HospitalInspections.org

Based on medical record review and interview it was determined the facility failed to include the patient's representatives to participate in development and implementation of his/her plan of care for 1 of 6 patients (#6).

Findings included:

Review of the medical record for Patient #6 noted documentation of a change in condition requiring that he/she have an "Emergent Bronchoscopy" on 05/10/2021. Continued documentation noted the "Case was declared emergent by physician and consent signed reflecting this," as well as review of the informed consent for surgical and special procedures noting physician's signature dated 05/10/2021 at 9:38 a.m. stating "Declaration of Emergent situation / unable to obtain consent." However, continued review of the medical record to include review of change of condition notes, nursing notes, and physician notes did not find that patient's Health Care Surrogate / POA was notified after the procedure was done, to update him/her on the patient's change in condition necessitating the emergency procedure.
This was confirmed by interview with the Chief Clinical Officer on 06/07/2021 at 4:00 p.m.

Based on observations, medical record reviews, review of the Candida Auris result log from the Department of Health, and interviews, it was determined the facility failed to utilize isolation technique regarding linen cards and personal protection equipment, and failed to prevent the transmission of Candida Auris infections to patients within the facility for five (#1, #2, #3, #4, #5) of seven sampled patients.

Findings included:

On 06/07/2021 at 9:30 AM, a tour was conducted on 2 North. During the tour, a staff member was observed coming out of the clean utility with a blue plastic gown on. She then proceeded to go to a room and hand off an alarm to a staff member in the room. The alarm fell, and the staff member placed it on the rails outside of the doorway and went down the hall to answer a call light from the doorway. She then walked up the hall and answered another call light, wearing the same blue plastic gown the whole time.
Interview conducted with the Director of Nursing for Acute Rehab Unit (ARU) on 06/07/2021 at 9:15 AM revealed that this staff member always wore a blue plastic gown in the hallways.

On 06/07/2021 at 5:53 PM a tour was conducted on 2 South. Observed a staff member place a blue garbage bag on top of the clean linen cart at the end of the hall in front of a patient's room. Also observed 2 blue bags on the floor. The staff member came out of the patient room and grabbed the blue bag from the floor and the one on top of the clean linen cart. The staff member was walking down the hall with another staff member pushing a patient in a wheelchair. The staff member then went to Acute Rehab Unit, where the patient was being transferred, with the 2 blue bags, one from the floor and the other from the top of the clean linen cart.
Interview on 06/07/2020 at 6:00 PM with the Director of Quality / Risk Manager confirmed the above findings.

Medical record review for Patient #1 revealed the patient was admitted to the facility on 02/18/2021. Further review of the medical record shows the facility did a point prevalence screen (PPS) for Candida Auris on 05/24/2021. The Candida Auris result log from the Department of Health the facility received on 06/02/2021 noted Candida Auris was detected and colonized in Patient #1's sample.

Medical record review for Patient #2 revealed the patient was admitted to the facility on 05/05/2021 with a diagnosis of respiratory distress. On 05/06/2021 Candida Auris test results showed it as "not detected." The facility did a point prevalence screen for all patients that have tested negative for Candida Auris on 05/24/2021. The Candida Auris result log from the Department of Health that the facility received on 06/02/2021 revealed Patient #2 with Candida Auris detected and colonized.

Medical Record review for Patient #3 reveals patient admitted to the facility on 05/07/2021 for Acute respiratory failure. On 05/24/2021, the facility collected PPS on patient for Candida Auris. On 06/02/2021, results from the Department of Health showed Candida Auris was detected and colonized in sample.

Medical record review for Patient #4 showed patient admitted on 03/23/2021 for respiratory failure. The facility did an admission test for Candida Auris on 04/20/2021 which revealed Candida Auris was not detected. Upon further review of Patient #4's medical record revealed the facility did a PPS on 05/24/2021 with the results received from the Department of Health on 06/02/2021, showing Candida Auris detected and colonized for Patient #4.

Medical record review for Patient #5 reveals that Patient #5 was admitted on 05/04/2021 and on 05/24/2021 the facility collected a PPS for Candida Auris. Upon further review of the Candida Auris result log from the Department of Health the facility received on 06/02/2021, it showed Patient #5's results for Candida Auris as detected and colonized.