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Based on staff interview, observation, record review, review of policy and procedure and review of manufacturer's instructions, it was determined the facility failed to ensure staff followed infection control practices for administration of intravenous medications, ventilator care and central venous catheter dressing changes (A749). The cumulative effects of these systemic practices resulted in the facility's inability to ensure that infection control practices were followed.

Based on observation, record review, staff interview, review of policies and procedures and review of manufacturer's instructions, the facility failed to ensure infection control procedures were followed for ventilator care, central venous catheter dressing changes and administration of intravenous medications. This affected eight (#1, #3. #4, #5, #6, #7, #8,and #13) of thirteen sampled patients. The active census 492.

Findings include:

1. Review of the facilities undated policy and procedure entitled Administering Medication by Peripheral IV (intravenous) Line Injection Push directed staff to prep (disinfection) the primary tubing injection port closet to patient, insert the medication syringe into the line port, inject the medication, withdraw the syringe following administration of medication, prep the injection port again before insertion of second syringe.

Surgical observation on 07/07/16 at approximately 7:41 AM revealed Medical Staff C was observed to gather multiple filled syringes from the anesthesia cart and approach Patient #8's bedside. Medical Staff C then scrubbed the injection port of the patient's intravenous fluid tubing with an alcohol preparation pad. Medical Staff C then proceeded to use the injection port to administer the first syringe filled medication, withdraw the first syringe and without any further disinfection of the injection port administer the contents of two additional syringes.

This deficient practice was confirmed with Staff F on 07/07/16 at 9:05 AM. Staff F verbalized "I saw that too."



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Review of hospital policy titled "Respiratory Care Policy and Procedure Manual Equipment Changing and Cleaning", Policy # 2.4.6, revised 01/14, revealed the Heat Moisture Exchanger (HME) is to been changed every 48 hours and as needed.

Review of the Manufacturer Directions for Use (MDFU) for the "Trach Care", brand of closed suction system used, revealed "Trach Care systems are intended for 24 hour use to decrease the potential for hospital acquired infections."

On 07/07/16 at 9:49 AM per interview, the Director of Clinical Application stated if the in-line suction and humidified moisture exchange (HME) was not documented in the ventilator circuit section of the ventilator/respiratory flowsheet, then it was not done.

2. On 07/05/16 around 2:22 PM, Patient #1 was observed, with Staff J present, in the Medical Intensive Care Unit (MICU), on a ventilator with in-line suction and HME attached.

Review of a medical record revealed Patient #1 was on the ventilator from 06/28/16 to 07/07/16, (9 days).

Review of the respiratory flowsheet's revealed a lack of documented evidence the in-line suction had been changed and the HME had been changed on 06/29/16, 06/30/16, 07/01/16 and 07/06/16 instead of the every 48 hours and as needed per policy.

3. On 07/05/16 around 2:28 PM, Patient #5 was observed, with Staff J present, in MICU, on a ventilator with in-line suction and HME attached.

Review of a medical record revealed Patient #5 was on the ventilator from 06/28/16 to 07/07/16, (9 days). Review of the respiratory flowsheet's revealed lack of documented evidence the in-line suction had been changed and the HME had only been changed on 06/30/16, 07/01/16, 07/05/16 and 07/07/16.

4. On 07/06/16 around 9:15 AM, Patient #6 was observed, with Staff J present, in the MICU, on a ventilator with in-line suction and HME attached.

Review of a medical record revealed Patient #6 was on the ventilator from 06/21/16 to 07/07/16, (16 days). Review of the respiratory flowsheet's revealed lack of documented evidence the in-line suction had been changed and the HME had only been changed on 06/30/16 and 07/01/16.

5. On 07/06/16 around 9:20 AM, Patient #3 was observed, with Staff F present, in the Surgical Intensive Care Unit (SICU), on a ventilator with in-line suction and HME attached.

Review of a medical record revealed Patient #3 was on the ventilator from 06/19/16 to 07/07/16, (18 days). Review of the respiratory flowsheet's revealed lack of documented evidence the in-line suction had been changed and the HME had only been changed once on 06/20/16.

5. Review of a closed medical record revealed Patient #4 was on a ventilator from 12/24/15 through 01/11/16, (18 days), in the Coronary Intensive Care Unit and was found to have Burkholderia Cepacia bacteria in the sputum.

Review of the respiratory flowsheet's revealed the in-line suction was changed once on 01/06/16 and the HME was changed on 12/25/15, 12/28/15, 12/29/15 and 01/05/16.

6. Review of a closed medical record revealed Patient #7 was on a ventilator from 02/08/16-02/18/16, (10 days), in the SICU.

Review of the respiratory flowsheet's revealed the in-line suction was changed once on 02/15/16 and the HME was changed on 02/10/15, 02/15/16 and 02/17/16.

On 07/07/16 at 2:18 PM per interview, the Infection Preventionist for the ICU's, stated there was no policy or procedure for the use of the in-line, closed suction system and confirmed it was not changed per MDFU.

8. On 07/07/16 at 8:42 AM Staff H was observed to change the central venous catheter of Patient #13 located in MICU. Patient #13 was observed to have a tracheotomy (artificial airway in the neck) with continuous humidified oxygen. Patient #13 had a congested cough which expelled over the central line access site after the dressing had been removed and the site cleaned. Staff H proceeded to apply the bio occlusive dressing over the now contaminated central line access site.

On 07/07/16 at 10:40 AM per interview, the Infection Preventionist for the ICU's confirmed the tracheotomy exhalation tubing should have been pointed in the opposite direction of the central line access site during dressing changes.