HospitalInspections.org

46511

Based on observation, interview, and policy review, the provider failed to ensure isolation protocols had been followed by one of one registered nurse (RN) (A) during a medication pass for one of one sampled patient (1). Findings include:

1. Review of patient 1's medical record revealed:
*She had been admitted on 11/17/24 and discharged on 11/20/24.
*A respiratory laboratory panel was ordered on 11/19/24.
*Her diagnosis was pneumonia and acute cystitis
*On 11/19/24 she was placed on isolation for droplet precautions.

Observation on 11/19/24 at 8:09 a.m. during patient 1's medication pass by RN A revealed she:
*Removed the patient's medications from the Pyxis (An automated medication dispensing device).
*Stopped outside of the patient's room with the medication cart and then:
-Performed hand hygiene, put on a face mask, and a clean pair of gloves.
--Posted outside of the patient's room was an isolation sign for droplet precautions.
--Droplet precautions required staff to wear the following personal protective equipment: goggles (recommended), a face mask, and a pair of clean gloves before entering the patient room.
-Entered the patient's room with the medication cart and administered several medications.
-Changed her gloves without performing hand hygiene in between.
-Assembled the nebulizer (neb) equipment, placed the medication in the neb machine's medication cup, and administered the patient two nebulizer treatments.
-Then wiped the top surface of the medication cart with a disinfectant wipe and exited the room.
-Removed her goggles and placed them on top of the isolation cart outside the patient's room, removed her mask, placed it in the wastepaper basket next to the isolation cart, and performed hand hygiene.
-Then returned the medication cart to the medication room.

Interview on 11/19/24 at 9:45 a.m. with RN A confirmed:
*The patient was in isolation for droplet precautions.
*She had taken the medication cart into the room to scan in the medications she administered.
*She was not aware of another process to scan the medications without the medication cart.
*She had only disinfected to top of the medication cart after leaving the patient's room.
*Only one medication cart was in use at that time for the medical unit.

Interview on 11/19/24 at 9:53 a.m. with RN A and infection control coordinator D confirmed:
*The medication cart should not have been taken into an isolation room.
*The potential for cross-contamination between patients could have occurred.
*Equipment used in isolation rooms required "deep cleaning" once the patient was no longer on isolation.
*Personal protective equipment worn in isolation rooms should have been removed prior to exiting the room.

Interview on 11/19/24 at 10:22 a.m. with director of patient care B confirmed:
*Nursing staff were to leave the medication cart outside the isolation room near the doorway.
*The scanning device was to be taken into the room and disinfected after use.
*She thought the supplies on that medication cart would have to be thrown away.
*She stated the nursing staff needed to be educated on not taking the medication cart into isolation rooms.

Review of the provider's November 2011 Droplet Precautions policy revealed:
*"Droplet Precautions are designed to prevent transmission of pathogens transmitted through respiratory droplets."
*"Any equipment brought into the patient's room for tests (e.g., EKG, x-ray, BP [blood pressure] cuffs, thermometers, etc.) must be cleaned with a facility approved disinfectant before it leaves the room).
*Whenever possible, dedicate equipment for duration of isolation (BP cuff, thermometers, etc.).
*Use disposable equipment whenever possible."
*"Masks are doffed [removed] in the patient room, near the door."

Review of the provider's February 2024 Avera Standard Precautions policy revealed
hand hygiene should have been performed immediately after gloves were removed and before new gloves were put on.