HospitalInspections.org

Based on interview and reenactment for the administration of medication it was determined that the facility failed to follow proper practice of securing controlled medications from potential unauthorized use until the administration of medication has occurred.

Findings include:

On interview with Staff D (Nursing) on 6/6/12 it was asked by surveyor to show how a case was set up prior to the patient entering the cath lab. Staff D was asked how the medication for the procedure was set up, and how the medication was drawn up. Staff D showed surveyor the type of syringe used, along with showing that a blunt tip needle was used. Staff D showed how each syringe was marked with a sticker with the name of the controlled medication, and then how to enter the Pyxis machine (medication cart). Staff D continued to explain that the Pyxis has a finger print scan along with a password. Once entered a single vial would be dispensed, each vial has 2 mg (milligrams) which would be drawn up into the syringe. Once the medications are drawn up Staff D stated that they are placed onto the Pyxis (medication cart) at which time Staff D would walk around the surgical table to get the lead apron on to proceed with the procedure. Staff D was asked during that time if the medications that were drawn up were in their possession or left on top of the Pyxis machine (medication cart). Staff D confirmed that the medications were left on the Pyxis machine when putting on the lead apron. Staff D stated that other co-workers are in the procedure area during this time including the cardiac cath technicians (who do not have the authority to handle medications). Staff D did state after the interview, "probably not the best practice".

Based on record review, interview, and review of CDC, and AORN national standards it was determined that the hospital failed to provide a sanitary environment, and avoid sources of transmission of potential infections by not developing and or implementing policy and procedures following recognized standards for 1) the cleaning and disinfecting of equipment between patient uses on five of seven distinct hospital areas, 2) the appropriate gowning when entering the room of a patient on infection precaution on one of seven areas, 3) the criteria for employees with potential infectious process for being able to work in direct patient care and 4) for allowing an employee with draining wounds to participate in an environment where invasive procedures were being performed.


Findings include:


CDC (Centers for Disease Control and Prevention) Recommendation and Reports "http://www.cdc.gov/mmwr/preview/mmwrhtml/00014845.htm" accessed on 6/8/12 pg 4 of 7, states "All HCWs [Health Care Workers] ....HCWs who have exudative lesions or weeping dermatitis should refrain from all direct care and from handling patient-care equipment and devices used in performing invasive procedures until the condition resolves...."

AORN (Association of periOperative Registered Nurses) 2009 Edition Perioperative Standards and Recommended Practices, pg 480 Recommendation XI "Activities of personnel with infections, exudative lesions, nonintact skin, and /or bloodborne diseases should be restricted when these activities pose a risk of transmission of infection to patients and other health care workers. identification, evaluation by a physician, and assessment of fitness for work performance in the perioperative setting should be required...

#2. Health care workers who have exudative lesions or weeping dermatitis should refrain from providing direct patient care or handling medical devices used in performing invasive procedures. Restricting personnel who have exudative lesions, nonintact skin, or weeping dermatitis reduces the risk of transmission of bloodborne and other pathogens between workers and patients".


On review of the facility's policy:

Page 1 SH(IC).003 Function: Surveillance, Prevention and Control of Infection. "PURPOSE: In accordance with regulatory requirements governing infectious disease, Exeter Health Resources, Inc. (EHR) has developed a program for early identification and prompt intervention for reporting and controlling the spread of contagious diseases in the workplace. STEPS IN PROCEDURE:...

#2. Per Guidelines for Employees with Contagious Disease (attached), Staff Health or the manager/supervisor/CRN [Certified Registered Nurse] will determine if it is necessary to relieve the person from direct patient contact or restrict form the work place.
#3. When Staff Health is unavailable, HCW must report to their manager/supervisor/CRN who will determine if it is necessary to relieve the person from direct patient contact or restrict from the work place".

Page 2. "GUIDELINES FOR EMPLOYEES WITH CONTAGIOUS DISEASES"

In chart form: for skin disease of Abscess, Infected acne, boils, skin lesions, impetigo, wounds, paronychia; and infective material pus, lesions, secretions; and symptoms open, draining areas; page 2 relates:

Under: Can employee report to work (patient care) it states "May work if areas is adequately covered until healed".

Under: Can employee report to work (non-patient care) "May work if areas is adequately covered until healed".

Under: Comments "All open wounds must be covered".

On interview with Staff A (Manager of Cath Lab) on 6/7/12 at 10:30 a.m. and again at 2 p.m. it was revealed through interview that Staff B (Scrub technician) had 3 open lesions and a finger cut that needed stitches at times during Staff B's employment from date of hire on 4/11/11 until 5/16/12. On further interview with Staff A it was revealed that Staff B was asked to leave the work area several times due to weeping / discharge of fluids and blood like stains in Staff B's scrubs [clothing] including at least once during a procedure.

On review of the facility's Staff Health Services report dated 9/6/2011 for Staff B it states "...[Staff B] had a procedure ...last Monday in the office, got a note to return to work. While working Tuesday, Incision bled, went back Wednesday, had more procedure performed in the office, got not [note] to return to work. On Friday, started to bleed again and ended up in ...for surgery due to incision near a blood vessel...s/p [status post] surgery ...open incision/packing in place..".

On review of another report for Staff B by the facility's Staff Health Services dated 3/5/2012 it states, "...[physician] did the procedure on 2/27/12...[Staff B] oow [out of work] on 2/27, 2/28. 2/29, and 3/2/12....Incision clean and dry, healing well. No s/sx [signs and symptoms] of infection. [Staff B] is able to keep the area covered while at work. States that [doctor] told him that he could go back to work as of today, [Staff B] does not have a note...Supervisor [Staff A] notified that [Staff B] can RTW [Return to work] full duty as of today"




21706

During the complaint survey, and review of the facility's policies and procedures it was identified that there was no policy for the cleaning of glucometers between patient use. Interviews on 6/6/12 and 6/7/12 on five nursing units 3 East, 4 West, ICU, Emergency Dept. and PCU identified no consistent methodology for the cleaning of glucometers after each patient use, some units reported cleaning only after use in precaution rooms and one unit demonstrated a sample document indicating that the cleanings were done in the morning and at night.


Cross refer to tag A 749 and A 748

Based on policy review, observation, and interview the facility failed to ensure that policies and procedures were developed and implemented for the cleaning and disinfection of glucometers between each patient use and failed to ensure that policies concerning the wearing of appropriate personal protective equipment were implemented in contact precaution rooms and failed to develop policies and procedures consistent with recognized infection control standards for employees with non intact skin returning to work in direct patient care areas.

Findings include:

During the complaint survey, and review of the facility's policies and procedures it was identified that there was no policy for the cleaning of glucometers between patient use. Interviews on 6/6/12 and 6/7/12 on five nursing units 3 East, 4 West, ICU, Emergency Dept. and PCU identified no consistent methodology for the cleaning of glucometers after each patient use, some units reported cleaning only after use in precaution rooms and one unit demonstrated a sample document indicating that the cleanings were done in the morning and at night.



13504

Review of the facility's policy and procedures dated 3/2011 Title Contract Precautions policy no.:IC-ISOL.005 revealed.
Purpose: "To provide guidelines for reducing the risk of transmission of epidemiologically important microorganisms that can be transmitted by direct contact with the patient (hand or skin-to-skin contact) or indirect contact with environmental surfaces or patient-care items in the patient's environment".

STEPS IN PROCEDURE:...
#3. Gowns (clean non sterile) and gloves are required when entering the patient's room. Remove the gown and gloves before leaving the patient's environment and discard, being careful that clothing does not contact potentially contaminated surfaces. Gowns are not used again even for repeated contact with the same patient.

During tour of the facility's surgical units on 6/7/12 4th floor east and south Staff C (Unit Manager) was asked which patients were under contact precaution. Staff C identified three rooms two were contact precaution and the third was droplet precautions. While on the unit a staff member was observed in a patent's room with the contact precaution sign outside the patient's door. The staff member was wearing a lab coat and was standing next to the patient's bed and did not have any contact precaution gear on. Staff C was asked during the observation who the staff member was in the patient's room, Staff C confirmed through interview that it was Staff D (Physical therapy) that was not wearing any contact precaution gear.

CDC (Centers for Disease Control and Prevention) Recommendation and Reports "http://www.cdc.gov/mmwr/preview/mmwrhtml/00014845.htm" accessed on 6/8/12 pg 4 of 7, states "All HCWs [Health Care Workers] ....HCWs who have exudative lesions or weeping dermatitis should refrain from all direct care and from handling patient-care equipment and devices used in performing invasive procedures until the condition resolves...."

AORN (Association of periOperative Registered Nurses) 2009 Edition Perioperative Standards and Recommended Practices, pg 480 Recommendation XI "Activities of personnel with infections, exudative lesions, nonintact skin, and /or bloodborne diseases should be restricted when these activities pose a risk of transmission of infection to patients and other health care workers. identification, evaluation by a physician, and assessment of fitness for work performance in the perioperative setting should be required...

#2. Health care workers who have exudative lesions or weeping dermatitis should refrain from providing direct patient care or handling medical devices used in performing invasive procedures. Restricting personnel who have exudative lesions, nonintact skin, or weeping dermatitis reduces the risk of transmission of bloodborne and other pathogens between workers and patients".


On review of the facility's policy:

Page 1 SH(IC).003 Function: Surveillance, Prevention and Control of Infection. "PURPOSE: In accordance with regulatory requirements governing infectious disease, Exeter Health Resources, Inc. (EHR) has developed a program for early identification and prompt intervention for reporting and controlling the spread of contagious diseases in the workplace. STEPS IN PROCEDURE:...

#2. Per Guidelines for Employees with Contagious Disease (attached), Staff Health or the manager/supervisor/CRN [Certified Registered Nurse] will determine if it is necessary to relieve the person from direct patient contact or restrict form the work place.
#3. When Staff Health is unavailable, HCW must report to their manager/supervisor/CRN who will determine if it is necessary to relieve the person from direct patient contact or restrict from the work place".

Page 2. "GUIDELINES FOR EMPLOYEES WITH CONTAGIOUS DISEASES"

In chart form; for skin disease of Abscess, Infected acne, boils, skin lesions, impetigo, wounds, paronychia; and infective material pus, lesions, secretions; and symptoms open, draining areas; page 2 relates:

Under: Can employee report to work (patient care) it states "May work if areas is adequately covered until healed".

Under: Can employee report to work (non-patient care) "May work if areas is adequately covered until healed".

Under: Comments "All open wounds must be covered".

On interview with Staff A (Manager of Cath Lab) on 6/7/12 at 10:30 a.m. and again at 2 p.m. it was revealed through interview that Staff B (Scrub technician) had 3 open lesions and a finger cut that needed stitches at times during Staff B's employment from date of hire on 4/11/11 until 5/16/12. On further interview with Staff A it was revealed that Staff B was asked to leave the work area several times due to weeping / discharge of fluids and blood like stains in Staff B's scrubs [clothing] including at least once during a procedure.

On review of the facility's Staff Health Services report dated 9/6/2011 for Staff B it states "...[Staff B] had a procedure ...last Monday in the office, got a note to return to work. While working Tuesday, Incision bled, went back Wednesday, had more procedure performed in the office, got not [note] to return to work. On Friday, started to bleed again and ended up in ...for surgery due to incision near a blood vessel...s/p [status post] surgery ...open incision/packing in place..".

On review of another report for Staff B by the facility's Staff Health Services dated 3/5/2012 it states, "...[physician] did the procedure on 2/27/12...[Staff B] oow [out of work] on 2/27, 2/28. 2/29, and 3/2/12....Incision clean and dry, healing well. No s/sx [signs and symptoms] of infection. [Staff B] is able to keep the area covered while at work. States that [doctor] told him that he could go back to work as of today, [Staff B] does not have a note...Supervisor [Staff A] notified that [Staff B] can RTW [Return to work] full duty as of today"

Based on record review, observation and interview with staff it was determined that the facility failed to implement professional standards for when infected hospital staff are restricted from providing direct patient care and/or are required to remain away from the healthcare facility entirely, and the facility failed to ensure that policies concerning the wearing of appropriate personal protective equipment were implemented in contact precaution rooms.

Findings include:

CDC (Centers for Disease Control and Prevention) Recommendation and Reports "http://www.cdc.gov/mmwr/preview/mmwrhtml/00014845.htm" accessed on 6/8/12 pg 4 of 7, states "All HCWs [Health Care Workers] ....HCWs who have exudative lesions or weeping dermatitis should refrain from all direct care and from handling patient-care equipment and devices used in performing invasive procedures until the condition resolves...."

AORN (Association of periOperative Registered Nurses) 2009 Edition Perioperative Standards and Recommended Practices, pg 480 Recommendation XI "Activities of personnel with infections, exudative lesions, nonintact skin, and /or bloodborne diseases should be restricted when these activities pose a risk of transmission of infection to patients and other health care workers. identification, evaluation by a physician, and assessment of fitness for work performance in the perioperative setting should be required...

#2. Health care workers who have exudative lesions or weeping dermatitis should refrain from providing direct patient care or handling medical devices used in performing invasive procedures. Restricting personnel who have exudative lesions, nonintact skin, or weeping dermatitis reduces the risk of transmission of bloodborne and other pathogens between workers and patients".


On review of the facility's policy:

Page 1 SH(IC).003 Function: Surveillance, Prevention and Control of Infection. "PURPOSE: In accordance with regulatory requirements governing infectious disease, Exeter Health Resources, Inc. (EHR) has developed a program for early identification and prompt intervention for reporting and controlling the spread of contagious diseases in the workplace. STEPS IN PROCEDURE:...

#2. Per Guidelines for Employees with Contagious Disease (attached), Staff Health or the manager/supervisor/CRN [Certified Registered Nurse] will determine if it is necessary to relieve the person from direct patient contact or restrict form the work place.
#3. When Staff Health is unavailable, HCW must report to their manager/supervisor/CRN who will determine if it is necessary to relieve the person from direct patient contact or restrict from the work place".

Page 2. "GUIDELINES FOR EMPLOYEES WITH CONTAGIOUS DISEASES"

In chart form: for skin disease of Abscess, Infected acne, boils, skin lesions, impetigo, wounds, paronychia; and infective material pus, lesions, secretions; and symptoms open, draining areas; page 2 relates:

Under: Can employee report to work (patient care) it states "May work if areas is adequately covered until healed".

Under: Can employee report to work (non-patient care) "May work if areas is adequately covered until healed".

Under: Comments "All open wounds must be covered".

On interview with Staff A (Manager of Cath Lab) on 6/7/12 at 10:30 a.m. and again at 2 p.m. it was revealed through interview that Staff B (Scrub technician) had 3 open lesions and a finger cut that needed stitches at times during Staff B's employment from date of hire on 4/11/11 until 5/16/12. On further interview with Staff A it was confirmed through interview that Staff B was asked to leave the work area several times due to weeping/discharge of fluids and blood like stains in Staff B's scrubs [clothing] including at least once during a procedure.

On review of the facility's Staff Health Services report dated 9/6/2011 for Staff B it states "...[Staff B] had a procedure ...last Monday in the office, got a note to return to work. While working Tuesday, Incision bled, went back Wednesday, had more procedure performed in the office, got not [note] to return to work. On Friday, started to bleed again and ended up in ...for surgery due to incision near a blood vessel...s/p [status post] surgery ...open incision/packing in place..".

On review of another report for Staff B by the facility's Staff Health Services dated 3/5/2012 it states, "...[physician] did the procedure on 2/27/12...[Staff B] oow [out of work] on 2/27, 2/28. 2/29, and 3/2/12....Incision clean and dry, healing well. No s/sx [signs and symptoms] of infection. [Staff B] is able to keep the area covered while at work. States that [doctor] told him that he could go back to work as of today, [Staff B] does not have a note...Supervisor [Staff A] notified that [Staff B] can RTW [Return to work] full duty as of today"


Review of the facility's policy and procedures dated 3/2011 Title Contract Precautions policy no.:IC-ISOL.005 revealed.
Purpose: "To provide guidelines for reducing the risk of transmission of epidemiologically important microorganisms that can be transmitted by direct contact with the patient (hand or skin-to-skin contact) or indirect contact with environmental surfaces or patient-care items in the patient's environment".

STEPS IN PROCEDURE:...
#3. Gowns (clean non sterile) and gloves are required when entering the patient's room. Remove the gown and gloves before leaving the patient's environment and discard, being careful that clothing does not contact potentially contaminated surfaces. Gowns are not used again even for repeated contact with the same patient.

During tour of the facility's surgical units on 6/7/12 4th floor east and south Staff C (Unit Manager) was asked which patients were under contact precaution. Staff C identified three rooms two were contact precaution and the third was droplet precautions. While on the unit a staff member was observed in a patent's room with the contact precaution sign outside the patient's door. The staff member was wearing a lab coat and was standing next to the patient's bed and did not have any contact precaution gear on. Staff C was asked during the observation who the staff member was in the patient's room, Staff C confirmed through interview that it was Staff E (Physical therapy) that was not wearing any contact precaution gear.