HospitalInspections.org

Based on review of medical records (MR), facility policies and procedures, and interviews it was determined the nursing staff failed to:

1. Perform wound care under physician orders.

2. Perform blood sugars according to physician order.

3. Assess pain prior to giving pain medications (s).

4. Reassess pain after giving pain medication(s).

This affected 1 of 3 Rehabilitation Unit inpatient records reviewed and did affect Patient Identifier (PI) # 8, and had the potential to negatively affect all patients served by the Rehabilitation Unit.

Findings include:

Policy: P_GN_PC_20_0318

Subject: Pain Management

Revised: 3/18

II. Purpose: To provide guidelines for the assessment, treatment, and documentation of pain management.

III. Policy: Organization-wide guidelines are provided for the effective relief and management of acute pain for all patients using an individualized interdisciplinary multi-faceted approach to pain management.

IV: Procedure:

C. The pain assessment tools/scales used will vary based on patient age, condition, and ability to understand. Most frequent used pain tool/scale will be the numeric scale...

1) Using a pain scale rating of 0-10, with 10 being the most intense pain the patient will be asked to report which point on the scale indicates their pain level.

2) For patient who are unable to self report using a pain intensity scale of 0-10 on a numeric scale alternative tools/scales may be used.

Facial Pain (Wong Baker) recognition scales may be used for any patient who can visually interpret the facial expression on the scale and associate the face with their pain...

4) Documentation in INET (electronic medical record system) Pain band will allow nurse to choose pain assessment scale used and contains a reference for the pain scale and score

5) Documentation of pain will occur in the patient's electronic medical record...

F. All licensed staff will assess and monitor patients for presence of pain and document in the medical record:

4) Before pain relieving intervention.

5) A reassessment for the presence and intensity of pain shall be performed as a component of the shift assessment for inpatient and following any intervention intended to lessen the patient's pain ( e. g., administration of pain medications...)

Reassessment should include but not be limited to:

1) Functional ability (ability to deep breath, turn in bed, walk with improved pain control.)

2) Side effects of treatment.

3) Risk factors for adverse events caused by the treatment.


*****

1. Patient Identifier (PI) # 8 was admitted to the Rehabilitation Unit on 5/10/18 with diagnosis including, Left Comminuted Subtrochanteric Femur Fracture with Extension into the Base of the Neck.

Review of the 5/11/18, 3:00 PM Order Sheet revealed physician order for wound care to LLE (Left Lower Extremity) surgical incision as follows: Every 48 hours clean with NS (Normal Saline), pat dry, may apply Mepilex AG for drainage.

Review of the 5/14/18, 5:24 PM Order Sheet revealed physician order for blood glucose by nursing as follows: Check blood glucose's every 2 AM. Call if below 90 mg/dl (milligrams per deciliter).

Review of the 5/15/18, 12:16 PM Order Sheet revealed physician order Tramadol 50 mg 1 tablet every 4 hours as needed for moderate pain, 6 (0-10 pain scale) and Acetaminophen-Oxycodone (Percocet) 325 mg-5 mg 1 tablet every 4 hours as needed for severe pain, 6. There was no documentation that clarification was obtained for both Tramadol and Percocet ordered for pain level of 6 on a 1-10 scale.


Initial Wound care to LLE was documented on 5/11/18 at 11:23 PM then documentated as provided again on 5/13/18 at 6:25 PM.

On 5/15/18 wound care was due to be performed per physician order of every 48 hours. Review of the Nursing - Shift Assessment notes at 1:04 AM, 7:48 AM, and 10:17 PM, revealed no documentation of wound care provided.

Based on the previous findings, the facility failed to document the wound care provided as ordered by physician.

Wound care was documented as provided to LLE on 5/16/18 at 4:36 PM.

Further Review of the Nursing - Shift Assessment notes revealed the following dates did not have documentation of wound care provided:

5/18/18, 5/19/18, 5/20/18, 5/21/18, 5/22/18, 5/23/18, and 5/24/18.

Based on the previous findings, the facility failed to document the wound care provided following documented wound care on 5/16/18.


Review of the Alere RALS (Remote Afterloading System) System Result Review report for the Accu-Check Inform II (blood sugar testing machine or glucometer) on PI # 8, revealed the facility failed to document blood sugar for the physician ordered 2:00 AM time on the following dates:

5/16/18, 5/17/18, 5/18/18, 5/19/18, 5/20/18, 5/21/18, 5/23/18, 5/24/18, 5/25/18, 5/26/18, 5/27/18, and 5/28/18.

Based on the previous findings, the facility failed to document 2:00 AM blood sugars per the physician order.


Review of the Medication Administration Record (MAR) dated 5/16/18 thru 5/27/18 for PI # 8 revealed the following pain assessments, reassessments, and pain medication administration:

On 5/16/18 at 06:41 AM Tramadol 50 mg (milligrams) was administered for a patient reported pain level of a "8" on a 1 to 10 numeric scale.

There was no documentation of pain being reassessed following administration of Tramadol.

On 5/17/18 at 05:42 AM Tramadol 50 mg was administered for a patient reported pain level of a "5" on a 1 to 10 numeric scale.

There was no pain medication ordered by physician for pain level of 5.

There was no documentation of pain being reassessed following administration of Tramadol.

On 5/18/18 at 05:54 AM Tramadol 50 mg was administered.

There was no documentation of a pain assessment tool/scale being used or reassessed following administration of Tramadol.

On 5/19/18 at 11:55 AM Tramadol 50 mg was administered for a patient reported pain level of a "5" on a 1 to 10 numeric scale.

There was no pain medication ordered by physician for pain level of 5.

There was no documentation of pain being reassessed following administration of Tramadol.

On 5/20/18 at 6:27 AM Tramadol 50 mg was administered.

There was no documentation of a pain assessment tool/scale being used prior to the administration of Tramadol.

On 5/21/18 at 10:40 AM Tramadol 50 mg was administered for a patient reported pain level of a "3" on a 1 to 10 numeric scale.

There was no pain medication ordered by physician for pain level of 3.

There was no documentation of pain being reassessed following administration of Tramadol.

On 5/21/18 at 2:10 PM Tramadol 50 mg was administered.

There was no documentation of a pain assessment tool/scale being used or reassessed following administration of Tramadol.

On 5/22/18 at 2:48 PM Percocet 5 mg /325 mg was administered for a patient reported pain level of a "10" on a 1 to 10 numeric scale.

There was no documentation of pain being reassessed following administration of Percocet.

On 5/23/18 at 6:53 AM and 5/24/18 at 5:57 AM Tramadol 50 mg was administered.

There was no documentation of a pain assessment tool/scale being used or reassessed following administration of Tramadol.

On 5/24/18 at 11:39 AM Tramadol 50 mg was administered for a patient reported pain level of a "10" on a 1 to 10 numeric scale.

There was no documentation of pain being reassessed following administration of Tramadol

On 5/25/18 at 2:21 AM and 5/25/18 at 11:34 PM Tramadol 50 mg was administered.

There was no documentation of a pain assessment tool/scale being used or reassessed following administration of Tramadol.

On 5/26/18 at 9:41 AM and 5/26/18 at 2:45 PM Tramadol 50 mg was administered for a patient reported pain level of a "3" on a 1 to 10 numeric scale.

There was no pain medication ordered by physician for pain level of 3.

There was no documentation of pain being reassessed following administration of Tramadol

On 5/26/18 at 10:52 PM, 5/27/18 at 5:29 AM, and 5/27/18 at 2:57 PM Tramadol 50 mg was administered.

There was no documentation of a pain assessment tool/scale being used or reassessed following administration of Tramadol.

Based on the previous findings, the facility failed to perform assessment of pain prior to administration of medication and reassessment of pain following the administration of medication per facility policy and procedures.

An interview was conducted on 5/30/18 at 3:15 PM with Employee Identifier (EI) # 8, Director of Rehabilitation Services, who confirmed the previous findings.

Based on review of facility policy and procedure, medical record and interview, it was determined the facility failed to ensure staff performed and documented results of patient monitoring during a blood transfusion. This affected Patient Identifier (PI) # 22, 1 of 2 records reviewed for blood transfusions and this had the potential to affect all patients treated at the facility.

Findings include:

Policy and Procedure Directive
Title: Administration of Blood and Blood Products
Revised 07/17

"Transfusion Record:

Transfusion Information:

Before starting this transfusion and in the presence of the patient, I certify that I have identified the recipient by inspection of the wristband and that patient name, medical record number, date of birth and the blood bank ID (identification) number are the same as on this form. I further certify that the donor unit label has the same unit number...type...group...as state on the form.

Name Transfused by:__________ Name: Certified by:__________
Transfusion Started: Initials__ Date___ Time _____ Transfusion Stopped: Initials___
Date____ Time____
Volume Transfused_________All or _____ml
Reaction: No_Yes:__(Notify Physician and contact the Blood Bank for instructions).

RN transfuses product according to policy.
After transfusion is completed, RN completes transfusion record."

****

1. PI # 22 was admitted to the facility on 5/23/18 with diagnoses including Intrauterine Pregnancy Delivered with Postpartum Anemia.

Record review revealed physician orders dated 5/26/18 to transfuse 3 units of packed red blood cells.

Review of the facility Transfusion Record documentation revealed on 5/26/18 at 5:50 PM, unit number three packed red blood cell transfusion was started. There was no documentation the time the transfusion was stopped or the end of the transfusion, the initials of the person who discontinued the transfusion, the volume (amount) transfused and the presence or absence of a reaction to the blood transfusion.

Staff failed to follow facility policy and procedure for patient monitoring and documentation during a blood transfusion.

In an interview conducted on 5/30/18 at 11:15 AM, Employee Identifier # 1, Accreditation Manager, Safety Officer confirmed the above finding.

Based on medical record review, the facility Acute Dialysis Standing orders, policies and procedures, Alabama Board of Nursing Standards of Nursing Practice and staff interviews, it was determined the facility staff failed to ensure:

1) the medical record included CVC (central venous catheter) care orders and heparin locking solution dosage and amount.

2) the specific CVC care performed during dialysis treatment was documented.

This affected 1 of 1 records reviewed for acute hemodialysis treatments and did affect Patient Identifier (PI) # 1. This had the potential to affect all patients treated at the facility.

Findings include:

Alabama Board of Nursing
Chapter 610-X-6
Standards of Nursing Practice

610-X-6.06 Documentation Standards

(1) The standards for documentation of nursing care provided to patients by registered nurses...are based on principles of documentation regardless of the documentation format.
(2) Documentation of nursing care shall be:
(a) Legible
(b) Accurate
(c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient's status including...symptoms, responses, treatments, other nursing care rendered, communication of pertinent information..."

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Acute Dialysis Standing Orders

"Effective today, 03/01/2018, the following standing orders for Brookwood Acute Dialysis are as follows:

2. CVC (central venous catheter) access-BFR (blood flow rate) 200-400 (as access will allow)
8. Tight Heparin (1,000 units/mL [milliliter])=1500 units bolus
9. Systemic Heparin=(1,000 units/mL) 300 units...

****

Hospital Services Policy & Procedure, # 1: Policy: 7-05-01
DaVita Inc.
Title: Prescription Verification and Safety Checks
Revision Date: April 2018

Purpose: To establish...Intradialytic monitoring and documentation for every patient...

7. The following prescription parameters indicate a complete physician order and will be documented on the treatment sheet prior to treatment initiation:
...Heparinization, bolus and hourly, if applicable
Access to be used...
Catheter locking solution/amount
...Additional orders (lab, meds (medications....etc)

****

Hospital Services Policy & Procedure, # 1 Procedure: 7-04-02 A
DaVita Inc.
Title: Central Venous Catheter (CVC) Procedure
Revision Date: October 2017

Device Disinfectant and Skin Antiseptic

2% Chlorhexidine Gluconate/70 % Isopropyl Alcohol...only CVC access exit site Only skin
...
70% Alcohol pad...Only CVC caps Only CVC lines...

Procedure

3. Use Dialysis Precautions and aseptic technique throughout procedure.
7. Remove dressing and discard.
10. Observe the CVC site...
11. Verify both arterial and venous catheter limbs are clamped.
12. Removes gloves and discard. Perform hand hygiene per procedure and re-glove.
13....using aseptic technique, clean exit site with...Chlorhexidine Gluconate...If using a disinfectant other than 2 % Chlorhexidine Gluconate/70% Isopropyl Alcohol...i.e. isopropyl alcohol, Povidone...
16. Remove gloves and discard, perform hand hygiene per procedure and re-glove.
17. Place sterile antimicrobial patch and occlusive dressing over catheter exit site...
22. Remove each CVC lumen end cap and disinfect with a new hospital approved disinfectant...Scrub the sides, threads and end of the hub...

Upon Completion of Dialysis

...46. Remove saline syringes and connect syringe with prescribed locking solution and volume to each catheter limb...
49. Label catheter limbs...then placing label on the outside of the gauze or the CVC dressing with the following information: Name and dose of locking solution per catheter limb...
52. Document findings and procedure in the patient's treatment record...

****

1. PI # 11 was admitted to the facility on 5/22/18 with diagnoses including Hypertension, Uncontrolled and Acute Renal Failure.

Record review revealed an operative report dated 5/27/18 that contained documentation the patient needed to be dialyzed and a right intrajuglar (IJ) vascular catheter was placed on 5/27/18.

Review of the 5/27/18 Acute Hemodialysis Flowsheet documentation revealed hemodialysis orders for the catheter locking solution were left blank. The treatment initiation note documentation revealed "...access cleansed per protocol..." and the post treatment note documentation included "...Heparin per protocol...access catheter locking solution Heparin Art (arterial) 1.0 mL Ven (venous) 1.2.

The 5/27/18 treatment documentation failed to include the specific access site care provided and there was no documentation of the dosage of heparin locking solution.

Review of the 5/28/18 Acute Hemodialysis Flowsheet contained documentation the "...R (right)...IJ vas cath (vascular catheter) prepped with Alcavis..." There was no documentation of the specific CVC care performed on 5/28/18.

Review of the 5/29/18 Acute Hemodialysis Flowsheet documentation included hemodialysis orders for heparin 1500 units bolus and Catheter Locking Solution. The 5/29/18 post treatment access documentation revealed catheter locking solution Heparin Art 1.0 mL Ven 1.2 mL instilled. There was no dosage documented for the heparin lock solution.

Further review of the 5/29/18 treatment note documentation revealed access cleansed per protocol.
There was no documentation of the specific care provided to the CVC access site.

There was no medical record documentation of a physician's order for CVC care and the acute hemodialysis standing orders did not contain the heparin locking solution and dosage for the CVC.

In an interview conducted on 5/31/18 at 8:20 AM, Employee Identifier # 4, Registered Nurse, DaVita Hospital Service Administrator confirmed the above findings, verbalized staff follow the standing orders, use a CVC dressing kit and follow procedure facility.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined the facility Failed to ensure:

1. The buildings were constructed, arranged and maintained to ensure patient safety.

2. The staff followed their policy and procedure for preventive maintance on all hospital equipment to include the equipment contained within the Brookwood Freestanding Emergency Department.

3. Supplies available for patient use were not expired.

This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to A 701, A 724 and Life Safety Code violations for findings.

Based on review of facility policy and procedure, observations and interviews with staff it was determined the facility failed to ensure the staff followed their policy and procedure for preventive maintance on all hospital equipment to include the equipment contained within the Brookwood Freestanding Emergency Department.

Findings include:

Policy: Medical Equipment Management Plan
Revised Date: 3/17
Reviewed Date: /18

I. Scope:

The Medical Equipment Management Program is designed to assure proper selection, of the appropriate medical equipment to support a safe patient care and treatment environment...Finally the Program is designed to assure continual availability of safe, effective equipment through a program of planned maintenance, timely repair...

III. Objectives:

The objective of the Medical Equipment Management Plan is to minimize the risks of using medical equipment through inspection, preventative maintenance.

VII: The Hospital Manages Medical Equipment Risks:

B. Criteria and Inventory

1. The Brookwood Baptist Medical Center Maintains a written inventory of all medical equipment or an inventory of selected medical equipment categorize by physical risk associated with use and equipment incident history...

D. Identification of Maintenance Activities and Inspection, Testing and maintenance Intervals:

Each piece/type of medical equipment included in the Medical Equipment Management Plan will have written inspection/planned maintenance procedures to provide for the safe and effective use of the equipment...

The Biomedical Engineering Depart identifies in writing the frequencies for inspecting, testing, and maintaining medical equipment on the inventory...

Policy: Maintaining, Testing and Inspecting Medical Equipment:
Revised Date: 3/16

Purpose:

A. This policy describes the process by which each piece of equipment is tested and documented at intervals determined by manufacturer recommendations, risk levels and current Client experience.

B. Policy:

To ensure that there is written equipment testing procedures for each piece/type of fixed or portable medical equipment the Medial Equipment Management Program encompasses in the inventory...

C. Procedure:

4. An inspection schedule will be developed to show the months when scheduled inspections are to be performed...

A tour was conducted at the Brookwood Freestanding Emergency Department (FED) on 5/30/18 at 7:30 AM with Employee Identifier (EI) # 13, Director of Quality Assurance and EI # 14, Director.

Review of the FED revealed the building contained 12 fully functional exam rooms.

During the observations of all 12 exam rooms revealed each exam room contained and electric bed. Further observations revealed no preventive maintenance stickers on any of the 12 beds with in the emergency department.

Observations conducted throughout the FED revealed 1 slip machine, 1 cast cutter and a set of stand up scale which did not contain a preventive maintance sticker.

On 5/30/18 at 2:00 PM the surveyor spoke to EI # 18, biomedical department director,and presented the surveyor with a log book of all the preventive maintenance completed. Further review of the logs revealed no documentation preventive maintance was completed on the 12 beds and the above mentioned other equipment at the Brookwood FED.

An interview was conducted on 5/30/18 at 9:30 AM with EI # 13 and EI # 14 who confirmed the above mentioned findings.

Based on review of facility policy, observations, and interview with staff it was determined the facility failed to ensure supplies available for patient use were not expired.

This had the potential to affect all patients served by this facility.

Findings Include:

Subject: Crash Cart / Code Blue
Revised Date: 9/2017

"II. Purpose:

The purpose of this policy is to:

A. Establish a standardized crash cart system for all units...

III. Policy:

... B. Crash Carts:

A standard crash cart system will be maintained on a replacement cart system to ensure adequacy of emergency supplies in all necessary areas...

4. Expiration dates will be checked by representatives from Pharmacy and Central Supply as the carts are returned for restocking and on unused carts every one (1) month."

******

1. A tour of the Pediatric Department (Lilly Pad Room # 5) was conducted on 5/29/18 at 9:50 AM.

The surveyor observed the following expired suppies in the crash cart:

1- Bard Bulb Syringe (Ear and Ulcer Syringe) expired 9/2017.

1 - Portex Tracheal Tube 3.5 mm (millimeter) expired 11/2017.

1 - Kendall Neonatal electrodes expired 3/28/18.

1 - Kendall Neonatal electrodes expired 4/28/18.

1 - Suture Removal Kit expired 4/2018.

Staff failed to remove expired supplies from crash cart per facility policy.

An interview was conducted on 5/29/18 at 9:50 AM with Employee Identifier # 11, Obstetrics Educator, who confirmed the above findings.



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2. A tour of the hospital Emergency Department (ED) was conducted on 5/29/18 at 10:10 AM with EI # 13, Quality Assurance Director and EI # 15, ED Director.

During the tour the surveyor was told there was 2 Adult Crash Carts, 1 Neonatal crash cart, 1 pediatric crash cart, and a chest tube cart.

During the observation the surveyor opened the Neonatal crash cart and the following expired supplies were found:

Emergency Trach kit:
1 - Tracheal Tube size 3.5 expired 11/17
2 - 14 gage Jelco IV (intravenous) needles expired 2/17
1 - Infant feeding tube expired 1/18
1 - 20 ml (milliters) syringe expired 12/16.

The surveyor then opened the Pediatric Crash cart and the following expired supplies were found:

5 - single wrapped tongue depressors expired 08/05

The surveyor opened and observed the supplies within the Chest tube cart. The following expired supplies were found:

3 - 2.0 silk Ethilon sutures expired 1/17
3 - 0 Chromic gut sutures expired 7/15
1 - 3.0 Prolene sutures expired 1/18
1 - Curad Petrolatum dressing expired 12/17
1 - 30 ml syringe expired 10/16
2 - 18 gage Monoject expired 6/17
1 - 20 gage Monoject expired 12/16

An interview was conducted on 5/29/18 at 1:30 PM with EI # 13 and EI # 15 who confirmed the above mentioned findings.

Based on review of facility policies and procedures, observations, Centers for Disease and Prevention Control (CDC) Morbidity and Mortality World Report (MMWR) report recommendations for Health Care Workers (HCW), it was determined the facility failed to ensure all staff:

a) Followed the facility policy and procedure for proper hand hygiene and glove use which included during CVC care (central venous catheter care) and PICC (Peripherally Insertation of Central Catheter)

b) Disinfected all re-usable equipement after use.

c) Disinfected medication vial septums before piercing.

c) Was offered the hepatitis B vaccine and the vaccine was made available to all health-care personnel who are occupationally exposed to blood or other potentially infectious materials in 1 of 1 laboratory staff personnel file reviewed.

This did affect PI # 7, and an unsampled patient, and had the potential to affect all patients and staff.

Findings include:

Policy and Procedure subject: Hand Washing and Hand Antisepsis
Revised date: 9/17

"Policy:

... This policy applies to Tenet Healthcare Corporation and its wholly-owned subsidiaries and affiliates, any other entity or organization in which Tenet Healthcare Corporation or affiliate owns a direct or indirect equity interest of ...

Purpose:

Hand Hygiene has been recognized as the single most important prevention measure to reduce the risk of infection transmission from patient to patient and from patient to healthcare provider. This policy outlines hand hygiene requirements ..."

Procedure:

A. Indications for hand washing and hand antisepsis:

... 3. Before and after direct contact with patients, blood/body fluids or equipment and environmental items that are likely to be contaminated ...

... 6. Prior to donning gloves and after removing gloves ...

C. Hand Hygiene should be performed before and after contact with the patient one. Hand hygiene compliance for the patient zone is noted by observing the 5 moments for hand hygiene:

1. Before touching a patient

2. Before a clean/aseptic procedure

3. After body fluid exposure risk

4. After touching a patient

5. After touching patient surroundings

D. Choosing a product to use, soap or alcohol?

... 4. If hands are not visibly soiled, use and alcohol based hand rub for routinely decontaminating hands in all other situations.

5. Decontaminate hands before and after having direct contact with patients ...

7. Decontaminate hand after contact with patient's skin, e.g., when taking a pulse or blood pressure and lifting patient ...

10. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

11. Decontaminate hands before inserting or caring for ... peripheral vascular catheters, or other invasive devices that do not require a surgical procedure.

12. Decontaminate hands after removing gloves ..."

******
Policy and Procedure subject: Vials and Medication containers, Single dose and Multi-dose
Revised date: 3/18

"Purpose:

To prevent common-source outbreaks of bacterial and viral infections in the healthcare setting. To insure that multiple dose containers are discarded within a specified time frame...

Policy:

... 4. Disinfect the vial's rubber septum before piercing by wiping (and using friction) with a sterile alcohol wipe. Allow the septum to dry before inserting a needle or other device into the vial. Avoid touch contamination of the device before penetrating the access diaphragm..."

******

Hospital Services Policy & Procedure, # 1 DaVita Inc.
Policy:7-03-01 Revision Date: April 2018
Title: Infection Control In the Hospital Dialysis Setting

"...Note: The Centers for Disease Control (CDC) Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients (Dialysis Precautions) will be followed when caring for all patients...

Policy: 2. Teammates will thoroughly wipe down all non-disposable items and equipment such as the blood pressure cuff, the inside and outside of the prime container, clamps, the dialysis delivery systems, and electronic devices (iPads) with 1:100 bleach solution or hospital approved disinfectant after every treatment...
3. Medication vials, syringes, tape, alcohol swabs, dressings, gloves or other supplies will not be carried in pockets or placed on the patient's bed.
4. Hand Hygiene is to be performed per Hand Hygiene policy..."

****

Hospital Services Policy and Procedure, # 1 DaVita Inc.
Policy: 7-03-02
Title: Hand Hygiene
Revision Date: April 2013

Policy:

1. Hands will be washed...prior to gloving, after removal of gloves...after patient...between patients, before touching clean areas such as...supply carts...

****

The Centers for Disease Control and Prevention (CDC) Morbidity and Mortality World Report (MMWR)
Recommendations and Reports
December 26, 1997...1-42

Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC)

Summary

This report summarizes recommendations of the Advisory Committee on Immunization Practices (ACIP) concerning the use of certain immunizing agents in health-care workers (HCWs) in the United States. It was prepared in consultation with the Hospital Infection Control Practices Advisory Committee (HICPAC) and is consistent with current HICPAC guidelines for infection control in health-care personnel. These recommendations can assist hospital administrators, infection control practitioners, employee health physicians, and HCWs in optimizing infection prevention and control programs. Background information for each vaccine-preventable disease and specific recommendations for use of each vaccine are presented. The diseases are grouped into three categories: a) those for which active immunization is strongly recommended because of special risks for HCWs; b) those for which immunoprophylaxis is or may be indicated in certain circumstances; and c) those for which protection of all adults is recommended. This report reflects current ACIP recommendations at the time of publication. ACIP statements on individual vaccines and disease updates in MMWR should be consulted for more details regarding the epidemiology of the diseases, immunization schedules, vaccine doses, and the safety and efficacy of the vaccines.

INTRODUCTION

Because of their contact with patients or infective material from patients, many health-care workers (HCWs)(e.g., physicians, nurses, emergency medical personnel, dental professionals and students, medical and nursing students, laboratory technicians, hospital volunteers, and administrative staff) are at risk for exposure to and possible transmission of vaccine-preventable diseases. Maintenance of immunity is therefore an essential part of prevention and infection control programs for HCWs. Optimal use of immunizing agents safeguards the health of workers and protects patients from becoming infected through exposure to infected workers...Consistent immunization programs could substantially reduce both the number of susceptible HCWs in hospitals and health departments and the attendant risks for transmission of vaccine-preventable diseases to other workers and patients...In addition to HCWs in hospitals and health departments, these recommendations apply to those in private physicians' offices, nursing homes, schools, and laboratories, and to first responders.

Any medical facility or health department that provides direct patient care is encouraged to formulate a comprehensive immunization policy for all HCWs. The American Hospital Association has endorsed the concept of immunization programs for both hospital personnel and patients...The following recommendations concerning vaccines of importance to HCWs should be considered during policy development...

BACKGROUND

Diseases for Which Immunization Is Strongly Recommended

On the basis of documented nosocomial transmission, HCWs are considered to be at significant risk for acquiring or transmitting hepatitis B....these diseases are vaccine-preventable.

Hepatitis B

Hepatitis B virus (HBV) infection is the major infectious hazard for health-care personnel. During 1993, an estimated 1,450 workers became infected through exposure to blood and serum-derived body fluids, a 90% decrease from the number estimated to have been thus infected during 1985 (18-20). Data indicate that 5%-10% of HBV-infected workers become chronically infected. Persons with chronic HBV infection are at risk for chronic liver disease (i.e., chronic active hepatitis, cirrhosis, and primary hepatocellular carcinoma) and are potentially infectious throughout their lifetimes. An estimated 100-200 health-care personnel have died annually during the past decade because of the chronic consequences of HBV infection (CDC, unpublished data).

The risk for acquiring HBV infection from occupational exposures is dependent on the frequency of percutaneous and permucosal exposures to blood or body fluids containing blood...Depending on the tasks he or she performs, any health-care or public safety worker may be at high risk for HBV exposure. Workers performing tasks involving exposure to blood or blood-contaminated body fluids should be vaccinated. For public safety workers whose exposure to blood is infrequent, timely postexposure prophylaxis may be considered, rather than routine preexposure vaccination.

In 1987, the Departments of Labor and Health and Human Services issued a Joint Advisory Notice regarding protection of employees against workplace exposure to HBV and human immunodeficiency virus (HIV), and began the process of rulemaking to regulate such exposures...The Federal Standard issued in December, 1991 under the Occupational Safety and Health Act mandates that hepatitis B vaccine be made available at the employer's expense to all health-care personnel who are occupationally exposed to blood or other potentially infectious materials...Occupational exposure is defined as "...reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties... The Occupational Safety and Health Administration (OSHA) follows current ACIP recommendations for its immunization practices requirements (e.g., preexposure and postexposure antibody testing). These regulations have accelerated and broadened the use of hepatitis B vaccine in HCWs and have ensured maximal efforts to prevent this occupational disease...

Prevaccination serologic screening for prior infection is not indicated for persons being vaccinated because of occupational risk. Postvaccination testing for antibody to hepatitis B surface antigen (anti-HBs) response is indicated for HCWs who have blood or patient contact and are at ongoing risk for injuries with sharp instruments or needlesticks (e.g., physicians, nurses, dentists, phlebotomists, medical technicians and students of these professions). Knowledge of antibody response aids in determining appropriate postexposure prophylaxis.

Vaccine-induced antibodies to HBV decline gradually over time, and less than or equal to 60% of persons who initially respond to vaccination will lose detectable antibodies over 12 years (28; CDC, unpublished data). Studies among adults have demonstrated that, despite declining serum levels of antibody, vaccine-induced immunity continues to prevent clinical disease or detectable viremic HBV infection (29). Therefore, booster doses are not considered necessary (1). Periodic serologic testing to monitor antibody concentrations after completion of the three-dose series is not recommended. The possible need for booster doses will be assessed as additional data become available.

Asymptomatic HBV infections have been detected in vaccinated persons by means of serologic testing for antibody to hepatitis B core antigen (anti-HBc) (1). However, these infections also provide lasting immunity and are not associated with HBV-related chronic liver disease.

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Hospital Services Policy and Procedure, # 1
Procedure: 7-04-02 B
Title: Central Venous Catheter (CVC) With Use of An Antimicrobial Patch Procedure
Revision Date: October 2017

Procedure

3. Use Dialysis Precautions and aseptic technique throughout procedure.
7. Remove dressing and discard.
10. Observe the CVC site...
11. Verify both arterial and venous catheter limbs are clamped.
12. Removes gloves and discard. Perform hand hygiene per procedure and re-glove.
13....using aseptic technique, clean exit site with...Chlorhexidine Gluconate...
16. Remove gloves and discard, perform hand hygiene per procedure and re-glove.
17. Place sterile antimicrobial patch and occlusive dressing over catheter exit site...

****

1. An observation of care was conducted on 5/29/18 between 9:57-11:10 AM with Employee Identifier (EI) # 10, Registered Nurse (RN) and EI # 12, Anesthesiologist, who was in PI # 7's room prepping the patient for a scheduled Caesarean section.

EI # 10 sanitized his/her hands and donned gloves. EI # 10 proceeded to place a fetal heart monitor on the patient's abdominal area. EI # 10 removed the gloves after placing the fetal heart monitor on the patient's abdominal area and failed to wash or sanitize his/her hands per facility policy and procedure.

EI # 10 discarded used supplies from bedside table after the initiation of an Intravenous insertion and blood draw procedures. EI # 10 cleaned the patient's bedside table by using a disinfectant wipe with gloved hands. EI # 10 removed his/her gloves and started typing on the computer keyboard without sanitizing his/her hands.

EI # 12, Anesthesiologist opened a vial of: Xylocaine (Lidocaine HCL [hydrochloride] and epinephrine Injection) 400 mg (milligram)/ 20 (milliliter), Fentanyl Citrate Injection 100 mcg (microgram) Fentanyl/ 2ml, and Naropin 150 mg/ 20ml to administer during an epidural procedure. EI # 12 inserted a needle with a syringe attached into the Xylocaine, Fentanyl, and Naropin without disinfecting the vials septums and administered the medications to the patient. EI # 12 fail to disinfect the septums with a sterile alcohol wipe and allow the septum to dry before piercing per facility policy.

An interview was conducted on 5/29/18 at 11:29 AM with EI # 11, Obstetrics Educator, who confirmed the above findings.



30952

*****

An observation of CVC exit care and dialysis treatment initiation was conducted on 5/29/18 at 11:40 AM with an unsampled patient and EI # 2, Registered Nurse (RN), Dialysis Unit.

EI # 2 positioned the patient, observed the left shoulder area CVC site, removed gloves and held the dirty gloves in his/her hands during a patient interview. EI # 2 discarded the gloves and retrieved clean gloves from the glove supply box. With clean gloves in hand, obtained hand sanitizer and performed hand hygiene and donned gloves.

EI # 2 failed to discard used gloves and perform hand hygiene after glove removal and prior to accessing clean supplies.

EI # 2 monitored the temperature with a disposable thermometer, attached the blood pressure cuff to the patient arm and auscultated the upper chest area with a stethoscope.

With gloved hands, EI # 2 removed a cell (cellular) phone from his/her uniform pocket, laid his/her left wrist and hand on the patient pillow, then monitored the pulse and re-placed the cell phone back in his/her uniform pocket.

EI # 2 failed to disinfect the cell phone after use and before replacing re-usable equipment (cell phone) to his/her uniform pocket.

EI # 2 removed gloves, completed medical record documentation, then sanitized hands and gloves. EI # 2 failed to perform hand hygiene immediately after glove removal.

EI # 2 removed and discarded the old CVC dressing. EI # 2 performed hand hygiene, donned sterile gloves, cleansed the CVC exit site with Chlorhexidine Gluconate and applied skin protectant.

EI # 2 removed and discarded gloves, then donned a new pair of sterile gloves without first performing hand hygiene.

In an interview conducted on 5/31/18 at 8:20 AM, EI # 4, RN, DaVita Hospital Services Administrator verified the findings and confirmed staff failed to follow hospital infection control policy and procedure.

*****

On 5/30/28 at 7:40 AM, observations of care during medication passes with EI # 5, Staff RN, 4th floor neurological unit and EI # 3, Respiratory Technician (RT) were completed.

EI # 5 performed hand hygiene on two separate occasions at the patient bathroom sink and turned off the faucet with the back of his/her hands, and not a disposable paper towel.

EI # 5 failed to follow the facility hand hygiene policy.

On 5/30/18 at 7:50 AM, EI # 3, RT administered 3 nebulizer inhalation treatments. With gloved hands, EI # 3 cleansed the pulse oximeter (device that measures blood oxygen saturation) and the respiratory cart top with a Sani-Cloth disinfectant wipe.

Using the same Sani-Cloth disinfectant wipe, EI #3 wiped his/her disposable gloves, then disconnected the patient from the nebulizer treatment mask.

EI # 3 failed to dispose of the dirty gloves after cleaning re-usable equipment, perform hand hygiene and don clean gloves.

In an interview on 5/31/18 at 9: 30 AM, EI # 1, Accreditation Manager, Safety Officer confirmed staff failed to follow hospital infection control policies and procedures.

****

An observation of a medication preparation and administration was conducted on 5/30/18 at 8:00 AM with EI # 15, Registered Nurse for an unsampled patient.

EI # 15 obtained a vial of Dilaudid 1 mg. in 1 ml. of solution. EI # 15 removed the covering from the vial, inserted a needle and withdrew the solution. EI # 15 failed to disinfect the septum with alcohol before piercing.

EI # 15 entered the patient's room, donned gloves, dropped a piece of paper on the floor, picked the piece of paper up off the floor with gloved hands, and began administering the Dilaudid with the same gloved hands through a Central Venous Catheter via jugular vein.

An interview was conducted on 5/30/18 at 9:00 AM with EI # 16, Administrative Director of Patient Care Services. EI # 16 verified the staff were to disinfect the septum with alcohol before piercing and change gloves after contact with a dirty surface.

*******

On 5/30/18 at 3:30 PM, the survyeor reviewed 1 of 1 contracted laboratory personnel file documentation for a Blood Bank Technologist, the date of hire was 11/29/10.

There was no health file documentation provided to the surveyor and no documentation the contracted laboratory employee had been offered the Hepatitis B vaccination.

In an interview on 5/30/18 at 3:40 PM, the surveyor requested the above documentation from Employee Identifier # 7, the Laboratory Director. No documentation was provided to the surveyor.



22965

An observation of care was conducted on 5/30/18 at 11:45 AM to observe a EI # 9, PICC team RN (Registered) inserted a PICC line on an unsampled patient. EI # 9 donned on new pair of gloves to palpate and assess the appropriate area to insert the needle and the patient's right upper arm was chosen, after assessment, EI # 9 removed his/ her gloves and donned on new pair of gloves without performng hand hygiene. EI # 9 proceeded to prepare the sterile field for the necessary equipments and supplies needed for the insertion, after preparation, EI # 9 removed his/ her used gloves and donned on new pair of gloves without performing hand hygiene. EI # 9 cleaned the area of insertion, discarded the used swabs and removed his/ her used pair of gloves and donned on new pair of gloves without performing hand hygiene. EI # 9 proceeded to perform the PICC insertion and after the procedure, dressed the area and removed his/ her gloves. EI # 9 did not perform hand hygiene after removal of used gloves.

An interview with EI # 17, CIC (Certified Infection Control) Practitioner conducted on 5/30/18 at 12:30 PM who confirmed the above mentioned findings.

Based on medical record review and interview, it was determined the facility failed to provide documentation the patient was offered a choice of home care providers. This affected Patient Identifier (PI) # 4, 1 of 2 discharge record reviews with a home care referral at discharge.

Findings include:

1. PI # 4 was admitted to the facility on 1/9/18 with diagnoses including Peripheral Vascular Disease with Dehiscense of Right Lower Leg Wound and Exposure of Bypass Graft.

The medical record contained physician orders dated 1/11/18 for home health care evaluation and treat, reason-wound vac (vacuum assisted closure) changes per wound vac orders and daily xeroform and dry dressing to right medical ankle ulcer.

There was no documentation PI # 4 was offered a choice of home health care providers and no documentation PI # 4 signed the facility Patient Choice form.

In an interview conducted on 5/31/18 at 8:00 AM, Employee Identifier # 1, Accreditation Manager, Safety Officer confirmed the above finding.

Based on an observation of care, medical record review and staff interview, it was determined the respiratory staff failed to follow physician orders for patient post care following the Pulmicort nebulizer inhalation treatment.

This affected 1 of 1 respiratory care observations and had the potential to negatively affect all patients who required respiratory treatments.

Findings include:

1. An observation of care on the fourth floor neurological care unit was performed on 5/31/18 at 7:40 AM with Employee Identifier (EI) # 3 Respiratory Technician. EI # 3 administered Pulmicort 0.5 mg (milligram)/2 ml (milliliter) via nebulizer inhalation.

Prior to the care observation, the surveyor viewed the patient electronic medical record with EI # 6, Nurse Manager, Neuro (neurological) Unit. The surveyor noted physician orders which included Pulmicort aerosol nebulized inhalation twice daily, have patient rinse mouth after administration. (Mouth rinse is to prevent dry mouth, hoarseness and oral yeast infections).

Following completion of the Pulmicort treatment, EI # 3 removed the respiratory treatment mask, performed hand hygiene and exited the patient room.

EI # 3 failed failed to follow physician orders and have the patient rinse his/her mouth after the Pulmicort treatment and EI # 3 failed to educate the patient to perform mouth rinse after Pulmicort was administered.

In an interview on 5/31/18 at 9:30 AM, EI # 1, Accreditation Manager, Safety Officer confirmed staff failed to follow physician orders during the respiratory treatment.