HospitalInspections.org

Based on hospital policy reviews, isolation order reviews, isolation census review, refrigerator temperature log reviews, refrigerated patient food items reviewed and staff interviews, the hospital failed to ensure that all patients being ruled out for infectious diseases were immediately placed on isolation for 2 out of 6 isolation patient records reviewed (Patient #7 and Patient #14), failed to ensure the patient nourishment refrigerators were monitored for expired food daily on 1 out of 7 units toured (3rd Floor) and were monitored for safe refrigeration temperatures on 2 out of 6 hospital units toured (ED and 3rd Floor).

The findings included:

1a. Review on 06/14/2022 of a hospital policy titled, "Isolation Precaution Guidelines", last reviewed on April 8, 2022, revealed "I. SCOPE/PURPOSE: This policy applies to all departments, units, and individuals providing or supporting patient care procedures...II. POLICY...Transmission Based Precautions are used in addition to Standard Precautions for patients known or suspected to be infected by epidemiologically important pathogens spread by airborne or droplet transmission or by direct or indirect contact with infected/colonized persons or contaminated surfaces...additional precautions are needed to prevent infection transmission...Patient Room Requirements...Enhanced - To be defined by Infection Prevention...Isolation Door Caddy with Isolation Sign: Droplet/Contact/Enhanced - Keep isolation caddy appropriately stocked with supplies based on isolation type...E. Droplet Precautions...Personal Protective Equipment: Wear a procedure mask and eye protection (goggles or face shield) each time you enter the room...8. Visitors: a. Visitors will wear a procedure mask in the room...F. Contact Precautions...Personal Protective Equipment: a. Wear gloves and an isolation gown when entering room. Isolation gowns should be tied securely in back to prevent contamination and are not to be reused...9. Visitors: a. Visitors are educated to wear appropriate PPE depending on type of isolation and are expected to perform hand hygiene as per standard precautions...Required Protective Equipment in addition to Standard Precautions: Gowns: Droplet - No...Contact - Yes...Enhanced - To be defined by Infection Prevention...Mask: Droplet - Yes (procedure) Contact - No...Enhanced: To be defined by Infection Prevention...Gloves...Contact: Yes...Enhanced - To be defined by Infection Prevention...Appendix A: CDC Type and Duration of Precautions... Infection/Condition: Coronavirus (COVID-19...); Type: Enhanced; Duration: IP [Infection Prevention] discretion based on current CDC guidelines; Precautions/Comments: Follow Enhanced Precautions as defined by Infection Prevention..."

Closed medical record review on 06/14/2022 revealed Patient #7, an 83-year-old female, was admitted to the hospital under observation status on 04/27/2022 at 2017 following a fall. Record review revealed a History and Physical (H&P) signed by Physician Assistant (PA) #2 on 04/27/2022 at 0835 that stated, "...She notes that she has had a congested cough...difficulty producing any sputum. Denies fevers and chills but has had sweats...Physical exam...no apparent distress. Coughing paroxysm [sudden attack] observed...Nonlabored respirations. Clear pulmonary exam anteriorly..." Review of Physician Orders dated 05/03/2022 at 1134 revealed an order by MD (Medical Doctor) #3 for a Respiratory Panel (aka Biofire) Nasopharyngeal Swab [panel of tests to rule out 19 different viruses, including COVID-19]. Review of a Physician Progress Note signed by MD #3 on 05/03/2022 at 0946 revealed, "...Addendum...CT [Computed Tomography] Scan of the chest without contrast showed scattered ground glass and consolidation suspicious for pneumonia. Atypical or viral sources could be playing a role. Respiratory bio fire panel including COVID testing was ordered...Seen/Discussed with...(named Primary Nurse)..." Record review revealed RN (Registered Nurse) #6 collected the respiratory nasopharyngeal swab specimen from Patient #7 at 1224. Review further revealed the order for Contact and Droplet Isolation [requires a surgical/procedure mask] was first entered by MD #3 at 1619 and later revised by the IP (Infection Prevention) nurse to add Enhanced Isolation [requirement for an N-95 respirator mask - filters 95% of airborne particles] on 05/04/2022 at 1352. Record review revealed Isolation Precautions were ordered 4 hours and 45 minutes after the Respiratory Panel Test was ordered and the Enhanced Isolation Precautions were ordered 26 hours and 18 minutes after the Respiratory Panel Test was ordered. Review of the Discharge Summary signed by MD #4 on 05/25/2022 at 1103 revealed, "...She reported having a congested but unproductive cough for at least several days prior to presentation...She continued to have cough for which a noncontrast CT of the chest was ordered...a COVID test was checked which was positive...She is medically stable..." Patient #7 was discharged from the hospital to a SNF (skilled nursing facility) on 05/25/202 at 1237.

Interview on 06/14/2022 at 1420 with the Infection Preventionist (IP) revealed she had no recollection of Patient #7. Interview revealed isolation orders were automated when providers placed an order for COVID-19 tests specifically but were not automated and required manual order entry by the nurse, provider or IP when the Respiratory Panel (aka Biofire) tests were ordered. Interview revealed that the regular Contact/Droplet Isolation got ordered by mistake, but for COVID, the correct order was for Contact/Droplet plus Enhanced. The IP stated that the medical staff were expected to enter isolation orders and nursing staff were expected to implement isolation precautions immediately after the rule out tests were ordered. Interview further revealed there was a delay in ordering isolation precautions on Patient #7 and the hospital policy was not followed.

Interview on 06/15/2022 at 0937 with the Nurse Manager (NM) for Patient #7's unit revealed she remembered Patient #7. The NM stated that her expectation was for the nursing staff to implement isolation precautions as soon as the rule out tests were ordered. Interview revealed nurses were able to enter Isolation orders if the provider failed to do so. Interview revealed there was no way of determining when Patient #7's Isolation signage and PPE caddy were actually placed on the door.

Interview on 06/15/2022 at 1031 with MD #3 revealed he had a brief recollection of Patient #7. MD #3 stated that physician orders for COVID tests automatically triggered a red banner in the hospital's eMR (electronic medical record) system to alert staff when patients were potentially infectious due to COVID-19. Interview further revealed that when a COVID-19 test was ordered specifically, an Isolation order was triggered along with the red banner, but when the Respiratory Panel (aka Biofire) was ordered, the Isolation order had to be manually entered by the provider or primary nurse. MD #3 stated, "In this case, the Respiratory Biofire Panel was ordered because our suspicion for COVID was not that great because she [Patient #7] only had a cough..." Interview revealed MD #3 did not recall exactly when the Isolation signage and PPE caddy were placed on Patient #7's door. MD #3 stated that on some days if he was really busy, the Isolation orders were delayed.

Interview on 06/15/2022 at 1053 with Certified Nurse Aide (CNA) #8 revealed she was assigned to Patient #7's room on 05/02/2022 through 05/03/2022, but vaguely remembered Patient #7. CNA # 8 stated that she thought she remembered the primary nurse asking her to put up the Isolation signage and PPE caddy on Patient #7's door, but she was unable to remember details and when exactly the isolation precautions were implemented.

Interview on 06/15/2022 at 1132 with the Microbiology Laboratory Manager revealed that the laboratory staff called positive results to nursing staff at the beginning of the pandemic but as the number of COVID positive patients increased, they were unable to keep up. Interview revealed their process changed and the eMR was now able to flag new, abnormal results with a red (! - exclamation) so providers and nursing staff were alerted of unread results that needed to be reviewed.

Interview on 06/15/2022 at 1643 with the Accreditation Manager revealed, the IP sent an email to the Vice President of IP to point out that the Respiratory Biofire Panel did not automatically trigger Isolation orders like the COVID specific test did. The Accreditation Manager acknowledged that the hospital's system for isolating Covid "rule-out" patients had a flaw and therefore may have caused delays in isolation precautions being implemented.

1b. Closed medical record review on 06/16/2022 revealed Patient #14, an 84-year-old female admitted to the ED on 06/15/2022 at 1225 for "Palpitations and Dizziness." Record review revealed a History and Physical (H&P) signed by MD (Medical Doctor) #9 on 06/15/2022 at 1526 that stated, "...Assessment and Plan...enteritis unclear etiology, check stool studies..." Review of Physician Orders dated 06/15/2022 at 1609 revealed an order by MD #9 for a GI Panel, Stool panel with a stated reason of "C. Difficile Rule-Out, Gastrointestinal Rule-Out..." Review of Physician Orders further revealed an order by MD #9 on 06/16/2022 at 0817 (16 hours and 8 minutes later) for "Contact Special Enteric Isolation." Patient #14 remained in the ED awaiting an inpatient bed on 06/16/2022.

Review of the hospital's Isolation Census revealed seven isolation patients were in the Emergency Department (ED) on 06/16/2022. Observations during a tour of the ED on 06/16/2022 at 0909 (52 minutes after the isolation order) revealed Patient #14, one of the seven isolation patients, did not have isolation signage or a PPE caddy on the door .

Interview on 06/16/2022 at 1622 with the ED Nurse Manager revealed the expectation for nursing staff was to implement isolation precautions immediately after the doctor's rule-out test order was entered. Interview revealed Patient #14's isolation precautions were delayed, and hospital policy was not followed.

2a. Review of the hospital policy titled "Refrigerators, Freezers and Ice Machines, Care of" last revised December 2021, revealed, "I. SCOPE/PURPOSE ...II. POLICY A. Keep all refrigerators, freezers, and ice machines clean and at the appropriate temperature to ensure the safe storage of food or medications...C. 1...refrigerators will contain only food and beverages that are in a proper container and within expiration dates...6. Maintain refrigerator temperature at a safe temperature, 34F to 40F ... 9. In patient care areas, document daily the temperature of the refrigerator/freezer ...11. Discard food prepared within the facility after 24 hours or the package label "use by" or expiration date..."

Observation on 06/14/2022 at 1101 during a tour of the 3rd Floor Medical Surgical unit revealed 4 out of 4 sandwiches in the patient nourishment refrigerator that had labels with expiration dates of 06/12/2022.

Review on 06/14/2022 of the 3rd Floor "Quality Control - Monitor - Refrigeration" Log dated June 2022 revealed missing temperature documentation for 6 out of the 14 days monitored.

Interview conducted on 6/15/22 at 0937 with the 3rd Floor Nurse Manager (NM) revealed the Unit Secretary (US) was responsible for checking the patient nourishment refrigerator and freezer temperatures and documenting them on the log daily. The NM stated, "I spoke with her [US] this morning and she apologized. She checked the small one, but did not check the large one..." Interview further revealed the dietary staff monitored patient food expiration dates as they replenished items in the refrigerators and freezers, but nurses were responsible for checking the expiration dates of food items as well because they were the ones who passed out the food to patients. Interview revealed the refrigerator/freezer temperatures were not checked and expired food was not discarded per hospital policy.


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2b. Observation on 06/14/2022 at 1414 during a tour of the Emergency Department (ED) revealed a patient nourishment refrigerator log that was incomplete 7 out of 13 days in June 2022.

Review on 06/14/2022 of the ED "Quality Control - Monitor - Refrigeration" log revealed the following dates were missing on the temperature log documentation: 06/03/22, 06/05/22, 06/06/22, 06/09/22, 06/10/22, 06/11/22 and 06/12/22. (7 out of 13 days)

Interview conducted on 6/16/22 at 0926 with the ED Unit Secretary #1 revealed it was part of her duties to log the patient refrigerator temperature daily. Interview revealed that sometimes she forgot to do it because it gets too busy at times. Interview revealed that if she does not do it the next shift will do it. Interview revealed hospital policy was not followed.

Interview conducted on 6/14/22 at 1414 with the ED Assistant Nurse Manager (ANM) revealed the patient nourishment refrigerator temperatures were supposed to be monitored daily. Interview revealed after review of the June 2022 temperature log for the patient nourishment refrigerator in the ED, the log was not checked per policy. Interview revealed the unit secretary was responsible for checking the refrigerator temperatures daily (every 24 hours). Interview revealed the hospital policy was not followed.

NC00188895