HospitalInspections.org

Based on interview, record review, and review of facility policy, it was determined that the facility failed to maintain and have available adequate laboratory services to meet the needs of two (2) of twelve (12) patients (Patient #25 and #31). Review of Patient #25's medical record revealed the facility sent a urine culture for Patient #25 (laboratory test to determine whether there is bacteria or other germs in the urine) to an outside laboratory because the facility did not have available supplies to conduct the test due to an unpaid debt. However, the facility failed to follow-up on the test results that were determined to be positive for bacteria; subsequently, Patient #25's bacterial infection was not treated with the appropriate antibiotic timely.

In addition, review of Patient #31's medical record revealed the Emergency Department physician ordered a blood culture for Patient #31 "stat" on 04/15/19. The facility obtained the blood specimen for the culture; however, the facility failed to ensure the blood specimen reached the outside facility's laboratory until 04/17/19, two days later (Refer to A0584).

Based on observation, interview, record review, review of facility policy, and review of the facility Infection Control Log, it was determined the facility failed to have an active program for the prevention, control and investigation of infections and communicable diseases for one (1) of twelve (12) sampled patients (Patient #25). Review of the medical record revealed Patient #25 was admitted to the facility on 05/01/19, with a diagnoses of Urinary Tract Infection (UTI) with gross hematuria (blood in urine). Review of Patient #25's lab results, dated 05/05/19 revealed the patient had a Multidrug-Resistant organism (MDRO), Extended-spectrum beta-lactamase (ESBL) in his/her urine. However, review of the medical record on 05/07/19 revealed no evidence the patient's Physician had been notified of the lab results and no evidence that action had been taken to prevent the spread of the infection to other patients. In addition, further review of Patient #25's medical record revealed he/she had a history of ESBL infection of a wound that was diagnosed on 03/29/19; however, interview with the Infection Control Nurse on 05/08/19 at 3:00 PM, and review of the facility's Infection Control Tracking Log revealed no evidence Patient #25's abnormal culture results were included on the tracking log. (Refer to A0749)

Based on interview, record review, and review of facility policy, it was determined that the facility failed to provide a written description of services provided to medical staff. An interview with the Laboratory Supervisor revealed the facility did not have the supplies to conduct cultures and had been sending the specimens to an outside, contracted laboratory for approximately one month. However, the facility failed to develop a written description of the services that the contracted laboratory would provide and failed to develop a policy/procedure to ensure the facility obtained the laboratory results and acted upon the results timely.

Review of Patient #25's urine culture results from the contracted laboratory dated 05/05/19 revealed the patient's urine contained bacteria that was resistant to the antibiotics prescribed for the patient. However, there was no documented evidence the facility notified the patient's physician of the test results timely.

The physician ordered a blood culture for Patient #31 "stat" on 04/15/19. The facility obtained the blood specimen for the culture; however, the facility failed to ensure the blood specimen reached the contracted facility's laboratory until 04/17/19, two days later.

The findings include:

Review of the facility policy titled, "Priority List for Laboratory," last revised April 2001, revealed the policy did not address the process the laboratory was required to follow when lab tests were sent out to other laboratories for processing.

1. Review of the Patient #25's medical record revealed Physician #5 admitted Patient #25 directly to the facility on 05/01/19 with diagnoses of Urinary Tract Infection (UTI) with gross hematuria (blood in urine), uncontrolled Diabetes, and Hypertension.

Review of Patient #25 Admitting physician orders revealed staff were directed to collect a urine culture with sensitivity on 05/01/19. Further review of Patient #25's medical record revealed Physician #5 ordered the following antibiotics (treats infection) to be administered: Levaquin (Levofloxacin) 250 milligrams (mg) intravenous (IV) daily and Bactrim (antibiotic combination of sulfamethoxazole and trimethoprim) 400-80 mg one tablet daily.

Further review of Patient #25's medical record revealed a urine culture was collected on 05/02/19 at 2:49 AM and the final urine culture results were reported on 05/05/19 at 3:35 PM. Review of the final results indicated the patient had a Multidrug-Resistant Organism (MDRO) called Extended-spectrum beta-lactamase (ESBL) in his/her urine. Review of the sensitivity report revealed the organism was resistant (would not respond) to Levofloxacin and sulfamethoxazole/trimethoprim antibiotic medications that the patient was receiving at the facility. There was no documented evidence the facility had notified the patient's physician that the medications that the patient was receiving would not treat the patient's infection.

Interview with RN #25 on 05/07/19 at 5:05 PM revealed she had been assigned to care for Patient #25 on 05/07/19 since 7:00 AM. Even though the patient's lab results were observed in the patient's medical record, the RN was not aware that the patient had laboratory results dated 05/05/19 (two days prior) that showed the patient had ESBL (an MDRO) in his/her urine. The RN acknowledged staff had not implemented contact precautions to protect staff and other patients from the MDRO and no action was taken until the facility was made aware by the surveyor.

Interview with Laboratory Technician (LT) #1 on 05/08/19 at 4:05 PM revealed "all cultures" were being sent to another facility laboratory to be processed because the facility was unable to purchase the needed supplies to run the tests in-house. She stated that had been the practice for approximately one month. The LT stated she was the only staff member working in the laboratory on 05/05/19 (when Patient #25's urine culture results were available) during the day shift (7:00 AM-7:00 PM). However, the LT stated she did not have access to the computer system to obtain laboratory results from the outside facility laboratory, nor was she trained to obtain the laboratory results. LT #1 stated she was unaware who was monitoring to ensure results from the outside laboratory were obtained timely.

Interview with LT #2 on 05/08/19 revealed the lab supervisor gave her laboratory results (Monday-Friday) and she faxed the results to the ordering physician's office. She stated she faxed Patient #25's abnormal lab results to MD #5's office on 05/07/19 (two days after the results were available). LT #2 stated she was not aware the patient remained an inpatient at the facility; therefore, she did not notify direct care staff of the abnormal lab results. In addition, LT #2 stated she had not spoken to Patient #25's physician to ensure he received the abnormal laboratory results because she had not been trained to do so.

Interview with the Laboratory Supervisor on 05/08/19 at 1:50 PM revealed the facility was not doing any type of cultures "because of money" and the cultures were being sent to an outside facility. She stated the facility did not have supplies needed to analyze blood cultures because facility administration had not paid the balance on the account with the company that provided supplies. She stated a payment plan had to be worked out with the supply company before needed supplies could be obtained to process the laboratory testing at the facility. The Laboratory Supervisor stated to obtain the results of laboratory tests that were sent to another facility, she had to "login to a direct link"; however, only she and one other staff member had access to the account. She acknowledged staff who worked on weekends did not have access to account to obtain laboratory results and stated, "We're not necessarily looking at lab results on the weekends." She stated she was required to track patient laboratory results Monday through Friday; however, she did not have a system to review/track laboratory results from the previous week because she "had other things to do."

2. Review of Patient #31's medical record for revealed the facility admitted the patient on 04/15/19 with a diagnosis of Atrial Fibrillation with Rapid Ventricular Rate (an irregular heart rate that commonly causes poor blood flow).

Review of the Physician Orders for Patient #31 revealed the physician ordered a Blood Culture on 04/15/19 at 8:24 PM STAT.

Review of the Laboratory Results for Patient #31 revealed the facility collected a blood specimen for a blood culture on 04/15/19 at 8:30 PM. However, further review revealed the facility did not send the blood specimen to another laboratory "Out Sourced Lab" until 04/17/19 at 5:03 AM, two days after the physician's order for the laboratory was written and the blood specimen was obtained. Review of the final report revealed the patient's blood culture was positive for Gram Negative Bacilli (bacteria in the blood).

Continued interview with the Laboratory Supervisor on 05/08/19 at 1:50 PM revealed Patient #31's blood specimen did not go to the "Out Sourced Lab" on 04/15/19 because the laboratory service had already picked up specimens when the blood specimen for the patient was obtained. The supervisor stated the specimen was picked up on 04/16/19, and did not arrive to the outside laboratory until 04/17/19, two days later.

A post-survey interview with the Chief Nursing Officer (CNO) on 05/13/19 at 3:15 PM revealed the laboratory department should have implemented processes to ensure laboratory tests that were sent out of the facility for processing were tracked to ensure timely physician notification.

Based on observation, interview, record review, review of facility policy, and review of the facility Infection Control Log, it was determined the facility failed to ensure that the infection control officer had a system for identifying, reporting, and controlling infections of patients and personnel for one (1) of twelve (12) sampled patients (Patient #25). Review of the medical record revealed Patient #25 was admitted to the facility on 05/01/19, with a diagnoses of Urinary Tract Infection (UTI) with gross hematuria (blood in urine). Review of Patient #25's lab results, dated 05/05/19 revealed the patient had a Multidrug-Resistant organism (MDRO), Extended-spectrum beta-lactamase (ESBL) in his/her urine (ESBL is an infection that is resistant to many antibiotics and is spread by contact with infected person or by contact with contaminated surfaces). However, review of the medical record on 05/07/19 revealed no evidence the patient's Physician had been notified of the lab results and no evidence that action had been taken to prevent the spread of the infection to other patients. In addition, further review of Patient #25's medical record revealed he/she had a history of ESBL infection of a wound that was diagnosed on 03/29/19; however, interview with the Infection Control Nurse on 05/08/19 at 3:00 PM, and review of the facility's Infection Control Tracking Log revealed no evidence Patient #25's abnormal culture results were included on the tracking log.

The Findings Include:

Review of the facility policy titled, "Transmission Based Isolation Precautions," approved February 2017 revealed all patients suspected of/or known to have a communicable disease will be placed in the proper category of isolation based on transmission mode of the disease. A Physician, Charge Nurse or Infection Control Nurse has the authority to order and place the patient in isolation. The policy stated that signage would be universal within the acute care areas and that signs would be place on the door of the patient rooms. Continued review of the policy revealed that contact precautions required gloves and handwashing, wearing of a gown in the patient's room, and to minimize transmission, patients would be placed in a private room if possible or cohorted as necessary. The use of disposable patient care equipment would be used whenever possible and all items in the patient's room should be cleaned daily.

Review of the facility policy titled, "Infection Prevention Plan," approved February 2017, revealed the facility had systems in place for reporting of infection surveillance, prevention, and control information to the following: appropriate staff within the facility, federal, state and local public health authorities, Accrediting bodies including infection control related adverse event reporting, and the referring or receiving organization when a patient was transferred. Continued review of the policy revealed the Infection Prevention Chairperson and the Infection Prevention Manager/Professional were responsible for overall monitoring and evaluation of the Infection Prevention Program. The Infection Prevention Manager was responsible for employee health and safety including identifying infection prevention and control risks, monitoring of patient care activities and the implementation of applicable precautions, environmental conditions related to control of infections, safety consulting in the selection of equipment and supplies relative to control infections, and communication of infection data to administrative leadership on a routine and emergency basis. Further review of the facility policy revealed Multi-drug resistant organisms are a major facility and community safety concern including colonization of MDRO, which have the potential to proliferate, invade and infect susceptible, immunocompromised individuals. Factors that may predispose the patient to acquiring MDRO's include, but are not limited to broad-spectrum antibiotics administration, and immune-deficiency. Risk reduction strategies related to reducing MDRO acquisition at the facility include but are not limited to MDRO initiatives, hand hygiene practices, and infection prevention education.

Observation of Patient #25 on 05/07/19 at 11:05 AM during the initial tour of the facility revealed the patient was lying in bed with eyes closed.

Review of the medical record for Patient #25 revealed the facility admitted the patient on 05/01/19 under the services of MD #5 with diagnoses of Urinary Tract Infection (UTI) with gross hematuria (blood in urine), uncontrolled Diabetes, and Hypertension. Review of the Physician's Orders dated 05/01/19 revealed an order for staff to collect a urine culture with sensitivity on 05/01/19. Further review of Patient #25's medical record revealed Physician #5 ordered the following antibiotics (medications to treat infection) to be administered: Levaquin (Levofloxacin) 250 milligrams (mg) intravenous (IV) daily and Bactrim (antibiotic combination of sulfamethoxazole and trimethoprim) 400-80 one tablet daily.

Review of Patient #25 admitting physician orders revealed staff were directed to collect a urine culture with sensitivity on 05/01/19.

Review of the patient's record revealed a urine culture was collected on 05/02/19 at 2:49 AM. Further review of the urine culture report revealed final results were reported on 05/05/19 at 3:35 PM, which indicated the patient had a Multidrug-Resistant organism (MDRO), Extended-spectrum beta-lactamase (ESBL) in his/her urine. Review of the sensitivity report revealed the organism was resistant (would not respond) to Levaquin or Septra antibiotics. Further review of Patient #25's culture report revealed Nitrofurantoin was effective to treat the patient's infectious organism.

Further review of the record revealed no evidence that the urine culture report had been reviewed or any action had been taken based on the report. Continued observation of Patient #25 on 05/07/19 at 11:05 AM revealed there was no evidence that contact precautions were in place. Further observation revealed there were two other patients on the unit, including Patient #26 was observed to be in the room across the hall from Patient #25. In addition, two nurse aides and a nurse were observed on the unit caring for Patient #25 and were not wearing protective equipment to prevent the spread of infection to staff and other residents.

Interview with RN #25 on 05/07/19 at 5:00 PM revealed she was responsible for Patient #25's care on 05/07/19. The nurse stated she was not aware that the culture results were back and therefore no action was taken until the surveyor notified the nurse of the test results.

Observation of Patient #25 on 05/08/19 at 1:22 PM revealed an "infection control box" on the door; however, there was no signage to indicate the type of precautions the patient required.

Interview with Laboratory Technician (LT) #1 on 05/08/19 at 4:05 PM revealed she stated "all cultures" had been sent out of the facility for approximately one month, because the facility was unable to purchase the needed supplies, to run the tests in-house. The LT stated she was the only lab personnel working on 05/05/19 during the day shift, 7:00 AM-7:00 PM, and she did not have access to the system the facility utilizes to obtain lab results, from labs sent out for processing from the facility. She had not been trained to track labs in the facility, and stated she was unaware of who was monitoring to ensure results were obtained of labs sent out for processing from the facility.

Interview with LT #2 on 05/08/19 revealed the lab supervisor gave lab results to her (Monday-Friday) and she had been trained to fax them to the ordering physician's office. She stated she had faxed Patient #25's abnormal lab results to MD #5's office on 05/07/19; however, was not aware the patient remained in the facility, therefore direct care staff had not been notified of the abnormal lab results. She stated she had not spoken to Patient #25's physician to ensure he received the abnormal labs, because she had not been trained to do so.

Interview with the Laboratory Supervisor on 05/08/19 at 1:50 PM revealed the facility was not doing cultures in the facility "because of money." She stated a payment plan had to be worked out with the supply company, because administration had not paid the balance due on the account, so needed supplies could not be obtained to run the physician ordered labs in the facility. She stated all cultures were being sent out to be resulted, and in order to receive the lab results, she had to "login to a direct link" and acknowledged weekend staff, did not have access to track labs that had been sent out, and also stated "we're not necessarily looking at lab results on the weekends." She stated she was required to track patient lab results Monday-Friday; however, had not tracked send out lab results from the previous week, on 05/06/19 {Monday} as required, because she "had other things to do."

Continued review of Patient #25's medical record revealed the patient had previously been admitted to the facility on 03/27/19 under services of Physician #5 with diagnoses of Osteomyelitis and Gangrene to his/her right foot, Peripheral Vascular Disease and Brittle Diabetes.

Review of Patient #25's physician orders from the previous admission revealed Physician #3 (the facility surgeon) evaluated Patient #25 on 03/27/19 and ordered a wound culture, which was collected on 03/27/19. Further review of the patients record revealed the final results of Patient #25's wound culture dated 03/29/19 indicated the patient had ESBL identified in his/her wound.

Review on 05/08/19 at 3:00 PM of the facility's Infection Control Tracking Log for the previous ninety days, revealed no evidence Patient #25's abnormal culture results for the MDRO, ESBL identified in the patient's wound on 03/29/19 or in his/her urine on 05/05/19 was included on the tracking log.

Interview with the Infection Control (IC) Nurse on 05/07/19 at 4:30 PM revealed lab staff were required to notify her with abnormal cultures; however, they had failed to inform her that Patient #25's urine was identified to have an MDRO, ESBL on 05/05/19. She stated the patient's physician should have been notified of the abnormal lab result on 05/05/19, and staff should have ensured the patient was on the appropriate antibiotic to treat the identified infectious organism. She acknowledged the antibiotics that Patient #25 was receiving in in the facility, was not the effective treatment for the patient's infectious organism. The IC nurse also stated contact precautions should have been implemented to protect staff and other patients from transmission of the infectious organism. Continued interview with the IC nurse acknowledged Patient #25 was previously diagnosed with an ESBL organism in his/her diabetic foot ulcer, during a previous hospital stay in March 2019. However, she was unsure why the patient information had not been included on the facility infection control tracking log. She also stated, because the electronic record system had not been updated due to outstanding debt, "nothing flags staff" that patients had been diagnosed with a MDRO during previous hospital stays.

A post-survey interview with the Chief Nursing Officer (CNO) on 05/13/19 at 3:15 PM revealed the physician should have been notified of Patient #25's abnormal lab results on 05/05/19. She also stated laboratory personnel should have developed an effective system, since cultures were being sent out of the facility for processing that ensured lab results were received in a timely manner. The CNO also stated patients should be placed in contact precautions when MDRO's were identified to protect staff and other patients from infectious organisms. Continued interview with the CNO revealed the facility infection control tracking log should be accurate and should include infectious organisms identified in the facility.