HospitalInspections.org

Based on medical record review and staff interview the hospital failed to ensure care plans include pertinent patient problems, are individualized and updated to reflect current patient care needs in 10 of 10 MR's reviewed (Pt #1,2,3,4,5,6,7,8,9,10). This can potentially effect all patients receiving care at this facility.

Findings include:

Review on 11/16/12 beginning at 9:25 am of Pt #1's MR, reveals Pt #1 was admitted on 10/15/12, Pt #1 is Hmong and non-English speaking and diagnosed with Multi drug resistant TB on 10/17/12. Per Pt #1's MR, Pt #1 is medication non-compliant. Review of Pt #1's care plan reveals no care plan initiated addressing communication barrier and medication non-compliance. Care plans for Pneumonia and Respiratory Distress are not individualized to specific patient needs and do not contain measurable goals. Pneumonia Plan of Care was last reviewed and signed off by staff on 10/23/12, 24 days prior to date of this survey, and the Respiratory Distress Plan of Care was last reviewed and signed off by staff on 11/3/12 13 days prior to date of this survey. Pt #1's Infection Plan of Care was not implemented until 11/16/12 over 1 month after Pt #1 was admitted to the hospital. This practice fails to ensure appropriate care plans are initiated and are kept current to address patients daily problems, goals, and interventions.

Review of Pt #2's MR on 11/16/12 beginning at 11:45 am reveals Pt #2 admitted for rule out TB on 10/16/2012, Pt #2's MR reveals Pneumonia Plan of Care used for Rule out TB, plan of care is not individualized to specific patient needs, and does not contain measurable goals. No interventions documented of respiratory hygiene or airborne isolation education given to patient to ensure patient understands treatment plan.

Review of Pt #4's MR on 11/16/12 beginning at 12:00 PM reveals Pt #4 was admitted on 10/4/12 for a diagnosis of Pneumonia, rule out TB. MR reveals Pneumonia Plan of Care used for Rule out TB, plan of care is not individualized to specific patient needs, and does not contain measurable goals. No interventions documented of respiratory hygiene or airborne isolation precaution education given to patient to ensure patient understands treatment plan as per Knowledge Deficit care plan.

Review of Pt #3's MR on 11/16/12 beginning at 12:15 PM reveals Pt #3 was admitted on 11/13/12 for a diagnosis of Pneumonia. MR reveals Pneumonia Plan of Care initiated. Plan of care is not individualized to specific patient needs, and does not contain measurable goals. No interventions documented of respiratory hygiene or droplet isolation education given to patient to ensure patient understands treatment plan as per Knowledge Deficit care plan.

Review of Pt #9's MR on 11/16/12 beginning at 12:25 PM reveals Pt #9 was admitted on 11/2/12 for a diagnosis of Obstructive Jaundice, rule out MRSA(Methicillin Resistant Staph Aureus). MR reveals GI Bleed Plan of Care is not individualized to specific patient needs, and does not contain measurable goals.

Review of Pt #10's MR on 11/16/12 beginning at 12:35 PM reveals Pt #10 was admitted on 11/13/12 for abdominal pain, rule out MRSA. No interventions documented of contact isolation precaution and MRSA education given to patient to ensure patient understands treatment plan.

Review of Pt #5's MR on 11/16/12 beginning at 12:40 PM reveals Pt #5 was admitted on 11/6/12 for a diagnosis of Pneumonia. MR reveals Pneumonia Plan of Care, plan of care is not individualized to specific patient needs, and does not contain measurable goals. No interventions documented of respiratory hygiene or droplet isolation precaution education given to patient to ensure patient understands treatment plan as per Knowledge Deficit care plan.

Review of Pt #6's MR on 11/16/12 beginning at 12:00 PM reveals Pt #6 was admitted on 10/31/12 for a diagnosis of asthma, rule out pneumonia. MR reveals No evidence of a Pneumonia Plan of Care initiated, Asthma plan of care is not individualized to specific patient needs, and does not contain measurable goals. Pt #6 was discharged on 11/3/12, asthma plan of care not reviewed or signed off on 11/2/12 or 11/3/12. No interventions documented of respiratory hygiene or droplet precaution education given to patient to ensure patient understands treatment plan.

Review of Pt #7's MR on 11/16/12 beginning at 1:00 PM reveals Pt #7 was admitted on 10/25/12 for a diagnosis of rule out Meningitis and Shingles. MR reveals Infection Plan of Care is not individualized to specific patient needs, and does not contain measurable goals. No interventions documented of respiratory hygiene or droplet precaution education given to patient to ensure patient understands treatment plan as per Knowledge Deficit care plan.

Review of Pt #8's MR on 11/16/12 beginning at 1:15 PM reveals Pt #8 was admitted on 10/15/12 for a diagnosis of Pneumonia. MR reveals Pneumonia Plan of Care was not initiated until 10/17/12, plan of care is not individualized to specific patient needs, and does not contain measurable goals. No interventions documented of respiratory hygiene or droplet precaution education given to patient to ensure patient understands treatment plan as per Knowledge Deficit care plan.

The above finding were confirmed at the time of MR review with Chief A, CNO F, RN K,

Based on observation and interview, the facility failed to provide adequate ventilation to maintain the required negative pressure of 0.01 in. of water column in one airborne infection isolation room of one patient sleeping unit in accordance with the recommendations in CDC and the American Institute of Architects (AIA) guidelines. This had a potential of affecting indeterminable number of patients and staff.

Findings include

During a tour of the facility with Staff B (director of facility services), and Staff C (facility manager) on 11/15/12 between 10 am and 12:45 pm, the surveyor observed that the pressure monitor visual alarm mounted on the outside of the Patient Room 265 was illuminated " Green " and that one HEPA filter fan was running in the ante room built on 11/9/12 just outside of the Patient Room 265. The HEPA fan exhausted air to the outside through one sealed opening in the exterior wall window.

When interviewed on 11/15/2012 between 1:40 pm and 2 pm, Staff D (maintenance technician) stated that he received a call from the unit staff, nurse supervisor, on 10/20/2012 at 1 am, and was informed that the red and green lights of pressure monitor alarm of the Patient Room 265 were turning " ON " and " OFF " instead of the green light continuously " ON " . Staff D stated that he came to the hospital a few minutes later, wore mask and went into the patient room, and heard the sound of exhaust fan running. He then asked the staff of the unit to relocate the patient in Room 265 to get access to the exhaust fan unit located in the ceiling space of the room. The patient was moved to Room 211. He stated that he found the 2 " thick pleated pre-filter of the fan unit very dusty, and replaced it with a new filter. He further stated that the negative pressure came back to normal with the green light of monitor alarm " ON " .

When interviewed on 11/15/12 between 1:45 pm and 2 pm, the facility manger acknowledged that the dirty exhaust grille was one of the contributing factors to a loss in negative pressure of the AII patient room 265. He further stated that the loss in negative pressure could also have been caused by a fluctuation in building static pressure.

The red light " ON " means a loss in negative pressure of the airborne isolation Patient Room 265 below the required minimum pressure differential of -0.01 in. of water column between the room and adjacent space. The room was occupied by an airborne infectious isolation patient on 10/19/12, based on review of pressure measurement log of the facility between 3 and 3:30 pm with Staff E (maintenane technician).

Upon reviewing the maintenance record of the exhaust fan serving the Patient Room 265, the
facility had performed a maintenance on the unit between 9/11 and 10/4/2012, but there was no evidence from the Work Order of 9/11/2012 that the pre-filter of the fan unit was checked and/or replaced.

The above deficient practice of not replacing the filter timely to allow the exhaust fan unit run efficiently and maintain required negative pressure in the AII patient room 265 had a potential of contaminating air in clean spaces with undesirable contaminants, and causing possible infection.

The above deficiency was acknowledged by the facility manager, who was present at the time of interview with the maintenance technician on 11/15/2012. Also, the surveyor confirmed the above deficiency with director of facilities services during a phone interview on 11/19/12 around 9:35 am.

Based on medical record review, staff interview, CDC guidelines for Preventing the Transmission of Mycobacterium Tuberculosis 2005, and the facilities TB Exposure Control Plan, the facility failed to initiate prompt detection and initiation of airborne precautions of persons presenting with signs and/or symptoms of TB (Tuberculosis) disease in 1 of 10 MR's reviewed (Pt #1). This can potentially effect all patients receiving care at this facility.


Per review of the "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005" facilities should develop a written TB infection-control plan that outlines a protocol for the prompt recognition and initiation of airborne precautions of persons with suspected or con?firmed TB disease, and update it annually. Patients with suspected or confirmed infectious TB disease should be promptly identified, evaluated?, and separated from other patients.

Per review on 11/16/2012, of the facilities "Tuberculosis Exposure Control Plan Part 1 (Patient)" last reviewed 1/12, there shall be a high index of suspicion for tuberculosis in patients presenting with pulmonary symptoms, particularly patients in high-risk groups including but not limited to the following: Foreign-born persons from countries with high TB prevalence i.e. Asia. Symptoms suggestive of TB disease include but are not limited to the following: Fever of unknown origin, night sweats, productive, persistent cough greater than 3 weeks, unexplained weight loss, blood in sputum, fatigue, loss of appetite.
Per the TB Exposure Control Plan Part 1, the nurse admitting the patient will assess the patient for possible TB using the "TB Assessment Airborne Isolation Determination Tool" and consult with a physician. All patient admissions with symptoms suggestive of TB shall be evaluated using the TB Assessment for Airborne Isolation Tool Attachment A. When a patient is put into airborne precautions, related to a positive assessment for TB, airborne precautions will be maintained until MD has ruled out TB and established a different diagnosis.

Findings include:

Per review of Pt #1's MR on 11/15/12 beginning at 2:21 PM, Pt #1 presented to the ER on 10/15/12 at 1:07 PM via ambulance. Per ER documentation, Pt #1 presented with a temperature of 100.3 Fahrenheit, Cough, generalized weakness, and a history of Tuberculosis. Per History and Physical completed by MD L on 10/15/12 at 6:49 PM, Pt #1 is a 85 year old Hmong female, non-english speaking who presented to the ER with complaints of generalized weakness and feeling tired. Per H &P, Pt #1 has a history of TB exposure in 1980 while in a refugee camp and was treated with INH (Isoniazid) medication for 6 months. Pt #1's X-ray is abnormal with "right upper lobe bronchiectasis with cystic changes". MD L's Assessment and Plan documented on the H & P states the following, "History of tuberculosis, status post 6 months of INH, (Pt #1) has chronic right upper lung abnormality, we are going to repeat a CT of the chest, make sure there is no change. Per MD L's H&P, Pt #1 was being treated for possible pneumonia and admitted with a diagnosis of Transient Ischemic Attack and rule out for a Cerebral Vascular Accident (Stroke).
Despite Pt #1's signs and symptoms of TB in the ER and MD L's plan on 10/15/12 to rule out possible TB via CT of the chest, Pt #1 was not placed in airborne precautions immediately to protect other patients and staff from the transmission of TB.
Per interview on 11/15/12 beginning at 2:21 PM, with RN I and ER Manager J, ER staff do not use specific TB screening tool or TB assessment to identify patients at risk for TB. Per RN I, Pt #1 presented to the ER with confusion and weakness so staff did stroke and pneumonia protocol and did not assess for possible TB.
Per review on 11/16/12 beginning at 9:25 AM, NP M signed the "Orders for Adult Suspect/Rule-out TB Physician order sheet and initiated TB protocol on 10/17/12 at 10:47 AM. NP M's Progress Note dated 10/17/12 at 11:22 AM reveals the following documentation, "This patient is Asian, has been losing weight and has upper lobe consolidation as well as other pulmonary findings on (Pt # 1's) CT, we will initiate the TB rule out order set and the patient will be placed in airborne isolation..." Review of Pt #1's MR reveals no documentation on 10/17/12 of what time Pt #1 was transferred to the negative pressure room or documentation of what immediate actions were taken to ensure Pt #1 was transferred promptly and precautions were immediately initiated to protect patients and staff. Per interview on 11/16/12 beginning at 10:45 am with RN K, Pt #1 transferred to negative pressure at 3:00 PM when RN documented accountability for Pt #1 on floor 2k room 265. Per Pt #1's MR review, there is no evidence that staff initiated any immediate protective measures to prevent further transmission of TB prior to transferring Pt #1 into negative pressure room to initiate airborne precautions between starting TB protocol at 10:47 am and transferring Pt #1 at 3:00 PM.
Per review of room #265's Negative Pressure Room Log, from 11/1/12 to 11/6/12 there is no documentation of room 265's negative pressure reading. Per the Tuberculosis Exposure Control Plan, Plant Operations is to check negative pressure daily while room is in use. This was confirmed with Chief A on 11/16/12 at approximately 12:30 PM.
Per Pt #1's sputum labs collected on 10/17/12 at 4:20 PM, Pt #1 tested positive for Mycobacterium Tuberculosis. The facility failed to promptly detect and initiate airborne precautions from 10/15/12 to 10/17/12 despite Pt #1 having a history and signs and symptoms of TB.
Facility tested all staff who had contact with Pt #1 from 10/15/12 to 10/17/12 and any other staff who had contact with Pt #1 after 10/17/12 who requested a TB test, and at the time of the survey no staff members had tested positive for TB.