HospitalInspections.org

Based on interview and record review, the hospital failed to develop and implement a system for cleaning and sanitizing devices employed in information technology (IT). This exposed any user, both staff and family, in patient rooms and in staff areas, to cross contamination of infection. The findings are:

A. On 04/20/16 at 12:15 pm during interview, the housekeeping supervisor, the lead for the facility housekeeping team, and the charge nurse on the floor were asked about maintenance of the IT devices in patient care area. All three denied any responsibility for cleaning and sanitizing the IT devices in both patient rooms and in staff areas.

B. On 04/19/16 at 2:15 pm during interview, the facility's infection control nurse acknowledged that she did not monitor the cleaning and sanitization of high activity IT devices and did not track this data in Quality Assurance Process Improvement.

C. On 04/19/16 at 3:00 pm during interview, the Director of Quality confirmed he did not track IT cleaning and sanitization in the facility's quality program.

D. Record review of the facility's quality program indicated no facility monitoring of cleaning and sanitizing IT devices by any staff or inclusion of that data in the quality program.

E. Review of "[Facility Name] Policy dated 05/2012 titled Infection Control Policy and Procedure Manual; Disinfection of Computer Devices," indicated the following.
"It is the responsibility of all staff and 'device' users to minimize the transmission of the pathogens by following principles of hand hygiene and the cleaning of devices with manufacturers approved products. All patient care computer devices will be cleaned and disinfected in order to prevent cross-contamination and the transmission of pathogens throughout the facility. Computer devices include but are not limited to computer keyboards, mice and bar code scanners.
Procedure: 1. The cleaning or disinfection of computer hardware are cleaned on a regular or routine basis by Environmental Services using and [an] EPA-registered hospital detergent/disinfectant, this includes the wheeled carts on which computers rest."

Based on interviews and record review, the facility's discharge planners failed to notify the family of changes in the plan of care, possible and scheduled procedures, changes in Patient #1's status, and the discharge needs of Patient #1. These failures in discharge planning denied the family the opportunity to actively engage in the development of the plan of care. Patient #1 was readmitted 2 weeks later to remedy the unaddressed issues, namely the accumulated fluid around Patient #1's lungs. The findings are:

A. On 04/17/16 at 03:30 pm during interview, Discharge Planner #1 could not explain why no discussions with the family were documented. She also could not explain the lack of nursing assessments in her notes.

B. Record review of the discharge planning notes throughout the first stay from 12/04/15 to 12/18/15 indicated the following:
1. Discharge planning notes on 12/05/15, 12/08/15, 12/10/15, 12/11/16, 12/14/15, 12/15/16, 12/16/15, 12/17/15, and 12/18/15, the day of discharge. No notes discussing any notifications of family were found.
2. No discussions of any infections were found. Several notes referring to contact with physical therapy and need for home oxygen were present.
3. The 12/14/15 note did not discuss the code blue called on 12/12/15 or why a pacemaker was subsequently implanted with the family.
4. The 12/16/15 note identified a need for cardiac rehab and that she did not qualify for a skilled nursing facility. Why she did not qualify is unclear.
5. No references for a referral for home health were found.
6. No discussions or notes referring to the status of the pleural effusion (excess fluid that accumulates in the sac surrounding the lungs) or any possible treatment (such as insertion of a chest tube to drain the fluid) were found.
7. No discussion was found to determine the safety of the home to which she was to be discharged.

C. Record review of Patient #1's medical record for her second stay (12/29/15 to 02/27/16) indicated the primary reason for this readmission was the excess fluid accumulation around the lungs.