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Based on interview and record review, the hospital failed to document the indication for urinary catheter insertion in 1 of 1 patient record reviewed.

Failure to document the need for urinary catheters risks catheters being placed unnecessarily or remaining in place longer than needed resulting in an increased risk of catheter-associated urinary tract infection.

Reference:

Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009
Healthcare Infection Control Practice Committee, CDC and Department of Health and Human Services

"I. Appropriate Urinary Catheter Use
Insert catheters only for appropriate indications, and leave in place only as long as needed."

Findings:

Patient #2 was a 77 year old patient admitted to the Intensive Care Unit on 8/5/2012 for treatment of abdominal pain/ischemic bowel. A urinary catheter was placed in the emergency department upon admission. Review of the medical record on 8/8/2012 revealed that the date of catheter insertion was documented but there was no indication for catheter placement documented nor was there documentation indicating the ongoing need for a urinary catheter.

An interview with a registered nurse (Staff Member #2) revealed that it was not the practice of the hospital to document indication for insertion of urinary catheters or to document ongoing need for a urinary catheter.
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Based on observation, interview, and review of hospital policies and procedures and infection control documents, the hospital failed to develop and revise infection control policies and procedures according to nationally recognized guidelines and recommendations; and to ensure that all hospital health care providers adhered to these policies and procedures.

Failure to develop, revise, and implement policies and procedures in accordance with nationally recognized guidelines and recommendations risks transmission of communicable diseases to patients, staff members, and visitors.

Findings:

Item #1 - Infection Prevention and Control Policies and Procedures

1. Review of the hospital's policy and procedures entitled "Infection Control Plan During Construction/Renovation" (Policy/Procedure #HW.IC.1.8; Revised May 2005) revealed the policy had not been reviewed since June 2008. The policy did not reflect references to current guidelines for infection prevention during facility construction and renovation, such as those published by the CDC ("Guidelines for Environmental Infection Control in Health-Care Facilities, 2003")

An interview with the hospital's infection preventionist (Staff Member #1) on 8/7/2012 at 1:30 PM confirmed that the policy had not been revised since 2005 and stated that the policy did not reflect the hospital's current online automated ICRA process.

2. Review of the hospital's policy and procedure entitled "Drug Resistant Microorganisms" (Policy/Procedure #HW.IC.1.4; Revised November 2004) revealed the policy had not been reviewed since June 2008. The policy stated that a patient colonized with an MDRO would be treated using standard precautions instead of being placed in contact isolation. The policy did not identify actions the hospital should take if a healthcare worker was colonized or infected with an MDRO. The policy did not reflect references to current guidelines for prevention of transmission of MDROs, such as those published by the CDC (Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006").

3. The hospital's policy and procedure entitled "Active Surveillance for Methicillin-Resistant Staphylococcus Aureus (MRSA)" (Policy #HW.IC.1.38; Approved August 2010) directed hospital staff members to obtain a nasal culture and initiate contact isolation for patients with a history of MRSA infection.

An interview with the hospital's infection preventionist (Staff Member #1) on 8/7/2012 at 1:00 PM revealed that patients were not asked if they had a history of MRSA during their nursing admission assessment.

4. On 8/7/2012 at 11:10 AM, a respiratory therapist (Staff Member #12) was observed performing a patient's nebulizer treatment (breathing treatment). Following the treatment the respiratory therapist placed the patient's mask, cup and tubing into a plastic bag and hung the bag on the wall behind the patient's bed. Staff Member #12 did not clean the equipment following the patient's treatment.

An interview with Staff Member #12 following the observation revealed that it was not the hospital's policy to clean the nebulizer equipment between treatments.

Review of the hospital's policy and procedure entitled "Small Volume Nebulizer" (Policy/Procedure #750-47; Revised August 2010) did not include instructions to staff regarding cleaning nebulizer equipment.
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CDC "Guidelines for Prevention of Healthcare Associated Pneumonia 2003" state that small-volume in-line or hand-held medication nebulizers should be cleaned, disinfected, and rinsed with sterile water (if rinsing is needed), and dried between treatments.

5. An interview with the hospital's infection preventionist (Staff Member #1) on 8/8/2012 at 11:00 AM revealed that the hospital did not have a policy and procedure for responding to recalls of sterilized surgical supplies, instruments, and other equipment in event of a reprocessing error or failure that could result in the transmission of infectious disease.

6. An interview with the hospital's infection preventionist (Staff Member #1) on 8/7/2012 at 3:00 PM revealed that the hospital did not have a policy and procedure that clearly identified responsibility and schedules for cleaning refrigerators, ice machines, eye wash machines, scrub sinks, and aerators on faucets


Item #2 - Hand Hygiene

1. The hospital's policy and procedure entitled "Hand Hygiene" (Policy # HW.IC.01.04.01.5; Effective date 4/4/2012) read as follows: "D. Personnel should always perform hand hygiene under the following settings: 1. Before and after having direct contact with patients; 2. After removing gloves; 3. Before handling an invasive device for patient care, regardless of whether or not gloves are used; ... 6. After contact with inanimate objects in the immediate vicinity of the patient; ... 7. Before handling medication or preparing food."

2. Observations for compliance with hand hygiene policies and procedures revealed the following:

a. On 8/7/2012 at 1:15 PM, a registered nurse (Staff Member #10) was observed preparing to place an intravenous (IV) catheter in a patient admitted to the emergency department. Staff Member #10 gathered supplies from a supply cart in the room and reported to Surveyor #2 that she/he had washed her/his hands prior to entering the room. After touching multiple surfaces and supplies Staff Member #10 put gloves on and started the IV without performing hand hygiene.

b. On 8/7/2012 at 3:30 PM, Staff Member #8 removed her gloves while performing terminal cleaning of Room #455, then did not perform hand hygiene prior to donning new gloves.

c. On 8/8/2012 at 8:10 AM in OR #1, Anesthesiologist #3 removed his gloves and replaced a vial of medication in the automated medication. He then touched a patient and equipment prior to performing hand hygiene

d. On 8/8/2012 at 9:00 AM, a registered nurse (Staff Member #11) was observed drawing blood from a central line. Staff Member #11 performed hand hygiene then left the room to collect supplies. Upon returning to the room Staff Member #11 proceeded with the blood draw by donning gloves but did not perform hand hygiene prior to putting the gloves on.

e. On 8/8/2012 at 9:20 AM in the sterile instrument reprocessing area, Staff Member #7 removed her gloves, then touched a clean cart prior to performing hand hygiene.

f. On 8/8/2012 at 11:25 AM, a registered nurse (Staff member #11) was observed administering oral medications to a patient. As Staff Member #11 entered the room she/he performed hand hygiene and put on gloves. Staff Member #11 handled the patient's water cup, and touched the patient's medication administration record with her/his gloved hands. The patient was unable to put the oral medications in her/his mouth so Staff Member #11 fed them to the patient one at a time (touching each of the pills) without removing her/his contaminated gloves, performing hand hygiene and donning clean gloves.


Item #3 Isolation Precautions

1. The hospital's policy and procedure entitled "Guidelines for Isolation Precautions" (Policy #HW.IC.01.04.01.1; Effective date 4/4/2012) read as follows: "I. Transportation of Patients 5. Notify receiving area of patient's isolation precautions."

2. Observations for compliance with isolation precaution policies and procedures revealed the following:

Patient #1 was a 75 year-old patient admitted on 8/7/2012 for treatment of a left hip wound that cultured positive for MRSA (methicillin resistant staphylococcus aureus).

On 8/8/2012 at 2:20 PM, Patient #1 was transported to the CT area in diagnostic imaging for a CT scan. There was no visible sign on the patient's transport bed or chart indicating the patient was in contact isolation.

Surveyor #2 observed a Radiologic Technologist (Staff Member #14) and Radiologist (Staff Member #15) move Patient #1 from the hallway into the CT scanning room and proceed with the scan without using appropriate attire (gloves and gown) when in contact with the patient.

Gloves were worn by both staff members (Staff Member #14, #15) when the patient's wound dressing was removed, when placing contrast dye into the wound, and when re-dressing the wound. Gloves were put on and removed multiple times during the procedure. Hand hygiene was not consistently performed after removing gloves and before touching supplies and surfaces within the CT scanning area.

Following the procedure Patient #1 was moved from the scanning table back to the transport bed and placed in the hallway while awaiting a transporter to take him/her back to his/her room. Staff Member #14 did not clean the CT scanner table after moving Patient #1 into the hallway.

Surveyor #2 asked Staff Member #14 if s/he knew that Patient #1 was in contact isolation. Staff Member #14 said that he/she did not know. Surveyor #2 asked Staff Member #14 what the normal protocol would be for doing a CT scan for a patient in contact isolation. Staff Member #14 stated that s/he would wear gloves and a gown when touching the patient and s/he would clean the CT scanner table with special wipes after scanning the patient.

An interview with the quality program coordinator (Staff Member #2) regarding the observation of Patient #1's CT scan and Staff Member #14's lack of knowledge about Patient #1's isolation status revealed that isolation status is communicated via a form entitled "Trip Ticket". There is an area on the form for staff transferring a patient to another area of the hospital to record pertinent information including isolation precautions. The sending and receiving staff were to sign the form in acknowledgement of receiving the patient as well as the information on the form.

Review of Patient #1's trip ticket revealed that isolation precaution was marked "yes" and sending staff had written "MRSA to hip L " but did not state the type of isolation precaution that was required. In addition, Staff Member #14 had not signed the document indicating receipt of the patient's transfer information.


Item #4 - Surgical Attire

1. The hospital's policy and procedure entitled "Surgical Services Attire - Personnel" (Policy #HW.IC.01.04.01.3.1; Effective 1/1/2012) stated that all personnel entering the semi-restricted and restricted areas of the OR were required to wear "appropriate apparel". The policy stated that hair must be completely covered per AORN and AST standards. The policy stated that individuals with facial hair were to wear a disposable hood. The policy state that surgical masks would be worn in the OR suite whenever a sterile environment was being maintained. The policy stated that surgical masks would be removed at the end of the surgical procedure and changed between procedures.

2. Observations for compliance with surgical attire policies and procedures revealed the following:

a. On 8/8/2012 at 7:30 AM, Surveyor #1 observed Anesthesiologist #1 wearing a cap that did not cover all the hair on his head and no covering over his beard.

b. On 8/8/2012 at 7:40 AM, Surveyor #1 observed Anesthesiologist #2 put on a surgical mask after entering the OR after sterile packs had been opened.

c. On 8/8/2012 at 8:45 AM, Surveyor #1 observed Anesthesiologist #2 wearing a surgical mask around his neck in the OR nurses station. When asked by the surgery director to remove his mask, the anesthesiologist stated he never changed his mask between cases.


Item #5 - Cleaning and Disinfection

Observations for compliance with cleaning and disinfection policies and procedures revealed the following:

1. On 8/7/2012 at 3:35 PM, Surveyor #1, the hospital's infection preventionist (Staff Member #1) and the hospital's housekeeping supervisor (Staff Member #9) observed Staff Member #8 clean room #455 after the patient had been discharged from the hospital. During this process, Staff Member #8 dusted the top of the patient clothes closet after cleaning the bed, the bedside tables, and other surfaces below. Staff Member #8 cleaned the patient's sink prior to cleaning the toilet. While cleaning the sink, Staff Member #8 placed the bottle of germicide on the floor, then placed the bottle on her cleaning cart.

The infection preventionist and the housekeeping supervisor stated at the time of the observation that these actions were not according to the hospital's policy and procedure for cleaning patient rooms.

Review of the hospital's policy and procedure entitled "Routine Discharge - Room Cleaning" (Policy/Procedure #HW.IC.1.27; Reviewed 6/13/2008), a second procedure not in hospital-approved format entitled "Discharge or Turnover Room Cleaning" (No date), and two checklists entitled "Patient Bathroom Rounding Checklist" and "Environmental Cleaning Checklist" revealed that there was no single policy and procedure to inform housekeeping staff members how clean a patient's room.

2. On 8/8/2012 at 8:20 AM, Surveyor #1 observed surgery department staff members clean OR #1 following a surgical procedure. One surgery staff member cleaned top of lights at same time another staff member was placing clean linen on the OR table. This risked cross-contamination of the linen with dust.

Review of the hospital's policy and procedure entitled "Surgical Suite "Turnover" Cleaning" (Policy #HW.IC.02.02.01.4; Effective 9/23/2011) revealed that the procedure did not direct staff to clean high level surfaces prior to replacing linen on the surgical table.

3. On 8/8/2012 at 9:40 AM, a registered nurse (Staff Member #11) was observed preparing an injection for a patient. Staff Member #11 opened a single dose vial, inserted the needle and drew the medication into the attached syringe. Staff Member #11 did not disinfect the vial septum prior to inserting the needle.

An interview with Staff Member #11 following the procedure revealed that it was not common practice for staff to disinfect the rubber septum of a newly opened medication vial prior to piercing with a needle.

An interview with the infection preventionist (Staff Member #1) on 8/8/2012 by Surveyor #1 revealed that it was the policy of the hospital that the rubber septum of medication vials be disinfected prior to piercing with a needle.

4. On 8/7/2012 at 11:40 AM, a nursing assistant (Staff Member #13) was observed checking patient's blood glucose levels using the Nova StatStrip device. Staff Member #13 removed the device from the docking unit located at the nursing station and used the device to check the blood glucose level of two patients then returned the device to the docking unit. Staff Member #13 did not clean the device between patients nor did s/he clean the device prior to returning it to the docking unit.

An interview with Staff Member #13 following the procedures revealed that s/he thought that the point of care device was to be cleaned once a day on night shift.

The hospital policy and procedure entitled "Glucose Testing the Nova StatStrip Device" (Policy No. HW.WT.03.01.01.4; Origin date 10/2009) read as follows: "VIII. Device Maintenance. 1. Between each patient: a. Wipe the entire device with a Sani Wipe that has been squeezed to remove excess moisture."

Staff member #13 did not follow hospital policy and procedure for cleaning the point of care device.

5. On 8/8/2012 at 7:25 AM, Surveyor #1 observed that the tips of three endoscopes were touching the side of the tray in the bottom of the endoscopy storage closet. An interview with the surgery director (Staff Member #3) at the time of the observation confirmed that storing endoscopes in this manner risks contamination of the scopes.


Item #6 - Ventilation

1. Review of hospital HVAC ventilation data dated May 22-26, 2012 that had been prepared by a HVAC calibration, certification, and decontamination consultant indicated that total air changes (ACH) per hour in OR #2, #3, #4, #5, and #6, in caesarian section OR #1, and in the sub-sterile area on the third floor were below 15 ACH.

OSHA, ASHRAE, and AIA recommend that hospitals maintain ACH in surgical areas at or above 15. An interview with the hospital's Director of Plant Operations (Staff Member #5) on 8/8/2012 at 1:25 PM revealed that there was no documentation of adjustments to the HVAC system that were made in response to the consultant's report.

The hospital's did not have a policy and procedure that specified whether surgical procedures should be canceled or postponed until acceptable ventilation parameters were achieved.

2. The hospital's policy and procedure entitled "Negative Air Flow Room Alarms" (Policy/Procedure #HW.EC.1.2.; Approved 4/30/2008) revealed that the policy had not been reviewed since April 2008.

The policy stated that negative air flow rooms were located on the 4th floor (Room 438), the newborn nursery, the post-anesthesia care unit, and trauma room #1 in the emergency department. On 8/8/2012 at 7:25 AM, an interview with a nurse in the hospital's endoscopy suite (Staff Member #6) revealed that when bronchoscopies were performed in the endoscopy unit, the air pressure was changed from positive to negative. The nurse stated that the air pressure was not tested and documented to verify that it was negative to the hospital corridor. The hospital's policy and procedure did not include the endoscopy suite as a negative air flow room.

The policy stated that "Infection Control" would monitor negative air flow rooms with smoke tubes or a tissue paper tests to verify that the pressure-sensing device was functioning. Instructions on the AIIR log for Room 438 stated that nursing staff members were to verify that the negative air flow was functioning correctly by performing a test using tissue paper on a daily basis. The policy was not clear regarding air flow testing responsibilities.

The policy stated that in the event the air pressure alarm system malfunctioned or alarmed for greater than five minutes, "On request from Infection Control, maintenance will print out a statement of activity for review at the end of the affected month if available". This direction did not ensure that malfunctioning alarms were checked by the maintenance department and repaired within acceptable time frames.

Review of the AIIR logs for Room 438 revealed that an air pressure verification check was completed on 5/26/2012. Review of the medical records for the patient who was occupying room 438 on that date (Patient #3) revealed that the patient was in airborne isolation from 5/24/2012 to 5/26/2012. Air pressure relationship checks were not completed and documented according to hospital policy and procedure.


Item #7 - Humidity in the OR

The hospital's policy and procedure entitled "Control of Hospital Temperature/Humidity" (Policy/Procedure #HW.EC.02.06.01.13; Approved 11/16/2012) stated that the acceptable range for humidity in perioperative areas would range from 35% to 60%. If the humidity was out of range, the staff member who identified the reading would immediately notify the plant operations department and initiate a work order. Plant operations would respond to evaluate and take appropriate actions. The plant operations manager would document actions taken to maintain proper settings.

Review of humidity reading records for 8/7/2012 and 8/8/2012 revealed that the humidity at 7:00 AM was 62.40% in OR #2 ; 66.80% in OR #4; and 64% in caesarian section OR #1. Documentation provided by the hospital's Director of Plant Operations (Staff Member #5) indicated that action had been taken to lower the humidity to acceptable levels on 8/8/2012 at 2:20 PM.

The hospital's policy and procedure did not identify whether surgical procedures should be canceled or postponed until acceptable humidity levels were achieved.
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Based on interview and review of infection prevention and control program and quality program documentation, hospital leadership failed to ensure that corrective action plans were developed and implemented through the hospital's QAPI program for problems identified as needing improvement.

Failure to systematically develop and implement performance improvement action plans limits the hospital's ability to achieve and sustain improvements in clinical care and patient outcomes

Findings:

1. On 8/7/2012, review of the hospital's 2011-2012 Annual Infection Prevention and Control Program evaluation (dated April 2012) revealed that the hospital did not meet targeted performance goals for ventilator-associated pneumonia and hand hygiene compliance. The evaluation also identified a need for process improvement for surveillance of surgical site infections.

An interview on 8/7/2012 at 10:35 AM with the hospital's infection preventionist (Staff Member #1) and the quality program coordinator (Staff Member #2) revealed that no systematic corrective action plans had been developed through the hospital's QAPI program to address these problems and improve hospital performance.


2. The hospital's policy and procedure entitled "Monitoring of Sterilization Process (No policy number; Reviewed January 2010) stated: "Immediate Use Sterilization is not a substitute for the conventional processing of instrumentation/equipment. It is only for emergency use."

On 8/8/2012, review of the surgery department's immediate use sterilization tracking log revealed that immediate use sterilization of surgical equipment was utilized for 14.9% to 26.5% of the total number of OR cases during the months of January through May 2012.

Infection Control Committee Meeting Minutes dated 5/23/2012 identified that the high percentage of immediate use sterilization was related to an increase in the number of orthopedic surgical cases and that the high rate of immediate use sterilization would continue until more instruments could be purchased.

The sterilization tracking log indicated that the percentage of immediate use sterilization increased to 46% in July.

An interview on 8/8/2012 at 10:30 AM with the hospital's infection preventionist (Staff Member #1) and surgery director (Staff Member #3) revealed that no systematic corrective action plan had been developed through the hospital's QAPI program to address the high rate of immediate use sterilization of surgical instruments.


3. On 8/8/2012 at 2:25 PM, Surveyor #1 observed that patient lift slings, disassembled shelving, pieces of sheet rock, a needles and sharps container, and a bedside commode were stacked next to a soiled linen cart in an alcove area of the soiled utility room on the hospital's intensive care unit (ICU). The ceiling tiles in the alcove area had been removed, and pipes were exposed.

During an interview at the time of the observation, a member of the housekeeping staff (Staff Member #4) stated that this condition had been present for "a couple of months". During an interview with the ICU director at the time of the observation, the director state s/he had submitted a work order "last week" to the hospital's maintenance department requesting repairs of the ceiling.

Review of a memorandum dated 3/27/2012 that had been written by the environment of care (EOC) committee director (Staff Member #5) revealed that this problem had been identified during environmental safety rounds on 3/20/2012, The memorandum stated that the equipment in the alcove area was to be removed and the ceiling repaired within 15 days. Corrective action had not been taken as directed by the EOC director.
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