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Based on staff interview and review of facility documents, the facility staff failed to ensure compliance with the reporting requirements for an identified outbreak of MRSA (Methacillin Resistant Staphylococcus Aureus) in the Neonatal Intensive Care Nursery (NICU).

The facility identified, on October 4, 2017, the occurrence of two cases of MRSA infection in the NICU area of the facility. The facility failed to promptly report to the local Health Department the two cases which were epidemiologically related.

The findings included:

The survey team conducted a tour and observations of the NICU and other relevant areas of the facility on 11/30/17 after meeting with facility Administration.

On 11/30/17 at 1:40 p.m., Staff Member #1 (System Director of Quality and Infection Control) stated, "[local Epidemiologist] on November thirteenth (2017), discussed with us in a meeting that they need to be notified by the second case...we talked about process improvements and what is going on across the state in other places regarding their processes...we asked for information on what (he/she) has seen in other facilities that could be of benefit to us in fine tuning and being compliant with our process and what the best practices are...we started an investigation immediately when we became aware of the two cases and we thought we needed to do that first..."

On 12/1/17 at approximately 9:30 a.m., the survey team met with Staff Members #1, #8 (NICU Manager), #13 (Facility Infection Preventionist), #15 (Environmental Services Manager), and #16 (Director of Environmental Services) regarding reporting of outbreaks/communicable diseases. Staff Member #13 stated, "We do a drill-down process on every HAI (hospital acquired infection)...which is our usual process...we have found that was incorrect for this case and we will not do that again. We should have reported it immediately after identification of the second case....it will not happen again... EPI (Epidemiology) has instructed us to call at the preliminary report and then all again with the final..." Staff Member #8 added, "Until we sat down with [Epidemiologist] we thought we were supposed to do a drill-down and get all the information and then report, but we found out that was incorrect on our part..." Staff Member #13 added, "When you look at the reportable disease list, MRSA (Methacillin Resistant Staphylococcus Auerus) is not on there and that's where it got confusing and that's why it slipped by..."

The surveyor reviewed the facility policy and procedure "Communicable Disease Reporting" which was dated as reviewed on 4/24/17. The policy evidenced, in part: "...reporting of the communicable diseases listed on the following page is required by the Health Laws of Virginia Code (Section 32.1-36 and 32.1-37) and the Virginia State Board of Health Regulations for Disease Reporting and Control (12VAC 5-90-80 and 12VAC 5-90-90; 2011...2. Infection Prevention will notify their local Health Department of suspected or confirmed reportable diseases. Communicable diseases requiring immediate notification will be reported within 24 hours of suspected or confirmed diagnosis by the most rapid means available. All others will be reported within 3 days of suspected or confirmed diagnosis...4. Infection Prevention will report the occurrence of outbreaks or clusters which may represent a group expression of illness that may be of public health concern to the local Health Department by the most rapid means available..." On page 2 of this document was the "Virginia Reportable Disease List" which evidenced, "Report Immediately...Outbreaks, all (including but not limited to foodborne, healthcare-associated, occupational, toxic substance related and waterborne)..."

The facility policy "Outbreak Investigation" dated as being reviewed/revised 12/2017, was reviewed. The policy evidenced, in part: "...An outbreak is an increase in the incidence of a disease above what is normally expected among a specific population during a specific time frame. When the occurrence of hospital associated infections exceeds the expected level, or when an unusual pathogen is isolated, an outbreak investigation will be conducted to identify the contributing factors and to prevent or minimize the spread of the disease...Reporting the Outbreak A. Health Department--All outbreaks...are reportable by state law (Refer to Infection Prevention policy Communicable disease reporting)..."

On 12/5/17 at 9:50 a.m., Staff Member #1 stated, "...We did not identify there was a problem until the (October) 4th, and began our investigation...the timing was not confirmed and we began the drill down... We also had some confusion after we notified [Epidemiologist] on November 8th (2017), that they communicated directly with your [State Agency] office since they are also under the Department of Health...it has been confusing and a process which we now understand..."

The surveyor was presented with a time-line and documents reflecting the course of the investigation which took place for the outbreak which began on October 4th 2017 and continued through November 2017. The investigation process, according to the facility is still on-going with revisions to policy and procedure regarding staff, as well as further education and observations for infection control compliance.

The concern regarding the facility failure to report promptly was discussed with facility Administration, (Staff Member #1,#3, and #25) on 12/6/17 at 11:30 a.m.

Based on staff interviews, review of medical records, and review of facility policy and procedure, facility staff failed to ensure that one (1) of four (4) patients, reviewed for restraints, was not injured during the use of restraints, Patient #7.

Findings include:

A review of Patient #7's medical record revealed the following documentation on 5/21/17 at 1:12 AM by Staff Member (SM) #21, a behavioral health technician (BHT). "0045 (12:45 AM) Patient was received on the BH unit at 0015 (12:15 AM) and was in the admission process with the unit RN (registered nurse) when [patient] became overwhelmingly uncooperative and verbally threatening, disoriented relative to the admission procedure, however [patient]was adamant that [patient] was not going to remove [patient] watch for submission to the security dept, as protocol recommends. Was placed in a physical hold and then into bed restraints as of 1250 AM (12:50 AM). 0145 (1:45 AM) Patient remains in the Psych 1 room and continues to be in bed restraints. [Patient] has reduced the frequency of [patient] speech, is not yelling nor presenting verbal thre (sic) and is q (sic) of physical restraint. [Patient] was examined. [Patient] vital signs were completed using the left arm at 125 am (sic) and were received as within a normal range. [Patient] appears to be calm interr (sic) observation and safety precautions at this time. 0245 (2:45 AM) Patient remains in 2 point restraints due to previous displays of aggression and agitation. Currently [patient] is quiet, as noted by [patient] body position and breathing pattern. ...1:1 observation and safety precautions continue at this time. 0330 (3:30 AM) Patient has been released from all bed restraints and has been transition (sic) into the Psych 2 room for line of sight observations".


At 12:40 AM Staff Member # 19, a Registered Nurse (RN,) documented the following information in a narrative note: "Specific patient behavior that led to need for PRN medication: physically threatening, aggressive, a danger to self and others. Staff interventions attempted prior to PRN being given: not responding to verbal redirection . PRN medication given : 20 mg Geodon IM given. Patient response/effectiveness of PRN medication: will reassess in 1 hour. Refused VS. Face to Face completed-noted to have blood around lips, small abrasion on lt knee. Pt complained of Back, neck and shoulders hurting. Not cooperative with staff examining mouth for cause of bleeding".

At 1:25 AM SM #19 documented "pt slightly less agitated and cooperative with VS. Mouth cleaned and no further bleeding noted. Hospitalist paged to see pt due to possible injury to mouth and c/o of pain. [nurse practitioner] in to see patient., (sic) new order for CXR at this time, unable to do Cervical spine xray portable and [nurse practitioner] Made (sic) aware. It was felt by this writer and [nurse practitioner] that the patient was not safe to go off the unit at this time and Cervical Spine would be done at a later time".

The facility's policy entitled "Restraints and Seclusion" was reviewed. Section 4.6 "Procedural Components " includes the following information, in part: "...The RN and or LPN (licensed practical nurse), under the supervision of the RN, will size the ordered restraint and assure correct body alignment and patient comfort...".

SM #19's personnel record was reviewed, and revealed that his/her restraint training and CPR (cardiopulmonary resuscitation) certification were both current.

A note dated 5/22/17 at 9:50 AM by SM #20, an RN, included documentation of a PRN medication at 9:10 AM which stated "Specific patient behavior that led to need for PRN medication; pt alert oriented, CIWA 7, c/o 5/10 aching left shoulder pain and "face pain"".

Further review of the record revealed that a Cervical Spine was ordered 5/21/17 at 2:11 AM and canceled immediately. A CXR (chest x-ray) was ordered 5/21/17 at 2:11 AM with the indication documented as "to evaluate for airspace disease".

During an interview with SM #1 on 12/6/17 at 8:45 AM, the surveyor asked if there was documentation available related to further assessment of Patient #7's complaints of back, neck, and shoulder pain after he/she was placed in restraints, and whether or not another cervical spine film was ordered. SM #1 stated "A C-spine was not reordered, and there was no documentation that the complaints were followed up".

Concerns related to lack of follow up for Patient #7's complaints of back, neck, and shoulder pain after an episode of restraint were discussed with SM #1 at 8:45 AM on 12/6/17 at 8:45.

Based on observation, staff interview, and facility document review, the facility staff failed to ensure:

1. Measures were implemented for the thorough investigation of an identified infectious disease outbreak.
2. Compliance with reportable disease requirements of the local health authority.
3. Facility staff implemented proper infection control practices.
4. Maintenance of sanitary food preparation and disinfection of surfaces in the food service area.

The findings included:

1. On 11/30/17 at 1:40 p.m., the survey team interviewed Staff Member #1 (Quality/Infection Control) regarding the report of two epidemiologically related cases of MRSA (Methacillin Resistant Staphylococcus Aureus) which occurred in the NICU (Neonatal Intensive Care Unit). Staff Member #1 stated the facility began a thorough investigation after the second case was identified in order to identify the potential source and prevent the spread of the bacteria. At that time, the surveyors requested the time-line of information and investigation regarding the outbreak to validate the facility implementation of their infection control plan.

At 9:30 a.m. on 12/1/17, the survey team met with Staff Members #1, #8 (NICU Manager), #13 (Infection Preventionist), #15 (Environmental Services [EVS] Manager, and #16 Director of Environmental Services, to review the plan of action and time-line.

Staff Member #13 (Infection Preventionist), on 12/1/17 at 9:30 a.m., stated, "We were notified by the clinical lead in NICU that one infant was bacteremia positive with MRSA in the blood. I notified my Director (Staff Member #1) and had the micro lab hold the specimen for electrophoresis. On 10/5 (2017), the second positive was final and we spoke with (Staff Member # 16- EVS) to add additional support for cleaning for the NICU to especially include all the high touch areas as well as routine cleaning areas. Information was sent to Administration about what we had found and what was going on. On 10/6 (2017) we did a full work-up and looked at the pairing of the infants, staff assignments, met with the CNO (Chief Nursing Officer) and the Advance Practice Nurse, and detailed the cases, the mother situations, delivery and status of the infants. On 10/9 (2017), we met again and went over our findings, continued further research, pulled info from the lab, reviewed the records, including the mothers, and information from the placentas. On 10/11 (2017), we reviewed all the information and set up a safety event. Throughout this process that occurred from the time of discovery until currently, we have worked very hard to try to isolate a source, but have not been able to at this point. We had a task force review which was Administrative leadership and included our CEO and CMO, Pathologist, Neonatology and Infectious Disease. We notified Epidemiology (EPI) on 11/8 (2017)... we do a drill down process on each HAI (Hospital Acquired Infection)- that is our usual process,, but we have found that to be incorrect. We should have immediately notified EPI..."

Staff Member # 8 added, "Until we sat down with EPI we thought we were to follow our drill-down process to get all the information we could and then report... it is a lesson learned...." Staff Member #13 continued, "We took immediate environmental steps and did nares cultures on all infants. Any that were positive were immediately isolated. We began screening on a weekly basis and any positives, of course would be treated...we have revised our policy which will be taken to the IP (Infection Prevention) meeting to include rescreening after any occurrence...we routinely screen upon admission and transfer but if positive, the infant will be treated, rescreened and be put on contact isolation until discharge..." Staff Member #16 (EVS) stated, "We do daily cleaning in the NICU. We have found opportunities for improvement...we sent in a team and pulled extra resources to do a thorough cleaning of the area. We have increased the number of times high-touch areas are cleaned, we have added some areas to our cleaning routine that were general cleaning, but now have an increased cleaning regimen...we continue to stress to staff daily the importance of the areas that are to be cleaned, and developed a check off-list to ensure nothing is over-looked or forgotten...staff are required to complete the list and turn it in. Now its written down and nothing can be forgotten or overlooked....we met with the staff and did a review of cleaning and infection control..." Staff Member #8 stated, "We meet with the staff daily in huddles and we have various education for them, but since this event we have been stressing and talking about Infection Control all the time- going back to the basics...we have discussed it and revisited it in huddles and staff meetings and education for the staff...the NICU Infection Prevention team is made up is staff nurses, IP, myself, the neonatologists, EVS, and Respiratory therapy. We meet monthly but have discussed this particular event in detail..."

The surveyor discussed the information that was provided regarding the investigation process. Further information was requested regarding the investigation of staff members who were identified as common care-providers for the infants as well as any re-education for staff after the event was identified.

The surveyor asked about the staff who were identified as caring for both infants and the facility was not aware as to whether or not the healthcare workers potentially could be the source of the transmission, as no testing had been done to rule this out. A document provided to the surveyor on 12/1/17 at 11:55 p.m. by the Infection Preventionist (Staff Member #13) was a communication from the Epidemiologist (dated 11/28/17) which documented , in part, "...In terms of staff screening, though, they said when they have a limited number of staff linked with infected infants, that they go ahead and screen- but employee health would need to plan for how to deal with that first..." At the time this document was presented to the surveyor, Staff Member #13 stated, "The plan is to talk with them (Employee Health) today..." The surveyor asked about that the facility not acting upon this information once it was received from the Epidemiologist. Staff Member #1 stated, there was nothing in the facility policy regarding the screening of employees in this circumstance. At 4:00 p.m., Staff Member #1 stated, "We have been in contact with Employee Health and have had a emergency meeting of leadership. We are putting a process in place and beginning screenings of the employees identified. If the employee is scheduled to work this weekend, they will have to wear PPE (personal protective equipment) including a mask until the results come back... we are doing a revision to our policy regarding this..."

On 12/4/17 at 11:30 a.m., the surveyor was given a document "Employee Wellness Services: Methacillin Resistant Staphylococcus Aureus". Staff Member #1 stated "There is an addendum to this document with the revision date on the bottom (12/4/17)." This document evidenced, in part: "...Bon Secours will take proactive steps to protect the workplace in the event of a potential or confirmed MRSA presence on any unit...Steps in process when employees' may be MRSA carriers: Employee Wellness Services will after receiving a list of employees from Infection Prevention and/or unit managers: Immediately schedule employees for nasal swabs (nasal swabs will be completed on all suspected employees by Employee Wellness Nurses). Report the nasal swab results, without identifying the employee to the investigatory committee. Ensure that during the period of time from nasal swab testing to posting of results: Infection Prevention is consulted on employee requirements to prevent the spread of MRSA and Inform employees being tested for specific work requirements such as masking, gowning and gloving..."

On 12/5/17 the surveyor reviewed the education and training for staff. This involved the NICU staff, EVS, Physicians, and other providers who were in contact with the infants and NICU area, and Respiratory Therapy. Based on a review of the materials and documents provided, it was evident that all staff had received re-training and re-education regarding work duties, infection control, and job specific re-education after the identification of the infection except for the physician providers. There was no specific documentation or reference provided that the surveyor could identify as re-education or discussion of work-related practices related to this event. Staff Member #1 stated, This is something we will have to take care of...all the providers have been involved in this and were part of the meetings and plan. We do not have anything that could be considered a formal re-training for them though, regarding the infection control practices and policy..."

The surveyor discussed the facility failure to initially screen identified employees/staff who were linked to the outbreak through care of the identified infants as well as the documentation of the re-education of the providers who were identified as providing care to the infants. This discussion occurred on 12/6/17 at 11:30 a.m., with Staff Members #1, #3, and #25.

2. The facility identified, on October 4, 2017, the occurrence of two cases of MRSA infection in the NICU area of the facility. The facility failed to promptly report to the local Health Department the two cases which were epidemiologically related.

The survey team conducted a tour and observations of the NICU and other relevant areas of the facility on 11/30/17 after meeting with facility Administration.

On 11/30/17 at 1:40 p.m., Staff Member #1 (System Director of Quality and Infection Control) stated, "[local Epidemiologist] on November thirteenth (2017), discussed with us in a meeting that they need to be notified by the second case...we talked about process improvements and what is going on across the state in other places regarding their processes...we asked for information on what [he/she] has seen in other facilities that could be of benefit to us in fine tuning and being compliant with our process and what the best practices are...we started an investigation immediately when we became aware of the two cases and we thought we needed to do that first..."

On 12/1/17 at approximately 9:30 a.m., the survey team met with Staff Member #1, #8 (NICU Manager), #13 (Facility Infection Preventionist), #15 (Environmental Services Manager), and #16 (Director of Environmental Services) regarding the delay in reporting the MRSA outbreak. Staff Member #13 stated, "We do a drill-down process on every HAI (hospital acquired infection)...which is our usual process...we have found that was incorrect for this case and we will not do that again. We should have reported it immediately after identification of the second case....it will not happen again... EPI (Epidemiology) has instructed us to call at the preliminary report and then all again with the final..." Staff Member #8 added, "Until we sat down with [Epidemiologist] we thought we were supposed to do a drill-down and get all the information and then report, but we found out that was incorrect on our part..." Staff Member #13 added, "When you look at the reportable disease list, MRSA (Methacillin Resistant Staphylococcus Auerus) is not on there and that's where it got confusing and that's why it slipped by..."

The surveyor reviewed the facility policy and procedure "Communicable Disease Reporting" which was dated as reviewed on 4/24/17. The policy evidenced, in part: "...reporting of the communicable diseases listed on the following page is required by the Health Laws of Virginia Code (Section 32.1-36 and 32.1-37) and the Virginia State Board of Health Regulations for Disease Reporting and Control (12VAC 5-90-80 and 12VAC 5-90-90; 2011...2. Infection Prevention will notify their local Health Department of suspected or confirmed reportable diseases. Communicable diseases requiring immediate notification will be reported within 24 hours of suspected or confirmed diagnosis by the most rapid means available. All others will be reported within 3 days of suspected or confirmed diagnosis...4. Infection Prevention will report the occurrence of outbreaks or clusters which may represent a group expression of illness that may be of public health concern to the local Health Department by the most rapid means available..." On page 2 of this document was the "Virginia Reportable Disease List" which evidenced, "Report Immediately...Outbreaks, all (including but not limited to foodborne, healthcare-associated, occupational, toxic substance related and waterborne)..."

The facility policy "Outbreak Investigation" dated as being reviewed/revised 12/2017 was reviewed. The policy evidenced, in part: "...An outbreak is an increase in the incidence of a disease above what is normally expected among a specific population during a specific time frame. When the occurrence of hospital associated infections exceeds the expected level, or when an unusual pathogen is isolated, an outbreak investigation will be conducted to identify the contributing factors and to prevent or minimize the spread of the disease...Reporting the Outbreak A. Health Department--All outbreaks...are reportable by state law (Refer to Infection Prevention policy Communicable disease reporting)..."

On 12/5/17 at 9:50 a.m., Staff Member #1 stated, "...We did not identify there was a problem until the (October) 4th, and began our investigation...the timing was not confirmed and we began the drill down... We also had some confusion after we notified (Epidemiologist) on November 8th (2017), that they communicated directly with your [State Agency] office since they are also under the Department of Health...it has been confusing and a process which we now understand..."

The surveyor was presented with a time-line and documents reflecting the course of the investigation which took place for the outbreak which began on October 4th 2017 and continued through November 2017. The investigation process, according to the facility is still on-going with revisions to policy and procedure regarding staff, as well as further education and observations for infection control compliance.

The concern regarding the facility failure to report promptly was discussed with facility Administration, (Staff Members #1, #3, and #25) on 12/6/17 at 11:30 a.m.

3. On 11/30/17 at 12:20 p.m. while touring the ICU (Intensive Care Unit) with Staff Member #5, the surveyor noted an "Enteric Precaution" sign posted outside of Room #10. The surveyor observed a visitor sitting in the room with the patient. The visitor was wearing gloves and a yellow isolation gown with a jacket draped over his/her legs, touching the floor on both sides. The visitor was talking on a cell phone, a silver tumbler sitting on a bedside table beside the visitor. The surveyor asked about the visitor in the isolation room to Staff Member #5, who said "the procedure is explained to the family when patients are on precautions".

At 11/30/17 at 12:25 p.m. the surveyor observed Staff Member #11 in ICU room #11 providing care and assisting a physician with the patient. There was a "Contact Isolation" sign posted outside of the door. Staff Member #11 had on an isolation gown; however, it was not tied properly, and was hanging off of his/her shoulders and not effectively covering his/her scrubs. The surveyor observed Staff Member #11 touching his/her mouth and face with gloved hands after touching the patient, equipment, and the privacy curtains. While making staff observations in ICU room #11, Staff Member #12 donned gloves and gown, entered the room, pulled the privacy curtain at the door and across the window to the room.

Staff Member #5 was present at the time the observations were made. The observations were again discussed with Staff Members #1, #3, and #25 on 12/6/17 at 11:30 a.m.

4. On 11/30/17 at 1:20 p.m., the survey team toured the facility kitchen and observed the following: In a small reach in cooler, identified as a "holding" cooler for prepared foods, there was shelving with a thick, sticky brownish material adhering to the front. There was a plastic bottle of (sports drink) containing approximately 1/2 inch of blue liquid. There was a six-ounce water bottle which was half-full of clear liquid. These items were identified by Staff Member # 9 (Director of Nutrition Services) as "Probably belonging to staff".

On the shelves identified as "drying racks" for the metal "hotel pans" the surveyors observed multiple pans which were identified as clean by Staff Members #9 and #10 (Head Chef). The surveyors observed multiple pans to have been "wet nested". Ten pans were also observed to have a dried material on the inside identified as "probable food residue".

A large cast iron skillet was located on the top of the drying shelf that, when removed for closer inspection contained a large amount of rust.

In the walk-in refrigerator, the surveyors observed a cart containing metal pans labeled:Chicken salad- date 11/29/17, Pasta salad- date 11/28/17, Cole slaw - date 11/28/17, modified pasta - date 11/28/17 and "cheese" - date 11/29/17. Staff Member #10 directed a staff member to remove and discard the items.

The surveyors observed in the prep area that a large colander was on one of the prep sinks, however in the sink basin itself was a large amount of cut up vegetables (squash and zucchini) which had been placed in the sink for "rinsing after being cut up". Staff Member #9 stated, "I don't know why they did that. The colander is right there." The surveyor asked Staff Member #10 to check the sanitizer concentration in a "red bucket" which was identified as the sanitizer solution used by staff to clean the counters and prep areas in the kitchen. Upon testing the solution Staff Member #10 stated, as the surveyor observed, "There is no change in the test tape. I don't know who prepared this bucket." The surveyor asked Staff Member #10 to re-check the bucket solution. Upon retesting, the test tape demonstrated less than a 50ppm (parts per million) concentration of cleaning/sanitizing solution present in the bucket. Staff Member #10 identified this bucket as one that was used to sanitize the prep counters.

On 12/5/17 the surveyor reviewed the facility policy and procedure "Sanitation and Infection Prevention: Sanitizing Food Contact Surfaces" which evidenced in part: "...Each work area will be equipped with sanitizing solution...Sanitizer solution must be at 200ppm to 400 ppm (parts per million) for Oasis 146 Multi-Quat Sanitizer...Red Buckets: Replace sanitizer in buckets every 2 (two) hours, or more frequently, if visibly dirty..." Attached to this policy and procedure was an example of a document "Red Bucket Log" which contained dates and times to document when the sanitizer solution was changed. The surveyor requested to examine the "Red Bucket Log" for the month of November and through the current date.

On 12/6/17 at 9:30 a.m.,the surveyor was provided with a "Red Bucket Log" for "Month of December". There were only two entries on the log for the 6th at 6:00 a.m. and 8:00 a.m., The rest of the document was blank. Staff Member #1 stated, "They (kitchen) do not have any other logs. They started this one today..." At that time the surveyor discussed the kitchen observations with Staff Member #1.

The facility policy and procedure "Storage of Pots, Dishes, Flatware, Utensils" was reviewed and evidenced, in part: "...Air dry all food contact surfaces, including pots, dishes, flatware, and utensils before storage, or store is self-draining position. Do not stack or store when wet..."

The surveyor discussed the concerns regarding the kitchen observations with Staff Member #1, 3, and 25 at 11:30 a.m.