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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation, §482.42 Condition of Participation: Infection Control was out of compliance.


A-0749- Standard: The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. Based on observations, interviews, and document review the facility failed to maintain appropriate infection control processes in cleaning and disinfection of glucometers, and in following infection control standards of the use and techniques of isolation precautions by clinical staff and visitors throughout the facility. Additionally, the facility failed to ensure proper infection control processes were used with storage of patient supplies used for direct patient care. These findings were observed in 7 of 7 observations conducted at the facility.

Based on observations, interviews, and document review the facility failed to maintain appropriate infection control processes in cleaning and disinfection of glucometers, and in following infection control standards of the use and techniques of isolation precautions by clinical staff and visitors throughout the facility. Additionally, the facility failed to ensure proper infection control processes were used with storage of patient supplies used for direct patient care. These findings were observed in 7 of 7 observations conducted at the facility.

Findings include:

Facility policies:

The policy, Infection Prevention and Control Plan, read the plan was designed to establish a hospital-wide, interdisciplinary program with guidelines and methods to identify, control and prevent hospital associated infections. The program was intended to address the needs of patients, healthcare workers, visitors, volunteers, students, and physicians. The policy identified a goal to provide initial and ongoing educational programs for all employees in the areas of infection prevention with a focus on the use of techniques for reducing the risk of infection to employees and patients.

The policy, Isolation Precautions Policy, read transmission-based precautions were implemented for patients with documented or suspected highly transmissible pathogens where additional precautions were needed to interrupt disease transmission. Three types of transmission based isolation precautions including airborne, droplet, and contact were to be used in addition to standard precautions. Contact precautions were designed to reduce the risk of transmission via direct contact involving skin-to-skin contact and physical transfer of microorganisms by direct or indirect contact. The policy described the use of gloves and hand washing, use of clean, non-sterile gowns, transporting the patient and dedicated patient-care equipment. Visitors should be limited as much as possible and when possible, the patient should have dedicated equipment not shared with other patients. If common use of equipment was unavoidable, the equipment would be cleaned and disinfected before use on another patient. The policy detailed empiric precautions were implemented with certain clinical conditions or symptoms and could be instituted by the nurse after patient evaluation.

The policy, Blood Glucose Point of Care Testing, read cleaning of the glucometer (machine which tests the level of sugar in a patient's blood) shall be performed in between patient use and daily with disinfectant wipes.

Reference:

The CDC (Centers for Disease Control and Prevention) document, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, provided from the facility, provided detailed information regarding precautions for infection control. This outlined the inclusion of patients, family members and visitors in preventing transmission of infections in healthcare settings. The need for healthcare personnel to explain the details of the precautions and directions for use of personal protective equipment (PPE). The document outlined the use of patient care equipment and instruments/devices when used for patients on isolation precautions. Computers, considered noncritical equipment, must be thoroughly cleaned and disinfected before use on another patient.

The Infection Prevention training document, provided by the facility, identified procedures for patients on isolation precautions. It read, dedicated equipment, correct application and removal of PPE, hand hygiene and education and enforcement to visitors, family and other employees were essential elements for patients on isolation. Staff members were role models for good infection prevention practices. The training identified the three types of isolation precautions, airborne, droplet, and contact as well as common diagnoses associated with each and the proper PPE necessary. In reference to contact precautions, the training identified some indications for use, including Methicillin Resistant Staphylococcus Aureus (MRSA), Vancomycin Resistant Enterococcus (VRE) and Respiratory Syncytial Virus (RSV).

1. The facility failed to ensure disinfection of multi-patient equipment between patients.

a. On 3/25/19 at 4:43 p.m., an observation was conducted with Patient Care Technician (PCT) #5. PCT #5 was observed obtaining blood glucose levels (BGLs) on two different patients within the facility. PCT #5 gathered the supplies necessary for the procedure including, test strips, lancet (small single use needle used to obtain blood sample), gauze and alcohol swab for cleaning the finger and placed them in a small cup located at the nurses station next to the glucometer.

PCT #5 took the supplies to room 6218, placed the supplies she obtained onto the bed next to the patient, and obtained the blood sample to apply to the strip. She proceeded to clean up the supplies and place unused supplies back into the cup. She exited room 6218 with the cup of unused supplies and glucometer and proceeded to room 6210.

The observation revealed PCT #5 did not disinfect the glucometer or cup with supplies prior to entering room 6210 and performing the BGL test on the next patient.

b. On 3/25/19 at 5:05 p.m., an interview was conducted with PCT #5. She stated equipment was cleaned between each patient and if a patient was on isolation precautions, the facility attempted to dedicate equipment for that patient only. She explained the disinfection process for the glucometer was the same between patient use but because the facility only had two, it was not possible to dedicate a glucometer to those patients on isolation precautions. PCT #5 stated she was trained during orientation to clean the glucometer between patients.

c. On 3/28/19 at 9:23 a.m., an interview was conducted with Infection Control Coordinator (IC Coordinator) #8. She stated staff were trained to clean equipment and there was a policy regarding cleaning equipment after use. She stated any equipment brought into a patient's room was expected to be cleaned between patient use, including the glucometer.

2. The facility failed to ensure proper precautions were followed with patients on transmission based isolation precautions.

a. On 3/26/19 at 7:55 a.m., PCT #6 was observed in Patient A's room. Hanging on the door of the patient's room was a laminated purple sign and a container holding PPE, indicating the patient was on contact isolation precautions. Review of Patient A's chart identified the patient was on contact precautions for a positive MRSA laboratory result. While in the patient's room with appropriate PPE on, PCT #6 was observed moving linen from the bed and placing it onto a chair in the room. Following this, PCT #6 removed a phone from a pocket on her pants, while wearing contaminated gloves, making a phone call, and returned the phone to the same pocket after completing the phone call.

A second observation was conducted on 3/26/19 at 4:58 p.m., of PCT #6 obtaining a blood glucose level (BGL) on Patient B. During this observation PCT #6 was observed in Patient B's room. Hanging on the door of the patient's room was a laminated purple sign, and a container holding PPE, indicating the patient was on contact isolation precautions. Review of Patient B's chart found the patient was on contact isolation precautions due to current antibiotic treatment for MRSA. PCT #6 was observed in the patient's room, wearing a gown and gloves, touching various surfaces in preparation to obtain the patient's current BGL. She was then observed, in the room with the contaminated gloves on, lifting her isolation gown in order to obtain the test strips from her shirt pocket, then returning the gown to cover her.

On 3/27/19 at 2:49 p.m., an interview was conducted with PCT #6. PCT #6 stated she had received training regarding infection control and isolation precautions through the facility's online education portal and during orientation on the floor. PCT #6 said if she was in an isolation room and needed something from her pocket, the right thing to do would be to finish the patient care first, if possible. If not, she stated she would remove the contaminated gloves in order to obtain the necessary item from her clean uniform, then apply new gloves to return to the task. She further stated the risk of not following the isolation precautions as described would be contamination for staff and other patients.

On 3/28/19 at 9:23 a.m., an interview was conducted with IC Coordinator #8. IC Coordinator #8 stated when staff were in a contact isolation room it was never acceptable to reach in their pockets under their PPE gown with contaminated gloves. She stated if staff needed an item from their pocket they should remove the contaminated gloves, obtain the item and put on clean gloves. She stated the risk associated with this was spreading the organism to other patient rooms or areas.

b. On 3/27/19 at 3:45 p.m., Physician #9 was observed in Patient B's room without using any isolation precaution PPE, despite the sign and supplies on the door.

At 4:03 p.m. on 3/27/19, an interview was conducted with Physician #9. Physician #9 stated he would know when he needed to wear PPE based on the patient's status upon review of the patient's chart. He stated he did not put in orders for isolation precautions and was not aware of how or who made the determination to place a patient on isolation precautions. Physician #9 stated he had no specific training for isolation precautions as it related to the facility. Furthermore, he stated that although the patient's had appropriate PPE available at the door, there was no consistency with dedicated equipment at the bedside, such as single use stethoscopes.

On 3/28/19 at 12:13 p.m., an interview was conducted with Director of Infection Prevention (Director) #7. Director #7 stated when a provider started practicing with the facility, they would receive a guidebook which addressed hospital acquired infections, PPE, and hand hygiene. After this, the providers received an annual newsletter and periodic presentations regarding infection control. Director #7 stated due to Physician #9's extended time practicing with the facility, there was no formal training provided regarding infection control practices within the facility.

c. On 3/25/19 at 3:04 p.m., a visitor was observed in room 6205 and was noted to be wearing civilian clothing with no PPE. On the door of the patient's room there was a laminated purple sign which identified the patient was on contact isolation precautions, requiring the use of a gown and gloves.

A subsequent observation was conducted on 3/25/19 at 4:57 p.m. of Patient A. Three visitors were observed in the patient's room without PPE despite the contact isolation precaution sign on the door.

On 3/26/19 at 4:55 p.m., during an observation with PCT #6 three visitors were observed in Patient A's room not wearing PPE. PCT #6 completed the BGL test on patient A, and four different visitors were observed arriving outside the patient's room. Director of Nursing (DON) #12 approached the new visitors prior to them entering the patient's room. She requested the visitors currently in the room step out of the room and instructed the visitors to perform hand hygiene and apply a gown and gloves. In response to DON #12's instructions, the visitors replied "they didn't tell us anything about this yesterday."

On 3/27/19 at 3:35 p.m., an interview was conducted with the visitors in Patient A's room. The visitors stated Patient A had been at the facility since 3/24/19 and until 3/26/19, after the surveyors observations, there was no mention to them by staff regarding the need to wear PPE. The visitors stated the facility staff informed them the contact isolation precautions were for MRSA but provided no other details.

On 3/28/19 at 9:23 a.m., an interview was conducted with IC Coordinator #8. She stated everyone in the facility was expected to follow precautions including staff, visitors and physicians. Additionally, she said if visitors were not educated regarding isolation precautions, the risk of exposure to the community would increase. IC Coordinator #8 stated it was mostly the responsibility of the nursing staff to educate visitors, but any staff member would be able to, and would be encouraged to.

d. On 3/26/19 at 9:42 a.m., an observation was conducted in the hallway outside Patient B's room. Hanging on the door of the patient's room was a laminated purple sign and a container holding PPE, indicating the patient was on contact isolation precautions. Review of Patient B's chart identified the patient was on contact isolation precautions for a positive MRSA laboratory result. A registered nurse (RN) was observed in the patient's room with a gown and gloves on, working on the computer and completing patient care tasks. During the observation, the RN removed the PPE, performed hand hygiene and exited the patient's room with the computer. The RN failed to disinfected the computer after leaving the isolation room.

The RN was observed going to room 6206, with no identification of isolation precautions on the door, and entered room 6206 without disinfecting the computer.

On 3/28/19, at 9:03 a.m., an interview was conducted with Clinical Nurse Coordinator (CNC) #2. She stated as consistent with CDC guidelines and policy, computers which were taken into isolation precaution rooms would be disinfected prior to bringing it out of the room. CNC #2 stated the risk of not disinfecting the computer would be transmitting the organism to another patient.


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3. The facility failed to ensure new boxes of isolation gowns used to prevent the spread of blood borne pathogens were stored in a sanitary manner.

a. On 3/25/19 at 2:55 p.m., a tour of the patient care area was conducted with Clinical Nurse Coordinator (CNC) #3. Four boxes of unopened overhead isolation gowns were found stored on the floor. Two of the boxes containing 100 gowns in each box were observed sitting directly on the tile floor. On the floor next to the boxes was a plastic graduated cylinder (a container used for measuring fluids) and a tablet with embedded blue specks. CNC #3 reported the isolation gowns were brought to the floor by the central supply technician and left at the nurses station. CNC #3 said it was the responsibility of all of the CNCs to take the gowns out of the boxes and store them on the designated shelf. She stated she had worked at the facility for the last year and a half. CNC #3 stated the boxes of isolation gowns had always been stored on the floor until they were taken out of the boxes and placed on the shelf. CNC #3 stated she did not think supplies were to be stored on the floor. CNC #3 stated she did not know why isolation gowns were not to be stored on the floor, but her guess would be for sanitary reasons.

b. Central Supply Technician (CST) #10 was interviewed on 3/26/19 at 10:40 a.m. He stated supplies were to be stored off of the floor so the floor underneath the supplies could be cleaned. CST #10 reviewed where the isolation gowns had been stored. CST #10 reported the closet where the gowns had been stored was not considered a clean storage area. CST #10 reported the nurses should not leave the boxes on the floor.

c. Assistant Director of Supply Chain (Director) #11 was interviewed on 3/26/19 at 11:03 a.m. He reported it was not the supply chain process for supplies to be stored on the floor. Director #11 stated boxes of isolation gowns should not be stored on the floor because the floor was considered a dirty area. Director #11 reported the reason for storing isolation gowns off of the floor was to prevent the supplies from becoming contaminated and spreading infection.

d. Director of Infection Control (Director) #8 was interviewed on 3/27/19 at 9:42 a.m. She confirmed clean supplies were not to be stored on the floor. Director #8 stated the basic principles of infection control identified the floor as a dirty area, therefore supplies were not to be stored there. Director #8 stated during orientation the staff had been trained, supplies were not to be stored on the floor.