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Based on observation, interview and record review it was determined the facility failed to ensure surgical services developed an infection control plan or system for identifying, reporting, investigating and controlling infections in the surgical area. The facility failed to collect data on post operative infections and the infection control log did not include post-operative infections. The Infection Control Officer failed to developed an effective infection control program for controlling infections of patients. The facility failed to follow policy and procedures to ensure a sanitary environment was maintained in the Intensive Care Unit (ICU) and throughout the hospital. The facility failed to consistently implement interventions to decrease the risk associated with patient infections and the risk of healthcare associated infections. The facility failed to follow policy and procedures regarding infection control for wound care dressing, hand hygiene, Central Supply/Sterile cleaning and packing, and maintaining a sanitary environment. The facility had experienced an outbreak of Carbapenem Resistant Enterobacteriaceae (CRE) and developed preventative strategies (core measures) recommended by the Center for Disease Control (CDC). However, observation during the survey revealed those interventions were not consistently implemented.


Refer to A749

Based on observation and interview, it was determined the facility failed to meet the requirements of Protection of Hazards in accordance with NFPA Standards. The deficiency had the potential to affect forty seven (47) residents, staff and visitors. The facility is certified for forty seven (47) beds with a census of forty five (45) on the day of the survey. The facility failed to maintain self-closing doors protecting hazardous areas.


The findings include:

Observation, on 08/20/13 at 2:33 PM, with the Maintenance Supervisor and Central Supply Room Coordinator (CSR Coordinator) revealed an open room that provided no separation from the dirty surgical equipment area to the cleaning machine area located on the third floor. Further observation revealed the cleaning area was separated from the sterile room by two doors that were not closed and not equipped with a self-closing device to ensure the doors would stay closed. Further observation revealed another door from the sterile room opened into a storage room containing storage of miscellaneous medical equipment. This door did not have a self-closing device installed to ensure the door would close and the storage room was protected from other areas.

Interview, on 08/12013 at 3:00 PM, with the CSR Coordinator revealed she was not aware the doors to hazardous rooms were to be self-closing, but agreed they probably should stay closed. Interview with the Plant Operator Manager, on 08/22/13 at 11:05 AM, the doors to the Central sterile processing room should have self-closure on them.







Reference:

NFPA 101 (2000 Edition).

19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. Any hazardous areas
shall be safeguarded by a fire barrier having a
1-hour fire resistance rating or shall be provided
with an automatic extinguishing system in
accordance with 8.4.1. The automatic
extinguishing shall be permitted to be in
accordance with 19.3.5.4. Where the sprinkler
option is used, the areas shall be separated
from other spaces by smoke-resisting partitions
and doors. The doors shall be self-closing or
automatic-closing. Hazardous areas shall
include, but shall not be restricted to, the
following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2
(9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2),
including repair shops, used for storage of
combustible supplies
and equipment in quantities deemed hazardous
by the authority having jurisdiction
(8) Laboratories employing flammable or
combustible materials in quantities less than
those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be
permitted to have nonrated, factory or field-applied
protective plates extending not more than
48 in. (122 cm) above the bottom of the door.

Based on observation, interview and record review, it was determined the Infection Control Officer failed to developed an effective infection control program for controlling infections of patients. The facility failed to ensure surgical services develope an infection control plan and/or system for identifying, reporting, investigating and controlling infections in the surgical area. The facility failed to collect data on post operative infections and the infection control log did not include post-operative infections. The facility failed to follow policy and procedures to ensure a sanitary environment was maintained in the Intensive Care Unit (ICU) and throughout the hospital. The facility failed to consistently implement interventions to decrease the risk associated with patient infections and the risk of healthcare associated infections. The facility failed to follow policy and procedures regarding infection control for wound care dressing, hand hygiene, Central Supply/Sterile cleaning and packing, and maintaining a sanitary environment. The facility had experienced an outbreak of Carbapenem Resistant Enterobacteriaceae (CRE) and developed preventative strategies (core measures) recommended by the Center for Disease Control (CDC). However, observation during the survey revealed those interventions were not consistently implemented.

The findings include:

Information from the CDC revealed CRE bacteria had become resistant to all or nearly all the antibiotics used today and they had seen an increase in the number of CRE cases in the past year. The CDC recommended contact precautions and hand hygiene as protection for patients.

Review of the facility's polices for contact precautions (dated 02/20/13) and hand hygiene (revised 08/2012) revealed hand hygiene is the most important method of control to prevent transmission. The hand hygiene policy instructed staff to perform hand hygiene before and after patient contact, between patients, and before donning and after removal of gloves.

1. Observation during tour of the ICU, on 08/19/13 at 3:58 PM, revealed staff did not perform hand hygiene before donning Proper Protective Equipment (PPE) gown and gloves and entering Room 210. The patient was in contact precaution related to active Methicillin Resistant Staphylococcal Aureus (MRSA). Continued observation revealed the nurse did not perform hand hygiene before donning gloves when entering Rooms 216 and 202. The patient in Room 202 had Multiple Drug Resistant and the patient in Room 216 was positive for CRE. All three patients were in contact precautions requiring PPE of gown and gloves.

Observation of the ICU, on 08/20/13 at 10:05 AM through 11:30 AM, revealed the floor outside the patients' rooms appeared dirty and dull. The trash receptacle beside the nurses station was dirty with brownish substance on the outside. The air vents (most were position directly over the patient) were dirty and rusty in Rooms 207, 209, 210, 211, 212, 213, and 215. In Room 205, the air vent had peeling paint. The wall air vent in Room 210 had heavy build up of dust and dirt. In addition, the room contained debris of a disposable pad, syringe cap, and dried alcohol wipes on the floor with a wash cloth at the bottom of the patient's bed. Room 216 was observed to have cracked ceiling tile, rust on the towel dispenser and medication cabinet. Room 213 observation revealed paper debris on the floor, broken ceiling tiles over the toilet, and dust in the air vent over the window. Observation of Room 211 revealed a dirty wash cloth at the head of the bed. The Clinitron bed mattress was stained with discoloration. The patient's feet were touching the bed due to pushing the sheet up the bed. The IV pole was dirty with spillage.

Interview with the ICU Manager, on 08/20/13 at 11:30 AM, revealed the floors were mopped daily and the trash receptacles were to be cleaned daily. She stated the patients' rooms were to be cleaned daily and was not aware of the frequency the air vents were to be cleaned and nobody had reported them to her.

Review of the 7 step cleaning method of a patient's room (checklist for environmental services) revealed high dust (anything over shoulder height) was included to be completed each time a patient's room was cleaned. In addition, trash cans were to be damp wiped and in the bathrooms, the vents were to be dusted. In addition, the facility utilized a monthly infection control rounds checklist that included a section to document when the air vents were cleaned. However, the facility did not provide any documented evidence that a monthly infection control round had been conducted for the ICU.

Interview with the Environmental Supervisor, on 08/20/13 at 10:30 AM, revealed the floors were scrubbed nightly but he did not know when the floors had been stripped and waxed. He confirmed he was responsible for ensuring the floors were cleaned but had not been allowed to strip and wax the floors in the ICU unless a patient moved out of the room. He stated some of those patients had been in the same room for a very long time. He revealed the housekeeping staff were to dust the vents during their cleaning; however, if the air vent was directly over a patient, they would not dust. The rooms were supposed to be terminally cleaned between patients. The air vents with heavy build-up of dust in Rooms 210 and 211 were not directly over a patient. Those in Rooms # 205, 207, 209, 212, and 215 were.


2. Interview, on 08/20/13 at 1:55 PM, with the Infection Preventionist revealed she did not develop an infection control plan or system for identifying, reporting, investigating and controlling infections in the surgical area. She stated she also did not collect data on post operative infections and the infection control log did not include post-operative infections because she did not tract and trend surgical cases for post-operative surgical wound infections. She stated she assumed the surgical services department was performing their own surveillance and infection control program.

Interview with the Surgical Services Department Manager, on 08/22/13 at 2:35 PM, revealed she did not track surgical site infections. She stated most wounds had infections when they came to surgery for debridement; therefore, she did not track or monitor those wounds. However, she revealed the three (3) surgical rooms were also used for new gastrostomy and colostomy placement.

Review of the OR case log revealed for July and August 2013, five (5) Peripheral Inserted Central Catheter (PICC) lines were placed, three (3) Peg tubes, and one (1) above the knee amputation were performed.

3. Review of facility policy titled: Cleaning housekeeping cart, revised November 2011, revealed a statement that housekeeping carts were to be clean and neat at all times. At the end of the day, wipe off the entire cart with a damp cloth.

Observation, on 8/21/13 at 9:23 AM of the 2-North Unit, revealed a housekeeping cart in the hallway outside Room 231. Closer observation of the housekeeping cart revealed the deck that held the bucket of disinfectant water and mop was dirty with black substance noted on the floor of the deck and in the corners of the cart. This was the designated unit for CRE patients.

Interview with the Housekeeper #1, on 08/21/13 at 10:05 AM, revealed this was not his normal housekeeping cart, that he had been called in to work to replace a regular assigned housekeeper. He stated the housekeeping carts were supposed to be cleaned after each shift and he had found the cart in that condition that morning. He confirmed the housekeeping cart was dirty and stated it appeared to have build up debris in the corners of the cart. Review of training for environmental services, conducted on 08/08/13, revealed Housekeeper #1 was in attendance with his signature present.

Interview with the Environmental Supervisor, on 08/22/13 at 8:57 AM, revealed housekeeping carts were to be cleaned daily at the end of the shift. The carts are to be wiped with bleach wipes before entering a patient's unit. If a housekeeping cart is dirty, it should be cleaned before use. On the 2-North Unit, the housekeeping carts are stored on the unit to prevent cross-contamination. He further stated the housekeeping staff had been trained extensively on how to clean a room and to clean their carts.

Observation of the fourth floor unit, on 08/22/13 at 9:03 AM, revealed a housekeeping cart with dust in the middle and bottom of the cart. Interview with Housekeeper #3 at 9:10 AM, revealed she should have cleaned the cart but had not. Review of the training records for 08/08/13 revealed Housekeeper #3 had received the same training as Housekeeper #1.

4. Review of the facility's policy titled: application of dressings and compresses, Care of patients (TX); Infection Control (IC) revised January 2012, revealed wound dressings can be aseptic or sterile technique. The nurse is to wash hands thoroughly and then apply gloves. The nurse would then remove the old dressing, put in plastic bag, remove gloves and wash hands. The nurse would then apply a new set of gloves, clean wound with prescribed solution, then apply ordered medication to the wound with sterile applicators. Apply clean dressing material and secure dressing with tape, or other methods. Discard the plastic bag, removed gloves, wash hands thoroughly.

Observation of a wound care treatment with RN #5, on 08/21/13 at 10:12 AM, on the 2- North Unit, revealed Patient #12 was in Contact Precaution for CRE. The nurse used hand sanitizer prior to donning clean gloves and gown. The nurse was observed to removed the soiled dressing from the patient's coccyx without changing her gloves. The patient was observed to be oozing fecal matter onto a disposable pad. The nurse cleaned the fecal matter from the patient's anus with a disposable wipe. She then wrapped the wipes inside the disposable pad that contained feces and rolled the pad under the patient's buttocks. The nurse proceeded to clean the wound with Normal Saline and patted dry with 4 x 4 gauze with the same gloves she had cleaned feces from the patient. The nurse then changed her gloves and used hand sanitizer. The nurse continued to apply the medication to the wound and covered it with dry 4 x 4 gauze and Abdomen pad. The nurse then removed the soiled pad and placed it into a plastic bag and removed the soiled gloves and washed her hands.

Interview with RN #5, on 08/21/13 at 10:40 AM, revealed she thought if she folded the fecal stained pad under the patient that would be okay. She didn't want to roll the patient over to remove the pad and cause the uncovered coccyx wound to touch the bed linens, so she just rolled it under the patient. She stated the staff have been told they could use hand sanitizer instead of washing hands between glove changes. She stated she remembered to change her gloves after she had already cleaned the wound.

Interview with a member of the Wound Care Team, on 08/22/13 at 11:35 AM, revealed they assess and measure wounds weekly. She would stage and provide a description of the wound. They take pictures of the wounds each month. She stated staff nurses on the units are trained by the team to use hand hygiene before they go into the room and before and after each glove change. When a soiled dressing is removed the nurses should remove gloves and perform hand hygiene, then apply new gloves to clean the wound. She stated the nurses are taught this method. With CRE and contact precautions you would use the same method according to CDC guidelines. She indicated the Wound Care Team would do random observations (no frequency was given) of staff nurses performing wound care treatment to ensure proper techniques are used.

5. Review of the facility's policy titled: Surgical Services Traffic Control, revised February 2010, revealed three distinct areas, Unrestricted, Semi-restricted, and Restricted areas. Surgical rooms where procedures are performed and supplies are sterilized are under the Restricted area. All doors to the surgical rooms will remain closed while surgical procedures are in progress. The policy titled: Care and cleaning of instruments and powered equipment, revised February 2010, revealed instruments will be care for in a manner to reduce the risk for infection or injury.

Observation of the Central Sterile room, on 08/20/13 at 2:31 PM, revealed the doors to the room were open. One door was adjoined to the cleaning room where surgical instruments were cleaned. The other door lead to a storage room for equipment such as IV poles.

Interview with the Central Sterile processing technician, on 08/20/13 at 3:00 PM, revealed she did not know if the doors should be closed but they probably should be. Additional interview with the technician at 3:55 PM, revealed the doors leading from the Sterile Processing room should be closed at all times. She acknowledged the doors were opened earlier and that she left the doors opened routinely when sterilization of surgical instruments were in process.

Interview with the Material Manager, on 08/21/13 at 1:23 PM, revealed the Central Sterile room was where sterilization of surgical instruments and instruments from the wound clinic are conducted. The instruments were sterilized by steam and this room was also used for sterile packing of the instruments used in surgery.

6. Inspection of the laboratory, on 08/20/13 at 2:13 PM, revealed two (2) tubes of blood on the floor of the walk-in cooler. Interview with the lab technician, during the observation, revealed she did not know how long the tubes of blood had been on the floor and then walked out of the cooler without picking the tubes up.

Continued interview, on 08/20/13 at 1:55 PM, with the Infection Preventionist revealed the facility was investigating an outbreak of CRE. According to the Center for Disease Control: CRE is an infection which typically occurs in intensive care units and healthcare settings housing very ill patients and rarely occur outside of healthcare settings. Careful attention to infection control procedures such as hand hygiene and environmental cleaning can reduce the risk of transmission. She stated in May 2013, the facility identified a few cases of CRE and reported to the local Health Department (as requested since February 2013). The facility conducted an extensive investigation with three (3) rounds of surveillance cultures sent to the Health Department. Mandatory (house wide) training was conducted from May 11-17, 2013 for all staff that included proper hand hygiene and contact precautions. Prevention strategies were implemented that included education, placing patients in contact precautions and cohorting those patients to designated areas (2-North and 6-Center). However, due to acuity level of care, three patients remain in the ICU. Those patients either positive for CRE or colonized, were placed in a private room. In addition, the laboratory would facilitate rapid notification when CRE had been identified from a clinical specimen to ensure timely implementation of control measures. House-wide screening of all patients (who were not known to have CRE) was conducted. The facility did a perianal swab and sent to the Health Department. First surveillance cultures were 05/21/13, second-06/17/13 and third-07/24/13.

During interview with the Infection Preventionist, she stated with each positive culture, an extensive investigation was conducted. She looked at the clinical record for seventy-two (72) hours previous to determine what was going on with the patient. She stated the facility initiated Best Practices and changed the disinfectant to a bleach based Sani-wipe. Environmental disinfectant was also changed. Each month the unit managers reported to the Infection Control Committee about hand hygiene and PPE compliance. Weekly meetings called "Huddles" were conducted on each unit. She stated new admissions were placed in contact precautions until results from surveillance cultures were received.

Review of the infection log for May 2013 revealed five (5) residents were positive for CRE and three (3) were colonized. June 2013 two (2) resident positive for CRE and three (3) were colonized. July 2013 two (2) were positive and six (6) colonized. The Infection Preventionist stated she reported all colonized cultures. Review of the infection log dated 08/20/13 revealed three (3) patients in ICU with CRE, eleven (11) on 2-North, three (3) on 6-Center, none on 4th and 5th floor units.

Validation of corrective actions implemented during the survey.


Interview, on 08/21/12 at 4:35 PM, with the Director of Quality Management revealed for all new patient admissions the hospital places them on contact isolation precautions, screens for CRE, and performs a surveillance culture before removing out of precautions. Further interview revealed in May 2013 all Primary Physicians were in serviced and the hospital did not open up the 2D unit until all physicians and nurses received education, June 2013.

Interview, on 08/22/13 at 10:35 AM, with the hospital CEO and Director of Quality Management revealed the hospital QAPI Committee addressed infection control issues with corrective action plans using CDC and Best Practice methods. Training had been 100% mandatory.

Record review of the in-service handout revealed a house wide training had been conducted from May 11 - 17, 2013 that included the topics of talking points for CRE and contact isolation, treatment, and hospital prevention. CDC handouts and Infection Prevention and Control Practices policies and procedures were provided to attendees.

Further interview with the CEO and Director of Quality Management revealed environmental round audits had been implemented as well as leadership rounds. Leadership rounds included interviews with patients, staff, and families regarding care received. Upon admission, patients have rectal swabs and blood cultures obtained with the isolation precautions in place until cultures are back in 3 - 5 days. Weekly "Huddle" meetings were held with a specific topic each week as the focus.

It was further stated by the CEO and Director of Quality Management that per units, blood stream infections are graphed, charted and reviewed by leadership and there is also a CRE plan posted in the hospital physician's lounge. This information is reviewed during the monthly Infection Control Committee meetings and QAPI meetings.

Interview, on 08/20/13 at 1:55 PM, with the Infection Preventionist revealed mandatory house wide training was conducted 05/11-17/2013 for all staff that included proper hand hygiene and contact precautions. Prevention strategies implemented included education on CRE, placing patients in contact precautions and cohorting those patients to designated wings; except three ICU patients that were too unstable to move.

Further interview with the Infection Preventionist revealed the laboratory initiated a rapid notification when CRE had been identified from a clinical specimen to ensure timely implementation of control measures. The hospital implemented Best Practice change to use a disinfectant of bleach based Sani-wipes. The environmental disinfectant was also changed. Each month, unit managers reported to the Infection Control Committee about hand hygiene and PPE compliance. This was implemented after the training of May 11-17, 2013.

Interview, on 08/22/13 at 11:03 AM, with the Facility Operational Manager revealed the week of 08/26/13 the AVAC vendor was scheduled to clean in the facility.

Observation, on 08/22/13 at 9:10 AM, revealed the housekeeping cart that was found dirty on 08/21/13 on 2-North was observed to be clean.

Observation, on 08/22/13 at 9:25 AM, revealed housekeeping began to clean, strip the wax, and buff the ICU floor found to be dirty during tour on 08/19/13 and 08/20/13.

During the survey, the hospital received a report from Kentucky Department for Public Health regarding their visit on 08/08/13. The epidemiological investigation focused on hand hygiene of healthcare workers, disinfection of equipment between patients, and environmental patient care areas. Through observations and interviews, it was validated the hospital had begun implementing measures to correct those problems identified during the visit. In addition, the hospital had developed an action plan for all the Public Heath recommendations which included disposal of bed scales, survey of all equipment and furniture, stripping and waxing of the ICU floors, and re-education of staff on hand hygiene and Isolation Precautions.