HospitalInspections.org

Based on observation, interview, and document review the facility failed to maintain an ongoing infection control program designed to prevent, control and investigate infections and communicable diseases for resulting in the potential for transmission of infectious agents for all patients served by the facility. See specific tags:

A 0749 - The facility failed to follow policy and procedure for reducing risk of infection, failed to ensure an in-use patient device (catheter bag) was kept free from exposure to potential infectious contaminates, failed to ensure the cleanliness of all areas within the facility, failed to ensure items were cleaned and stored in designated areas.

A 0756 -- The facility failed to ensure that the infection control program was integrated into the quality assessment and performance improvement program (QAPI),

Based upon observation, interview, and document review the facility failed to ensure staff followed policy and procedure for reducing risk of infection, failed to ensure an in-use patient device (catheter bag) (one of seven) was kept free from exposure to potential infectious contaminates, failed to ensure a clean environment in the dietary kitchen servicing patients and visitors, and failed to ensure items were clean and stored in designated areas resulting in the potential of the spread of infection to all patients receiving services at the facility. Findings include:

On 10/16/2018 at 1025 during observation it was noted staff TT, a cardiologist, was walking through the unit donning a surgical skull cap. On 10/16/2018 at 1040 during observation in the sterile surgical area staff DDD, a cardiologist, was observed donning a surgical skull cap without the presence of a bouffant covering.

On 10/16/2018 at 1040 an interview occurred with staff L, the manager of the Cardiovascular Catheterization Lab. Staff L was queried if staff were required to wear bouffant coverings in restricted areas. Staff L stated, "I am not aware of the requirement, but we can change that effective immediately."

On 10/17/2018 at 1615 a document review occurred of the policy titled, "Surgical Attire", policy no. 2 POS 012, effective date 06/01/2018, states "2. c. Disposable skull caps must be covered with a hospital provided disposable bouffant head covering."

On 10/16/18 at 1500 while touring 6 ICU (Intensive Care Unit) a urine collection device (catheterization collection bag) in patient use (room #6504) was observed to be hanging from the side of the bed frame and touching the floor. At the time of the observation staff Y was queried if the catheter bag should be in direct contact with the floor. Staff Y responded, "well it is because there is urine in the bag." Staff Y was again queried if the catheter bag should be in direct contact with the floor. Staff Y responded, "no...it should not be touching the floor."

On 10/17/2018 at 1330 a tour was conducted of the hospital kitchen. The floor in the kitchen preparation area was found to have multiple large spills. The floor in the grill area was found to have an accumulation of dirt and debris. The tray holding rack near the grill area was found to have a black film substance on each holding rack arm where trays sit for holding food. The designated clean gray tubs (four of four observed) for holding clean instruments were observed to have a large quantity of dust and debris located in the bottom of the tubs. The walls located near trash receptacles were found to be splattered with a red fluid substance. The floor area in-between the grill area and the storage area of clean cooking instruments was found to have a floor drain with thick silver tape surrounding the drain. On 10/17/2018 at 1338 the walk-in cooler used for the storage of food prepared for patient use was found to have a large bowl of prepared romaine lettuce wrapped but failed to have a date of preparation displayed. Additionally, in the walk in cooler 46 single serve dishes of peaches were found to be unwrapped and undated open to air. Four full sized trays approximately 21" x 29" of red gelatin were found to be open without wrapping and exposed to the air. Three trays containing approximately 28 individual servings of chocolate cake were found uncovered and exposed to the air. Staff NN, the Director of Dietary was queried if items were to be covered and dated. Staff NN replied, "yes." Further tour of the kitchen area revealed three service carts with debris located on top and bottom shelving. Four cardboard boxes used which had been used from outside delivery of items were found within the kitchen area. Staff NN was queried if boxes which had been used for outside delivery were to be located in the kitchen area. Staff NN stated, "no ...boxes that have been exposed to the outside are supposed to be discarded and not brought into the actual kitchen preparation or storage areas."
Further tour of the kitchen area revealed a covered silver drain located in the floor in the clean food preparation area was found to have silver tape surrounding the drain. Staff NN was asked why the tape was covering all the edges of the drain. Staff NN stated he wasn't sure why the tape was surrounding the drain.


38269

On 10/16/18 at 1335 during a tour of 8 ICU (intensive care unit) in room 8509 three filled patient belonging bags were observed sitting directly on a functioning heating system. At 1337 the tour continued to room 8506 where an electrical unit identified as a pulse oximeter was observed sitting directly on a functioning heating system. In addition to the items sitting on the heaters, the heating systems at either end of the 8 ICU hallway were observed to have a large amount of accumulated dust in the vents. When queried at the time of observation Staff Nurse Manager U stated, "nothing is supposed to be placed, on the heat vents and they know that. I will have EVS (environmental services) get the vents cleaned out too."

On 10/16/18 at 1345 during observations on 8 ICU at 3 different times small black bugs were observed flying around. At the time of observation, 8 ICU Charge Nurse Staff X stated that "these bugs have been here for a long time, more than three months. We usually see more of these gnats in the summer, but this fall has been bad." On 10/16/18 at 1350 during an interview, Nurse Manager Staff U stated, "we are aware of the gnats and have placed several work orders." Copy of work orders were requested for review, but not received prior to survey exit.

On 10/16/18 at 1407 in 8 ICU room 8508 a digital thermometer was found stored in a cabinet located beneath the sink. The beneath sink cabinet was filthy, brownish rust discoloration was noted with dust and debris scattered throughout. At 1408 Staff U stated "I am not sure why this thermometer is there it is old. We do not even use those thermometers anymore. Everyone knows we do not store things under the sinks."

On 10/16/18 at 1410 in 8 ICU room 8505, unlabeled/undated irrigation fluid was found stored in a below sink cabinet. The cabinet beneath the sink was observed to be filthy, debris and dust easily visible.

Review of policy No. 2IC 033, effective date 04/20/2018 Titled "Infection Control in the Environment of Care" page 2 of 4 under "5 Bedside supplies ...C. Sterile water or sterile saline must be discarded 24 hours after opening." Page 3 under "ADMINISTRATION RESPONSIBILITY" last sentence of paragraph read "The supervisor/coordinator in each clinical service site has operational day-to-day responsibility for administering this policy."

On 10/16/18 at 1415 the tour continued to 8 ICU room 8502, the beneath sink cabinet was observed to be in disrepair with evidence of water damage and brown/rust discoloration.

On 10/16/18 at 1416 during an interview, Staff U stated, "Great we are batting a thousand, this is an old area slated for remodel, but who knows when. They know there should be nothing stored under the sinks. Environmental services should have kept these cabinets clean, actually they should be permanently closed."

On 10/16/18 at 1500 while touring 6 ICU the laminate on the nurse's station was observed to be chipped in multiple areas and drawers to be in general disrepair. At the time of tour "gnats" were observed in the patient care areas of 6 ICU. On 10/16/18 at 1505 while touring 6 ICU, caulk located behind the sink area, between the counter and wall was observed to be loose, not intact, lifted from the wall and discolored, leaving the area suitable to harbor bacteria and unable to be disinfected, in four of four (rooms 6501, 6502, 6505, 6506) patient rooms observed.

On 10/16/18 at 1515 the nourishment room on 6 ICU was observed to be unkept and generally disheveled. The floors were unclean, all drawers where patient nourishment snacks were stored, had debris and crumbs scattered throughout. When a hand was run across the top of the microwave and refrigerator, high dust was found. The bottom shelving inside the refrigerator had a dried spill, whitish gray in color and of unknown origin. In addition, a patient identifier sticker was observed adhered to the bottom shelf in the refrigerator. Three utensil dispensers hanging on the wall were noted to be filled with debris and dust in the dispensed area. At the time of observation, (the Manager of 6 ICU) Staff Y stated, "I put a work order in to have that cleaned, that is disgusting I wouldn't use that silverware." Evidence of work order was not available for review prior to survey exit.

On 10/16/18 1535 while touring 5 ICU, five WOWs (work stations on wheels) were observed to be sitting outside of patient rooms along the wall. Five of five WOWs observed had a large amount of dust around the lower base of the wheeled cart. At the time of observation, when queried as to who's responsibly it was to keep the WOW free of dust, Staff Y stated, "it's really unclear, we need to do better."

Review of policy No. 2IC 033, effective date 04/20/2018 Titled "Infection Control in the Environment of Care" page 2 of 4 under "4 ...G Bedside computers, handheld devices and bar code scanners will be cleaned with DMC (Detroit Medical Center) approved disinfectant wipes on a weekly basis, when visibly soiled, if contaminated with blood or body fluids and upon exit from an isolation room." Page 3 under "ADMINISTRATION RESPONSIBILITY" last sentence of paragraph read "The supervisor/coordinator in each clinical service site has operational day-to-day responsibility for administering this policy."

On 10/17/18 at 1400 while touring third floor Webber, labor and delivery/ high risk unit Staff HHH (environmental service, "housekeeper") was observed pushing a white wheeled cart with two shelves. The upper shelf was observed to have a travel cup with a straw, two cans of open soda, a lunch bag, a bottle of cleaning solution and a bag with what appeared to be material of some sort. The lower shelf held a large bag of blue replaceable mop heads. When queried Staff HHH stated, "these are my drinks, my lunch bag and my coat is in the bag, the bottle has cleaning solution in it and the bottom shelf has our mop heads. I am the housekeeper for this floor including the operating rooms. I just came back from lunch. I do not know what the policy is for transporting personal items with cleaning supplies."

Review of policy No. I CLN 022, (no effective date found) Titled "Staff Covered Beverages" page one, paragraph one. "According to the Occupational Safety an Health Administration (OSHA) ... .....employees should prohibit eating, drinking, smoking applying cosmetics and lip balm and handling contact lenses in work areas where there is reasonable likelihood of occupational exposure to blood, body fluids or chemicals." Page one on the table clarifying locations where beverages may and may not be present line 14 reads as follows: under column, location "Housekeeping carts" Under column, Covered Beverages (Staff) Permitted? "NO"

On 10/17/18 at 1410 the tour continued to the sterile corridor of the OR (Surgical Operating Room area) of third floor Webber. Upon entering OR suite two a table was observed in the back area of the suite, to have blue towels draped over it. At the time of observation, when queried regarding what was under the blue drapes, Nurse Manager Staff VV stated, "we received a call regarding an impending delivery, the scrub opened the trays and prepared the room." When staff VV was asked how far ahead of time may a room and sterile equipment be open and if staff would have to stay in the room once the trays were open. Staff VV stated, "If we receive a call we open, staff can be in the corridor they just can't leave the sterile corridor."

Review of "Policy No. 2POS 011 Title Sterile Technique Effective Date: 10/15/16" page One, "IV. Provisions: ...d. Establishing and maintaining a sterile field includes the following 1. The field is prepared as close to the time of use as possible. 2. The sterile set up may be used if the sterility of the field has been visually maintained. 3. Sterile fields are not to be covered.

Based on interview and document review the facility failed to ensure the Infection Control Program was incorporated in the Quality Assurance Performance Improvement Program for four of six months (January 2018 through June 2018) resulting in the potential for missed opportunities for corrective action and quality improvement. Findings include:

On 10/17/2018 at 1100 an interview was conducted with the designated Infection Control Preventionist, staff LL. Staff LL was queried what infection control surveillance encompasses in the infection control program at the facility. Staff LL stated, "I monitor several areas for infection control..." Staff LL provided a document for review referencing the eleven surgical site infections post Cesarean section which occurred from June 2018 to September 2018. Staff LL was queried if the information had been shared with Quality. Staff LL stated, "it has been shared with physicians but I don't think Quality has met for September data to be shared."

On 10/18/2018 at 0900 during review of the quality minutes titled, "Leadership Performance Improvement Coordinating Committee (LPICC)" it was revealed the Infection Control Department presented information on January 24, 2018 and on March 28, 2018. A request for any additional infection control information shared with the LPICC committee was made prior to exit. Additional information provided consisted of graphs of reportable NHSN requirements for hospitals with tracked data but failed to indicate any Infection Control Improvement Projects for the facility or facility specific areas for needed improvement for Infection Control measures.

On 10/18/2018 at 0955 an interview was conducted with staff SS, the Director of Infection Control. Staff SS was asked how information and data was shared with the Quality Program for the facility. Staff SS stated, "I have presented information to the Quality Program twice this year ...once in January and once in March." Staff SS was then asked how information is shared with quality once an increase is identified with infections such as the two hysterectomies in July 2018 related to post-surgical infections from Cesarean sections. Staff SS responded, "The data is shared with the physicians and the data is reported to quality." Staff SS was asked whether she reported the data in quality meetings. Staff SS stated, "No ...I have not been invited to quality since March (2018), but my information is sent to quality."