HospitalInspections.org

Based on observation, document review and staff interview the hospital failed to implement and maintain an active, hospital wide program for the prevention, control and investigation of infections and communicable diseases. The hospital failed to ensure healthcare workers followed infection control standards of care and hospital policy for hand hygiene, equipment cleaning, and trash disposal to avoid the potential transmission of infections and communicable diseases which placed all patients, visitors and staff at risk for healthcare associated infections.

Findings included:


- The hospital's infection control officer failed to ensure 18 staff members followed infection control policies and acceptable standards of practice when they provided 18 of 24 sampled patients' care. The infection control officer failed to ensure staff followed acceptable standards of practice and hospital policy for hand hygiene, cleaning of equipment and trash removal.

The widespread failure to follow hand hygiene standards, equipment cleaning standards and isolation policies by hospital staff and lack knowledge about hospital staff's inappropriate day to day infection control practices placed patients, visitors and staff at risk for exposure to potentially infectious microorganisms. See further evidence of widespread infection control breaches at at A-0749, CFR 482.42 (a)(1)

Based on observation, interview, and document review the hospital failed to provide personal privacy for three patients observed receiving personal care (patient #'s 22, 23 and 24).

Findings include:

- Review on 10/18/10 of the hospital's Patient Rights provided on admission, directed "...You have the right to expect staff to respect your right to personal privacy and conduct treatments with discretion, providing as much modesty as possible..."

- Staff I was observed providing patient #23 perineal care on 10/19/10 at 9:00am with a visitor in the room. Staff I failed to pull the privacy curtain.

Staff M interviewed on 10/19/10 at 9:00am acknowledged Staff I failed to provide patient #23 with privacy during personal care.

- Observation of patient #22 in room #412 on 10/20/10 at 7:15am revealed patient #22 on the bedpan. Staff failed to provide the patient with privacy by closing the door or pulling the privacy curtain.

Staff G interviewed on 10/20/10 at 7:15am acknowledged the hospital staff failed to provide patient #22 privacy while on the bedpan

- Observation of patient #24 in room #4343 on 10/18/10 at 2:15pm, revealed staff assisted patient #24 to the commode. Staff failed to close the door or pull the privacy curtain prior to the moving the patient.

- The hospital failed to provide personal privacy to all patients.

Based on document review, record review and staff interview, nursing staff failed to follow hospital policy for blood administration for 1 of 3 sampled patients that received blood (#2).

Findings include:

- Review of the hospital policy for "BLOOD/BLOOD COMPONENTS ADMINISTRATION (PACKED CELLS, PLASMA, PLATELETS...)", last revised on 5/13/09, stated "...10. Only a RN (Registered Nurse) or physician can hang blood...Documentation: 3. Complete the Blood Administration Record ... "

- Review of patient #4's medical record on 10/19/10 at approximately 2:30pm revealed a physician's order for two units of packed red blood cells (PRBC) on 10/13/10. The blood transfusion record indicated staff administrated both units of blood but documentation lacked a signature by the nurse.

Staff U interviewed on 10/19/10 at 10:25am reviewed patient #2's blood transfusion record dated 10/13/10 and acknowledged the Blood Administration Record lacked a signature from the nurse who administered the blood. Staff U acknowledged without a signature they were unable to determine who administered the two units of PRBCs.

Staff W, from the contracted dialysis provider, interviewed on 10/20/10 at 7:16am reviewed patient #4's medical record and acknowledged the Blood Administration Record lacked a signature from the nurse who administered the blood.

Based on observations, staff interview and document review, the hospital's infection control officer failed to ensure 18 staff members followed infection control policies and acceptable standards of practice when they provided 18 of 24 sampled patients' care. The infection control officer failed to ensure staff followed acceptable standards of practice and hospital policy for hand hygiene, cleaning of equipment and trash removal.

The failure to follow hand hygiene standards, equipment cleaning standards and isolation policies placed patients, visitors and staff at risk for exposure to potentially infectious microorganisms.

Findings include:

- Review on 10/19/10 at 10:50am of hospital policy IC III-2 "Hand Hygiene" based on MMWR: October 25, 2005 described two method of acceptable hand hygiene: soap (detergent) and water and an alcohol based hand rub. The policy directed staff to perform hand hygiene at the beginning of scheduled shift, before and after every patient-patient environment contact, when moving from high contamination patient care activities to cleaner activities, before donning with sterile or non-sterile gloves, between glove changes, before any patient procedure or medication administration, after removing gloves at the completion of the episode of care and before going into a patient room and before leaving a patient room. Other Important considerations about hand hygiene listed: when hands are visibly soiled- use soap and water. If caring for a clostridium difficile patient - use soap and water....."
Clostridium difficile (klos-TRID-e-uhm dif-uh-SEEL), often called C. difficile or C. diff, is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon. Illness from C. difficile most commonly affects older adults in hospitals or in long term care facilities and typically occurs after use of antibiotic medications.
- The hospital placed alcohol based gel/foam dispensers outside each patient room for staff to perform hand hygeine as staff/visitors entered and exited each patient room.

- Staff N on 10/18/10 at 4:05pm performed a dressing change to the left foot of patient #6 in isolation for clostridium difficile. Staff N removed the old dressing and cleansed the wound. Staff N took off their gloves and applied new gloves. Staff N failed to wash their hands after removing the contaminated dressing.

- Physician O on 10/18/10 at 4:10pm failed to wash their hands or apply gloves and a gown as they entered the isolation room of patient #6 diagnosed with clostridium difficile. Physician O touched the patient and left the room without washing their hands. The contact isolation sign posted on the door of the room clearly stated that gloves and an isolation gown were required to enter the room and hand washing with soap and water was required before leaving the room. Physician O failed to follow hand hygiene and contact isolation precautions.

- Nursing staff M on 10/19/10 at 9:00am failed to perform hand hygiene when they entered room 443 to administer medication to the patient.

- Staff P on 10/19/10 at 11:00am performed a blood sugar check on patient #16 in contact isolation. Staff P failed to perform hand hygiene when they entered the patient room. Staff P applied gloves and a gown, repositioned the patient and proceeded to check the patient's blood sugar. Staff P reached into the pocket of their uniform with gloved hands to retrieve supplies and answer their cell phone. Staff P removed the glucometer (a machine used at bedside to test a patient ' s blood sugar level) from a protective plastic bag and performed the test. Staff P failed to clean the glucometer, then placed the contaminated glucometer back in the clean bag. Staff P removed their gown and gloves, washed their hands and left the room. In the hallway, Staff P removed the contaminated glucometer from the bag, cleaned it, and placed it back in the contaminated bag.

Staff P interviewed on 10/19/10 at 11:00am acknowledged they failed to follow acceptable infection control practices when they retrieved items with their gloved hand from their uniform pocket and placed the cleaned glucometer back into the contaminated bag.

- Staff P on 10/19/10 at 11:15am failed to perform hand hygiene when they entered patient #20's room to provide personal care.

- Staff Q on 10/19/10 at 1:00pm failed to perform hand hygiene when they entered room #408 to administer medication pass and provide patient care.

- Staff F on 10/19/10 at 9:00am failed to perform hand hygiene when they entered patient isolation room 402. Staff F determined the patient had soiled themselves. Staff F needed supplies not available in the room.. Staff F removed their gloves and gown, performed hand hygiene and left the room. At 9:25am Staff F failed to perform hand hygiene when they returned to the room.

- Staff T on 10/19/10 at 9:20am failed to perform hand hygiene when they entered patient #11's room to administer medications.

- Staff H on 10/18/10 at 2:30pm failed to perform hand hygiene when they entered patient #3 room to perform wound care.

- Staff I on 10/19/10 at 11:00am failed to perform hand hygiene when they entered patient #6's isolation room to perform an blood sugar check.

- Dialysis nurse X on 10/20/10 at 8:25am failed to perform hand hygiene when they entered patient #2's contact isolation room to perform a dialysis catheter dressing change.

- Staff E on 10/19/10 at 2:55pm failed to perform hand hygiene, gown and glove when they entered and exited a clostridium difficile isolation room 435/436. Staff U on 10/19/10 at 2:55pm acknowledged isolation precautions were required when entering room 435/436. Staff E acknowledged they failed to wear the required gown and gloves when they entered room 435/436.

- Review of hospital policy IC VIII-4 "Equipment Cleaning" on 10/19/10 at 4:00pm directed, "...Equipment can serve as a vehicle for transmitting pathogens"..."a sleeve device will be used or the equipment will be disinfected after use by the clinical staff, immediately after use..."

- Observation of staff X on 10/18/10 at 4:15pm revealed they entered isolation room 436, to get a chair for another patient's room. The staff member wiped the seat, backrest and arms of the chair with Dispatch Hospital Cleaner Disinfectant Towels. The staff member failed to clean the back of the chair or the legs and took the chair to another patient room. Failure to completely disinfect equipment or furniture could potentially transmit infectious microorganisms to other patients.

- Observation of patient #5 on 10/19/10 at 1:00pm revealed the urinary catheter bag laid on the floor. Staff Q interviewed on 10/19/10 at 1:00pm acknowledged the urinary catheter bag was on the floor and could potentially transmit infectious microorganisms from the floor to the patient.

- Observation of patient room 417 on 10/19/10 at 8:45am revealed an air mattress pump directly on the floor.

- Observation of room 406 on 10/19/10 at 9:30am revealed an air mattress pump sitting directly on the floor.

Staff A on 10/19/10 at 4:30pm acknowledged that patient care equipment laid on the floor could potentially transmit infectious microorganisms from the floor to patients.


- Staff L on 10/20/10 at 7:45am failed to perform hand hygiene when they entered patient #5's room to provide an aerosol treatment. Staff L placed a clipboard and the patient's daily chart on the bed. Staff L completed the aerosol treatment, removed the contaminated clipboard and chart from the bed, performed hand hygiene, and left the room. Staff L returned to the nurses station, laid the contaminated clipboard and daily chart on the counter. Staff L failed to disinfect the clipboard and daily chart.

- Staff G failed to perform hand hygiene on 10/20/10 at 8:10am when they entered patient #10's room, laid the daily chart in the windowsill, administered medications, picked up the contaminated chart from the windowsill, performed hand hygiene, and left the room. Staff G returned to the nurses station and laid the contaminated patient's daily chart on the counter, and then laid the contaminated chart on the medication-dispensing machine. Staff G failed to disinfect the patient's daily chart.

Staff A and Staff K interviewed on 10/20/10 at 8:30am reported they are required to take the patient's daily chart into the room for the final medication check. Staff members are required to disinfect the chart when leaving the patient's room.

- Staff V on 10/20/10 at 8:20am failed to apply a gown and gloves when they entered the room of patient #2 who was in a contact isolation.

- The hospital policy titled IC VIII-1 "Routine Daily Cleaning and Disinfection" reviewed on 10/19/10 at 10:50am directed "...Tie full trash liners securely before depositing into trash cart..."

- Housekeeping staff on 10/18/10 at 2:45pm removed trash bags from two overflowing trash cans from isolation room 435/436 and set the trash bag on the floor in the hallway. The hospital failed to follow their policy when staff placed trash bags on the floor.