HospitalInspections.org

Based on observation, staff interview, review of infection control documents, and review of policies and procedures; the hospital failed to ensure that the procedure which directed dietary staff to pass meal trays to patients who were in contact and/or droplet isolation, followed nationally recognized infection control practices and/or guidelines. Random observations of dietary staff passing meal trays to 3 of 3 patients who were in contact isolation precautions during 1 noon meal, revealed that dietary staff used a plastic apron and gloves as their PPE (personal protective equipment) instead of the PPE gown that was provided. The hospital identified 7 patients on contact or droplet isolation precautions the day of this observation. This failed practice had the potential to spread infections to all patients receiving meals from dietary. The census on the first day of survey was 89.

Findings are:

A. Observation of the noon meal on 11/18/14 on 6th floor from 12:10 PM to 12:28 PM revealed PCR-S (Patient Care Representative - title of the dietary staff that delivers meal tray into patient rooms) delivered meal trays into Rooms 605, 606 and 611. Signs posted on the doors of these rooms read "Contact Precautions". Directions listed on this sign included the following:
- "Practice hand hygiene before entering the room. Practice hand hygiene upon leaving and after removing gloves."
- "Wear gloves for all activities in the room. Remove gloves before leaving room."
- "Wear a gown for all activities in the room. Remove gown before leaving room"

The isolation cart placed outside the door of these rooms held a supply of yellow gowns and gloves for staff to put on prior to entering the room. The design of the yellow disposable gowns allows a person to cover themselves from the neck to the trunk and most of the leg areas in front and back and also the full length of their arms.

Before entering Room 605 PCR-S took a white plastic apron off the top of the food cart and put the apron on. The plastic apron design only covered a portion of the chest and the front part of the lower trunk and legs. PCR-S also put gloves on and entered the patient room. The patient was seated in a chair next to the window with a walker placed in front of the chair and the end of the bed in close proximity. While delivering the tray to this patient PCR-S picked up linen/bedding items by the patient and placed them onto the bed, retrieved a towel from the bathroom and placed the towel on the patient's lap. When finished PCR-S removed the plastic apron by pulling on the front, removed both gloves and disposed of these items in the waste basket in the room. Hand sanitizer was used upon leaving the room. PCR-S used a new apron and gloves when entering Room 606 and disposed of them in the same manner as before and used hand sanitizer when leaving the room. PRC-S used a new apron and gloves to deliver the tray to Room 607, however, the process of removing the apron and gloves and hand hygiene was not observed. After delivering the trays to these 3 patients PCR-S delivered trays to 2 more patients.

B. Interview with the Director of Nutrition Services on 11/18/14 at 2:30 PM concerning the use of the white plastic aprons instead of the yellow gowns revealed the following:
- The reason plastic aprons were used was to shorten the time it took to deliver trays so food would not get cold.
- The Manager of Infection Control was involved in the decision to use plastic aprons.
- When asked if there was a policy and procedure for the use of plastic aprons, the Director of Nutrition Services indicated there was an Operation Standard (easy directions on how to complete a task), but no policy and procedure for the use of plastic aprons.

Review of the undated Operation Standard for Isolation Tray Delivery revealed the following steps:
- "Remove isolation tray from food cart, place on top of cart";
- "Put on white plastic aprons";
- "Use hand sanitizer";
- "Put on disposable gloves";
- "Deliver tray to room";
- "Remove apron in room and place in waste basket"; and,
- "Remove gloves and place in waste basket".

C. The policy and procedure titled Contact Isolation Precautions (effective date of 5/15/14) listed the following under Isolation Attire: "Gown: Don gowns before entering the room to prevent uniform contact with the patient or patient's environment. Remove prior to leaving room and practice hand hygiene before leaving the patient-care environment." The policy also stated "No healthcare worker should enter the room without PPE per signage." The policy and procedure gave the following direction for Nutrition Services: "Will deliver trays into the room wearing designated PPE."

Interview with the Manager of Infection Control on 11/18/14 from 3:45 PM - 4:00 PM and again on 8/19/14 at 8:25 AM revealed the following;
- We allowed the dietary staff to wear plastic aprons because they were in the room for only a brief amount of time and we felt that it covered all area that might come in contact with anything in the room.
- The use of plastic aprons speeds up the process of passing trays.
- Dietary staff have been using plastic aprons for at least 2 years.
- When asked what "designated PPE" referred to in the Contact Isolation Precautions policy and procedure, Manager of Infection Control stated "the white plastic aprons".
- When the Manager of Infection Control was asked for supporting documentation for this practice responded "Found no information that it was an acceptable practice for some people not to wear the PPE gown".

The Manager of Infection Control provided a copy of the meeting minutes of the Infection Control Committee dated 1/17/12. The meeting minutes reflected the approval by the committee to change the Contact Isolation policy to reflect the current practice of dietary wearing a disposable apron instead of a gown.

The Manager of Infection Control also provided a copy of their infection surveillance for October 2014 with the following information:
"October infection rates showed 4 infections (1 surgical site infection, 1 soft tissue infection and two C Diff infections) we had to claim." (C Diff or Clostridium difficile is a bacteria that causes watery diarrhea, fever, loss of appetite, nausea and abdominal pain. When a person takes antibiotic, good germs that protect against infection are destroyed for several months. During this time, patients can get sick from C. difficile picked up from contaminated surfaces or spread from a health care provider.)

D. Review of the 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health care Settings (located on the Centers for Disease Control Website) provided the following information concerning PPE for healthcare personnel:
"PPE refers to a variety of barriers and respirators, used alone or in combination to protect mucous membranes, airways, skin, and clothing from contact with infectious agents. The wearing of isolation gowns and other protective apparel is mandated by the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standard. When Contact Precautions are used...donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental surfaces. "