HospitalInspections.org

Based on record review and interview the facility failed to ensure nursing staff assessed and changed intravenous (IV) catheter access dressing per policy and procedure for 1 (#1) of 2 patients reviewed for intravenous therapy out of a total of 10 sampled patients resulting in the potential for less than optimal outcomes. Findings include:

An interview and record review for patient #1 were conducted with Nurse Manager Staff Q on 7/11/18 at 1410. A review of the patient's medical record revealed the patient had a Peripherally Inserted Central Catheter (PICC) placed on 6/4/18. Staff Q said it was their policy to change the dressing for PICC lines with 24 hours of placement. However, there was no evidence in the medical record that documented the patient's PICC line dressing had been changed until 6/10/18 (6 days after insertion) at 1300. Additionally, Staff Q said after the first dressing change, PICC lines were changed every 7 days thereafter. However, there was no evidence in the medical record that documented the patient's PICC had been changed after 6/10/18 until 06/19/18 at 1000 (9 days after the last dressing change).

At that time Staff Q said it was usually PICC team's responsibility to monitor and change patient's dressing per the facility's policy.

On 7/11/18 at 1430, a review of the facility's "Peripherally Inserted Central Catheter (PICC) and Midline Catheter Care)" policy, dated 4/2015 documented:
Dressing Changes: "...2. The Unit RN will change the transparent dressing, Statlock, PICC cap, and remove gauze 24 hours after insertion, unless the dressing is soiled, damp, or loose then the dressing can be changed sooner than 24 hours...4. The subsequent dressing changes will be every 7 days and prn (as needed) if the dressing becomes wet, soiled, or loose. The positive pressure caps and StatLock must be changed every 7 days, and can be done in conjunction with the dressing change, with particular given to cleansing the hub...".

Based on observation, interview and record review, the facility failed to maintain an ongoing infection control program designed to prevent, control and investigate infections and failed to ensure a sanitary environment resulting in the potential for transmission of infectious agents for all 110 patients served by the facility. See specific tags:

See specific A tag:

A-0749 Failure to monitor and consistently conduct active surveillance activities for staff illnesses, monitor and maintain PPE compliance for Isolation Precautions, ensure blood glucose test supplies were labeled and dated when opened, and ensure expired foods were discarded.

Based on observation, interview and record review, the facility failed to 1) ensure staff maintained isolation precautions for 1 (#3) of 2 patients reviewed for infection control out of 10 sampled patients, 2) the facility failed to ensure staff labeled and dated blood glucose test strips and test solutions when opened, 3) the facility failed to ensure staff discarded expired refrigerated yogurt in 1 of 2 nutritional refrigerators, 4) the facility failed to conduct surveillance activities for personal protective equipment (PPE) compliance for patient's on isolation precautions and 5) the facility failed to monitor employee illness, resulting in the potential for the spread of infections for all 110 patients served by the facility Findings include:

On 7/10/18 at approximately 1000 a tour of the 2 South Nursing Unit was conducted while accompanied by House Supervisor Staff D and Nurse Manager Staff E and the following was observed:
1. 3 vials of opened undated blood glucose test strips.
2. 1 vial of opened undated level 1 blood glucose test solution.
3. 1 vial of opened undated level 3 blood glucose test solution.
4. 2 containers of expired yogurt dated 6/20/18 were observed in the nutritional room patient storage refrigerator. Staff D was observed as she discarded the expired yogurt at that time.

When queried on 7/10/18 at 1015 Staff E said, we don't keep the test strips or the test solutions on the floor. She said I will have to call down to lab to have them replaced. Staff E said they (test strips and test solutions) should be labeled when opened. She said I'm not sure how long they are good for.

On 7/10/18 at approximately 1115 Nurse H was observed standing at patient #3's doorway. A sign was a posted for "contact precautions". A hanging shelf was observed with PPE. Staff H said gloves and gowns were required for all staff members. Staff H explained she was going to administer the patient his medications. She said she could also do his wound care after giving him his medications. At that time the surveyor observed a visitor and a staff member in the patient's room. The visitor was not wearing PPE nor was the staff member. When queried Staff H said the visitor (patient's) daughter had been informed not to touch the patient without gloves. At that time the visitor for patient #3 was observed rubbing the patient's chest. Staff H was overheard as she instructed the patient's daughter to don gloves if she was going to touch him. The patient's daughter was overheard to tell the nurse, "The doctor says he no longer has an infection."

On 7/10/18 at 1130 a review of the patient #3's medical record was conducted with Staff E and revealed patient #3 was on Contact Isolation precautions for ESBL (Extended spectrum beta-lactamases, enzymes that can make antibiotics not work for bacterial infections). There were no orders by the medical doctor to discontinue Contact Isolation precautions.

On 7/10/18 at 1530, a review of the facility's "Outside Food for Hospitalized Patients" policy dated revised 10/2016 documented:
Procedure: "...4...f. Food is discarded two (2) days after food is dated."

On 7/10/18 at 1155 a tour of the Medical Surgical unit was conducted while accompanied by Staff D and Staff E and the following was observed:
1. 1 vial of opened undated blood glucose test strips.
2. 1 vial of opened undated level 1 blood glucose test solution.
3. 1 vial of opened undated level 3 blood glucose test solution.
At that time Staff E was overheard as she said I will have to call lab to get those things
replaced.

On 7/10/18 at 1530, a review of the facility's policy titled "Blood Glucose Testing at Bedside", dated 10/2017, documented:
"...typically each bottle of control solution is stable for 90 days after opening or until expiration dated printed on the label, which ever comes first."
A review of the Manufacturer's undated recommendation for blood glucose test strips documented: "Always date blood glucose test strips vials when opened".

On 7/11/18 at 0955 a review of the Infection Control Program was conducted with Registered Nurse Staff K and Medical Graduate Staff L. A review of surveillance logs dated 1/2018 through 6/2018 were reviewed. When queried at 1015 Staff L said she monitored all patients in Isolation. Patient #3 was on the list for "Contact Precautions". Staff J was queried regarding monitoring Staff for illness (call-ins) and monitoring Staff compliance with PPE. Staff J said she did not monitor staff illnesses. Staff J said she did random audits for staff compliance with PPE. However, Staff J did not provide the surveyor any evidence that documented PPE surveillance compliance was monitored, reviewed and/or analyzed for patterns or trends with staff illnesses.

On 7/11/18 at 1500 Staff J said she reviewed the chart for patient #3. She explained there was no orders to discontinue Contact Isolation Precautions. She said, technically the patient was still on precautions. She said the patient would have to have a negative culture for precautions to be discontinued. She said he did not. She said the patient also expired last night.

A review of the facility's "Infection Prevention 2017 Program Assessment and 2018 Annual Plan" revealed the facility had a goal for 2018 that included monitoring staff compliance with PPE as related to decreasing the risk for exposures during splashing procedures. However, there was no evidence to date that documented surveillance for staff compliance with PPE was being performed prior to the survey exit.

Additionally, the 2018 Surveillance Plan revealed the Infection Control Preventist (ICP) would conduct surveillance via direct observation during infection control rounds on the facility's nursing units. The ICP responsibilities listed on the 2018 Infection Control Plan included identifying and analyzing any breaks in technique with isolation cases. However, there was no evidence that documented the facility had monitored staff compliance with PPE for patient that were on Isolation Precautions.

A review of the "Employee Handbook", dated revision on 12/2016 documented:
The attendance procedure is as follows:
"...11. Returning to Work: If an employee is absent due to a communicable disease or disorder, or ill for three or more work days, he/she may be requested to present a written release-to-return-to work from his/her physician to his/her department head/director/manager/supervisor before he/she will be permitted to return to duty. Limited releases will be accepted only if reasonable accommodation is possible."