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Based on record review and interview, the facility failed to ensure infection control measures were implemented and followed to prevent the spread of infections throughout the facility.

Findings include:

Patient # 12

Patient #12 presented to the Emergency Room (ER) on 6/7/12 at 15:38 (3:38 pm), from the physician's office with complaints of left shoulder pain for two weeks and increased shortness of breath.

Patient #12's history and physical dated 6/7/12 documented "History of Present Illness ...for the past 2 weeks started experiencing some back pain that progressively started getting worse. That migrated from her left hip, up to her left side, to her left back, and shoulder. Patient does have some chills, as well as some night sweats. Patient states that for the past few weeks it has progressively gotten worse, and when she started having increased shortness of breath where she could hardly ambulate without stopping for shortness of breath ...she decided to come to see her PCP (Primary Care Physician) ... Chest x-ray showed pneumonia and pleural effusion ...referred here for further evaluation .... Laboratory Data : CBC (complete blood count) showed a white count of 28,000 ...CT (Computerized tomography) (preliminary) showed a left-sided locullar effusion ...Plan: ...Given her symptoms, I will go ahead and check an AFB (Acid Fast Bacillus-Tuberculosis (TB) culture and sensitivity) on her sputum and PPD (purified protein derivative - a Tuberculin skin test) "

The physician's orders dated 6/7/12 included Quantiferon (TB skin test), Sputum for AFB x2 (2 specimens).

On 6/8/12, Patient #12 was admitted to the facility and placed in a room designated as a negative pressure isolation room, required for respiratory isolation.

The Quantiferon test was given and the results were negative as documented on 6/8/12.

Patient #12's laboratory results documented the first sputum for AFB was obtained on 6/8/12 and the results were negative.

The second sputum for AFB was sent on 6/12/12. The preliminary results were negative reported 6/15/12.

On 6/12/12 at 11:40 am, an interview was conducted with the Infection Control Director (ICD). The ICD verbalized when a patient was in the ER with suspected TB, they should be placed in the dedicated negative pressure room (#19). The isolation precautions should be initiated as soon as TB was considered and was being ruled out. The results of positive tests or cultures were not necessary.

The ICD indicated the facility tracks all patients who are on isolation by type of isolation such as respiratory, droplet, or contact, by a daily generated report. The ICD added she did not know if Patient #12 was on isolation while in the ER.

On 6/12/12 at 4:00 pm, the Director, Quality and Risk Services (DQRS) verbalized Patient #12 had not been in a bay designated for respiratory isolation while in the ER, and isolation precautions had not been initiated. The DQRS indicated there had been another patient in the designated bay (#19).

The facility policy titled Isolation Precaution Practices effective 5/12 documented "Definition ...Airborne - airborne isolation precautions are required when patients are known or suspected to be infected by micro-organisms transmitted by airborne droplet nuclei which are small particles less than or equal to five micrometers in size of aerosolized droplets remaining suspended in the air and can be dispersed widely by air currents. "

Attachment A - Isolation Precautions Table documented - Disease/ Condition - Tuberculosis required Airborne precautions; Mask type N95 (a mask that filters 95% of airborne particulates); Place in a negative pressure room.