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Based on interview and record review, the facility failed to ensure the facility's infection control program was maintained or methods to prevent the transmission of infections were implemented within the facility when:

1. Patients were not placed on Enteric Precaution (special steps taken in the hospital to prevent the spread of germs this means wearing gloves and gown when entering the patient's room and washing hands with soap and water) when orders for testing were placed for Clostridium difficile (C. diff., a bacteria found in the colon and large intestines), for 11 of 30 sampled patients (Patient 5, 8, 9, 14, 19, 20, 21, 22, 23, 25, and 26); and

2. Patients were not provided indwelling urinary catheter care (a thin tube that drains urine from the bladder into a bag) /peri care (washing the genital and anal areas), in accordance with the facility's policy and procedures (P&P), for three of 30 sampled patients (Patients 2, 7, and 17 );

These failures had the potential to result in the transmission and spread of pathogens (bacteria, virus, or other microorganism) to the patients receiving care in the facility.

Findings:

1 a. A review of Patient 5's medical record was conducted on September 6, 2024, at 9:20 a.m., with the Regulatory Specialist (RS) 2.

A review of the facility document titled, "History and Physical," indicated Patient 5 was admitted to the facility on July 14, 2024, for diarrhea of presumed infection origin (infection starting in a certain part of the body), acute abdominal pain (pain in the abdomen), and colitis (inflamed colon).

A review of the facility's untitled, document indicated, C. diff. Glutamate Dehydrogenase (GHD)/Toxin test ( a chemical found in the bacteria Clostrium difficile, that can be used to detect the presence of C. diff in stool) for Patient 5 was ordered on July 14, 2024, at 10:02 a.m. It further indicated the specimen was collected on July 14, 2024, at 11:40 a.m. The C. diff. resulted on July 14, 2024, at 11:40 p.m., as negative.

On September 6, 2024, at 9 a.m., an interview was conducted with RS 2. RS 2 stated Patient 5 was not placed in isolation during the rule out of C. diff, and should have been.

b. A review of Patient 8's medical record was conducted on September 6, 2024, at 10:30 a.m., with RS 2.

A review of the facility document titled, "History and Physical," dated June 26, 2024, indicated Patient 8 was admitted to the facility on June 26, 2024, for diarrhea of infectious origin, acute febrile illness (sickness that comes on suddenly and causes a fever), and septic shock (serious condition when an infection spreads throughout the body).

A review of the facility's untitled document, indicated, C. diff. GHD /Toxin test for Patient 8 was ordered on June 27, 2024, at 1:44 p.m. It further indicated the specimen was collected on June 27, 2024, at 7:50 a.m., The C. diff. resulted on June 27, 2024, as negative.

On September 6, 2024 at 10: 40 a.m., an interview was conducted with RS 2. RS 2 stated Patient 8 was not placed in isolation during the C. diff. rule out period and should have been per hospital policy.

c. A review of Patient 9's medical record was conducted on September 6, 2024, at 3:30 p.m., with RS 2.

A review of the facility document titled, "History and Physical," dated June 21, 2024, indicated Patient 9 was admitted to the facility on June 21, 2024, for acute coronary syndrome (when blood flow to the heart is suddenly blocked), symptomatic anemia (low red blood cells), and high risk pulmonary embolism (serious blood clot in the lungs).

A review of the facility's untitled, document indicated, C. diff. GHD /Toxin test for Patient 9 was ordered on June 23, 2024, at 9:02 a.m. It further indicated the specimen was collected on June 23, 2024, at 9:48 a.m. C. diff. test resulted on June 24, 2024, as positive and an enteric isolation order was placed on June 25, 2024 after the positive result.

On September 6, 2024, at 3:45 p.m., an interview was conducted with RS 2. RS 2 stated Patient 9 was not placed in isolation during the C. diff rule out time and should have been per hospital policy. RS 2 stated Patient 9 was placed on isolation precaution two days after initial testing and one day after positive test result.

d. A review of Patient 14's medical record was conducted on September 9, 2024, at 9:40 a.m., with the RS 2.

A review of the facility document titled, "History and Physical," dated June 24, 2024, indicated Patient 14 was admitted to the facility on January 24, 2024, for essential paroxysmal tachycardia (fast heart beat), hyperkalemia (high potassium in the blood), altered mental status (confusion, acting differently than normal), and sepsis.

A review of the facility's untitled, document indicated, C. diff. GHD /Toxin test for Patient 14 was ordered on February 1, 2024, at 10:25 a.m. It further indicated the specimen was collected on February 1, 2024, at 1:05 p.m. C. diff. test results on February 2, 2024, at 2:15 p.m., as positive for C. diff.

On September 9, 2024, at 10 a.m., an interview was conducted with RS 2. RS 2 stated Patient 14 was not placed in isolation during the C. diff rule out time and should have been per hospital policy. RS 2 verified Patient 14 was placed on isolation precaution two days after initial testing.

e. A review of Patient 19's medical record was conducted on September 6, 2024, at 9:23 a.m., with RS 3.

A review of the facility document titled, "History and Physical," dated June 2, 2024, indicated
Patient 19 was admitted to the facility on June 2, 2024, for colitis, suspect infectious, rectal bleed, and diarrhea.

A review of the facility's untitled, document indicated, C. diff. GHD /Toxin test for Patient 19
was ordered on June 2, 2024, not timed. If further indicated the specimen was collected on June 2, 2024, at 12:55 p.m. C. diff. test resulted on June 2, 2024, not timed, as negative.

On September 6, 2024, at 9:40 a.m., an interview was conducted with RS 3. RS 3 stated Patient 19 was not placed in isolation during the C. diff rule out time and there was no documented evidence Patient 19 was placed in isolation. RS 3 further stated there was no order for isolation and the facility's P&P was not followed.

On September 6, 2024, at 1:49 p.m., an interview was conducted with the Executive Director of Epidemiology and Infection Control (EDEIC). The EDEIC stated any time there is a rule out C. diff. the patient should be placed on Enteric Precautions. She further stated when there is an order to rule out C. diff. the nurse should call and get the isolation order right away, place signage on the door, and PPE (personal protective equipment) readily available.

f. A review of Patient 20's medical record was conducted on September 6, 2024, at 2 p.m., with the RS 3.

A review of the facility document titled, "History and Physical," dated August 5, 2024, indicated, Patient 20 was admitted to the facility on August 5, 2024, for rectal bleeding, colitis, and rectal carcinoma (cancer that forms in the tissues of the rectum).

A review of the facility's untitled, document indicated, C. diff. GHD /Toxin test for Patient 20
was ordered on August 2, 2024, at 5:04 a.m. It further indicated the specimen was collected on August 2, 2024, at 5:35 a.m. C. diff. test resulted on August 3, 2024, at 3:19 p.m., as negative.

On September 6, 2024, at 2:28 p.m. an interview was conducted with RS 3. RS 3 stated patient 20 was not placed on Enteric Precautions during the C. diff. rule out time and the policy was not followed.

g. A review of Patient 21's medical record was conducted on September 9, 2024, at 9:20 a.m., with the RS 3.

A review of the facility document titled, "History and Physical," dated June 3, 2024, indicated, Patient 21 was admitted to the facility on June 3, 2024, for pancolitis (inflammation of the entire colon) and watery diarrhea.

A review of the facility's untitled, document indicated, C. diff. GHD /Toxin test for Patient 21
was ordered on June 3, 2024, not timed. It further stated the specimen was collected on June 3, 2024, at 3:57 a.m. C. diff. test resulted on June 3, 2024, at 1:36 p.m., as negative.

On September 9, 2024, at 9:35 a.m. an interview was conducted with RS 3. RS 3 stated there was no order for Patient 21 to be placed on Enteric Precautions during C. diff. during rule out period. RS 3 stated the expectation would be to place the patient in Enteric precautions as soon as the patient is tested for C. diff. RS 3 further stated the policy was not met.

h. A review of Patient 22's medical record was conducted on September 9, 2024, at 10 a.m., with the RS 3.

A review of the facility document titled, "History and Physical," dated June 14, 2024, indicated, Patient 22 was admitted to the facility on June 14, 2024, for chest pain, diarrhea, with a history of C. diff. 2 months ago.

A review of the facility's untitled, document indicated, C. diff. GHD /Toxin test for Patient 22 was ordered on June 10, 2024, at 3:34 p.m. It further indicated the specimen was collected on June 10, 2024, at 6:21 p.m. C. diff. test resulted on June 11, 2024, at 5:39 p.m., as positive and Patient 22 was placed on Enteric Precautions on June 14, 2024, three days after a positive result.

On September 9, 2024, at 10:06 a.m., an interview was conducted with RS 3. RS 3 stated the patient should have been placed on Enteric Precautions when the C. diff. test was ordered. RS 3 further stated the Patient 22 was placed on Enteric Precautions June 14, 2024, despite a positive C. diff. result on June 11, 2024. RS 3 stated the policy was not followed.

i. A review of Patient 23's medical record was conducted on September 9, 2024, at 10:20 a.m., with the RS 3.

A review of the facility document titled, "History and Physical," dated May 16, 2024, indicated Patient 23 was admitted to the facility on May 16, 2024, for a postoperative infection (infection that occurred after surgery), elevated troponin (protein found in muscles of the heart), and sepsis.

A review of the facility's untitled, document indicated, C. diff. GHD /Toxin test for Patient 23 was ordered on May 25, 2024, at 6:41 p.m. It further stated the specimen was collected on May 25, 2024, at 6:43 p.m. C. diff. test resulted on May 26, 2024, at 3:20 p.m., as positive.

On September 9, 2024, at 10:39 a.m., an interview was conducted with RS 3. RS 3 stated the patient was placed on Enteric Precautions after a positive result of C. diff. not during the rule out period. She further stated the patient should have been placed on Enteric Precaution on May 25, 2024, when the specimen was collected, the policy was not followed.

j. A review of Patient 24's medical record was conducted on September 9, 2024, at 2 p.m., with the RS 3.

A review of the facility document titled, "History and Physical," dated July 24, 2024, indicated Patient 25 was admitted to the facility on July 24, 2024, for C. diff., colitis.

A review of the facility's untitled, document indicated, C. diff. GHD /Toxin test for Patient 24 was ordered on July 23, 2024, at 4:28 p.m. It further indicated the specimen was collected on July 23, 2024, at 5:27 p.m. C. diff. test resulted on July 24, 2024, at 1:19 p.m., as positive.

On September 9, 2024, at 2:04 p.m., an interview was conducted with RS 3. RS 3 stated Patient 24 was placed on Enteric Precautions after a positive result of C. diff. not during the rule out period. She further stated the patient should have been placed on Enteric Precaution on July 23, 2024, when the specimen was collected, the policy was not.

k. A review of Patient 26's medical record was conducted on September 9, 2024, at 2 p.m., with the RS 3.

A review of the facility document titled, "History and Physical," dated July 30, 2024, indicated Patient 26 was admitted to the facility on July 30, 2024, for nausea, vomiting, and diarrhea.

A review of the facility's untitled, document indicated, C. diff. GHD /Toxin test for Patient 26 was ordered on July 30, 2024, at 12:12 p.m. It further indicated the specimen was collected on July 30, 2024, at 12:58 p.m. C. diff. resulted on July 31, 2024, at 2:46 p.m., as positive.

On September 9, 2024, at 2:32 p.m., an interview was conducted with RS 3. RS 3 stated Patient 26 should have been placed on Enteric Precautions during the C. diff. rule out period. RS 3 further stated the the policy was not followed.

A review of the facility's Policy and Procedure (P&P) titled, "STANDARD AND TRANSMISSION-BASED PRECAUTION," dated January 2021, was conducted. It indicated, "...Enteric Precautions shall be used when caring for patients for whom fecal personal hygiene is unable to be maintained OR who are known/suspected to be infected/colonized with epidemiologically important microorganisms transmitted by fecal material..."

2a. A review of Patient 2's medical record was conducted on September 6, 2024, at 9:23 a.m., with the Regulatory Specialist 2 (RS 2).

A review of the facility document titled, "History and Physical," dated September 4, 2024, indicated Patient 26 was admitted to the facility on September 4, 2024, for acute exacerbation of chronic obstructive pulmonary disease (COPD, lung disease), symptomatic bradycardia (slow heart rate), dementia (condition that affects the brain), and COVID-19 (coronavirus, symptoms like fever cough and trouble breathing.)

A review of the facility's untitled document, indicated Patient 2's foley catheter (a flexible tube placed into the bladder to drain urine) was placed on September 3, 2024.

A review of the facility's document titled, "Hygiene Flow Sheet," dated September 4, 2024, through September 5, 2024, day shift (7 a.m.- 7 p.m.) and night shift (7 p.m. - 7 a.m.), indicated perineal care (cleaning the genitals and buttocks area) was not provided to Patient 2 on September 5, 2024, day and night shift.

On September 6, 2024, at 10 a.m., an interview was conducted with RS 2. RS 2 stated Patient 2 did not receive perineal care on September 5, 2024, for day or night shift and should have been per hospital policy.

b. A review of Patient 7's medical record was conducted on September 9, 2024, at 9:50 a.m., with the RS 2.

A review of the facility document titled, "History and Physical," dated June 10, 2024, indicated Patient 7 was admitted to the facility on on June 10, 2024, for postoperative wound infection (infection that developed after surgery), acute osteomyelitis (infection in a bone), and acute cystitis (infection of the bladder) without hematuria (blood in urine).

A review of the facility's untitled document, indicated Patient 7's foley catheter was placed on on June 10, 2024.

A review of the facility's document titled, "Hygiene Flow Sheet," dated June 11, 2024, indicated perineal care was not provided to Patient 11 on June 11, 2024.

On September 9, 2024, at 10 a.m., an interview was conducted with RS 2. RS 2 stated Patient 7 did not receive perineal care on June 11, 2024, per hospital policy.

c. A review of Patient 17's medical record was conducted on September 6, 2024, at 11 a.m., with the RS 2.

A review of the facility document titled, "History and Physical," dated September 2, 2024, indicated, Patient 17 was admitted to the facility on September 2, 2024, for COVID-19, pneumonia (infection to the lungs) and weakness. The History and Physical document indicated, "...patient has a foley catheter in place due to bladder infection..."

A review of the facility document titled, "Hygiene Flow Sheet," dated September 2, 2024, p.m. shift (7 p.m. to 7 a.m.) indicated, perineal care was not provided for Patient 17.

On September 6, 2024, at 11:06 a.m., an interview and record review were conducted with RS 3. RS 3 stated I did not see that pericare was provided for Patient 17 on September 2, p.m. shift. She further stated the policy was not followed.

On September 6, 2024, at 2:07 p.m., an interview was conducted with the Director of Quality and Patient Safety (DQPS). The DQPS stated there is no policy for foley catheter care, however, the facility follows the nursing skills guidelines, and the nurses are held to it.

A review of the facility undated skill titled, "URINARY CATHETER MALE [NAME OF CITY]," indicated, "...Perineal Care...Perineal care should be performed once per shift and PRN (as needed) when a patient has a dwelling catheter..."















































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