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Based on observations, interviews and documents reviewed it was determined the facility staff failed to ensure they followed their infection control plan by identifying, reporting, investigating and controlling potential areas and behaviors that could result in the spread of infection by:

A. Inability to disinfect porous wood surfaces between patients for three (3) of three (3)observations; Failure to thoroughly clean and disinfect patient rooms after discharge for two (2) of three (3) observations; Staffs' lack of knowledge related to the use of disinfectant products for four (4) of four (4) interviews; Staffs' inappropriate use of disinfectant wipes for three (3) of three (3) observations; the use of a non-commercial washer to launder all mop-heads utilized to clean patient rooms and hydrocollator pack covers reused between patients for six (6) of six (6) covers.


B. Staffs' failure to appropriately disinfect point of care device for one (1) of two (2) observations.

C. Staff transporting a patient on contact precautions failed to sanitize their hands prior to entering patient's room for one (1) of three (3) observations; and transporting a patient on contact precautions without the patient being in a mask (Staff #32 and #33); and Staff being unaware of which personal protective equipment was needed to enter the room of a patient on contact precaution (Staff #5).

D. Failure to disinfect anesthesia carts in the operating room between patients for one (1) of one (1) observations.

E. Failure to utilize sterile personal protective equipment during all chemotherapy mixing in the clean area of the pharmacy.

F. Failure to ensure the surfaces of walls were maintain in a manner to allow disinfection in the operating rooms, to maintain an air gap for one (1) of one (1) ice machines observed and ensure expired supplies were not available for use with a patient in one (1) one (1) observation.

G. Failure to ensure equipment was maintained in a manner to promote disinfection between use for one (1) of one (1) physical therapy observation.

H. Staffs' failure to ensure keyboard on workstations on wheels (WOWs) were clean and disinfected for three (3) of three (3) WOWs stored in clean rooms.

I. Staffs' failure to date intravenous (IV) lines to decrease the risk of infections for one (1) of three observations.

The findings included:


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1. On 07/06/15 from 1:30 P.M. to approximately 3:00 P.M. observations were made in the ED (Emergency Department), ICU (Intensive Care Unit) and 2 South and the following was noted:

A. The isolation room in the ED had a pillow on the gurney that did not have a surface that could be disinfected. The surface of the pillow on the gurney was made of fabric.

In ICU 3 rooms were observed Rooms #3, 4 and 6. Room #3 had a night stand beside of the bed that was made of wood. The finish was worn to the point of leaving exposed wood. The porous surface of the wood could not be disinfected between patients.

Room #4 also had a night stand beside of the bed that was made of wood. The finish was worn to the point of leaving exposed wood. The porous surface of the wood could not be disinfected between patients. Room #4 also had a metal walking cane missing the rubber tip left in the closet and a plastic coat hanger with an "L" on the hook part of the hanger. Staff Member #10 stated, "That does not belong to our PT department."

Room #6 also had a night stand beside of the bed that was made of wood. The finish was worn to the point of leaving exposed wood. The porous surface of the wood could not be disinfected between patients. Also in Room #6 were 5 to 6 magazines in the night stand one of which had the name and address of a person on the magazine. Beside of the sink in Room #6 was a pinkish brown substance on the wall and a glob of substance on the ceiling just above the foot of the bed. Staff Member #16 reported the walls of the rooms are to be cleaned once a person is discharged but the ceilings are not cleaned.

Staff Member #9 provided a random audit of patients which noted night stands were in need of repair.

Four various staff (Staff Members #11, 18, 34 and 35) were asked in various locations (surgical area including PT (Physical Therapy Department), Pre Op/PACU and Endoscopy) what type of product was used for cleaning surfaces and what the process was for cleaning. The staff identified the "Purple top Containers" (PDI Sani Cloth Wipes). None of the staff interviewed could tell what the wet time for this product was or the purpose of the wet time.

Staff Member #11 was observed cleaning the anesthesia equipment including the cords attached to the cardiac monitor with 2 wipes over approximately one minute. Staff Member #34 was observed cleaning the glucometer with one wipe which was wiped down and placed back in the glucometer's plastic holder within approximately 40 seconds. Staff Members #18 and 35 were not observed cleaning equipment but were interviewed.

On 7/7/15 observations were made in PT. Staff Member #18 confirmed the PT department utilizes hydrocollator hot packs as a part of therapy for some patients. The process for wrapping the hot pack was demonstrated and the hot pack was placed on a patient in PT. Staff Member #18 was asked how often and where the wraps were laundered. Staff Member #18 stated, "The wraps are removed from the department placed on a cart and transported to Environmental Services who takes care of ensuring they are laundered." Staff Member #18 simulated the transport of the wraps.
Staff Member #15 stated, "The wraps are laundered here over the weekend so they are ready on Monday." Staff Member #15 escorted this surveyor to an area containing 2 front loading washers and 2 front loading dryers. Staff Member #15 stated, "The washers reach temperatures between 140 and 160° Fahrenheit."
Staff Member #16 stated, "The water temperature in the hospital is maintained at 120° Fahrenheit which means the washing machine water level can't go higher than 120° Fahrenheit unless the washer has a booster. The washer does not have a booster." Staff Member #10 stated, "(Name of Staff Member #16) called the manufacturer of the washing machine and reported it would not reach temperatures of 140 to 160° Fahrenheit." The Use and Care Guide of the Maytag front-loading automatic washer where the actual temperature of the water can be changed only the mixture of the water. The selections are sanitize/cold, hot/cold, warm/warm, warm/cold and cold/cold (wash/rinse).
Staff Member #16 also stated, "The mop heads used all over the hospital are also laundered in these washing machines."
B. On 7/7/15 at approximately 8:20 A.M. Staff Member #34 was observed obtaining a blood sugar from Patient #6. Staff Member #34 removed the lancet used in sticking the finger of Patient #6 after getting the blood sugar results. Staff Member #34 then placed the glucometer on top of the glucometer's plastic holder. Staff Member took the glucometer and the plastic holder to the nurses station, laid the plastic holder on the counter and wiped the glucometer with one wipe and placed the glucometer back in the glucometer's plastic holder all within approximately 40 seconds.
After asking Staff Member #34 about the wet time for the cleaning product (PDI Sani Cloth Wipes) Staff Member removed the glucometer wiped the glucometer and the inside of the plastic holder. Staff Member #34 did not clean the outside of the plastic holder or the counter on which the plastic holder had been placed.
D. Staff Member #11 was observed cleaning the anesthesia equipment including the cords attached to the cardiac monitor with 2 wipes over approximately one minute. Staff Member #11 was asked to describe what the instructions for cleaning the equipment with the wipes being used was. Staff Member #11 began a description that did not include a 2 minute wet time for the use of the wipes. Staff Member #11 stated, "I did not know it had to be wet for 2 minutes. We changed wipes because the others took 4 minutes. I thought that was the amount of time it took to kill the bacteria on the equipment once we wiped it down."

The PDI Sani Cloth Wipes product label states the following:

"ENVIRONMENTAL HYGIENE
Effective against 30 microorganisms in 2 minutes including the following MDROs, bloodborne pathogens and viruses:1
·
E. On 7/7/15 the pharmacy was observed. Staff Member #24 was interviewed regarding the area of the pharmacy where chemo-therapy products are mixed. The area does not have a door but utilizes enclosed hoods. Staff Member #24 stated, "We treat the area like a clean and sterile room." Staff Member #24 described the dress code for the area as putting on sterile gloves, mask, bonnet, shoe covers and a gown to protect the person mixing the chemo-therapy product (non sterile gown). When asked about the scrubs the staff wore in the area Staff Member #24 stated, "They have their own scrubs laundered at their homes." Staff Member #24 stated, "We do not use scrubs like they were in surgery and we do not use gowns like are used in surgery."
CDC Workplace Safety and Health Niosh Alert Preventing Occupational Exposures to Antineoplastic and other Hazardous Drugs in Health Care Settings DHHS (NIOSH) Publication Number 2004¿165 September 2004 states the following:
"Wear PPE (including double gloves and protective gowns) while reconstituting and admixing drugs:
Make sure that gloves are labeled as chemotherapy gloves and make sure such information is available on the box [ASTM in press] or from the manufacturer.
Consider latex-sensitive workers [NIOSH 1997] and remember that a number of glove materials are suit¿able for protecting workers from an¿tineoplastic drugs [Connor 1999; Singleton and Connor 1999; Klein et al. 2003].
Consider using chemotherapy gloves for hazardous drugs that are not chemotherapy¿ drugs or for which no in¿formation is available.
Use double gloving for all activities in¿involving hazardous drugs. Make sure that the outer glove extends over the cuff of the gown [Connor 1999; Brown et al. 2001].
Inspect gloves for physical defects before use.
Wash hands with soap and water be¿fore donning protective gloves and immediately after removal.
Change gloves every 30 minutes or when torn, punctured, or contami¿nated. Discard them immediately in a yellow chemotherapy waste container [ASHP 1990; Brown et al. 2001].

Use disposable gowns made of polyethylene-coated polypropylene (which is nonlinting and nonabsor¿bent). These gowns offer better pro¿tection than polypropylene gowns against many of the antineoplastic drugs [Connor 1993; Harrison and Kloos 1999]. Make sure gowns have closed fronts, long sleeves, and elas¿tic or knit closed cuffs.
Dispose of protective gowns after each use. Use disposable sleeve covers to pro¿tect the wrist area and remove the covers after the task is complete. "
F. On 7/7/15 during observations of the surgical area; Rooms #1 and 2 and the sterile hallway there were holes observed in the walls. In room #2 the holes had been plastered but not painted. Staff Member #16 stated, "Those will be fixed tonight." There were chairs in both room #1 and #2 that had worn porous exposed surfaces that could not be properly disinfected.

Also observed during the tour of the surgical area in the anesthesia cart were 2 magnets stuck to 2 "C" batteries and a New Testament Bible. The anesthesia medication cart had approximately 10 angiocath needles expired in 2014 available for use. Staff Member #11 stated, "We don't even use that size since we don't really do any surgical peds [pediatric] cases. I don't know why they are in here. We would use them on a small elderly person possibly."

An ice machine was stored in a locked room with the Pyxis machine (medication administration cabinet) and stored extra clean supplies. The ice machine did not have a visible air gap to prevent contamination in the event of sewage back up. Without an air gap any contaminants could travel up the ice machine drain pipe and cross-contaminate the ice supply.

H. Keyboards of the computers on wheels (WOWs) were observed in cleaned patient rooms on 2 South. Staff Member #17 stated, "The nursing staff clean the keyboards of the computers." Room #217 had one WOW stored in the room and Room #270 had 2 WOWs stored in the room. All 3 keyboards were labeled as washable. The keyboards had staples, paper and various other types of debris in between the keys. Staff Member #10 stated, "I will get someone to clean those."


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C.1. An observation conducted on Acute Care Unit (ACU) Two (2) North on 07/07/2015 at approximately 10:55 a.m. revealed Staff #32 and #33 transporting a patient on contact isolation (Patient #11), down the hallway back into Room #213. Staff #32, Staff #33 and Patient #11 were not observed wearing any PPE (personal protective equipment). Staff #32 stopped at the entrance to the contact isolation room, donned a gown and gloves, but failed to perform hand hygiene prior to donning gloves. Staff #33 entered the contact isolation room with no PPE on, assisted with Patient #11, preceded back to the entrance of Patient #11's room and donned gloves, failed to perform hand hygiene prior to donning gloves, re-entered Patient #11's room to pick up an oxygen tank. Staff #33 wiped the oxygen tank down with a sanitizing wipe, removed gloves and exited the contact isolation room. Staff #33 never performed hand hygiene during this process.

Staff #10 was present during the findings and was interviewed by the surveyor to verify if this observation of contact isolation precautions is consistent with hospital infection control policies and procedures. Staff #10 reports that Staff #32 and #33 failed to follow contact isolation procedures because the staff members should have had gloves on. Staff #10 states, "Even if one hand has a glove on so they can take the other hand that hasn't touch the patient's items and touch the elevator button if they need to." Staff #32 and #33 failed to follow proper contact isolation precautions during the transport of Patient #11, including not ensuring the infected or colonized areas of the patient's body are contained and covered placing other patients at higher risk for an infection or communicable disease.

A record review on 07/07/2015 revealed Patient #11 was placed on contact isolation precaution to rule out Methicillin Resistant Staphylococcus Aureus (MRSA) in the nares. At approximately 11:00 a.m., Staff #10 confirmed the MRSA laboratory test was still pending for the results and contact isolation precautions were still active for Patient #11.

An interview was conducted at 3:56 p.m. on 07/07/2015 during the end of the day meeting. The facility staff were informed of the findings and a policy/procedure was requested.

Review of the facility's policy titled "Contact Precautions," updated 09/2014 which read in part: "Policy I. In order to reduce the risk of transmission of microorganisms, Contact Precautions will be routinely practiced by all SVRMC personnel whenever indicated. The following strategies for Contact Precautions as recommended by the Centers for Disease Control (CDC) must be adhered to in order to protect patients and personnel. III. Patient Transport B. When transport or movement in any healthcare setting is necessary, ensure that infected or colonized areas of the patient's body are contained and covered. C. Remove and dispose of contaminated PPE and perform hand hygiene prior to transporting patients on Contact Precautions. D. Don clean PPE to handle the patient at the transport destination."

C.2. On July 6, 2015 at 1:55 p.m., with Staff #5 a second surveyor was directed to enter a patient on "Contact Precautions" without the use of personal protective equipment (PPE) to interview the patient (Patient #7). Staff #5 entered Patient #7's room to ask if the patient and/or family was willing to speak to the surveyor. Staff #5 did not don PPE prior to entering Patient #7's room that was clearly designated that the patient was on "Contact Precautions." Prior to entering Patient #7's room the surveyor asked Staff #5 regarding the required PPE needed for a patient on "Contact Precautions." Staff #5 reported the surveyor did not need to don PPE unless there would be contact between the surveyor and the patient. The surveyor performed hand hygiene and entered the room. Patient #7's room did not have a designated demarcation of an area were individuals could enter the room and be in a safe area to avoid being in contact with potentially contaminated items. The surveyor conducted a brief interview on discharge planning and performed hand hygiene on exiting Patient #7's room.

An interview was conducted on July 7, 2015 at approximately 5:15 p.m., with Staff #10. The surveyor informed Staff #10 of the findings. Staff #10 reported the second surveyor was misdirected by Staff #5. Staff #10 reported there was a potential of coming into contact with contaminated areas within Patient #7's room. Staff #10 reported the facility did not have a policy which provided for a demarcation of a safe zone in patient's rooms. Staff #10 reported the surveyor had been misinformed and Staff #5 and the surveyor should have donned PPE prior to entering Patient #7's room. The surveyor requested the facility's policy for contact precautions and the required PPE.

Review of the facility's policy titled "Contact Precautions" read in part: "II. Use of Personal Protective Equipment (PPE) ... B. Gowns 1. Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient ..."

G. An observation conducted in the Physical Therapy Department on 07/06/2015 at approximately 1:35 p.m. revealed cracks and tears on both of the black pull bar covers on the Quantum machine. Staff #18 stated the equipment is cleaned with sanitizing wipes between patients. Staff #10 stated he/she recalls the director of Physical Therapy putting a work order in for the replacement of these covers. Staff #10 and Staff #18 were aware of the findings.

I. On 07/06/2015 and 07/07/2015 in the ICU (intensive care unit) the following observations were made:

ICU Clean Supply Room on 07/06/2015 at approximately 2:40 p.m. an uncovered isolation caddy was hanging on a metal rack with clean supplies. Staff #10 was present during the findings and immediately removed the isolation caddy from the Clean Supply Room, cleaned it, placed a clear plastic bag over it, placed it back in the room; however no items in the Clean Supply Room were removed or cleaned in case of cross contamination. Staff #10 was informed of the findings and a policy/procedure was requested.

Review of the facility's policy titled "Isolation Caddies" which read in part: "Introduction/Purpose: To reduce the risk of spreading infections/germs to other patients, employees, visitors, etc. that requires one of the following types of isolation precautions:..... Procedure: A. Once a patient is placed on Isolation Nursing will et the Isolation Caddy from the ICU storage room OR the ACU storage room. Remove the clear plastic bag and place on the outside of the door. C. Once the Caddy has been cleaned Nursing will take the ICU Caddy itself, leaving the clear suction cup on the ICU glass Door and return to the designated area in the ICU Storage Room OR take the hanging caddy back to the designated area in the ACU storage room. A clear plastic bag will be placed on the clean Isolation Caddy. Stocking: A. ICU and ACU Nursing staff will be responsible for stocking and maintaining the supplies for the Caddies."

ICU Room #2 on 07/07/2015 at approximately 10:00 a.m. one (1) liter bag of Normal Saline Intravenous Solution, one (1) bag labeled 125 milligram (mg) of Diltiazem and one (1) bag labeled Intravenous Solution Additives Levaquin 750 milligram (mg) were hanging spiked without any date, time or inserter's initials found on the tubing. Staff #10 was present during the findings and stated the intravenous tubing can have the blank label and it doesn't need to include the date, time or inserter's initial's.

An interview was conducted 3:56 p.m. on 07/07/2015 during the end of the day meeting. The facility staff were informed of the findings and a policy/procedure was requested.

Review of the facility's policy titled "Guidelines for Infection Control in Intravenous Therapy" which read in part: "E. General Recommendations for Replacement of Administration Sets, and Catheters. IV administration sets should be replaced no more frequently than at 72 hour intervals, unless a catheter related infection is suspected. All administration sets are to be labeled with the date, time and inserter's initials."

Based on interviews and document review, it was determined the facility's discharge planners and case managers failed to implement readmission assessment tools to determine the appropriateness of discharge plans for four (4) of four (4) patients readmitted to the facility within thirty (30) days. (Patients #1, #2, #3 and #12)

The findings included:

An interview was conducted on June 7, 2015 at approximately 8:15 a.m., with Staff #5. Staff #5 reported the facility's software would automatically include a "Readmission" screen for patients returning within sixty (60) days. Staff #5 explained the case managers' readmission assessment tool was used to determine if the patient's discharge plans had been adequate and what factors impeded the patient's implementation or inability to follow the discharge plan, which possibly led to the patient's readmission.

1. A review of Patient #1's electronic medical record (EMR) was conducted on July 7, 2015 from 8:30 a.m. to 10:21 a.m., with Staff #5. The review was of the following admissions/readmissions within thirty (30) days: April 11-13, 2015 [Acute Pancreatitis and substance use]; May 12-14, 2015 [Chest pain and substance use]; May 19-21, 2015 [Drug withdrawal]; and June 4-7, 2015 [Acute Pancreatitis and substance use]. Patient #1's April 11, 2015 admission was also a readmission within 30-days. Review of the case managers' readmission assessment tool for Patient #1's readmissions on April 11, 2015, May, 19, 2015, and June 4, 2015 had not been completed.

2. A review of Patient #2's EMR was conducted on July 7, 2015 from 10:21 a.m. to 10:47 a.m., with Staff #5. The following admission/readmissions within 30-days were reviewed: June 13-15, 2015 [Paralytic Ileus]; June 29-30, 2015 [Intestinal Obstruction]; and his/her current admission starting July 6, 2015 [Partial Small Bowel Obstruction]. The case manager failed to utilize the readmission assessment tool for Patient #2's readmission on June 29, 2015.
[According to www.medical dictionary.com: An "Ileus is a partial or complete non-mechanical blockage of the small and/or large intestine."]
3. A review of Patient #3's EMR was conducted on July 7, 2015 from 11:26 a.m. to 11:57 a.m., with Staff #5. Patient was readmitted to the facility on June 25, 2015. The case manager did not perform a readmission assessment.
4. A review of Patient #12's EMR was conducted on July 8, 2015 from 8:29 a.m. to 9:14 a.m., with Staff #37 with Staff #5 present. The following admission/readmissions within 30-days were reviewed: April 12-18, 2015 [Major Depression with Alcohol use]; May 2-7, 2015 [Major Depression with Alcohol use]; May 27, 2015 - June 2, 2015 [Major Depression with Alcohol use]; and an Emergency Department visit on June 25, 2015.

The interview and review conducted on July 8, 2015 with Staff #37 revealed the unit discharge planner did not have access to the readmission assessment tool utilized by case management. Staff #37 reported patient readmissions were discussed and their discharge plans reviewed but that "discussion may be informally in the hallway or formally during treatment team meeting, but it's not always documented." The surveyor inquired if Staff #37's unit utilized the same policies for discharge planning as the other units of the hospital. Staff #37 reported he/she had not necessarily read the policies for discharge planning and evaluation of the patient's previous discharge plan for readmitted patients. Staff #5 reported case management would supply the needed tools.

Review of the facility's policy titled "Case Management Plan for Discharge Planning Policy" that read in part: "V. Reassessment- B. This reassessment most commonly takes place in the form of evaluation of readmissions to identify opportunities for improvement in the discharge planning and transitions of care processes."