HospitalInspections.org

Based on record review, interview, and observation the facility failed to follow their Policies and Procedures to properly isolate or cohort 4 of 4 patients (Patients# 1, 2, 3, and 4) with drug resistant infections, to conduct surveillance activities for all infections in the facility, and to ensure equipment was cleaned between patient uses.

The findings included:

The facility Policy and Procedure titled Infection Prevention and Control Program, release date 06/2017, documents "The Infection Prevention and Control Program include processes to minimize healthcare associated infection through an organization-wide program. These processes include but are not limited to the: ...Developing systems and a plan for reporting infection surveillance results including calculation of infection rates within the facility to employees, medical staff..." and "Records identify community acquired infections and HAIs (healthcare acquired infections) and report any infection patterns or trends to the Infection Prevention and Control Committee and/or the Performance Improvement Committee."

The facility Policy and Procedure titled Transmission-Based Precautions, release date 06/2018, documents under Guidelines for Patient Placement when Initiating Transmission-Based Precautions "When single patient rooms are available, assign priority for these rooms for patients with known or suspected MDRO (multi-drug resistant organisms) colonization or infection. When single patient rooms are not available, cohort with patient having same MDRO organism. When cohorting patients with the same MDRO is not possible, place MDRO patients in rooms with patients who are at low risk for acquisition of MDROs and associated adverse outcomes from infection and are likely to have short lengths of stays... A patient who has secretions or excretions with an MDRO that can be contained (for example, with a dressing, indwelling catheter), the chances of cross-infection to a roommate may be lower than those who have excretions and secretions that cannot be contained."

The facility Policy and Procedure titled Standard Precautions documents "Standard precautions apply to all patients regardless of diagnosis or presumed infectious status" and "All staff and persons attending or visiting the patient should perform hand hygiene by washing his/her hands or using alcohol-based handrub before entering and when leaving the patient's room EVERY TIME" (sic) and "Reusable equipment is not used for the care of another patient until it has been appropriately cleaned, disinfected and reprocessed."

1) On 03/07/19 Patient #1, who was observed breathing through a tracheostomy (tube in his neck) was observed sharing a room marked for contact isolation with Patient #2. Review of daily report sheets revealed Patients# 1 & 2 shared the room since 02/21/19. The hospital census was reported by the Quality Manager as 60 patients on 03/06/19. The hospital is licensed for 119 beds.

Patient #1's History and Physical dated 02/16/19 documents he is greater than 70 years old, completely dependent on a ventilator to breath for him through a tracheostomy, was admitted on 02/15/19 for treatment of sepsis (a life-threatening condition that arises when the body's response to infection injures its own tissues and organs) after recent pneumonia, and had a pressure ulcer that extended into the underlying bone and/or muscle. Patient #1's Infectious Disease Consultation dated 02/17/19 documents his blood cultures since 01/19/19 contained the bacteria MRSA (methicillin (antibiotic)-resistant Staphylococcus aureus), Escherichia coli, and Proteus, and his urine culture had Proteus; further cultures were pending; and that a chest x-ray completed on 02/17/19 showed infiltrate throughout his entire left lung, which would significantly inhibit air exchange. Patient #1's cultures and sensitivities from tracheal secretions, reported on 02/21/19, revealed the following bacteria: heavy growth of Acinetobacter baumannii that was resistant to every antibiotic listed as tested, Klebsiella aerogenes and Proteus mirabilis that were each resistant to 14 of 20 antibiotics tested. On 02/21/19, Patient #1 became roommates with Patient #2 who had different multi-drug resistant organisms throughout his system.

2) Patient #2's record documents he was admitted on 02/21/19 and had a history of congestive heart failure with decreased heart function, diabetes and stroke, and recently had a tube inserted to drain fluid from a lung. Review of Patient #2's Infectious Disease Consultation dated 02/21/19 documented severe sepsis with Klebsiella pneumoniae and ESBL (extended spectrum beta-lactamase, an enzyme that causes antibiotic resistance) Proteus mirabilis, infected heel wounds, and that he was on the antibiotic Meropenem. Patient #2's roommate since his admission on 02/21/19, Patient #1, had a respiratory infection with Acinetobacter baumannii that was resistant to meropenem. Furthermore, Patient #1 had a tracheostomy which increases the likelihood of spreading secretions and germs in the room.

On 03/07/19 at 1:19 PM, the Infection Control Practitioner explained the decision to cohort Patients# 1 & 2 was made by herself with the Chief Clinical Officer, Nurse Manager, Respiratory Department Manager, and Nutrition Manager. When asked about the criteria they considered in reaching this decision, she read out loud from a policy that it is not always possible to cohort the same MDROs so they can put the isolated pt with another pt who is at low risk for getting the infection. Upon further inquiry, she said heel wounds that are contained would be low risk but someone with a tracheostomy or respiratory infection would be high risk. The Infection Control Practitioner stated patients with different organisms can be put together as roommates if the secretions and excretions can be contained, such as by covering wounds, and staff use standard precautions between patients. The Infection Control Practitioner confirmed she didn't consult a physician about rooming the patients together but said they considered whether the patients are stable, close to the same age, and have no central lines. The Infection Control Practitioner denied awareness that Patient #1 had a tracheostomy and was on a ventilator for most of his stay with Patient #2.

3) Patient #3's History and Physical dated 12/25/18 documents he was admitted 12/24/18 with a ventilator to help him breathe through a tracheostomy, fed through a tube in his stomach, was bedbound with no purposeful movements of his extremities, was over 80 years old with recent history of urinary tract infection, stroke and head injury, and had a "poor" prognosis. Patient #3's Infectious Disease Consultation dated 12/26/18 documented he had persistent diarrhea with no known cause. Patient #3's sputum culture and sensitivity from 01/03/19 documented Pseudomonas with multiple drug resistance. Patient #3's orders were dated 1/10/19 for the intravenous antibiotics cefazolin and vancomycin. Review of daily report sheets revealed he shared a room with Patients# 4 from 01/07/19 until at least 01/15/19 (end of time frame reviewed), who had recent infections with multi-drug resistant organisms: Pseudomonas, Klebsiella, and VRE (vancomycin-resistant Enterococci). Patient #3 did not have documentation of recent cultures containing Klebsiella or VRE before they shared a room. There was no documentation that a physician was consulted in the decision to place these 2 patients together since they did not have identical organisms and additional risk factors specific to the patients should be considered, such as their trach/ventilator status, open wounds, and complicated medical conditions that made them vulnerable to complications, such as death, from further infection.

Patient #4's History and Physical dated 10/31/18 documents he was admitted on 10/31/18 on a ventilator per tracheostomy; fed through a tube in his stomach; was bedbound; recently treated for multiple infections with Klebsiella pneumoniae, Pseudomonas, MRSA, and Candida fungemia; had a muscle/bone-deep sacral pressure ulcer; and arrived with a fever of 102.8 degrees Fahrenheit. A Consultation Report for Infectious Disease dated 11/14/18 documents he was being treated for multi-drug resistant Pseudomonas and Klebsiella cultured from the lungs, and that a sacral bone biopsy and culture before admission showed osteomyelitis with VRE (vancomycin-resistant Enterococci).

On 03/07/19 at 4:19 PM the Chief Clinical Officer explained the infection control nurse and nurse supervisors assign beds for admissions or transfers, that they consider any infections the patients may have, the safest way to accommodate the patients, whether by private room or a compatible roommate, and whether they can be safely cohorted (roomed together). On 03/07/19 at 4:19 PM the Chief Clinical Officer said staff do not need to call the physician for cohorting decisions unless they have uncertainties, and that the "team," not physician(s), decides which patients should be on contact isolation and when to discontinue it, that physicians do not give orders regarding isolation.

During telephone interview with Infectious Disease Physician "A" on 03/07/19 at 5:11 PM, who stated he regularly saw patients in this hospital, he denied being consulted before cohorting Patients# 1 & 2 and he would have said it's "not such a good idea" to place a patient with ESBL with another who does not have it, and that staff should discuss with himself/medical staff before cohorting patients when the patients considered do not share the same organisms and sensitivities.

The Centers for Disease Control documents on the web page https://www.cdc.gov/drugresistance/about/how-resistance-happens.html, last updated: August 22, 2018: "Often, resistance genes are found within plasmids, small pieces of DNA that carry genetic instructions from one germ to another. This means that some bacteria can share their DNA and make other germs become resistant."

4) On 03/06/19 at 2:27 PM the Infection Control Practitioner, stated she tracks urinary catheter, central line, and ventilator associated infections as well as multi-drug resistant organisms but does not track other infections that are not drug resistant. The Infection Control Log was requested and provided that includes 7 drug resistant organisms that they track, but no other infections in the facility. On 03/06/19 at 2:27 PM the Infection Control Practitioner said there may be more data in the computer but she does not know how to access it. She could not explain what she meant or where the data would have come from but said she had been in the position since November 2018 and not needed it. During further interview on 03/07/19 at 12:15 PM the Infection Control Practitioner showed worksheets for each patient in the facility to follow their infections and antibiotics, but stated she throws them out after discharge and does not keep data or information from them after patients leave.

5) During observation on 03/06/19 between 10:38 AM and 11:14 AM Housekeeper "B" was observed to exit room 208 carrying a corded bed control in one gloved hand, to enter room 210 without performing hand hygiene and go out of sight behind the patient's curtain, to come out of the room now carrying a phone in her gloved left hand and the bed control in her right ungloved hand, to enter room 207 and go out of sight behind a patient curtain, then exit the room without the phone but with the bed control still in her ungloved right hand, and enter yet another room. Throughout the continuous observation, she did not wash her hands, use hand sanitizer, or clean the equipment between patient rooms but walked past the Sani-Cloth wipe dispenser and hand sanitizer without using them.

6) During observation on 03/06/19 between 10:38 AM and 11:14 AM Nursing Assistant "C" exited room 210, entered room 215, and rummaged through the cabinets for folded linens which she took behind the curtain to the far patient, left the room and went directly to room 214 where she removed linens from those cabinets and took them to bed B. Looking at the surveyor, she then donned gloves and proceeded to make the bed. Nursing Assistant "C" did not wash or sanitize her hands throughout this observation. During interview on 03/06/19 at 3:26 PM Nursing Assistant "C" said she should wash and sanitize her hands every time when entering a room, before touching or doing anything, between patients, and again when leaving the room. In regards to the described observation she said she didn't have to wash or sanitize her hands because she "didn't touch anything."