HospitalInspections.org

Based on record reviews and interviews, the facility failed to ensure that nursing staff followed the facility's Assessment and infection control policy/ procedures for 1 of 1 patient's (Pt# 1). Facility nursing staff failed to implement the facility's policies and procedures regarding bedbug infestations after patient #1 stated that bedbugs were in her room.

This deficient practice placed all patients in the facility at risk of bedbug infestations.

Findings include:

Record review of the nursing documentation, dated 05/03/2023 to 05/08/2023 revealed the following:

- No documentation regarding the Patient's complaint that bed bugs were seen in ther hospital room.
- No evedeince that nursing staff assessed patient #1's skin condition for bug bites/ sores/ injuries of unknow origin, after she alerted staff that bed bugs were seen in her room.
- No evidence that nusring staff followed facility policy/ procedure regarding contact isolation or bed bug protocol.

Record review of the facility policy entitled: Assessment/ Re-Assessment, revised 10/2022, revealed the following:

III. Reassessment

A.) Each patient is to be reassessed according to the guidelines established by the clinical discipline. Further assessment and reassessment will be based on a collaborative effort as warranted by the patient's condition.
B.) Reassessment is to be ongoing and may be triggered by key decision points and at any interval(s) specified by the departments/ancillary disciplines directly involved in providing patient treatment and/or care.
C.) Reassessment is based on the patient's diagnosis, the care setting, the patient's desire for care, and the patient's response to any previous care.

Record review of the faility guiadnce policy entitled: PROCEDURE FOR BED BUG MANAGEMENT, undated, revealed the following:

1.) PrecautionsStandard Precautions apply to all patients including those known or suspected of havingbed bugs. Contact Precautions may used until environment cleared.
2.) Procedure for environmental control. If a bed bug infestation is suspected in the health care facility, the following environmental procedures are recommended:
a.) If possible, capture a bed bug and place it in a sealed container to assist pestmanagement in their assessment. Call EVS and Nursing supervisor and givethem the room number for documentation.
b.) Leave the suspect room intact without cleaning or removal of items (e.g., linens,furniture, equipment) to facilitate determination of the extent, if any, of theinfestation
c.) Close off the room or area from use, place signage ("Do Not Enter, Do NotRemove Equipment, Linen or Furniture from Room").
d.) Notify Housekeeping Supervisor and Nursing Supervisor immediately (24/7) andInfection Prevention during normal business hours.
e.) Once control measures have been implemented, routine follow-up inspections are required to monitor the effectiveness of the treatments. Since bed bugs are well-adapted to hiding, repeated implementation of control measures and inspections are often necessary for complete eradication.

3.) Procedure for suspected or diagnosed infestation for a hospital admission or ED visit If bed bugs are found on the patient or in the patient's belongings, the following actionsare required:
a.) Collect potential bed bugs in a sealed container and call EVS for pick up.
b.) The patient should be showered or bathed; if unable to shower, the patient shouldbe changed into hospital-laundered clothing, and be moved to a new room/area.
c.) Close off the old room or area from use and place appropriate signage ("Do NotEnter, Do Not Remove Equipment, Linen or Furniture from Room") on closed door.
d.) Notify Housekeeping Supervisor and Nursing Supervisor immediately andInfection Prevention during normal business hours.

Record review of the facility Pest control records revealed that Patient #1's room was treated for bed bug infestation on 05/05/2023 at 6:24 pm.

In an interview conducted on 06/29/2023 at 2:40 pm, the Director of Infection Prevention revealed that nursing staff should have immediately closed off Patient# 1's room for pest control treatment, and placed the patient on Contact isolation.

In an interview conducted on 06/29/2023 at 3:10 pm, the Vice President of Quality confirmed that nursing staff failed to document Patient #1's outcry of bedbugs in her patient room, skin assessment after patient's complaint that bedbugs had bitten her, and/or any interventions conducted related to the bedbugs.

Based on record reviews and interviews, the facility failed to ensure that nursing staff followed the facility's infection control policy/ procedures for 1 of 1 patient's (Pt# 1). Facility nursing staff failed to implement the facility's policies and procedures regarding bedbug infestations after patient #1 stated that bedbugs were in her room.

This deficient practice placed all patients in the facility at risk of aquiring bedbug infestations.

Findings include:

Record review of the nursing documentation for Patient #1 revealed no evidence that nursing staff enacted contact isolation protocol after the patient told staff that bedbugs were seen in her room and on her body (stated that she had bedbug bites.)

Record review of the nursing documentation, dated 05/03/2023 to 05/08/2023 revealed the following:

- No documentation regarding the Patient's complaint that bed bugs were seen in ther hospital room and/ or on her body (stated that she had bedbug bites.)

- No evidence that nusring staff followed facility policy/ procedure regarding contact isolation or bed bug protocol.


Record review of the faility guiadnce policy entitled: PROCEDURE FOR BED BUG MANAGEMENT, undated, revealed the following:

1.) PrecautionsStandard Precautions apply to all patients including those known or suspected of havingbed bugs. Contact Precautions may used until environment cleared.
2.) Procedure for environmental control. If a bed bug infestation is suspected in the health care facility, the following environmental procedures are recommended:
a.) If possible, capture a bed bug and place it in a sealed container to assist pestmanagement in their assessment. Call EVS and Nursing supervisor and givethem the room number for documentation.
b.) Leave the suspect room intact without cleaning or removal of items (e.g., linens,furniture, equipment) to facilitate determination of the extent, if any, of theinfestation
c.) Close off the room or area from use, place signage ("Do Not Enter, Do NotRemove Equipment, Linen or Furniture from Room").
d.) Notify Housekeeping Supervisor and Nursing Supervisor immediately (24/7) andInfection Prevention during normal business hours.
e.) Once control measures have been implemented, routine follow-up inspections are required to monitor the effectiveness of the treatments. Since bed bugs are well-adapted to hiding, repeated implementation of control measures and inspections are often necessary for complete eradication.

3.) Procedure for suspected or diagnosed infestation for a hospital admission or ED visit If bed bugs are found on the patient or in the patient's belongings, the following actionsare required:
a.) Collect potential bed bugs in a sealed container and call EVS for pick up.
b.) The patient should be showered or bathed; if unable to shower, the patient shouldbe changed into hospital-laundered clothing, and be moved to a new room/area.
c.) Close off the old room or area from use and place appropriate signage ("Do NotEnter, Do Not Remove Equipment, Linen or Furniture from Room") on closed door.
d.) Notify Housekeeping Supervisor and Nursing Supervisor immediately andInfection Prevention during normal business hours.

Record review of the facility Pest control records revealed that Patient #1's room was treated for bed bug infestation on 05/05/2023 at 6:24 pm.

In an interview conducted on 06/29/2023 at 2:40 pm, the Director of Infection Prevention revealed that nursing staff should have immediately closed off Patient# 1's room for pest control treatment, and placed the patient on Contact isolation.

In an interview conducted on 06/29/2023 at 3:10 pm, the Vice President of Quality confirmed that nursing staff failed to document Patient #1's outcry of bedbugs in her patient room, skin assessment after patient's complaint that bedbugs had bitten her, and/or any interventions conducted related to the bedbugs.