HospitalInspections.org

Based on review of hospital documents, medical records, observation and staff interview, it was determined that the hospital failed to implement an active program for the prevention and control of infections for 125 of 125 inpatients (refer to A 749). The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the prevention and minimization of infections and communicable disease.

Based on review of hospital documents, medical records, observation and staff interview, it was determined that the hospital failed to implement an infection prevention system to minimize the possibility of infections for 125 of 125 inpatients. Findings include:

The hospital policy entitled "Infection Control Plan" stated, "...Reduce, prevent and control cross-contamination in the occurrence of infections...by development...of policies and procedures essential in minimizing the possibility of infections, cross-contamination..."

The hospital's job description entitled "Infection Control Nurse" stated, "Duties...Develop, implement, update, and enforce the hospital's infection control policies and procedures..."

A. Current guidance from the Centers for Disease Control and Prevention (CDC) recommended the use of contact precautions for patients diagnosed with Clostridium difficile (C. diff) to prevent the transmission of C. diff. Contact precautions include:
- use of a single room or share a room only with someone else who also has C. diff
- healthcare staff will put on gloves and wear a gown over their clothing while taking care of patients with C. diff
- visitors may be asked to wear a gown and gloves
- hospital staff and visitors should remove their gown/gloves and clean their hands when leaving the room
- patients on contact precautions are asked to stay in their hospital rooms as much as possible; they should not go to a common area such as a cafeteria

1. Review of Patient #6's medical record revealed the following:

a. Admission physician orders, dated 7/7/15 at 6:00 PM, contained an order for Vancomycin (antibiotic) 125 milligrams every 6 hours by mouth for 10 days for "C. diff"
b. Consultant documentation, dated 7/8/15 at 10:00 AM, stated, "...Pt (patient) presented to hospital with dx (diagnosis) of C. diff...Pt to remain in room alone with only one bathroom not being shared. Medical group to review chart to verify need for antibiotic, isolation, and plan of care..."
c. "Precautions Record" documentation, dated 7/7 - 7/15/15:
- stated, "Must use own bathroom - C. diff"
- revealed that Patient #6 was observed in the dayroom, hallway, quiet room, cafeteria, bathroom and his/her own room
d. No evidence of the following:
- that the physician reviewed the chart to verify the need for contact precautions
- a physician order for contact precautions

2. During an interview on 7/14/15 at 9:20 AM, Director of Nursing (DON) A reported that there were no patients requiring contact precautions.

3. During an interview on 7/14/15 at 12:15 PM, registered nurse (RN) C reported the following:
- Patient #6 was on antibiotics and contact precautions for C. diff
- Patient #6 was in a private room
- staff were to wash hands before and after care and wear gloves
- staff were not required to wear a gown when entering Patient #6's room

4. Interview with Medical Director A on 7/14/15 between 1:30 PM and 1:50 PM revealed that he/she would expect contact precautions to be used for a patient that was on antibiotics for C. diff.

5. On 7/15/15 between 11:40 AM and 12:00 PM, RN A was observed entering Patient #6's private room without a gown to perform a finger stick to obtain blood.

6. During the exit conference on 7/16/15 between 3:40 PM and 4:15 PM, DON A confirmed that the hospital did not have a policy to address contact precautions to be used with C. diff.

B. The hospital policy entitled "Hand Washing" stated, "...personnel shall wash their hands, to prevent the spread of infections...Before applying and after removal of gloves...Before patient contact...Between providing care of individual patients...After contact with patient's skin...On leaving isolation area...After contact with or using equipment/supplies in contact with bodily fluids..."

1. Patient #'s 9, 10 and 12

On 7/15/15 between 8:00 AM and 8:15 AM, the following was observed during the monitoring of patients' vital signs, performed by RN B:

a. Patient #9
- sanitized hands
- donned gloves
- disinfected blood pressure (BP) cuff
- removed gloves
- donned new gloves
- placed BP cuff on patient's arm
- touched temperature probe cover box
- placed thermometer in patient's mouth
- touched temperature probe cover box
- touched BP machine
- removed thermometer
- removed BP cuff
- entered vital sign data in log book
- removed and discarded gloves
- donned new gloves as Patient #9 left exam room, and Patient #12 entered room

b. Patient #12
- sanitized BP cuff
- placed BP cuff on patient's arm
- touched BP machine
- entered data onto 2 documents
- removed BP cuff
- placed pen in pocket
- discarded left glove only
- obtained disinfectant cloth from jar
- cleaned BP cuff
- removed right glove
- donned clean gloves as Patient #12 left exam room, and Patient #10 entered room

c. Patient #10
- placed BP cuff on patient
- touched BP machine
- touched temperature probe cover box
- placed thermometer in patient's mouth
- removed thermometer
- removed BP cuff
- disinfected BP cuff
- removed gloves

RN B failed to perform hand hygiene:
- before applying gloves
- after removing gloves
- before patient contact
- between providing care of individual patients
- after contact with or using equipment

During an interview on 7/16/15 at 8:30 AM, DON A confirmed that the observed practice did not conform to the hospital's hand hygiene policy.

2. Patient #6

On 7/15/15 between 11:40 AM and 12:00 PM, the following technique was observed during the blood glucose (sugar) monitoring procedure performed by RN A:

- washed hands
- donned gloves
- performed finger stick to obtain blood
- picked up blood glucose meter (glucometer)
- applied blood to glucometer test strip
- exited patient room
- removed gloves and discarded
- reached in pocket with right hand and removed keys
- inserted keys in lock and opened medication room door
- placed glucometer on counter
- retrieved and donned gloves
- cleaned glucometer with wipes
- removed gloves and discarded
- washed hands

RN A failed to perform hand hygiene:
- after glove removal
- after contact with equipment (glucometer)
- before applying gloves

During an interview on 7/14/15 at 12:30 PM and on 7/16/15 at 2:15 PM, DON A confirmed that the observed practice did not conform to the hospital's hand hygiene policy.

C. The hospital policy entitled "Cleaning of Reusable Equipment" stated, "Supplies and equipment will be cleaned immediately after use and between each patient use...Monk® wipes are acceptable product for...equipment cleaning...Shared glucometers need to be disinfected between patient use..."

1. On 7/14/15 between 11:44 AM and 12:00 PM, licensed practical nurse (LPN) A was observed as he/she obtained blood via finger stick method first from Patient #7 and then from Patient #8.

LPN A failed to disinfect the glucometer after use on Patient #7 and before use on Patient #8.

2. During an observation on 7/15/15 between 11:40 AM and 12:00 PM, RN A used the EvenCareG2® glucometer to obtain Patient #6's blood glucose. RN A cleaned the glucometer with a Monk® disinfectant wipe after use.

The manufacturer's guideline for the cleaning and disinfection of the EvenCareG2® glucometer did not list Monk® wipes as one of the disinfecting wipes to be used to clean and disinfect the monitor surface.

During an interview on 7/15/15 at 3:30 PM, DON A confirmed that the Monk® wipes were not listed in the manufacturer's user guide as a wipe to use to clean and disinfect the glucometer.

D. The hospital policy entitled "Infection Control Plan" stated, "...in the areas of prevention, care and control of...infections...through surveillance and activities of combined staff support of all departments...implementation...of policies and procedures essential in the provision and maintenance of a safe and therapeutic environment that is sanitary..."

The hospital job description entitled "Food Service Worker" stated, "...Clean...floors, food prep areas...daily..."

1. During an observation on 7/14/15 between 11:20 AM and 11:38 AM, an accumulation of dirt and particulate covered the flooring throughout the kitchen.

These findings were witnessed and confirmed by both DON A and Director of Food Services A on 7/14/15 at 11:38 AM.

2. Review of kitchen cleaning logs and schedules revealed no evidence of floor cleaning between 7/4/15 and 7/13/15 (over 9 days).

This finding was confirmed by Director of Food Services A and DON A on 7/15/15 at 2:00 PM.

E. The hospital policy entitled "TB (tuberculosis) Skin Test Converters" stated, "...To provide a guideline for the management of employee's converting from tuberculosis skin test (PPD) negative to positive...'Converter' is defined as those...previously tested as PPD...skin test negative...are now PPD skin test positive...TB skin converters (PPD) positive personnel...Chest x-ray will be ordered by the hospital...The physician will determine if conversion is Active or Non-Active tuberculosis...'Converters' are to return to the physician at 1 month, 4 month, 6 month and 12 month intervals for follow up...Document employee refusal of treatment on the Employee's Health Record. The employee must sign the 'Refusal of Treatment' for the refusal to be valid...In-Active Tuberculosis Employment to be continued with mandatory close medical monitoring of the employee's tuberculosis status..."

1. Employee #10

a. Review of the Employee Health Record revealed the following documentation:

6/3/13 "Mandatory Test" Annual PPD results: zero (0) millimeters (mm) by zero (0) mm indurated area (negative)
6/10/14 "Radiograph of Chest": completed for a "Clinical History: Positive PPD test result"
6/10/14 QuantiFERON TB Gold (a blood test used to diagnose a TB infection) results: "Positive" (a positive test indicates infection)
3/11/15 "Delaware Division of Public Health Tuberculin Skin Testing and Treatment of Latent TB Infection (LTBI) Record": Employee #10 received treatment for LTBI from 7/30/14 until 4/30/15

b. Employee Health Record review revealed no evidence of the following:
- that the physician determined if conversion was Active or Non-Active tuberculosis
- that Employee #10 was seen by the physician at 1 month, 4 month, 6 month and 12 month intervals for follow up

Interview with DON A on 7/16/15 between 2:15 PM and 3:15 PM confirmed the following:
- Employee #10 was a "Converter" as defined by the hospital's policy
- no evidence that Employee #10 was seen by the physician for follow up visits at the intervals defined in the hospital policy
- no evidence that the physician determined if conversion was Active or Non-Active tuberculosis