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Based on observations, interviews with visitors and staff, review of patient medical records and review of hospital policy and procedure, it was determined the hospital failed to (1) aggressively re-educate 31% of the Nursing Department staff or 29% of all hospital staff regarding infection control practice, (2) aggressively educate visitors regarding infection control practice, (3) ensure staff strictly adhered to infection control practices when providing medications, when exiting rooms, and when terminally cleaning/disinfecting patients rooms after discharge; after a visit in March 2011 from a US Federal entity responsible for monitoring disease transmissions. The visit was related to the hospital's infection control practice. The failure of the hospital to provide a sanitary environment to prevent transmission of Multi Drug Resistant Organisms (MDRO) resulted in this Condition of Participation not being met.
Findings included:
1. Random observations on 7/12/2011 at 9:15 a.m. revealed a visitor on the 2nd floor in patient room #239. A laminated sign was observed posted on the left side of the door frame. The sign indicated "Contact Precautions", with instructions to wear gloves to enter, wear gowns when entering patient room, and wash hands. The visitor did not have a gown on, nor did they have gloves on. An unidentified hospital employee, walking down the hall, noticed the visitor in the patient room and told them they must put on a gown.
Review of the patient's Cardex revealed he was in isolation related to testing positive for MRSA (Methicyllin-resistant Staphylococcus aureus) and VRE (Vancomycin-resistance Enterococci).
An interview was conducted with the visitor on 7/12/2011 at 11:10 a.m. The visitor indicated they were a spouse of the patient and confirmed that the hospital staff had reminded her to wear a gown. She was observed in a blue plastic gown, which was open in the back, untied. When asked what training had been provided regarding the need to wear protective equipment, she indicated the only information that she had been provided was to make sure she wore a gown when in the patients room. Further inquiry about possible documents that she and her spouse might have received revealed that she did not receive any handouts. When asked about wearing gloves and hand washing, she indicated she had received no instructions or guidance from the hospital staff related to hand washing or wearing gloves.
An interview was conducted with the Registered Nurse in charge of the Infection Control Program on 7/12/11 at 1:10 p.m. She indicated that the patient and family are provided information on the infection control measures they should use. She provided two brochures, which she indicated are provided at admission.
Review of the brochure titled "Quick Guide To Isolation Precautions", undated, indicated "Standard Precautions", "These are practices that all health care workers follow in the care of all patient, no matter what their diagnosis or disease process. 1. Staff and visitors must wear gloves when likely to come into contact with blood, body fluids or wastes. This doesn't apply to sweat." "Visitors should seek advice from staff about the disposal of items that might be contaminated." Under "Transmission based Precautions" the brochure indicated "The CDC has identified 3 isolation/precautions systems might be used when a patient has conditions or diseases that might be spread by the following routes. Instructions on special protective gear and practices are found on the signs." "Patients on transmission based precautions are not permitted in the public areas such as cafeteria or lobby." The brochure had reproductions of the signs included on the third page with titles that included Airborne Precuations, Droplet Precautions and Contact Precautions. Under the titled section "Contact Precautions" the brochure indicated "The most common form of disease transmission is direct skin-to-skin or indirect contact with contaminated items in the room. For diseases or conditions spread by touching, such as antibiotic-resistant microbes, lice/scabies, or diarrhea. Staff will wear gowns and gloves whenever entering the patient room or to touch any environmental surfaces. Patients should not leave the room unless medically necessary." There was no verbiage to indicate that visitors must adhere to these "Contact Precautions" with the exception of the statement regarding wearing gloves when likely to come into contact with blood, body fluids or wastes or that visitors should seek advice from staff about the disposal of items that might be contaminated. The brochure contained a disclaimer on page four that indicated "This brochure provides basic general information. It should be used as a guide and not as a complete resource on the subject." "If you have any further questions, please ask your Physician, Nurse or the Hospital Infection Control Nurse". The brochure contained the name, phone number, and phone extension number for the Infection Control Nurse.
The second brochure had a CDC logo on page one on the bottom left corner. The brochure was titled "Hand Hygiene Saves Lives" with a secondary heading of "A Patient's Guide". The brochure was undated. Page one also had another secondary heading "hand hygiene" with the following information below it, "Washing hands with soap and water. Cleansing hands using an alcohol-based hand rub. Preventing the spread of germs and infections." Under "Why?" on page two, the brochure indicated, "In the United States, hospital patients get nearly 2 million infections each year. That's about 1 infection per 20 patients! Infections you get in the hospital can be life-threatening and hard to treat. All patients are at risk for hospital infections. You can take action by asking both your healthcare providers and visitors to wash their hands." "To make a difference in your own health. Hand hygiene is one of the most important ways to prevent the spread of infections, including the common cold, flu, and even hard-to-treat infections, such as methicillin-resistant Staphylococcus aureus, or MRSA." The brochure went on to identify when the patient and healthcare provider should perform hand hygiene, how to perform hand hygiene, which type of hand hygiene to perform, and who should perform hand hygiene (patient, loved ones, and healthcare providers).

The "Infection Prevention and Control Practices" policy #H-IC 02-008, related to "Multi-Drug Resistant Organisms (MDRO), with a revision date of 05/2010 was reviewed. The purpose of the policy was "To provide guidelines for controlling the spread of antibiotic-resistant organisms, included but not limited to Methicillin-resistant Staphylococcus Aureus (MRSA), Vancomycin-resistant Enterococci (VRE), Extended Spectrum Beta Lactamases (ESBL) producing organisms and any other resistant organism deemed appropriate..." Page 4, under the number 8. indicated "All visitors must have Isolation Precuation requirements explained to them by clinical staff, especially hand hygiene."

2. Observations were conducted of room 235 on 7/12/11 at 9:15 a.m. which had been terminally cleaned as documented by a sign posted to the left of the door. The sign indicated, "Attention - Environmental Service has cleaned this Room", "Please do not enter into this room", the date "7/12/11" was indicated as well as the 1st name of the employee (employee# 6). The toilet seat and the rim of the toilet was observed to have dried yellow spots on them, presumably urine. The Director of Clinical Services joined the surveyor shortly after the initial observation, she confirmed that the room was terminally cleaned and that the employee failed to adequately clean the bathroom for room 235.

The "Infection Prevention and Control Practices" policy #H-IC 02-008, related to "Multi-Drug Resistant Organisms (MDRO), with a revision date of 05/2010 was reviewed. Page 4, under #10, indicated "Terminal room cleaning after discharge: a. Rooms are to be cleaned per Environmental Services policy."

Review of the "Terminal/Discharge Room Cleaning" policy, dated 11/13/2009, from the Environmental Services manual revealed the purpose was "To provide guidelines for appropriate room cleaning for discharged patients, with the exception of isolation rooms for clostridium difficile (c. diff)." Step 20 indicated, "Clean the bathroom: a. Wipe down all surfaces in bathroom to remove visible organic matter (blood, feces, urine). b. Pour disinfectant into the bowl and swab clean with bowl mop. Flush. Spray outside and top of toilet with germicidal spray. Allow to air dry."

3. Observations were conducted of a medication pass on 7/11/2011 at 12:40 p.m. with staff #2, Registered Nurse. Patient #12 was noted to be on Contact Precautions. The nurse donned gloves and checked the patient's Blood Pressure. The nurse then removed gloves, washed hands, donned new gloves, crushed the medications and obtained water for PEG tube administration and irrigation. The nurse aspirated for residual gastric contents and gave medications through PEG tube. Immediately after, the nurse opened a vial of injectable Heparin 5,000 units and drew up the drug with a needle and syringe then administered it to the patient, using the same gloves. PEG tube medication administration is a clean procedure however, the injectable is an aseptic procedure. Additional observation revealed the patient's urinary catheter bag and tubing which was on the floor with a cloth partially covering it. When the surveyor asked the nurse regarding this, she stated the C.N.A. found that the suprapubic site does not leak around it when the bag is very low. Discussion with the nurse and the Clinical Director resulted in the Clinical Director asking for the bag to be placed in a basin and not on the floor.

4. Observations were made in the ICU on 7/11/2011, at 3:00 p.m. of terminal cleaning in progress. The privacy curtain was in place while staff cleaned/mopped. It was observed that the curtains were not taken down and bagged. The surveyor asked staff #5, Environmental Services Aide, if the curtain would be taken down and replaced. She stated, "not yet, I will have to go see if we have any." No clean privacy curtains were noted in the linen room in the ICU. A set of ten privacy curtains were observed in the main linen room on 7/12/2011.

A review of policy and procedure, titled "Terminal/Discharge Room Cleaning", approved 11/13/2009, revealed the procedure consists of 27 steps. Step #1 was to "Remove privacy curtains and place in bag." This ICU room was not terminally cleaned in accordance with basic infection control standards or the facility policy and procedure. The terminal cleaning observation was conducted with the Clinical Director.

5. Observations made with the Clinical Director on 7/11/2011 at 3:15 p.m. revealed patient #9's foley catheter tubing to be on the floor. The Director donned gloves and positioned the tubing to not touch the floor.
6. On 7/11/2011, at 9:30 am, observations were made on 2 South with the Clinical Director. A family member of patient #6, was observed in the room leaning over the patient and adjusting a blanket. A staff member stated, "Mr. (name) you did not put your gown on" . The person responded, " I know " . A sign outside the door stated that the patient was on Contact precautions.
7. On 7/12/11 at approximately 9:15 a.m. observation of employee #2, a Certified Nursing Assistant, revealed he was leaving patient room # 243. The patient was on contact isolation precautions for C-Diff. He was observed to remove his gown and gloves, but did not complete hand hygiene before leaving the room. Observation of this CNA revealed he went to the nursing station, sat down at the desk and began writing without performing any hand hygiene.
Immediate interview with the employee's Supervisor revealed hand hygiene, washing with soap and water, is to be performed after contact with a patient on contact isolation who has C-Diff.
Review of the Infection control policy # H-IC 02-006, with a revision date of 11/2010, revealed Hand hygiene will be performed as follows: Before and after patient contact.
Review of the Contact Precautions Policy # H-IC 02-002, with a revision date of 05/2010, revealed; The empiric use of Contact Precautions may be used based on the definitive diagnosis as indicated in CDC/HICPAC- Guideline for Isolation Precautions in Hospitals.
8. An interview was conducted with the Infection Control Nurse on 7/12/11 at 9:15 a.m. and at 1:10 p.m. Information relayed included that Federal entity responsible for monitoring diseases had visited the facility for 10 days at the end of February 2011 and into March 2011. At that time, there was a discussion related to infection control and transmission of Carbapenum-resistant Kliebsiella pneumonia (CRKP) in the hospital. The Nurse indicated that currently the hospital is re-educating all staff in infection control practice.
The Nurse provided a master list related to CRKP education/Donning and Removing Personal Protective Equipment along with education material for 2010. Review of the list revealed an "x" documented under "completed" or "skills fair" to indicate the training was completed. The list indicated "n/a" (not applicable) for three of five Business Office personnel and six of ten Dietary employees. The following employees did not complete the training; two of eleven Pharmacy employees , four of 109 Nursing, one of three Plant Operations employees, three of seven Laboratory employees, two of twenty Respiratory Therapy employees, one of nine Environmental Services employees, and three of ten Rehab employees.

A Master attendance list was provided related to the 2011 training for "Reducing Spread of KPC and MDRO" on 7/12/2011. Documentation reflected the following employees had not completed the training; two of eleven Administration employees, three of ten Dietary employees, two of ten Pharmacy employees, two of two Purchasing employees, two of two Plant Operations employees, one of five Radiology employees, four of twenty Respiratory Therapy employees, 28 of 91 Nursing employees (2 were noted to be on leave "loa"), three of eleven Rehab employees, and two of nine Environmental Services employees. Based on this documentation, there are 28 of 91 Nursing Department employees that have not completed this education/re-education which is 31% of Nursing Department staff (28/91 *100=31). If you consider all employees, there are 49 of 171 remaining employees that have not completed this education which calculates as 29% of staff.

9. A review of the Infection Control Program revealed transmission of infections from infected patients to non-infected patients continue for April, May and June, 2011. Recent data for "KPC" Klebsiella Pneumononiae Carbapenemase, a Carabapenem-resistant Enterobacteriaceae (a form of CRKP, Carbapenem-resistant Kliebsiella pneumoniae) was transmitted to patients as follows: in April 2011 there were 13 in-house transmissions, in May 2011 there were 3 in-house transmissions, and in June 2011 there was 1 in-house transmission.

The surveyor requested specific root cause analysis of transmissions from the Infection Control Practitioner on 7/12/2011. Verbal information was provided regarding the previous year and reassignments of ICU staff and review of patient's trips out of the facility. No specific written root cause was made available to the survey team for the recent transmissions.

The Infection Control data also revealed transmissions of resistant Acinetobacter organism from infected patients to non-infected patients for April, May, and June, 2011. The hospital had 6 in-house transmissions of this organism in April 2011, while in May 2011 there were 3 in-house transmissions, and in June 2011 there were 2 in-house transmissions.

The infection control data, related to in-house transmission of Clostridium difficile, for April, May, and June 2011, was reviewed. The hospital had 0 transmissions in April 2011, 2 transmissions in May 2011, and 1 transmission in June 2011.

10. Patient #5, was admitted to the facility on 3/30/2011. Surveillance admission screening specimens were documented as obtained on 3/30/2011, and results reported on 4/1/2011 which included; KPC-Negative. Further testing for KPC was documented as follows: 4/6/11- Negative, 4/20/11 - Negative, 5/1/11 - Negative, 5/18/11 - Negative, 6/3/11 - Positive, and 6/17/11 - Positive.

On 7/12/11, the surveyor asked the Infection Control Practitioner (ICP) for root cause analysis on this case. The ICP stated that the patient has had several out-of facility trips to a local hospital. Information presented was that the patient had left the facility on 4/29/11 for incision and drainage of leg abscess; 5/17/11 Outpatient hospital visit for "wash of abscess"; and 6/2/11 to physician's office. No other root cause analysis, in-house investigation or corrective measures were made available related to the transmission of this drug resistant organism to this patient.

11. An environmental tour that entailed observations of randomly selected bathrooms, unoccupied cleaned rooms, and nourishment rooms on the second floor was conducted on 7/12/11 at 11:50 a.m., while accompanied by the Clinical Officer. The public restroom on the 2 North unit, close to the elevator, had grout missing from a tile behind the toilet stool, compromised caulking around the base of the stool. These conditions impede the disinfection of the floor and the base of the stool. Room 255 was observed to have a stain on the wall. A paper towel was dampened and the stain was wiped 4 times resulting in something yellow wiping onto the towel. The public bathroom located on the 2 South unit was observed to have a cracked tile, 2 tiles from the stool. The hot and cold water faucet handles were corroded. Cracked tiles and corroded surfaces impede disinfection of the surface. The bathroom sink in room 222 was observed to have corroded hot and cold faucet handles. The refrigerator in the ICU Nourishment room was observed to contain dried yellowish-white crusty matter in the bottom. The Clinical Officer confirmed all observations.