HospitalInspections.org

Based on observation, staff interview, medical record review, and review of policies and procedures, it was determined the hospital failed to ensure staff followed the standard of care related to infection control practices (A749). This included the staff dress code, maintaining a sanitary environment, and admission testing of infectious disease in the neonatal intensive care unit (NICU). The hospital failed to fully implement the initial action plan and ensure monitoring of the plan for sustainability. The cumulative effect of these systemic practices resulted in the hospital's inability to prevent transmission of Serratia marcescens in the (NICU). The census in the (NICU) was 19.

*Based on observations made during the tour of the facility, a review of medical records and of the facility's polices and procedures, and interview with the facility staff, the facility failed to ensure staff followed the current facility infection control policies related to the cleaning of patient care areas, dress code, and isolation. This had the potential to affect all patients receiving care in the Neonatal Intensive Care Unit (NICU).

Findings include:

1. The facility's administrative staff were interviewed on 07/05/16 at 9:45 AM. According to Staff A, Vice President Regulatory, Infection Prevention, six infants receiving care in the NICU tested positive for the bacteria Serratia marcescens. The administrative staff stated that there have been two infant deaths, where both tested positive for Serratia marcescens. The source of the bacteria has not been identified.

The facility's initial action plan for the prevention of the spread of the bacteria was reviewed. The plan stated that the "entire" NICU was "deep cleaned" from 07/01/16 through 07/02/16, except in rooms where infants were currently housed. The deep cleaning included floors, carpeting, walls, ceilings, equipment, and furniture.

The 25 bed NICU was toured on 07/05/16 at 11:00 AM. The census during the tour was 19. The following observations were noted during the tour:

a. Room A1 was noted to be occupied by an infant colonized with the Serratia bacteria in his/her rectum. There was no isolation signage noted on the door. A nurse was observed providing care to the infant without a gown and/or gloves. Staff G stated that the only infants required to be in isolation precautions are those symptomatic of an infection.

b. A layer of dust was noted on a shelf in Room A3. This finding was pointed out to Staff G and Staff F during the tour.

c. Room A6, occupied with an infant, was noted to have a layer of dust on the surface of a box of gloves. This finding was pointed out to Staff G and Staff F during the tour.

d. Room B3, a vacant room, was noted to have dust on the isolette. A card on the counter revealed that this room had been cleaned and was ready for occupancy.

e. Room B5, occupied with an infant, was noted to have adhesive residue on the arm of the monitor. Dust was also noted on the back of the monitor.

f. A sticky substance was noted on the computer keyboard in the Procedure room.

g. A layer of dust was also noted along the top of the computer monitor.

h. The screen of a Drager ventilator in the NICU workroom was noted to be covered with a thick layer of dust. The ventilator was designated as clean.

i. A dark colored hair was also noted on a storage cart next to the door in the NICU workroom.

j. Transport isolettes were noted in the back hallway of the unit. A thick layer of dust was noted on top of the first transport isolette. A brown residue was also noted around the two circular doors of the isolette. There were pieces of tape stuck to the ledge of the isolette. Dust was also noted on two other isolettes lined in the hallway. Staff G was interviewed during the tour and asked who was responsible for cleaning the isolettes that are used to transport infants from other facilities. Staff G stated that he/she believed Environmental Services staff were responsible for cleaning the isolettes. Staff F stated he/she was under the impression nurses cleaned the isolettes prior to transporting infants. A policy on cleaning the transport isolettes was requested at that time. Staff F stated there was no policy in place to describe the cleaning of the isolettes.

k. The dark colored carpet in Room C3 was noted to have visible stains. There was also adhesive residue on the monitor.

l. Room C6, occupied with an infant, was noted to have a layer of dust on the monitor. There was also a brown substance splattered on the wall behind the isolette. Staff G stated that she suspected the brown substance was from intravenous iron being administered to the infant.

m. A laminated card was noted to be laying on top of a scale on the counter in Room D4. When this surveyor picked up the laminated card, a wet substance was noted to be on the back of the card and on the scale. An attempt was made to hand the laminated card to Staff F. He/She refused to take the card stating: "I'm not touching that. I don't know what that is! That is not acceptable." There was also a stethoscope noted in this room. A brown substance was noted on the bell of the stethoscope.

The facility's policy entitled "Discharge Cleaning Procedure" was reviewed on 07/05/16 at 1:50 PM. According to the policy, environmental services staff should disinfect the over-the-bed table, all ledges, sills, and shelves. Environmental services staff are further instructed to high dust. These facts were confirmed with administrative staff (Staff A, Staff B, Staff C, Staff D, and Staff E) on 07/05/16 at 2:00 PM. The administrative staff confirmed none of the rooms toured, whether vacant or occupied, should have dust, adhesive residue, etc.2. Various staff members in the NICU were interviewed on 07/06/16 and 07/07/16. These interviews revealed re-education of all staff was completed within the past week related to the facility's hand washing policy, isolation policy and dress code policy. Interview with the nursing staff revealed that they all wear hospital-provided scrubs, which are kept in the locker room and further revealed that they do not wear the scrubs in or out of the facility.


2. Interview with Staff K, a housekeeper, on 07/06/16 at 1:00 PM revealed that housekeepers wear scrubs from home when they work in the NICU and then wear those same scrubs back home where they are laundered. Interview with Staff L, The Director of Respiratory Therapy, revealed that the respiratory therapists that work in the NICU wear dark blue scrubs from home and not hospital-provided scrubs. Staff K further stated that the respiratory therapists are aware that this is against facility policy.

The facility's policy entitled "Birth Center Dress Code" was reviewed on 07/08/16. The policy instructs staff in the NICU to wear short sleeve scrubs that are laundered by the hospital. It further instructed NICU staff not to wear rings or have artificial nails, gels or tips.

Staff M, a neonatal nurse practitioner, was interviewed on 07/08/16 at approximately 10:00 AM. Staff M stated that he/she had participated in the re-education related to hygiene upon returning to work from vacation. Staff M was observed to have gel nails. Staff A was asked to verify with Staff M if his/her nails were indeed gel. Staff H, the Chief Executive Officer, verified that Staff M was wearing gel nails on 07/08/16 at 2:00 PM. He/She further stated that the staff member was sent home.

3. The facility's policy entitled "Isolation Protocol" was reviewed on 07/06/16. The policy defines a cohort system isolation protocol is to be used in certain circumstances to separate patients (more than one) with communicable disease from those without communicable disease, in order to minimize disease transmission. The policy further stated that implementation of a cohort system is used to minimize the spread of infection in clusters of organisms or during contagious outbreaks; at no time will employees assigned to a cohort group of patients care for non-cohorted patients; patients with clinical symptoms and suspected infection or colonization will be moved to rooms in the same geographic section of the unit and will be cared for by nurses who have already been exposed or who are assigned to the cohort patient and to no patient who is not in the cohort; and the assignment should persist as long as the cohort exists in order to avoid cross-contamination to non-infected/non-colonized patients and staff.

Staff N, a NICU staff nurse, was interviewed on 07/07/16 at 12:15 PM. Staff N explained a cohort system is used when an infant is identified as colonized or symptomatic with an organism and the infant remains paired with the infant it was with at the time the positive culture was identified. The staff nurse further explained that in the cohort system, it does not matter whether the infant that the infected or colonized infant is paired with is colonized/infected or not. Staff N lastly explained that all staff should be practicing standard precautions with all infants.

The NICU staffing and census sheets from 07/01/16 through 07/06/16 were reviewed on 07/06/16 at 2:00 PM.

The staffing sheet for 07/01/16 revealed that Patient #7, a preterm infant isolated for a positive Serratia marcescens culture in his/her tracheal aspirate, was cohorted with Patient #8, a preterm infant who was not colonized or infected with the Serratia marcescens bacteria. These infants were cohorted as required by facility policy until 07/03/16 between 3:00 PM to 11:00 PM. At that time, Patient #8 was removed from the cohort. Patient #9, a preterm infant colonized with Serratia marcescens in the rectum, was now being cohorted with Patient #7.

The assignment sheet for the 3-11 shift on 07/04/16 did not reveal that Patient #6, a preterm infant identified as colonized with Serratia marcescens bacteria on 07/04/16, was cohorted with the infant he/she had been assigned with when the patient was identified as being colonized with Serratia marcescens. Patient #6 had previously been assigned with Patient #10, who was not infected or colonized with Serratia marcescens. Again, during the 11-7 shift on 07/04/16 and the 7-3 shift on 07/05/16, Patient #6 and Patient #10 were not cohorted as required by facility policy. Review of the 3-11 staffing sheet on 07/05/16 indicated that Patient #6 was assigned with Patient #8, the infant previously cohorted with Patient #7. Patient #6 occupied Room A5 in the A pod and Patient #8 occupied Room C6 in the C pod.

Review of the medical record of Patient #6 revealed that he/she began to clinically deteriorate and when the infant self-extubated himself/herself, a culture of the tracheal aspirate was sent to the laboratory. The aspirate was positive for the Serratia marcescens bacteria. It was confirmed with the administrative staff on 07/06/16 at 5:30 PM that staff did not follow the cohorting system described in the facility's infection control policy.












32059