HospitalInspections.org

Based on observation and staff interview, it was determined that the hospital failed to maintain the building in a manner to ensure the safety for 190 of 190 inpatients on 2/4/15 and for 1 of 1 off-campus designated provider-based entities. The hospital failed to meet the applicable provisions of the 2000 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (see the attached CMS-2567s referencing LSC deficiencies).

Based on observation and staff interview, it was determined that the hospital failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association (see the attached CMS-2567s referencing LSC deficiencies).

Based on observation, medical record review, document review and staff interview, it was determined that for 7 of 17 patient care observations (Patient #'s 4, 28, 32, 44, 45, 50 and 51), the infection control officer failed to ensure that staff adhered to infection control policies during the provision of care. Findings include:

The "Position Description" entitled "Infection Preventionist" stated, "...Position will serve as a knowledgeable...resource of infection control information, regulation and guidelines...This position will provide support to all activities involving infection control...Supports Infection Control team in the on-going review and evaluation of aseptic technique...disinfection..."

The hospital policy entitled "Hand Hygiene" stated, "...procedure for appropriate hand hygiene as the most effective way to prevent transmission of disease...Moments for Hand Hygiene...Before you touch the patient...Before an aseptic/clean procedure...After a potential blood or body fluid exposure...After touching the patient...After touching the patient surroundings...The use of gloves does not eliminate the need for hand hygiene...perform hand hygiene before and after putting on (donning) gloves..."

A. Patient #4 (pediatric intensive care unit)

1. On 2/4/15 between 1:20 PM - 1:29 PM, the following technique was observed during medication administration provided by registered nurse (RN) A:

- washed hands
- retrieved medication from Pyxis unit (an automated dispensing cabinet and computerized device designed for hospitals) at nurses station
- sanitized hands
- donned gown, face mask, gloves
- entered patient room, scanned patient arm band and medication
- removed gloves
- sanitized hands
- donned gloves
- opened alcohol swab, wiped the rubber septum on the medication vial with alcohol swab
- opened syringe and pulled up medication into syringe
- discarded used supplies
- removed gloves
- donned gloves
- wiped access port (implantable device utilized for intravenous (IV) medication, usually placed just under the skin on the upper part of the chest wall) with alcohol
- administered medication
- discarded syringe in sharp container
- removed gloves
- sanitized hands

RN A failed to perform hand hygiene:
- after glove removal

Interview on 2/10/15 at 2:50 PM with Infectious Disease Physician A and Infection Preventionist A, confirmed that the observed practice did not conform to the hospital's hand hygiene policy.

B. Patient #28 (3 West)

1. On 2/6/15 between 9:45 AM - 10:16 AM, the following technique was observed during central venous catheter (CVC) site care and dressing change by RN H:

- washed hands
- donned clean gloves and mask
- inspected and removed old dressing covering CVC insertion site
- removed gloves
- donned sterile gloves
- disinfected CVC insertion site
- applied new sterile dressing

RN H failed to perform hand hygiene:
- before donning sterile gloves

Interview on 2/10/15 at 2:58 PM with Infectious Disease Physician A and Infection Preventionist A, confirmed that the observed practice did not conform to the hospital's hand hygiene policy.

C. Patient #44 (Emergency Department)

1. On 2/4/15, between 11:30 AM - 11:40 AM, the following technique was observed during medication administration provided by RN G:

- sanitized hands
- donned gloves
- opened packet containing alcohol pad and wiped injection port of IV tubing
- injected normal saline through the IV
- discarded syringe
- touched patient supply cabinet
- retrieved medication scanner from inside uniform pocket
- scanned bar code on medication and patient identification (ID)
- touched IV tubing and stretcher
- entered data onto computer
- touched patient
- removed gloves
- sanitized hands
- donned clean gloves
- continued medication administration

RN G failed to perform hand hygiene:
- after touching patient
- after touching patient surroundings
- before touching patient

Interview on 2/10/15 at 2:50 PM with Infectious Disease Physician A and Infection Preventionist A, confirmed that the observed practice did not conform to the hospital's hand hygiene policy.

D. Patient #45 (3 West)

1. On 2/6/15 between 9:00 AM - 9:08 AM, the following technique was observed during medication administration provided by RN H:

- washed hands
- entered data on computer
- retrieved medication scanner
- scanned patient's ID band
- donned gloves
- retrieved medication syringe and alcohol wipe packet
- put syringe and packet down
- with left gloved hand, retrieved phone from inside of pocket, touched phone, hair, face and left ear
- returned phone to pocket
- removed gloves
- donned gloves
- picked up medication syringe and removed end cap
- attached syringe to IV tubing
- wrote on and attached label to syringe tubing
- discarded used supplies
- wiped injection port of IV tubing with alcohol wipe
- connected syringe to IV tubing
- hung syringe on IV pole
- touched infusion pump
- discarded supplies
- removed gloves
- washed hands

RN H failed to perform hand hygiene:
- after touching patient surroundings
- before touching patient
- before donning gloves
- after removing gloves

Interview on 2/10/15 at 2:52 PM with Infectious Disease Physician A and Infection Preventionist A, confirmed that the observed practice did not conform to the hospital's hand hygiene policy.

E. Patient #50 (neonatal intensive care)

1. On 2/5/15 between 8:15 AM - 8:30 AM, the following was observed as RN D administered medications via patient's gastric tube (a tube inserted through the abdominal wall into the stomach):

- sanitized hands
- donned gloves
- uncapped gastric tube and attached syringe
- administered medication after checking for residual gastric contents
- recapped gastric tube
- opened cart drawer and retrieved pen
- removed one glove and placed on top of cart
- picked up pen
- touched medication packaging
- removed the remaining glove and placed on top of cart
- touched computer
- discarded trash
- touched patient
- sanitized hands

RN D failed to perform hand hygiene:
- after glove removal
- before/after patient contact
- after touching the patient surroundings

Interview with Infection Preventionist A on 2/11/15 at 2:57 PM, confirmed that the observed practice did not conform to the hospital's hand hygiene policy.

F. Patient #51 (neonatal intensive care unit)

1. On 2/5/15 between 8:30 AM - 8:45 AM, the following was observed as RN E administered medications via patient's nasal gastric intestinal tube (a thin tube inserted through the nose and into the small intestine):

- touched feeding pump
- disconnected gastric tube from pump tubing
- administered medication
- clamped end of gastric tube
- touched scanner
- picked up medication
- unclamped gastric tube
- administered medication, reattached gastric tube to pump tubing
- touched feeding pump, tubing and patient
- reached in pocket and removed pen
- used pen on medication packaging
- touched computer
- sanitized hands

RN E failed to perform hand hygiene:
- before/after patient contact

Interview with Infection Preventionist A on 2/11/15 at 3:00 PM, confirmed that the observed practice did not conform to the hospital's hand hygiene policy.

G. Patient #32 (4 East)

The "Infection Prevention and Control" educational document utilized by hospital staff stated, "...Droplet/Contact Isolation...wash hands, wear an isolation mask, gown, & (and) gloves...Sequence for Removing PPE (personal protective equipment) (gloves...gown, mask)...follow steps for donning/doffing (removing) in order specific to Isolation status..."

1. Physician's order dated 2/5/15 at 12:10 AM included an order for isolation: Contact and Droplet Precautions

2. On 2/5/15 between 10:15 AM - 10:30 AM, RN B was observed removing PPE after providing patient care:

- removed isolation gown
- removed gloves
- removed mask
- washed hands
- exited isolation room

RN B failed to:
- remove PPE in the proper sequence

Interview with Infection Preventionist A on 2/5/15 at 3:05 PM confirmed this finding.