HospitalInspections.org

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Based on document review, Medical Record review and interview, in one (1) of two (2) patients, the Medical Staff did not ensure that discharged patients who developed post-operative infections were reported to the Infection Control Officers as required by the facility's "Rules and Regulations".

This lack of reporting post-operative infections has the potential for placing surgical patients at risk of exposure to infectious diseases.

Findings include:

The facility's "Rules and Regulation of the Medical Staff "dated 01/24/2017, stated the following: "The Medical Staff ... shall comply with all Infection Control and Prevention Regulations to identify infections and implement measures to prevent transmission and development of infection .... In addition, all ... surgical site infections identified by the practitioner following discharge shall be ... reported to the Department of Epidemiology / Infection Control Officers for further investigation."

Review of Patient #10's Medical Record identified the following information: On 07/28/17, the patient underwent bilateral revisions of the previous breast reconstructions and the patient was discharged home in stable condition.

The patient returned on 08/11/17 for an exploration of the left breast and the Operative Note documents that a culture was sent to Microbiology. The culture result became available on 08/12/17, after the patient had been discharged and was positive for E. Coli.

The "Breast Reconstruction - Surgical Site Infection Log" for 2017 does not include Patient #10.

The "Thera-Doc Infection Report" dated 09/11/17 revealed that the Infection Control Practitioner received a call from another system facility reporting that Patient #10 had developed a surgical site infection. However, there was no documented evidence that the Surgeon notified the Department of Epidemiology / Infection Control Officers prior to this notification.

Interviews in the morning of 03/23/18 with both Staff K (Medical Director) and Staff L (Director) confirmed that the Physician had not reported that Patient #10 had a developed a surgical site infection.
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Based on observation, Medical Record review, document review, and interview, the staff did not document: (a) Pre- and post-parameters for nebulizer treatments in two (2) of two (2) patients; (b) a urethral catheter insertion in one (1) of three (3) patients; and (c) the insertion date of a Peripherally Inserted Central Catheter (PICC) that was Present on Admission (POA) in one (1) of one (1) patient.

This lack of documentation may prevent Health Care Staff from accessing and retrieving information necessary to monitor patients' condition and provide appropriate care.

Findings for (a) include:

Observations in the facility's 5 Monti Respiratory Care Unit (RCU) during a tour between 3:30PM and 5:00PM on 03/23/18 identified the following:

Patient #16's Medical Record identified a Physician's Order dated 03/13/18 at 5:11AM for Albuterol nebulizer treatments every four (4) hours (while awake). Nebulizer administration times were scheduled for 6:00AM, 10:00AM, 2:00PM, 6:00PM and 10:00PM each day. Patient #16's Medical Record identified missing documentation of the patient's pre-treatment heart rate and respiratory rate, and post-treatment heart rate and respiratory rate for eleven (11) of the forty-five (45) doses required since 03/13/18, at the time of the Medical Record review. In addition, three (3) of the thirty-four (34) documented doses were incomplete, missing either pre- or post-treatment information.

Patient #17's Medical Record identified a Physician's Order dated 02/12/18 at 11:12AM for Albuterol nebulizer treatments every six (6) hours. Nebulizer administration times were scheduled for 12:00AM, 6:00AM, 12:00PM and 6:00PM each day. Patient #17's Medical Record identified missing documentation of the patient's pre-treatment heart rate and respiratory rate and post-treatment heart rate and respiratory rate for nine (9) of forty-four (44) doses required since 03/12/18, at the time of the Medical Record review.

During an interview with Staff Hh (Respiratory Therapist) caring for Patients #16 and #17 at the time of observation, she stated: "Today was a busy day. I just did not get around to documenting them [pre- and post-parameters]."

This was confirmed with Staff Ii (Assistant Director) at the time of observation, who stated: "The expectation is for staff to document the patient's heart rate and respiratory rate both before and after nebulizer treatments are administered."

The facility's Policy and Procedure titled "Aerosolized Medication Therapy via Small Volume Nebulizer (SVN)" stated: "...Obtain the following parameters before therapy: ...Heart Rate and Respiratory Rate ... [After nebulizer treatment is complete] ... record the date, time, medication amount and dilution, [and] pre- and post-parameters ...."


Findings for (b) include:

Patient #18's Medical Record identified that this patient had been transferred to 2DSU from 2Cohen on 03/22/18 at 9:17PM. A Physician's Order for the insertion of a urinary catheter was dated 03/22/18 at 8:25PM, prior to patient transfer. Nursing Assessment Flowsheet dated 03/22/18 did not identify a urinary catheter insertion date, time or indication for catheter placement. Patient #18's Plan of Care or Nursing's Progress Notes also did not identify a catheter insertion date, time or indication.

Observation of Patient #18 on 03/23/18 at 12:30PM identified that the patient had an indwelling urinary catheter in place. This was confirmed with Staff Ee (Nurse Liaison) and Staff Gg (Nurse Manager). Staff Gg explained that the date and indication for the catheter insertion should have been documented into the Nursing Assessment Flowsheet.

The facility's Policy and Procedure titled "Prevention of Catheter-Associated Urinary Tract Infection (CAUTI) Policy" last reviewed 03/19/15, stated: "...document the indwelling urinary catheter insertion date ... indications for catheter insertion, date and time of catheter insertion, individual who inserted the catheter and date and time of catheter removal ... ensuring that documentation is accessible in the patient record ...."


Findings for (c) include:

Review of Patient #4's Medical Record on 03/19/18 identified that the patient presented to the Emergency Department (ED) on 03/15/18 at 5:41PM from a nursing home, with a right upper arm, single lumen Peripherally Inserted Central Catheter (PICC) that was Present on Admission (POA). Patient #4 was later admitted to the Medical Intensive Care Unit (MICU) on 03/15/18 at 10:48PM.

An ED Provider Note dated 03/15/18 at 6:09PM erroneously stated that Patient #4 did not have a central line. An ED Adult Nursing Note dated 03/15/18 at 7:28PM, a Physician's History and Physical Note dated 03/15/18 at 10:54PM, and the MICU Initial Nursing Assessment, dated 03/15/18 at 11:25PM, failed to identify the POA PICC's insertion date.

During a tour of the facility's MICU on 03/19/18 at 12:30PM, confirmation or documentation of Patient #4's PICC insertion date could not be obtained. The PICC insertion date was later identified from the nursing home's transfer paperwork that had accompanied the patient to the ED. The PICC's original insertion date of 03/15/18 had not been entered into the facility's Medical Record.

These findings were confirmed with Staff Cc (Senior Director) and Staff Dd (Nurse Manager).

The facility's Policy and Procedure titled "Care of the Adult Patient with Central Venous Catheters, including Peripherally Inserted Central Catheters (PICCs), Implanted Central Venous Catheters (Ports), Hemodialysis Catheters" effective 03/30/16, lacked direction for staff to document insertion dates for patients with PICCs that were POA.

An interview with Staff L (Director of Infection Control) on 03/23/18 at 3:24PM confirmed that the current Policy did not direct staff to document POA central line insertion dates, and that the POA central line insertion date should have been documented in the patient's Medical Record. Staff L acknowledged that without the original insertion date in the patient's Medical Record, the actual age of the PICC would be difficult to determine.
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Based on document review and interview, the Infection Control Officer failed to develop a Policy / Procedure that addresses positive intra-operative culture results which become available after surgical patients have been discharged.

This lack of a Policy / Procedure has the potential for the facility not identifying post-operative infections of discharged surgical patients and providing appropriate interventions.

Findings include:

Review of Patient #10's Medical Record identified the following information: On 07/28/17 the patient underwent bilateral revisions of the previous breast reconstructions. The Operative Report documented that there were no complications and minimal blood loss. The patient was discharged home in stable condition.

The patient returned on 08/11/17 for an exploration of the left breast implant pocket with evacuation of a small hematoma, irrigation of the pocket and placement of a new implant of the left breast. The Operative Note documented that a culture was sent to Microbiology from the implant pocket. The patient was then discharged with outpatient follow-up.

The culture result became available on 08/12/17, after the patient had been discharged and was positive for E. Coli. There was no documented follow up by the Infection Control Practitioners on the positive culture until approximately one (1) month later, on 09/11/17, when the Infection Prevention Coordinator was notified of the surgical site infection.

The facility's Policy and Procedure titled "Ambulatory Services" last revised 06/2/17 states the following: "...Post discharge surveillance for ambulatory services that are affiliated with the hospital ... in an effort to identify adverse outcomes after a surgical procedure ... ... should be identified by the practitioner and referred to Infection Control." However, the Policy lacks guidance for the review of positive intra-operative cultures results of patients that have been discharged.

Interviews with both Staff K (Medical Director) and Staff L (Director) confirmed that there was no current process for reviewing these positive intraoperative cultures.
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Based on observation, Medical Record review, document review and interview, the facility failed to ensure that Facility Staff: (a) followed current Infection Control standards for cleaning Patient Care Areas and equipment; (b) followed facility Policy for cleaning Procedure Rooms between cases in one (1) of two (2) observations; (c) performed appropriate hand hygiene or hand washing in one (1) of two (2) observations; (d) wore PPE (Personal Protective Equipment) consistent with facility Policy; and (e) educated patients, visitors, or caregivers about infections to reduce transmission in one (1) of three (3) Medical Records.

These Infection Control breaches place all patients at risk for exposure to infectious diseases.

Findings pertinent to (a) include:

(a1)
Observation in the Ambulatory Surgery PACU (Post Anesthesia Care Unit) on 03/23/18 at 11:00AM, with Staff Y (Administrator) revealed the compartments of three (3) of ten (10) bedside tables appeared soiled.

Per interview at the time of the observation Staff Y stated that the first table had been cleaned, then took a cleaning wipe and removed the material soiling the compartment. Staff Y then cleaned the second table compartment in the same manner.

The findings were confirmed by Staff L (Director) and Staff N (Associate Executive Director) at the time of the observation.

The facility's Policy and Procedure titled "Cleaning and Disinfection: Cleaning, Low Level Disinfection and Storage of Patient Care Equipment" last revised 06/02/17 states the following: "...The following items are examples of non-critical patient care equipment that requires low level disinfection ... Items for which low level disinfection is appropriate include ... bedside tables ... equipment that is used throughout the day [for] multiple patients should be cleaned and disinfected between patients."

(a2)
Observations in the facility's Medical / Surgical Unit (4DSU) during a tour between 10:55AM and 12:15M on 03/20/18 identified the following:

During a discharged Patient Room cleaning, Staff T (Housekeeper) failed to perform high dusting on the ceiling and light fixture above the bed and in the closet. Staff T also failed to sanitize the closet.

This was observed in the presence of Staff Kk (Assistant Director) who confirmed the findings and stated that high dusting should be done throughout the room and the closet should have been cleaned.

The facility's Policy and Procedure titled "Patient Room Cleaning / Discharged" last revised July 2016, stated: "Wash furniture and fixtures using disposable wipes with germicide solution. Include all ... fixtures ... closets ...", "Follow 10 step cleaning procedure ... High Dust- Dust all areas ... including all ledges, hand rails, closets ...."


Findings pertinent to (b) include:

Observations in the facility's Operating Room (OR) during a tour between 10:15AM and 12:30PM on 03/20/18 identified the following:

In OR #18, Staff Members G, H, I and J (Perioperative Assistants) were observed performing OR room cleaning after a neurological surgical procedure.

Staff J was observed cleaning an intravenous (IV) pole. After she wiped the bottom of the pole and its wheels and casters, she then wiped the horizontal surface of the anesthesia machine. After wiping the bottom of the anesthesia machine, its wheels, casters and cables that were lying on the contaminated OR floor, she proceeded to clean the horizontal surface of the anesthesia medication cart.

This was confirmed with Staff F (Administrative Director) who stated that Staff J should have cleaned the patient equipment working from high to low. Although Staff F changed wipes between equipment cleaning, she failed to clean all the horizontal surfaces of patient equipment prior to cleaning wheels, casters and cables that were in direct contact with the floor.

The facility's Policy and Procedure titled "Daily Invasive Procedure Room In-Between Case Cleaning Procedure" dated 08/26/16 stated: "(10a) ... staff will clean and disinfect ... IV poles ... from high to low; (10b) clean all horizontal surfaces including ... anesthesia cart ... cords ... with a new EPA-approved disinfectant wipe working from high to low; (11b) [During mopping] wheels and casters of furniture and equipment are cleaned ... before moving these items to a clean section of the floor."


Findings pertinent to (c) include:

Observations in the facility's Medical / Surgical Unit (4DSU) during a tour between 10:55AM and 12:15PM on 03/20/18 indicated the following:

After cleaning the glucometer, Staff W (Patient Care Associate) removed her gloves and without performing hand hygiene, donned new gloves then proceeded to perform blood glucose monitoring on Patient #14.

This was observed in the presence of Staff S (Quality Coordinator) and Staff U (Nurse Manager) who stated that Staff W should have performed hand hygiene after removing her gloves.

The facility's Policy and Procedure titled "Hand Hygiene" last revised 08/05/16, stated: "Perform hand hygiene ... Before and after contact with each patient ... After contact with an inanimate object that is potentially contaminated ... Before donning gloves and after removing them."


Findings pertinent to (d) include:

(d1)
The facility's Policy and Procedure titled "Personal Protective Equipment (PPE) Donning and Doffing" last reviewed 06/23/14 stated: "PPE ... is worn for protection from risk to health and safety by creating a barrier between the potential infectious material and the HCP [Health Care Provider] ... Gowns help protect skin and/or clothing from contamination of potentially infectious material."

Observations in the facility's Neonatal Intensive Care Unit (NICU) during a tour between 11:15AM and 12:15PM on 03/19/18 identified the following:

In Nursery C, a Methicillin-Resistant Staphylococcus Aureus (MRSA) Isolation Nursery, Staff C (Registered Nurse [RN]) was observed providing direct patient care with her PPE gown untied and her back uncovered and unprotected.

Also in Nursery C, Staff D (Ophthalmologist) was observed donning an isolation gown that was too small and did not adequately cover and protect his uniform. Although tied, his back remained open and exposed.

These observations were confirmed with Staff AA (Director Patient Care Services) and Staff Z (Nurse Manager). Staff AA acknowledged that the HCPs were not fully protected if the PPE gowns did not adequately cover their exposed uniforms.

(d2)
Observations in the facility's Medical / Surgical Unit (4DSU) during a tour between 10:55AM and 12:15PM on 03/20/18 revealed the following:

Staff V (Patient Care Associate) was observed performing blood glucose monitoring on Patient #15 while inappropriately wearing a mask under her chin.

These observations were confirmed by Staff U (Nurse Manager) and Staff S (Quality Coordinator), who reported that Staff V is required to wear a mask in Patient Care Areas because she declined the Flu shot.

The facility's Policy and Procedure titled "Workforce Influenza Vaccination" last revised 12/02/16 stated: "Unvaccinated health care personnel (HCP) who decline vaccination ... must wear mask ... while in areas where patients ... are typically present. This would include ... patient rooms ...."

(d3)
Staff X (Journeyman) was observed getting on the elevator from the second floor at 12:40PM on 03/23/18 with a disposable blue jumpsuit on and a disposable bouffant cap in his pocket.

Interview with Staff X at the time of observation in the presence of Staff S, revealed that he was fixing a door knob to the Sterile Linen Room in the Operating Room [A Restricted / Semi-Restricted Area] and left the area to get a part. He reported that he didn't know he was supposed to take off the jumpsuit.

The facility's Policy and Procedure titled "Infection Control / Aseptic Technique" last revised 02/18 stated: "Dress code when leaving restricted and semi-restricted areas: ... Surgical gowns, shoe covers and masks should be removed prior to leaving the restricted and semi-restricted areas."


Findings pertinent to (e) include:

Observations in the facility's Telemetry Unit (4 Monti), between 12:15PM and 12:50PM during a tour on 03/19/18, identified that Patient #2, who was on Contact Precautions, had three (3) visitors in the room. One (1) visitor had on a gown but no gloves; the other two (2) visitors had gowns on and gloves but both had the gowns off their upper torsos.

Those observations were made in the presence of Staff A (Nurse Manager) and Staff Jj (Quality Coordinator) who confirmed the findings.

Chart review of Patient #2 with Staff B (Registered Nurse) revealed that the patient was admitted on 03/16/18 and was educated on Infection Precautions on 03/19/18. The education was documented in the Electronic Medical Record on 03/19/18 at 11:38AM but no education was documented for family members or visitors at the time of the observation.

The facility's Policy and Procedure titled "General Patient and Family Education" last revised 01/15/15 stated: "Patient or designee should be ... provided with education ...", "Document the patient's or designee's response to teaching and learning ... Documentation should include specific education, skills and information needed ... to meet the ongoing health care needs ... include ... The safe and effective use of medical ... supplies."


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