HospitalInspections.org

Based on record review and interview, the hospital failed to implement an effective infection prevention and control program to control the transmission of infections within the hospital as evidenced by:
1) failing to control the spread of an identified outbreak of Aspergillus (mold) infection for 5 (#1, #2, #3, #4, #5) of 94 patients admitted into the 3 East COVID-19 Intensive Care Unit (ICU) from 08/16/2021 through 10/10/2021 who developed the infection; and
2) failing to ensure 2 (R1, R2) of 2 patients on the fourth floor with known COVID-19 infection were isolated according to policy.
Findings:

1) Failing to control the spread of an identified outbreak of Aspergillus (mold) infection.

Review of Patient #1's medical record revealed in part: Admitted 08/02/2021 to room "a" with diagnoses of Pneumonia due to COVID-19, Acute respiratory failure (ARF), demand ischemia of myocardium, acute renal failure and primary thrombocytopenia. On 8/11/21 a tracheal aspirate was collected for microbiology with results described as moderate yeast, mold typical of Aspergillus species. Patient died on 08/21/2021.

Review of Patient #2's medical record revealed in part: Admitted 08/13/2021 to room "b" with diagnoses of ARF with hypoxia, pneumonia due to COVID-19 and sepsis. On 08/28/2021 an endotracheal tube aspirate was collected for microbiology with results described as moderate growth of mold. Patient died on 09/02/2021.

Review of Patient #3's medical record revealed in part: Admitted 09/06/2021 to room "c" with diagnoses of COVID-19 pneumonia, ARF, sepsis, acute metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and diabetes mellitus. On 09/09/2021 an endotracheal tube aspirate was collected for micro biology with results described as yeast and mold typical of Aspergillus species. On 09/12/2021 a tracheal aspirate was collected for micro biology with results described as yeast and mold typical of Aspergillus species. Patient died on 09/19/2021.

Review of Patient #4's medical record revealed in part: Admitted 09/14/2021 to room "d" with diagnoses of acute hypoxic respiratory failure, COVID-19 pneumonia, demand ischemia, acute kidney injury on possible chronic kidney disease and transaminitis. On 09/25/2021 a bronchial washing sample was collected for microbiology with results described as mold typical of Aspergillus species. Patient died on 09/27/2021.

Review of Patient #5's medical record revealed in part: Admitted 09/27/202 to room "e" with diagnoses of COVID-19 pneumonia and ARF with hypoxia. On 10/01/2021 the patient was transferred to room "f" so room "e" could be terminally cleaned. On 10/06/2021 an endotracheal tube aspirate was collected for micro biology with results described as mold typical of Aspergillus species. The patient was transferred to the main ICU on 10/12/2021.

Review of the hospital policy IC 38 titled, "Outbreak Investigation" revealed in part: Policy - Infection Control staff will investigate any suspected or actual infectious disease outbreaks. An outbreak is defined by State Health Department as two or more cases over the normal endemic rates of healthcare associated infections.
Procedure - A. 1. An outbreak shall be suspected when: Healthcare-associated infections (HAIs) occur above the baseline rate or endemic level. 2. Clusters of infection or similar symptomology are noted or reported among patients or employees.
B. Elements of an Outbreak Investigation - The Infection Control Practitioner will act as the coordinator and principle investigator for follow-up of any suspected outbreak.
3. Establish or verify the diagnosis of reported cases and identify the causative agent, if possible.
4. Search for additional cases and develop a line-list.
5. Characterize the cases by person, place and time.
6. Institute control measures
8. Perform additional cultures or tests
9. Implement longer range control and preventative measures
10. Initiate surveillance - a. The efficacy of the intervention(s) can be measured by further surveillance to determine if cases cease to occur or return to endemic levels.

In an interview on 10/13/2021 at 3:00 p.m. S3IC stated on 8/14/2021 she was aware of Patient 1's tracheal aspirate culture which was positive for Aspergillus (mold). On 08/28/2021, Patient 2 had a positive tracheal aspirate culture which was positive for mold. At this time, she did not correlate the connection between the two molds. S3IC was notified by S4Physician on 9/14/2021 that there was a third case. Patient #3, had an aspirate culture which was positive for Aspergillus and the physician to S3IC, "We have a problem". It was at this time that the Outbreak Investigation began. S3IC stated an action plan was initiated on 09/15/2021. All the patient's rooms, nurses' station and utility rooms were terminally cleaned by 09/20/2021 with the exception of room "f" and "g". Environmental Company-A (ECA) was consulted on 09/22/2021 for an environmental hygiene study and ECA performed air samples on 09/25/2021 of the nurses' stations and the rooms which had previously housed patients who tested positive for Aspergillus (rooms a, b and c). Room "g' was terminally cleaned on 9/24/2021 and room "h" was terminally cleaned on 10/05/2021 due to the critical nature of the patient's occupying those rooms.

Review of the air sampling report by ECA dated 09/25/2021 revealed in part: the samples within 3 East ICU room "a", "b" and "c" as well as the nearby nurses' stations indicate Aspergillus (as well as other airborne fungi). The patient rooms sampled were unoccupied at the time of the sample. At the time of the inspection, the negative air machines/air scrubbers were operating on low at 1300 cubic feet per minute (CFM). Based on preliminary observations, ECA recommended the hospital consider using negative air machines/air scrubbers with no more than 500 (CFM) so the negative pressure in the rooms is decreased but robust. The hospital reported to ECA that the machine changes were completed on September 28 and September 29, 2021. However, following the changes made to the negative pressure rooms in the 3 East ICU COVID-19 unit, the environment and the air was not resampled until October 11, 2021. At the time of this survey, there was no proof that Aspergillus had been removed from the air and surrounding environment within the unit.

In an interview on 10/13/2021 at 4:30 p.m., S1Administrator stated they did not close the unit to new admits or remove the patients from the unit because they had nowhere to move them. All of the patients on the 3 East ICU were COVID-19 positive. S1Adminstrator continued to state that ECA performed air samples on 10/11/2021 of the 3 East IC nurses' stations and rooms "a", "b", "c", "d", and "e" and stated the finalized results and report were still pending.

2) Failing to ensure patients with known COVID-19 infection were isolated according to policy.

Review of the Hospital's Infection Control Manual revealed "Current/Updated Health Care Facilities Ventilation Controls and Guidelines for Management of Patients with Suspected or Confirmed SARS-CoV-2 (COVID-19)". Review of this guideline revealed in part: Patients suspected of COVID-19 infection that are admitted to the facility should be placed in a single-occupancy patient room with the door closed.

10/13/21 at 10:42 a.m., observation of rooms "i" and "j" revealed the doors were ajar and not fully closed. Further observation revealed the doors were equipped with Personal Protective Equipment (PPE) kits suspended at the top of the doors which required the doors to be physically closed. There were signs on the doors indicating the patients were on contact and droplet precautions.
During an interview at this time, S2CNO confirmed that the patients were COVID positive and the doors to the patient's rooms should be closed.