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Based on record review and staff interview, it was determined the hospital failed to ensure:

a. infection control policies were developed and based on nationally recognized guidelines and applicable state and federal laws;

b. the hospital had policies and procedures relevant to construction, renovation, maintenance, demolition and repair; and

c. healthcare staff were aware and there were specific policies that addressed the appropriate use of soap and water handwashing versus alcohol based hand rubs. The hospital also failed to ensure those healthcare staff working with high-risk patients, such as the intensive care unit and the OR, did not wear artificial nails or extenders.

Findings:

1. On 09/04/12, staff A was asked to provide the hospital's current infection control policies and procedures for all departments. There was no global infection control plan and no comprehensive manual of hospital-wide infection control policies and procedures.

2. Staff G was asked if there infection control policies specific to facility maintenance. He stated there were no such policies. He further stated there was no infection control risk assessment applied to construction projects.

3. Staff A was asked for policies and procedures related to soap and water handwashing versus alcohol-based rub. No policies were provided. Unit staff interviewed did not know that alcohol-based rubs could not be used with patients who had c-difficile or the norovirus.

4. Staff B stated there were no hospital infection control policies regarding artificial nails and nail extenders.

5. In an interview in the patient unit Staff K told surveyors intravenous (IV) antibiotics were mixed by nursing staff. Staff K told surveyors she was trained when she came to the facility but did not receive any further education. Staff K told surveyors nurses would mix antibiotics in the medication room and out by where the supplies were kept. There was no documentation nursing staff were trained to mix IV antibiotics using aseptic technique. There was no documentation the Infection Control Practitioner and Quality Assurance reviewed antibiotic admixture techniques, medication administration techniques and practices to ensure safe medication practices.

5. Surveyors reviewed the housekeeping policies and procedures. Policies and procedures did not include current infection control practices. Policies and procedures were dated 1984. There was no documentation the current disinfection solutions utilized by the facility had been reviewed and approved through Infection Control committee. There was no documentation housekeeping employees were trained to use current hospital disinfectants and sanitizers.

6. On 9/4/12 surveyors were told the facility performed gastroenterology (GI) and surgical procedures. There were no policies and procedures reviewed, approved and implemented for the surgical services department. The facility did not have a log for sterilized equipment or a "flash" sterilization log. Staff B told surveyors the tapes from the sterilizers were the log. There was no identification as to what each load contained. There was no patient identification on the "flash" sterilizer tape as to what had been flashed and what patient the flashed instruments were used on . There was no policy on cleaning and disinfection of the operating room. There was no documentation the Infection Control practitioner or Quality Assurance Committee reviewed sterilization practices, hand hygiene, cleaning/disinfecting processes in the GI and surgery departments.

Based on record review and staff interview, it was determined the hospital failed to ensure:

a. the AIIR meets specifications for air exchanges;

b. patients and healthcare workers identified with MDROs are isolated according to policy;

c. a system was in place to identify infections present upon admission;

d. an updated list of stated reportable diseases was available and there were policies and procedures in place to submit reports as required to the OSDH;

e. healthcare personnel received job-specific training on hospital infection control practices, policies and procedures upon hire and at regular intervals;

f. the hospital followed current guidelines and practices for response to employee exposures to blood-borne pathogens;

g. the hospital provided appropriate follow-up for healthcare personnel with a TB test conversion;

h. healthcare staff wore gloves when contact with body fluids was anticipated and wore appropriate mouth, nose, and eye protection when aerosol-generating activities were likely to generate sprays or splashes;

i. there was an established cleaning schedule for areas/equipment such as HVAC, refrigerators, ice machines, eye wash stations, scrub sinks, and aerators on faucets;

j. soiled linen was maintained under negative pressure;

k. reusable non-critical patient care devices, such as blood pressure cuffs and oximeter probes, were disinfected when visibly soiled and on a regular basis, and that there was clear designation on who was responsible to clean them;

l. high-level disinfection of reusable instruments was performed to prevent infection and communicable disease;

m. updated and approved respiratory therapy infection control policies and procedures were available to all staff performing respiratory therapy care;

n. updated and approved infection control policies related to spinal injection procedures were available to all staff working with this procedure;

o. point of care devices, such as glucometers and lancet-delivery devices were used consistent with hospital infection control procedures;

p. isolation precaution policies and procedures addressed actions to be taken when a patient must leave the isolation room for diagnostic testing or procedures; and

q. the OR used cleaners and EPA disinfectants according to hospital infection control policies and manufacturer instructions.

Findings:

1. On 09/04/12, staff G stated the hospital had no method to monitor or ensure a certain number of air exchanges per hour in the OR or in the designated airborne isolation patient room.

2. The hospital had no written infection control policy that addressed how patients and healthcare workers would be identified with MDROs and what actions should be taken when they were identified.

3. Other than a few questions related to infection on the initial nursing assessment, there was no formal process in place to identify infections present upon admission. There were no infection control policies that addressed a system of identifying and responding to infections found at the time of admission.

4. Staff A was asked to provide a list of state reportable diseases used by the hospital, and for policies and procedures used for reporting. An August 2007 state reportable diseases list was provided to the surveyors. (The most recent list of state reportable diseases was published in July 2012.)

Staff H stated the lab reported diseases sometimes and the infection control nurse reported diseases sometimes as well. There were no policies and procedures to guide reporting to the OSDH. There was no comprehensive log of diseases reported to OSDH.

5. Staff I was asked to provide the course outline and curriculum used to train healthcare workers in job-specific infection control practices. The documentation provided was an employee orientation agenda with topics that included, "...TB, Infection Control, Universal Precautions and Bloodborne Pathogens.." No curriculum was provided for these topics. Staff I stated this training took about 20 minutes to complete, as it was a true/false question test.

There was no documentation of any job-specific infection control training upon hire or re-training annually.

6. The hospital was asked to provide documentation of the facility-wide blood-borne pathogen exposure control plan. Various policies and procedures were provided. There was no documented comprehensive blood-borne pathogen exposure control plan. One handout for employees from the CDC was dated 1993. A handout from the OSDH on Hepatitis C was dated 1994. A consent for testing after an occupational exposure was dated 1997.

A nursing department policy titled, "Needlestick", was dated 2002 and referenced an attached procedure for occupational exposure dated 1996.

There was no documentation the infection control plan included an updated occupational exposure control plan from OSHA or the CDC.

7. The hospital was asked to provide the facility-wide TB control plan. No plan was provided. There was no policy in place to address TB skin test conversion.

8. On 09/04/12 at 2:00 p.m., Staff J was observed carrying a full urinal to the dirty utility room. She did not wear gloves as she handled the urinal. She poured the urine into a large hopper and flushed it. The hopper stood at waist-level and generated a forceful flush with a potential to splash or aerosolize the material in it. She did not wear personal protective equipment.

9. Staff F stated there was no established cleaning schedule for HVAC, refrigerators, ice machines, eye wash stations, scrub sinks, and aerators on faucets. She stated they were cleaned as necessary. Environmental services policies had not been reviewed or updated since 1984.

10. Staff G stated the soiled linen was not stored under negative pressure before it was sent to the contract linen service.

11. Staff F stated blood pressure cuffs were cleaned when a patient room was terminally cleaned. She stated she did not know who cleaned the portable devices or how often they were cleaned. There were no housekeeping, nursing or infection control policies to address this or other reusable patient care items. There were no manufacturer's instructions for cleaning the reusable items.

12. Staff B was asked to provide documentation of high level disinfection for endoscopes. A spiral notebook was provided that included dates an endoscope was processed and a "pass-fail" notation. There was no documentation that indicated patient identifying information was recorded when an endoscope was used. There were no manufacturer's instructions provided to guide the care and cleaning of the endoscopes and no manufacturer's instructions for the processor itself or for the disinfecting solution used.

The sterile processing policies were last reviewed in 1994. The policies did not include:

~ the care and cleaning/disinfecting/sterilizing of brushes used in the decontamination area

~ how often and when enzymatic cleansers and detergents should be discarded during use

~ how instruments should be wrapped and packaged for sterilization

~ how chemical, process or biological indicators were used

~ sterile packs were labeled with the sterilizer used, the cycle or load number and the date of sterilization

~ handling and retention of sterilizer maintenance records

~ flash (immediate use) procedures and designated limits on its use

~ recall and risk assessment in the event of a reprocessing error/failure.

13. Respiratory therapy policies and procedures were reviewed. The policies had not been updated and reviewed annually to include all elements of infection control, such as the proper use and care of nebulizers.

14. There were no infection control policies and procedures related to spinal injections.

15. There were no infection control policies and procedures related to glucometers, pen lancets and other point of care devices. Unit staff stated sometimes the glucometers were wiped with alcohol after use. Some staff said a pen lancet was used on multiple patients but was not disinfected between them.

There were no manufacturer's instructions for the disinfection of these devices.

16. Isolation procedures did not include information about what staff should do and what precautions should be taken, and what information should be shared with another department, when an isolated patient needed to leave isolation.

17. Staff B and staff F were asked for policies, procedures and manufacturer's instructions for the use of cleaners and disinfectants in the OR. None were provided.

Based on review of meeting minutes, hospital policies, documents, and interviews the facility failed to ensure the governance was responsible for overseeing problems identified in the infection control program were addressed in Quality Assurance Performance Improvement (QAPI) committee.

Findings:

1. Review of Medical Staff Meeting Minutes and Quality Meeting Minutes for 2012 did not include findings from Infection Control activities with recommendations for implementing corrective action. There was no documentation in the Medical Staff Meeting Minutes or Quality Meeting Minutes the infection control data collected was reviewed, analyzed, trended with findings used for corrective action.

2. The facility did not have a current Infection Control Plan reviewed and approved through governance. There was no documentation the facility had a functioning infection control program.

3. The facility did not have current Infection Control Policies and Procedures reviewed and approved through governance. There was no documentation the facility had adopted and implemented Infection Control Policies and Procedures to improve patient safety and reduce the risk of hospital acquired infection.

4. There were no documented evidence of healthcare personnel competency and compliance with job-specific infection control policies and procedures. There was no mechanism for objective surveillance of healthcare workers as they performed infection control-related tasks. There was no identification of problem areas.

5. There was no documentation the hospital evaluated infection exposure events and developed and implemented corrective action plans in response to reduce the incidents of such events.

6. On 9/4/2012 Staff G told surveyors some areas of the hospital requiring special ventilation could not be assessed for compliance with the requirements. Staff G also told surveyors this information had been provided to administration. There was no documentation in any hospital meeting minutes regarding areas of the hospital not meeting ventilation requirements or plans to improve ventilation systems in an effort to come into compliance. Staff G told surveyors there were no policies and procedures for the physical plant which addressed infection control processes.

7. There was no documentation the facility had a blood borne pathogen exposure control plan reviewed, approved and implemented. There was no process in place which indicated how exposed employees would be treated and counseled. There was no documentation presented in governance meeting minutes indicating staff injury, illness, and immunization status information. See tag 0749

8. The hospital was asked to provide the facility-wide TB control plan. No plan was provided. There was no policy in place to address TB skin test conversion. Staff B told surveyors the facility was considered "low risk" for TB. There was no documentation provided which included a yearly TB risk assessment for risk determination.

9. The above findings were presented at the exit conference with administration. No further documentation was provided.