HospitalInspections.org

Based on observation, record review and interview the facility failed to develop and implement a hospital wide infection prevention and control measures for patients requiring Isolation Precautions, and did not collaborate with the Environmental Services to develop an infection prevention and control policy for the transportation of clean and contaminated supplies.

Findings Included:

Observation on 9/29/15 at 2:15 p.m. on the Pediatric Inpatient Unit revealed Staff #5, Registered Nurse (RN) donning protective equipment, yellow disposable gown, disposable blue gloves, and face mask, then enter room 376. The room did not have an isolation sign reflecting the type of protective equipment required. Staff #5 came out of the room, she had removed the gown and mask in the room. She was holding a full opened trash bag with the yellow gown being visible. Staff #5 stepped out of the room and proceeded to close and tie the trash bag in the hallway. Staff #5 was still wearing the contaminated blue gloves.

Continued observation revealed Staff #5 picked up her patient assignment papers, with the contaminated gloves, and placed them under her arm. She carried the closed trash bag down the hallway, over 50 feet away, to a key pad locked door. Staff #5 punched in the code, with the contaminated glove, and threw the trash in a bin in the room. Staff #5 then exited the room, removed the contaminated gloves and threw them in a common use trash can and washed her hands. Staff #5 then removed the contaminated assignment papers from under her arm with her clean hands.

During an interview on 9/29/15 at 2:20 p.m., on the Pediatric Unit, Staff #5, RN, when the surveyor asked why she used protective equipment for room 376, Staff #5 stated the patient is on Droplet Precautions. She stated the sign must have fallen off the door on to the floor. Staff #5 stated the staffs are informed during shift report and the communication board tells them what type of precaution is required. She confirmed a visitor would not know what type of protection is required without the sign.

Review of Patient #11's Medical Records reflected a 3 year old male with multiple admissions related to a diagnosis of cancer, weakness, and pneumonia.

Review of Patient #11's Physician's Orders revealed:
On 6/15/2015 an order for Neutropenic (low immune system, making them at risk for acquiring infections) Precaution
On 5/25/2015 an order for Neutropenic Precaution
On 5/11/2015 an order for Neutropenic and Droplet Precaution
On 4/6/2015 an order for Reverse Isolation Precaution.

Review of Patient #11's Microbiology reports revealed:
During Patient #11's admission on 4/6/2015, blood cultures were drawn and the patient was positive for Klebsiella Pneumonia. There was no order for Droplet precautions.


During an interview on 9/29/15 at 3:30 p.m. in the conference room, Staff #2, RN the Infection Control Director stated a patient with Klebsiella Pneumonia should be on Droplet Precautions. She stated the Isolation Carts are restocked by the Central Supply Department and that all carts have a Neutropenic Sign. Staff #2 stated, "Neutropenic means the white blood cells are so far down that the patient are at risk of acquiring infections and need to be protected. Gowns, and masks should be worn to protect the patient."

Observation on 9/29/15 in the afternoon with Staff #2 of the Isolation Carts on the Pediatric Inpatient Unit and the Neonatal Unit revealed five (5) out of (5) carts did not have a Neutropenic or Reverse Isolation sign.

During an interview on 9/29/15 in the afternoon, in the conference room, Staff #1, Vice President of Patient Care Services stated the facility does not have a policy on Neutropenic precautions. She stated the facility has a Protective Environment Isolation Environment Precautions, which would be similar, but that it is only used for patients who have undergone stem cell transplantation.


Observations during a tour of the Pediatric Unit on 9/29/15 at 2:00 p.m. revealed a housekeeping staff pushing a metal cart with a large removable vinyl bag liner. The vinyl bag was lined with a clear removable plastic bag. In the clear plastic bag were multiple rolls of clean toilet tissue and she was observed removing the rolls of tissue and placing them in a clean supply closet. Further observation revealed the clear plastic bag had a large rip that exposed the interior vinyl liner.

During an interview on 9/29/15 at 2:00 p.m. Staff #4, housekeeper, stated she was taught to use the cart to transport clean items to the units. She stated she usually places two plastic bags in the vinyl liner but only used one that day. She stated the cart is also used to pick up the trash from the patient rooms. When the surveyor asked about her training, the housekeeper was not aware of any particular training regarding transporting clean and dirty items to and from the units.

Observation on 9/29/15 in the afternoon of the Environmental Services Clean Storage room revealed a housekeeper with a metal cart with two clear plastic bags. The plastic bag was filled with clean supplies. She was observed leaving the clean room with the supplies.

During an interview on 9/29/15 in the afternoon, in the Environmental Services Office, Staff #3, the Environmental Services Manager stated the housekeeping staff use the metal carts with vinyl liners to pick up the trash from the rooms. The vinyl lined cart should not be used to transport clean supplies. He stated the housekeepers are supposed to use a special metal cart or the closed housekeeping cart to transport clean items. When questioned about a policy for transporting clean supplies and contaminated items, Staff #3 stated he was not aware of any policy for transporting clean and contaminated items.

During the EVS department tour, on 9/29/15 in the afternoon, the EVS manager confirmed the above findings.

Review of the facility Isolation Precautions (revised 11/11) reflected:
Purpose: To provided guidelines for the implementation of Isolation Precautions for communicable diseases. Transmission of infection within the hospital requires three elements:
1) A source of infections agent- can be human or inanimate environmental source
2) A susceptible host - individual susceptibility to infection varies
3) A mode of transmission- contact (direct and indirect); respiratory droplets; airborne
Policy:
1. Isolation Precautions require a physician's order
2. Standard Precautions are used in the care of all patients ...
4. Isolation Precautions are used in addition to Standard Precautions whenever Standard
Precautions alone offer inadequate protection from exposure to communicable diseases ...
6. There are 5 categories of Isolation Precautions:
1. Contact Precautions (green sign)
2. Special Contact Precautions (yellow sign)
3. Droplet Precautions (orange sign)
4. Airborne Infection Isolation (All) (Pink sign)
5. Protective Environment (PE) (HSCT unit)
7. Appropriate Isolation Precautions are considered on an individual basis for patients with a
potentially communicable disease until diagnosis is made or for patients who have undergone allogeneic hematopoietic stem cell transplantation (HSCT) in order to prevent acquisition of fungi from the environment. Some disease processes require more than one type of Isolation Precautions be used ...

8. The patient and family/visitors will be provided with education and instruction on infection prevention measures specific to the type of isolation the patient requires.
9. Hand hygiene is performed before entering and upon leaving the patient's room ....
19. Dispose of trash/linens inside the room.

DROPLET PRECAUTIONS
1. Droplet Precautions are implemented whenever a patient is known or suspected to have a communicable disease transmitted by large particle droplets that travel short distances, 3-6 feet, but do not remain suspended in the air.
2. Droplet Precautions are used in addition to Standard and Contact Precautions. Gloves, gown and a mask are worn when entering the room ...
2. Place Droplet Precautions sign on room door (found in cart).
4. Perform hand hygiene and put on gloves when entering the room. Change gloves after contact with infective material and perform hand hygiene. Dispose of gloves inside the room.

ISOLATION GUIDELINES CHART
Standard Precautions are used with ALL patients
Pneumonia- use contact and droplet Isolation Precautions.

Review of the Environmental Services Policy and Procedure Manuel on 9/29/15 in the EVS office, did not reflect a policy for the transporting of clean supplies to the patient nursing units or the transporting of trash off the patient nursing units.

During an interview on 9/29/15, in the afternoon, in the conference room, Staff #1, Vice President of Patient Care Services and Staff #2, Director of Infection Prevention confirmed the above findings.