #2 was diagnosed with C-diff. They were placed in a seclusion room with a bathroom next door to isolate them.

A tour was conducted of eight (8) units on 1/19/22 from approximately 1:00 p.m. to 3:30 p.m.. Six (6) out of eight (8) units had single seclusion rooms with a hallway bathroom next door. On five (5) of those units the door next to the seclusion room was locked. On one (1) unit (unit E1) the seclusion room with a bathroom next door was unlocked and standing open.

An interview was conducted on 1/19/22 at approximately 8:50 a.m. with the Infection Control Director (ICD). The ICD stated they were not aware of any situation where a C-diff patient would be using a hallway shared bathroom. They concurred this situation should never occur. The ICD stated in part, "If that were to happen, I would be jumping stiff legged." They would be angry. Two (2) units have rooms with anterooms. Two (2) patients who had C-diff recently (including patient #2) were not placed in an anteroom "because the house was too full." When questioned if patients who had no infections that could be spread would be moved out of the anterooms to make room for a patient with C-diff, the ICD stated, "No." The State surveyor discussed the facility policy and procedure which states patients with C-diff are to be placed in an isolation room with an anteroom. The ICD did not concur facility policy which requires a patient with C-diff to be placed in a room with an anteroom should be followed. The ICD stated, "In the perfect world ... the C-diff policy would be followed."

An interview was conducted on 1/19/22 at approximately 10:40 a.m. with the Nurse Manager (NM) on unit E2. The NM stated an uninfected patient occupying their room with an anteroom would not have their room switched with a patient with C-diff so the patient with C-diff could be in the room with the anteroom.

An interview was conducted on 1/19/22 with the Registered Nurse (RN) charge nurse on unit E1 at approximately 10:50 a.m. The charge nurse stated they have never known of a patient with C-diff being switched with a non-infectious patient so they could be in the room with the anteroom.

An interview was conducted on 1/19/22 at approximately 12:35 p.m. with the Registered Nurse charge nurse on unit N2 and 3 (these are a combined unit). The charge nurse stated it would be "unlikely" a patient with C-diff would be moved into the room with an anteroom. The bathroom of a patient with C-diff would be cleaned when visibly soiled. Otherwise it would be cleaned by housekeeping once daily unless the patient with C-diff refused to leave their room. In that case, the patient would be escorted from their room after three (3) days and the bathroom would be cleaned.

A follow-up interview was conducted 1/19/22 at approximately 1:00 p.m. with the NM on unit E1. They stated when the seclusion room is used as an isolation room for a patient with C-diff, the bathroom is cleaned frequently but they were not sure if it is done after every bowel movement.

An interview was conducted on 1/19/22 at approximately 1:45 p.m. with the RN charge nurse on unit G2. The charge nurse stated a patient with C-diff might be placed in the seclusion room for isolation. The bathroom next to the seclusion room is always left unlocked when a patient is in the seclusion room. This would be true even if the patient had C-diff.

An interview was conducted on 1/19/22 at approximately 2:30 p.m. with the Lead Nurse on unit N1. They stated a patient with C-diff would be moved to their room with the anteroom and their bathroom would be cleaned by nursing staff if visibly soiled. Otherwise housekeeping would clean it daily.

Review of a document titled, "Clostridium Difficile Management," effective date 7/2/19, revealed, "Any patient with a positive C. Diff. diagnosis will be placed on Contact Precautions in an Isolation Room with an anteroom to enable staff members to perform hand hygiene when entering and exiting the room ...The Charge Nurse will notify Housekeeping daily of the C. Diff or suspected C Diff. diagnosis for them to use only hypochlorite disinfectant to clean this patient area. The patient's room will be cleaned twice a day and the bathroom cleaned with hypochlorite disinfectant after each loose stool."