HospitalInspections.org

Based on staff interview and policy review it was determined the hospital failed to document, per policy, the analysis of an incident in which a nursing home reported a lack of notification at discharge of a patient's multiple drug resistant organism (MDRO) status. This deficient practice was identified in one (1) of one (1) patient reviewed who was discharged to a nursing home with MDRO (patient #1). This failure creates the potential for an adverse impact on the quality of care for all patients with MDRO who are discharged to nursing homes.

Findings include:

1. On 4/13/15 at 2:00 p.m., the Risk Manager stated the hospital had no record of any incidents or complaints involving patient #1.

2. An interview was conducted with the Infectious Disease Specialist on 4/14/15 at 12:00 p.m. He stated he remembered the nursing home called the hospital and was very upset. He stated he spoke by phone, along with the Care Management Director, to the nursing home staff and they were very angry that they were not informed of the MDRO status by the hospital.

3. An interview was conducted with the Care Management Director on 4/14/15 at 3:35 p.m. She confirmed she received a phone call from the nursing home, approximately three (3) days following the 5/21/14 discharge of patient #1. The Director stated the nursing home was very upset the patient's MDRO status was not shared with them prior to discharge. The Director stated she told the nursing home she would do an investigation into what happened and call them back.

On 4/15/15 at 11:45 a.m., the Care Management Director confirmed she failed to document the incident regarding patient #1.

4. On 4/15/15 at 10:30 a.m., the Quality Manager confirmed the above referenced incident regarding patient #1 had not been recorded and/or investigated, per policy.

5. The policy, "Incident Reporting", last revised 10/3/13, was provided for review. The policy states, in part: "It is the policy of University Healthcare, Berkeley Medical Center and Jefferson Medical Center that all incidents be reported and investigated in a timely manner."

Based on policy review, document review and staff interview it was determined the hospital failed to designate a person/persons to function as infection control officer(s) for the facility. Failure to designate an infection control officer to direct and coordinate the infection control program has the potential to result in missed opportunities to prevent and control the spread of infections within the hospital and community.

Findings include:

1. The hospital's Infection Control Policy entitled, "Structure and Functions of the Infection Control Committee", last revised 08/11, states, in part: "...the Infection Control Practitioner has the responsibility for coordinating and directing a program of surveillance, prevention and control of infection as approved by the Infection Control Committee. The IC Practitioner is directly responsible to the Director of QR&M and the Chairperson of the Infection Control Committee as appropriate per situation...There shall be an Infection Control Practitioner provided at least 40 hours a week for maintenance of the Infection Control Program throughout the hospital."

2. The Infection Control Committee (ICC) meeting minutes for 2013, 2014 and 2015 were reviewed. The minutes from the 9/25/13 ICC meeting revealed the Infection Control Practitioner (ICP) resigned in September 2013 and the Director of Employee Health (EH) was designated as interim Infection Control Officer. Further review of minutes revealed the 4/14 ICC meeting was the last meeting attended by the Director of EH/interim ICP. There was no evidence found to indicate any further appointments to the ICP position.

3. During an interview with the Chief Nursing Officer & Vice-President of Patient Care Services on 4/13/15 at 3:00 p.m., she stated the current Employee Health (EH) Nurse "is covering" the infection control nurse position and has been designated as the ICP. The Director of Quality was interviewed on 4/14/15 at 11:50 a.m. and she stated the ICP resigned in September 2013 and the EH Director was appointed as interim ICP; however, the interim ICP resigned and the position has been vacant since April 2014.

4. During an interview with the current EH nurse on 4/15/15 at 2:00 p.m., she stated she has not been appointed as the ICP and she does not have any infection control responsibilities except as they relate to employee health.

Based on record review, policy review, document review and staff interview it was determined the hospital failed to counsel the nursing home staff related to the multi drug resistant organism (MDRO) status for one (1) of one (1) patient reviewed who was discharged to a nursing home with MDRO (patient # 1). This failure creates the potential for an increased risk of transmission of MDRO for patients and care providers of patients with MDRO.

Findings include:

1. Review of the medical record for patient #1 revealed the patient was admitted to the hospital from nursing home #1 on 4/26/14. Review of the record revealed positive culture results were called to nursing staff at 8:36 a.m. on 4/28/14. The result confirmed the presence of a MDRO. On 4/30/14 at 9:11 a.m., positive surveillance swab results, indicating a MDRO, were also called to nursing staff. On 5/21/14 the patient was discharged to nursing home #2.

2. Review of the 5/21/14 Discharge Summary and Discharge Instructions for patient #1, provided at the time of discharge, revealed no mention of the MDRO results.

3. Both the Discharge Summary and Discharge Instructions were reviewed by the Infectious Disease Specialist at 12:00 p.m. on 4/14/15, the Clinical Nurse Specialist at 11:40 a.m. on 4/15/15, the Case Management Director at 1:00 p.m. on 4/15/15 and the 5th Floor Nurse Manager at 2:30 p.m. on 4/15/15; all agreed the MDRO status was not referenced in either the Discharge Summary or Discharge Instructions.

4. Review of the 5/21/14 Case Management note documented at 11:24 a.m. revealed Social Worker #1 documented the Discharge Summary was being faxed to the nursing home.

An interview was conducted with Social Worker #1 at 1:30 p.m. on 4/14/15. She confirmed she had not discussed MDRO results with the nursing home.

5. Review of the 5/21/14 note, documented by Registered Nurse #1 at 12:38 p.m., revealed the nurse documented a report was called to the nursing home but did not not indicate what information was provided.

Registered Nurse #1 was interviewed at 8:10 a.m. on 4/15/14. She stated she could not remember for certain, but acknowledged she most likely would not have told the nursing home staff about the MDRO status if it was not listed in the history of the discharge summary.

6. The Medical Staff Bylaws and Rules and Regulations, effective 11/24/10, were provided for review. The Rules and Regulations state, in part, at #12: "Discharge Summary/Final Diagnosis: A discharge summary will be completed which includes the reason for admission, the complete final diagnosis (principal and all secondaries), operative procedures performed, significant findings, treatment rendered, the condition of the patient on discharge and specific instructions given relative to diet, activities, medications and follow-up."

7. The policy, "Discharge Planning-Nursing Home", last reviewed 3/13, was provided for review. The policy states, in part: "Demographic and medical information are given to the Admissions Directors or social worker at the nursing home initially by phone..."

8. The nursing policy for provision of discharge instructions was requested from the Chief Nursing Officer (CNO). At 10:30 a.m. on 4/15/15 she provided a Lippincott Nursing Procedure for Discharge, revised 4/3/15. The procedure states, in part: "If the patient is being discharged to another facility, such as an assisted-living or long-term care facility, or will receive care at home from a home health care agency: Provide hand-off communication for the person who'll assume responsibility for the patient's care. Allow time for questions, as necessary, to avoid miscommunications that may cause patient care errors during transitions of care."

Staff interviews revealed the above noted policies/procedures were not followed.