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Based on staff interviews, facility document review, and patient record review, the Governing
Body failed to establish an effective Infection Control Program to ensure patient safety; and to ensure the accountability of the Governing Body for oversite of the Infection Control Program.

For these reasons, the Condition of Governing Body was found to be out of compliance. These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being.

Findings:

Reference: A0747 Based on observation, staff interview, facility record review and medical record review the facility failed to insure that a qualified Infection Disease Practitioner is employed, that the facility has a safe and effective Infection Control Program and the Governing Body provides oversite and is actively involved in the facility's Infection Control Program.

Based on observation, staff interview, facility record review and medical record review the facility failed to insure that a qualified Infection Disease Practitioner is employed, that the facility has a safe and effective Infection Control Program and the Governing Body provides oversite and is actively involved in the facility's Infection Control Program

Findings:

1. Based on interview and facility document review the facility failed to ensure that the Infectious Disease Practitioner has received sufficient training in hospital related infection control.

2. Based on staff interviews and facility document review, the Governing Body failed to ensure oversite of the facility's Infection Control Program, and implement corrective action for identified problems.

3. Based on observations, interviews and record review the facility failed to ensure that for the Intensive Care Unit, Emergency Room, Medical/Surgical Unit and the Surgical Suite followed acceptable infection control practices.

Based on interview and facility document review the facility failed to ensure that the Infection Disease Practitioner has received sufficient training in hospital related infection control.

Findings:

1. Review of the Infection Disease Practitioner employee file revealed that in the fall of 2013 she was transferred into the position of Infection Disease Practitioner. The file revealed that she is a Registered Nurse that has worked a a floor nurse at the facility since 11/22/2004. Review of her file did not reveal any past experience or qualifying education as a Infection Disease Practitioner.

2. Review of the education record for the Infection Disease Practitioner revealed that she attended a 3 day 20.5 contact hour continuing education program provided on October 6-8, 2013. by APIC, (Association for Professionals in Infection Control and Epidemiology), titled The Fundamentals of Infection Surveillance, Prevention and Control.

The education file revealed a 2 and ½ day, (March 3-5), program provided by University of Florida on Tuberculosis.
Again in March 2014 she received a Certificate, Tuberculin Skin Test Train-the-Trainer Course
Review of the education file revealed that on September, 2014 she received a certificate on Hazardous Waste in Medical Facilities Annual Training.

Review of the Infectious Disease Practitioner's education record did not reveal any other education in 2014 other that completing 2 courses towards a Master of Public Health..

3. Interview with the Chief Nursing Officer (CNO) revealed that she is the director supervisor of the Infection Disease Practitioner. When CNO was asked what education was planned for the Infection Disease Practitioner she stated that none is planned and that she is waiting to see what happens with the possible purchase of the hospital by Hospital Corporation of America, (HCA)

Review of the Job Evaluation performed by the CNO completed on 12/08/2014 did not reveal any plans or that the facility is planning to assistance the Infection Disease Practitioner in her development of role as the facility's Infection Disease Practitioner.

Based on observations, interviews and record review the facility failed to ensure that for the Intensive Care Unit, Emergency Room, Medical/Surgical Unit and the Surgical Suite followed acceptable infection control practices.
Findings:
1. On 01/05/2015 at 10:40 AM an observation of Patient #2 ' s IV (Intravenous) site revealed there was no label to show the date, time, or initials indicating who started the IV and when. The IV bag was Lactated Ringers labeled 1/4/2015 started at 1700 with a flow rate of 0 (zero). The date and time on the IV tubing was absent
Patient # 2 was interviewed on 01/05/2015 at 10:40 AM. She said she came in on Saturday 01/03/2015 and the IV was started that day.
Chart review showed the IV started on 01/03/2015 by EMS (Emergency Medical Services). On 01/03/2015 at 12:56 PM the nurse's note stated "maintain field IV. Dressing intact. 20 gauge left antecubital space". Further review of the patient ' s chart showed the patient had a history of chronic Hepatitis C.
An interview with the Infectious Disease Practitioner on 01/06/2015 at 4:00 PM revealed the infection control information is covered in nursing orientation and instructs the staff to label all IV sites and tubing. Further interview with the Infectious Disease Practitioner revealed there is not a specific hospital policy for labeling IV ' s and IV tubing. She stated the hospital uses Lippincott as nursing references for IV ' s.
The DON faxed the Lippincott Procedures to the Area 3 office on 01/09/2015. The procedures state to label the IV with the type, gauge, and length of the catheter, date and time of insertion, and initials. It further states, during an emergency if an IV catheter is inserted, it should be replaced as soon as possible, within a maximum of 48 hours, to reduce the risk of vascular catheter associated infection. In the IV tubing change policy provided revealed: Label the administration set and solution container with the date and time.
2. On 01/05/2015 at 10:45 AM, during the endoscopy for Patient # 2, the Certified Registered Nurse Anesthetist (CRNA) was observed putting a bite block in the mouth of the patient. The CRNA touched the monitor with gloves, then syringe, held patient ' s chin. He took the gloves off at 10:54 AM. He charted, and then touched the monitor with no gloves. He put his gloves back on and touched the syringe. The biohazard container, which was approximately ¾ full of material with noticeable blood on it, had a black and red bag sitting on top of it.
The CRNA was observed cleaning the anesthesia equipment at 11:30 AM on 01/05/2015. He used Super Sani wipes. He cleaned the anesthesia cart, anesthesia equipment, lines, and poles. He did not wipe the monitor clean.
An interview with the CRNA on 01/06/2015 at 12:05 PM revealed he did not wipe down the monitors. He said the personal red bag had his goggles and personal gear and his black bag has his reference manuals in it. He said he carries the bags in and out of the procedure rooms daily. He stores them on top of the hazardous waste container. Asked if he knew the hazardous materials container was clean, he responded, no.
Review of the patient ' s chart showed the patient had a history of chronic Hepatitis C.
Review of the policy Environmental Sanitation approved date: 08/2002, reviewed 01/2013 revealed:
Policy:
(4.) All blood/body fluids, and tissue specimens are placed in red plastic biohazard bags prior to transport or in containers that are impervious and contain an agent to solidify solutions, if being disposed.
(5.) At the end of a surgical procedure, the furniture, equipment, and floors are cleaned with a germicidal solution.
Conclusion of operative procedure:
d. All equipment and furniture used during a case is considered contaminated.

3. 01/05/2015 at 11:17 AM turnover cleaning was observed in the procedure room. The housekeeper wiped down the counters, keyboards, under keyboards, and sink. She wiped down the trash container after trash was taken out. The spray cleaner used was in a white plastic container labeled with dates only.
An interview with the housekeeper on 01/05/2015 at 11:25 AM revealed she could not remember the name of the cleaner in the bottle. She said she knew what it was but could not remember. She dated the bottle when it was put into the bottle for cleaning.
An interview with the Manager of Environmental Services on 01/06/2015 at 9:00 AM revealed the labels are available to label the bottles when the bottle is filled with the cleaner. The label is preprinted to be applied immediately when the bottle is filled. The manager stated she did not have a policy for labeling the bottles when the bottle is filled with the cleaner.
Review of the policy and procedure guideline for surgical services with effective date 08/2002, reviewed 01/2013 with policy description Environmental Sanitation revealed:
Procedure:
3. To disinfect surfaces and equipment not requiring sterilization use either:
a. EPA approved hospital grade, tuberculocidal solution, mixed as directed by manufacturer:
b. Ten percent (10%) bleach solution prepared with 24 hours of use.
4. On 01/05/2015 at 4:40 PM during a tour of the emergency department housekeeper B was observed cleaning an emergency department bay. She was putting trash in a red bag and closing it with gloved hands. She then closed a second red bag with same gloved hands. She then opened the cabinet and removed a clean sheet and made up the stretcher. She then proceeded to clean the counter.
An interview with housekeeper B on 01/05/2015 at 4:42 PM revealed she wears one pair of gloves while cleaning the entire room. She changes the gloves if they tear. She washes her hands or uses hand sanitizer when done.
Observation of the Express Care area of the ER revealed two patient recliners with torn arm rests and observation of the main ER waiting rooms revealed 12 chairs with seat cushion that either were torn or have separated for the base of the cushion
5. 01/05/2015 at 12:10 PM a, peripherally inserted central catheter (PICC) line insertion was conducted in room 205. The nurse stated the room was Contact Isolation for Methicillin-resistant Staphylococcus aureus (MRSA) in the sputum. The RN set up a sterile field. The RN put on gloves, hat, and mask. The RN applied the mask below the nose.
During the procedure the face mask noted below nose. The RN shifted the mask onto her nose. The patient was not wearing a mask, was confused, turning his head toward the sterile field and talking. A surgical hand scrub was performed by the RN. The sterile tray set up at 12:30 PM. The mask again noted below the nose. The sterile field was draped over the patient exposing the area for insertion. The area cleaned. The catheter was inserted. The area covered, secured.
An interview on 01/05/2015 at 12:45 PM with the RN revealed she inserts PICC lines daily and does PICC line dressing changes every 7 days. She does central line dressing changes. She said she did not realize the mask was slipping down. She has a problem with her glasses fogging up when she wears a mask if her nose is covered.
6. On 01/05/2015 at 4:10 PM a Patient Care Tech (PCT) was observed taking vital signs for two patients sharing one contact isolation room. The PCT failed to remove his gloves and perform hand hygiene when moving from one patient to the next. At 4:10 PM when asked why he did not change his gloves, the PCT responded he realized he did not change his gloves between patients and apologized.
7. 01/05/2015 at 4:30 PM during the tour room 184 was observed with a sign for contact and droplet isolation. The posted sign included instructions for eye shields to be worn for droplet isolation. Across the hall, the container with PPE (Personal Protective Equipment) supplies did not contain eye shields.
An interview with the DON (Director of Nursing) at 4:30 PM revealed if there are no eye shields available staff will have the family go to the nurses.
Observation of the signs posted did not direct the visitors to see nursing personnel for eye shields.
8. Observation on 01/05/2015 at 11:19 AM of the sub-sterile decontamination room in the Surgical Department revealed a 2ft x 2ft return vent located in the ceiling had a significant buildup of dust. The return vent is located over and near to the area cleaned instruments are assembled for sterilization. During an 11:25 AM interview with the Operating Room Director, he/she stated the housekeeping staff is to clean vents.

9. Observation of the spinal injection performed on patient #4 in her room on 01/05/2015 at 11:30 AM revealed that after the Anesthesiologist explained the procedure to the patient he sanitized using the hand sanitizer located outside of the bathroom door. He then returned to the patient and located the injection site. He removed the gloves, re-sanitized, and put on sterile gloves. The physician did not wash his hands at any time before performing the spinal injection. Interview with the Infectious Disease Practitioner on 01/06/2015 at 2:44 PM revealed that before performing a sterile procedure the Anesthesiologist should perform a complete hand wash and not just a hand sanitization.

10. Observation on 01/05/2015 at 1:40 PM of wound care provided by the Physical Therapist/Wound Care Therapist on patient #7 revealed that the Therapist removed wound dressing that covered two surgical drain tubes. The drain tubes exited the right side of abdomen and on a vertical plain were about 8 inches between each drain. The Therapist did not change her gloves between each drain wound dressing.

11. Review of the medical record for Patient #5 revealed:He was triaged in the emergency department on 12/02/2014. The hospital stay was from 12/2/12 to 12/11/14.The lab report dated 12/14/2014 showed Faxed acid fast bacillus (AFB) results to physician on 12/11/2014 at 1532 hours. On 12/25/2014 Patient #5 triage in the emergency department showed: Tuberculosis (TB) screening: being checked for TB Cultures sent from hospitalization for pneumonia.Cat scan of the abdomen showed Lung bases large 9 cm thick-walled cavitary lesion in the posterior periphery of the right lung lower lobe that presumably represents a lung abscess/cavitating pneumonia, cavitating/superinfected neoplasm, and/or fluid filled/superinfected bulla. On 12/26/2014 Patient #5 ' s triage in the emergency department showed Tuberculosis screening: Possible symptoms: being tested for it by MD.
Review of the EMS transfer form (to another hospital) showed the first vitals taken 12/26/2014 at 1705 hours. Past medical history: Chronic obstructive pulmonary disease, Cardiac (heart disease) and Gastroesophageal Reflux. There is no mention of TB.
The hospital transferred patient #5 to another hospital on 12/26/14. Review of the receiving hospital's history and physical on 12/26/2014 showed the patient presented as a transfer due to right sided kidney stone. The patient arrived in the emergency department at 6:00 PM. A late entry 12/26/2014 at 9:33 PM revealed the health department called staff and informed them the patient was actively undergoing treatment for tuberculosis.
Review of the transferring hospital's policy on Mycobacterium Tuberculosis Exposure Control Plan 2014, 922600, revealed A. Known/Suspected M. TB: 2. upon arrival to the hospital, any patient with known/suspected M. TB will be masked (surgical Mask and will remain masked until admission to an AFB Airborne isolation room (negative pressure).
On 01/06/2015 at 2:44 PM, the Infectious Disease Practitioner stated she could not locate a hospital policy for notification of transport personnel that were exposed to Tuberculosis (TB). She further stated she did not send written notice to the transport personnel that transported the patient with TB to the ED (emergency department) and from the Putnam Community Medical Center emergency department to another hospital.
Further interview with the Infectious Disease Practitioner revealed the patient was admitted to the hospital on 12/02/2014. He had bronchial washings done on 12/08/2014 for AFB (acid fast bacillus). The patient had no isolation at any time. The hospital discharged him home on 12/11/14.
Further interview with the Infectious Disease Practitioner revealed the patient returned on 12/25/2014 and 12/26/2014 to the emergency room. During these visits, the patient was not placed in isolation. She said the patient length of time for exposure to the staff was short 2 & 1/2 hours on the second visit and the third trip about 9 hrs.

Based on staff interviews and facility document review, the Governing Body failed to ensure oversite of the facility's Infection Control program, and implement corrective action for identified problems.

Findings:

1 Review of the minutes of the Infection Control Committee for 2014 did not reveal that the facility experienced any cases of Stenotrophomonas Maltophilia, (Steno). Review of the Multi Drug Resistant,(MDR), for 2014 revealed a total of 17 cultures for Seno.

Review of the minutes for 2014 through November 17, 2014 failed to reveal any positive steno cultures although the MDR report revealed a year to date prior to November 17,2014 total of 12 cases.

2. Interview with the Director of Nursing for the Putnam County Department of Health on 01/05/2015 at 10:00 AM revealed that Steno is a reportable infectious disease and that only the last 3 cases diagnosed in December 2014 were reported to her office. She stated that she holds weekly meeting with the facility to review infectious disease issues and the fact that the facility has had positive Steno cultures was never brought to her attention.

3. Interview with the CNO on 01/09/2015 at 3:23 PM revealed that when the facility identified 3 cases of Steno in December 2014 she informed the Laboratory, ICU, and ED staff, but did not make any written records. She stated that she did not want to overly alarm anyone. She stated that after talking with Department of Health she informed everyone but not in writing. She stated " We verbally told people, educated but due to media, did not put it in writing. The Infection Control Medial Director was informed but not included in any meetings " .

4. Interview with the CNO and the Infectious Practitioner revealed that the same report that is presented at the Infection Control Committee is the same report that is reported first to the Quality Committee and the Governing Body Committee.

Based on observations, interviews and record review the facility failed to ensure that for the Intensive Care Unit, Emergency Room, Medical/Surgical Unit and the Surgical Suite followed acceptable infection control practices.
Findings:
1. On 01/05/2015 at 10:40 AM an observation of Patient #2 ' s IV (Intravenous) site revealed there was no label to show the date, time, or initials indicating who started the IV and when. The IV bag was Lactated Ringers labeled 1/4/2015 started at 1700 with a flow rate of 0 (zero). The date and time on the IV tubing was absent
Patient # 2 was interviewed on 01/05/2015 at 10:40 AM. She said she came in on Saturday 01/03/2015 and the IV was started that day.
Chart review showed the IV started on 01/03/2015 by EMS (Emergency Medical Services). On 01/03/2015 at 12:56 PM the nurse's note stated "maintain field IV. Dressing intact. 20 gauge left antecubital space". Further review of the patient ' s chart showed the patient had a history of chronic Hepatitis C.
An interview with the Infectious Disease Practitioner on 01/06/2015 at 4:00 PM revealed the infection control information is covered in nursing orientation and instructs the staff to label all IV sites and tubing. Further interview with the Infectious Disease Practitioner revealed there is not a specific hospital policy for labeling IV ' s and IV tubing. She stated the hospital uses Lippincott as nursing references for IV ' s.
The DON faxed the Lippincott Procedures to the Area 3 office on 01/09/2015. The procedures state to label the IV with the type, gauge, and length of the catheter, date and time of insertion, and initials. It further states, during an emergency if an IV catheter is inserted, it should be replaced as soon as possible, within a maximum of 48 hours, to reduce the risk of vascular catheter associated infection. In the IV tubing change policy provided revealed: Label the administration set and solution container with the date and time.
2. On 01/05/2015 at 10:45 AM, during the endoscopy for Patient # 2, the Certified Registered Nurse Anesthetist (CRNA) was observed putting a bite block in the mouth of the patient. The CRNA touched the monitor with gloves, then syringe, held patient ' s chin. He took the gloves off at 10:54 AM. He charted, and then touched the monitor with no gloves. He put his gloves back on and touched the syringe. The biohazard container, which was approximately ¾ full of material with noticeable blood on it, had a black and red bag sitting on top of it.
The CRNA was observed cleaning the anesthesia equipment at 11:30 AM on 01/05/2015. He used Super Sani wipes. He cleaned the anesthesia cart, anesthesia equipment, lines, and poles. He did not wipe the monitor clean.
An interview with the CRNA on 01/06/2015 at 12:05 PM revealed he did not wipe down the monitors. He said the personal red bag had his goggles and personal gear and his black bag has his reference manuals in it. He said he carries the bags in and out of the procedure rooms daily. He stores them on top of the hazardous waste container. Asked if he knew the hazardous materials container was clean, he responded, no.
Review of the patient ' s chart showed the patient had a history of chronic Hepatitis C.
Review of the policy Environmental Sanitation approved date: 08/2002, reviewed 01/2013 revealed:
Policy:
(4.) All blood/body fluids, and tissue specimens are placed in red plastic biohazard bags prior to transport or in containers that are impervious and contain an agent to solidify solutions, if being disposed.
(5.) At the end of a surgical procedure, the furniture, equipment, and floors are cleaned with a germicidal solution.
Conclusion of operative procedure:
d. All equipment and furniture used during a case is considered contaminated.

3. 01/05/2015 at 11:17 AM turnover cleaning was observed in the procedure room. The housekeeper wiped down the counters, keyboards, under keyboards, and sink. She wiped down the trash container after trash was taken out. The spray cleaner used was in a white plastic container labeled with dates only.
An interview with the housekeeper on 01/05/2015 at 11:25 AM revealed she could not remember the name of the cleaner in the bottle. She said she knew what it was but could not remember. She dated the bottle when it was put into the bottle for cleaning.
An interview with the Manager of Environmental Services on 01/06/2015 at 9:00 AM revealed the labels are available to label the bottles when the bottle is filled with the cleaner. The label is preprinted to be applied immediately when the bottle is filled. The manager stated she did not have a policy for labeling the bottles when the bottle is filled with the cleaner.
Review of the policy and procedure guideline for surgical services with effective date 08/2002, reviewed 01/2013 with policy description Environmental Sanitation revealed:
Procedure:
3. To disinfect surfaces and equipment not requiring sterilization use either:
a. EPA approved hospital grade, tuberculocidal solution, mixed as directed by manufacturer:
b. Ten percent (10%) bleach solution prepared with 24 hours of use.
4. On 01/05/2015 at 4:40 PM during a tour of the emergency department housekeeper B was observed cleaning an emergency department bay. She was putting trash in a red bag and closing it with gloved hands. She then closed a second red bag with same gloved hands. She then opened the cabinet and removed a clean sheet and made up the stretcher. She then proceeded to clean the counter.
An interview with housekeeper B on 01/05/2015 at 4:42 PM revealed she wears one pair of gloves while cleaning the entire room. She changes the gloves if they tear. She washes her hands or uses hand sanitizer when done.
Observation of the Express Care area of the ER revealed two patient recliners with torn arm rests and observation of the main ER waiting rooms revealed 12 chairs with seat cushion that either were torn or have separated for the base of the cushion
5. 01/05/2015 at 12:10 PM a, peripherally inserted central catheter (PICC) line insertion was conducted in room 205. The nurse stated the room was Contact Isolation for Methicillin-resistant Staphylococcus aureus (MRSA) in the sputum. The RN set up a sterile field. The RN put on gloves, hat, and mask. The RN applied the mask below the nose.
During the procedure the face mask noted below nose. The RN shifted the mask onto her nose. The patient was not wearing a mask, was confused, turning his head toward the sterile field and talking. A surgical hand scrub was performed by the RN. The sterile tray set up at 12:30 PM. The mask again noted below the nose. The sterile field was draped over the patient exposing the area for insertion. The area cleaned. The catheter was inserted. The area covered, secured.
An interview on 01/05/2015 at 12:45 PM with the RN revealed she inserts PICC lines daily and does PICC line dressing changes every 7 days. She does central line dressing changes. She said she did not realize the mask was slipping down. She has a problem with her glasses fogging up when she wears a mask if her nose is covered.
6. On 01/05/2015 at 4:10 PM a Patient Care Tech (PCT) was observed taking vital signs for two patients sharing one contact isolation room. The PCT failed to remove his gloves and perform hand hygiene when moving from one patient to the next. At 4:10 PM when asked why he did not change his gloves, the PCT responded he realized he did not change his gloves between patients and apologized.
7. 01/05/2015 at 4:30 PM during the tour room 184 was observed with a sign for contact and droplet isolation. The posted sign included instructions for eye shields to be worn for droplet isolation. Across the hall, the container with PPE (Personal Protective Equipment) supplies did not contain eye shields.
An interview with the DON (Director of Nursing) at 4:30 PM revealed if there are no eye shields available staff will have the family go to the nurses.
Observation of the signs posted did not direct the visitors to see nursing personnel for eye shields.
8. Observation o